Letter To The Editor: Strengthening Forensic Science

 

A comment left on http://medicalmisdiagnosisresearch.wordpress.com/2010/11/09/strengthening-forensic-science/ was such that I wished to publish it also in a post of its own.

Abstract:

Shaken baby syndrome theory, by whatever name it morphs into, which holds that a small dead child displaying certain limited soft tissues pathologies but no other injuries was shaken to death by the last person who held the child when he or she was conscious. Of all the questioned forensic theories and practices, this is the one I would put at the top of the list for the threshold examination. Of all the currently questioned practices, this is the only one asserted by a respectable minority of specialists to be completely invalid. While a vitriolic dispute continues between the pro and con groups, defendants continue to be sentenced to exceedingly long prison terms based on the theory. While the theory’s supporters accuse the doubters of profiting from defending baby-killers, the doubters label the supporters as zealots lacking any knowledge of physics or of the scientific method. It is long past time that an authoritative body outside the adversarial system examined the underpinnings of the theory and published its results.

Response:

The Shaken Baby Syndrome is a fabricated diagnosis. It was fabricated by doctors who do not understand the pathophysiology of haemostasis and osteogenesis.

Editor,

Vitamin K is a fat soluble vitamin and is a co-factor for an enzymatic conversion of
glutamic acid (Glu) to γ-carboxyglutamic acid (Gla) by γ-glutamyl-carboxylase  and
along with other essential nutrients including Vitamins C and D is  necessary for the
biological activity of the blood coagulation factors and the formation of bone.

A reduction or abnormality of Vitamin K is known to cause  Haemorrhagic Disease of the New Born and fractures in children with Cystic Fibrosis.

Subdural and retinal hemorrhages, encephalopathy and fractures in children which have hitherto been attributed to Shaken Baby Syndrome, Non-accidental injury, Abusive Head Trauma or Inflicted Brain Injury are features of Vitamin K and/or C deficiency and other essential nutrients – Innis’ Syndrome would be an appropriate name change for this combination of signs and symptoms.

Commencing in the mid 20th Century with the publication of a report by an American Radiologist on fractures and haemorrhages in infants1  a Neurosurgeon in England suggested that the cause of the lesions was  violent shaking of the infant by an adult2  a claim echoed by the Radiologist3.  This was the first mention of the “Shaken Baby Syndrome”.

When it was realized that skull fractures could not be explained by shaking, a Professor of Paediatrics in England suggested that a violent impact of the skull against a hard object was the most probable cause of this type of fracture4.  The Shaken Baby Syndrome morphed into “Shaken –Impact  Syndrome”.

Retinal haemorrhages  seen in these children were claimed to be conclusive proof of abuse and Ophthalmologists  added  acceleration –deceleration of the head  as it is violently rotated by the abuser as the cause of the retinal haemorrhages5.

Throughout Academia the current teaching is,  it is the  triad of subdural and retinal haemorrhage with brain damage, as well as the characteristics of each of these components that allow a reconstruction of the mechanism of injury, and assessment of the degree of force employed. Academics claim it is the application of rotational acceleration and deceleration forces to the infant’s head which causes the brain to rotate in the skull. Abrupt deceleration, it is claimed, allows continuing brain rotation until bridging veins are stretched and ruptured, causing a thin layer of subdural haemorrhage on the surface of the brain6-17.

Maguire et al;17  claim that their review, the largest of its kind, offered for the first time, a valid “statistical probability of Inflicted Brain Injury” when certain key factors are present. The “key factors”  included retinal hemorrhages and apnoea both of which are known to be associated with vitamin K deficiency18,19 .

Michael Innis
References

1. Caffey J. Multiple fractures in the long bones of infants suffering from chronic subdural hematoma. Am J Roentgenol 1946;56:163–173.

2  Guthkelch AN. Infantile subdural haematoma and its relationship to whiplash injuries. BMJ 1971;ii:430-1.

3.  Caffey J. The whiplash shaken infant syndrome: manual shaking by the extremities with whiplash-induced intracranial and intraocular bleedings, linked  with residual permanent brain damage and mental retardation. Pediatrics  1974;54:396-403.

4. David TJ. Shaken baby (shaken impact) syndrome: non-accidental injury in infancy. J R Soc Med 1999;92:556-561.

5.  Update from the Ophthalmology Child Abuse Working Party Royal   College  Ophthalmologists Eye (2004) 18, 795-798. doi:10.1038/sj.eye.6701643  Published online 25 June 2004
6.    American Academy of Pediatrics: Shaken Baby Syndrome. Rotational Cranial Injuries.- Technical Report. Committee of Child Abuse and Neglect  PEDIATRICS:2001:198:206-210.

7.    Hoskote A, Richards P, Anslow P, McShane T.  Subdural haematoma and non-accidental injury in children. Child’s Nerv Syst 2002; 18:311-317

8.  Duhaime AC, Christian CW, Rorke LB, et al.  Non-accidental  head injury in infants – the shaken baby syndrome. N Engl J Med 1998;338:1822-1829

9.  Joint statement on Shaken Baby Syndrome.Paediatrics & Child Health
2001;6(9) 663-7

10.  Minns RA.  Busuttil A. Patterns of presentation of the shaken baby syndrome Four types of inflicted brain injury predominate BMJ  2004;328:766

11. Harding  B, Risdon RA, Krous HF Shaken baby syndrome
BMJ, Mar 2004; 328: 720 – 721

12. Green MA. A practicle approach to suspicious death in infancy – a  personal view. J Clin Pathol 1998, 51; 561-563

13  Reece RM. The evidence base for shaken baby syndrome: Response to editorial from 106 doctors. BMJ, May 2004; 328: 1316 – 1317 ;  doi:10.1136/bmj.328.7451.1316

14. Alexander RC, Sato Y, Smith W, Bennett T. Incidence of impact trauma with cranial injuries ascribed to shaking. Am J Dis Child 1990;144: 724-6

15   Protocol for the investigation of sudden and unexpected deaths in children under 2 years of age [Memorandum No 631].Ontario: Ministry of the  Solicitor General and Correctional Services, 1995.

16.  Kempe CH, Silverman FN, Steele BF, et al. The battered child syndrome. JAMA 1962;181:17–24.

17.Maguire SA,  Pickerd N, Farewell D,  Mann MK, Tempest V, Kemp AM. Arch Dis Child. Which clinical features distinguish inflicted from non-inflict brain injury? A Systematic Review Published Online First: 15 June 2009. doi:10.1136/adc.2008.150110

18. Innis MD. Vitamin K Deficiency Disease Jour OrthoMol Med 2008:23;15-20

19.  Innis MD.  Inflicted Brain Injuries: Don’t Disregard Differential Diagnosis. Jour  Amer Phys an d Surg;2010:15  11-12

Strengthening Forensic Science

Abstract:

Shaken baby syndrome theory, by whatever name it morphs into, which holds that a small dead child displaying certain limited soft tissues pathologies but no other injuries was shaken to death by the last person who held the child when he or she was conscious. Of all the questioned forensic theories and practices, this is the one I would put at the top of the list for the threshold examination. Of all the currently questioned practices, this is the only one asserted by a respectable minority of specialists to be completely invalid. While a vitriolic dispute continues between the pro and con groups, defendants continue to be sentenced to exceedingly long prison terms based on the theory. While the theory’s supporters accuse the doubters of profiting from defending baby-killers, the doubters label the supporters as zealots lacking any knowledge of physics or of the scientific method. It is long past time that an authoritative body outside the adversarial system examined the underpinnings of the theory and published its results.

Strengthening Forensic Science A Way Station on the Journey to Justice

 

“In any legitimate justice system, … truth must play a paramount and integral role…. The very survival of the rule of law depends not only on a justice system that administers the law fairly, but a system that is just by being well-grounded in … truth….[M]ore research is needed in the techniques and science already in use. With the importance of forensic science to truth and justice, the science employed and relied upon by judges and juries must be valid. It does not matter how well forensic scientists abide by testing protocols, or how reliable the techniques are, if the underlying science does not actually reveal what the expert says it does. Method validation studies and new research must be on-going even in the area of traditional forensic disciplines.”¹ [Emphases added.]—Kenneth E. Melson, President, AAFS, 2003–2004

Melson’s words, published 6 years before Strengthening Forensic Sciences in the United States: A Path Forward² was issued saying much the same thing, made me immensely proud to be a member of the American Academy of Forensic Sciences. So much so that I placed a special order for reprints of his essay to show others what the Academy stood for. The absence of any anti-defense-bar attitude in this writing by a career federal prosecutor further strengthened its explicit message: the duty of all in the criminal justice system is to seek out the truth and act on it. Although, because of the inherent asymmetry of the system, this duty falls more heavily on prosecuting attorneys than on defense attorneys, it must be the touchstone for all forensic science practitioners. Their allegiance, our allegiance, must always be to the truth. Although this may seem too obvious to merit stating, this is clearly not the case as long as we have crime lab directors who speak of defense attorneys as “the enemy.” It is not the case as long as anyone questioning an established forensic practice is labeled a “defense hack” or told “well, I don’t know how you stand on law enforcement.” As one whose work in criminal matters is with the prosecution as often as with the defense, I find these attitudes reprehensible and the antithesis of the view set out in the words cited at the top of the page. The counterpart of these attitudes on the civil side is found in forensic practitioners who, at the behest of their employing attorneys, destroy their notes or never create them, in order to avoid writing down a truth that can in some scenario assist the other side.

