Author: Shaun Webb

Shaun Webb is a class of 2018 medical student at Western University of Health Sciences in Pomona, California. He graduated from Weber State University with a B.S. degree in Medical Laboratory Sciences, and was born and raised in Kaysville, Utah. He loves playing any type of sport and getting outdoors to go camping and hiking.

Categories
Clinical

Journey to the Center of the Lab

What is a stat laboratory? As far as most doctors are concerned, the stat lab is a mysterious place, located somewhere in the dungeon of the hospital, wherein a slew of unkempt “lab people” feverishly work to turn tubes of blood into useful numbers in the electronic medical system. While this view is not a complete misconception, I do think it would be constructive to provide a quick overview of how exactly these labs work, and how they fit into the overall healthcare picture.

There are two kinds of laboratories in the healthcare world: reference laboratories and stat laboratories. Reference laboratories perform high-volume, routine (non-time sensitive), specialized testing on samples sent from outpatient clinics and hospitals. These labs are generally located away from hospitals, in their own buildings, so they may have the extra space required to house highly specialized testing equipment and personnel. The downside to these labs is that the “turnaround time” for tests is slow (many hours to days), both because they are located offsite and because the specialized tests may take much longer to run. On the other hand, stat laboratories are smaller labs located on site in order to perform time sensitive (“stat”) tests. Although not very many highly specialized tests are available from these smaller labs, they provide all the basic testing necessary to support the emergency room and inpatient floors in a hospital, with turnaround times usually under an hour. Considering my work experience has been entirely at stat laboratories, I will focus on them in this article.

Stat labs have understandably become a staple in ERs and hospitals around the world because they quickly provide vital information about patients, allowing doctors to plan proper treatments in the short term. I mean, sure, you might be fairly certain that your patient has DIC, but wouldn’t it be nice to have a positive D-dimer to be sure?

First off, what is actually considered a laboratory, and how can you be sure the lab at your hospital isn’t churning out garbage? Well, according to the Centers for Medicare and Medicaid Services (the governing body for laboratories in the U.S.), the law requires:

“all facilities that perform even one test. . . on ‘materials derived from the human body for the purpose of providing information for the diagnosis, prevention, or treatment of any disease or impairment of, or the assessment of the health of, human beings’ to meet certain Federal requirements.”

I find it comforting that people (who are not me) dedicate their careers to quality control. Incorrect results lead to inappropriate treatment, which can have disastrous consequences on patient care. As such, each lab has its own quality control (QC) program in place, which includes running instrument calibrations/QC daily and monitoring the results over the short and long term. Much of the labor in the lab is dedicated to QC; in fact, depending on the test, the daily calibration and running of QC samples for one test can take the better part of an hour, and that’s if all the samples come into range as they are supposed to.

QC is the only way to be sure test results coming off the analyzer are accurate and precise. It is an unforgivable sin to release patient results when QC has failed, even when the other members of the healthcare team are adamant about getting the test results now. If QC has failed, all the results from that instrument are garbage until QC comes back in. Period.

Most stat laboratories are divided into roughly the following departments: hematology, urinalysis, chemistry, microbiology, blood bank, coagulation (PT/PTT), immunology, and specimen processing. In smaller labs, there are “float” lab techs who work in all of these departments. In larger labs, the techs are usually more specialized and stay in one department.

When, in this computerized day and age, an ER doctor puts an order for a blood test into the electronic medical system, the phlebotomist receives the draw order (if the nurse isn’t going to draw it). The draw order is usually a printed label, with the patient information, orders, and tube types listed on it. The tube type is very important; each colored tube contains specific additives tailored to certain tests (a CBC is run on a “purple top” tube with EDTA as the anticoagulant, etc.). Additionally, some tests require special handling (e.g. “on ice”) or can’t be opened until just before the test is run, as is the case for ionized Calcium.

