My Father Killed Himself — Advice from a Physician and Suicide Survivor.

Originally published in MedPage Today August 16, 2018 (https://www.medpagetoday.com/psychiatry/depression/74589)

“My father killed himself when I was 13 years old.” That was the opening line of my medical school admission essay, the one in which I tried to convince an anonymous administrator in another state that, as a suicide survivor, I was specially possessed of both strength and empathy—and that these traits made me specially worthy of becoming a doctor. In the essay I reminisced about the fun times with my dad, like when he would paint and I would sit on the floor poring over his medical textbooks. I described the medical diagrams he sketched on the backs of napkins at the KFC, when he took me out to dinner on our mandated Thursdays and every other weekend. My parents were divorced by then, and these were the only times I got to see my Dad. I treasured them. I didn’t tell the whole story in that essay, though. I didn’t mention how, a week before his death, my dad showed me where his will was located. “Just in case something happens to me,” he said. I also left out the night that he attempted suicide the first time. He called my mom to tell her he’d taken pills. She got the police to trace the call to a hotel. They found him, rushed him to the hospital, and pumped his stomach. He lived two more days, until he hanged himself. I didn’t tell those stories. I was focusing on the positive, you see. I wanted to get in. The real story was too messy and painful for the confines of a university admission essay.

In my first year of medical school we learned about the warning signs of suicidality, and how to intervene by asking “are you thinking of hurting yourself?” and “do you have a plan?” That was when I realized that his showing me the will and first attempts were our chances to intervene. In medical school I learned about how to contract for safety and, maybe, save a life. I learned that suicide is preventable and that public safety measures—restricted access to guns, the installation of barriers on tall buildings and bridges—has not only thwarted individuals, but has also lowered the overall suicide rate in entire regions after they have been implemented. I learned that when patients survive a suicide attempt they are unlikely to try again and die by suicide. Learning about how to prevent suicide made me feel empowered, but it also made me feel guilty, because I didn’t know these things when I was 13, and I wish I had.

I see the bodies of the suicidal on my autopsy table every week: the hangings, the incised wounds and gunshot wounds to the head and chest. Family members, survivors, are often in denial. The manner of death “just doesn’t make sense.” Sometimes I will confide that I am a survivor too, and that, even after 35 years, my father’s death still doesn’t make sense to me, either. I’ve been criticized for writing that suicide is a “selfish act”—but I stand by those words. Not out of a sense of abandonment from my dad, but because I too have lived long enough to be suicidal myself. In those moments, when suicide “made sense,” I was so engrossed in my own pain that the tunnel vision of depression made everything else—and everyone else—irrelevant. In that way the suicidal person is selfish; as in “self focused,” unwilling to believe that their pain can fade over time, and that other people rely on their presence in this world. Having coming through those periods myself with the unwavering love and support of my mother and, later, my husband, has made me stronger and more empathetic. I have overcome my father’s suicide, even if the wound it left me has never fully healed.

I have learned that it helps to talk openly about it. The more I speak out about my father’s death, the more I discover friends who have also been touched by suicide. Silence = death when it comes to suicide, just like with HIV/AIDS. By talking openly about suicide, we can overcome the stigma associated with mental illness, and signal to those who may be suffering and suicidal (even when they aren’t mentally ill, but just going through a difficult time) that it’s okay to reach out for help. Others like me have been through it. We’ve made it to the other side. It may be hard to imagine—but it gets better. 

If you are thinking of hurting yourself or you know someone who needs help call the National Suicide Prevention Hotline 1-800-273-8255.

Bio: Dr. Judy Melinek is a forensic pathologist in San Francisco, California, and the CEO of PathologyExpert Inc. She is the co-author with her husband, writer T.J. Mitchell, of the New York Times bestselling memoir Working Stiff: Two Years, 262 Bodies, and the Making of a Medical Examiner. They are currently writing a forensic fiction series entitled First Cut. You can follow her on Twitter @drjudymelinek and Facebook/DrJudyMelinekMD. 

Reasonable Uncertainty: The Limits and Expectations of an Expert’s Testimony

Reasonable Uncertainty: The Limits and Expectations of an Expert’s Testimony. Originally published in Forensic Magazine September 2017, 14, 3:18-19 (https://www.forensicmag.com/article/2017/09/reasonable-uncertainty-limits-and-expectations-experts-testimony)

The lawyer had a gleam in his eye. He had backed me into a corner—or so he thought.

“So, doctor, you just said that the article you referenced indicates that only twenty percent of patients with this disease die a sudden cardiac death, correct?”

“Yes.”

“And your testimony is given under the standard of more likely than not, right?”