Melson’s essay appeared as we were beginning to grasp the magnitude of the wrongful convictions brought to light through forensic science and the efforts of the Innocence Project. It was quickly found, again largely through efforts of the Innocence Project, that the wrongful convictions arose from incompetent defense attorneys, unethical prosecutors, misguided reliance on “eyewitnesses,” and flawed forensic testimony, occurring either singly or in combination. Scores, and then hundreds, of persons were discovered to have been convicted of heinous crimes of which they were innocent. Even as this depressing news was being assimilated, we realized that we were seeing but a small fraction of the total: those wrongful convictions discoverable through forensic DNA analysis. Criminal acts leaving no DNA, by far the largest category, are prosecuted using the same procedures and evidence types that led to the known wrongful convictions. For example, eyewitness testimony, in spite of mountains of peer-reviewed studies showing it to be perhaps the least reliable type of evidence, continues to be considered the strongest evidence by most laypersons and many judges. Consequently, it remains an effective means of gaining convictions even in the absence of other evidence and even when the testimony is from a single witness. Unfortunately, it is going to be a long time before this flaw in our justice system can be eliminated, and longer still before consideration will be given to reversing single-eyewitness convictions. Another problem that will be difficult to solve in the short term is the conjunction of incompetent defense work and incompetent forensic testimony. Although appeals claiming insufficient assistance of counsel do get considered, the odds against success for such efforts are very high. This leaves forensic science as the single part of the system amenable to near-term improvement.

• (1)

[ —Thomas L. Bohan, President, 2009–2010, American Academy of Forensic Sciences. ]

Although the trials known to have led to wrongful outcomes rarely turned on forensic testimony alone, there appears to be a reasonable likelihood that, had the forensic work been correct, the outcomes in those trials would have been different. Therefore, flawed forensic testimony cannot be absolved from blame just because it was not the sole cause of the bad outcome. For the most part, that flawed testimony was delivered by an incompetent or overreaching practitioner. However, the National Academy of Sciences report that arose in part from concern about wrongful convictions quite rightly went further than simply calling for better supervision and certification of forensic practitioners. Stating that many common crime-lab forensic practices had never been scientifically validated, the report called for research to determine which practices were valid and over how broad a range of application the validity existed. It has been noted that during the months immediately following its release, the report did not have a significant effect on criminal trials, including those in which the prosecution was relying on the same types of evidence criticized by the report. This lack of immediate response may be due to the conclusory manner in which the criticisms were framed. Although, given the breadth of the study, this brevity with respect to specific practices is understandable, it means that more review work needs to be done. An illustration of what remains to be done is provided by other National Academy of Sciences reports on forensic practices, such as that regarding the use of polygraphs³ and that regarding the use of trace-metal analysis in bullets.⁴ Those earlier reports tick off all of the studies claimed to have validated the practice in question, then describe strengths and weaknesses of those studies as support for opining that the practice in question has not been validated. With respect to the pattern-based techniques the latest report criticized, the tabulation of prior studies needs to be done. As it stands, the report’s conclusions about lack of validation have not been accepted by practitioners of the questioned practices, most of whom continue to cite studies that they claim constitute validation. This contrasts, for example, with the effect of the cited National Academy of Sciences report on trace-metal analysis of bullet lead. Once that report issued, there was an immediate and complete cessation of attempts to proffer evidence based on the use of the criticized technique.

The studies that Melson, the National Academy of Sciences, and the American Academy of Forensics Sciences call for will have several benefits in addition to the direct one of establishing the ranges of validity of commonly used forensic theories and techniques. For example, they will help call the attention of judges and trial attorneys to basic forensic facts. What if the Montana judge or defense attorney in the hair-morphology travesty-of-justice trial had possessed the then-widespread knowledge that basic hair morphology is worthless for individualizing hair specimens to a defendant? What if the judge in the Willingham case in Texas⁵ had been aware that scientific studies had eliminated from fire investigators’ armamentarium the rule-of-thumb analysis of the prosecution’s expert witnesses?

In summary, what is needed immediately is a series of validation investigations. A validation investigation is a threshold study to determine whether a technique or theory the scientific validation of which has been questioned has in fact already been scientifically validated. This is a necessary first step in each instance, given that the practitioners of the respective techniques claim with some heat that their practices have already been validated. In order to secure their needed cooperation in studies aimed at finding the limits of reliability of these practices, a body with the recognition and respect of the National Academy of Sciences must first investigate whether the practice has already been validated, and, if so, what the limits of its validity are. More importantly, once the investigation is complete, this body must publish a definitive report on its conclusions. These threshold studies would not involve any experimentation or lab research, but rather an examination of all the prior studies (especially those reported in the refereed literature), that the practitioners believe have established the validity of their practices.

There will be three possible outcomes to the threshold studies. One, an unlikely one, will be that the practice in question has already been validated. The second, more likely one, is that it has not been validated, at least with regard to determining its range of validity. The third outcome would be, like that of the “bullet-tracing” method study, a finding that the theory or practice was invalid. A particularly important potential example of the latter is the so-called shaken baby syndrome theory. If the critics of this forensic theory are correct, there will be thousands of convictions and plea bargains to be re-examined. Yes, plea bargains, since most such bargains are entered into by defendants convinced that if they go to trial they will be convicted and sentenced to much longer terms than they can obtain through a deal with the prosecutor.

It should be obvious to all that the forensic practices that have come under serious challenge should be subjected to these validation studies. Calling for them is not a defense scheme for getting criminals released or acquitted on a technicality. It is an effort to prevent persons from being wrongfully convicted, to release those who have been, and to redirect law enforcement resources to the apprehension of the actual criminals.

The National Academy of Sciences February 2009 report drew the complaint from some that it had attacked the field of forensic science and, what in a perverse manner carried much the same message, the assertion that it had not attacked forensic science. Given the definition accepted by the AAFS among many others that forensic science is the application of science to questions arising in law, it is difficult to see how it is possible to attack “forensic science.” The report was in fact a criticism of the U.S. justice system for its misuse of science and of the individuals and laboratories who would misuse science. It was an attack on those who use nonvalidated applications of science in prosecuting defendants. It was an attack on those practitioners who claim zero error rate for their work and those who assert that only they are qualified to determine whether their methods are valid.

Another concern raised by those resisting a systemic examination of questioned forensic practices is that this examination will lead to a disruptive witch hunt or fishing expedition (depending on one’s taste in metaphors). This is far from being the case. Although scientists in different forensic specialties may be able to add a few practices to the list, I believe that it is fairly complete in terms of those practices that have been identified by the National Academy of Sciences and others as needing evaluation, that is, those that have come under questioning that is not frivolous. Some examples of the practices needing threshold studies follow:

• Bite mark analysis used to identify perpetrators who have bitten their victims, a method the limits of which have never been delineated and which probably in the hands of some practitioners is applied far beyond the extent for which any validation exists.
• Tool mark analysis, an extremely broad field, parts of which can be subject to validation but nevertheless appear never to have been studied for this purpose.
• Handwriting comparison analysis to determine whether two specimens were written by the same person or whether a specific person had written a particular specimen is a field that since the handing down of the Daubert
  decision emphasizing the need for quantification of reliability has been carrying out a series of tests to establish the different aspects of reliability in the described undertakings. In spite of this continuing research, there are some practitioners in the field who claim levels of reliability that have not yet been established.
• Friction ridge analysis for purposes of identification and in particular latent fingerprint analysis where a small fractional print from a crime scene is compared with databases of full fingerprints, seeking a match that will place a particular individual at the scene, is a traditional forensic discipline holding one of the longest pedigrees. Unfortunately, that long history has been used by many of its practitioners to resist calls for quantification. Contrary to the straw men erected by some of these practitioners, calls for quantitative studies do not hinge on a suggestion that fingerprints are not unique. The studies needed are those of the probability, however one wishes to define it, that, as the practitioners progress from the discovery of a fractional latent print to the identification of that print with a particular individual, an error is made, a false positive occurs. Although initially the Federal Bureau of Investigation was the ideal entity to carry out such studies, providing it published its results in the open refereed literature, I believe that this is no longer the case. Its resistance to the very idea that such studies are needed will cast a shadow on whatever it now undertakes. Unlike those techniques that must be evaluated to determine whether they have already been validated, latent fingerprint identification needs basic research to determine its limitations with respect to latent-print quality and quantity, and some measure of the probability of false positives—the type of work that academic research teams are suited for, providing they can get access to the large fingerprint databases now in existence. Nevertheless, an evaluation by the National Academy of Sciences or an equivalent entity of the work that has already been done would provide a valuable boost to any program for additional research.
• Shaken baby syndrome theory, by whatever name it morphs into, which holds that a small dead child displaying certain limited soft tissues pathologies but no other injuries was shaken to death by the last person who held the child when he or she was conscious. Of all the questioned forensic theories and practices, this is the one I would put at the top of the list for the threshold examination. Of all the currently questioned practices, this is the only one asserted by a respectable minority of specialists to be completely invalid. While a vitriolic dispute continues between the pro and con groups, defendants continue to be sentenced to exceedingly long prison terms based on the theory. While the theory’s supporters accuse the doubters of profiting from defending baby-killers, the doubters label the supporters as zealots lacking any knowledge of physics or of the scientific method. It is long past time that an authoritative body outside the adversarial system examined the underpinnings of the theory and published its results.

