National Association of Medical Examiners Position Paper: Recommendations for the Documentation and Certification of Disaster-Related Deaths.

ABSTRACT: Collecting and reporting accurate disaster mortality data are critical to informing disaster response and recovery efforts. The National Association of Medical Examiners convened an ad hoc committee to provide recommendations for the documentation and certification of disaster-related deaths. This article provides definitions for disasters and direct, indirect, and partially attributable disaster-related deaths; discusses jurisdiction for disaster-related deaths; offers recommendations for medical examiners/coroners (ME/Cs) for indicating the involvement of the disaster on the death certificate; discusses the role of the ME/C and non-ME/C in documenting and certifying disaster-related deaths; identifies existing systems for helping to identify the role of disaster on the death certificate; and describes disaster-related deaths that may require amendments of death certificates. The recommendations provided in this article seek to increase ME/C's understanding of disaster-related deaths and promote uniformity in how to document these deaths on the death certificate.

Psychosocial risk factors as contributors to pregnancy-associated death in Virginia, 1999-2001.

OBJECTIVE: To determine if substance abuse, mental illness, and domestic violence contributed to preventable pregnancy-associated death and to describe characteristics of women for whom these factors contributed to death. METHODS: The medical records of 121 women who had pregnancy-associated deaths in Virginia between 1999 and 2001 were reviewed. The incidence of substance abuse, mental illness, and domestic violence was noted during systematic review. Multidisciplinary review of cases was conducted to determine if these factors contributed to death and if reasonable changes may have prevented death. RESULTS: The pregnancy-associated maternal mortality ratio for women experiencing substance abuse, mental illness, or domestic violence as contributors to death was 17.1. Thus, for every 100,000 live births in Virginia, 17.1 women had at least one of these factors directly contribute to death. Substance abuse contributed to death in 28.9% of all cases reviewed (pregnancy-associated maternal mortality ratio = 12.2); 45.7% of those deaths were considered preventable. Mental illness contributed to death in 16.5% of cases (pregnancy-associated maternal mortality ratio = 6.9), with 50.0% considered preventable. Domestic violence contributed to death in 14.0% of cases (pregnancy-associated maternal mortality ratio = 5.9), with 64.7% of cases considered preventable. Median household incomes and years of education completed varied widely. Pregnancy-associated maternal mortality ratios for each factor were higher among African American women than among white women. CONCLUSIONS: Psychosocial risk assessment with appropriate referral should be completed for all women seeking care regardless of social status, education, or race.

Mass murder in a university setting: analysis of the medical examiner's response.

BACKGROUND: Seung-Hui Cho, a student at Virginia Polytechnic Institute and State University (Virginia Tech), shot and killed 33 students and faculty, including himself, on the morning of April 16, 2007. METHODS: A retrospective review of the medical examiner system response to this multiple fatality event was undertaken to identify which procedures were and were not effective. Case records, spreadsheets, telephone call logs, notes, and after-action interviews of staff were reviewed and analyzed. Recommendations were developed to improve the management of the multiple components of a high-profile multiple fatality event. RESULTS: One autopsy took place on Monday, April 16, 12 on Tuesday, April 17, and 20 on Wednesday, April 18. Pathologists archived the biopsies of major organs in formalin. Slides were made of entrance wounds that exhibited residues. Blood for alcohols was collected from victims. Blood for alcohols, acid, base, and neutral drugs was collected from Cho for analysis. CONCLUSIONS: Standard forensic pathology procedures worked and timely postmortem examinations were completed. The victim identification component of the family assistance center must be established and staffed at the time of the initial response. Public information officers need training in morgue and medicolegal death management and in ways to effectively communicate with different audiences about multiple fatality management procedures.

Toxicology findings in child and adolescent suicides in virginia: 1987-2003.