The phlebotomist then goes to the ER, draws the blood, and transports it back to the lab. The specimen processor will then double-check to make sure all has been collected correctly, and mark in the system that the tubes have been received. At this point, the tubes diverge. The “red top” or “yellow top” tubes, which have no anticoagulant in them, must be set aside to be allowed to clot before being put into the centrifuge. The anticoagulated chemistry and coagulation tubes are thrown into the centrifuge and spun immediately to separate the RBCs, WBCs, and platelets from the plasma. The hematology tubes, which are also anticoagulated, are not spun, but put directly on the analyzer as whole blood.

After the proper tubes have been placed on the proper analyzers, most tests are automatically run and resulted. Exceptions to this include: a) chemistry results that are above the linear range of the instrument need to be diluted and re-run, b) blood slides that the hematology analyzer flags for tech review need to be looked at under the microscope, and c) the results that are critical values need to be called in. A critical value is the cutoff value at which the tech must call up to the patient’s nurse or doctor and report it. For example, the cutoff for a low potassium level may be <2.6 mEq/L at a particular lab, so if a potassium level of 2.4 comes off the machine, it cannot be resulted in the computer until the tech has verbally passed the information along to the direct caregiver. This is done because critical values are deemed dangerous enough that the doctor must know about it as soon as possible so as to treat it immediately.

After all the tests have been reported out, the tubes are taken off the analyzers and saved for a week in the refrigerator. This is necessary in case additional orders are added on later, or the patient dies and the medical examiner needs the blood, or to troubleshoot in the case of mislabeled specimens, etc.

And that’s the lab, at least the basics. Is it less mysterious now? I hope so.

 

Featured image:
The Chemistry Of Inversion by Raymond Bryson

Categories
Clinical Reflection

Working Miracles With Gravity

Before medical school, I worked as an assistant at the clinic of a physical therapist. Half of the physical therapist’s business was bread-and-butter physical therapy, but the other half was vestibular rehabilitation. The therapist specialized in diagnosing and treating balance and dizziness disorders of the inner ear. And guess what? Most of his patients were there as a last resort, because the doctors and their drugs weren’t working. They had fallen through the cracks, and the tragedy is that the most common cause for their dizziness is easily treatable, in 5 minutes, with only a table and some body positioning.

Benign paroxysmal positional vertigo, or BPPV, is caused by rogue calcium carbonate otoliths. These otoliths escape from the utricle of the inner ear and make their way into the semicircular canals (usually the posterior semicircular canal). These otoliths cause aberrant movement of the fluid in the semicircular canals with changes in head position, confusing the brain, which is getting mixed signals about the body’s orientation in space from the right and left semicircular canals. Predictably, the brain’s confusion manifests as vertigo, which  defines as “an illusion of self or environmental motion.”

Patients with BPPV suffer from sudden dizzy spells triggered by changes in head position, usually lasting 15-20 seconds. Movements like looking up, rolling over in bed, or getting up out of bed in the morning set the world spinning, often with an accompanying nausea. As you can imagine, these patients do everything they can to minimize their head motion. They move in a characteristically rigid fashion, keeping their heads as still as possible in order to avoid repeat attacks. Clearly, this is an extremely unpleasant condition; one that is experienced at least once by 2.4% of the population. The good news, however, is that it is easily treatable, as long as it is recognized.

A certain amount of diagnostic finesse is required to rule out central nervous system problems, but once the proper neurological exams have been performed, BPPV should be high on the differential for patients with the symptoms described above. The test for BPPV is called the Dix-Hallpike Maneuver, in which the practitioner provokes a dizzy spell by changing the patient’s head position and observing the eyes for nystagmus.

Once a diagnosis has been made, treatment consists of The Epley Maneuver, which is nothing more than a simple series of head and body positions designed to use gravity to reposition the rogue otoliths into the utricle where they can no longer confuse the brain by moving semicircular canal fluid inappropriately. When the patients I saw were cured of their vertigo so quickly, with such a simple technique, they wasted no time in hailing the physical therapist I worked for as a miracle worker. They had been miserable for months, and that’s all it took to fix it?? In these situations, the patients were always ecstatic. I couldn’t help but smile.

As we go into rotations, residency, and practice, I hope we will be able to catch these patients before they fall through the cracks. My purpose in writing this article is to get the word out , because it is so easily treatable without the use of expensive, ineffectual, toxic medications. All we have to do is recognize it when we see it. As an added benefit, maybe someone will call you a miracle worker one day.