As people of good will across the criminal justice system have grappled with how to implement the strengthening of forensic science called for by the National Academy of Sciences, I have been struck by the composition of those invited to partake in this crucial work. In particular, I have been struck by the near-absence of scientists from this group. I have heard lobbyists without the slightest idea of what scientific research consists of call for “research but not so that it interferes with our solving the most important problems.” I have had the experience of being in a roomful of people discussing the form legislation addressing scientific issues in the forensic arena should take and realizing that I was the only person present who had spent any time at all doing scientific research. It seems obvious that a broad swath of scientists should be engaged in examining each forensic technique about which serious questions have been raised. In determining the degree, for example, that handwriting comparison analysis has already been validated there should of course be an expert in that field. However there must also be statisticians and indeed scientists and engineers familiar with the examination of evidence. As stated above, this study and the threshold studies in other areas will not involve direct research of the type needed to validate the practice in question. Rather, they will be examinations of the professional literature in the field, including especially that put forth by practitioners to support the proposition that validation has already taken place. Until an authoritative body such as this has reached a conclusion as to what has already been validated and what has not, very little progress is likely in the basic validation research. Those tests that will ultimately be indicated are nontrivial undertakings and will not be undertaken until those who can carry them out are convinced of their need.

This is a crucial period with respect to forensic science in this country. The 2009 National Academy of Sciences report on forensic science in the United States has opened an opportunity for beneficial change that will soon be gone, gone for the foreseeable future. We must take advantage of it to erect the framework now that will instill and ensure a continuing robustness throughout all of forensic science. The result of this work will be to the immeasurable benefit of us all, because it will be of benefit to the American system of justice.

 

Footnotes

• 1 President’s Editorial—The Journey to Justice, J Forensic Sci, July 2003, Vol. 48, 705.
• 2 National Research Council, The National Academies, National Academies Press, Washington, DC, 2009.
• 3 The Polygraph and Lie Detection, National Research Council, The National Academies, National Academies Press, Washington, DC, 2003.
• 4 Weighing Bullet Lead Evidence, National Research Council, The National Academies, National Academies Press, Washington, DC, 2004.
• 5 For one account of this tragic case, see TRIAL BY FIRE, by David Grann, page 42, New Yorker, September 7, 2009.

Source:

http://onlinelibrary.wiley.com/doi/10.1111/j.1556-4029.2009.01255.x/full

Forensic Epidemiology: A Systematic Approach To Probabilistic Determinations In Disputed Matters

Authors:

Michael D. Freeman PhD, MPH, DC (Adjunct Associate Professor of Forensic Medicine and Epidemiology, Clinical Associate Professor)

Institute of Forensic Medicine, Faculty of Health Sciences, University of Aarhus, 205 Liberty Street, Suite B, Salem, OR 97301, USA
and Department of Public Health and Preventive Medicine, Oregon Health and Science University School of Medicine, USA

Annette M. Rossignol ScD (Professor)

Department of Public Health, Oregon State University, USA

Michael L. Hand PhD (Professor)

Atkinson Graduate School of Management, Willamette University, USA

 

Abstract

Forensic medicine testimony often relies upon terms of probability to enhance the strength of the testimony. Such terms must have a demonstrably reliable and accurate basis; otherwise their use is speculative, unjustified, and potentially harmful. Forensic Epidemiology is introduced as a framework from which probabilistic testimony can be assessed in settings in which it is either proffered or encountered. In this paper, common forensic uses of probability are reviewed, appropriate methods for presenting such testimony are proposed, and inappropriate uses of probability and epidemiologic concepts and data, as well as a logical fallacies commonly observed in forensic settings are presented. A previously unpublished logical fallacy, the ‘‘Prior Odds” Fallacy, is also introduced.

Conclusions

The 19th century essayist and novelist Charles DudleyWarner (1829–1900) is credited with the quote ‘‘Everyone complains about the weather but no one does anything about it”. In some ways, the quote is apropos for the widespread but unsystematic use of probability in forensic medicine, in that everyone uses it but not everyone understands it. The purpose of this paper, in which the concept and some of the applications of Forensic Epidemiology have been introduced, is to fill a void that presently exists in forensic medicine with the addition of a general heading under which the proper and improper forensic use of probability is systematically described. As demonstrated by the tragedy of the Sally Clark case, there is little doubt that the use of probability in forensic medicine is in need of standardization; there is a high potential for continued harm and injustice if nothing is done in this regard. Better and more explicit heuristics are needed to describe and implement the concepts introduced in this paper for the wide variety of circumstances encountered in forensic medicine. A few recommendations are as follows:

1)  Be alert for the language of probability or epidemiology in forensic opinions.
2)  When epidemiologic data are referenced as a basis for an opinion, evaluate the propriety of their use. Are the sample population and circumstances sufficiently similar to allow for extrapolation to the facts in the present case?
3)  When in doubt regarding causal determinations, return to the three essential elements of causation: biologic plausibility, temporality, and lack of likely alternative explanation.
4)When a clinical outcome is known, be aware of the potential for Prior Odds and other fallacies.
5) If a test or criterion is set as an evidentiary standard, determine if the Specificity, Sensitivity, and Positive Predictive Value is known or can be determined for the test or criterion. Use these tools to help determine the real utility of the test or criterion in a forensic setting.

For full a paper please see source. You can also download the PDF version medicalmisdiagnosisresearch BoxNet files.

Source:

http://www.internationalbrain.org/pdf_public/lisbon/Freeman%20Lisbon,%20Forensic%20Epidemiology.pdf

Post-Mortem On A “Shaken Baby Syndrome” Autopsy

Author:

F. Edward Yazbak, M.D.

Introduction:

At a clinical pathological conference, a resident usually reviews
the history and findings of a case, the radiologist describes the
imaging studies, and the department chief leads a small discussion.
The conference is then turned over to the pathologist who in a few
minutes describes the autopsy findings and announces the actual
diagnosis. As we file out of the hall, we are all quite confident that
we know exactly what happened to the patient.With an autopsy, the
diagnosis is final, and the conclusions cannot be questioned.
Those of us who examine medical records and testify in shaken
baby syndrome (SBS) cases have at times been surprised and even
shocked at some of the autopsies we have recently reviewed. One
such autopsy sent an innocent man to jail for 7 years, and
surprisingly helped to set him free.

Conclusions

Testimony by pathologists about autopsy results can help
condemn innocent persons to life imprisonment or even death. The
autopsy table is accepted as the altar of truth by physicians and
courts alike.Yet, as this case shows, medical examiners are fallible,
and autopsy reports must always be analyzed critically.
Minor errors such as mistaking the child’s race may seem
immaterial, but signify the lack of meticulous care that should be
demanded when life and liberty are at stake. Such errors raise the
possibility that the body being examined was misidentified.
It is possible that these seemingly immaterial but indisputable
errors helped to get the case opened for review, so that egregious
failures to obtain all pertinent information and to consider all
possible diagnoses were ultimately revealed.

Further contents include the Summary Of Events and Errors And Omissions. To view the full PDF version of this article please see source below.

