The "mini-packer" syndrome. Fatal ingestion of drug containers in Baltimore, Maryland

We report seven fatalities resulting from the ingestion of illicit drugs packaged in condoms, rubber balloons, or plastic bags which were observed in the last 4 years at the Office of the Chief Medical Examiner, State of Maryland. All the victims, with the exception of one, were men ranging in age from 19 to 37 years. There was no racial predominance. No drug paraphernalia was found at any scene. In two cases, seizure-like activity was documented. One victim had recently returned from Nigeria; therefore, Lassa fever was initially suspected. Two of the victims were "body packer" contrabanders who had just arrived from Africa. They used body cavities to hide large amounts of heroin to avoid U.S. Customs. The other five cases were "mini-packers," small-time illicit drug dealers who had swallowed a single bag of cocaine to avoid police detection. The possible mechanism of leaking or rupture of the latex container is discussed.     

Accidental non-commercial aircraft fatalities: the 7-year Metro-Dade County experience from 1977-1983

A study of accidental non-commercial aircraft fatalities was performed on the case files of the Office of the Medical Examiner of Metropolitan Dade County in Miami, FL, U.S.A., between the years 1977 through 1983. A total of 57 cases were collected and analyzed as to the age of the victim, the race and sex of the victim, the cause of death, the blood alcohol content at autopsy, the drugs detected at autopsy, the type of aircraft, the occupant role, the risk factor responsible for the crash, the time of the fatality, and the nature of usage of the aircraft. Essentially, these 57 cases comprised 1.2% of the non-vehicular accidental fatalities during the period. The age of distribution is relatively evenly distributed from age 16 to 65 years with white males predominating. Multiple injuries were the most common cause of death although conflagration injuries (e.g., smoke inhalation, burns) were frequent. The victims were sober and free of drugs in the majority of cases. Most fatalities occurred in a single engine plane with the victim, the pilot, flying for private reasons in the afternoon or evening hours. The most common identifiable risk factor was human error (e.g., judgement), rather than mechanical or plane failure.     

Fatal hunting injuries in North Rhine-Westphalia

The investigation covers 14 fatal hunting accidents which occurred in North Rhine-Westphalia in the last 23 years, among them 13 firearm fatalities. All the accidents happened during the statutory hunting season reaching a peak in the main small game season. 86% of the persons causing the accidents and 73% of the victims were over 41 years and experienced hunters. 36% of the accidents were caused by the victims themselves. The fatal gunshot injuries were inflicted by rifle bullets in 7 cases (54%) and shotgun pellets in six cases (46%). No accidents were due to shotgun slugs or handgun ammunition. The main factors responsible for the fatalities were: covering the victim while swinging on the game (31%), failure to discharge the firearm while descending from the raised hide or transporting the weapon in vehicles (31%), mistaking the victim for game (15%), failure to discharge the weapon during a hunting break or while pressing down obstacles or careless handling of the weapon (23%). In no case was the accident caused by a defective weapon or ammunition. In conclusion aspects of preventing fatal hunting accidents are discussed.     

Palliative pain therapy at the end of life and forensic medicine issues.

An 83-year-old woman with a history of Alzheimer's disease and breast cancer died at home while receiving palliative pain therapy with oral morphine from her family for metastatic breast cancer. Allegations of mistreatment were made, and this case was ultimately referred to the Office of the Chief Medical Examiner, State of Maryland. An autopsy failed to identify any injuries or residual cancer, leaving no anatomic explanation for the pain that had been presumed to be metastatic breast carcinoma involving bone. The blood free morphine concentration was 5,200 ng/ml, and the total morphine concentration was 15,000 ng/ml. This case demonstrates the challenges and difficulties in forensic medicine when faced with the interpretation of toxicologic results at the end of life.     

Provoked shooting by police as a mechanism for suicide

We report a case which was processed by the Philadelphia Office of the Medical Examiner in which a person with a previous known suicide attempt clearly provoked the Philadelphia police into shooting him. We believe that this is but one of many such incidents in which the victim provokes another into administering fatal injury. This is a mechanism of suicide which, we believe, is exemplified by the case presented.     

