SWIFS Office of The Medical Examiner General Policy and Procedures, 128 Pages (01.03.2008)

This is an uncontrolled copy of a controlled document
SOUTHWESTERN INSTITUTE OF FORENSIC SCIENCES (SWIFS)
OFFICE OF THE DALLAS COUNTY MEDICAL EXAMINER (DCME)
GENERAL POLICIES AND PROCEDURES
Institute of Forensic Sciences Office of the Medical Examiner
1/03/08
**************************************************************** This manual is meant as a general guideline to policies and procedures of the Medical Examiners department of the Southwestern Institute of Forensic Sciences. It is beyond the scope of the manual to go into detail on all procedures, which continually have minor changes. DCME cases are handled on an individual basis, and may not always follow the procedures described here. If there are procedural changes that need updating, or errors found in the manual, please bring them to the attention of the Administrative Secretary or Dr. Spotswood. The manual will be periodically updated and reprinted, with the original signed copy kept by the SWIFS Quality Manager. A current version will be kept in the Field Agent area with the Dallas County Policies and Procedures manual and other related manuals and reference materials. *******************************************************************
Reviewed and approved: __________________________________ Chief Medical Examiner
___________________ Date
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CHAPTER 1 INTRODUCTION CHAPTER 2 FIELD AGENTS I. II. III. IV. V. VI VII. VIII. IX. X. XI. XII. I. II. III. IV. V. IX. I. II. III. IV. V. VI. GENERAL POLICY JURISDICTION / TYPES OF CASES TRANSPORTATION OF BODIES BODY TAGS IDENTIFICATION NOTIFICATION OF NEXT-OF-KIN CASE FILE INVESTIGATION PROCESSING MEDICATIONS, EVIDENCE, AND PERSONAL EFFECTS RELEASE OF INFORMATION / MEDIA CONTACT / REQUESTS FOR REPORTS DISPOSITION OF UNCLAIMED AND UNIDENTIFIED BODIES MISCELLANEOUS DUTIES BODY ACCEPTANCE PROCEDURES BODY IN BODY RELEASE PROCEDURES "BODY OUT" BODY TRANSFERS FROM PARKLAND, CHILDRENS AND LIPSHY MORGUE VEHICLE PROCEDURES SECURITY/SAFETY PROTOCOL / PROFESSIONAL CONDUCT GENERAL BODY RECEIVING FIELD AGENTS INVENTORY PROPERTY RELEASE MEDICATIONS PATHOLOGISTS
1.1 2.1 2.1 2.1 2.4 2.5 2.6 2.7 2.7 2.8 2.14 2.15 2.16 2.19 3.1 3.1 3.4 3.6 3.7 3.7 3.8 4.1 4.1 4.1 4.1 4.3 4.4 4.4 5.1 6.1 6.1 6.1 6.1 6.2 6.3 7.1 8.1 8.1 8.2 8.3 8.6 8.6 8.6 8.7 8.9 8.9
CHAPTER 3 BODY RECEIVING AND RELEASE
CHAPTER 4 PERSONAL EFFECTS
CHAPTER 5 AUTOPSY TECHNICIANS CHAPTER 6 PHOTOGRAPHY I. II. III. IV. V. GENERAL POLICY HEALTH AND SAFETY FIELD AGENTS / SCENES AUTOPSY REQUESTS FOR PRINTS
CHAPTER 7 PATHOLOGISTS CHAPTER 8 RECORDS / REPORTS / RELEASE OF INFORMATION I. II. III. IV.` V. VI. VII. VIII IX. RELEASE OF INFORMATION PHOTOGRAPHS DEATH CERTIFICATES UNPENDING/AMENDING DEATH CERTIFICATES CAUSE OF DEATH REPORTS CREMATION PERMITS AUTOPSY AND EXTERNAL EXAMINATION REPORTS AUTOPSY (LEVEL I AND II) AND EXTERNAL EXAMINATION FEES NOTIFIABLE DISEASES
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CHAPTER 9 DESCRIPTION OF INJURIES I. II. III. IV. V. I. II III. IV. V. VI. VII. VII. IV. GUNSHOT WOUNDS SHOTGUN WOUNDS STAB WOUNDS BLUNT FORCE INJURIES STRANGULATION FINGERPRINTS AUTOPSY / INSPECTION / FORM 16 GUIDELINES X-RAY AUTOPSY PROCEDURES / EVISCERATION TOXICOLOGY REFERRAL LABORATORY ANALYSES HISTOLOGY CULTURES CHROMOSOME ANALYSIS 9.1 9.1 9.3 9.4 9.5 9.6 10.1 10.1 10.2 10.3 10.4 10.6 10.8 10.9 10.10 10.10 11.1 11.1 11.2 11.2 11.3 11.3 11.4 11.5 11.5 11.6 11.6 11.7 11.8 12.1 12.1 12.3 12.4 12.4 12.5 12.5 12.6 12.6 12.7 12.8 13.1 13.1 13.1 13.2 13.2 13.3 13.3 13.4 14.1 14.1
CHAPTER 10 ROUTINE HANDLING OF CASES
CHAPTER 11 EVIDENCE COLLECTION AND SUBMISSION I. GENERAL II. BLOOD/DNA III. HEAD HAIR STANDARDS IV. FINGERNAIL CLIPPINGS V. SEXUAL ACTIVITY KIT VI. BITE MARKS VII. TRACE EVIDENCE VIII. CLOTHING IX. HEAD HAIR FOR GUNSHOT RESIDUE X. PROJECTILES XI. GUNSHOT RESIDUE KIT XII. TOOL MARKS CHAPTER 12 SPECIFIC TYPES OF CASES I. II. III. IV. V. VI. VII. VIII. IX. X. I. II. III. IV V. VI. VII. I. HOMICIDES SUICIDES TRAFFIC AUTOPSIES AIRCRAFT ACCIDENTS OTHER ACCIDENTS FIRE DEATHS CUSTODY DEATHS/POLICE SHOOTINGS SUDDEN INFANT DEATH SYNDROME (SIDS) UNIDENTIFIED BODIES SKELETONIZED REMAINS HOSPITAL CASES- GENERAL INFO FIELD AGENTS BODY RECEIVING AND RELEASE PATHOLOGY RESIDENT / MEDICAL EXAMINERS AUTOPSY TECHNICIANS RECORDS/REPORTS PRIVATE CASES DEMONSTRATION OF THROMBI IN THE CALVES
CHAPTER 13 HOSPITAL / PRIVATE CASES
CHAPTER 14 SPECIAL PROCEDURES
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II. III. IV. V. VI. I. II. III. I. II. III. IV. V. VI. VII. VIII. IX. X. I. II. III. IV. I. II. DEMONSTRATION OF PNEUMOTHORAX DEMONSTRATION OF AIR EMBOLISM REMOVAL OF THE SPINAL CORD FIXATION OF THE BRAIN REMOVAL AND EXAMINATION OF EYES TRANSPLANTATION RESEARCH / OTHER DONATION RELATED LAWS GENERAL INFECTION TRANSMISSION INFORMATION UNIVERSAL PRECAUTIONS KNOWN INFECTIOUS AND HAZARDOUS CASES OCCUPATIONAL INJURY AND EXPOSURE CHEMICALS FIRE/EMERGENCY EVACUATION ELECTRICAL SAFETY RADIATION SAFETY BIOLOGICAL AND HAZARDOUS WASTE DISPOSAL SECURITY GENERAL PAYROLL/COMPENSATION UNIVERSITY OF TEXAS PERSONNEL ETHICS EQUIPMENT STAFF 14.2 14.3 14.5 14.6 14.6 15.1 15.1 15.3 15.4 16.1 16.1 16.2 16.4 16.5 16.6 16.7 16.8 16.8 16.8 16.9 17.1 17.1 17.1 17.3 17.3 18.1 18.1 18.2
CHAPTER 15 ORGAN AND TISSUE DONATION
CHAPTER 16 SAFETY
CHAPTER 17 PERSONNEL
CHAPTER 18 QUALITY ASSURANCE
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APPENDICES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Consultants Lists Conference Schedule Dental Charting Transplantable Tissues Donor Criteria Notifiable Conditions Toxicology Lab: Toxicology Testing Overview Processing of Highly Infectious or Contaminated Bodies Records Storage Protocols Autopsy Report Release Practices Guidelines for Hospitals and Physicians
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CHAPTER 1 INTRODUCTION The Dallas County Medical Examiners Office (DCME) is a department of the Southwestern Institute of Forensic Sciences (IFS or SWIFS), an agency of Dallas County also affiliated with the University of Texas Southwestern Medical School at Dallas. Authorization for a County Medical Examiner is provided by Article 49 of the Texas Code of Criminal Procedure, which allows and in some cases requires the transfer of inquest duties from the Justice of the Peace to a Medical Examiner. A Medical Examiner is a physician trained in forensic pathology, which involves the investigation of sudden, unexpected, violent, suspicious, or unnatural deaths. The Institute is responsible for the investigation of all these deaths that occur in Dallas County, and is also involved in the investigation of similar deaths in other counties at the request of the local authorities. The following list is a guideline of the types of deaths that must be reported to our office: 1. 2. All cases in which the deceased is dead on arrival (DOA). Cases in which an individual expires within 24 hours following admission to the Emergency Room or hospital. 3. When death is, or is suspected to be, from accidental, suicidal, or homicidal causes, no matter how long the person has been hospitalized, or has survived the injuries. The time span may run from minutes to years. 4. Cases of anesthetic death, including those under the initial induction and those who do not recover following anesthesia. 5. Deaths that occur during, following, or as a result of any diagnostic or therapeutic procedure in the hospital. 6. Any death where the disease process responsible is either work-related or suspicious of being aggravated or accelerated at work. 7. All deaths of children under the age of six, including neonates. 8. Stillbirths when maternal injury has occurred or is suspected either prior to admission or during delivery. 9. Maternal deaths, whether during or following delivery and including any death where abortion is suspected. 10. The death of any person in custody or confinement. 11. Any death known or suspected to be due to drug or other substance abuse. Upon notification of the death, the Medical Examiners office will determine if the case is properly included under the Medical Examiners Law (See Field Agent Section). Just because a case has to be reported, it does not mean that the body will be brought to the office; at the very least a report will be generated to document the call. Furthermore, the decision to bring a body to the office does not imply that an autopsy will necessarily be performed. Autopsies are performed when the Medical Examiner determines there is a medico-legal requirement which can only be satisfied by autopsy. An autopsy will not be performed simply because the attending physician refuses to sign the death certificate or wants to know the extent of the natural disease process. The Institute's medical examiners have the authority to perform autopsies when a death occurs in the jurisdiction of Dallas County, or on cases from outside of Dallas County with a written order from the Justice of the Peace. Family permission is not required, although, in some cases, if a family is strongly opposed to
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autopsy or needs one to be performed quickly, their wishes will be considered. The Southwestern Institute of Forensic Sciences at Dallas is composed of two departments, the Office of the Medical Examiner and the Criminal Investigation Laboratory. These are briefly summarized below: Institute of Forensic Sciences Director and Chief Medical Examiner: Jeffrey J.Barnard,MD A. Medical Examiner Section: Chief Medical Examiner, Dr. Jeffrey J. Barnard Deputy Chief Medical Examiner, Dr. Joni McClain This Section includes several separate areas: Field Agents, Pathologists (includes medical examiners), Autopsy Technicians, Transcriptionists, Records Staff, and Administration. Most of these will be explained in more detail in later sections of this manual. B. The Criminal Investigation Laboratory has two Sections, each with their own Chief, who reports to Dr. Barnard. 1. Physical Evidence Section: Timothy Sliter, Ph.D. Section Chief. This section performs criminal investigative laboratory services for the Medical Examiner Section and a large number of other agencies, including crime lab work for the Dallas County police departments and district attorney's office. These departments and some of their responsibilities are: a. Trace Evidence - Includes such examinations as gunshot residues, accelerants, pepper spray analysis, collection of some body specimens from suspects, and microscopic comparison of hairs, fibers, paints, and glass. b. Forensic Biology performs examinations of sexual activity kits and includes the DNA lab, which performs extraction, analysis, and comparison of DNA from wet or dried blood, semen, and saliva of suspects and victims. c. Firearms - Evaluation of all projectiles removed from bodies, bullet and cartridge case comparisons, examination of suspect weapons, tool mark comparisons, and, in some cases, gunshot residues. 2. Drug and Environmental Toxicology Section: Elizabeth Todd, Ph.D., Section Chief. The laboratory is divided into three sections. a. Toxicology Laboratory - Performs testing of biological
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samples for drugs, metals, electrolytes, alcohols, volatiles, and other substances. This section will also send out samples to private laboratories for testing not done at IFS. This section primarily serves the Medical Examiner's Office but also provides analyses for various outside agencies. b. Drug Laboratory - Performs analysis of solid dosage capsules, tablets, powders, liquids in syringes - and plant materials. A small percentage of the caseload is submitted by the medical examiner's office as material found at the scene or with a body. Other samples are submitted primarily from local law enforcement agencies. Breath Alcohol Section - Provides training of officers in the operation of breath alcohol equipment, supervision of operation of breath alcohol equipment, maintenance of equipment, and testimony regarding alcohol intoxication in courts.
c.
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CHAPTER 2 FIELD AGENTS I. General Policy
The duty of the field agents, or medico-legal death investigators, is to obtain and communicate correct and accurate information, in a professional manner, for the advantage and benefit of the medical examiners, authorities, bereaved families and the general public. Their primary responsibility is to investigate all deaths that fall under the medical examiner jurisdiction. They staff a 7-day, 24-hour office and make a series of decisions relating to the disposition of a body. The information provided here is primarily policy, with most procedural details available in other resources in the field agent office. II. Jurisdiction / Types of Cases
A list of the types of cases that are reported to the DCME office is in chapter 1. Texas law requires that any person who becomes aware of a death that may fall into the ME Case guidelines may make the notification to our office. When a death is reported to our office (usually by hospital personnel or police at the scene), the Field Agent has three primary options: CASE , NO CASE, and NON-REPORTABLE. If there is any question as to this choice, a supervisor or medical examiner may be called for consultation. The decision as to what case category to assign a death report may not always be made immediately, but may depend on further investigation, including potentially a scene investigation. All cases reported to the office get a case report, whether a No Case (NC#), Case (#, JP#, AB#, or AF#), or Non-Reportable (NR#). Occasional cases will be brought in for a private or hospital autopsy, due to DCME s affiliation with UT Southwestern Medical School. See the separate chapter on Hospital and Private Cases for more information. Field agents will be involved in any body that is brought to DCME for any reason. If a call is received from someone asking general questions about the reporting requirements for educational purposes, without referencing a specific case in question, no report needs to be made. 1. NON-REPORTABLE If a case is called in to DCME then discovered to not fulfill any of the state criteria for reportable cases, a Non-Reportable (NR#) case report should be made. The report may be brief, and the paperwork is handled in the same way as the No Case reports. Even though DCME has no jurisdiction, this will allow a record of all deaths that have been reported. 2. NO CASE The NO CASE option is used for deaths that fall into any part of the reportable guidelines, but when DCME releases the body to the funeral home of the next of kins choice. The DCME policy is that a NO CASE must fulfill all of the following criteria: A. Death by natural causes, with no history of or suspicion of trauma that could be related to the death.
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B. C. D. The attending physician possesses a valid medical license (Texas license required except for Veterans Administration doctors), and must be willing and able to sign the death certificate. Death must have occurred within the jurisdiction of the inquest authority (Dallas County). The death is not considered in-custody. A death in jail or considered in-custody that otherwise fulfills No Case criteria might be made an Absentia (AB) case, but can not be a No Case.
Texas state law requires that all deaths that are not natural causes be certified only by a medical examiner or justice-of-the-peace. Even if the death certificate is properly completed by the reporting physician, it will not be accepted by Vital Statistics and will be sent to us if that physician marks a manner or includes any causes of death other than natural. Several conditions are often thought of by the reporting physician as adequate natural causes for a No Case, but are actually not acceptable without further explanation. For example, organ failure is not a cause but a mechanism of death, and needs to be due to an acceptable cause of death (ex., liver failure due to chronic alcoholism, or heart failure due to hypertension). Acute liver or renal failure suggest toxins, so need more history to explain them as natural. Chronic failure, however, tends to be natural. Intracranial (within the cranium) hemorrhage is non-specific and must have further clarification. Epidural, subdural, and subarachnoid hemorrhages suggest trauma, but may be natural, for example, if due to ruptured aneurysm or vascular malformation. Hemorrhages within the brain may be traumatic, but are often spontaneous, i.e. intracerebral, cerebellar, or brainstem hemorrhages = hemorrhagic stroke or CVA, often due to hypertension. Some cases reported because of trauma might still be natural and No Cases, such as someone who falls and receives a fracture and whom the doctor believes died of natural disease not related to the injuries. Circumstances and/or history developed during the investigation may cause a death, which fulfills all of the above No Case criteria, to be classified as a CASE. Although a body may be released as a No Case without examination, the Office of the Medical Examiner cannot release jurisdiction in any case reported for any reason (except those that are actually Non-Reportable). At the very least, a No Case or Non-Reportable information report will be generated when the DCME is notified of a death. These NC and NR reports are reviewed regularly by the medical examiners, approved, and kept on file. The medical examiner may choose to change a No Case into a Case if further investigation is needed or an M.E. signature is required on the death certificate. If the case fits the No Case criteria, and the person has a Veterans Administration or Parkland Memorial Hospital medical history which indicate that a VA or PMH doctor should sign the death certificate, the case should be made a No Case and an attempt should be made to identify the attending physician. If the doctor refuses to sign when they should, the field agent supervisors or DCME administration can arrange later to subpoena the doctor or make the case an Absentia if necessary. Some cases may be assigned No Case status after attending the scene, if circumstances are appropriate.