“That is correct.”

“That’s the same thing as a balance of the probabilities—more than fifty percent likelihood, correct?”

“Yes.”

“Yet less than half of patients with this disease die of the cause you are advocating. How can you possibly testify that it is more likely than not?”

I have faced versions of this question over the years from countless attorneys and I can’t always tell whether they are truly confused by statistics and probability or whether they think I am. They are employing an unsound argument called the ecological fallacy: applying a statistical finding generated by a large population to an individual case. For people who have no understanding of math it “makes sense.” For an expert, these types of questions are an opportunity to educate the judge and jury—and, perhaps, even the questioning attorney—about the science of statistical power and how probability really works.

Courts require experts to testify “within reasonable scientific certainty.” Sounds legit, right? It isn’t—not to scientists. “Reasonable scientific certainty” holds no currency in the scientific community. The National Commission on Forensic Science was a federal body created in 2013 to address conflicts of professional culture between the law and the sciences. Before its charter expired in April 2017, the NCFS released a document that called for the cessation of the use of the term “reasonable scientific certainty” in forensic expert testimony. (https://www.justice.gov/archives/ncfs/page/file/641331/download). There is no agreement among experts of the actual meaning of the phrase. For one thing, nothing in science is based on reason alone; it’s based on evidence and testing. Science is rarely certain—it relies on statistical probability, and acknowledges that outliers can and do exist. We forensic scientists operate in a liminal space between science and law. In the past, we have had to accommodate our professional rhetoric to the demands of attorneys by accepting the use of this phrase when we testified. Why have we done so? Because the cost of rejecting this accommodation was to open ourselves to attack. An opposing lawyer would declare that we have no credibility as an expert, and the judge might dismiss our testimony as not adhering to evidentiary standards. If you can’t testify to something with “reasonable scientific certainty” because the evidence was insufficient, the court might throw out all your testimony rather than allowing you to testify to the uncertainty of the science.

Okay, I hear you: This is absurd! Uncertainty is not a sign of poor scientific testimony—it’s the hallmark of the honest scientist! Our paradox rises from the United States Supreme Court’s Daubert decision which limited the bounds of scientific opinion testimony by expert witnesses. Daubert v. Dow (1993) set the federal standard for admissibility of evidence. It never required “reasonable certainty,” but it did set guidelines for testimony to be admissible if the science is reliable. What did the Supreme Court say is reliable? Reliable expert testimony in science and technical fields must be tested and subject to peer review, must have a known error rate, must be maintained by standards, and must be accepted by the scientific community.

As a consequence of Daubert, forensic science disciplines that rely on inference and experience (such as forensic pathology) have been subjected to accusations of unreliability because practitioners have no published error rate and they incorporate ancillary evidence—such as information from witnesses or police—which can be inaccurately perceived as generators of cognitive bias. While testimony about the likelihood of a particular event being within a 95% confidence interval may be appropriate when describing epidemiological research or while performing lab studies on fruit flies, these types of statistics have no bearing on the day to day work of forensic disciplines such as pathology and criminalistics. Our branches of science rely on training, experience, observation, and scientific inference. There is ample inferential literature to support our observations, but not enough statistics to allow us to report on our own error rate. We don’t operate in the zone of experimental science. We can’t run double-blind tests on murdered human beings. We can’t generate fatal industrial accidents to study the mechanical dynamics at play. And so, thanks to the Daubert ruling and the persistent repetition by lawyers of the magical phrase “reasonable scientific certainty,” we have to sit up there on the stand and teach juries about statistics and probability, about inductivism and the scientific method. 

Humility is baked into scientific semantics. There are things that are not knowable based on the current state of your field of specialty. But if you are asked to answer a question on the stand and the answer is just “I don’t know” then some lawyer will find an “expert” with no credentials or integrity to follow you and declare “I know!” In my experience, juries and lawyers will prefer the expert who is willing to speak with confidence and certainty. They will defer to the voice who “knows” even if it is not based in good science. It's not good enough to say “I don't know.” If you care about justice prevailing you have to also take the time to explain why you don't know what you don’t know. You have to explain the limits of your science.

The stakes are high. In many states, once a defendant is convicted it is not possible to appeal based on scientific advancement or factual innocence, but only on procedural grounds: that the original trial judge or attorneys erred in some way. Expert testimony that had been deemed reliable by the courts in the past is now being questioned by scientists because the science has advanced, but the new data can’t be used to free those who were incarcerated based on expert witness testimony that is now obsolete or was overstated.

