Friday, December 02, 2005

12/02/05

9:51 a.m. Well, today I thought I'd give you all a bit of a quiz. (Sharpen your #2 pencils, kiddies.) And no cheating by looking stuff up online! (That means you, Higgy.) Oh, and I like trick questions.

When an ME investigator gets a call, they often have to make a decision whether to bring a body in for an autopsy or not. I'm going to present you with a few different scenarios and you can tell me what the manner (natural, homicide, suicide, accidental) and cause-of-death are in each case and whether the body should be released or brought in for autopsy.

1) Deputy ME gets a call on a case from a local nursing home. They had a resident who passed away from pneumonia. Further inquiry revealed that the resident was a quadrapoligic. Seventeen years earlier a drunk driver hit him as he rode his bike down a country road. The decedent had been been wheelchair bound for years and was admitted to the nursing home two years ago when his health began to fail. He was bedridden most of his remaining life.

So what do you think? Should the ME bring him in? What other questions would you ask before making that decision? What do you think the manner and cause of death should be in this case?

2) Deputy ME gets a call from dispatch directing her to a home death scene. When she gets there, she notes that the 78-year-old man is lying on his bedroom floor near a nightstand. He has a moderate gash above his left eyebrow and a pool of blood around his head. The man was being cared for by his daughter. He had a significant medical hx of emphysema, hypertension, and diabetes that was so severe that he recently had several toes amputated off his right foot. According to the daughter, his health was failing precipitously for the past couple of months and he needed help getting out of bed to go to the bathroom because he couldn't walk without getting dizzy. The decedent was on 14 medications for his various conditions.

The investigator moved to the body and did a physical examination. The decedent was initially found face-down, but had been rolled on his back by rescue. There were EKG patches still adhered to his chest. His torso was warm and his extremities were cool. There was no evidence of lividity or rigor mortis. She noted a bandage around the foot that had recently been operated on. She noted a large yellow bruise along the midline of the torso. The investigator examined the head trauma. The blood was encrusted on the forehead and it made it difficult to determine the severity of the injury. The laceration appeared to be approximately 1/2 inch in length. The investigator examined the nightstand and noted a slight amount of blood smeared on the corner nearest the door. There was an empty water bottle lying on the floor.


Okay. What about this one? What further questions would you ask? Would you bring the body in? What manner and cause of death would you assign this case?

3) This case was called into the Deputy ME in the late afternoon from the emergency room of a local hospital. The decedent had been brought in unconsious with a brain bleed at the base of his skull. His blood pressure was skyhigh when he arrived and the ER staff was never able to bring it under control. The decedent was being treated by his primary care physician for alcoholism. He had cirrhosis of the liver, esphogeal ulcers, anemia, and alcohol-enduced anorexia. His doctor said he'd be willing to sign the death certificate if the ME refused the case.

Would you bring him in? What's the cause and manner of death in THIS circumstance?


Good luck!!

21 comments:

motw said...

I'm glad you're back, Polly! (do I get to be first?)
I can't really guess whether to bring in the body or not - what is your criteria? do you consider cost to taxpayers?

1) Questions: What time was he discovered? Is there any previous contact with this nursing home in regards to suspicious patient deaths? How long had he had pneumonia? Unless there's some suspicion w/ the home, I'd guess natural, and whatever the term is when lungs drown because of pneumonia.

2) Questions: What time was he discovered? If he was still warm, was it possible that he was still alive when the ME arrived? (how long do bodies remain warm after they die? how long before rigor sets in?) Diabeties would explain the empty water bottle – he probably had high blood sugar, was thirsty, had to urinate. Were ketones present in the blood? Was he DKA? Hypertension med (blood thinners) might explain him quickly bleeding to death when he struck his head. What’s the bruise on the torso from? Is it yellow because it was in the process of healing? COD- complications from diabetes.

3) You've provided a lot of detail, so no questions. My guess would be: Natural, due to complications from alcoholism.

motw said...

2) 'nuther Q. Why did he have EKG patches on his chest?
tiqow

Trillian DBB said...

1. I say bring him in. if his failling health stems from the car accedent, couldn't the drunk driver be resposible for the guys death?

Polly P.I. said...

I won't tell you whether you're right or wrong yet, but I'll answer your questions.

1) Discovered at 3am during rounds. The nursing home is reputable with no suspicious deaths reported. The decedent had pneumonia for 7 days.

