tmp3EC8

by Murder

  THE CORONER, THE CRIME LAB, AND THE AUTOPSY

  Who Can Serve as Coroner?

  Q: My story is set in a small town. For plot purposes the county coroner (or is it the medical examiner?) is also the local sheriff. Can this happen? Who can serve as coroner? What are his or her qualifications?

  A: Yes, the sheriff can be the coroner, but he cannot be the medical examiner. Let me explain.

  There is often a great deal of confusion regarding the roles of the coroner and the medical examiner (M.E.). The coroner is an elected official. He is responsible for all the legal aspects of death: death certificates, court appearances, and overseeing all the functions of the coroner's office. The M.E., by definition, is a physician who specializes in forensics and is usually a forensic pathologist.

  Often, the elected coroner is the M.E., and there is a move in most states to require M.E. credentials for anyone running for the position of coroner. In jurisdictions where the coroner is not required to be medically trained, an M.E. is appointed who has the proper training to perform the forensic duties needed. He is often called the deputy coroner.

  In most metropolitan areas of the United States the M.E. is the coroner. However, if your story is set in a small remote town, the

  coroner could be the local sheriff, undertaker, or auto mechanic. Here, the possibilities are wide open and the story twists endless.

  When Are Autopsies Done, and Who Can Request Them?

  Q: Under what circumstances are autopsies required? Who officially makes the request? Can the family of the victim prevent an autopsy?

  A: The laws that govern the coroner's or medical examiner's office vary in different jurisdictions. However, most operate under similar guidelines. Violent deaths (accidents, homicides, suicides); those that occur at the workplace; those that are suspicious, sudden, or unexpected; those that occur while the person is incarcerated; and those that occur within twenty-four hours of admission to a hospital would typically become "coroner's cases."

  Physicians are often asked to sign a death certificate for a patient they know who has died at home. If the patient had severe heart disease or cancer or any disease where death is likely, the physician usually signs the certificate, and the coroner isn't typically involved.

  If a patient enters a hospital and dies from any cause within the first twenty-four hours, it automatically becomes a coroner's case. The twenty-four hours is extended indefinitely in the case of a patient who enters the hospital unconscious and never regains consciousness prior to death. The coroner may then contact the physician caring for the patient, and if a satisfactory reason is apparent, the coroner signs the death certificate, and that's the end of it. If the death is unusual or unexplained, an autopsy will take place.

  In addition, a court may request an autopsy, as can the coroner, in any case where one might be helpful. The coroner has subpoena power for records and testimony, and has jurisdiction over the body in such cases.

  No, in most jurisdictions the family cannot prevent an autopsy by refusing permission. No permission is required if the medical examiner or coroner or the court deems that an autopsy is needed. However, since our legal system allows lawsuits for almost anything, the family could perhaps file suit to block the procedure, in which case a judge would decide the matter. Most likely the autopsy would be performed.

  How Detailed Are Routine Autopsies?

  Q: How detailed are most autopsies in situations in which the dead person would not at first blush appear to be the victim of foul play? I'm thinking of plot situations, for instance, in which a wife is poisoned or drowned by a seemingly loving husband and the circumstances appear accidental or otherwise not suspicious.

  A: The key issue for the killer in this type of circumstance is to prevent an autopsy in the first place. If the victim is elderly, chronically ill with potentially lethal diseases such as heart or lung disease, diabetes, or cancer, and is under the care of a physician, the physician may sign the death certificate stating that the death was due to one of these processes. The certificate would be filed with the coroner's office, of course, but more than likely it would not make him sit up, take notice, and ask questions. The murder would go undiscovered. On the other hand, if the victim was a teenager, both the physician and the coroner would probably be suspicious, and an autopsy would be requested.

  Even routine autopsies are typically very thorough. A gross exam and dissection is followed by microscopic tissue examinations and toxicologic studies. The coroner then issues a "cause of death." That said, a "medico-legal autopsy"—that is, one in which the cause of death is suspicious or unexplained—is even more thorough and is generally performed by a pathologist trained in

  forensics. In your scenario the medical examiner could easily determine that the cause of death was a poison or drowning. As for who pushed her in the water or gave her the poison, your sleuth will have to figure that out.

  What Information Does an Autopsy Report Contain?

  Q: What information is contained in the typical autopsy report? Does the coroner or medical examiner always state the cause of death?

  A: Each pathologist has his or her own way of preparing an autopsy report, but certain things must be addressed for the report to be complete. And yes, one of those is the cause of death as well as a determination as to whether the death was natural or possibly criminal.

  The name, age, sex, and race of the deceased, the estimated time of death, the location of death or where the body was discovered, and the date and time of the autopsy examination are commonly indicated on the first page. Also included are the name and qualifications of the person performing the exam, the names of all persons present, and a brief note concerning the circumstances of the death.

  The first section of the actual examination would be titled "External Examination." The M.E. would describe the appearance of the body and comment on any abnormalities, including external injuries and signs of medical intervention. For example, if the person died in a hospital, he may have IV needles and various tubes in place. These are not removed by hospital personnel before the body is sent to the coroner's office since they may be valuable evidence in cases of homicide or medical malpractice. Any injuries from trauma, gunshots, or knives, or external marks of any kind, includ-

  ing tattoos, surgical scars, old wound scars, cutaneous (skin) diseases, and birthmarks, would be commented on and photographed.