Source:

Journal of American Physicians and Surgeons

http://www.jpands.org/vol10no2/yazbak.pdf

Neuropathology: Questions And Answers On Brain and Spinal Cord Trauma

NEUROPATHOLOGY FOR MEDICAL STUDENTS

Presented by William I. Rosenblum, MD

Material in this chapter provided by AJ Martinez, MD

CHAPTER 8–BRAIN AND SPINAL CORD TRAUMA

PRETEST: Answers will be found in the text of this chapter or click on link at end of questions

1. Two lesions of the brain produced by trauma are____________ and ____________.
2. Trauma to the head can produce hemorrhages on either surface of the dura. These are called _____________.
3. They are produced respectively by rupture of the  ______________ or of a _________________.
4. A linear hemorrhage at the grey -white junction, produced by trauma, has been called a ____________ contusion.
5. Contusions are preferentially found at the crest/base of the gyrus [pick one].
6. An old contusion appears as a ____________.
7. Sequelae of head injury may be caused by widespread damage to _________. This pathological consequence of trauma has been named ________.
8. There are three grades of the entity referred to in previous question. Grade three includes “lesions” (i.e. necrosis or hemorrhage) that are either grossly or microscopically visible–in what area of brain?
9. Describe the resolution of  subdural hemorrhage. What do we mean by subdural membranes and how did they form?
10. Distinguish a subdural of 5 or 6 days from one of one day or one of two weeks.
11. What is a contra-coup injury?
12. After cord injury Wallerian degeneration can occur. The dorsal columns may degenerate above/below [choose one]. The lesion and the pyramidal tracts or lateral columns may degenerate above/below the lesion [choose one].

ANSWERS TO QUESTIONS

TRAUMA TO THE BRAIN

General Principles

A blow to the head, or any other severe physical force, can deform, displace, and tear the tissues covering the brain and the brain itself. This may produce loss of function, necrosis, and hemorrhages. Head injuries can be classified as:

(a) Closed: when a blunt object damages the brain and its coverings without actually perforating the skull or dura.

(b) Penetrating: when the skull and brain are directly lacerated by an object, such as a bullet.

The closed type of injury constitutes the majority of civilian injuries. Extensive intracranial damage may result from an injury to the head which produces little damage to the outside. Instead, the force may be communicated through a rigid, bony vault (calvarium) to the soft tissue within.

When the head is struck, it often moves until it is abruptly brought to a stop against a solid object. At this moment, the brain continues moving for a brief instant until it hits the bony prominences inside the now stationary skull. Sometimes, the injury to the moving brain takes place at a site opposite the point at which the skull was initially struck. This type of injury is called “contra-coup,” as opposed to a “coup” injury occurring on the same side as the initial impact (coup = blow, French; contra-coup = opposite the blow).

Traumatic lesions, whether they are the product of closed or penetrating injuries, and whether they are coup or contra-coup, may be said to have direct effects, and secondary effects as listed below.

A. DIRECT EFFECTS

1. Skull fracture

2.  Hemorrhages–epidural, subdural, intraparenchymal

3.  Lesions to brain–contusion, laceration [ the most minor "lesion" has no identifiable gross or microscopic counterpart in human material and is the concussion which produces unconsciousness].

4.  Diffuse axonal injury [DAI]

B. SECONDARY EFFECTS

1.  Cerebral edema or swelling

2.  Herniations of brain tissue

3.  Infarction

4.  Infection

As a result of traumatic brain damage, there may be permanent localizing neurologic defects or post-traumatic epilepsy.

SPECIFIC TRAUMATIC LESIONS

SKULL FRACTURE

EPIDURAL HEMATOMA

The image below displays a  large epidural hematoma in the temporo-parietal region. The epidural hemorrhage is outside the dura, and is located between the bone and the dura. The patient fractured the squamous portion of temporal bone and lacerated the middle meningeal artery. The brisk arterial bleeding produced a rapidly expanding mass of blood. This can produce rapid increase of intracranial pressure with consequent death. The patient may be awake at the beginning of the period of expansion and this interval is called the lucid interval and may fool the physician into believing that the trauma was benign.

SUBDURAL HEMATOMA

A subdural hematoma is the accumulation of blood under the dura mater. This arises from rupture of the veins that course through the subdural space (bridging veins) as they pass from the cerebral hemispheres to the dural sinuses. These veins may be torn by any force suddenly applied to the head.

The natural history of subdural hematoma which finally resolves (organization) is as follows. Approximately two days after the hemorrhage, an outer membrane of fibroblasts begins to form under dura on the outer surface of clot. This membrane thickens over the ensuing weeks. Meanwhile, later in week one, an inner membrane of fibroblasts begins to form between arachnoid and inner surface of clot. During the following weeks, both membranes thicken. The clot between them organizes and thins; eventually the two thickened membranes become opposed. The resultant “membrane” varies in thickness, depending on size of original clot. It may be as thin as paper or it may be several mm thick.

The subdural hematoma just described is one which stopped bleeding, and often is not associated with clinical symptoms. However, a large subdural can cause acute symptoms because it acts as a space occupying mass. Sometimes these symptoms develop after an initial silent period. In such cases the subdural has continued to grow until it became symptomatic. These are often called chronic subdurals. We still do not understand why some subdural hemorrhages continue to grow.

In the image below the accumulation of blood in the subdural space is recent. The blood clot is soft, friable, and easily separated from the dural membranes. The dura mater has been reflected to demonstrate the extension and location of the blood clot.

In the image below the hemorrhage has become organized and largely resolved. A membrane, discolored by blood pigment is left adherent to the dura (arrows).

In the image below a microscopic whole mount of the cerebrum has been stained with a stain that colors collagen green. The old [organized] subdural hemorrhage consists of collagenous tissue seen here in the upper left portion of the figure adherant to dura and over the underlying brain.

The image below gives a low power microscopic view of the membrane itself stained with hematoxylin and eosin. Fresh hemorrhage is still present (A), Granulation tissue (B) grows from the inner surface of the dura. Thus, this subdural is still organizing.

CONCUSSION

A concussion is the temporary loss of consciousness with a variable period of pre- and post-traumatic amnesia, but without permanent detectable clinical or morphologic damage. The patient recovers consciousness within a few seconds or hours, and has no permanent residual ill effects.

CONTUSION

A contusion is the superficial bruising and necrosis of brain tissue following its impact against a hard surface (bone or the dura mater). The necrosis may be the result of the vascular damage and edema that are products of the mechanical shock wave, as well as of the shock wave itself. Contusions of the brain are often confined to the crests of the gyri. The majority of contusions occur on the orbital surface of the frontal lobes and at the frontal pole of the hemispheres and the tips of the temporal lobes. They are usually areas of hemorrhagic necrosis.

The image below shows a lateral view of the brain with contusions (hemorrhagic necrosis) at the frontal poles, and along the temporal lobes.

The next image shows a histologic section of an older contusion, which like any older area of previous necrosis, is now a cyst. The location at the crest of the gyrus helps us distinguish the contusion from an old infarct which generally has a less restricted distribution.

The zone of cystic degeneration extends into the white matter beneath the injured cortex. This is most likely the result of edema, which spread into the white matter at the time of injury. Though not shown here, old blood pigment (hemosiderin) often remains in macrophages in the old contusion.

INTRACEREBRAL HEMORRHAGES

As shown in the image below, hemorrhages are a common feature of head trauma. They arise from vessels torn by shearing forces within the brain tissue.

PENETRATING BRAIN INJURY

This coronal section of cerebral hemispheres demonstrates a penetrating brain injury. This was a gun shot wound. Note not only the extensive destruction of brain tissue in the path of the bullet, but also the ependymal lining tinged with blood, suggesting the presence of an intraventricular hemorrhage. When the bullet leaves the skull (exit wound), the skull defect may be larger than that at the point of entry. This is because the bullet wobbles as it passes through the brain and because bone fragments may be carried out of the skull with the exiting bullet. However this classical rule of thumb may not apply to modern high power weapons and modern explosive bullets or bullets with other than the old fashioned “bullet shape”.

DIFFUSE AXONAL INJURY

This important concept explains both short and long term neurologic deficits in patients whose trauma did not produce either contusions, hemorrhages or lacerations sufficient to account for the deficits. Frequently, the latter lesions are minimal but the deficit is severe.

What has happened is that rotational and other movements of the brain during trauma has resulted in injury to numerous axons in both cerebrum and brain stem. This may be seen at autopsy following injury by many days. There will be many focal swelling or “balls” or “bulbs” visible on H&E stain [they will be eosinophilic--pink] and especially on silver stain. Sites where they may be most readily recognized are deep white matter and corpus callosum. In its most severe form–what many workers have called grade 3- there are not only swollen axons in the mid brain, but also focal “lesions” consisting of either small areas of hemorrhage or necrosis. These tend to be around the aqueduct or on the later margin of the dorsal midbrain or in the cerebellar peduncle. When hemorrhagic they should be distinguished from secondary brain stem hemorrhage caused by herniation. The secondary hemorrhages are generally more central [i.e. medial, along the midline] and ventral within the brain stem and are more likely to be present more caudally in the pons.Patients with grade three diffuse axonal injury are in coma fron the time of the injury and will not recover.

The presence of the diffuse axonal alterations may be recognized on autopsy when death occurs within hours of injury, but only with special staining techniques involving use of antibodies to the amyloid precursor protein. This is found to accumulate in the affected axons, often focally.