2) He was discovered at 2am. ME arrived at 3:45am. He was last seen alive sitting up in bed watching television at 12:00am by one of his grandsons. He wasn't still alive. The ME pronounced him when she got there. The patches were from EKG feeds the rescue squad uses to determine any electrical activity in the heart. (There was none upon their arrival.) The amount of time a body stays warm is variable depending on the size of the body, weather, and a few other factors. This guy was at room temp and about 250 lbs, so it was consistent that he'd still have a warm torso and cool extremities. Rigor is also variable, but generally starts within a couple of hours. It's progressive and works its way from the extremities to the large joints. Jaw and fingers are usually first. As a general rule, rigor is full at about the 12 hour mark. The bruise on the torso was yellow. Which means it was older. Remember that he grew dizzy when he stood up and it's likely he bumped into a few things over the past several weeks. Not sure about the bloodwork. That wouldn't be relevant, anyway, since there is no way of testing for ketones at the scene.

Tamara said...

*not reading any comments before I post*

Oh, this is so totally easy!
The answer to ALL these scenarios is:

I haven't the frickinest idea! And I refuse to guess on the grounds that I might be wrong, and I HATE being wrong!

But, that's no way to learn anything, is it? Okay, I'll be wrong just this once. And if it doesn't work out, I'll go back to being right all the time.

1) Cause: Natural. Or MURDER! Because isn't that what nursing home staffers do with their free time?

Questions to ask: How long had he had this "pneumonia"? Was he on medication for this "pneumonia"? Was the receptionist in his will?

2) Cause: Accident. Or MURDER! By whatever quack put him on 14 different medications.

Questions to ask: Where was the daughter? Did she hear him fall? Did she come right away? Did she call for help right away? I really think "accident".

3) Cause: Stupidity. Suicide! Or MURDER! How can a physician treat alcoholism? Helloooo? Bad doctor! Bad, bad, bad!

Questions to ask: Didn't he know excessive quantities of alcohol and not-eating would KILL him?! Was the doctor in his will?

Use your red pen all over my entry, Boss. Looking forward to the real answers! TEEEAAACH MEEEE!


On the radio: Simply! Having! A wonderful Christmas-time!

ijzkcl

motw said...

One more question: how's your hand feeling?
venupawq - new name for a healing balm for burned hands? (get it - nupaw? nevermind)

BulletBill said...

Case #1 - Bring him in. Could be a result of previous car accident which could result in a homocide at which point the autopsy will be needed as evidence.

Case #2 - Release due to accidental causes.

Case # 3 - Release due to natural causes.

Here comes some more advice for your book. I would go get a copy of STORY by Robert McKee. It was written for screenwriters and you may find it to be of value. The big difference between a screenplay and a novel is that in a novel, you can express your characters thoughts and feelings.

I always liked to use the skeleton approach. Get the basic idea spine down and then fill in the rest rather than just write from the start to finish.

qmjvi - sounds like a African crotch disease

Higgy said...

Case #1 - same as Bill - if the pneumonia can be traced to the accident, then the person that hit him should be charged. I seem to remember this from somewhere else. I would ask :IS pneumonia C.O.D? Is there any retechial (sp?) hemorraging indicating he'd been suffocated (yes, I watch a lot of CSI) which could mean MURDER (to quote Rhymes with Camera) on the part of the staff. Was the medication having any effect on the pneumonia, and if it hadn't been after 7 days, why was he not in the hospital for it? Might indicate negligence on the staff.
2. Was the head wound C.O.D (i.e. was it deep enough to scramble the gray matter?) Again with the reticheal hemorrage question - in case the daughter wacked him. If yes and no to those, then I'd probably not bring him in.
3. WTF caused the brain bleed? Did one of his drinking buddies whack him upside the noggin with a bottle of gin? What was the cause of the anemia? Probably leave this one as is unless there was any evidence of foul play.

I didn't look ANYTHING up online (well, besides nekkid pictures of Rosie O'Donnell of course - whoops, TMI.)

Looking forward to the answers! I bet I got them all wrong!

Tamara said...

*Itching for answers*

I think this is my most favoritest game ever!

Do I need to start watching CSI??
naxyu

Polly P.I. said...

Higgy, can I just say ewwwww! TMI is right!

