Colby-- the end

I was sad to see the conference come to a close. It was the best Colby meeting I've been to ever.

The last day I gave a talk about sudden death in epilepsy and Cliff Nelson gave a very interesting talk on the issues surrounding religious objections to health care and the medical examiner (think Christian Scientist).

The day ended with Greg (Kentucky) Davis giving an overview of toxicology related deaths.

I learned quite a bit this week and enjoyed meeting some wonderful new people.

Next year Colby is Aug 5 to 9, so book your vacations now!

Now back to the real world. With summer beginning to come to a close I suspect that my blog posts will become more frequent!

Colby day 3 and 4

Not much to say about day 3. I had to leave after my talk on child abuse. I think it went well. It's such a difficult area now, all bets are off.

Today was great. It started off with Richard Callery going over psych/suicide cases. That was followed by two amazing talks by Dr. Bill Smock. His talk on car accidents and determining the driver was fantastic, I will use a lot of that.

Dr. Tom Gilson did a review of homicide and opened up some debate over the use of 'homicide by unspecified means'. He also a gave a cool review of recent serial killers.

At lunch we had a brief faculty meeting and discussed topics for next year. It's already shaping up to be a good meeting. Come if you can.

Tomorrow is the final day. I have a talk on epilepsy related deaths in the a.m..

So far, this is one of the best Colby meetings I have been to. It has been fun being a faculty member after sitting in the audience for some many years. I feel like a grown up!

Colby Day2

The highlight of the course: Dr. Richard Callery's exercises. Always worth the trip to Waterville to see Dr. Callery talk. Always informative, interesting, and hysterical. The man should do stand-up. All fun aside, there were a number of useful cases that stimulated debate. So far the theme for the weeks seems to be 'what's the manner'. I also learned quite a bit more than I needed to about cement and quicksand porn. Yes, it really exists. Google it if you're not at work.
Dr. Greenwald gave a nice talk on in-custody deaths. These are always difficult. The best part of her talk were the huge list of great references. I will use those for sure.
My talk on abusive head trauma is tomorrow. One hour. Seems like I could take 10 hours. We'll see if I can squeeze it all in. 122 slides though, it's going to be tough. But I talk fast....
Still, I had time this evening for a great canoe trip with the fam to the little island in the middle of the lake were we are staying. We encountered many pirates we had to fight off, hope they didn't follow us home...

Colby Day One

I can't say enough nice things about this meeting. If you've never been, you need to come.

The first talk was by Dr. Bill Smock from KY. He's an ER doctor who did a forensic path fellowship. He had the most amazing collection of pattern injury photos I have ever seen. If you can name an object someone has used to hit another person with, he had a photo of it. Dr. Smock also gave some great advice on how to opine about the origin of the wounds to juries. Wonderful talk. It reminded me of a couple of weeks ago when my son nailed me with a lightsaber and I had a perfect tram-line contusion on my leg.

Dr. Greg Davis (also from KY) gave a good talk on manner of death. Nothing really new, just good food for thought. Manner seems to be the thing we argue about the most. What would you call a 20-year-old-woman with no psych history, good student, star athlete, who does acid, tells her friends she can fly and then jumps out the window? Accident? Suicide?

The last talk was by Dr. Thomas Gilson now of Cleveland. He discussed drafting a clear and understandable autopsy report.

I ended the day with dinner in the caf with the family. There were no sprinkles for the ice cream so we had to use fruit loops. Oh yeah.

Tomorrow Dr. Peggy Greenwald (the Chief of the State of Maine is giving a talk on in custody deaths. That's going to be good!

Colby College forensics

I'm at the 38th annual New England Seminar in Forensic Science. This is my favorite meeting of the year. I'm going to try and post cool stuff from each day. Keep checking in. It's about time I got back to blogging after most of the summer off!

First up this afternoon is Dr. Smock's talk on pattern injuries in victims of interpersonal violence. I'm looking forward to that!


- Posted using BlogPress from my iPhone

What's the Diagnosis June 24, 2011

Date it! How old is this lesion?

What's the diagnosis June 5, 2011

Sorry to be so slow with the next case, but here it is! What's the diagnosis??

What's the Diagnosis May 13, 2011

What is the most common genetic mutation associated with this condition? (just trying to be a pain in the rear-end, like the FP boards, this is the type of question they'll ask, not what's the diagnosis of the slide)

The ID of Bin Laden

The forensic issues surrounding this case are numerous. Most important is identification. How do we know this is in fact Osama Bin Laden?