However stained, and at whatever time after death, the focal swellings of axons are now thought to be the result of metabolic alterations in damaged axons and ultrastructural changes that cause damming up of axoplasmic flow. This may or may not result in ultimate breakage or disconnection of the affected axon. Thus the large bulbs [cross section] or “torpedoes” [longitudinal section] seen with H&E or silver stains are not really the “retraction bulbs” resulting from a springing back of the proximal portion of disconnected axons as was though by the classical neuropathologists.

SPINAL CORD INJURIES

TRANSECTION OF CORD

Spinal cord injuries may result from fractures and dislocation of the vertebral column, from penetrating missile wounds, and from compression by tumors. The image below demonstrates an almost complete transection of the spinal cord at the level of the thoracic region (arrow). Naturally transection leads to paraplegia or quadraplegia (paralysis of limbs).

The image below shows a microscopic section at the level of the lesion. Note the extensive degeneration of almost the entire cord, with relative preservation of the posterior tracts. Only the latter are stained (arrows).

One consequence of cord transection is Wallerian degeneration (See also chapter on neuropathology of the neuron and its processes).  The entire length of axons distal to the lesion [i.e.  between lesion and tip of axons] die because they have been separated from their nourishing cell bodies. Above the lesion of the cord the affected tracts will be those ascending to the brain because the cell bodies from which they arise are in the dorsal root ganglia, from which the axons ascend to reach the sensory cortex. The image below shows a photomicrograph of a section of the spinal cord above the lesion stained with Weigert technique for myelin (black-brown color). Note the extensive paleness (degeneration, arrows) of the dorsal columns. This is Wallerian degeneration above the lesion

In the image below you are being shown the cord below the level of the lesion. Therefore the dorsal columns are intact and it is the descending tracts which have undergone Wallerian degeneration, since below the lesion it is these tracts that have been cut off from their nourishing cell bodies. These descending tracts are the lateral and ventral corticospinal tracts [arrows]  cut off from their nourishing cell bodies above the lesion, in the motor cortex of the cerebrum.

SECONDARY EFFECTS OF BRAIN TRAUMA

As indicated earlier these include infection and infarction. Infection can occur if the infectious agent penetrates the brain at the site of a depressed fracture or missile wound. Infarction can occur as a result of cerebral edema, which itself is another secondary effect of trauma. The brain swelling can produce herniations as described in chapter concerning vascular diseases. The brain stem herniation is lethal. Edema can also cause infarction by causing compression of an artery adjacent to the edematous swollen lesion. Infarcts can also be produced if arterial flow is disrupted by thrombi in  bruised or otherwise injured arteries and arterioles.

Source:

http://www.pathology.vcu.edu/WirSelfInst/neuro_medStudents/trauma.html

Last Updated 15-May-2007

Impact And Short Fall Costs Infants Life

Falling Branch Kills Baby

June 27 2010

Six month old Gianna Ricciutti from Union City, N.J was killed on Saturday, after a large branch fell from a tree outside the Central Park Zoo, striking her and injuring her mother. Karla Ricciutti was holding her infant outside of the famous New York attraction, when the huge limb somehow separated itself from a tree 30 feet over their heads, and landed on them. The impact knocked the 33-year old women to the ground and caused her infant daughter to fall out of her arms, also landing on the hard pavement.

After being rushed to New York Presbyterian hospital, the baby was pronounced dead, while her mother remains in critical condition as a result of the accident.

Witnesses report the entire incident happened so quickly, there wasn’t enough time for anybody to react. The father, Mike Ricciutti was snapping photographs at the time and was visibly upset and too shaken up to respond to questions about either his wife or daughter.

This is not the first fatality involving a falling limb in this area. In February of this year, Elmaz Oyra was struck in the head by a snow covered branch while strolling along Literary Walk, killing him almost instantly.

Source

http://www.overthelimit.info/curiosity/2010/06/27/falling-branch-kills-baby/

Resuscitation Injuries

Resuscitation Injuries Complicating the
Interpretation of Premortem Trauma and Natural
Disease in Children

CASE REPORT       Dr. John Plunkett, MD

J Forensic Sci, January 2006, Vol. 51, No. 1
doi:10.1111/j.1556-4029.2005.00027.x
Available online at: www.blackwell-synergy.com

ABSTRACT:

Minor soft tissues injuries are common in both adults and children who have had cardiopulmonary resuscitation (CPR). Potentially life-threatening injuries are rare. The pre-arrest history in a resuscitated adult often assists the pathologist to interpret autopsy findings. In contrast, an infant or child may not have a reliable history. In this situation, it may be difficult if not impossible to distinguish resuscitation injuries from preexisting accidental or inflicted trauma. I describe two children who had significant autopsy-documented injuries initially attributed to abuse. The State filed murder charges against the caretaker in each case. However, further history and review of the medical records suggested that resuscitation rather than pre-arrest trauma caused almost all of the injuries. The State dismissed the charges in the first case. A jury returned a ‘‘not guilty’’ verdict in the second. It is essential to consider the entire history and not just autopsy findings when performing a death investigation

Resuscitation frequently causes skin, soft tissue, and skeletal injuries in children and adults. Iatrogenic injuries include contusions and puncture wounds from IV placement (1), burns from defibrillation, and rib and sternal fractures (in adults) (2). However, lip contusions, lacerations and tooth fractures from attempted intubation, facial contusions
from air-bag valve-mask use (1,3), and extensive subcutaneous hematomas from attempted jugular or subclavian catheter placement may be more difficult to interpret, especially if the resuscitation history is unknown or not sought. Published life-threatening infant resuscitation injuries include right atrial rupture (4); trachea perforation and gastric rupture (5); hepatic, splenic, and pancreatic lacerations (6); and retroperitoneal hemorrhage (7). The incidence of
these complications is not known. Krischer et al. (8), in a comprehensive prospective study of 705 autopsied deaths in which cardiac resuscitation had been performed, documented liver and spleen lacerations in a 10-month-old child, and gastric rupture in a 16-monthold child. However, this study does not state the age range or distribution of the subjects, or tabulate specific injuries to a specific age. This report describes two children with significant injuries most
likely caused by resuscitation. In each case, the injuries were initially interpreted to represent pre-arrest trauma, resulting in capital murder charges against the caretaker who was with the child at the time of the collapse at home.

Case #1

A 6-year-old male with no significant past medical history (according to the Medical Examiner’s initial investigation) lived with his biologic mother and his mother’s boyfriend. The boyfriend had lived with the mother and child since the child was a baby. There was no Child Protection involvement with the family; the mother and boyfriend’s had a stable and nonviolent relationship; and the child’s mother and other friends reported that he had a good relationship with the child. The boyfriend stated that he had been alone with the child since approximately noon and that he had last seen him alive at 12:30 pm. The child had been complaining of abdominal pain and was ‘‘sleepy,’’ but otherwise appeared
and acted normally. He found the youngster collapsed and not breathing on the bedroom floor at 1 pm, and called rescue personnel. The ‘‘911’’ operator instructed him in cardiopulmonary resuscitation (CPR), and he initiated and continued chest compression until paramedics arrived 11 min after the call. The child was in a complete cardiopulmonary arrest (asystole) and early rigor, but the resuscitation attempt was continued enroute to a local
hospital. He was dead on arrival in the emergency room (ER), and the ER personnel discontinued the resuscitation.

A postmortem examination indicated no cutaneous injuries. However, there was a 2.5 cm laceration of the liver at the attachment of the ligamentum teres; a 2.0 cm laceration of the right adrenal gland adjacent to and beneath the hepatic laceration; and an estimated 300mL of intra-abdominal blood. Microscopic examination indicated that the hemoperitoneum was ‘‘acute’’ and had no evidence for an inflammatory infiltrate. The autopsy report stated that the other internal organs were grossly and microscopically normal. The pathologist told the Prosecutor that the condition of the child when he was first examined by emergency medical services (EMS) personnel (rigor with asystole) was inconsistent with the history of a maximum 30 min postmortem interval given by the boyfriend, that the death was caused by the hemoperitoneum due to hepatic and adrenal lacerations, and that it was a homicide. The State filed first-degree murder charges against the boyfriend.

Outcome

Two pathologists and a pediatric pulmonologist independently reviewed the death investigation and autopsy at the request of the defense attorney. Review of the child’s medical records indicated that he had unstable asthma for which his physician had prescribed albuterol sulfate syrup. Examination of the autopsy lung slides showed striking emphysematous changes (Fig. 1). Mucous plugs occluded all of the large and small bronchi and bronchioles, and there was mucous gland hyperplasia and thickening of the bronchiolar muscle walls (Figs. 2–3). An independent witness, a
workman in the apartment complex, stated that he had seen the child alive and apparently okay approximately 20 min before the ‘‘911’’ call. The reviewers discussed their findings with the State’s attorney, and the State dismissed the charges.