  The next section would be titled "Internal Examination" and would deal with what the M.E. found inside the body. This section is typically subdivided into these areas: head, neck, body cavities, cardiovascular system (heart and blood vessels), respiratory system (nose, throat, larynx, trachea, bronchial tubes,lungs), gastrointestinal system (esophagus, stomach, intestines), hepatobiliary system (liver, gallbladder, pancreas), genitourinary system (kidneys, bladder, prostate, ovaries, uterus), endocrine system (thyroid, pituitary, and adrenal glands), lymphoreticular system (spleen, lymph nodes), musculoskeletal system (bones, muscles), and central nervous system (brain, spinal cord). Under each of these headings the M.E. would describe the gross and microscopic appearance of the relevant organs and tissues as well as any abnormalities found.

  Next would come a summary of the pertinent and relevant findings. As an example, the summary of the exam on someone who died of a heart attack might include the following:

  1. Cardiovascular System

  A. Extensive atherosclerotic vascular disease involving the left main, left anterior descending, and circumflex coronary arteries

  B. Large area of myocardial necrosis in the distribution of the left anterior descending coronary artery

  This means the person had severe hardening of the arteries and died from a heart attack (myocardial necrosis).

  Last would be a statement titled "Conclusion." Here the M.E. would state his belief as to the cause of death and whether the death was natural or at the hand of another. He would then sign the report, making it official.

  Attachments to the rep
ort would detail any toxicologic, ballistic,

  DNA, or other examinations that had been performed in that particular case.

  What Information Is Placed in a Death Certificate, and Who Can Sign It?

  Q: I have a few questions regarding death certificates. Who can sign a death certificate? Is one completed for everyone who dies? I'm also confused by the terms "mode," "cause," and "manner" of death. Are they all the same thing? What information is placed on the actual certificate?

  A: In most if not all jurisdictions a death certificate must be signed by a licensed physician. If someone dies in the hospital or from an expected death (someone with terminal cancer or heart disease, for example) at home, his or her personal or treating physician will likely sign the certificate. If not, the M.E. or coroner will. Of course, if the death is under suspicious circumstances, unexpected, unusual, or occurs within twenty-four hours of a hospital admission, the coroner would be involved, and he would sign the certificate whether an autopsy was performed or not.

  Everyone who dies should have a legally registered death certificate.

  Regarding the terms you mentioned, you are not the only one who finds them confusing. Simply put, the "mode of death" refers to the pathophysiologic abnormality that led to death—for example, a cardiac arrest. The "cause of death" is what led to this abnormality, such as a gunshot wound to the heart. The "manner of death" is a legal, not a medical, statement and refers to whether the death was natural, a homicide, a suicide, or an accident.

  The certificate contains the usual demographic information: name, address, age, sex, race, occupation, place of death (if known),

  and information regarding the next of kin. The physician then adds the immediate cause of death (actually, this is often a combination of cause and mode—see, it is confusing) as well as conditions that led to or contributed to the stated cause and the duration that each of these was probably present. For example, in someone with high blood pressure and diabetes who suddenly fell dead from a heart attack, the physician might state the cause as follows:

  He then signs and dates the certificate, making it official. How Is the Time of Death Determined?

  Q: How does the coroner determine the time of death?

  A: Unless the death is witnessed, it is impossible to determine the exact time of death. The medical examiner can only estimate the time of demise. It is important to note that this estimated time can vary greatly from the legal time of death, which is the time recorded on the death certificate, and the physiologic time of death, which is when vital functions actually ceased.

  The legal time of death is when the body was discovered or the time a doctor or other qualified person pronounced the victim dead. These may differ by days, weeks, or even months if the body is not found until well after physiologic death has occurred. For

  example, if a serial killer kills a victim in July but the body is not discovered until October, the physiologic death took place in July, but the legal death is marked as October.

  That said, the coroner can estimate the physiologic time of death with some degree of accuracy. He uses the changes that occur in the human body after death to help him in this endeavor. These changes consist of measuring the drop in body temperature, the degree of rigidity (rigor mortis), the degree of discoloration (livor mortis or lividity), the stage of body decomposition, and other factors.

  Body temperature drops approximately 1.5 degrees per hour after death until it reaches the temperature of the environment. Obviously, this measure is greatly affected by the ambient temperature. A body in the snow in Minnesota in January and one in a Louisiana swamp in August will lose heat at widely divergent rates. These factors must be considered in any estimate of time of death.

  Rigor mortis typically follows a predictable pattern. Rigidity begins in the small muscles of the face and neck and progresses downward to the larger muscles. This process of progressive rigidity takes about twelve hours. Then the process reverses itself, with rigidity being lost in the same fashion, beginning with the small muscles and progressing to the larger muscles. This phase takes another twelve to thirty-six hours. So rigor is useful only in the first forty-eight hours. After that the corpse is flaccid (limp), and the M.E. cannot determine if death occurred forty-eight or more hours earlier using this criterion alone.