Medicolegal investigation in New York City. History and activities 1918-1978

Medicolegal investigation in America can truly be said to have begun in an organized manner in 1918. The Massachusetts medical examiner system, which began in 1877, never developed with the central control and the completeness that characterizes the New York Office of the Chief Medical Examiner, nor did it influence the spread of this form of medicolegal investigation. An overview of the period before the establishment of the New York Office in 1918 and early experiences in coroner's investigation in New York is presented. The roots of the development of the office are discussed, as were the early days of the office under Dr. Charles Norris, whose influence on the spread of knowledge and of providing an important service to the community in general is detailed. The contributions of Alexander Gettler, the father of forensic toxicology in America, are also discussed. The contributions of Gonzales, Vance, Helpern, Umberger, and Wiener are also included. Special problems of New York City are described, including narcotic deaths, gas refrigerator deaths, malaria in addicts, plastic bag hazards, sudden infant deaths, operative deaths, as well as many famous cases involving murder, disasters, and unusual deaths over a period of 60 years. Milestones in the Office of the Chief Medical Examiner of New York City are listed, as are chronological details of major cases and problems. Several comparative figures of the workload and frequency of various types of death are also included. A relationship of deaths to different life-styles is noted.     

Accidental firearm fatalities during hunting

Swedish legislation concerning firearms is highly restrictive. It is illegal to possess weapons (except airguns) without a license. From 1970 through 1982, there were 79 accidental firearm fatalities in Sweden. This number, corresponding to 0.074/100,000/year, is very low in comparison with similar statistics worldwide. Of these fatalities, 47 were associated with hunting and were studied carefully. Despite an increase in both the popularity of hunting and in licensing of weapons, on change in the number of accidents per year could be confirmed. Twenty-nine accidents occurred during small game hunting, of which 24 involved shotguns, and 18 occurred during moose hunting. The mean age overall was 46 years. All victims and shooters were men. Most accidents occurred before noon and during the autumn. During moose hunting, the victim most commonly was either mistaken for game or was standing beyond game. During small game hunting, the most common reason for death was improper handling of the weapon. Firing of defective weapons caused at least 10 fatal accidents. Alcohol inebriation was uncommon. It is unlikely that more restrictive firearm legislation would further decrease the number of fatal accidents. Instead, we believe that accidental firearm fatalities during hunting can be prevented by safer and more careful handling of weapons, including unloading weapons before transporting them; by replacing older weapons with more modern and safer ones; and by not allowing children to handle weapons. No shots should be fired until it is clarified that the target really is a game animal, and when hunting with rifles, the fields of fire should be clarified beforehand. Shooters at stand must be instructed not to leave their stands until explicitly told to do so.     

Evaluation of aortic injury in driver fatalities occurring in motor vehicle accidents in the State of Maryland for 2003 and 2004

Incorporating epidemiological and pathologic factors, a retrospective analysis of aortic injury and driving fatalities was conducted. To better understand the mechanism of injury, data were compiled for decedent demographics, autopsy and toxicology findings, and accident circumstances, with emphasis on directional impact. Review of the autopsy files of the Office of the Chief Medical Examiner in the State of Maryland in 2003 and 2004, identified 150 cases of aortic injury recorded in 537 autopsied drivers. Aortic lacerations occurred in 96% of the cases with aortic injury, two thirds of which were complete or near complete transections. A large percentage of cases involved a side impact collision. Consistent with extant research on frontal and lateral impacts, the majority of aortic injuries occurred at the ligamentum arteriosum. Also, the mechanism of aortic injury seems to be similar for side and frontal impact collisions, involving a combination of rapid deceleration forces along with chest and/or upper abdominal compression. This study emphasizes the importance of side impact collisions as a cause of aortic injury. Aortic lacerations have a high mortality rate and better motor vehicle design may prevent this type of injury.     

美国马里兰州涉及电击枪死亡案例分析

目的 研究美国马里兰州涉及电子武器(电击枪)死亡案件的特点,探讨其法医学鉴定要点.方法 收集2004-2009年美国马里兰州法医局鉴定的涉及电击枪死亡案件13例,案件均经详细的现场调查,尸体进行系统解剖,并进行全面的毒(药)物检测及组织病理学检验.从一般情况、电击枪类型及接触方式、毒物检测结果、死亡方式、死亡原因等方面...     