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No Cases must include at least the following information. In the narrative, explain all the details of the death. Identify the doctor who has agreed to sign the death certificate, and the cause of death that will be certified. For justification, explain why the case was not made a Case. The No Case reports are placed as they are completed into the designated area for collection, review, and approval daily by a medical examiner. 3. The CASE option allows several variations. These include: a. Dallas County Case (no prefix before the case number): Any reportable death that occurs in Dallas County and does not meet all the requirements of a "No Case" will be accepted as a medical examiner case, and generally the body will be brought to our office (exceptions - absentia and after the fact, see below). This includes all deaths involving trauma or suspected trauma, custodial deaths, deaths where the cause of death is unknown, any suspicious death, and suspected SIDS cases. The field agent should never speculate whether or promise that an autopsy will or will not be performed. The decision to perform an autopsy or external examination will be made by the medical examiner. b. Out-of-County Case (prefix JP): This is any body sent to the DCME office by another inquest authority (generally a Justice of the Peace). The authority must send a completed and signed written court order for the autopsy. If an autopsy is performed, it will always be a complete autopsy; partial autopsies cannot be requested. The reporting authority should be told to have the body placed in a body bag prior to transportation to DCME. More information on the investigation, reporting, etc. of the two previous categories of cases follows in the rest of the chapter. c. Absentia case (prefix AB): The prefix "AB" is to be assigned to those cases in which the field agent elects to release the body without causing it to be viewed by the medical examiner, but in which the inquest authority (DCME) is required to certify the cause of death. The "AB" prefix indicates that the death was reported to the Medical Examiner's Office in a timely manner, and that it was the Medical Examiner Office making the decision not to view the body. AB cases include some natural deaths where there is good history but no current doctor to sign the death certificate, and may include a few trauma cases such as PMH burn patients and elderly hip fracture patients. Deaths in jail custody may on occasion be AB cases when they are due to documented natural disease with an extended hospital course. Most traumarelated deaths, even with prolonged survival and injury documentation, including motor vehicle collisions and subdural hematomas, are brought in as a regular case. It is imperative that the circumstances be clearly determined and that adequate clinical history be available before it is decided to handle these deaths "in absentia".
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Some cases may be assigned AB status after attending the scene, if circumstances are appropriate. Homicide or suspected homicide cases are never to be handled "in absentia", regardless of the time interval or medical documentation. When completed, the AB case reports are given to a medical examiner for review and death certification. Although this is generally an assigned doctor, the reports should never just be left for a doctor without confirming their presence. The papers should include the AB/AF page, the typed field agent report, the death certificate including the case number, labels, and any appropriate medical records. d .After The Fact Case (prefix AF): The prefix "AF" is to be assigned to those cases which were not reported to the Medical Examiner's office in a timely manner, and the body was released by the hospital or other facility without medical examiner notification and authorization. Generally, notification of the Medical Examiner's office is made by the funeral home when no physician may be located to sign the death certificate, or when the Registrar of Vital Statistics rejects an improperly certified death certificate. Examples include when a physician has included a hip fracture or subdural hematoma due to falls. AF cases include the same paperwork and are handled in the same way as the previously described AB cases. In most cases, the medical records are reviewed and the death certificate is issued without requiring an exhumation. 4. HOSPITAL / PRIVATE CASES Cases which do not fall into any of the previous categories, and which are brought into DCME for autopsy include St. Paul and Zale-Lipshy cases being brought for an autopsy to be performed by a Parkland pathology resident under the supervision of a medical examiner, and outside cases brought for a true private autopsy performed by a pathologist for a fee and at no expense or time to Dallas County. See the separate chapter for details on these types of cases. III. Transportation of bodies
Field Agents coordinate the transportation of bodies to DCME, through the contractor specified by Dallas County. The contractor also delivers other items such as medical records, clothing, and blood samples that are with the body. The field agents may grant approval to the contract transfer service for the transportation of more than one body (never more than two) in the same vehicle. When a county transfer service double load arrives, the field agent tags the bodies (one or both) if they were not already tagged at the scene by a field agent. The field agent initials the toe tags and the Body In and Out logbook. Field agents do not have to tag bodies during checkin from double loads transferred by DCME employees (PMH, CMC, or Zale Lipshy), out-ofcounty cases, or if both bodies were already tagged at the scene by a field agent.
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It is the field agents responsibility to follow up on all cases to ensure that bodies are made available for pick-up in a timely manner. A chaplain is generally the contact person at hospitals. For cases from Parkland Hospital, Zale-Lipshy, and Childrens Hospitals, the field agent usually notifies the pit boss who notifies the autopsy technicians to pick up these bodies. For Parkland cases, the pit boss or technician should not be notified until we have received Parklands body release form, and it can be given to the autopsy technician to take with them for body pick-up. If more than one body is ready, the decision of whether or not to double load them can be made by the transferring technician. The techs also usually pick up the hospital charts and belongings on most of these cases. Parklands policy, however, is to release the charts only to field agents. Original hospital blood may also be picked up by the technicians, but is usually picked up later by a field agent (see Investigation Reports later). If the autopsy technicians are unable to go get a body (e.g., staffing or vehicle problem), the pit boss or other medical examiner may authorize the field agent to utilize the transport service. Transportation of bodies coming from Zale-Lipshy or St. Paul for a hospital autopsy is arranged by the ordering hospital; see separate chapter on Hospital Cases. All bodies are to be placed into body bags prior to transport to DCME. The field agent may remind transport services delivering bodies from other locations of this requirement. The name of any decedent known to be coming to DCME should be written in the Funeral Home book. This is for all bodies coming here, whether a case or not, from any location, and no matter who is delivering them. A Body Disposition form also has to be started on any body coming to DCME, as well as other forms, depending on the type of case, as discussed elsewhere. IV. Body Tags
Identification tags are to be made by the field agents for all bodies coming to the Medical Examiners Office. The tags must include the DCME case number, name, age, race, and sex of the decedent if known, and should be written with a pointed felt tip pen or other large pen, in a manner that will be legible in the body photographs. If the field agent goes to the scene, the field agent must place the tags on the body before leaving the scene. The tags should be placed on the body as follows if possible: one tag on a toe/foot/ankle area or wrist and one tag at the foot end of the body bag. Clothing should never be removed to attach a tag. If none of these areas on the body are available, one tag can be tied onto another area of the body if possible (or clothing, only if no place on the body). The tag on the bag should be at the foot end so it is easily identified later in the DCME cooler. If the field agent does not go to the scene, the prepared tags are placed in the plastic tray in the elevator. Except for cases arriving without prior notice, the body tags must be available to the receiving area prior to the arrival of the body to facilitate the receiving process. For drop-in cases, the tags should be completed by the field agent upon arrival of the body. Special tags are required by state law to be used in cases with certain known or suspected communicable diseases (see Ch. 16, Known Infectious and Hazardous Cases). Red tags are used for unknown bodies. If the body has a tentative identification, it is still tagged and entered into the report as unknown until identification is made positive.
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V.
Identification
The DCME uses several methods to establish identification, including: -Identification at the death scene by the family, friends or someone who knew the decedent (e.g. supervisor, apartment manager); -Hospital identification worn by the decedent, with documentation in the case file of how that identification was originally made (i.e., by the NOK at the hospital); -Visual comparison by the DCME of identification paperwork present on the decedent; -Transport service identification, which typically is identifying tags placed on the decedent by the service transporting the body to the DCME facility (e.g., Justice of the Peace cases often are identified in this manner); -Identification by fingerprint comparison; -Identification made through comparison of dental radiographs or medical x-rays, with the consultation of a Forensic Odontologist, Forensic Anthropologist or UT Southwestern/Parkland Radiology Staff, if needed; -Family identification by viewing photographs of the body at the DCME facility (used in a small number of cases); -Circumstantial identification, which is used in conjunction with other methods or when visual identification is not possible, but other information is available to allow positive identification (e.g. location of the body, presence of particular jewelry or clothing on the decedent, etc), and only with medical examiner approval. On JP cases, the Justice of the Peace may need advice regarding identification procedures. If a judge calls in a death of a person that is decomposed, charred, or injured in a way that photo identification is impossible, and the judge feels comfortable with a positive identification by circumstances, we need to advise the judge, especially in homicide cases, that a more positive identification would be more prudent, ie, dental records, fingerprints, DNA etc. If the judge refuses to go any further with the positive identification, it should be noted in the narrative section of the field agent report that you so advised the judge and the judge prefers that the positive identification stand as is. The field agent is responsible for documenting in the report how the body was identified. If a body has a tentative identification, it will be listed as unknown on the face sheets, log books, tags, etc. Comments about a tentative identification are only to be placed in the narrative report, and the decedent is officially unknown until the identification is confirmed. If the identification is unknown, it is the field agents responsibility to coordinate obtaining the information needed for identification, for example, getting the fingerprints to the police, working with the medical examiner in collecting such items as dental and medical records, and obtaining previous x-rays and photographs of a suspected match. Fingerprints will initially be searched by local jurisdictions and then forwarded to the state and federal authorities. The field agent also works with the medical examiner in completing and submitting the various "missing persons" reports as required for entry into NCIC missing persons data file. Following confirmation of identification of a body initially unidentified or tentatively
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identified (or initially misidentified), a series of notifications is made. The field agents are charged with insuring that these notifications, including updating body tags, are made. A Body Identification Notification Checklist is completed by the field agents to insure all necessary notifications are made. The sequence in which actions required by the checklist are performed is not dictated by the checklist. On completion of the checklist, it will be placed in the original medical examiner file by the field agent completing the last required notification. The notification checklist is available in the Field Agents office records cabinet. If a body is found to have been misidentified, the field agent supervisor should be notified. The field agent making the corrections should work closely with the medical examiner(s) on the case(s). The identified manila toe tags are tied to the initial red unknown tags, and all are left together on the body and bag. After a body has been received by the Office of the Medical Examiner, the number associated with that body is NEVER to be altered. The body and number are unique and inseparable. VI Notification of Next-of-kin
The field agent is ultimately responsible ensuring next-of-kin notification in a timely manner. The person considered to be the next-of-kin for the purpose of custody and disposition of a decedents remains (body and belongings) according to Texas Health and Safety Code, Chapter 711, is in this sequence: 1) The person designated in a written instrument signed by the decedent, 2) The decedents surviving spouse, 3) Any one of the decedents surviving adult children, 4) Either one of the decedents surviving parents, 5) Any one of the decedents surviving adult siblings, or 6) Any adult person in the next degree of kinship in the order named by law to inherit the estate of the decedent. Hospitals and nursing homes will take care of the notification in many cases. Some cases will obviously have the next-of-kin at the scene and additional notification would be redundant. It is the field agents responsibility to document any such notification in the report and to notify the nextof-kin, sometimes with the help of law enforcement personnel, if it has not already been done. The appropriate foreign consulate may be notified if no family can be located and the decedent is suspected of being a foreign national. VII. Case File
All DCME cases are assigned a unique case number. Once a body is assigned a number, they remain permanently linked; information regarding the case may change, including the name, but the number associated with the body is never changed. All cases coming to DCME for examination get a case folder. The original file folder (later redone by the Records secretaries) is plastic and color- coded as to the probable manner of death as follows: red-homicide, yellow-
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suicide, blue-accident, green-natural, and orange-undetermined. All folders get: 1) an investigation report including general information and a narrative of the circumstances surrounding the death, 2) a toxicology request form, 3) a clothing and jewelry inventory form, 4) a body release/disposition form, and 5) a set of adhesive case number labels. If more than one case is related (multiple victims in an MVA, homicide-suicide pair, etc.), the cases should be cross-referenced and copies of all investigative reports included in all of the case files. DCME cases not coming into the office (AB, AF), storage cases, and hospital autopsy cases have limited paperwork, as described elsewhere. Field agents are to complete all reports (Case or No Case) before leaving their shift. This is the case field agents responsibility, although other agents may sometimes assist with the paperwork. VIII. Investigation
A. OVERVIEW The primary responsibility of the field agent is to assist the medical examiners by providing a detailed investigation report regarding the circumstances of the deaths which are reported to the DCME. Part of the field agent's function is to work with the police and medical examiners in the investigation of deaths, including responding to the scene of death. The field agent will write a detailed investigation report including demographic data, the circumstances of the fatal event, pertinent medical history, scene information, witness statements and any other relevant information including names and how to contact the reporting person(s) and the decedents family. Photographs are taken for all scene response deaths and shall accompany the investigative report. Refer to the photography chapter and instructions for more information. Field Agents will provide a schematic of the death scene as appropriate. Throughout the report, complete sentences and whole words should be used. Acronyms and abbreviations are acceptable when they are standard in the practice of medicine. Non-medical acronyms must be defined the first time they are used in a report, such as Federal Bureau of Investigation (FBI). Medical histories are to be confirmed, as appropriate, by conversation with the attending physician or review of the medical records. If only a hospital name is known, but not the physician, the hospitals medical records department can be called during office hours. The medical records clerk should be able to give the attending physicians name, who can be contacted for a verbal history. B. INVESTIGATION REPORTS All cases, regardless of whether the body will be brought to DCME, must have an investigative report that includes sufficient detail to justify the case type and certify the death (if necessary). Refer to the computer entry instructions for line-by-line instructions. The front page is the general information page and requires attention to detail. All information possible should be obtained so each block can be completed. Blocks should not generally be left blank. The name, age, race, sex, address, next-of-kin, and funeral home information is critical to subsequent actions such as completing the death certificate and releasing the body. If the person has no job, put unemployed; otherwise put student, particular job, etc. Particular attention should be paid to the section on date and time of death. The earliest known accurate date and time should be used, with found being
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Revised 1/03/08