References
http://vestibular.org/understanding-vestibular-disorders/types-vestibular-disorders/benign-paroxysmal-positional-vertigo
Harrison’s Principles of Internal Medicine, 19th Edition, Chapter 28
http://www.neurology.org/content/70/22/2067.long

Featured Image:
Vertigo by Diana Mehrez

 

 

Categories
Humour Lifestyle

Study Strategies: The Good, The Bad, and The Ugly

The Tortoise
The tortoise is in it for the long haul. He studies for a fixed amount of time, every day. He has a routine. He never has to worry about cramming or catching up, because he’s always on top of things. The med school years for him are simple years; he studies and refrains from indulgence. Indulgence is too time consuming, and throws him off his rhythm. “If I party on Friday night,” he says, “then how will I get up at 6:30 to study on Saturday?”

The Hare
The hare is usually a social butterfly. So much energy, and so productive . . . in spurts. But the hare also enjoys taking time for herself. She takes evenings or maybe even whole days off studying. If she didn’t do this, she would fall victim to the dreaded burnout. At least that’s what she tells herself. Although she is often behind, her ability to catch up is second to none. Many of us have probably heard the adage that it’s impossible to cram in medical school. Well, not for the hare. Cramming for the hare just starts a few days earlier than it did in college. It really is impossible to cram for a neuro test the day before the test, but it is possible to pull 3 consecutive 20-hour cram days and still do well. As for long-term retention, who knows? Only boards will tell.

The Moocher
The moocher is lazy. He keeps to himself most weeks. He does not make study guides or contribute to anyone else’s learning. If at all possible, he will not show up to lecture. When a test is not looming, he can be found in his underwear at home, drinking beer and cruising the interwebs. Then, when a test looms near, he breaks free from his filthy cocoon of lethargy and can be seen on campus and social media snatching up all the condensed study guides everyone else in the class has made in the previous weeks. The moocher usually does okay on the tests, but one wonders how he will perform during rotations and residency when he does not have such helpful resources on hand.

The Memorizer
The memorizer is the queen of facts. Her ability to absorb large tables of seemingly random bits of information is unparalleled. While some may struggle to recall even the names of different medications, the memorizer will calmly recite all of the generic drug names, all of the brand names, how to spell them, how each of them is metabolized, their side effects, and which are contraindicated under what circumstances. She can do this after only going over the material once. Her classmates are in awe of her. Truly she is blessed.

The Reader
The reader… reads! Truly he is a rarity in our times. While he abhors the brute memorization of random facts, he loves to read textbooks. Bringing together a large body of knowledge into a logical system is what the reader enjoys most. He is a systematic learner who loves finding out how the little details fit into the bigger picture. The reader also must have strong shoulders, for textbooks are not known for being lightweight.

The High Yielder
The high yielder is focused first and foremost on the next exam. Perhaps it is a flaw, or maybe just an efficient allocation of her resources, but the only thing she cares about is information likely to be on the next test. She might be heard on campus saying something resembling the following: “Did the professor say that’s going to be on the test? No? Then I’m punting it. I’ll learn it later for boards if I have to.”

The Recluse
The recluse is only seen on mandatory days. Nobody really knows what he does. The only thing known for certain is that he does not go to class or social events. He doesn’t have a Facebook, and certainly shuns the company of others when he is forced to be on campus. The recluse may either be an actual loner, who would much rather be alone than in a group, or he may just be an older, married father of 3 who spends his time with family and studying at home. Either way, whenever he shows up, everybody turns and whispers to each other “Who IS that? Is he in our class?”

The Deity
The deity is revered by all. She is at the top of the class. Her study methods are mysterious. She somehow gets top scores on tests, actively participates in multiple clubs, is on student government, volunteers regularly at free clinics, and conducts research. She has a strong presence at social events and on social media. All of the students and professors adore her. Many have tried to discover her secret, but it remains a mystery. The current hypothesis is that she only sleeps 3 hours per night.