Spontaneous cerebellar hemorrhage in children

Spontaneous cerebellar hemorrhages are a rare but often fatal occurrence in children. Although there are several predisposing factors such as blood dyscrasias or astrocytomas, the most common cause of cerebellar hemorrhage in an otherwise healthy child is the rupture of a vascular malformation. We reviewed the files of the Office of Chief Medical Examiner of the City of New York and found four such instances over a period of less than two years. We present these here and outline the approach the forensic pathologist should take in evaluating such deaths.     

Subdural Hemorrhage,a Retrospective Review with Emphasis on a Cohort of Alcoholics

Subdural hemorrhage (SDH) is a common cause of death. As external evidence of injury may be absent, an autopsy is frequently needed to detect it. We conducted a 3‐year review of SDH from the New York City Office of Chief Medical Examiner, with emphasis on a cohort of alcoholics. Our study population of 1942 included 1588 alcoholics. Of the alcoholics, c. 8% had SDH (26% of the total number of SDH). Of the alcoholics with SDH, 57% had associated brain injuries. As alcohol intoxication is frequently associated with aggressive and violent behavior, we are concerned that 6% of alcoholics in our review had no autopsy or imaging studies. It is possible that a portion of these may have had a SDH due to an unrecognized inflicted injury. We recommend that autopsies be performed on all alcoholics without a clear cause or mechanism of death.     

Suicide by jumping from buildings

A study of 82 suicides during 1982-1986 that were committed by jumping from buildings was performed using the case files of the Office of the Medical Examiner of Metropolitan Dade County in Miami, Florida, U.S.A. The analysis involved the age, race, and sex of the victim along with the results of toxicologic studies and the cause of death. Additionally, the decedent's place of residence, location of the suicide, height of the building, and the reason for the suicide were investigated. Whether or not a note was left by the decedent was also ascertained. The suicidal "jumper" most commonly was a white man who was greater than 60 years of age who died from the resultant multiple injuries. The victim commonly was sober and drug free at the time of the incident. In approximately two-thirds of the cases, the location of the suicide was the victim's residence, which frequently was an apartment or condominium-type dwelling that was seven floors or higher from the ground. The victim often had experienced depression prior to the incident and did not usually leave a suicide note. This article compares the Dade County cases with others that have been studied and discusses the reasons why jumping from a building may have been chosen as the suicidal mechanism.     

Interaction between carbon monoxide and ethanol in fire fatalities.

Impairment due to ethanol is clearly a risk factor in deaths due to fire. However, it is less clear whether there is a physiological interaction between ethanol and carbon monoxide (CO) that would alter the carboxyhemoglobin saturation level (COHb sat.) that accounts for death. In an attempt to explore this issue further, 196 fire fatalities investigated by the Office of the Chief Medical Examiner, State of Maryland over a 3-year period were examined. COHb sat. and blood ethanol concentrations (BAC) were tabulated. Twelve cases positive for therapeutic or abused drugs other than lidocaine or atropine were excluded; 184 cases were included. The data indicate that ethanol does not affect the COHb sat. that accounts for death, since the percentage of cases positive for ethanol at a given COHb range shows no trends. Therefore, we conclude that although ethanol remains a risk factor in fire fatalities, the risk appears to be related to the impairment that it produces as opposed to a direct interaction with CO.     

Investigation of sudden infant deaths in the State of Maryland (1990-2000)

The Office of the Chief Medical Examiner (OCME) has recorded a significant decline in the deaths of sudden infant death syndrome (SIDS) in the state of Maryland since 1994. However, infants who died of accidental or non-accidental injuries remained consistent during the same time period. This report focuses on the epidemiological characteristics and scene investigation findings of infant victims who died suddenly and unexpectedly in Maryland between 1990 and 2000. A retrospective study of OCME cases between 1990 and 2000 yielded a total of 1619 infant fatalities. 802 infant deaths were determined to be SIDS, which represented 50% of the total infant deaths in our study population. Five hundred and twenty-three (31.8%) deaths were due to natural diseases, 128 (7.9%) deaths were accidents, and 74 (4.6%) were homicides. The manner of death could not be determined after a thorough scene investigation, review of history and a complete postmortem examination in 92 (5.7%) infants. SIDS deaths most often involved infants who were male and black. The peak incidence of SIDS was between 2 and 4 months of age. The majority of SIDS infants (60%) were found unresponsive on their stomach. Among SIDS infants, 269 (33.4%) were found in bed with another person or persons (bed sharing). Of the bed-sharing SIDS cases, 182 (68%) were African-American. In the past 11 years, 52 infants died of asphyxia due to unsafe sleeping environment, such as defective cribs, ill-fitting mattresses, inappropriate bedding materials. Of the 74 homicide victims, 53 (70%) involved infants less than 6 months of age. Twenty (27%) exhibited the classical abuse syndrome characterized by repeated acts of trauma to the infants.     