The future of forensic science in the United States is in flux, and scientific literacy is becoming harder to come by in the courtroom and outside it. Nowadays one of the most daunting challenges an expert has to face is to convey uncertainty without appearing unqualified. It is an unfortunate tenet of our nature that we human beings gravitate toward the person who can exude conviction with charisma, no matter his or her actual base of experience. Couple that with the testimonial result of the Dunning-Kruger effect—that the expert with the least experience and qualifications is more likely to testify with absolute certainty—and it becomes even more critical that we forensic professionals train ourselves to express clearly the limits of scientific testimony when the evidence in a case just isn’t there. As individuals with integrity we have to apply rigorous scientific principles in our reports and our testimony, and we have to acknowledge that uncertainty exists. Your training and experience is reliable. Your professional opinion (even when you are uncertain) is reasonable. Be certain that attorneys, judges and juries get that.

Bio: Dr. Judy Melinek (link to: http://www.pathologyexpert.com/drjudymelinek/)is a forensic pathologist and does autopsies for for the Alameda County Sheriff Coroner's office in California. Her New York Times Bestselling memoir Working Stiff: Two Years, 262 Bodies, and the Making of a Medical Examiner, (link to: http://www.drworkingstiff.com) co-authored with her husband, writer T.J. Mitchell, is now out in paperback. She is the CEO of PathologyExpert Inc.

Jury Duty: Inside the Box.

Originally published in Forensic Magazine June 2017 14,2:23-24. (https://www.forensicmag.com/article/2017/06/expert-witness-jury-duty-inside-box)

Last week I was called to jury duty at my local courthouse, where I have testified as an expert witness before. I showed up. I signed in. I watched two videos explaining how our justice system works. Then I was assigned a courtroom—and this time, instead of addressing the people in the jury box, I found I was one of the people in the jury box. A lawyer stepped before us and announced that the legal action for which we’d been selected was a civil matter: asbestos injury litigation.

No way, I said to myself. No way a forensic pathologist can serve as an impartial juror in an asbestos lawsuit. I have got to get excused from this. If this were a lawsuit about larceny, or financial fraud, or building code violations, it would be perfectly appropriate for me to be impaneled. But a case that relies on medical expertise as the evidentiary lynchpin? I felt confident that the attorneys litigating the case would agree that it would be inappropriate to have a medical expert on their jury.

Each of the several attorneys trying the case had a set of questions. They went one by one through the jury candidates. Do you know anyone who died of asbestosis? Do you have any strong feelings against corporations? If a smoker has a smoking-related illness, would you consider it their fault? Every lawyer finished with the same catch-all: Do you have any biases that would influence your judgement in a case like this one?

Each time I was asked this last question, I gave the same answer: Yes. I am a medical doctor and I diagnose asbestosis when it is present in a dead body that comes to my autopsy table. I have my own very definite opinions in the matter, professional opinions founded on years of medical education and practice. To my shock, attorney after attorney then nodded, thanked me—and told me to sit back down in the jury box.

I have a lawyer brother-in-law. That evening, I called him and asked what the heck was going on. Why wouldn’t they excuse me?

“Simple," he replied. "They want someone smart on the jury. They want someone who is going to listen to the facts they present. They don't care about bias as much as they want someone rational."

The next day, when another one of the lawyers asked how I was biased, I had an answer ready. "Let me explain something to you. I am a professional expert witness. I can’t say right now exactly how I am biased, whether it is for the prosecution or for the defense, but I guarantee you that I cannot be impartial when it comes to scientific testimony. If you have medical ‘experts’ get up there and testify? I'm not going to listen to them. I'm going to listen to this”— and here I pointed at my own head—“and then I'm going to convince all these people”—and I pointed at the rest of the members of the jury—“of my opinion. Because that’s what I do."

So that's how I got excused from jury duty. I don't know if my argument finally convinced the attorneys on its merits, or if my hand-waving and air quotes when I sneered medical ‘experts’ convinced them I was a lunatic. Whichever the case, they made a wise decision. I would not be capable of accepting what another medical expert told me was the absolute truth. I would question that expert’s opinion. I would challenge it, based on my training and experience, in the jury room; and, in the end, I would come to my own opinion. I can’t do that in a case about insurance fraud, but I can’t avoid it in a case about asbestosis. It is the litigants’ job to convince the entire jury as individuals. You need everyone on the jury to participate in the process of deliberation. If one juror is instead able to sway everyone else to her opinion because she has relevant expertise and professional authority, the trial lawyers have failed.