used when necessary. For example, if the person is known alive on one day, and found dead later the same day, the date would be known, but the time would be found. If known alive on a day other than the day found, both the date and time of death would be found. If unclear exactly when a body was found, but the person was pronounced dead by the paramedics then later by the field agent, the most accurate time of pronouncement would be the earlier paramedics time. If the EMS responders discontinue resuscitation measures using BIOTEL communication, the death pronouncement will use the date, time, and name of the pronouncing physician. If the EMS times are not available, the later field agent pronouncement time may be used. The CIRCUMSTANCES line at the bottom of the front page is for a brief meaningful statement regarding the circumstances of death. Examples include driver of MV hit pole, chest pain, ER death, multiple GSWs, witnessed collapse in store, and pedest. hit by MV(s) that FSRA. Witnessed death in hosp bed would not be appropriate, for example, for someone who was shot then died in the hospital. The NARRATIVE section has several subsections, which should all be completed. Before the first subheading, make an initial statement if the family has expressed a desire for or against autopsy, if there is a transplant issue, or if there is an infectious disease (AIDS, hepatitis, etc.) that should be flagged. To highlight the statement, put **** on both sides of the statement. The reports should flow in a smooth chronological order. It is critical that any information in the narrative section must identify who provided it, and their contact information For example, if a police officer provides medical history, it was not first hand information. The report must indicate where the police officer got the information. - INITIAL NOTIFICATION TO DCME: This area should include the information pertaining to the initial death notification. This can be from law enforcement, Justice of the Peace, medical personnel, etc.. The first sentence of this section should address the date, time of call, fully identify the persons, name, department, phone number, and a brief statement as to the nature of the death. Example: On Dec 9,2005, at 1430 hours, Officer John Smith, Badge # 1111, Dallas County Sheriffs Office (DSO) (phone 214-555-5555), advised he is reporting the death of a two year old child which occurred at a day care center. After this initial statement, start a new paragraph with all the details of the reporting official. Obtain as much information pertaining to the circumstances of the death as possible from the initial call. This is the area that requires your investigative skills, not just accepting a phone call and writing what the caller said. Ask questions, and try to think what a medical examiner would request and need to assist in determining the cause of death. The initial call is only the beginning. Certain situations suggest some standard type questions. For example, if a person collapses at home/work and dies there or subsequently in the emergency room, we need to know at least what was the person doing before he/she collapsed? And was what the person was doing a normal activity for him/her at work, home, etc? / / / If possibly heat/cold related, was there air-conditioning or heating? What type? Was it on? Functioning? Temperature of decedents environment versus inside or outside? Windows open and fans on? / / / If a baby dies or is found unresponsive in bed, we need to know a number of things about the babys medical history, and all the sleeping details sleeping alone: in a crib, on sofa, in a bed (twin, full, queen, king size)? What position (back, side, etc, and in middle of bed, on edge, etc)? If with other person(s), their relative positions, who
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they are, their general body size, any suspicion of drugs or alcohol, etc. These are not complete lines of questioning, just examples of the type of information needed on a case. When taking a report on a decedent without known family contacts, who may be a potential county disposition case, obtain the decedents drivers license and social security numbers to aid in searching for next-of-kin. Most cases will require more than the initial reporting phone call to obtain the necessary information. In many cases the person reporting the death does not have first hand information. For example, a nurse or doctor reporting a hospital death only knows the events that happened after the decedent arrived at the hospital. It is important to obtain first hand information from people who were with the decedent prior to the incident that resulted in calling the ambulance; they are the people who will have the most accurate information regarding the circumstances surrounding the death. On all homicides, suspicious deaths, and cases involving firearms which will not get a field agent scene response (JP cases and deaths in hospitals), the field agent should notify the reporting person that paper bags should be placed over the hands to help protect evidence. On JP cases, notify the judge/investigating agency to not send the firearm with the deceased. A note should be made in the Narrative section that this was done. The medical records and earliest hospital blood (O-blood) should be requested on all deaths occurring in the hospital. These items should be available for pick-up with the body. Most hospitals will release them with the body to the transfer service. Parkland, Childrens, and Zale-Lipshy will only release the records to a field agent. The entire medical chart may not be needed on all cases. For example, after prolonged hospitalization, specific portions of the chart might be requested. If a field agent brings in hospital blood or other specimens, they should be labeled (leaving the original hospital label visible), and placed into the autopsy room refrigerator, and a supplemental report should be made so the medical examiner will know to submit the specimens. - SCENE OBSERVATIONS: In this area, describe the scene of the place / location of death. This observation can be from your observations, or responsible persons present at the scene (JP, police, etc.). Get as complete a picture as possible. Refer to the later sections on scenes for more information. - OTHERS INTERVIEWED: This space is for the results of additional persons you interviewed. For each person interviewed, start a paragraph by identifying the person (same info as above). This space can be for anyone you need to interview to resolve this case. Annotate the information provided to you, then ask questions to fill in the gaps. Separate each interview with a new paragraph. If this section is not used, write not used or none. - PAST MEDICAL HISTORY: This area should contain information to give a clear understanding of the deceaseds prior medical history, including the details of his/her past symptoms, diagnoses, and surgical procedures, medications the person had been using, and details of previous counseling (for drugs, alcohol, depression, etc.). Depending of the nature
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Revised 1/03/08

of the death, there will be times when a description of the medications is needed, the date prescribed, the size of the pills and the dosing instruction, the number of pills originally in the bottle, and how many are currently in the bottle. It may also be helpful to get similar information on medications in the household prescribed to other people, or on nonprescription medications, if medication abuse is suspected. This will assist the medical examiners in determining if medications possible had anything to do with the death. This section is also used to identify the location of the medical records. Medical records on decedents are to be made available for death investigation. If a hospital or physicians office refuse to provide records based on the HIPAA Privacy Rule, they can be referred to the Code of Federal Regulations 45 CFR 164.512 (g) Standard: Uses and disclosures about decedents. (1) Coroners and medical examiners. A covered entity may disclose protected health information to a coroner or medical examiner for the purpose of identifying a deceased person, determining a cause of death, or other duties as authorized by law. A covered entity that also performs the duties of a coroner or medical examiner may use protected health information for the purposes described in this paragraph. - CASE JUSTIFICATION: Briefly describe why this death was made a Case. - FOLLOW UP ACTION: This section is to be used to identify what actions need to be completed to fully resolve the case, such as if NOK needs to be identified, witnesses interviewed, records obtained, etc. Be precise as to what follow up is required. Any field agent should be able to look at the follow up notes and know exactly what you need to resolve the case. Example: 1. Contact Detective John Doe and determine if deceased had a criminal history. 2. Contact deceaseds physician Dr. Mary Smith and determine if the radiology results are available. 3. Contact deceaseds mother, Sarah Jones, and determine if deceased was employed, if deceased lived alone, and if deceased had ever owned a firearm. It is the responsibility of each field agent to coordinate all activities necessary to follow up on the disposition of bodies he/she brings to DCME so that the bodies are released as soon as possible. C. SCENES The field agents are responsible for personal investigation at the scene of death on such cases as: trauma related deaths, decomposed bodies, suspected SIDS case, bodies of people without good medical history to explain the death, some nursing home deaths, or any suspicious death. If the scene is passed, a notation should be made in the report stating the reason (staffing, no suspicions by police at the scene, etc). In some cases, the body may not be at the scene, for example, an infant death where the body was transported to and pronounced at a hospital. A scene investigation can be just as valuable in these types of cases. Any case may potentially be a scene. A case with borderline or unclear history, for example, could have a scene investigation with enough findings to result in the case being made a No Case or Absentia case. Some judgment is required by the field
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Revised 1/03/08

agents in determining which cases should have a scene investigation. If having to choose between two cases to go to the scene (e.g., if one agent available for both scenes, or going would leave the office unattended), the case should be chosen that appears most likely to add information that would be valuable to the case investigation. Scenes are a regular part of case investigation, and field agents are expected to attend an appropriate number for their caseload (generally approximately ten per month for a full-time agent). The scene section in the Narrative should contain a detailed report of the field agents observations at the scene, including diagrams as appropriate. Photographs are always taken at scenes, and downloaded into the DCME computer on a daily basis. Refer to the chapter on photography for more information. Rider/observers, including Institute employees other than medical examiners, accompanying field agent responders, are prohibited. Exception to this policy may be granted only by the Chief Medical Examiner, the Chief Field Agent or the Deputy Chief Field Agent, consistent with Dallas County Policy, and generally includes pathology residents and medical students doing DCME forensic pathology rotations. Additional on-duty field agent response due to anticipated scene requirements is permitted. Off-duty field agents responding as observers require the same advance exception as any other observer. Persons granted permission to ride as observers must make a conservative professional appearance. Jeans, scrubs and other casual wear are not permitted. Field agent responders are not permitted to waive this requirement. Responders (field agents and rider/observers) representing this office are always either uninvited guests in a private setting or subject to public observation and critique, or both. It is important to remember that the Dallas County Medical Examiner shares investigational jurisdiction with a number of other agencies which may be involved, such as law enforcement, the National Transportation Safety Board, the Occupational Safety and Health Administration, etc. Whether or not a particular investigation by one or more of these agencies is focused on the commission of a crime, it is our duty to work cooperatively in order to ensure the proper identification, collection, and preservation of not only the evidence that is under our jurisdictional control (the body and items on or near the body), but the evidence which is under the control of these other agencies as well (the surrounding scene). This includes the appropriate use of personal protective equipment (see the SWIFS Health and Safety Manual), which, in addition to protecting the wearer from biological fluids, will help prevent the potential compromise of another agencys investigation. An example would be using gloves to prevent leaving fingerprints at a crime scene. When entering a scene, it is imperative to interact and consult with other agencies present regarding our activities within the scene perimeter. Generally, the police department's Physical Evidence Section will collect weapons and evidence, with the field agents working with them to collect other materials as appropriate. Evidence is any material that contributes to the cause or manner of death and is considered important in supporting the facts of the case. What is considered to be evidence depends on the type of death being investigated. The field agent will consult with police officers at the scene to determine which agency will be responsible for taking possession of the evidence/personal property recovered at a scene. It is generally the police departments responsibility to collect weapons-related evidence,
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Revised 1/03/08