Case #2

A 21-month-old male lived with his 3.5-year-old brother, his mother, and his mother’s boyfriend in an apartment. The children and adults ate dinner at approximately 6 pm, and the children went in their bedroom at 8 pm. The mother stated that she was doing housework, then took a shower 20 ft from the bedroom, and that she heard nothing unusual. The boyfriend stated that the older child came out of the bedroom at 8:15 pm and said his younger brother fell out of bed. (The top of the mattress was 19 in above a carpeted floor.) The boyfriend went into the room and found the child on the floor, groggy but arousable, with blood on the right side of his head. He and the child’s mother took the infant by car to a hospital 10 min from their home. He was hypotensive and bradycardic on admission, breathing agonally, and had a rectal temperature of 91.71F. He was intubated in the ER. A computed tomography (CT) scan indicated a depressed fracture of the petrous portion of the right temporal bone associated with temporal lobe lacerations and a subdural hematoma. The subdural hematoma continued to enlarge. He had a cardiac arrest while being transported to the operating room (OR) approximately 4.5 h after admission. Trained pediatric hospital personnel resuscitated him, but he developed a consumption coagulopathy and arrested four more times over the subsequent 4 h. Resuscitation restored cardiac activity after each arrest, but the child was brain dead. The attending physicians removed the respirator 12.5 h after the initial arrest and 17 h after admission to the hospital. An autopsy indicated a depressed fracture of the petrous portion of the right temporal bone extending through the right mastoid process to the lambdoid suture. The fracture lacerated the right temporal lobe and caused a right hemisphere subdural hematoma. The child also had abraded contusions of the upper and lower lips (Fig. 4); multiple cutaneous contusions; a fracture of the right tenth rib posteriorly in the mid-scapular line; 100mL of intra- peritoneal blood associated with a splenic laceration (Fig. 5); a 300mL retroperitoneal hemorrhage; edema and ecchymosis of the scrotum; and a healing fracture of the right inferior pubic ramus. The rib fracture had no associated subperiosteal or subpleural blood. The State indicted the boyfriend for capital murder. The Prosecutor indicated that he would seek the death penalty because of the vulnerability of the victim and the brutality of the attack.

Outcome

The autopsy pathologist concluded that defibrination caused the skin contusions; and that perforation of the right femoral artery during attempted placement of an arterial catheter caused the retroperitoneal hemorrhage and the scrotal ecchymosis and edema. He stated that resuscitation may have caused the lip lacerations and contusions. (The initial ER physician and nursing assessments, independently documented in the Medical Record, indicated that the child’s lips and mouth were ‘‘normal.’’) However, he attributed the splenic laceration, the rib fracture, and the intra-abdominal hemorrhage to pre-admission trauma. An abdominal contrast- enhanced CT performed approximately 2.5 h after admission indicated no intra-abdominal or retroperitoneal hemorrhage, normal abdominal organs, and no rib fracture (Figs. 6 and 7). The CT findings suggested that it was possible if not likely that the child’s only pre-admission injury was the skull fracture causing a cerebral laceration, for which there was a reasonable nonabuse explanation.
The jury deliberated for 4 h and acquitted the defendant.

Discussion

There are a number of factors in Case #1 that strongly suggest that the liver and spleen lacerations and the intra-abdominal blood were due to the resuscitation, not abuse. It is unlikely that a child with a blood volume of approximately 2000mL will die acutely from a 300mL intra-abdominal hemorrhage. The pathologist was not told that the child had a history of asthma and had complained of abdominal pain on the day of his death. The defendant’s statement, the ‘‘911’’ tape, and the statement by the workman that he had seen the child alive and well less than half an hour before the paramedics arrived were not available or disclosed to the pathologist until almost 4 months after the autopsy. Further, the macroscopic and microscopic description of the lungs as ‘‘normal’’ was inaccurate. The child had severe acute and chronic asthma. Children with asthma frequently complain of abdominal pain (9– 11), and tissue hypoxia forcing peripheral muscle anaerobic glycolysis accelerates rigor, explaining both the child’s symptoms and the rapid onset of rigor.

Interpretation of the injuries in Case #2 is more difficult. The head injury; the healing pelvic fracture; the splenic laceration with intra-abdominal hemorrhage; an acute posterior rib fracture; retroperitoneal hemorrhage; and the abraded contusions of the lips were all consistent with multidirectional force injury. However, the autopsy findings were inconsistent with the known social history of the defendant (no domestic violence and an excellent relationship with both children), and the history as reported by the mother. The older child, who was in the bedroom with his brother, gave several inconsistent and contradictory accounts to Law Enforcement of what happened. These included that ‘‘he choked,’’ that his mother dropped him, and that ‘‘he fell and blood was coming from his nose and ears and mom put a bandaid on his ear and he vomited.’’
The mother’s statement to Law Enforcement, translated and transcribed by an interpreter, was not available to the defense attorney until shortly before the trial, 3 years after the death. In this statement, she said that the older child initially told her that the younger child had been jumping up-and-down on the bed, then fell to the floor. The defense attorney asked me what would happen if the younger child was laying on the floor and his older brother, who weighed 45 lb, jumped off the bed, landing on the side of his head. Biomechanical reconstruction using a variety of scenarios
indicated that this possibility was reasonable and consistent with the observed injury. No one ever asked the sibling if this is what happened, and I did not consider it until I reviewed the mother’s statement several years after the death.
Incision of the femoral artery during catheter placement caused the retroperitoneal hemorrhage, and the scrotal edema and hemorrhage. Hospital personnel described that the skin contusions, accentuated by defibrination, developed with the slightest pressure during the closed-chest CPR. Placement of an orotracheal tube caused the lip contusions and abrasions: The initial ER nursing and physician assessments independently and clearly state that the
child’s lip, mouth, and buccal mucosa were normal. The cause of the remote pubic ramus fracture is not known. He had a witnessed fall down a flight of stairs at his grandparents’ home approximately 2 weeks before his death, and an earlier unwitnessed fall at a playground. One radiologist who reviewed the radiographs stated that the fracture had occurred at least 2 weeks prior to the death; a second said that the fracture occurred at least 4 weeks earlier. He never showed any signs or symptoms of a groin injury, and the fracture did not affect his ambulation. The chest radiograph
performed in the hospital did not show the rib fracture. However, the diaphragm partially obscured the rib, and plain films are insensitive to acute nondisplaced rib fractures. The contrastenhanced abdominal CT performed 2.5 h after admission to the hospital (3 h after the head injury) indicated no intra-abdominal bleeding, parenchymal lacerations, or rib fractures. Although the sensitivity of an abdominal CT for intra-abdominal blood is not 100% (12–15), this scan’s excellent technical quality and the extended time between hospital admission and the scan strongly suggest that the rib fracture, splenic laceration and hemoperitoneum occurred after it was performed. It was likely, based on all of the above considerations, that a single unidirectional force caused the head injury, allowing a reasonable nonabuse explanation to be considered.

Conclusion

Resuscitation injuries may be consistent with ‘‘a’’ cause of death independent of other pre-arrest trauma or natural disease. The untrained caretaker likely caused the hepatic and splenic lacerations in Case #1. Skilled hospital personnel likely caused the injuries other than the head and groin injuries in Case #2. Any of the injuries in Case #2 (lip lacerations; cutaneous contusions; rib fracture; retroperitoneal hemorrhage; and splenic laceration with intra-abdominal hemorrhage), if isolated, would have had a high likelihood of correct interpretation, especially if the medical record was examined and the hospital/prehospital personnel were interviewed. However, if the injuries in Case #2 are considered in total, it would be difficult to conclude that this was not a battered child and that the death was not due to abuse, especially with the background of a severe unexplained head injury. Excellent written and photographic autopsy documentation; correlation of the autopsy findings with the medical record by the autopsy pathologist in Case #2; verifiable social histories; and detailed medical and prehospital records made it possible to consider alternative explanations.
Resuscitation is an uncommon if not rare cause for significant injury in a child. Most cases that appear to be abuse are abuse. However, some are not. The only way to differentiate between the alternative conclusions is to consider the unique characteristics for each case. If there is new information, the conclusion must be reevaluated. To do otherwise is an injustice and may cause great harm.

Acknowledgments

To Michael Arnall, M.D., who assisted with Case #1; to Randy
Berman, J.D., Peggy Natale, J.D., and Scott H. Cupp, J.D., for the
courage to pursue truth rather than resolution; and to John E.
Smialek, M.D., who assisted with Case #2, and whose life was too
short. Conflicts: none. Sources of support: none.