Attorney friends have confided—and griped—that they don’t get much law school training on jury selection. They learn it on the job; and, unfortunately, that means they apply their own biases when trying to elicit the biases of potential jurors. They might make assumptions based on a combination of factors, including race, gender, religion, educational background, and professed life experience. They might make the assumption that a well-educated person is going to be able to evaluate an expert’s testimony. In fact, the opposite may be the case. A juror with education and experience in the relevant area of expertise may instead dismiss what an expert witness says, even if the expert is correct. This is a flaw in jury selection as it is currently practiced in the United States: It doesn’t succeed at eliciting implicit bias.

Implicit bias has been in the news lately. These are the prejudices and predispositions you don’t even know you have. In the course of jury selection, lawyers rely on jurors to self-report their biases—but there is nothing predictive that will tell a lawyer whether jurors are biased if the jurors aren’t even aware of the preconceptions they carry with them. Lawyers may ask about educational level as a benchmark of a juror’s knowledge base and reasoning ability, but that is a poor way to assess implicit bias. You need to delve deeper, into which sources of information people consume—especially if the case involves a scientific expert witness. In a “post-truth” age of fake news and intentional, sophisticated campaigns of mass-media deception, those who rely on the internet as their primary news portal may be woefully misinformed. And a misinformed juror is worse than an uniformed one. 

An expert doesn't win or lose a case: We neutralize other experts. If we’re going to do so effectively, we need to be aware of which false news stories might bias the public. A good expert will address this challenge directly: teach the jury the basic forensic terminology, and explain how misconceptions are spread by television dramas and police procedurals. For instance, bullets do not spin people around. Not everyone who confesses to a crime under police interrogation is telling the truth. Time of death determinations based on postmortem changes are not always accurate or ironclad. 

Just because people subscribe to scientific myths doesn’t mean a good forensic expert can’t challenge misinformation and get the jury to understand the science of a case. Unscientific misconceptions might appeal to common sense and might calcify a juror’s biases that have built up over years spent absorbing the zeitgeist’s pseudoscientific claptrap. That doesn’t mean we should surrender to scientific illiteracy. It is our duty as forensic experts to provide the remedy to implicit bias—one jury at a time.

Bio: Dr. Judy Melinek (link to: http://www.pathologyexpert.com/drjudymelinek/) is a forensic pathologist who does autopsies for the Alameda County Sheriff Coroner's office in California. Her New York Times Bestselling memoir Working Stiff: Two Years, 262 Bodies, and the Making of a Medical Examiner, (link to: http://www.drworkingstiff.com) co-authored with her husband, writer T.J. Mitchell, is now out in paperback. She is the CEO of PathologyExpert Inc.

A successful career postmortem — in the flesh: The fun house mannequin that wasn’t

By A.J. Chapman

In the 1970s, “The Six‐Million‐Dollar Man” was a popular television show. It concerned a man who had met with a disaster that extensively destroyed much of his body that was then replaced with bionic parts that gave him incredible strength, x‐ray vision, and the like. In preparing to shoot one episode of the series, the crew was preparing the set, which was at the “Laff in the Dark” fun house in the Nu‐Pike Amusement Park in Long Beach, California. One member of the crew moved what he thought was a garishly painted mannequin that was designed to glow very bright orange in the dark when illuminated with a black light. The right forearm of the supposed mannequin fell off, having disjointed at the elbow. The crew member picked it up and was astounded to see that this particular mannequin had an actual bone in its arm. Since mannequins do not contain bones, the police were notified. They confirmed that the body was human, and the remains were transported to the office of the Los Angeles County Medical Examiner‐Coroner.

An autopsy was performed. The cause of death was a bullet wound, and the body was found to have been preserved with arsenical compounds that were used for embalming only in the period between 1905 and 1930. As an aside, arsenical compounds preserve remains wonderfully. Their use was eventually prohibited because in any case in which arsenic poisoning was the cause of death, that fact could not be proven once the body had been so embalmed.

A news release was issued, and a member of a family who had once owned the remains contacted the Los Angeles Police Department. The information provided ultimately led to the identification of the body.

Eventually, the facts of the case were established. The “mannequin” was the body of Elmer McCurdy, a less‐than‐successful outlaw, who was killed on 7 October 1911 in Pawhuska, Oklahoma. He and two others held up a “Katie” (MKT—Missouri, Kansas, Texas) train, believing it was carrying a great deal of money for a payroll.

The bungling, less‐than‐savvy robbers, however, picked the wrong train and escaped with very little booty. A local newspaper described the fruits of the robbery as “one of the smallest in the history of train robbing . . . . They failed to find as much as a copper cent in the safe in the express car. . . . They also made away with two gallons of whiskey, and during the holdup, they knocked in the head of two kegs of beer and drank part of the contents.”