suicide notes, and hard drugs such as bags of cocaine or marijuana, but the field agents may collect some drug-related evidence such as a syringe from next to a body. Personal property is defined as property found on or near the body and that can eventually be released to the next of kin. If the item(s) is considered personal property, the field agent will assume custody of the item(s) and transfer the personal property back to the DCME for inventory. Refer to the chapter on personal effects for more information on the inventory procedures. If the item(s) is considered physical evidence, then the police agency will take custody of the property and or evidence. Special circumstances may warrant special disposition of evidence/property. If a field agent submits anything as evidence, a copy of the evidence submission page must be provided to the DCME evidence registrar, as well as placed with the original case folder. See later section in this chapter for more on processing medications, evidence, and personal effects. Field Agents will place paper bags over the hands of any decedent involved in a suspected homicide or where firearms may have been involved in order to protect physical evidence if at a scene investigation. The field agent may also be called by the autopsy technician to go to the morgue to bag the hands if a homicide or suicide arrives without bags on the hands, or to redo the bags if they arrive with plastic bags over the hands instead of paper. The body will be placed in a light duty, or heavy duty body bag (as necessary) prior to transport to DCME. Environmental temperatures are to be taken at all scene investigations. The air temperature is always taken, recording the time that it was taken. Water temperatures should also be taken in drownings, suspected drownings, and any other death in which the body is found in water. These thermometers are not to be used to attempt to take temperatures of the deceased. Body temperatures are not routinely taken by the field agent. The report should include a notation as to whether the body is cool, warm, or hot to the touch, and ancillary information such as the position of the body relative to shade / sunlight, heavy clothing, air conditioning, etc. Invasive body temperatures will NOT be taken by the field agent unless a medical examiner is consulted first. If hypo- or hyperthermia is suspected, and the post-mortem time interval is short enough that a body temperature may be of value, a medical examiner should be called for direction. The debris of the investigation (such as gloves) should not be left at the death scene or with the bodies. Waste items should be disposed of properly in a biohazard bag (or multiple bags if necessary) marked WASTE. This will help ensure that no items of waste are confused with evidence and that no evidence associated with the body is mistakenly identified as waste; it will also prevent the transfer of evidence between the waste and the body. Large items (disposable fire department blankets, etc.) are placed in large red biohazard waste containers and delivered by the field agent to the DCME and disposed of as biohazard materials. Small items are delivered to DCME by the transfer crew in small clear biohazard bags to the body receiving area and disposed of in an appropriate biohazard waste container. There may be situations were the body transfer service may be willing to deliver red bags as well. Note that biohazard containers may also be used to protect and preserve evidence as well. The transfer service must be instructed if these bags are to be handled as waste or preserved with the body as evidence.
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Revised 1/03/08
D. FOLLOW-UP The field agents are responsible for ensuring that the follow up originally listed in the narrative reports is obtained. In addition, follow up may be requested by the medical examiners if additional information is needed to help in determining the cause and/or manner of death. These follow up requests should be made through the field agent supervisor who then distributes them to the appropriate field agent and follows up on their completion. Occasionally, follow-up scene investigation may be necessary, for example, to look at exact circumstances of an industrial accident or an after the fact SIDS investigation if the infant was transported from the residence to the hospital. Other follow-up may include obtaining police reports, medical records, and the earliest antemortem hospital blood if such items did not arrive with the body. Any additional information is added to the file on supplemental investigative reports and forwarded to the medical examiner for review. The field agent also functions as an intermediary between transplant and the medical examiners, supplementing in the case file any transactions, such as ME approval for organ or tissue donation. Refer to the chapter on transplantation for more information. The field agents call the local investigating agencies on cases involving any agency other than the Dallas Police Department, and complete an evidence request form started by the medical examiner after the collection of evidence at autopsy. This form is to document whether the agency wants the evidence released to them, or to have us examine it for a fee. IX. Processing Medications, Evidence, and Personal Effects
Processing of all medications, property, and evidence will be conducted in the designated contaminated area in the field agents office. See the Miscellaneous Duties section later in the chapter for information on infection control procedures. Medications transported by the transfer service will be transported in tamper resistant pouches provided by the DCME. The transfer service will carry the pouches in their response vehicles, as they will most commonly be used when the field agent does not respond to the scene. These pouches will not normally be used for other property and valuables, unless recovered separately or separated from the body during the investigation and transported by the transfer service. Medications and personal effects will be placed into two separate pouches. Medications, personal effects, and valuables that are recovered by the field agent will usually be transported by the field agent. If the field agent does not attend the scene, the agent will ask the officer (or other responsible person) at the death scene to collect prescription medications and send them with the decedent. The
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Revised 1/03/08

officer should be asked to ensure the decedents personal property or valuables are not in the medications container, to sign and seal the pouch, and also to place their signature on the transfer service trip ticket (for comparison, if necessary). The pouch should then remain sealed, and each change of possession of the pouch be documented on the chain of custody portion of the pouch, including officer to transfer service, transfer service to DCME body receiving employee, and from them to field agent. The pouch is to be transferred sealed. Routinely, no inventory is done and the field agent will drop the sealed pouch in the evidence registrars medication locker. This drop should be witnessed and the Medication Drop Log signed or initialed by both people. A Drug Evidence Submission form is completed; one copy is provided for the case file and the original is placed in a basket near the medication drop box. The sealed pouch will not initially be opened to count or identify items; a list for the investigation report may be compiled without opening the pouch. If the nature of the investigation requires the pouch to be opened for an inventory (immediately or at a later date), the field agent will perform the inventory, place the medications and the opened pouch into another pouch, seal the new pouch, initial and date over the seal, and drop it into the evidence registrars medication locker. Document the need to open the sealed pouch with a Supplemental Investigation Report. Drug evidence such as suspected cocaine or paraphernalia is submitted in the same way as medications, into the drop box, with a Drug Evidence Submission form completed and copied. Testing is generally not performed by the lab unless a specific request is made by the medical examiner or investigating authority, so it is important to let the medical examiner know the material was submitted (via the form), so they can request analysis if it is appropriate. Evidence (non-drug) includes anything being submitted to the physical evidence section of SWIFS for examination, storage, or release back to the local agency. This should be rare, since this material is usually collected by the police. During day hours, the field agent can submit directly to the evidence registrar. After hours, the evidence is to be placed into the evidence lockers near the front door, which have instructions. An evidence submission form is completed and attached to the evidence, with a copy made for the ME case file. The lockers are routinely checked by the evidence registrars. Personal effects are to be inventoried as per the procedures in the chapter on Personal Effects. X. Release of Information / Media Contact / Requests for Reports
The Field Agents are often called and asked to release information regarding cause of death, findings, toxicology results, etc. to investigating agencies, families, and others. Refer to Chapter 8, Part I, Release of Information for general guidelines regarding this. If a JP or investigating agency calls for a blood alcohol result (often needed for their reports before the toxicology and autopsy report are complete), the field agent is to record the investigators name and contact information, and the decedents name and case #, and forward that information by e-mail to the designated toxicology supervisor. If the result is available, the toxicologist will make
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Revised 1/03/08

and document the verbal notification. Any and all requests for copies of autopsy reports should be directed to call the Records office. The reports are public information, but our office must usually have a written request and the appropriate fee payment. Some agencies are automatically sent reports on some types of cases, but any question should be referred to Records. A notation in the investigative narrative is not an acceptable request for a report. XI. Disposition of Unclaimed and Unidentified Bodies
The field agents are responsible for the disposition of unclaimed bodies which include: a) unidentified bodies, and b) identified bodies who either have no family or family that cannot afford or refuse to pay for burial. By law, (Art. 2351 of the Revised Civil Statutes of Texas, 1925, revised 1961) an attempt must be made for a period of 72 hours to search for kindred. All efforts to identify the body and contact any family members will be pursued and documented prior to the release of the remains for county disposition. On JP cases, the field agents work with the local authorities to help identify a body, but it is the JPs responsibility to do the search for family. An unknown or unclaimed body maybe released to a funeral home of the JPs choice. Once a potential pauper or unclaimed deceased individual is identified, a field agent will be assigned to investigate the circumstances and document same. Assignment will be at the discretion of the Chief or Deputy Chief Field Agent. The Unclaimed Body Affidavit (OME F-47) lists the minimum search criteria that must be made before declaring a decedent an unclaimed body. The field agent is free to search further if appropriate. Note that unlike the sequence of people listed as next-of-kin (earlier section in this chapter), any friend, associate, person with power-of-attorney, or even an organization may take custody of a body if the legal next-of-kin cannot be found or refuses to take custody within 72 hours. Field agents who receive a call requesting assistance in disposition of a body are to help the caller at that time. These families are seeking our help at that time, therefore agents are not to ask them to call back at a later time. Responsible agents are to gather as much information about the deceased as possible, for use on the death certificates IDENTIFIED ADULTS (18 years of age or older): When a family inquires about county assistance in burying a deceased Dallas County resident and DCME case, the field agent taking the call will explain that DCME will release the body to the State Anatomical Board (SAB) at UT Southwestern Medical Center for possible use in the anatomy classes or for research purposes. SAB does not accept all cases, and is not interested in bodies with known infectious diseases or drug abuse, oversize remains, children, those greater than five days after death, or after autopsy unless under 65 years of age. The FA will advise the caller the body will be cremated or properly disposed of when the medical school is through with it, depending on the nature of the research. If SAB accepts a body donated by the family, the ashes may be returned to the family later. If the body is not accepted by SAB, it would then become a county disposal, and be cremated, with the ashes not obtainable by the family.
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Revised 1/03/08

When a family indicates at the time the death is reported that they cannot afford or refuse to pay for burial or cremation, and if the body is not already coming to DCME for examination (a No Case or AB), the field agents are to call the State Anatomical Board so they can immediately contact the family for potential donation. If SAB accepts the body, they will pick up the body, and DCME will not be involved in transport or county disposal. If there is no family, and the case is Non-Reportable or a No Case, the body may be held temporarily in the hospital while the hospital searches for family. If none are found, the body is brought to DCME for county disposition. If not in a hospital, even if the death is a No Case, these bodies are brought to DCME while the field agents search for family. If an identified body is cremated because no family could be found to take custody of the remains, and the family is found within 90 days of cremation, the ashes MAY be obtainable, but that would have to be discussed with the medical school representative. Any homeless veteran with no known family is eligible for the Veterans Dignity burial program. If, however, the veteran is homeless but does have a family they are not eligible. One of the following forms is to be completed prior to cremation: 1) OME F-45, Deceased Adult Unclaimed Body Disposition Request and Waiver(completed by the next of kin), 2) OME F-47, Unclaimed Body Affidavit. This form indicates the six actions taken in an effort to locate next-of-kin in cases where no NOK is initially identified. Each action will have a written supplement indicating the success or lack of success in finding family of the deceased individual in question. This form also will indicate the date on which these efforts commence, and the date on which the search was suspended. The field agent will sign this form, which is then reviewed and signed off on by the Chief or Deputy Chief Field Agent. This form must be notarized. If DCME locates the decedents next of kin but they refuse to claim the remains and to sign the F-45, the field agent will complete the F-47, and note the refusal by the next of kin. INFANTS AND CHILDREN: A child is defined as an individual who is of the age 17 years or younger. An infant is an individual who is less than 1 year of age. The medical school does not accept deceased individuals under the age of 18. Therefore, Dallas County will provide a direct cremation. The ashes will NOT be made available to the families, but interred in a common casket and then buried at the crematory vendors site. One of the following forms is to be completed prior to release of a child for disposition: 1) OME F-46, Deceased Indigent Infant/Child Body Disposition Request and Waiver (if NOK) 2) OME F-47, Unclaimed Body Affidavit. This is the same form as described above and will be completed in the same way. UNIDENTIFIED BODIES: Dallas County will bury those individuals who remain unidentified after all workable leads to
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an identity have been exhausted. These bodies will be processed as per already established policies, prior to burial. See Chapter 12, Sections IX and X for procedures to be completed before their release. Bodies that remain unidentified are buried at county expense or are released back to the county from which they were sent. A field agent will be assigned to ensure the following procedures are completed prior to burial and documented on the DCME Unidentified Person Checklist form: Fingerprints sent to DPD, DPS, and FBI, Photographs, including frontal and lateral face, unique marks, scars, tattoos, clothing, etc Description sheet Dental X-rays and charting done Full body X-rays taken and filed Blood, tooth, or bone for DNA taken and submitted Extra FTA blood card (or bone) for submission to the Univ. of North Texas Health Science Center Human Identification Laboratory These bodies will be placed in a cadaver bag and will not be embalmed. If a buried unidentified body is later identified, the family will be notified of the disposition of the remains. OVERSIZED REMAINS If a decedent is oversized for the crematory (generally weighing 600 pounds or more) and is indigent or unclaimed, they will not be cremated, but will be buried the same as the unidentified bodies. In compliance with state law regarding direct burials, no funeral will be held. UNCLAIMED BODIES, SUMMARY: Identified adults Family donates to SAB (body at DCME or elsewhere) remains used, then cremated, ashes available - body not accepted by SAB, or direct county disposition cremation (at county expense), no ashes No family county disposition, cremation, ashes only if family found 90 days Unidentified adult county disposition, burial Child county disposition, cremation, no ashes Oversize (any age, IDd or unknown) county disposition, burial RELEASE PROCEDURES: The deputy chief field agent (DCFA) supervises the release of all unclaimed/indigent /SAB bodies. The DCFA will transport the bodies of the adult unclaimed/indigent cases to the medical school or cemetery. The vendor for cremation of indigent children or infants will pick up those bodies. The DCFA will ensure that appropriate paperwork has been filled out and notarized as necessary, and will personally confirm that the body being released is the correct person. Standard Body-Out procedures will be followed. All paperwork and computer entries are to be completed the same day of release. Personal effects, including jewelry, will be released or retained according to established
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DCME policy and procedures. XII. Miscellaneous duties
Radio Communications DCME vehicles have radio communications capability with the Dallas Sheriffs Office and the Dallas Police Department. Portable radios are also available in the field agents office and should be taken to scenes such as mass fatalities or if a high workload / short staffing situation arises. These radios may used to communicate with the Sheriffs Department (channel 5) dispatcher and directly with the Medical Examiners Office (channel 1). Each field agent is assigned an individual radio call sign. Dallas Sheriffs Office Each medical examiner vehicle is equipped with a mobile radio capable of communication with the Dallas Sheriffs Office dispatcher and mobile units. Channel 5 is assigned to the Sheriffs Department patrol, CID, PES, and the Medical Examiner. Channel 2 is assigned to warrant units. The field agents are to monitor channel 5 while en-route to a death scene. Field agents are required to check in service with the Sheriffs dispatcher as follows: 1. Check in service providing the destination 2. Check out of service at the location 3. Check back in service when cleared from location 4. Check out of service upon arrival at DCME Channel 14 on the vehicle radios will allow you to communicate directly with the DCME. Dallas Police Department Each county vehicle is also equipped with a City of Dallas radio. These radios are to be monitored on channel 7 unless otherwise directed by the police dispatcher. The radio call signs for the medical examiner base station in the field agents office is 3520. The base station utilizes channels 1-12 with the exception of Channel 9. When communicating with the Dallas police dispatcher, simply identify yourself as Medical Examiner if they do not recognize the call sign. County Vehicles The field agents office is assigned response vehicles by Dallas County. They have designated parking spaces in the front of the DCME office. Each vehicle has a notebook, which contains a response log, refueling log, vehicle keys, and general field agent vehicle usage guidelines including instructions for employees involved in motor vehicle accidents. The vehicles are only to be used for
2.19
Revised 1/03/08