References

1. Bush CM, Jones JS, Cohle SD, Johnson H. Pediatric injuries from
cardiopulmonary resuscitation. Ann Emerg Med 1996;28:40–4.
2. Spevak MR, Kleinman PK, Belanger PL, Primack C, Richmond JM.
Cardiopulmonary resuscitation and rib fractures in infants: a postmortem
radiographic—pathologic study. JAMA 1994;272:617–8.
3. Kaplan JA, Fossum RM. Patterns of facial resuscitation injury in infants.
Am J Forensic Med Pathol 1994;15:187–91.
4. Reardon MJ, Gross DM, Vallone AM, Weiland AP, Walker WE. Atrial
rupture in a child from cardiac massage by his parent. Ann Thorax Surg
1987;43:557–8.
5. Hulewicz B. Gastric trauma following cardiopulmonary resuscitation.
Med Sci Law 1990;30:149–52.
6. Waldman PJ, Walters BL, Grunau CFV. Pancreatic injury associated with
interposed abdominal compressions in pediatric cardiopulmonary resuscitation.
Am J Emerg Med 1985;2:510–2.
7. Corbett SW, O’Callaghan T. Detection of traumatic complications of
cardiopulmonary resuscitation by ultrasound. Ann Emerg Med 1997;29:
317–22.
8. Krischer JP, Fine EG, Davis JH, Nagel EL. Complications of cardiac
resuscitation. Chest 1987;92:287–91.
9. Beer S, Laver J, Karpuch J, Chabut S, Aladjem M. Prodromal features of
asthma. Arch Dis Child 1987;62:345–8.
10. Caffarelli C, Deriu FM, Terzi V, Perrone F, De Angelis G, Atherton DJ.
Gastrointestinal symptoms in patients with asthma. Arch Dis Child 2000;
82:131–5.
11. Ronchetti R, Villa MP, Matricardi PM, La Grutta S, Barreto M, Pagani J,
et al. Association of asthma with extra-respiratory symptoms in schoolchildren:
two cross-sectional studies 6 years apart. Pediatr Allergy
Immunol 2002;13:113–8.
12. Marx JA, Moore EE, Jorden RC, Eule J Jr. Limitations of computed
tomography in the evaluation of acute abdominal trauma: a prospective
comparison with diagnostic peritoneal lavage. J Trauma 1985;25:933–7.
13. Tsang BD, Panacek EA, Brant WE, Wisner DH. Effect of oral contrast
administration for abdominal computed tomography in the evaluation of
acute blunt trauma. Ann Emerg Med 1997;30:7–13.
14. Poletti PA, Wintermark M, Schnyder P, Becker CD. Traumatic injuries:
role of imaging in the management of the polytrauma victim (conservative
expectation). Eur Radiol 2002;12:969–78.
15. Nwomeh BC, Nadler EP, Meza MP, Bron K, Gaines BA, Ford HR.
Contrast extravasation predicts the need for operative intervention in
children with blunt splenic trauma. J Trauma 2004;56:537–41.

Investigations In Infant Death

INFANT DEATH INVESTIGATION

John Plunkett, M.D.

October 6, 1989
(Revised December 5, 2000)

Synopsis:

There are four objectives in every infant death investigation:
1. To differentiate a natural cause of death from one which may be accidental or homicidal;
2. To differentiate an accidental cause of death from one which may be homicidal;
3. To document injuries and preserve evidence if the death may require civil or criminal litigation; and
4. To document all data and observations supporting your conclusion.
The third and fourth goals are easily achieved with a camera, attention to detail, and a report written in Standard English using simple declarative sentences (subject, active verb, object, and no misplaced modifiers). The first and second may be more difficult, but are best achieved if you ask (and answer) four questions:
1. How old is the child?
2. Has there been family contact or involvement with child protection?;
3. Is the family unit functional or dysfunctional?; and
4. Does the child have any external injuries?
This discussion will stress the significance of the response to these four questions.

Introduction:

The Minnesota Legislature, during the 1989 session, directed the Minnesota Department of Health to develop uniform investigative protocols and guidelines for Coroners and Medical Examiners who conduct death investigations and autopsies of children under two years of age. The impetus for the bill was the inability of the Minnesota Department of Human Services Child Mortality Review panel to obtain essential information concerning the deaths of a number of infants, many certified as being due to Sudden Infant Death Syndrome (SIDS), who had been followed by local Social Services for a variety of reasons. The lack of basic data and/or a postmortem examination was, in some cases, appalling, especially considering the history of the child and his/her family.
The following guidelines address the legislative concerns and should assist professionals when investigating any infant death. The postmortem examination and the biographical and narrative portion of the investigative report should be complete. Correspondence, verbal or written, with any other investigating agency should be documented in the report or autopsy protocol. Color slides or prints should be used to document your findings at the death scene and during the
autopsy. Photographs at the death scene are mandatory if the death is suspected to be due to causes other than natural.

Investigation Guidelines

I. Investigative Report:

(Note: If the child was brought to a medical facility in a moribund state, the death scene is the home, child care center or other location where the fatal event occurred, not the emergency room).
A. Complete all biographical, technical, historical and dispositional information on a standard
investigative form, using the Hennepin County, Ramsey County or MRCO forms as examples.

B. Describe the general geographical setting of the home or other location where the body
was found, and compare the dwelling with others in the neighborhood.

C. Note the general condition, including temperature and cleanliness, of the residence or area
where the body was found.

D. Determine if there is evidence for a history of tobacco, alcohol or other drug use by the
parents or caretakers and describe drug paraphernalia you observe in the home.

E. Immediate death scene:
• Determine where the body was found.
• Describe the condition of the room where the body was found.
• Describe the condition of the bed or crib where the body was found (if applicable).
• State if there is blood, vomit, urine or feces on or near the body.
• State if there is evidence for alteration, addition of deletion of anything at the scene.
• State if there is any abnormal environmental condition in the residence or area where
the body was found, such as the room being very hot, very cool, or lacking ventilation.

F. Body:
• Describe the condition and position of the body as you first observed it.
• Record the temperature, if the body seems abnormally hot or cold.
• Record the extent of rigidity and lividity.
• Describe and retain the clothing worn by the child, including clothing removed before
you examined him/her.
• State if there is evidence for alteration, addition or deletion of anything on the body.

G. Immediate history (the terminal event):
• Determine the time and place the child was last seen alive, the time and place the body
was found, and the names of the people who last saw and found the body.
• Describe the precise location and position of the body when it was found, and the name
of the person finding the body.
• Describe any actions by any other person when the body was found, such as picking it
up, attempting resuscitation (details), or adding, deleting or altering anything on or
near the body. If the circumstances were altered, why and by whom were they altered?
• Determine the time and content of the last feeding.
• Describe the reaction of the parents or caretakers to the death.

H. Social History:
• Determine the parents’ ages, education, occupation, marital status and social habits (including
smoking, drinking, illegal drug use or periods in which the child was unsupervised),
and any recent changes in employment or living arrangements.
• Obtain the names and ages of other siblings.
• Determine if there has been a previous death or injury of a sibling (or other child if the
death occurred in a child care facility), a known significant familial disease, or a recent
illness in any other family or child care center member.
• Determine if there are any medications or toxic substances at the scene.
• Determine if there has been any contact by family, caretakers or other caregivers with
social services (including child protection) or law enforcement.

I. Medical History:

(Note: The medical history may be obtained from the parents, but must be confirmed by the family and child’s primary care physician(s).
• Determine the mother’s parity and gravidy, the length of gestation, the extent of prenatal
care, if there were any complications of the pregnancy, and if there was any
known or suspected drug use.
• Determine if the delivery was vaginal or a Cesarean section, if there were any complications,
and the Apgar score.
• Determine if the postnatal development was normal, if the child had well-baby checks
and received immunizations, and if he/she had any significant illnesses requiring prescription
medications or hospitalization.
• Obtain the height and weight as the last clinic visit, compare them with previous measurements,
and plot them on standard development chart.
• Determine if the child had any illness, change in appetite or feeding patterns, or change
in level of activity in the week prior to the death.

II. Postmortem Examination:

(Note: A complete postmortem examination is an essential part of any infant death investigation, and may be omitted only under extreme extenuating circumstances. Any autopsy must be performed if the family has had any contact with Child Protection Services of if there is any suggestion form the investigation that the death may be due to neglect, homicide or an injury. If a postmortem examination is not performed because of parental religious objections, and the death is suspected to be due to SIDS on the basis of the initial investigation, total body x-rays must be obtained and interpreted by a Board certified radiologist before the body is released, and vitreous, urine and blood must be saved).

A. Describe, photograph (35-mm format) and measure all areas of external and/or internal trauma.

B. Measure the crown-heel length, the head circumference and weigh the body, comparing the height and weight to those obtained at last clinic visit.

C. Obtain and have a board-certified radiologist interpret total body x-rays if any internal examination is not performed, if there is a history of child abuse or neglect in this child or a sibling, if the investigation or external examination suggests that the death may be an accident or homicide, or if you find any trauma during the internal examination.

D. Examine and describe the skin, muscle development and subcutaneous fat.

E. Examine the sclera, mouth, anus and vagina or penis for petechial hemorrhages or lacerations.

F. Examine the epiglottis, larynx and trachea.

G. Examine the coronary arteries, especially for an aberrant origin or absence of the right coronary artery.

H. Save representative pieces of the following organs for microscopic examination: heart (two), lung (three), larynx (cross section), thyroid, pancreas, adrenals, liver, spleen, thymus, kidney, bladder wall, medulla, midbrain and the base of the frontal or temporal lobe (including meninges). (Certain working diagnoses may dictate that other or additional sections be obtained, i.e., small bowel, skin, any area of external or internal trauma).