What role the whiskey and beer may have played in Elmer’s killing by lawmen can only be speculated. The robbers were trailed to a ranch where Elmer—after drinking with ranch employees—had gone to sleep in the haymow of the barn. He exchanged gunfire with the posse that had found him for about an hour before being shot dead in the barn. The fatal shot was in the chest.

Elmer’s body was taken to Pawhuska, Oklahoma to the Johnson Funeral Home where it was embalmed with arsenical preservatives. No one claimed the body, and after about six months, it was perfectly preserved and could be placed in an upright position. Thus, the “Embalmed Bandit”, as he became known, was dressed in the clothing he wore during his last gunfight, was placed in the corner of a room, and a rifle was placed in his hand. There he stood for five years with curiosity seekers paying a nickel to see him.

In 1916, two men appeared, and one of them claimed to be Elmer’s brother. He managed to get the body turned over to him. In reality, however, these con artists were the owner and the manager of Patterson Carnival Shows. Elmer’s body was shipped to Arkansas City, Kansas, and the following morning, the carnival left for Woodward, Oklahoma. Thus, Elmer’s show biz career was launched.

Elmer traveled with the show until 1922 when he was sold to Louis Sonney, the owner of a wax figure museum sideshow that was called the “Museum of Crime”. He became an instant “hit” among the other outlaws collected in the show since he was one of the figures who was a very real, even if dead, outlaw.

The sideshow did not do well, and in 1971, Elmer went to work for Ed Liersch and D. R. Crydale, partners who set up a wax museum of their own on the Long Beach Pike and purchased Elmer from the show. They displayed him as “The 1,000 Year Old Man”. Five years later, he was “hanging around” in the fun house in the amusement park where the body was subsequently found when the place was leased to Universal Television Studios for filming of the episode of “The Six Million Dollar Man”.

All things considered, Elmer’s postmortem career was far better and more successful than his antemortem one.

The information concerning the travels and identity of Elmer McCurdy consisted mainly of hearsay, and a more substantial identification was required by Los Angeles County Medical Examiner Coroner, Dr. Thomas T. Noguchi aka “coroner to the stars”, before release of the body. The late Dr. Clyde Snow, the celebrated forensic anthropologist and personal friend of mine from Oklahoma, accomplished this primarily by superimposition of a postmortem x‐ray of the skull onto an existing photograph of Elmer from archives in Oklahoma.

Additionally, the positioning of the hands was compared to the postmortem positioning of the hands in a photograph that had been taken when Elmer’s body was in the funeral home in Pawhuska sometime between 1911 and 1916. Elmer McCurdy’s stature, age, gender, and race were known, and a scar had been described on his right wrist—a deep one that had resulted from a drunken knife fight in a bar. The bullet wound was also confirmed. These comparisons provided perfect matches. DNA verification was, of course, not possible since the DNA technology and procedures were relatively far in the future at the time.

Dr. Noguchi would release the body only to the Chief Medical Examiner of Oklahoma, who happened to be me, so I met Elmer on the tarmac of Will Rogers World Airport when he returned to Oklahoma on a Boeing 727.

For a little perspective: When Elmer was killed, the very first flight of an aircraft by the Wright brothers had taken place only eight years earlier at Kitty Hawk, North Carolina and Oklahoma had only been a state for four years. Arizona and New Mexico had not yet achieved statehood.

Hence, his “glorious” return to Oklahoma could never even been in the wildest, drunken imaginings of Elmer.

The body was taken to the morgue where it was photographed and placed into a casket that had been handcrafted for the occasion. Steve Lower, my assistant, and I fastened the lid of the casket with corrugated nails to insure it would not be opened prior to burial.

Each year in April the ‘89er Celebration is held in Guthrie, Oklahoma, which is located approximately 30 miles north of Oklahoma City and which was the original capitol of Oklahoma until 1910. The celebration commemorates the opening of the Oklahoma Territory to settlement—”The Run of ’89”—22 April 1889. It was during this celebration in 1977 that Elmer was laid to rest in Summit View Cemetery—“Boot Hill”—in Guthrie.

Many people dress in period costumes and grow beards for these celebrations, and horses and horse‐drawn vehicles are the preferred modes of transportation. Elmer’s casket was placed into an immaculately preserved horse‐drawn hearse with glass sides that made the casket visible to those along the route of the funeral cortege. The driver of the hearse was formally attired. After the casket was lowered into the ground, a lay preacher intoned a few words for the burial. A romantic girl tossed a single yellow rose onto the casket, which was otherwise bedecked with a spray of white lilies.