Featured image:
Studying in Starbucks by Nicola Sapiens De Mitri

Categories
General

Neurology and Us: What Are Our Minds?

Conceptual side profile of a human face, with see through illustration of the brain.

As medical students, we have to take many classes. Some of them are relatively easy, and some of them are hard. One class notorious for being very difficult is neurology. Despite this, though, I find neurology to be one of the most fascinating subjects we study. Think about it: everything we call “us” arises somehow out of vast networks of interconnected neurons. It is mind-blowing to even begin to contemplate the complexity of the neuronal machinery responsible for such tasks as creating our thoughts, emotions, personalities, etc. etc.

For millennia, philosophers have been attempting to accurately describe what it is to be human without the aid of neuroscience. Only recently has neuroscience been added into the mix of this speculation; the first notable contribution of neuroscience to theories of mind appeared in 1949 as Donald Hebb’s book The Organization of Behavior. For the first time in a major publication, a neuroscientist postulated that it was possible for the purely physical processes of neuronal circuitry to explain psychological phenomena like states of mind and learning. Before the advent of neuroscience, learning was considered a psychological phenomenon, and any attempt to explain it in detail had no recourse to neurophysiology. Now, learning is taught in medical school curricula as at least partially due to changes in both presynaptic and postsynaptic neuron adaptations (changes in neurotransmitter release rate in the presynaptic neuron and long term potentiation in the postsynaptic neuron). This represents a paradigm shift in the way we think about ourselves. Is learning the only psychological phenomenon explainable by changes in neurotransmitter release and altered receptor densities? Are all aspects of our minds the result of nothing but extremely complex neuronal circuitry?

Proponents of a theory termed eliminative materialism believe all of the commonly held beliefs about our minds will soon be replaced by neurophysiological explanations at the level of neuron circuitry. As the Stanford Encyclopedia of Philosophy puts it in the entry on the philosophy of neuroscience:

“Eliminative materialism (EM) is the conjunction of two claims. First, our common sense ‘belief-desire’ conception of mental events and processes, our ‘folk psychology,’ is a false and misleading account of the causes of human behavior. Second, like other false conceptual frameworks from both folk theory and the history of science, it will be replaced by, rather than smoothly reduced or incorporated into, a future neuroscience. . . according to EM, continuing development in neuroscience will reveal that there are no such things as beliefs and desires as characterized by common sense.”

Will eliminative materialism turn out to be the correct account of our behavior? Who knows? The debate rages on. Neuroscience continues to uncover more physical processes underlying the way we experience the world, but competing theories claim the irreducibility of our experiences to mere materialistic phenomena. Even if I could, for example, fully explain the state of your nervous system down to the smallest detail after you learned of the passing of your loved one, does that mean I really know what you’re feeling? Does a specific brain state actually equate to an emotion as we experience it as conscious beings? I don’t know, that’s above my pay grade, but it’s fun to think about, isn’t it?

Source: Stanford Encyclopedia of Philosophy

Featured image:
object. by Evan

Categories
Clinical Reflection

Chronic Fatigue Syndrome

The year was 2011 and I was an undergraduate student at Weber State University in Ogden, Utah. I was on the premed track and looking for doctors to shadow and research to participate in. I was also working part time at a physical therapy clinic and one day I started a conversation with one of the patients. After hearing a little about my interests and career goals, she became enthusiastic about introducing me to her doctor who was conducting research on chronic fatigue syndrome.   I had never heard of the syndrome, but I was eager to take on any new medical experience and jumped at the opportunity. One week later I found myself at the clinic of Dr. Lucinda Bateman in Salt Lake City.

After meeting with Dr. Bateman and discussing chronic fatigue syndrome, I followed her throughout her day and sat in on several appointments. Because chronic fatigue syndrome is a relatively unknown condition, Dr. Bateman and her patients were strong advocates of educating as many people as possible about the condition, including me.