1) Can't tell you the COD... Nice try, cheater. ;-)

Petechial hemmhorage is not present in this case and, as you said, is a sign of elevated cranial pressure (indicative of head trauma and/or lack of oxygen, for example...hanging victims generally have significant petechial hemmhoraging.) The guy wasn't in the hospital because he'd signed a release indicating that he did not want unusual measures to be taken to keep him alive. DNR and all that.

2) Again, can't tell you the COD. But I CAN say that there did not appear to be any cranial fx associated with the head injury. There was no petechial hemmhoraging in this case, either.

3) VERY good question! It was an aneurysm. (Hint: There are several lifestyle factors that can enhance the risk of developing a ruptured aneurysm.) Alcoholics often develop anemia, malnourishment, and anorxia. All they do is drink alcohol and they are no longer interested in food.

Polly P.I. said...

Tamara,

I'll post the answers tomorrow around noon. Give a few more people the chance to guess.

bvsdiklh --- Jane Keeler??? That looks Russian! What does it mean?

Tamara said...

2.) MURRRRDERRRRRR!!

zopxrd

[I should start making up verification codes and get people to guess whether or not each one is actually authentic. It'll be like when the audience members try to guess who's a real woman and who's transgender on "The Maury Povich Show". ...Or not.]

Mad Scientist said...

I wouldn't bring any of them in, but that is just because I am lazy and none of them have any interesting pathogens involved unless the pneumonia was from SARS because the guy traveled the world in his wheel chair.

vdile - used to describe the cheese that has been in the back of your refrigerator for 2 years.

BulletBill said...

Polly,

I have a question on procedure. Do detectives get called out to every demise outside of a hospital or do you call them if something looks hinky?

Oh and BTW, is an ME the same as a coroner?

I am thinking of a senario where the local ME goes out and brings a body back to the shop, meanwhile the scene is cleansed by the perp before the cops find out it is crime.

Thanks,
BB

Slyeyes said...

A TEST?!?!? On a FRIDAY?!?!

Well...fqjqdlyt!

Slyeyes said...

pssssssssssst, Polly; The Higgy's are in labor...it was induced.

Polly P.I. said...

OH MY GOSH!!!

They're having a Higglet!

Please keep me posted!


Hinzotcl --- A perfect name for a boy OR a girl...

J Smith said...

Your site is becoming a bore. you are losing your focus.

J. Smith

Eleanor said...

Memo to J. Smith:
She is not and neither is the site!!! Foof to you!!

RE: the quiz:
My answers:

What everyone said. :)
So - Do I win??

Bill Peschel said...

I'd been meaning to get to this, so I'd better get started now.

(One side note, is it the ME investigator's job to assign cause of death before an autopsy? I thought that was the ME's bailiwyck):

1. About the pneumonia victim, I'd ask about the status of the DUI case. I'm not sure about local law, but a person who dies from injures in a DUI may see the driver face additional charges, such as vehicular homicide. Otherwise, it seems like natural causes to me.

2. Question: Which side of the bed was he found on? That would ensure that the gash over the left eyebrow matches the corner of the nightstand. Why were there EKG patches on his chest? I see no mention of a machine nearby. Cool extremities indicates he'd been lying there awhile, so there might be a neglect issue. I'd bring him in and wait for the autopsy, since cause of death could be either blood loss or that combination of 14 drugs (remember, Elvis had at least 10 drugs in his system, and several of there were at lethal levels).

3. I'd bring this one in. I'm not up on the effects of late-stage alcoholism (would there be a thinning of the membranes that would cause the bleeding?), but right now I'd wonder about the bleeding and the blood pressure. Was he taking another drug at the time that caused the heart to go a-pitter-pat?

I'd also want to know where he was found and what the site looked like.

Polly P.I. said...

You guys did great! These are tricky cases and you all had thoughtful questions and perspectives.

JSmith,
I don't get paid to write Polly PI, therefore, I feel no obligation to tailor it to suit anybody's needs other than my own. I have this blog because it's a release for me and a place where I can communicate with my friends and family. If you don't like the current content, I wholeheartedly encourage you to go away.

And you can rest assured that if my mother wasn't reading this blog I'd tell you to kiss my ass.

Pucker up, buttercup.

But my mother IS reading this blog so I can't do that.

ilumv -- "I love you" with a mouth full of peanut butter.