Office of the Chief Medical Examiner (OCME) Flu Issues

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Office of the Chief Medical Examiner(OCME)Flu
Issues
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Objectives

• Explain OCME jurisdiction
• Describe OCME responsibilities
• Explain how OCME works with many partners
• Discuss unresolved issues for OCME

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What Part does the OCME Play?

• 32..1-283 outlines the jurisdiction of the OCME
• The OCME is charged with the medicolegal
  investigation of deaths that are sudden and
  unexpected or violent.
• Jurisdictional categories are listed

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Jurisdiction
Deaths in these categories

• Trauma
• Violence
• Poisoning
• Accident
• Suicide
• Unusual
• Cremation/
• burial at sea

• Homicide (All Terrorism)
• Unnatural manner
• Sudden in apparent good
• health
• Unattended by physician
• In jail, prison, in custody
• State Mental Health
• patients

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Natural Death v Natural Event

• A natural event is a happening such as hurricane
  or earthquake and may cause unnatural accidental
  deaths due to drowning, blunt force, CO poisoning
  from generators, cave-in etc. These are by
  statute, medical examiner cases
• A natural death is due to a natural disease
  process arising out of the ordinary course of an
  individuals life e.g. diabetes, cancer, ASCVD,
  COPD
• Pandemic flu is a natural disease occurring under
  natural circumstances provided terrorism is
  excluded.

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Jurisdiction

• Under ordinary circumstances, if a disease is
  naturally occurring, resulting from the normal
  course of evolution, the deaths are natural
  deaths and are NOT Medical Examiner cases the
  OCME has no jurisdiction over natural deaths even
  if the numbers are large.
• E.g. Flu is naturally occurring and deaths are
  natural
• E.g. Smallpox is not naturally occurring and
  deaths are unnatural because it is most likely a
  bioterrorism agent making smallpox deaths
  homicides.

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Jurisdiction
However, there are a few special circumstances
that may make a death due to a naturally
occurring biologic organism, - bacterial or
viral -, that might bring the death under the
jurisdiction of the OCME
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OCME - Natural Deaths under Special
Circumstances

• Example Pandemic flu
• The OCME would take jurisdiction when
• Suspected first native case of pan flu - to
  establish by culture the first presence of the
  disease in Virginia
• Suspected pan flu death in a poultry worker to
  prove flu was contracted from poultry
• Flu in a poultry workers family to establish
  person to person transmission of pan flu has
  occurred

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OCME - Natural Deaths under Special
Circumstances

• Pan Flu suspected in a foreign traveler from a
  place where flu is present
• A Virginia native who was at risk for flu because
  of travel to a place where pan flu is present
• If, the first diagnosed case in a hospital needs
  documentation of the virus in tissue for presence
  in the community
• Otherwise, flu deaths are not ME cases

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OCME Unnatural Deaths

• If the disease is a result of
• a terrorist act - death is a homicide due to a
  biological bullet
• an accidental release from a lab death is an
  accident
• purposeful suicide by a terrorist in the course
  of spreading the disease death is a suicide
• All of the above are unnatural deaths and subject
  to ME jurisdiction

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OCME Missions

• Determine the cause of death the disease,
  injury or poison causing the physiological death
  of a person
• Determine the manner of death the circumstances
  under which death occurred Natural, Accident,
  Suicide, Homicide, Undetermined

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OCME Missions

• Collect medical evidence hairs, fibers, bullets
  and cultures (under certain circumstances)
• Reconstruct how injury occurred body position,
  distance of GSW etc.

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OCME Isolation and Quarantine Responsibilities

• The State Health Commissioner may impose
  quarantine under 32.1-45
• The Medical Examiner does not determine who or
  how persons are placed in isolation and/or
  quarantine.
• However, if a person should die while in a
  isolation or quarantine situation, the OCME role
  will be determined by the contagiousness of the
  agent (smallpox, Ebola v flu), the origin of the
  agent (terrorism v natural) and the circumstances
  of its spread (natural, homicide by terrorism,
  accident, suicide)

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Management of the Hazardous Body

• 32.1-288.1 empowers the State Health
  Commissioner to determine if a body is hazardous
  to the public health and enables the Commissioner
  to identify and make a respectful final
  disposition
• This section utilized only for bodies too
  dangerous for anyone to handle in large numbers,
  e.g. Ebola, other hemorrhagic fevers

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Who Signs the Certificate of Death?