III. Microbiology:

Obtain an aerobic bacterial culture from any suspected parenchymal organ infection.

IV. Toxicology:

1. Measure the sodium and urea nitrogen in the vitreous if there is any evidence from the investigative or autopsy for dehydration or malnutrition.
2. Screen the urine for cocaine or other suspected drugs if the investigation suggests illicit
   drug use by the parents or caretaker. (Save approximately 20 gms of liver if urine is unavailable and the history suggests illicit drug use).
3. The pathologist doing the post-mortem examination will request other toxicological analyses or specimens.

V. Certification:

A. State “Sudden Infant Death Syndrome” if the investigation and postmortem examination confirm this diagnosis, and do not defer the death certificate for the autopsy microscopic examination.

B. List the cause of death in International Classification of Diseases’ terms (ICD) in non- SIDS deaths.

VI. Follow-up:

1. Make sure that you or the pathologist phone the parents (and child care center of other caretaker, if applicable) immediately after the autopsy to discuss your findings, inquire about the availability of a family support network, and inform them of the Minnesota Sudden Infant Death Center or other appropriate local support services.

2. Contact the Minnesota Sudden Infant Death Center for any infant death (612-813-6285).

Investigation Checklist

1. I. Investigative Report:

A. Is the standard investigation form complete? Yes___No____
B. General geographic setting of the home or other location where the body was found
________________________________________________________________________
C. General condition of the residence or area where the body was found
________________________________________________________________________
D. Alcohol and other drug use by parents or caretakers?
Suspected ______ Confirmed ______
Drug (s) ____________________________________________________________
If suspected, reason ___________________________________________________
If confirmed, by whom _________________________________________________
Whom is a suspected of drug use _________________________________________
Who is a confirmed drug user ___________________________________________
E. Immediate scene:
• Where in the residence was the body found __________________________________
• Condition of the room or area where the body was found ________________________
• Condition of the bed/crib where the body was found ___________________________
• Presence of blood: Yes _____ No _____
vomit: Yes _____ No _____
feces: Yes _____ No _____
urine: Yes _____ No _____
• Is there evidence for scene alteration? Yes _____ No _____
If “Yes”, describe_______________________________________________________
• Is there evidence for any abnormal environmental condition related to heating, cooling1
or ventilation? Yes _____No _____
If “Yes”, describe_______________________________________________________
F. Body:
• The position and location of the body when you first observed it __________________
______________________________________________________________________
• Body temperature _______________________________________________________
• Rigor: No ____ Extent _________________________________________________
MRCO: Infant death investigation guidelines Page 7 of 10
• Livor: No ____ Extent _________________________________________________
• Clothing, including any removed prior to your examination ______________________
______________________________________________________________________
• Is there evidence for alteration If yes, what? _______________________________
______________________________________________________________________
G. Immediate history (the terminal event):
• Last seen alive: Found:
Day/Date/Time: ___________________Day/Date/Time:__________________
Place: ______________________________Place:____________________________
By whom: ___________________________By Whom:_________________________
• Location of the body when it was found (precise):_____________________________
_____________________________________________________________________
• Any actions taken after the body was found, including attempted resuscitation, picking
up the body, or adding or removing anything on or near the body that altered the body
or the scene:___________________________________________________________
_____________________________________________________________________
By whom:______________________Reason given____________________________
• Time the child was last fed___________Source of this information________________
Content of the last feeding________________________________________________
• Reaction of the parents or caretakers to the death
H. Social History:
• Parents: Marital status _________________________________
Mother: Father:
Age ____________ Age ____________
Education______________________ Education______________________
Occupation _____________________ Occupation ____________________
Any recent changes in employment or in living arrangements of either parent or
caretakers __________________________________________________________
Any significant social habits of the parents or caretakers (such as smoking, drinking,
illegal drug use, or periods in which the child was unsupervised):_______________
• Siblings:
Name _________Age _____Name _________Age _____ Name _________Age _____
Name _________Age _____Name _________Age _____ Name _________Age _____
MRCO: Infant death investigation guidelines Page 8 of 10
• Other persons living with the child:
Name:________________________________Age______Relationship_____________
Name:________________________________Age______Relationship_____________
• Previous death or injury in the family:
Name:_______________________________Relationship:_______________________
Date:____________Cause of death:_________________________________________
• Known familial disease: Yes _____No ______What ________________________
Name of family member affected___________________________________________
Relationship to child___________________________________
• Any recent illness in a family member: Yes ______No ______
If yes, name of family member___________________________
Illness and date diagnosed_______________________________
• Any recent illness in any other person who was in contact with the child:Yes___No __
Name of person_________________________________________________________
Illness and date diagnosed________________________________________________
Means of contact _______________ Date of last contact________________________
• Medication(s) or toxic substances at the scene:________________________________
_____________________________________________________________________
• Is there any involvement by the family or the caretakers with child protection?
Yes_____No_____Agency________________________________________________
Reason for agency involvement with the family/caretaker________________________
• Is there any involvement by the family or the caretakers with any other social services?
Yes ____No_____Agency______________________________________________
Reason for agency involvement with the family/caretakers_______________________
_____________________________________________________________________
• Is there any involvement by the family/caretakers with law enforcement?
Yes____No___Agency__________________________________________________
Reason for agency involvement____________________________________________
_____________________________________________________________________
• Is there any involvement by another caregiver of the child with child protection, any
other social services, or law enforcement? Yes ____ No _____
MRCO: Infant death investigation guidelines Page 9 of 10
Agency_________________________Name of caregiver______________________
Reason for agency involvement___________________________________________
I. Medical History (provided by_________________________relationship_____________)
• Number of prenatal visits____Complications of pregnancy______________________
Drug exposure during pregnancy: Yes____No____
Type and name of drug_________________________________________________
Number of previous pregnancies ____ and previous live births ______
• Type of delivery: Vaginal____Cesarean_____Weeks gestation____
Complications of birth ______________Birth weight _______Apgar scores ________
• Date of last physician visit _________Reason_________________________________
Date of last well-baby check _____________________________
Immunizations up to date? Yes _____No _____
Was growth and development similar to other children of the same age?
Yes _____No _____Growth chart completed? Yes ____No ____________________
Was the child on any medications?Yes _____No ___
If yes, what medication(s)?____________________Last dose amount ___________
and time given ________________________________
Any recent respiratory symptoms Yes _____No _____
Any recent gastrointestinal symptoms Yes _____No _____
Any recent falls or injuries Yes _____No _____
• Last measured height ________Date __________
Last measured weight _______Date __________
(Plot all available weight, length and head-circumference data on growth charts)
• Recent illness or hospitalizations, changes in appetite, feeding patterns or level of activity
_______________________________________________________________
Medical history confirmed by the primary physician: Name___________________Date_______
Discrepancies______________________________________________________________
II. Postmortem Examination:
A. Describe, photograph (in 35 mm format) and measure all areas of external and/or internal
trauma.
B. Crown-heel length:_____Head circumference__________Weight_________
Comparison to the measurenients at the last clinic visit: ______________________
C. X-rays?
MRCO: Infant death investigation guidelines Page 10 of 10
D. Skin, muscle development and subcutaneous fat _________________________________
E. Sclera, mouth, anus and vagina or penis________________________________________
F. Epiglottis, larynx and trachea________________________________________________
G. Coronary arteries__________________________________________________________
Tissue for microscopic examination:
Heart (2) ___Lungs (3) ___Larynx (cross section) ____Thyroid _____Pancreas _____ Adrenal
____Liver ____Spleen ____Thymus ____Kidney _____Bladder _____
Medulla ____Midbrain ____ Base of the frontal or temporal lobe including meninges ____
Other, including any area of external or internal trauma __________________________
III. Cultures?
IV. Toxicology
A. Vitreous: Sodium ____Urea nitrogen ____if dehydration is suspected.
B. Urine screen for cocaine or other drugs if illicit drug use (or administration to the child) by
the parents or caretaker is suspected. Negative ___ Positive ___ Drug found ________
C. Save unfixed liver and kidney, refrigerated, for a minimum of 2 months if illicit drug use
may have caused or contributed to the death.
D. Save blood (red top tube) ____, urine ___, vitreous ____ and stomach contents ______for
a minimum of two months (refrigerated)
V. Certification: SIDS? _____ Non-SIDS? ______
VI. Follow-up:
A. Call the parents and the caretakers_____Date______________________
B. Call the Minnesota SIDS Center (612-813-6285) with the information on how the death
was certified _____Date ___________
Other/synopsis/impression:________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Source:

MRCO: Infant death investigation guidelines