Many of the patients shared their stories with me. One woman I remember vividly: she was quite thin with short cropped hair and wore a smart business suit and trendy glasses. The immediate impression I had when I saw her was that she was someone who got things done. Her story was heartbreaking. I listened as she described her life before chronic fatigue syndrome and how she was a “go, go, go” person. She worked full time, ran long distance races, and was active in every sense of the word. Then, one day, she could not get out of bed. Her muscles ached intensely despite the fact that she had not exercised the day before. She was debilitated by an intense fatigue she could not overcome. These symptoms lasted for days before she scheduled an appointment with her primary care doctor. All the tests came back negative and she was prescribed bed rest, which did not resolve any of the fatigue or pain.

I could tell as she was recounting her story that she was trying not to become emotional. She was still experiencing the fatigue and recalling the activities she used to enjoy was difficult for her. I felt I could begin to understand some of what she was going through, because I could remember how cripplingly fatigued I had been when I had contracted infectious mononucleosis as a teenager.   I could not imagine having to deal with that kind of fatigue for months or years on end.

After shadowing Dr. Bateman, I went on to finish my undergraduate degree and was accepted into medical school. I heard nothing of chronic fatigue syndrome for years. In February, 2015 I was surprised to see that NPR had published an article on the syndrome. The article was written to cover a new report published by the Institute of Medicine. The report legitimizes chronic fatigue syndrome (known as myalgic encephalomyelitis in Europe), establishes  new diagnostic criteria  , encourages more research into pathophysiology and treatment, and recommends that the name of the disease be changed to Systemic Exertion Intolerance Disease (SEID).

According to the report, “between 836,000 and 2.5 million Americans suffer from myalgic encephalitis/chronic fatigue syndrome,” and the hallmark of the disease is “a substantial reduction or impairment in the ability to engage in pre-illness levels of occupational, educational, social, or personal activities, that persists for more than 6 months and is accompanied by fatigue, which is often profound, is of new or definite onset (not lifelong), is not the result of ongoing excessive exertion, and is not substantially alleviated by rest.”

As we go through medical school and enter practice, I think it is a good idea to be on the lookout for these patients. I highly recommend reading the report for educational purposes, especially since, according to the report, less than one-third of medical schools educate their students about chronic fatigue syndrome and fewer than half of medical texts mention it. The disease is poorly understood, but increased awareness and future research may help fill in our knowledge gaps and assist in finding effective treatments for those who suffer from chronic fatigue syndrome.

Read the NPR article: “Panel Says Chronic Fatigue Syndrome Is A Disease, And Renames It”

Read the Institute of Medicine report “Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Redefining an Illness”

Featured Image:
cfs by Jem Yoshioka

Categories
General Opinion

Be Kind to Your Med Techs (And Everybody Else)

Before I was accepted to medical school, I was a medical technologist. This basically means I worked in the laboratory at a large hospital. I was playing one of the “behind the scenes” roles that many of us probably played while we were getting the medical experience required to get into med school.

Med techs are the people who run the CBC’s, comprehensive metabolic panels, amylases, lipases, pregnancy tests, urinalyses, cross-matches, etc. etc. ordered by the doctors. Usually, I was in direct contact with the nurses and doctors, who either called my line directly or came down to the lab if something needed to be clarified or a specimen needed to be delivered.

I’ll tell you right now the difference between a good day and a bad day at work. Two factors contributed: how swamped we were with patient samples, and how good of a mood the doctors/nurses were in (I say “doctors/nurses” because the moods of these two groups of people usually parallel each other quite well on any given day, and often the doctors communicate to other staff through nurses).

Of course, no matter what part of healthcare you work in, there are going to be days when the patients just don’t stop coming and you can’t catch a break. That’s unavoidable; the only thing you can do then is pray to the all-powerful but oft malicious gods of healthcare for some sort of respite.

But the second factor is something you and I can do something about as future doctors. I don’t know what your feelings are on “Reaganomics” (a.k.a. “trickle-down economics”), but I can tell you for sure that “trickle-down attitude” is most definitely a thing. If a doctor has an ungrateful, self-important, entitled, or simply negative attitude, then all of the people that doctor works with will absorb that negative energy.