I doubt there will be an accurate visual ID, especially if he was struck in the head with a high velocity round from an automatic rifle. Also, one has to wonder if he may have altered his appearance in some way while living in such a populated area. Visual ID is presumptive and in a case like this, I doubt anyone would release news of this magnitude on a presumptive ID.

Presumptive ID's identify someone was a subset it does not as a unique individual. Presumptive ID's include scars, drivers licenses, passports and tattoos. Islam does not allow tattoos, so if Bin Laden has any scars, it may be helpful. But again, this is not a positive ID

A positive ID relies on unique characteristics attributed only to that individual. DNA, X-ray, dental and fingerprints result in a positive ID.

DNA has become a useful tool in forensic ID, but it takes time. If the raid occurred yesterday at 3:30 pm EST, and the news broke around 5 hours later, I doubt there was enough time to run a sample from the body. DNA will most likely be used to confirm whatever means was used for the ID.

Fingerprints are another excellent means if positive ID as everyone's fingerprints are unique, even among identical twins. The major problem with fingerprints is obtaining antemortem samples. Less than 20% of the US population has fingerprints on file. However, I bet the CIA has Bin Laden's fingerprints on file.

X-ray is also a possibility. I don't know if Bin Laden has any antemortem records on file, but if he does, X-ray can be quick and easy.

My money is on dental. From photographs, it looks like he has well kept dentition, and I would wager he has a dental record sitting on the desk of some CIA agent!

It is often best to use more than one method. Maybe the military used fingerprints and dental and will 100% confirm it with DNA.

Regardless of the methodology, they must have been pretty damn sure it was him before they buried his body at sea (at least I hope they were!).


- Posted using BlogPress from my iPhone

What's the Diagnosis April 29, 2011

This is a very typical board-type question: What's the manner of death?

What's the diagnosis April 22, 2011

Let's do something a bit different and give you all a break from the histo. What am I going to so with these vitreous electrolytes??
Na 130 mmol/L
Cl 110 mmol/L
VUN 30
Cr 2.0 mg/dl
Glucose 580 mg/dl
Ketones negative

What's the Diagnosis April 15, 2011

This is a low and high power view of the cervical spinal cord. What's going on here? Good luck!!

What's the Diagnosis April 8, 2011

What's happening in these brain sections? The second photograph is a higher power view of the region indicated by the arrow in the first photograph.

What's the Diagnosis March 30, 2011

What is this?

What's the Diagnosis march 18, 2011

What's the diagnosis?

What's the Diagnosis March 11, 2011

These photos are from a 30-year-old-man found dead in bed. His history is significant only for remote substance abuse. The histology of the coronary arteries and the myocardium shown below were the only pathological findings at autopsy. His toxicology was negative. What's going on and how would you sign this case out (both cause and manner)?

What's the Diagnosis March 4

First, what tissue is this?  Second, what is the underlying process responsible for these findings?

Interesting Case Report About Retinal Hemorrhages

Othon Mena, Ian Paul and Ross Reichard have just published a very interesting case report in the latest American Journal of Forensic Medicine and Pathology titled Ocular Findings in Raised Intracranial Pressure (Am J Forensic Med Pathol. 2011;32(1): 55-56.) They report the presence of retinal hemorrhages following the rupture of an intracerebral aneurysm.

Here is a link to the abstract: http://journals.lww.com/amjforensicmedicine/Abstract/2011/03000/

For more on the topic, see my blog on the Cambridge University Press website:
 https://cambridgemedicine.wordpress.com/2010/12/20/


Or read my blog on this site from Dec 19 (which is pretty much the same blog as the Cambridge blog.)

Always keep an open mind!

What's the Diagnosis for Feb 25, 2011

This fell out of the pulmonary arteries of a person who died suddenly. What is it?? You can click on the image to make it larger.

What's the Diagnosis?

What is the organ and what is the diagnosis?? You can click on the picture for a larger view!

What's the diagnosis?

Ok, I am a day late. I had a great case for this week, but my camera is not working for some reason. Anyway, here is today's diagnostic puzzle. Vosbeck should nail this one!

What's the Diagnosis?

I shouldn't have to tell you where this from, I bet you can figure it out! What's the dx??

Shaken Baby Story From the New York Times

Shaken-Baby Syndrome Faces New Questions in Court

What's the diagnosis?