OBJECTIVE: In a follow-up report of child and adolescent suicides in Virginia, we describe postmortem toxicology findings in a subset of these youths. METHOD: We analyzed "unnatural" deaths from Virginia's Office of the Chief Medical Examiner for 1987 to 2003. There were 2818 unnatural deaths in children and adolescents. We grouped unnatural deaths as accidents, homicides, and suicides. Toxicology records were available for 753 cases, of which 732 were black or white youths. RESULTS: There were no age differences among suicide victims and accident or homicide victims. Whites were more likely than blacks to die by accident and suicide. White females were more likely than black females to commit suicide. Black males were more likely than white males to suffer homicide. For all unexpected deaths, antidepressants were more commonly found among whites than blacks. Suicide by poisoning occurred more commonly among whites. Recreational drugs were more commonly found among blacks than whites. Suicide by gun occurred more commonly among blacks. Antidepressants were found in 39 black and white suicide victims. Anti-depressants (all tricyclic antidepressants) were causally related in 17 cases of suicide by poisoning. No other antidepressants were found in lethal levels in suicide by poisoning. Selective serotonin reuptake inhibitors (SSRIs)/venlafaxine appeared more commonly in the suicides (p < .0001) than in accidents or homicides. For suicides, SSRIs appeared no more commonly in poisoning than in gun or hanging deaths (p = .695). CONCLUSIONS: Antidepressants appeared more commonly among youths committing suicide than those dying by accident or homicide. SSRIs did not appear more commonly among youths committing suicide by poisoning than those committing suicide by gun or hanging. Because our data are descriptive, they are subject to over-interpretation. Cause-effect inferences should not be drawn.

Metabolic disorders detectable by tandem mass spectrometry and unexpected early childhood mortality: a population-based study.

Investigators have reported that certain metabolic disorders (fatty acid oxidation (FAO) disorders and organic acidemias) contribute to unexpected early childhood deaths. We estimated the contribution of these metabolic disorders to a population-based sample of unexpected early childhood deaths. The study population included children less than 3 years of age who died during 1996-2001 and whose deaths were investigated by the Virginia Office of the Chief Medical Examiner (ME). Dried post-mortem blood on filter paper was sent to a reference laboratory for metabolic screening by tandem mass spectrometry. When molecular DNA analysis was available to identify known gene mutations, positive screens were confirmed. If molecular DNA analysis for a suspected disorder was not available, tandem mass spectrometry was performed on newborn blood spots when available. If DNA analysis was not available and newborn blood spots could not be obtained, an independent expert biochemical geneticist confirmed the post-mortem interpretation. We obtained screening results for 793 (88%) of 904 children examined. Eight children had a positive screen for FAO disorders or organic acidemias. One child would not have benefited from identification in the newborn period. However, seven children's outcomes might have been improved had they been identified during the newborn period and effectively treated. Post-mortem metabolic screening may identify a cause of death for about 1% of children who die unexpectedly before 3 years of age, allowing for identification and treatment of affected siblings. Identifying and treating affected children during the newborn period may offer an opportunity to reduce early childhood mortality.

Child and adolescent suicides in Virginia: 1987 to 2003.

OBJECTIVES: The aim of this study was to better understand suicides in children and adolescents using records from the Office of the Medical Examiner of Virginia from 1987 to 2003. MAIN FINDINGS, KEY DATA, AND STATISTICS: Suicide accounted for 16.8% of unnatural deaths. Suicide rates were highest for Caucasians. Guns were the most common method of death for suicides, followed by hanging and poisoning. Poisoning other than carbon monoxide accounted for 7.8% of suicides, with tricyclic antidepressants (TCAs) the most identifiable poison. Female youths were 10 times more likely to die from TCAs than male youths, after adjusting for race and age. CONCLUSIONS: Guns and hanging were the principal methods of suicide. Among the antidepressants, TCAs have been the most common poisons used in suicide. Increasing age was a powerful determinant of suicide. Some patients may have stockpiled their TCAs for a while before their TCA overdose. Other suicide victims may have used TCA supplies from family members. Hence, some of the suicide victims may not have taken TCAs on a regular basis before committing suicide. Further exploration of TCA-induced suicidal thoughts is needed. Conclusions cannot be made at the time about the precise role that TCAs played in TCA-induced suicide reported in our study.