As a med tech, I absorbed plenty of this negativity while working long night shifts. I’ve been yelled at for not having the test results of an order that was never put in. I’ve been hassled unnecessarily for CSF WBC counts before the tubes had even gotten to the lab. I’ve been berated by frazzled nurses because I needed them to get me a redraw due to hemolysis. Every time this happened, it shifted my stress and discontentedness level up a notch. It only takes a few notches to ruin an entire shift,and a few bad shifts in a row can cause burnout to quickly sink in. Work becomes death. Getting out of bed before a shift becomes nigh impossible. It gets more and more difficult to be fully engaged at work, which increases the likelihood of errors.

It’s not just med techs, either. The same thing happens to all allied health professionals. Phlebotomists, X-ray techs, radiology techs, nurses, CNA’s, orderlies, and even janitorial staff are affected by how the doctors in the facility are acting. Whether we like it or not, being a doctor means being a leader. So please, I beg you: be kind to your med techs (and everyone else).

 

Featured image:
Work Hard And Be Kind Wallpaper by Clay Larsen

Categories
Forensics

Forensic Pathologists: Public Servants

In this second part of my three part series on forensic pathology, I will be exploring the role of the forensic pathologist in society at large. Of all the specialties, forensic pathology seems to be largely ignored and/or unknown to the medical students I have met. Certainly, the prospect of working with dead patients doesn’t appeal to the majority of medical students, but hopefully a review of what forensic pathologists do will remind everyone that we should not take for granted the important social role they fill. In her book Postmortem: How Medical Examiners Explain Suspicious Deaths, Stefan Timmermans puts it the following way:

“Death is not an individual but a social event. When, with a barely noticeable sigh, the last gasp of air is exhaled, the blood stops pulsating through arteries and veins, and neurons cease activating the brain, the life of a human organism has ended. Death is not official, however, until the community takes notice.”

Many practicing physicians are surprisingly hazy on the subject, which becomes a problem when these physicians improperly fill out death certificates (a common occurrence which drains public resources to straighten out) or fail to recognize deaths as suspicious and warranting investigation.

Medical examiners are usually certified forensic pathologists who have been appointed to the medical examiner position as an employee of the government. They serve a vital role in the government’s public health systems; if a public health danger emerges of an unknown nature and is killing members of the community, who better to solve this pressing puzzle than a medical examiner? When death occurs under unexpected or unknown circumstances, i.e. when it is suspicious, then the probability that a public health danger is lurking about increases. If we don’t know why people are dying, how do we know who is at risk? How can we mitigate the threat? It is the responsibility of the medical examiner to figure this out, whether the threat is a murderer, an infectious disease, a faulty product on the market, etc.

When death occurs under certain circumstances, the body and investigation come under the jurisdiction of the medical examiner. In fact, by law (in San Francisco at least), a medical examiner must investigate the following types of deaths: violent, sudden, unusual, unattended by a physician in the last 20 days or with no medical history, related to an accident (either old or recent), homicide, suicide, due to an infectious epidemic, anything due to criminal acts, all deaths in operating rooms or following surgery or a major medical procedure, all deaths in prisons, jails, or of a person under the control of a law enforcement agency. Some of these categories are purposefully vague, in order to encourage doctors and other agencies to contact the medical examiner if the death is questionable in any regard whatsoever.

Medical examiners have the responsibility to unearth public health threats as they investigate all of these unusual deaths. For example, it was medical examiners who helped identify the mysterious and deadly powder distributed through the U.S. Postal Service in 2001 as anthrax, and who determine infant deaths are caused by defective cribs on the market, and who do the initial work in identifying infectious disease epidemics.

Bacillus anthracis
A photomicrograph of Bacillus anthracis bacteria using Gram-stain technique, courtesy of Centers for Disease Control and Prevention’s Public Health Image Library (PHIL)

Clearly, forensic pathology is essential in maintaining a safe and just society in modern times. Well trained medical examiners performing top-notch forensic work ensures the timely, correct identification of threats to the community. Their role as public servants should never be taken for granted. They may work behind the scenes, but their work is necessary for our society’s high standards of well-being.

 

Featured image:
the colour of blood by anjamation

Categories
Forensics Law

Forensic Pathology and Death Investigation in the United States

This piece is the first in a three part series on Forensic Pathology in the United States. I will focus on how death investigation works in this country, the critical role physicians play in the process, and how to fix the enormous shortcomings of our current system.