OFFICIAL COUNTY BUSINESS, and drivers must adhere to the policies and procedures of Dallas County regarding vehicle use. No smoking, and no food or beverage other than water, is allowed in the vehicles. No trash or other items are to be left in the vehicles. They are to remain locked while parked at the Institute. Before driving a county vehicle to a scene, make certain that: 1) the gas gauge shows more than tank, 2) the tires are not low, 3) the lights are functioning, 4) the windshield wipers work, and 5) the car shows no new damage or excessive bird droppings or dirt. If any of these problems exist, drive another car and notify the chief or deputy chief to address the problem (a note may be left if offshift). During normal business hours, vehicles shall be serviced at ASC (Automotive Service Center) located at 738 Ft. Worth Ave., Dallas, Texas 214-748-3417. The appropriate logs shall be completed upon the return of the vehicle to the DCME. Instructions for refueling after normal business hours are referenced in the vehicle notebook (usage of the FINA credit is required). Any time the vehicle is serviced, the vehicles fluid levels should be checked along with tire pressure and cleanliness of the vehicle. Any problems related to the maintenance or cleanliness of the vehicles should be addressed to the field agent designated to coordinate vehicle maintenance. The vehicles are to be vacuumed and washed regularly at ASC. The field agents clerical assistant is responsible for obtaining and documenting the routine maintenance of the field agents vehicles and the morgue van. Safety / Infection Control Processing of all property and evidence, including drugs, medications and fingerprint cards, will be conducted in the designated contaminated area in the rear corner of the field agents office. Gloves will be worn at all times when these items are being handled. Protective wear is not limited to gloves; however, items which seem to require more extensive protective wear should be processed in the body handling areas. Items used in processing evidence (pens, pencils, erasers, staplers, staples removers, etc.) will not be removed from the contaminated area. Food and drink will not be taken into or consumed in the contaminated area. After each task in that area, use the disinfectant spray to clean the desk and counter tops, the computer keyboard, and telephone(s). Used gloves and other biologically contaminated materials will be disposed of in the biohazard containers provided. After gloves are removed, the disinfectant gel will be used (remember to NOT dry hands with towels after using the disinfectant gel). The contaminated area should be disinfected at least one time each day in addition to the required cleanup following each task completion. The daily cleaning is documented on the posted cleaning checklist. Each field agent is to use the disinfectant spray to clean the desk and counter tops, the computer keyboard, and the telephone(s) in their own work area at least once each of each shift in addition to any required cleanup in the contaminated area. For more information, refer to the SWIFS Safety Manual.
2.20
Revised 1/03/08
Release of Personal Effects Field agents may be called upon to release personal effects or valuables to a decedents next-of-kin . After determining that the items may be released and that the receiving person is the appropriate next of kin, the release may be performed following the procedures in chapter 4 on personal effects. Visitors and Security Outside of the usual DCME office hours, the field agents perform the function of front-door receptionist, checking in and out any visitors. Field agents have the discretion of allowing or refusing non-DCME persons into the building after office hours. Field agents are also responsible for answering to Dallas Security Systems Inc. in response to the Institutes burglar and environmental alarms. A field agent will check the security alarm panel each shift, confirm that the alarm panel is in the armed status, and document this on the adjacent checklist. For more information on these procedures, refer to the SWIFS Facility Security Manual. Fingerprints Field agents have the responsibility of forwarding fingerprint cards to the investigative agencies and of later distributing them or the decedents criminal history reports for filing in the case files. See Chapter 10, Fingerprint section for further information. Body Receiving / Release The field agents are responsible for covering the duties of the body receiving and release area at night, and occasionally during the day, depending on staffing. They are also responsible at any time of performing certain duties as previously described such supervising the receipt of double-loads from the transport service, and releasing any unclaimed or unidentified bodies. Refer to the Body Receipt/Release chapter for those procedures. As in the chapter on body receiving, the Body In copies are left during autopsy hours on the clean counter in the autopsy room, and taken upstairs after hours for inclusion in the case file. If an early morning field agent checks in a body and takes the Body-In copy upstairs, the form should be placed in the case folder tray if the case report/file will not be ready in time for the medical examiners in the morning. In the rare case that a body arrives with a firearm, if during office hours, immediately contact a firearms examiner from the DCME Crime Lab to come down and render the weapon safe. If after hours, on weekends, or holidays: 1) Remove the firearm from the bag carefully and safely, 2) Place the firearm in the decomposition autopsy room which is located adjacent to the body check-in area, 3) Notify a supervisor that the firearm is locked in the decomposition autopsy room, and 4) E-mail Dr. Sliter (tsliter@dallascounty.org) and evidence registrars, Sylvia Hernandez (sareyes@dallascounty.org) and Shirley Wynn (swynn@dallascounty.org), with copies to the chief and deputy chief field agents.
2.21
Revised 1/03/08
Body Cooler Inventory and Temperature An early morning field agent is responsible for checking the body cooler temperature and recording it on the log sheet posted on the door. This is usually around 2-4am, and always before the morning rush of opening the cooler doors. The temperature should also be noted on the body inventory board in the hallway. An inventory of the cases in the cooler is also done daily, at the same time, or later by the field agents clerk. It is the field agents responsibility to watch the cooler capacity, and to encourage families to select funeral homes to help with quicker body release when needed.
2.22
Revised 1/03/08
CHAPTER 3 BODY RECEIVING AND RELEASE The body receiving and release area is open 24 hours a day, with the autopsy technicians and field agents covering this function. I. Body Acceptance Procedures BODY IN
General Body Acceptance Procedures All bodies must be in a body bag on arrival to DCME. Should a body arrive that is not in a body bag; it will be placed into one prior to admission past the secured hallway morgue doors. Bodies are accepted into the office 24 hours a day and 7 days a week. Funeral homes and/or ambulance crews may become impatient if a body acceptance or release takes too long, but do not allow them to rush you to the point that you make mistakes. Always complete one body admission or release before starting another. If additional help is needed, a back-up autopsy technician or field agent should be called. Funeral home and contract transfer service personnel may be permitted to wait inside the morgue body acceptance/release area. However, if the room is too crowded, the funeral home or transfer service personnel may be asked to wait outside the morgue - preferably in the transport vehicle. The delivering funeral home or contract transfer service agent is responsible for moving the body and placing it on the Institute cart. If time permits, you may assist with the transfer of the bodies as a courtesy. Funeral home and transfer service (contract, EMS, etc.) personnel may use the Decomp Autopsy Room (if not in use by ME) to wash the transfer cot. "Double Loads" If the contract transfer service brings a double load (two bodies delivered at the same time in the same vehicle), and both bodies were not already tagged at the scene by a field agent, then a field agent is to come and tag the bodies that do not already have the DCME tags. The field agent will initial the toe tags and the Body In & Out logbook. Double loads brought by DCME employees from the adjacent hospitals, from out-of-county, or from scenes where the field agent already placed the tags may be checked in without a field agent. Expedite Assistance for Contract Transfer Service The contract transfer service can be expedited if they are delivering one or more bodies, other bodies are already being received, and they have a call to go pick up another DCME case. A back-up DCME employee should be called to assist in the admission of bodies to get to the transfer services more quickly, or they maybe taken out of order if necessary. Body Identification All local cases, delivered to DCME by the current body transport vendor, must arrive with a transport vendor ID tag on the body or on the body bag. If a field agent scene investigation was done, tags will also have been placed on the body at the scene by the field agent. If a body arrives
3.1
Revised 1/03/08

without a tag, the transport agent must complete a tag and attach it to the body before DCME accepts the body. The individual receiving the body is then responsible for noting on both the transport receipt and the Body In Form that the body was not tagged when delivered, and notifying the field agent supervisor of the situation. All other bodies delivered to IFS by any transport service must also be tagged by the transport agent (if not already tagged) before acceptance and tagging at SWIFS. If they do not have their own tags, the agent may use one of the Institute's tags after cutting off the top portion, which identifies it as a DCME tag. This tag is to be placed prior to and in addition to our own body tags. The two Institute body tags will be prepared by the field agent and either placed on the body at the scene or delivered to the morgue prior to the arrival of the body to the morgue. If a body arrives unexpectedly, the field agent is to be notified to initiate the death investigation, to prepare and deliver (generally by elevator) the body tags and to enter enough information to be able to use the computer. The tags will be written with a pointed felt-tip black pen or other large pen so they will be legible in the body photographs, and will include the decedent's name, age, race, sex, and the field agents initials. The tags prepared by the field agent should be placed as follows if possible: one tag on a wrist or toe/ foot/ankle area, and one tag on the body bag. NEVER remove clothing to attach a tag. If a toe, ankle, or wrist is not available, tie one tag onto another area of the body (or clothing if no place on the body). Do not leave tags loose on the body or cart. Try to have a tag at the foot end of the bag, so it is easily identified in the cooler. The case number may also be written directly on the outside toe end of the bag to facilitate easily finding the body. All body bags are opened to confirm or place the body tag and for a quick check that the general characteristics of age, race and sex of the body match those on the identification tags, as well as for inventory, described later. Special Processing Occasionally, there will be a request for special processing of a body, such as for latent fingerprints. On an individual case basis, handle these bodies as instructed by the medical examiner, field agent, or trace evidence analyst. Tagging procedures might be altered to allow for the special processing, but in no case is a body to be moved into the cooler without tags. If a body arrives with a weapon or other clearly obvious evidence (e.g., gun with body, grenade in hand), a field agent should be contacted to provide assistance/direction. Refer anyone at the back door with evidence to the field agent on duty. Inventory An inventory of the body is performed on all cases in the presence of the transfer person. It is the responsibility of the admitting employee to conduct the inventory, not the transfer person, who is present only as a witness. It is important to do as thorough and accurate an inventory as possible, searching the body from head to toe. The inventory is limited to visual observation and physical examination of the parts of the body and clothing that are accessible without removing or cutting any clothing or turning over the body. Personal bags such as totes, backpacks, and purses will be
3.2
Revised 1/03/08

inventoried at this time. Hospital bags of clothing will be noted, not opened for inventory, and sealed with evidence tape with the sealing DCME employees initials and the date written on the tape. Bags will not be opened or removed from the hands or other bagged areas. Anything missed at this time will be picked up at the inventory done later in the autopsy room or at body release. The clothing part of the inventory is limited at this time to simply noting on the form whether or not the decedent is dressed, lying on cut-away or removed clothing, nude, and/or if clothing is received with the body in a hospital bag. All jewelry on the body is left in place, and is inventoried on the Body In form. The jewelry is described in generic terms, using words such as yellow metal instead of gold, white metal instead of silver, and clear colorless stones instead of diamonds. Any personal effects (on the body, loose, or separately received) are inventoried and placed in an envelope. If jewelry is loose with the body, it is handled as personal effects. Money is to be itemized, with the number of each denomination listed. Serial numbers do not need to be listed. Credit cards are listed according to the issuer's name and the account number. Each blank section or the inventory form is to be completed, either with the items present or the word "none". The personal effects envelope and the copy of the Body In form are later taken up to the initiating field agent, who will reinventory the items, generate a receipt, and take the envelope with the receipt back down to the body. If the initiating field agent has left work, deliver the property to the senior field agent on duty who will be responsible for ensuring the inventory is completed and placed with the body. If medications are with the body, it is noted on the Body In page and they are placed into a labeled clear tamper-evident envelope. The envelope is sealed and the date and the sealing employees initials or signature are written across the seal. The envelope is given to the investigating field agent if available. If unavailable, the envelope is given to any field agent. If medications arrive in a sealed evidence-type bag, the bag is initialed in a chainof-custody area if available or near the sealed end. The bag is taken unopened to the investigating or other field agents as just described. Personal effects and medications bags are to be handed directly to a field agent, not left unattended in the field agent area. The field agent may need you to witness placing the medications in the lock-box at that time, or if busy, may choose to accept the medications for later storage. Forms and Paperwork Each section of the Body In form will be completed by the admitting employee with appropriate notations. It is also your responsibility to complete the morgue ledger with the appropriate information, which must include the case number, name, age, race, and sex of deceased, date and time of receipt, name of transfer service, and admitting employees signature. All personal property, medication, records, clothing, specimens, etc. which may arrive with a body will be recorded and routed appropriately. Please pay special attention to the "jewelry" and "valuables" sections, and make sure that these are completed based on your review of the body at the time of acceptance. The acceptance and inventory of a body will be witnessed by the funeral home or transfer personnel, who will sign and fill in the information at the bottom of the page. Use military time on the Body In and Out sheets, the toe tags, and the morgue ledger. The final step in forms completion is to enter the acceptance "Body In" information into the computer forms. The employee accepting the body is the individual responsible for entering the information into the computer, which should be done as soon as possible after each case.
3.3
Revised 1/03/08

