CSI St. Francis, Ks (or how to be a rural coroner)

1. C. T. Allred, M.D. Coroner, 28th Judicial District CSI St. Francis, Ks(or how to be a rural coroner)

2. WARNING • This talk does contain graphic pictures and sensitive subject material. • I apologize if you stayed after the above and the material was not graphic enough. • Of course, the material herein also contains my opinions. There are certainly other opinions that would disagree.

3. Case # 1 • You are called by local police about a 78 y.o. man found dead in his duplex. He had not been seen for a few days and police were asked to check on him. His home was locked from the inside. He was sitting on a rocking chair, fully clothed, with no sign of trauma, no blood at the scene. The TV is on. Further history indicates he had recently been diagnosed with terminal lung cancer.

4. Do you order an autopsy? • I did not. • In our community, getting an autopsy costs about $2000 to $3500. • While the duty of a coroner is to determine cause and manner of death, it is also to use common sense and try to utilize your county resources as best you can.

5. The rest of the story

6. Legal duties of a coroner • Web site for the Kansas legislature http://www.kslegislature.org/li/b2011_12/measures/bills/ • Click Statute in the bottom of left hand box. • Then click Chapter 22a in the column and select District Coroner. • 17 statutes. 22a-231 and 242 are actually worth reading.

7. The basic stuff • Any death of a person by accident, suicide, homicide, suspicious, sudden and/or unexplained, or when not regularly attended by a physician, in police custody or jail, or when the cause of death is held to be in the public interest, shall be reported to the coroner. • Any death of a child (a person under the age of 18) shall be reported to the coroner.

8. Basics, cont. • Once notified, the coroner can decide if this is a “coroner case.” • A 65 year old man with a bypass operation 5 years before who c/o chest pain and dies suddenly on arrival to the ER is not a “coroner case” unless no one else will sign the DC. Does not need an autopsy. • A 65 y.o. man who has the same medical history and is found with a white powder in the straw he has in his nose is a “coroner case.”

9. Basics, cont. • If it is a coroner case, it is the duty of the coroner to determine the cause and manner of death. • This may require only calling the person’s regular doctor or looking at medical records at the hospital to discover that the deceased person has a long history of COPD or diabetes or heart disease. • Or one could assume that most 89 y.o. folks found dead at home without any sign of trauma or blood probably died from ASVD – atherosclerotic vascular disease, be it CAD or CVD. Even if they never saw a doctor.

10. Basics, cont. • Determining manner and cause will usually mean finding out the events leading up to the death as much as possible, perhaps a visual inspection of the body, perhaps drawing blood or obtaining urine for toxicology. • Or maybe an autopsy will be needed. Or maybe a forensic autopsy. • More on that later.

11. Definitions • Cause of death – what you put on the death certificate. • Is the best diagnosis to explain the death in your opinion. • A coroner does not have to know with certainty what a person died from to put down a diagnosis. The best a person can do is required. • Rarely, even after autopsy, a cause is not found. “Not able to be determined” is written down.

12. Definitions • Manner of death • Natural • Homicide • Suicide • Accidental • Pending investigation • Unable to be determined

13. Case # 2 • A 44 y.o. woman was pushed down the stairs by her husband when she was 21. She has been quadriplegic since that time and for many years has had an indwelling Foley catheter with repeated UTIs. • She is admitted to the hospital with hypotension, fever, renal failure, and e coli in her urine and blood. She subsequently dies. • Her cause of death is e coli sepsis secondary to e coli UTI. Contributing factors include acute renal failure, quadriplegia, old cervical fracture. • Her manner of death is accidental because the accident is what led to everything else.

14. Case # 3 • A 72 y.o. woman with known osteoporosis and numerous vertebral fx. falls and breaks her hip. This is repaired and she convalesces in a nursing home. Two weeks later, she develops pneumonia and dies. • The cause of death is pneumonia. Contributing factors are hip fx and osteoporosis. • The manner of death is accidental due to the fall. If the fx were spontaneous or due to cancer, it would be natural.

15. Timing of death • Algor mortis • Livor mortis (lividity) • Rigor mortis • The Allred method

16. Algor mortis • The gradual cooling of the body temperature after death. • Many formulas vary in complexity. • A simple one – a decrease of 1.5 degrees Celsius for every hour past time of death from an assumed temperature of 37 degrees. • Can’t get lower than the ambient temperature so that needs to be measured as well.

17. Algor Mortis • Has to be a core body temperature – either rectal or liver. • Numerous variables make this hard to depend on (and I have never done it). • What was the body temperature at time of death? Maybe it was 39 degrees, not 37. • Others – clothing, inside or outside, in the sun, dehydration, weight of body, carpet or tile floor? • And it turns out it is actually a log rhythmic curve of cooling.

18. Livor mortis (lividity) • Within 20 minutes of time of death, the blood begins to pool due to gravity. • If not present at all, probably dead less than 2 hr. • Causes a purple red discoloration of the dependent area of the body. (except cyanide and carbon monoxide and severe hypothermia – all bright red in color.) • After 8 -12 hours, lividity will no longer blanch if a thumb is pushed on the skin and it said to be fixed.