  The reason for the rigidity is the loss of adenosine triphosphate, or ATP, from the muscles. ATP is the compound that serves as energy for muscular activity, and its presence and stability depend on a steady supply of oxygen and nutrients, which are lost with the cessation of cardiac activity. As the supply of stable ATP declines, the muscles tend to contract, which produces the rigidity. The later loss of rigidity and the appearance of flaccidity (relaxation) of the muscles occur when the muscle tissue itself begins to break down.

  As decomposition and putrefaction occur, the contractile components (the actin and myosin filaments within the muscles that are responsible for muscular contraction) decay, and the muscle loses its contractile properties and relaxes.

  Lividity is caused by stagnation of blood in the vessels. It lends a purplish color to the tissues. The blood, following the dictates of gravity, seeps into the dependent parts of the body—along the back and buttocks of a victim who is supine after death. Initially, this discoloration can be shifted by rolling the body to a different position, but by six to eight hours it becomes fixed. If a body is found facedown but with fixed lividity along the back, then the body was moved at least six hours after death, but not earlier than three or four, or the lividity would have shifted to the newly dependent area.

  At death the body begins to decompose. Bacteria begin to work on the tissues, and depending on ambient conditions, by twenty-four to forty-eight hours the smell of rotting flesh appears and the skin takes on a progressive greenish red color. By three days gas forms in the body cavities and beneath the skin, which may leak fluid and split. From there things get worse. Add to this the preda-tion by animals and insects, and the body can become completely skeletonized before long. In hot, humid climes this can happen in three or four weeks, sometimes less.

  As you can see, this is a very inexact science and is greatly altered by the environment. In cold areas body temperature changes are magnified, but decomposition changes are slowed. The inverse is true for hot, humid climes.

  Would Storing a Body in a Cold Room Hinder the Determination of Cause of Death?

  Q: Is there a way that my character could try to cover up a crime of passion by cooling the body (in a wine room, perhaps) and then moving it but wind up with a pool of

  blood when the corpse heats up in its new location? The crime occurs in the hot Arizona summer, if that makes a difference.

  A: Actually, cooling the body would work against the killer by preserving the evidence. This is exactly what the coroner does when he stores a body in a refrigerated room until the autopsy can be performed. Cooling slows the process of decomposition and putrefaction. Gunshot wounds, knife wounds, and any poisons would be preserved longer and would make the coroner's job easier.

  On the other hand, if the body was left outdoors in the heat, bacterial putrefaction would be greatly accelerated, so that by the time the body was discovered, tissue decomposition may be so far advanced that gun and knife wounds would be difficult to evaluate—that is, the depth and width of stab wounds and the characteristics of gunshot wounds that help determine how close the gun was to the victim, and so forth, would be lost in severely degraded tissues. If the decay was far advanced, even some poisons may no longer be detectable.

  As for leaving a blood pool later, I'm afraid that won't work. Bleeding or oozing of blood requires that the heart still be pumping and the blood still circulating, which means that bleeding ceases at death. In fact, at death all the blood in the body clots very quickly, in a matter of minutes, and thus couldn't flow or ooze or drip and form a pool outside the body. Unlike ice cream, blood doesn't melt. Once it's clotted, it can't unclot.

  This was
brilliantly and subtly illustrated in the Coen brothers' 1984 film noir classic Blood Simple. The husband is shot as he sits behind his desk and is presumed dead. Later, another character comes in and sees the "corpse." The camera angles on the victim's hand, dangling above a pool of blood, and we see blood ooze down his fingers. At that moment the knowledgeable observer says, "Aha! He's not dead." Less clever viewers have to wait another scene or two to learn the same thing.

  Can the Coroner Distinguish Between Electrocution and a Heart Attack as the Cause of Death?

  Q: My victim is electrocuted while sailing by touching a boarding ladder that has been electrified, causing an apparent heart attack. Would there be any physical signs at autopsy that might show the victim died as a result of the electrocution rather than a heart attack? Skin surface burns, and so forth?

  A: The autopsy findings depend on the amount of voltage applied. If the voltage was high, burn marks would be left at the points of contact and grounding—that is, the entry and exit points of the current. These would be readily identifiable by the medical examiner. Also, when a strong electrical current flows through the body, it damages (cooks) everything in its path, and these effects can be seen when the various tissues are examined microscopically. This is particularly true of the liver, which seems to be prone to this type of injury.

  If the voltage was low, no skin changes would occur. And to be puristic, in this situation the victim wouldn't die from a heart attack (myocardial infarction, or MI). In its true and simplest definition an MI means that a coronary artery (the arteries that course over the surface of the heart and supply blood to the heart muscle) became blocked, and a portion of the heart dies due to lack of blood supply. In a true MI the M.E. would find the blocked artery and the damage to the heart muscle. An electric current could not directly cause this.

  Though a lower-voltage electrical shock would not cause heart muscle damage, it could precipitate a lethal change in heart rhythm, such as ventricular tachycardia or ventricular fibrillation. These could only be diagnosed if an electrocardiogram (EKG) was