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INTRODUCTION Once
again a depressingly long interval has elapsed since our last general
communication with you. This was partly the result of the budgetary
restrictions we have had to work with given the current economic
downturn and state revenue shortfall, partly due to significant
personnel changes within our own office, and at least partly also
due to our own inertia.
We have had a number of significant changes in our senior pathology staff within the last year. In December 2001, Dr. Robert Thompson, our Deputy Chief and head of the pathology branch retired after 20 years of service. Dr. Thomas Clark has moved into the position of Deputy and Chief of the pathology branch. Dr. Karen Chancellor left in November of 2001 to attend graduate school in medical informatics. Dr. Deborah Radisch who had in the past been a full time pathologist with our office but had been serving as the Medical Director of our State Child Fatality Prevention Team while providing part-time weekend coverage stepped into Dr. Chancellor’s position to once more become a full time pathologist. She will continue to oversee the operation of our State Child Fatality Prevention Team and the OCME’s commitment to assist in the effort to reduce the number of deaths in infants and children. We have been fortunate to obtain the services of Dr. Aaron Gleckman to fill our vacant senior pathologist position. Dr. Gleckman is a graduate of Columbia and the University of Massachusetts Medical School. He did his pathology residency and fellowships in Neuropathology at the University of Massachusetts, Columbia and Brown respectively. His forensic fellowship was at the Massachusetts Chief ME Office. He worked in Santa Clara, California for a year before returning east to be with us. Our “Fellow” this year is Dr. Maryanne Gaffney-Kraft. Dr. Gaffney-Kraft was a Fellow in Forensic Pathology at Wake Forest last year and was kind enough to agree to spend an additional year as a “Super-Fellow” with us. Our Fellow from the year before, Dr. Kenneth Snell, has moved to Charlotte to take a full time job within the Mecklenburg County Medical Examiner’s Office. As a result of the increased revenues generated by the OCME secondary to the autopsy fee increase of several years ago we have been able to add a pathology position to the Charlotte office and are now routing cases for autopsy from the surrounding counties of Union, Stanly, Anson, Cabarrus and Rowan to the Charlotte facility. Medical Examiners from those counties are now contacting Charlotte rather than Chapel Hill to arrange for postmortem exams. We are particularly pleased that Dr. Snell has in this fashion remained both within our state and active in the Medical Examiner System. In the toxicology laboratory, Dr. Diana Garside, who obtained her PhD from the University of London (England) and did a post-graduate fellowship at the University of Florida in Gainesville, has just joined us to serve as laboratory manager. Since our last communication Mr. Glenn Cutler who had assumed the position as our Administrator left to take a different position in Raleigh and now is the State Registrar, the head of Vital Records. Ms. Pat Barnes who for years served as our Case Management Supervisor is now our Administrator. Another momentous change in the office came with the retirement of Mr. Ron Boone, Autopsy Facilities Manager. Ron joined the office in 1973 and in recent years in addition to duties at the OCME had been active in DMORT. He gave a report on his involvement in the repatriation of washed out human remains during Hurricane Floyd at one of our recent medical seminars. Mr. Kevin Gerity has moved into the position of Autopsy Facilities Manager and we are in the process of completing staffing in that area.
Communication dilemmas in the aftermath of Hurricane Floyd a few years ago and the more recent anthrax episode that involved North Carolina has made it abundantly clear that our ability to assist in the public health response required in mass disasters and/or other terrorists incident is hampered by our inability to communicate with all of you on a real time basis. To this end we will be stepping up our campaign to be able to reach all of you electronically - ideally through e-mail but failing that through fax. We have been asking you for both fax numbers and e-mail addresses in our appointment and reappointment applications and further urge those of you who acquire these capabilities between appointment renewals to pass this information on to us. The OCME pathology staff has found these e-communications a convenient way to communicate with MEs referring cases for autopsy and many of you are already receiving toxicology results in this manner. We will be further exploring the possibility of making the ME Report of Investigation itself an electronic form.
Effective as of August 1st, 2000, the fee for a medical examiner certification prior to cremation was raised from $35 to $50. Some funeral homes and crematories are still apparently unaware of this change and we are learning that many medical examiners as well were not familiar with it. Please remember that medical examiner authorization for cremation is not needed in those instances where deaths are certified by an attending physician and occur in a licensed hospital, nursing home, or while under the care of a licensed hospice, or when a body is donated to the Commission of Anatomy or any of the medical schools for dissection purposes. Additionally, if you have already certified the death as a medical examiner, that is, on a Medical Examiner Death Certificate, no additional authorization for cremation is needed. If you are approached in regard to authorizing a cremation for someone who died outside of North Carolina, you should consider whether, had the death occurred in North Carolina would it have required medical examiner authorization? If it was in a category that would have been excluded from ME review in North Carolina, you should apply the same rules to the out of state death. It would not require ME authorization simply because the death occurred in another state.