Schizophrenia and sudden death: a medical examiner case study.

This study reviews the causes of sudden death of 66 schizophrenic patients who presented to the Office of the Chief Medical Examiner (OCME) for the State of Maryland over a 3-year period from 1994 through 1996. We identified an increased incidence of suicide compared with the general population of OCME cases. This observation is consistent with reports by other investigators. The majority of the deaths were the result of natural diseases, mostly atherosclerotic cardiovascular disease. Accidents, suicides, and 1 homicide were also present in this group.     

Ultralight aircraft fatalities. Report of five cases

A study of ultralight aircraft fatalities was performed based on the cases files of the Office of the Medical Examiner of Metropolitan Dade County in Miami, Florida. A total of five cases were collected during the years 1981-1985. These are presented in some detail. A discussion ensues concerning the safety of ultralight aircraft and whether people should be allowed to fly them.     

Homicide by fire

A study of homicide perpetrated by fire was performed on the case files of the Office of the Medical Examiner of Metropolitan Dade County in Miami, Florida, during the years from 1977 until 1984. A total of 26 cases were collected and analyzed as to age, race, sex, and the cause of death of the victim along with the blood alcohol content, the drugs detected at autopsy, and the blood carboxyhemoglobin level. Additionally noted were the geographic location of the terminal incident, the scene circumstances, how the fire started, who started the fire, and the reason for the fire. The most common victim was a 31-50-year-old white man who died from smoke inhalation while sober. Commonly, drugs detected were negative, and the carboxyhemoglobin levels were elevated. The fire occurred at "home" while the victim was sleeping. Usually, a flammable liquid was poured and ignited by a drifter who was a brief acquaintance and earlier involved in an argument with the victim.     

Spontaneous fractures in the differential diagnosis of fractures in children

A four-year-old male with cerebral palsy and spasticity, as a result of a non-accidental head injury sustained when he was two years old, died of pneumonia. Postmortem full body X-rays revealed fractures of varying ages of the left humerus and both femora, tibiae, and fibulae. This led to a thorough investigation of the case by the Office of the Chief Medical Examiner. Child abuse, accidents, metabolic bone disorders, other primary or secondary diseases of the bones, and pathological fractures were ruled out. The final diagnosis was spontaneous fractures secondary to osteopenia. The term spontaneous fractures is used to define fractures that occur without any known external cause, especially in cerebral palsy patients with spasticity.     

Accidental railway-related fatalities. The Metro Dade County experience, 1980-1984

A study of accidental railway-related fatalities was performed using the case files of the Office of the Medical Examiner of Metropolitan Dade County in Miami, Florida, during the years 1980-1984. The nine cases that were collected are presented here in some detail. A discussion ensues concerning the most common type of accidental railway-related fatalities, why they occur, and what future work remains in order to avoid such fatalities. Evidently, fatalities more frequently result from victims' disregard for safety--either by crossing the tracks despite warning, or by utilizing railroad trestles as a fishing pier--than from mass disaster. Future work involving forensic engineers, forensic pathologists, and lawyers along with community activists should include both public education and a design of less accessible trestles to avoid such tragedies. In conclusion, it is hoped that this article will serve as a catalyst for further research on this subject.     

Evaluation of sudden death in epilepsy

Records of the Office of the Chief Medical Examiner of the State of Maryland were reviewed for all cases of natural deaths due to epilepsy occurring in 1981 and 1982. Cases involving unclear seizure history, alcoholism, or other superimposed disorders were excluded. Twenty-nine cases were accepted and analyzed with respect to age, race, sex, circumstances of death, neuropathology, and anticonvulsant therapy. Most cases involved black males, the median age at death was 26 years, and the vast majority died in bed or in the bedroom. Less than half of these individuals had neuropathological lesions. Most had detectable levels of anticonvulsants in post-mortem blood; more than half the decedents with detectable levels of phenobarbital showed therapeutic levels of this drug.