In order to be certain that Elmer’s postmortem career and traveling about the country was put to an end once and for all, approximately two cubic yards of concrete were poured over the casket before it was covered with the red Oklahoma earth.

How Designer Drugs and the Opioid Epidemic Affect Modern Forensic Practice

This article was originally published in Forensic Magazine. To read the original article click here (http://digital.forensicmag.com/forensics/september_2016/MobilePagedReplica.action?pg=18#pg18)

The decedent was a bright young woman with a promising acting career. She and a friend had spent hours in her apartment memorizing lines for a new play, and wanted to relax. The actress went into the fridge for a pot brownie she had bought at a music festival the day before. A nibble didn’t yield enough of an effect. She took a bigger bite. Then she ate the whole thing. 

Half an hour later, the woman began to act strangely. Instead of reciting the dialogue she was trying to memorize, she started to describe—and react to—vivid visual and auditory hallucinations. She wanted to go out the window. She needed to, she said. The friend had to restrain her. 

But this actress was stronger than her friend. She got to the window. She opened it. She made it out. She died of multiple blunt injuries sustained from a three-storey fall to the pavement below. In the course of their investigation, the police located the woman who had baked the brownies. She told them, first of all, that the brownies were vegan, and also that they had been laced with both marijuana and "Spice"—a designer drug that affects the same cellular receptors as THC. She had purchased the Spice online. Based on the police report and the witness statement about the decedent’s behavior immediately before her death, I requested that the blood specimen be tested for synthetic cannabinoids. The toxicology report came back positive for both THC and a synthetic analog.

Illicit drugs are consumer products, subject to market forces. As law enforcement agencies have found more effective ways to crack down on supplies of the most common recreational drugs, enterprising producers have responded by trafficking new ones, synthetic analogs that alter the chemical structure of known psychotropics. These analogs may cause a much more pronounced high—and they have deleterious properties that can include fatal side effects. Synthetic cannabinoids like the Spice baked into that pot brownie have been linked to psychosis. Ecstasy and Molly, stimulants derived from methamphetamine, cause hypothermia and cardiac arrhythmia. Street drugs marketed as analgesics like alprazolam, oxycodone, and hydrocodone are being adulterated with fentanyl or fentanyl analogs, synthetic opioids that increase the risk of fatal respiratory depression. 

These emerging designer drugs are a headache for us forensic pathologists. Routine toxicology may not even detect them, and if there’s enough of the more common drug in the sample then it can camouflage the novel compound. The pathologist will not even realize it’s there, and won't have the blood tested further to isolate it. A pathologist would only think to look for these synthetic analogues if the toxicology came back negative or if the common-drug levels were so low that they shouldn't have caused death.

Overdoses have reached crisis levels all over the country. Some jurisdictions, such as Richland County in Ohio (http://www.mansfieldnewsjournal.com/story/news/crime/2016/07/25/autopsies-wont-performed-routine-drug-overdose-cases/87524864/), have decided to stop performing autopsies in cases of apparent drug overdose, because they are overwhelmed with bodies. They're stuck between a rock and a hard place. They are violating standard forensic practice and taking a tremendous risk of missing other causes of death by bypassing autopsies, but they’re doing so because of a lack of funding and staffing. An office that exceeds the annual number of autopsies per pathologist will lose accreditation, but the government agencies funding that same office still view drug overdoses through the lens of law enforcement, not public health. According to the Centers for Disease Control and Prevention, the number of drug overdose deaths in the United States is officially at epidemic levels. The rate of deaths has increased 137% since 2000, including a 200% increase in the rate of opioid deaths (http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6450a3.htm). Could street drugs adulterated with synthetic adulterants be to blame? We can't say—not without full autopsies and complete toxicology testing in all overdose cases.  

Without adequate funding at every level of government, we will not be able to track which specific chemical agents are killing people. Police labs need budgets for synthetic drug testing and screening. Medical examiner and coroner offices need money to track the impact and scope of the epidemic. Every death investigation agency in the country would benefit from a federally-funded national database to correlate overdose deaths with illicit drug seizures across state lines. 