During autopsy hours (approximately 7 a.m. to 2 p.m.), the paperwork received with the body (JP order, Funeral Home release, hospital chart, etc.), and the Body In copy (if it was not already taken up with the personal effects) are taken with the body directly into the autopsy room and placed on the clean counter near the door. These papers are not to be placed on or under the body carts. During autopsy hours the body is taken directly into the autopsy area; the remainder of the time the body is placed at the east end of the cooler (at the end closest to the autopsy room) away from the bodies that have already been autopsied (west end/loading dock side). After autopsy hours, the papers are to be taken upstairs to the field agent for inclusion in the case file. Record the name of the field agent on the Body In form. If the case field agent is unavailable, the papers should be given to another duty field agent. During all shifts, any hospital specimens received with the body are to remain with the body. II. Body Release Procedures "BODY OUT"
General Body Release Procedures Just as in checking in a body, accuracy takes priority! The "check list" provided on the Body Out form should be reviewed and completed to ensure that the body is ready for release. When a body is being released, call the field agent to send the Body Disposition form down on the elevator. Bodies are never released on any type of case without this form. There may also be a death certificate, although most are now electronic or picked up from Records. A Funeral Home Release (or JP order with an included FH Release) is also required for body release. This may be sent down with the Disposition Form by the field agents, or may be brought at the time of body release by the funeral home. The releasing employee should review the Body Disposition and Funeral Home Release to confirm that the decedents name, the named next-of-kin, and the name of the funeral home are all the same. If there is any discrepancy, call the field agent. The funeral home representative must have a valid photo identification (such as a Texas drivers license) and a business card or other means of showing employment/association with that funeral home. All identification tags should be carefully checked, making certain the body being released has the correct tags (i.e., tags and release paperwork match). The employee and funeral home agent will sign the back of one of the body tags. Keep the tag with the measurements, date, time, and signatures. Cut or untie the body tag string so the tag remains intact. Do NOT tear off the tag. Also keep the transfer service identification tag. If the body has sets of both regular and Infectious Disease tags, get the signatures on and keep one of each. If the body has a set of attached red unknown and manila identified tags, the funeral home needs to only sign the identified tag with the decedents name. Bodies are never released to funeral home/transport services with only the red tags. Red tagged unknowns may be taken for Dallas County burial/cremation, and rarely by JP cases for disposal in their own county but only with field agent involvement. The removed tags are placed into a small biohazard bag. The receiving funeral home or transfer service agent is responsible for moving the body and placing it on the their cart. If time permits, you may assist with the transfer of the bodies as a courtesy. All carts are to be washed with soap and water after the release of each body. This also applies to trays and parts of the cart such as wheels and frames, if needed. It is critical that carts be completely clean, with no trace of the previous case before being used for a new case.
3.4
Revised 1/03/08
Release of Clothing and Other Personal Effects All clothing, jewelry, and personal effects need to be accounted for - in general, items not retained by the ME will be released to the funeral home/transfer service. No clothing or personal effects are ever released without inventory and receipts. All cases have a Clothing, Personal Effects, and Jewelry form completed by the pathologist, and those originally inventoried at the back door and/or by the field agent at the scene may also have a sealed pouch with an attached inventory completed by the field agent titled Receipt for Evidence. In conducting the body release process, do not rely on the original inventory on the Body In form, as this was preliminary and may not include additional items later found and recorded on the medical examiner's Clothing List or on the field agent's inventory. Do NOT release any clothing or other items without the proper release by the medical examiner (marked "release" and signed by the ME on the Clothing List). If the ME did not mark either retain or release, call the ME or the ME on call. Make a note on the clothing list near the area where the ME should have marked as to the final disposition (e.g., "called Dr. X, kept clothing"), including the date and time, and your initials. If no one is reached who can make the decision, retain the clothing and/or other items in question to be addressed the next day. The funeral home also signs the Receipt for Evidence for any additional personal property being released to them. Copies of additional receipts for items being retained (such as government cards) may be provided to the funeral home, but no signature is required. The funeral home has the option of opening the bag(s) and confirming the inventoried contents, in the presence of the SWIFS employee, before signing the receipts. They may be resealed here and initialed and dated by them if desired. If a discrepancy is found, a field agent supervisor should be called for guidance. If a funeral home refuses to take personal effects, the property may be taken to a field agent supervisor who can arrange its release later directly to the family. Occasionally, a body will be released that has a sealed hospital bag of clothing and/or personal effects that was never inventoried prior to the time of release. This would be cases that did not have a medical examination such as a No Case with temporary storage. These bags must be opened and inventoried in the presence of the funeral home person before release. Clothing does not need to be listed in detail. The blank Receipt for Evidence forms are to used, the funeral home person signs as they do other receipts, and a copy of the receipt is given to them. If the Body Disposition form says Property in Lock box, the Deputy or Chief Field Agent will remove the property from the secured storage area. The releasing employee will sign for the property from that field agent and take it down for release with the body. If the Deputy or Chief Field Agent are unavailable, the body and other personal effects may be released at that time and the funeral home asked to call back later to arrange to pick up the secured property. Body Out Form Completion The Body Out form must be completely filled out. The upper half is the responsibility of the person releasing the body to complete. A check mark must be placed in each of the blanks in the list of items required for body release. If a body is released without any of these forms (for example, No Cases and State Anatomical Board cases), put "NA" in the appropriate blanks. The lower half must be completed by the receiving funeral home or transfer personnel. Anytime a funeral home leaves
3.5
Revised 1/03/08

us a replacement heavy-duty body bag, an Evidence Receipt is completed and a copy given to the funeral home. The number of the case being replaced is written on the receipt and on the box containing the new bag, and both are taken up to the field agent supervisors office. Before the funeral home agent leaves, make certain they have signed: our toe tag, Body Out form, Clothing List, field agent's Personal Effects/Valuables Inventory (if one was completed), and the morgue ledger book, which is countersigned by the IFS employee. Assemble and staple the paperwork in the following order: Body In and Out form, bagged toe tags, Funeral Home release (or JP order if it has the FH release information), (ME's) Clothing /Personal Effects/Jewelry List, Body Disposition form, (FA's) Personal Effects/Valuables Inventory (if completed; currently titled Receipt for Evidence), and any others (JP order, FA supplement, crash bag receipt, etc). The order of the forms assists with the review of the paperwork to ensure accuracy and completeness. The completed stack of forms is left in the appropriate spot in the office for review by the autopsy supervisor and later addition into the case files. The final step in forms completion is to enter the release information into the computer forms. The employee releasing the body is the individual responsible for entering the information into the computer. All data entry must be completed as soon as possible after each case.
County Disposal / SAB Cases Bodies being released for county disposal or donation to the State Anatomical Board (SAB) are all supervised by the deputy chief field agent (DCFA). The DCFA acts as both the releasing DCME employee and the funeral home on county disposition cases as far as the paperwork. On SAB cases, the DCME employee on body release duty releases the body to SAB, who sign as would a receiving funeral home; the DCFA also assists if any property is involved. Clothing and other personal effects are never released at this time on either of these type of cases; see Personal Effects chapter. Error Correction Procedure (applies to all forms) Errors are to be corrected by the person who made the error, i.e., the IFS employee corrects their own errors, and the funeral home or transfer person corrects their own errors. To correct an error, draw a single line through the incorrect information, write in or circle the correct information, and initial the correction. Do not use liquid paper or obliterate the error with pen or pencil.
III.
Body Transfers from Parkland, Childrens and Lipshy
When a body is ready for transfer from PMH to DCME, the hospital chaplain sends their Body Release form by fax to the field agents, who then notify the autopsy techs that the body and its corresponding release form are ready. Parkland will not release the body for the transfer without their release form. CMC and Zale Lipshy will release bodies to us after the transfer is arranged though the chaplains office without a special release form.
3.6
Revised 1/03/08

Transfers should be completed in a timely manner. If you anticipate a transfer delay (longer than thirty minutes after notification by the field agent) as the result of a logistical problem (e.g. locating a chaplain, chaplain fails to return your call, the PMH/CMC dock is inoperable, or DCME transfer vehicle will not start), contact the duty field agent or the ME pit boss to advise them of this situation and obtain direction. If the contract transfer service is used for a PMH case, the service will come by the DCME back door to get the necessary PMH release form to take with them to get the body. Autopsy technicians should notify the pit boss or their supervisor before going to get a body. If more than one body is ready, the decision of whether or not to double load them can be made by the autopsy technician. Before leaving the hospital, make certain to obtain the blood, valuables, and hospital's charts (at CMC and Zale-Lipshy, if possible). The policy of certain hospitals (PMH) requires field agents to obtain records that are not accessible by the medical examiners through the computer system. IV. Morgue Vehicle Procedures
Vehicle keys are to be kept in the key lock box in the field agent area. The vehicle is to be kept locked at all times. Anyone who drives the vehicle should initial the appropriate date square in the drivers log and document the destination, times, and ending mileage. Body cots shall be disinfected after each use, along with any affected areas of the vehicle anytime a mess or spill occurs. Notify the field agent supervisor immediately of anything that might indicate mechanical trouble that could result in damage to the vehicle. REPORT ALL SAFETY PROBLEMS IMMEDIATELY. If you are involved in an accident while operating a county vehicle, refer to the information in the vehicle operations book, which is in each vehicle. NEVER LEAVE THE SCENE OF AN ACCIDENT. Fuel can be obtained at the county service center, where a car wash can also be done. The monthly mileage/fuel log, the drivers log (destination and mileage), and the pink ARC gas receipts (and any other appropriate receipts) are given to the field agents clerical assistant, who is also responsible for documentation of routine maintenance of the vehicles. More information on the vehicles is in the field agent chapter.
V.
Security/Safety
Only personnel with legitimate business reasons should be allowed access to the morgue area. Routine visitors allowed access into the loading dock area only are the funeral home and transfer service personnel, biological waste disposal vendor, hazardous chemical waste disposal vendor, and the clinical laboratory testing courier. The gas cylinder vendor and the X-ray service person are allowed beyond the pneumatic doors escorted by IFS staff. Deliveries of equipment or supplies is not routinely allowed at the back door. Large deliveries for the morgue which will stay in the morgue, such as formalin, are allowed in the loading dock area escorted by IFS staff. On rare occasion, an Institute supervisor may authorize morgue entry for delivery of large or heavy items in
3.7
Revised 1/03/08