• VA Code requires a physician who treated a
  patient to sign the death certificate for a death
  due naturally occurring diseases. 32.1-263)
  within 24 hours of death.
• The medical certification shall be completed,
  signed and returned to the funeral director
  within 24 hours after death by the physician in
  charge of the patient's care for the illness or
  condition which resulted in death except when
  inquiry or investigation by a medical examiner is
  required by 32.1-283 or 32.1-285.1.
• Certificates filed in Vital Records promptly so
  families can settle estates and receive benefits.

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Certification of Death

• Who signs if there are large numbers of natural
  deaths?
• The attending physician
• May be the ER physician who, if after history and
  physical of a living patient who dies while being
  treated, is satisfied death is due to flu
• An associate physician
• Chief medical officer of the institution in which
  death occurred
• Physician who performed an autopsy on the
  patient

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Working with Partners EMS, Law Enforcement

• OCME relies upon first responders/ receivers to
  notify ME of cases that are possibly ME cases
  (including Epi).
• OCME will work directly with Police forensic and
  investigative divisions as usual for violent
  deaths (Unified Command)

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Working with Partners Hospitals and Law
Enforcement

• Hospitals/Community resources are tasked with
  holding bodies locally if deaths are natural
  until kin claim them Hospitals should notify
  police if the body is unidentified
• Police are tasked in cooperation with hospitals
  to establish identification by usual means
  viewing or fingerprints

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Working with Partners Hospitals and Law
Enforcement

• If bodies remain unidentified after documented
  diligent hospital and police search for several
  days, notify the OCME who will be responsible for
  further identification efforts
• OCME will authorize transport to a OCME district
  office or regional morgue

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Working with Partners Medical Dental Community

• For longer term unidentified bodies medical/
  dental treatment agencies can assist the OCME
  under HIPAA exclusion with
• Antemortem medical records
• Antemortem radiographs
• Antemortem dental records
• Next of kin information

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Working with Partners Law Enforcement

• If bodies are identified but unclaimed after
  diligent documented search for next of kin,
  notify the Sheriff of the jurisdiction of death
  for final disposition 32.1-288
• The identified but unclaimed are not medical
  examiner cases

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OCME role in Outbreak

• Accept identify and/or determine the first
  outbreak cases for public health purposes.
• Certify those who die at home without an
  attending physician or whose attending is not
  licensed in Virginia
• Accept and assist in identification of the dead
  if the local police cannot do so with
  investigation and fingerprinting.

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Unresolved IssuesManagement of Large Numbers of
Bodies

• Local natural deaths should stay local for the
  convenience of hospital, family, funeral
  directors and police
• Question is surge capacity for holding bodies
  close to home
• If number of identified bodies are huge,
  localities need to integrate local resources

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Unresolved IssuesManagement of Large Numbers of
Bodies

• Local hospitals, nursing homes, police, funeral
  directors, vital records, health departments,
  social services and others need to work together
  to
• Augment local hospitals and overworked funeral
  homes, cemetarians with refrigerated holding
  capacity
• Identify regional locations/refrigerated trucks
  for storing and cooling bodies until kin can
  claim
• Number bodies. and track release to kin

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Primary Objectives

• Primary objectives are to secure remains until
  funeral homes can catch up with final
  dispositions on the local natural deaths and
  until -
• The OCME can establish an incident morgue to
  manage its usual caseload of day to day deaths,
  any bioterrorism deaths, and the unidentified
  bodies.

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Summary

• ME jurisdiction over dead bodies depends on the
  nature of the infectious agent and the
  circumstances under which it spread
• ME accepts suspected index or first cases to
  establish presence of agent in Virginia
• ME accepts bodies that are unidentified after
  diligent local search by hospital and police
• ME accepts deaths at home with no attending
  physician