But money alone won’t fix the problem—we also need legislative and policy changes. Instead of criminalizing the drug based solely on its chemical composition, legality should be defined by toxicity, the accreditation of manufacturing labs, and distribution method. Our federal agencies need to target online distributors. Medical examiners and coroners need to document medications found at overdose death scenes, check those lists against state databases, and report cases of prescription drug diversion. We also need to alert prescribing physicians in these cases so they can re-evaluate their prescription guidelines. Coroners must certify overdose deaths properly—listing all the medications by name instead of just writing "mixed drug intoxication" on the death certificate, for instance. Medical examiners should work with the Drug Enforcement Administration to apply comprehensive testing techniques to pills collected from death scenes, looking for emerging contaminants and designer drugs. This is especially crucial in cases where the drug levels in the OD are low or do not correspond with the reported symptoms of intoxication. Most importantly, forensic pathologists need to perform autopsies in all cases of apparent overdose, and coroners must staff their offices appropriately to manage the caseload. You should be autopsying these cases. If your toxicology report comes back negative in a presumptive OD because the panel is unable to test for a neoteric designer drug, then you'll have buried a body without providing a cause of death. You will have failed at your job's core mission.

Bottom line: if we don't have enough money to autopsy all deaths that we are required by statute to investigate, then we damn well better be spending what we can on prevention strategies to keep those bodies from piling up. Prevention is more cost effective than investigation in cases of avoidable lethal intoxication. Surplus mortality should not be ordained by the local supply of recreational drugs.

Mind Your Manners: Where Death Certification Ends and Prevention Begins

This article was originally published in Forensic Magazine. To read the original article click here (http://digital.forensicmag.com/forensics/june_2016/MobilePagedReplica.action?pg=18#pg18?)

The police pick up a 45 year old man, a robbery convict, for speeding. The arrest is a parole violation. The man has a history of smoking and substance abuse, and is obese. On his third day back in jail, he refuses to cooperate during a routine search of his cell. The corrections officers address this behavior problem by strapping the man into a restraint chair for several hours until he calms down. After he is released, he immediately starts a fight with another inmate. Once again the guards strap him into the restraint chair, for several more hours, until he is compliant. The man goes back in the chair twice more over the course of the next four days. After the final time, he stands up—and then, without a word, collapses. He's lying on the floor of the jail, unconscious. He is not breathing. The guards initiate CPR immediately, but after a few minutes the man is still not breathing and no longer has a pulse. The guards continue CPR until paramedics arrive ten minutes after the man's collapse. The medics declare him dead.

The forensic pathologist conducting the autopsy finds that the man has a large saddle pulmonary embolus and blood clots in both legs associated with the strap marks from the restraint chair. The cause of death is clear—pulmonary embolus. What's the manner, though? A blood clot traveled from the man's legs to his lungs. Obese smokers commonly develop dangerous blood clots, so should this be certified as natural? The man had been immobilized and showed signs of injury on his legs from the restraint straps, so is this death an accident? But, wait—his immobilization was forced. He had been restrained and injured at the hands of the guards. This prisoner's death should be a homicide. How about undetermined? Suicide is the only manner of death we would categorically discount.

Medical examiners and coroners agonize over manner of death all the time, and for good reason. The cause of death, the disease or injury leading to the lethal event, may be patently clear, but it's the manner of death that the family hears and that the press pounces on. Call an in-custody death such as this one a homicide, and the media will immediately pronounce that the police killed the inmate, even if the corrections officers were only following their training and jail protocol. Call an in-custody death accident or natural, and you might be accused of a cover up. Call it undetermined (a way of saying the death doesn't fully categorize into one manner or another) and no one is happy: You get branded as either unscientific or indecisive. Or both.

What is manner of death? It's a required part of the death certificate, a system of classification most often used for data analysis in the realms of public health and academic research. Every time you read an article that contains information about the ways people die, or compares types of deaths across geographic regions, the researchers likely started their analysis with publicly-available death certificate data, sorted by manner of death.

But manner of death has a social function as well, because, like it or not, we attach different moral value to different ways of dying, even when the mechanism is the same. In my experience, families who have lost a loved-one to a drug overdose don't object to the determination that the cause of death was by acute mixed drug intoxication as much as they object to my manner ruling that the overdose was an accident or a suicide, in some cases because of religious prohibitions against suicide. One Pennsylvania coroner has been in the news lately for classifying overdoses of illegal drugs as homicides, so that the drug dealers will be prosecuted for murder, even if the user injected the drugs himself in order to get high. Sounds like a good idea, right? Drugs are illegal and the dealers should be punished. The problem is, such an approach conflates the duties of scientific death classification with those of law enforcement. Our job is statistical and unbiased, and we need a uniform classification system in order to understand how people die in the real world, and to study regional differences. Coroners in jurisdictions surrounding this Pennsylvania county have avoided following suit with this reclassification of manner in drug deaths.

We in the forensic sciences must work to communicate with the police, the families of decedents, and with the public at large about the different manners of death, about the national standards used in classifying deaths, and about our decision-making process in arriving at a conclusion in each individual case. We must do so as part of our professional duty to public health in seeking to reduce our national burden of avoidable deaths. We spend a lot of time agonizing about the manner—but the determination of manner doesn't matter if we don't then do something to counsel the decedent's family, to explain what happened to the public, and to prevent this from happening again, if what happened was at all preventable.