the loading dock area or escorted by IFS staff. All visitors who enter the building through the secure double doors will sign the morgue Visitor Record, usually handled by their IFS staff escort. (Reference IFS Facility Security Manual). All personal visitors should come to the main building entrance and go through the normal visitor sign-in process; after hours, visitors must request access from duty field agents. Personal visits are allowed during break or lunch, and are not permitted in the morgue area. FOR YOUR OWN SAFETY, especially at night, be sure you know who you are letting in. If you have any misgivings as to the legitimacy of a request for access to the building, contact the duty field agents for assistance. If a field agent is not available, contact the UT Southwestern Medical Center Police for assistance. The morgue area (bay doors, back door, decomp autopsy room door, pneumatic doors, cooler doors, morgue hall door) is to be secured at all times. Any security concerns should be reported immediately to the duty field agent. For more information, refer to the SWIFS Facility Security Manual. Appropriate precautions should be taken to protect from biohazard exposure during body handling or any other procedures with a chance of splash or aerosol exposure. Refer to the Institutes Environmental Health and safety Manual, Chapter on Biological Exposure Control for more information. IX. Protocol / Professional Conduct
Signals from the back door should be answered promptly. All visitors and co-workers should be treated in a courteous manner. A professional work atmosphere must be maintained at all times. If any problems arise regarding interactions with funeral home or transfer service personnel, the supervisor, a field agent or senior staff should be contacted to assist with the resolution of the matter. All SWIFS employees must maintain the confidentiality of all Institute business matters. The logbook must be secured and is not available for review except by appointment with Institute Administration. Any inquiries (telephone or other) regarding the status of a case must be forwarded to a field agent for response. The telephone on the morgue desk is used only for business matters. For personal calls, another phone line must be used.
3.8
Revised 1/03/08
CHAPTER 4 PERSONAL EFFECTS I. General
All clothing, jewelry, and other personal effects are inventoried on all bodies at SWIFS at least one point in time. When items are being inventoried, care should be taken to make an accurate and thorough examination. Money should be accurately counted, recording the number of each denomination of currency bills, the total amount of coin change, and the combined total of all money. If the field agent or medical examiner finds more than $300 cash, it is handled according to a later paragraph. Jewelry should be described in generic terms, such as yellow metal instead of gold, white or silvery metal instead of silver and clear colorless stones instead of diamonds. Credit cards are individually listed with their number. All government issued identification-type cards are retained as in Section III below. All personal effects, after being inventoried by field agents or pathologists, are placed into labeled transparent tamper-evident envelopes, sealed, then initialed and dated across the seal by the field agent or pathologist. II. Body Receiving
An inventory is done at body check-in of clothing (simply record whether none, wearing, lying on, or with the body), of all visible jewelry, and of the personal effects after going through the pockets to collect the items. The inventory is limited to a visual examination and physical pat-down of the common areas of the body/clothing in which items may be located. The employee should not turn over the body, remove clothing, or remove paper bags from the body. Hospital bags containing clothing do not need to be opened for detailed inventory at this time; they are to be sealed with evidence tape. Items missed in this initial inventory will be picked up later by the pathologists inventory This inventory is done in the presence of the transfer person (but is not done by the transfer person), the items are recorded on the Body-In sheet, and the form is signed by the receiving employee and countersigned by the witnessing transfer person. The jewelry on the body and all clothing are left in place, and the personal effects and other valuables are placed into a transparent tamper-evident envelope and taken with the carbon copy of the Body-In to the field agent area. Any medications with the body are also taken up to the field agents as per a later paragraph. The Body Receiving and Releasing chapter has more information on the details of inventory, paperwork, etc. at the back door. III. Field Agents Inventory
From Scene: If the field agent releases property to a family at the scene, the release should be documented in the investigative report. If the field agent retains any property/personal effects from the scene, the field agent inventories the items at the scene in the presence of a witnessing police officer, at the least including counting any valuables such as money and credit cards. The field agent then completes a detailed inventory of the items upon their return to the office, seals the items in a tamper-evident transparent envelope, writes their initials and date across the seal, and places the items and the inventory back with the body. Items deemed appropriate for further examination or identification as evidence or drugs/medications will be removed from the property and submitted appropriately. Property is expected to be inventoried and placed with the body prior
4.1
Revised 1/03/08

to examination by the medical examiner. Only under extenuating circumstances should the property not be available to the medical examiner at the time of examination. The field agent prints three copies of the inventory receipt: one to attach to the property bag, one to attach to the Body Disposition form (later signed at body release by the funeral home), and one for the case file. All items are inventoried as previously described (General Section). Money over $300.00 is handled as below. Government ID cards, whether recovered by the field agent or brought by the receiving tech or medical examiner, will be handled as below. They should be included on the personal effects inventory, with the notation (retained). From Body Check-In: When property is recovered at body check-in, it is brought up to the initiating field agent on the case, or to the senior field agent on duty in their absence. The field agent generates a detailed inventory on the computerized Evidence Receipt form, whether the body was checked in by a field agent or an autopsy technician. The items inventoried should be compared against the Body-In inventory. If there are both items from a scene and from body check-in, they may be combined into the same envelope if appropriate, but the inventory should reflect the two separate origins of the items. The property and inventory (copies distributed as in previous paragraph) are placed with the body for examination by the pathologist. The Body-In copy is placed in the case file. From Autopsy Pathologist: If $300 or more is found at examination of the body, the pathologist will inventory the property, place it into a labeled tamper-evident transparent bag and retain it as described below. If any other valuables are brought to the field agents by the pathologist they are handled the same way and should be directed to the Deputy or Chief Field Agent. The field agents do not re-inventory property recovered by the pathologist. Governmentissued identification-type cards, whether recovered at the scene, at body receiving, or by the pathologist, are retained. This includes local, state, national, and international cards, including drivers licenses, immigration cards, passports, Lone Star (food stamp) cards, social security cards, concealed handgun licenses, and more. The personal effects inventory list should show (retained) after these items for the funeral homes/familys information. All Texas drivers license / identification cards are placed into a clear biohazard bag, which is then taped to the receipt for storage in the case file. No additional receipt is needed. All other cards are placed into clear bags then photocopied. Except for the Texas drivers license, the other cards may be combined into a single bag, as long as each card can be seen in the photocopy. A separate receipt is generated for the retained cards. One is for the case file and one is for the bag of cards for destruction. A copy does not need to be attached to the Body Disposition form if the items are already listed as retained on the personal effects inventory. The photocopy of the bag of cards is placed with one receipt into the case file, and the original cards in the bags with the other receipt attached are placed into the designated temporary container for periodic disposal by the field agent supervisor. Over $300.00: If cash over $300.00 is found during inventory by either a field agent or pathologist, it is placed into a labeled tamper-evident transparent envelope, sealed, and the date and
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Revised 1/03/08

initials or signature of the sealing field agent or pathologist is written across the seal. A copy of the completed inventory by the field agent or pathologist is attached. Property should generally be kept together, but if the money or other valuables are separated for secure storage it should be noted on the inventory. Pathologists, at their discretion, may submit any property in this manner for secure storage. If a computerized field agent inventory was done, the field agent makes three copies of the inventory and distributes them as previously. The field agent or pathologist will note Property in Lock Box on the Body Disposition form. The inventorying field agent or pathologist takes the property and inventory to the Chief or Deputy Chief Field Agent for placement in a secure storage area. If the Chief or Deputy Chief are unavailable, the property and inventory are to be placed in the Police lock box located near the front entrance. One copy of the inventory is attached to the property bag, one is for the case file, one is attached to the Body Disposition form (and later signed at body release then added to the case file), and one is given to the Chief or Deputy Chief field agent with a note stating where the property is stored (example in police lock box A).The Deputy or Chief Field Agent will later obtain the items from the Physical Evidence Custodian, and place the property in the secure property storage area. When the Deputy or Chief receives property, they will check to see that the property was inventoried, packaged, and labeled in accordance with the established procedures; the Field agent supervisor will address any issues with the submitting field agent or pathologist. Property in the secured storage area is only retrievable by the Deputy or Chief Field Agent, so it is best to request funeral homes to pick up decedents during the day shift hours if the Body Disposition form shows Property in Lockbox. The person sending the paperwork down at the time of the body release will notify the Deputy or Chief Field Agent of the need to retrieve the property. The employee releasing the body signs for the property from that field agent and takes the property down for release. If the body is being released without the property due to inaccessibility, it is noted on the release forms and the funeral home is told to call during the proper hours to arrange its pickup. IV. Property Release
If any personal property is to be released by field agents to the family before the body is released, it may be retrieved from the body cart. Property may only be released to the listed next-ofkin or to another person with the NOKs written permission. A photocopy of the receiving persons drivers license / identification is made and stapled to the receipt for the case file. The receipt for evidence is signed by both the receiving and releasing persons, and the date and time are recorded. After the property is released, a coy of the signed receipt is attached to the Body Disposition form, so the employee releasing the body and the receiving funeral will know the disposition of the items. If the envelope is opened for any reason to divide property, the field agent must cut off the previously sealed and initialed end, place it into the bag, and re-seal the end when finished, recording the date and their initials or signature over the new seal. A supplemental report is generated regarding any changes made in the inventory, with copies distributed as the original inventory (property bag, Body Disposition form, and case file). At body release, the funeral home signs for any property being released with the body. Personal effects to be released are generally with the body; if property is in the lockbox the
4.3
Revised 1/03/08

procedures in the preceding section regarding money over $300.00 are followed. Refer to the Body Receiving and Release chapter for the body and property release procedures. Property is never released with the body on county disposal or State Anatomical Board cases. Property disposition is supervised on these cases by the deputy chief field agent. Clothing on all of these cases is destroyed. If family is known, property and jewelry is released to them, if it is not otherwise being retained (rare, as in for evidence). If no family can be found, or they refuse to accept the releasable property, it is held for 90 days then donated to Dallas County. V. Medications
From Scene: Refer to the Field Agents chapter for information regarding collection and transport of medications from the scene. From Body Check-In and Pathologists: If medications are received in a sealed evidencetype bag, the bag is initialed on a chain-of-custody area if available, or near the sealed end. The unopened bag is taken to the investigating field agent to securely store or inventory as appropriate. If that field agent is unavailable, the bag may be given to any field agent who will then or later log it into the medication book and place it into the drop-in lockbox. Medication bags are to be handed directly to a field agent by the employee receiving the body or the pathologist, not left unattended in the field agent area. If other medications are found on or with a body, they are placed into a labeled transparent tamper-evident (Kapak) envelope, which is then heat-sealed and initialed or signed and dated over the seal. The bag is taken as above to the initiating or another field agent. The pathologist also has the option of submitting any medication to the laboratory for examination if indicated. VI. Pathologists
When the body is being examined by the pathologist, all remaining items on or with the body are inventoried by the pathologist as described earlier in the General Section. The pathologists inventory is recorded on the Clothing List, with areas for clothing, personal effects and jewelry; all three sections must be completed. The pathologist should correlate their inventory with any previous inventories made at body receiving or by the field agent. Sealed hospital bags are opened and inventoried at this time. If there is a sealed envelope of personal effects with an inventory by the field agent, the ME reviews both (usually without opening the envelope), and approves the release of all items if appropriate. To open the tamper-evident envelope, cut off the previously sealed and labeled end of the bag and place it inside the bag. Reseal the newly cut end, write the date and pathologists initials or signature across the seal. Note on the field agent inventory any alteration of the contents, and sign and date the note. Make copies or note the same changes on the inventories attached to the Body Disposition and in the case file. Clothing on homicide and many suicide cases is routinely retained, and may be submitted for either evidence analysis (such as for gunshot residue analysis or examination for possible semen or trace evidence) or to be returned to the investigating agency. Even if clothing is retained, the personal effects are often released with the body for the family. If over $300 is found, it is taken to the chief or deputy chief field agent and handled as in the
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Revised 1/03/08

earlier section. The pathologist has the option of taking any valuables such as jewelry or lower amounts of cash in the same manner for secure storage if desired. If government issued identification-type cards are recovered by the pathologist, they are to be given to a field agent for a receipt, photocopy, and filing / disposal as appropriate as in the earlier section III. If medications are found with the body, they are placed into a tamper-evident bag, sealed, labeled, and given to a field agent as in the previous section. Refer to the Field Agent chapter for more information on handling and disposal of medications. House-arrest type monitors are usually wanted back by the monitoring agency. If the medical examiner finds one, the field agent should be requested to call the appropriate agency (most often Dallas County Probation) to determine the disposition of the monitor, which is usually cut off and returned. When the Clothing List is complete and signed by the pathologist, the last (yellow) copy is retained in the file for dictation purposes, the pink copy is kept with any items being retained, and the remainder is placed into a clear sleeve and placed on the cart with the body. One copy, or a photocopy, is to be attached to the valuables bag if one is taken up for secure storage. The funeral home receiving the body will confirm the items, and sign for those taken on the top white copy. This signed top copy is permanently kept in the case file with the other body receiving and release papers. The funeral home also signs and leaves the field agent inventory page for additional personal effects if there is one. At the time of examination of the body, the pathologist has these options: If the clothing is being released with the body, either wet or dry, it is placed in red biohazard bags and left with the body. All bags must be labeled. If wet clothing is retained for Criminal Investigation Laboratory examination, storage, or release, it is placed into breathable tamper-evident bags. Care should be taken to not shake off any possible evidence. The items in the bag should correlate with the inventory list. Most cases will fit into one bag, but more than one can be used as needed. If the clothing is wet, it must be dried in the tamper-evident bag before that bag is placed into a paper bag. The pink inventory copy is placed in a clear plastic envelope and placed with the clothing into the drying bag which is then sealed to prevent cross-contamination between cases. The bags are stored during drying in the secure clothing closet. The exception to this is suspected arson cases, which are placed into paint cans or non-permeable plastic bags and sealed. Refer to the clothing section in the evidence submission chapter for more information on the handling and submission of clothing, including the use of chloroform to kill insects. When placing dry clothing into paper bags, either at the time of autopsy or after drying, the items should be placed into the bag and the top of the bag folded over so that there is some remaining room in the bag. Label the outside of the bag; if more than one bag, label each
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Revised 1/03/08

specifically with something like #1 of 2 bags. The medical examiner seals the folded edge of the bag with evidence tape, writes their initials and the date on the tape, then re-tapes over that with clear packing tape if it looks like there is any risk of the evidence tape tearing (which frequently happens later during handling of the large irregular paper bags).
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Revised 1/03/08
CHAPTER 5 AUTOPSY TECHNICIANS The autopsy area is operated during the day shift every day, including holidays, generally from 7-3:30. The autopsy technicians responsibilities include preparing the autopsy area with instruments and supplies, preparing the bodies for autopsy, assisting the medical examiners or other pathologist in performing autopsies and external examinations, assisting in the collection of physical evidence from bodies, cleaning the autopsy area, sealing, labeling and delivering specimens to various departments, and performing other duties as assigned. The autopsy technician must conduct duties in a safe, orderly, and prudent manner following proper safety procedures (see Safety Chapter). They assist the pathologists in the training of residents, fellows, and other professional persons in this field, and must also be able to cooperate and work with other groups such as police and Transplant Services. Each case is handled on an individual basis as determined by the pathologist, but the job generally includes: 1. Ensure that supply inventory is maintained, that the proper instruments and supplies are ready for the day's examination at each workstation, and that knives are sharp. Ensure also that technician staffing is appropriate for the day. Consult the pathologist with any questions regarding the proper processing of each case. Remove body from morgue storage and compare case number and information in folder with that on the body tag. Assist the pathologist in obtaining an as-is photograph if needed (possible homicides and suicides) before any further processing of the body. In violent deaths (firearms, stab wounds, child abuse), skeletal remains, decomposed or burned bodies, or possibility of air embolism, take necessary x-rays (including the case number, generally on the left side and before removing the clothing), develop them, and show the pathologist. The X-ray exposure badge must be worn when performing X-rays. Procedures and settings are posed in the X-ray area. Under direction and supervision of pathologist, assist in collecting physical evidence as needed and give to the pathologist. This may include gunshot residue kits from the hands, sexual activity kits, head hair standards, fingernail clippings, hairs and fibers, etc. Under direction of pathologist, undress the body, review clothing with pathologist, and assist with its release or storage. If the clothing is being released, it is placed in plastic Biohazard bags. If for the crime lab, storage, or release to authorities, it is dried and bagged as appropriate (see Personal Effects and Evidence chapters). If submitting for accelerants, it is placed into paint cans or non-permeable plastic bags and sealed. Make certain all clothing, evidence, etc. is properly labeled.
2. 3. 4. 5.
6.
7.
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Revised 1/03/08