19. Livor mortis

20. Livor mortisareas where there is pressure on the skin will not show livor mortis

21. Livor mortis

22. Cyanide poisoning

23. Livor mortis • Important for two reasons: • One is timing. If still blanches, probably dead less than 12 hours. The more difficult it is to blanch, the closer to 12 hours. • If one ever examines a body where the livor mortis is not consistent with the current position of the body, it means the body has been moved after death. • Still, from my experience, not entirely dependable for time of death.

24. Tardieu spots of livor mortis

25. Rigor mortis • ATP (finally something I remember from medical school.) • Decrease to 85% depletes the energy needed for muscle relaxation and therefore muscles contract causing a stiffness. • Begins in small muscles and then effects large muscles.

26. Rigor mortis

27. Rigor mortis • Usually begins within a few hours of death, progresses over 12 to 24 hours, then recedes over the next 24 hours. • Can set up more quickly in people who have fever, were exercising, had a sz. at the time of death (faster depletion of ATP). • Cold temperature may delay onset and resolution. • Resolves with the beginning of decomposition.

28. Decomposition • “Death is a part of life and decomposition is a part of death.” • Autolysis – the body’s breakdown of itself due to its own enzymes working on tissues. • Mummification – a drying out process combined with autolysis more common in very dry and warm climates. • Putrefaction – the destruction of tissues by the body’s bacteria.

29. Mummification Drying process can be seen with the entire body or more commonly those areas with less tissue – nose, ears, hands, and feet. Can see desiccation of some areas with bloating of others.

30. Putrefaction Early change is green color over the cecum.

31. Putrefaction This is followed by bloating and further color changes and skin slippage as bacteria multiply.

32. Putrefaction Marbling is caused by the reaction of hydrogen sulfide, produced by bacteria, with hemo- globin remaining in the vasculature.

33. Putrefaction Purge fluid is a byproduct of bac- terial decomposition. Brownish red in color, it can come from any orifice but is common from the mouth and nose when the body is moved. Other post- mortem changes would suggest this is the cause and not bleeding but only an autopsy could say definitively.

34. Putrefaction Within 12 hours of death and temperatures above 50 degrees, in areas where it can access a body, a blowfly will lay eggs that then will hatch and become maggots.

35. Putrefaction There are actually three larval stages of the blow- fly that increase in size until the last stage pupates. Taking specimens from the scene can be of some help in determining time of death.

36. So what do I actually do? • In our county, I am notified by law enforcement if someone died at home in any case other than if they were in hospice. • From the hospital, I am called by the ER doctors if someone died in the ER, even if they died from known cancer. • I get the story from whoever calls me – name, date of birth, time of death, and the details. • I then make a decision if this is a “coroner case” and if I will visit the scene.

37. So what do I actually do? • If the person is 89 years old and there is no suspicion, I tell them the body is released. Sometimes I call their doctor but a lot of the time, I just find out what meds they were taking and assume the disease is related. And if they are on no meds at that age, they died from coronary artery disease.

38. So what do I actually do? • If I know I am going to get an autopsy, I frequently don’t go to the scene. • Exceptions are babies and murders. Almost always go. Don’t add much but occasionally I can see something that looks wrong. • If I don’t think an autopsy is needed but the death is not natural, I will either visit the scene or I will examine the body at the mortuary.

39. So what do I actually do? • Afterward, I type up a report. • I keep a copy. • A copy goes to the law enforcement agency involved. • The original is sent to the Clerk of the District Court. • These are open records and anyone can get a copy by sending a written request to the Clerk of the District Court.

40. Sample report Name: John T. Smith Date of birth: 6/1/1934 Date and time of death: 4/1/2012, pronounced at 0700 hours. Address: 221 S. Sante Fe, Salina, Ks. Place of death: same. Autopsy: none. (Or put in whoever did the autopsy.) Law enforcement: Salina Police Department, Lt. Jones. Information from: medical records and above. Body identified by: family. Physician: Bill Jones, M.D. Manner of death: natural. Mr. Smith lived alone at the above address. His daughter went to his house at the time noted above to take him to breakfast. His house was locked. When she entered with her key, she found him deceased in bed. I visited the scene. There were no signs of trauma. rigor was present in the small and large muscles. Lividity was not fixed and was consis- tent with the position the body was found in. Mr. Smith took medication for heart disease and hypertension. He had stopped smoking

41. many years before. He had recently complained to his daughter about some chest pain, but declined to go to his doctor.This is a natural death and requires no autopsy. Police agreed. Final diagnosis: Coronary artery disease. Contributing factors include HTN and past use of tobacco. Toxicology: none. Charles T. Allred, M.D. Coroner, 28th Judicial District

42. What do I get paid? • $24,000 plus $100 for every case. • Out of this I pay two deputy coroners and whatever other costs I may have. • In Saline County, I receive about 100 calls in a year. The majority of these are natural deaths that occurred at home. Usually one SIDS death, 5 suicides, 2-5 homicides, a number of accidents, most commonly from drug overdose. • Spend about an hour on each case on average.

43. For more information • http://medschool.slu.edu/mldi/ • St. Louis University School of Medicine offers a medicolegal death investigators course three time a year. • 5 days, $825. • A very good course geared toward nonpathologists. • Plenty of books and weird websites available.

44. Allred method for time of death • Count up the number of newspapers in the front yard. • Subtract that number from current date = date of death. • If they don’t take the newspaper, count number of Buyer’s Guides.