Some jurisdictions will call our hypothetical case study of the prisoner with the embolus a homicide. Others might call it an accident. A few might even decide this was a natural death. Regardless, they will all be remiss if they stop with cause and manner. We coroners and medical examiners have an ethical duty to do more than just check a box on a death certificate and wait for the inevitable lawsuit. We have a duty to reach out to those in power to change the lethal environment by educating the jail staff and the corrections department managers who write the policies and procedures. If we don't reach out to other professionals in other county agencies, one man's avoidable death will repeat with others under similar circumstances. If we don't publicize it in the press, how will others learn from our experiences and adjust their policies accordingly, before the next death? The next time it happens, what will you do about it? Will you call it another homicide, another accident, another natural death? Whatever your answer, you will have a harder time explaining why another such corpse has come to a slab in the morgue, and why you didn't do anything to stop it getting there. We forensic pathologists are physicians working in the realm of public health. Our job—our duty—does not end with the death certificate.

Don't Share a Bed with Your Baby

It was one of the toughest phone conversations I have made in my 15 years as a forensic pathologist. I had just completed the autopsy of a three month-old infant. He had spent the night sharing an adult bed with his mother and six year-old brother. In the morning they found him prone, with his face against the pillow, dead. During the autopsy I found that blood had pooled under the skin of the baby’s face and abdomen after death, and I documented characteristic areas of pallor where the pillow had pressed against his nose and mouth. He had asphyxiated. After leaving the morgue I had to go pick up the phone and tell a mother she had accidentally smothered her son.

I investigate sudden infant deaths three or four times a year. Parents who lose a child to a bed-sharing accident inevitably ask me why the cause of death isn't SIDS, sudden infant death syndrome. I have to explain that SIDS is a diagnosis of exclusion: the autopsy and scene investigation rule out injury, and we can't find any fatal natural disease. A child who is found face-down with his nose and mouth covered has been injured. The cause of death in such a case is positional asphyxia, and the manner of death is accident. Accidents are avoidable, which makes that postmortem conversation all the harder. The parents blame themselves. I frequently end up in tears along with them. I have three children who were babies not that long ago, and though I’m a doctor I am not made of stone.

My medical colleagues and I were dismayed to read the Los Angeles Times Op-Ed of September 18, 2016 titled "It's OK to sleep next to your infant child. In fact, it's beneficial," showing a photo of a smiling mom sharing an adult bed—with soft blankets and pillows—with her three month-old. The authors, two professors of human development, cite anthropological research while dismissing the recommendations for safe sleep promulgated by medical professionals, including those in the CDC and the American Academy of Pediatrics. This article operates under the fallacy that cross-cultural anecdotes trump hard scientific data. It conflates SIDS deaths with all sudden infant deaths, betraying an ignorance about asphyxial death in unsafe sleep environments. It also ignores differences in death investigation and certification between countries. For instance, the authors cite Japan’s low rate of reported infant mortality while ignoring the fact that fewer than 30% of infant deaths in Japan are autopsied. (Taylor BJ, et al. Arch Dis Child 2015;100:1018–1023. doi:10.1136/archdischild-2015-308239). They press the absurd and dangerous assertion that "the proven benefits of mother-infant co-sleeping far outweigh the largely imaginary risks." These are not imaginary risks. They are real and they are tragic.  According to the CDC, infant asphyxia is the leading accidental cause of death in infants under one year of age. Parents who lose a child to a preventable death and parents whose children end up in a vegetative state after an anoxic brain injury suffer grievously. They have created support organizations like Charlie's Kids and First Candle to educate others about safe sleeping, including co-sleeping without bed-sharing.

There are safe ways of sleeping next to your child in the same room without sharing the same bed, but most parenting websites and magazines do not distinguish between co-sleeping and bed-sharing. Self-appointed parenting experts who actively advocate for bed-sharing ought to recognize the recklessness of such a position. According to ICAN, the Inter-Agency Council on Child Abuse and Neglect, sudden infant deaths in unsafe sleep environments dropped from 69 per year to 35 after a 2013 safe-sleeping campaign in Los Angeles County. Public health outreach saves lives. Misleading parents about published death statistics in the interest of promoting unprovable life-balance benefits is irresponsible, and the endorsement of bed-sharing as a safe approach to co-sleeping is dangerous. Do not share a bed with your infant. It isn't worth the risk of an autopsy.