We are deeply saddened by the recent death of Art McBay, our first Chief Toxicologist. Dr. Page Hudson, after becoming North Carolina’s first Chief Medical Examiner in 1968, recruited Dr. McBay from Massachusetts, where he had headed the State Police Crime Laboratory. He was the Chief Toxicologist for the OCME from 1969 to 1989 and was instrumental in bringing quality forensic toxicological services to the State of North Carolina. Dr. McBay was active nationally within the forensic toxicology community and had served as the president of the Society of Forensic Toxicologists (SOFT). He remained active following his retirement regularly attending professional meetings and taking occasional consultations. He would, from time to time, drop by the OCME to check for misdirected mail and regale us with a good story. Art was a pre-eminent practitioner in his field as well as a fine gentleman with a good sense of humor. We shall all miss him.
The currently accepted criteria for the diagnosis of Sudden Infant Death Syndrome (SIDS,) include: the unexpected death of a child less than 1 year of age in which a complete autopsy examination has failed to identify a specific cause of death, for instance congenital heart disease, pneumonia, or evidence of trauma. The circumstances under which the child’s death occurred must be evaluated and this must include an understanding of the physical location of the child at the time its body was discovered with no evidence to implicate positional asphyxia as a cause. An inquiry into the medical and social history of both the child and its family should be conducted to eliminate factors that may be inconsistent with the diagnosis of SIDS such as a history of previous SIDS death in the family. We also feel it is inappropriate to render a diagnosis of SIDS except in those instances when the death has occurred during a period of sleep. The typical presentation for Sudden Infant Death Syndrome is a child approximately 2 to 4 months of age who is fed, put down to sleep and then found to be unresponsive when next checked by the caretaker. The most important cause of death in children of this age that must be ruled out is positional asphyxia. Infants are particularly vulnerable to respiratory compromise if they become wedged between mattresses, or mattress and walls, or entrapped by other means in bedding. Since it is usual for a child to be removed from where it is first discovered unresponsive it is critical to carefully inquire into the exact position of the child at the time of its initial discovery and if necessary actually examine the bedding to understand that positioning. Asphyxiation should only be designated the cause of death when the positioning clearly has the potential for respiratory compromise. Simple entanglement in ordinary bed clothes or blankets is not felt to be sufficient for asphyxiation whereas entanglement in an impervious material such as a plastic bag or the tight twisting of some object around the neck could be reasonably inferred to have compromised respiration. Sleeping face-down, particularly face-down in soft bedding has been implicated as a risk factor for SIDS but the presence of a child face-down in soft bedding does not merit a diagnosis of suffocation. We do not believe that simply lying down on a soft yielding surface such as a pillow or water bed is alone sufficient to cause suffocation unless the material pressing against the child’s face is impervious to the passage of air. Another common situation encountered in sudden unexpected infant deaths is co-sleeping. While it was at one time felt that children could/would not be asphyxiated in this fashion, this view is no longer accepted. Conversely, it is not appropriate to designate an infant death as due to asphyxiation/overlying simply because the child was in bed with another individual at the time that it died. We would reserve the diagnosis of overlying for those instances where an individual is found lying on top of or over the deceased infant or where the individual admits to having rolled over on the infant. The size of the individual in bed with the infant as well as the size of the bed itself should be taken into account. There is certainly a much greater likelihood for overlaying when a child is on a couch with an obese individual than when an adult of ordinary size is present with the infant on a queen size bed. Unless there is some other historical or environmental factor of concern present a death that otherwise meets the criteria for SIDS should not be classified as overlaying or undetermined simply because the child was in bed with another person.
When the death of an unidentified individual falls under your jurisdiction it is reasonable to delay notifying the OCME of the remains while an initial inquiry into identity is conducted locally. If, however, after several days the body remains unidentified you should contact the OCME. We will make sure that in all such instances the remains get fingerprinted and the fingerprints submitted both locally and nationally, that adequate photographs for identification purposes including facial and tattoos or other unusual features, x-rays, dental charting, and samples for potential DNA testing are obtained. Most inquiries in regard to unidentified remains and missing persons come through the OCME so it is important for us to have all the pertinent identifying information here within the central case file. Mr. Clyde Gibbs, our investigator and anthropologist, is the person to contact for such cases and to make arrangements for disposition or transfer to the OCME.
Pathologist on call (24 hours) (800) 672-7024
600
copies of this public document were printed at a cost of $112.71,
or 19 cents per copy. 11/02 Office
of the Chief Medical Examiner
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