Frontline's Postmortem

As I have said to a number of people this morning via email, I think they did an excellent job at highlighting the problems associated with death investigations in the US. The idea of national standardization is not new and is something that we have been requesting for decades. The major issue is the National Association of Medical Examiners (NAME). They have no voice in Washington and do nothing to advocate for our profession. Yes, the accredit morgues, but does that matter? No, most of the places discussed in the show were accredited. NAME produces white papers claiming to be 'position papers' that take no position; the 'Shaken Baby' paper is an excellent example--it needed further investigation. The organization does nothing to impact the way I practice medicine. The groups publication, The American Journal of Forensic Medicine and Pathology is poorly edited and full of typos and grammar mistakes. This is supposed to be my standard of practice?  When the NAS published their report on the forensic sciences, NAME stated they agreed, but did nothing. NAME needs to do something more.

We need to delete the coroner system. But who is going to do the work? No one goes into forensic pathology anymore because it is one of the lowest paid medical specialties and the working conditions are difficult. Who can make 'state money' and pay off student loans? NAME should be in D.C. fighting for reform and for federal and state tuition reimbursement of doctors who go into forensic pathology. A wonderful agreement would be for a state to say "if you agree to work for us for X number of years, we'll pay off X% of your loans". The district attorney's lobbing group were able to do it, why can't NAME? The current major project I get spammed about from NAME is the creation of a pie chart describing what Chief trained which fellow, it's the creation of a forensic family tree. Who cares?

Here is the link to the show: http://www.pbs.org/wgbh/pages/frontline/post-mortem/

These are my thoughts, and my thoughts only, they do not reflect any organization I may work for.

Long over-due

I thought with two weeks of 'vacation' I could do a little more with this blog. However, finishing my novel proved to be more work than I expected! Regardless, here it goes.

Other than 'what's the most disgusting thing you've ever seen?' the question I get asked most frequently is 'how can you tell how long someone has been dead?' There are many things I take into account when determining how long someone has been dead. Most commonly I use livor mortis, rigor mortis, and algor mortis.

Livor mortis is the redish discoloration that appears on a body due to the gravitational pooling of blood. It's sometimes called lividity. Once the heart stops pumping the blood travels in the direction of gravity and starts to collect in the dependent region. Areas of the body that are pressed up against an object, like the floor or a bed, leave white 'blanched' spots because the blood can't get there. Lividity can altered by changing the position of the body. After about 12 hours it 'fixes' and no longer moves around. This means if you find a body before 12 hours and move it, the lividity will change position. It does this because the blood, although not being pumped by the heart, is still liquid, and will flow towards the new direction of gravity. BUT, after around 12 hours if you move the body the lividity will have become fixed and will not travel towards the new dependent area and I will know someone moved it! There is a gray area around 12 hours where there may be two patterns of lividity. This happens because the blood is moving slowly and hasn't had time to relocate yet. It still tells me that the body has been moved. There are a couple of interesting things about lividity. One. it happens quickly, almost immediately after death. It has even been reported in elderly people in heart failure. Second, the color of the lividity can sometimes help you determine the cause of death. They typical color is purple. Cyanide and carbon monoxide can make lividity pink and cherry red, respectively.

Rigor mortis is the postmortem stiffening of the body. It happens because the muscles are no longer making ATP, which is the chemical that supplies energy to the muscle. Without ATP, the muscles can't relax and they get stiff. Rigor is dependent on a number of factors such as body temperature, room temperature, and the temperature outdoors. It's highly variable. Interestingly, rigor fixes, or becomes 'stuck' after about 12 hours, too. So, if you find a body before 12 hours and move it, and then leave it, the rigor will cause the body to fix in the new position that it's in; again, if you find a body after 12 hours and move it, the rigor will have 'frozen' the body in the original position and I will know you moved it! It's not uncommon for someone to find a dead body in bed, face down, with the arms hanging; the person will roll the body over to check for a pulse. Rigor will have set in and the arms will be sticking straight up in the air. I will know someone moved the body. Rigor vanishes after about 36 hours. This is because the muscles decompose and turn to mush.

Another thing that is sometimes used is algor mortis. Algor mortis is not what happened to Al Gore's political career after his loss in the presidential elections, it's the loss of body temperature. I do have to say that the name is ironic given how Al Gore was so concerned with our global temperature. The body will lose about 1.5 to 2 degrees celsius per hour. Again this is HIGHLY variable and dependent on so many factors such as initial body temp, the room temp and the outside temp. It's not really used that much anymore.

So, what do I do? I use these simple little rules, and despite what you see on TV, it's the best science can do! If you find a body, don't touch it. But, these are my rules:

If a body is warm and flaccid, it's been dead less than 3 hours.
If a body is warm and stiff, it's been dead between 3 and 8 hours.
If a body is cold and stiff, it's been dead 8 to 36 hours.
If a body is cold and flaccid, it's been dead more than 36 hours.