It is perhaps necessary to begin by distinguishing medical examiners from coroners. Coroners do not have to be medical doctors in most states, and are usually elected. Typically a sheriff or another member of law enforcement fills the role of coroner. The requirements for being a coroner vary, but in most states no intensive training is required. For example, in California (where I live), a coroner must take a 2 week course, after which he or she may write death certificates in traumatic injury cases. Coroners do not perform autopsies, but do have the final say regarding the cause of death. They may or may not send bodies out to contracted pathologists for autopsies, and may or may not follow the recommendations of the pathologists who perform the autopsies.

A medical examiner is, by definition, a medical doctor. He or she is usually board certified in forensic pathology with the American Board of Pathology. Becoming board certified requires 4 years of medical school, plus a 3-4 year residency in anatomic pathology, plus a one year fellowship in forensic pathology. Once this extensive training has been completed, the individual may perform autopsies and present evidence as a medical expert in a court of law.

In 2009, the National Academy of Sciences released a report entitled Strengthening Forensic Science in the United States:  A Path Forward, which outlines how death investigation in the United States is conducted. The report begins in the following manner: “Recognizing that significant improvements are needed in forensic science, Congress directed the National Academy of Sciences to undertake the study that led to this report.” Clearly, the government saw that there was a need to look into the way forensic science is practiced. As it stands, each state and each county has a different system put in place for death investigation. The following map shows this patchwork of systems:

coroners_map_624-984843ef9bf65fc47d2a04b4ae952caf047bfae6-s800-c85
Photo courtesy of NPR

 

Unfortunately, this means that where an individual dies determines the quality of investigation into his or her death. Many factors contribute to the quality of the investigation, including whether there is adequate funding for the coroner and/or medical examiner’s office, and whether the physician performing the autopsy happens to be board certified in forensic pathology. There are no national standards for this; the National Academy of Sciences report mentioned above states that “the hodgepodge and multiplicity of systems and controlling statutes makes standardization of performance difficult, if not impossible.” There is no proficiency testing for the individuals who carry out these investigations, which results in incompetent practitioners being able to work unnoticed for decades.

Occasionally, court cases with heavy media coverage will bring the glaring need for standardization front-and-center. Horror stories abound about lost body parts, bullet holes being overlooked, wrongful convictions, murderers walking free as a result of botched autopsies, etc.

In cases involving police brutality, conflicts of interest often arise because elected coroners usually have strong ties to law enforcement. If an individual in custody is beaten to death, or if there is a police shooting similar to the one making headlines now in Ferguson, Missouri, do we really want the person in charge of the body and/or in charge of the entire death investigation to be an ex- or current police officer?

PBS Frontline: Post Mortem aired in 2011 and took a look at the problems mentioned above. This program featured two forensic science professionals who shared their opinions about the deplorable state of death investigations in the United States:

“In this country, many medical-legal offices are producing garbage.”
-Vincent Dimaio, M.D., former Chief Medical Examiner, San Antonio, TX


“It amazes me that such an important aspect of our government as medical-legal death investigation doesn’t have accreditation.”
-Ross Zumwah, M.D., Chief Medical Examiner, New Mexico

Clearly, we need to improve on our processes, and as future physicians and citizens we need to understand the importance of forensic pathology and death investigation, for the sake of our communities at large and for the sake of the families of those who have passed away. Our patients do not stop being our patients after they pass away; everyone deserves the right to a proper investigation surrounding the circumstances of their death.

Featured image:
Forensics – Spurensuche by Margrit

References:
http://www.whitehouse.gov/sites/default/files/microsites/ostp/NSTC/forensic_science___may_2014.pdf
http://www.pbs.org/wgbh/pages/frontline/post-mortem/map-death-in-america/
http://www.pbs.org/wgbh/pages/frontline/post-mortem/
https://www.ncjrs.gov/pdffiles1/nij/grants/228091.pdf
https://www.youtube.com/watch?v=yFPW016ocXI/