8. Prepare the body for external examination and/or autopsy, including weighing and measuring, fingerprinting, palm printing (homicides and suicides), foot printing (small children and pilots), and cleaning the body. Give prints to pathologist to approve and initial for filing. See Chapter 10, fingerprint section, for more information on fingerprinting, including decomposing bodies. Ensure the body and cart are clean and suitably positioned for identification photographs and photographic documentation of wounds or their absence. Assist the pathologist in taking photographs (keeping the areas to be photographed clean, moving labels, etc). With the pathologist's supervision, collect toxicology specimens (collecting vitreous fluid into a new syringe, and rinsing the syringe with water between other specimens), open the body, measure fluids in body cavities, assist the pathologist in determination of penetrating and perforating wound tracks and in recovery of projectiles, cut and remove vital organs (see Ch. 10, Evisceration section), weigh and place organs near examination table, open skull and remove brain. Wear appropriate protective apparel (see Safety chapter). Upon completion of case, return organs in a large doubled or heavyweight plastic bag into body cavity of deceased, close the body, clean the body and cart, close the body bag, and return it to the cooler. In some cases, use special procedures such as removal of eyes in babies for examination, removal of spinal cord, removal of brains in babies by suspending in water, or opening of body cavity or heart under water to check for air. If requested, suspend brains in 20% formalin in labeled buckets for fixation. Use special techniques such as injection or soaking the fingers, or the "glove" method for obtaining legible fingerprints from deceased's fingers if decomposed, mummified, or burned. Label, seal, and put away the "stock" tissue bag and the toxicology specimens
9.
10.
11.
12.
13. 14.
Refer to later sections for more details regarding specific procedures, especially Chapters 10 Routine Handling of Cases, 11 Evidence Collection and Submission and 12 Specific Types of Cases. Many other duties of the autopsy technicians are not directly related to individual cases. Some of the responsibilities divided among the technicians are 1. Daily, file x-rays and submit the toxicology and histology specimens and request forms.
2. Daily (or more frequently if necessary) clean and decontaminate the autopsy room (including the cutting stations, clean paperwork counters, stands, and floors) and x-ray area. (See Safety Chapter). Document the cleaning procedures on the daily cleaning log. 3. Weekly, remove preserved brains as instructed for Neuropathology Conference and wash in running water, then put away the specimens as directed after the conference. Periodically do the
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Revised 1/03/08

same with hearts saved for Heart Conference. 4. As needed, dispose of the biohazard trash following the current guidelines, and save used formalin for proper disposal. 5. Launder and put away the institutes scrubs.
6. Staff the body receiving/release station during autopsy hours and in the evenings as scheduled. The evening back door tech is also responsible for checking the body storage and autopsy area refrigerators and freezers and recording the temperatures and their initials onto the posted log pages. If any temperature is outside of the posted ranges or if a rising trend is noted, maintenance should be called (see Quality Assurance chapter).
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Revised 1/03/08
CHAPTER 6 PHOTOGRAPHY I. General Policy
All DCME cases, whether autopsies or inspections, are photographed in the autopsy room by the pathologists, and all cases with scene investigations are also photographed there by the field agents. The photographs are meant to be fair and accurate representations of the body at the time of the examination. Each case is handled on an individual basis. For specific instructions regarding use of the cameras, refer to the instructions. Photographs should be downloaded into the decedents case file at least daily. They may be thinned at that time of duplicates, poor quality (and unnecessary) photographs, etc. They should not be thinned at a later time, since copies may have already been made, and no deletions or alterations may be made after they have been provided to anyone. Photographs are permanently retained, either in the original form or another approved archive method. II. Health and Safety
All material being photographed should be treated as contaminated. Refer to the Safety Manual for details on personal protective equipment (PPE) for the job being performed. Gloves must be worn when moving autopsy carts, handling bodies, gross specimens, bloody clothing, and evidence, and any other tasks that would require safe handling. The cameras are clean and should be kept clean and away from contaminated surfaces. Gloves should not be worn when handling photographic equipment. The use of gloves, even clean, promotes the blurring of the clean/dirty separation, and the presence of any powder can easily damage the expensive cameras. III. Field Agents / Scenes
Photographs are to be taken at any scene attended by the field agent. An identifying case number must be included in at least one photograph from each case, preferably the initial photograph. The photos generally consist of the decedent, with at least one orienting shot showing the decedents position relative to the surroundings, and maybe close-up views of the body. Additional photographs may include the surroundings, related articles such as drug paraphernalia or empty medication bottles, the neighborhood, and other items as appropriate for the case. The photographs should be able to document the scene as it was at the time of the field agents investigation, and to help tell the story of decedent as related to the death. The field agent report should state if photographs were taken.
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IV. Autopsy
All photographs include the appropriate case number and a scale. The more distant views using the large metal case numbers are on plates of a standard size.. Close-up views should use a ruler or the preprinted labels with an included ruler scale. Pedestrian cases may use the yardsticks, and small patterned injuries such as bite marks should use the ABFO #2 scale. When scales are used, they should be in alignment with, and in the same plane of focus as, the injury/object being photographed. Non-DCME personnel, including law enforcement attending an autopsy, are not allowed to take photographs in the morgue. State law requires that medical examiner autopsy photographs be under the control and custody of the medical examiner. They may obtain copies of the autopsy photographs through the Records department in the same manner as other qualified people (refer to the Records chapter). All homicides, suicides, custody deaths, and some accidents (including pedestrian failure to stop and render assistance cases) generally require as-is photographs of the upper and lower anterior views of the body in the condition it is received. Body bags obviously have to be opened first, and sometimes a sheet loosened or pulled back to reveal the body. This photograph is to document any evidence, i.e. whether the hands are bagged, clothing in place, etc. All cases must have overall photographs: an identification photo of the face and upper and lower anterior views of the clean nude body. Some cases may require a clean upper and lower posterior view. Babies generally get both front and back views. The photographs are taken after the body is clean, wounds are clean, and there is no more blood or hairs on the body or cart. The case number on the overall photos is placed at approximately the hand or hip level, and the photos taken so the number is visible in both upper and lower views. The toe tag should also be visible in the lower photograph. General tips for camera use in the autopsy area: Keep the camera perpendicular to the target; using the tilting LCD monitor enables this to be done without having to lean over the body. Head shots and close-ups work best if the camera is held back and the zoom function is used; if the camera is too close, the head looks distorted. There are lighting variations in the room that can have a significant effect of the picture. If all pictures for a given case are taken with the cart in the same spot in the room, this variation will be minimized. The cameras are optimized for the artificial lighting of the autopsy room, so the areas near the windows where sunlight is streaming in should be avoided (or the blinds closed). Take the photo from the decedents right side, and take the head-identification shot before the upper and lower body shots, just for consistency. Any wounds or other close-up photographs should be taken when the body is clean. The case number and a small scale are always included. The number should be oriented so that the top of the label is toward the head end of the body if possible; this way even a photo too close to see any anatomic landmarks can be oriented as to direction. The first shot is an orienting view taken at enough distance to show the injury and to show a frame of reference of where it is on the body. The
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Revised 1/03/08

next one will be the close-up view with the label in the same location as in the orientation shot. Some areas such as hands or face may need only a close-up view if the would can be oriented in the same photograph. Each case is handled differently, with the photographs taken up to the discretion of the pathologist. In general, the following types of cases get these photographs, in addition to the routine overall and identification photos. Refer to the chapter on the handling of specific types of cases for more information. Homicide and suicide cases As-is photos (including clothing, hospital tubes, blood, etc.), possibly back overall views, orientation and close-ups of injuries. Intra-oral gunshot wounds may require the use of a mirror. Hanging and ligature strangulation cases may get multiple views of the neck with the ligature in place, photos of the neck after the ligature is removed, and possibly photos of the ligature alone. The overall and identification shots are taken after removal of the ligature. Child abuse Back views, both clean and after the pathologist dissects and reflects the skin. These cases get extensive documentation, even of negative findings. Bite marks and small patterned injuries always use the ABFO #2 ruler. Pedestrian traffic cases as-is sometimes on FSRA cases, Lower half of overall photos are taken with a yardstick next to the legs, with the zero end at the level of the bottom of the heel of the straighter of the two legs. Custody death / Police shooting cases same as regular autopsy plus a walk around of the body, which usually includes both left and right sides (upper and lower shots) of the body, and sometimes scrotum and back views. If wrists and feet are incised, photos are taken before and after cutting. Unidentified persons addition of a lateral view of the face, and close-ups of identifying features such as tattoos, unusual scars or marks, and possibly clothing. Skeletons photos of any identifying feature, and a walk around series of front, back, left, right, top, and bottom views of the skull. The front view should be taken in the Frankfort Horizontal Plane, with the bottom of the eyes in line with the top of the ear canals. V. Requests for Prints
Autopsy photographs are not currently considered public records under Texas law, but are available under subpoena or court order. Scene photos are available as public record. Certain photographs are made available by the field agents to local investigating agencies for use in identification of decedents, but all other requests for photos have to be made through the Records department. Refer to Chapter 8, Records, for more information on procedures, fees, etc. regarding release of photographs.
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Revised 1/03/08
CHAPTER 7 PATHOLOGISTS The Medical Examiners are all Forensic Pathologists who have been hired by the county in regular staff positions. They are all qualified physicians who have done residency training in pathology and subspecialty fellowship training in forensic pathology. The medical examiners at DCME must be board-certified in anatomic and forensic pathology within two years of the hire-date, and must be licensed, or in the process of becoming licensed, to practice medicine in the State of Texas. The medical examiners report to Deputy Chief Medical Examiner Joni McClain and to the Chief Medical Examiner Jeffrey Barnard. In addition to the medical examiner staff, there are usually two Forensic Pathology Fellows, who are pathologists doing a one-year fellowship training program here in forensic pathology. The Fellows generally do the same type casework (with some exceptions) as the staff Medical Examins, but are under the supervision of the Medical Examiners. The pathologists, both staff medical examiners and fellows, are involved in a wide variety of activities including investigating the circumstances of death, performing postmortem examinations, certifying the cause and manner of death, and providing information to families. The medical examiners sign the death certificates on all unnatural deaths in Dallas County (fellows may sign their own cases if they have a Texas medical license). The death certificates on out-of-county cases are completed by the local Justice of the Peace. Medical examiners also review all No Case reports, and either approve them or request further investigation if there are any questions as to a case fulfilling all the requirements for a No Case (see Field Agent chapter for more on jurisdiction). They also review the medical information and sign death certificates on all Absentia and After the Fact cases. A medical examiner is required by law to review the death certificate and sign a permit for the cremation of any body that died in Dallas County (see Ch. 8, section on cremation permits). The pathologist may be involved in the initial decision by a field agent as to whether a case should be brought into the office, and may occasionally be called after hours with such questions. They may also be called to determine whether organs may be donated for transplantation prior to a body being transported to DCME (see Transplantation Chapter). The pathologists take photographs and supervise and work closely with the autopsy technicians to ensure that all appropriate procedures are performed during the postmortem examination. The pathologist completes and signs the clothing and jewelry inventory forms and the toxicology request form, and dates and initials the specimen labels. The medical examiners rotate the pit boss duties of staffing the fellows cases, ensuring that bodies are transferred from the local hospitals, ensuring that all cases of the day are taken by a pathologist or held over as appropriate, assigning pathologists paperwork days as appropriate, and following up on the autopsy technicians general duties (especially in the absence of the autopsy supervisor) such as the daily cleaning checklist and stocking workstations and supplies. The same day that the examination is performed, the pathologist is to dictate a report (see Chapter 8, Records and Reports), which can later be completed and/or changed following review and inclusion of any additional test or investigation results. If a cause of death is left after the
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Revised 1/03/08

examination as pending, it is up to the pathologist to complete whatever is necessary to determine the cause of death and "unpend" the case. After the original file is created by the field agent, all supplemental information received is routed through the pathologist before going into the decedent's file. Other departments may be involved in the gathering of information, testing, or typing of a case, but it is the pathologist's responsibility to see that the report is completed in a timely manner. It is also the pathologists responsibility to cull the final case file, such as disposing of preliminary incomplete versions of the autopsy report and disposing or thinning the medical record copies to only those considered important to retain in our file. The medical examiners review and cosign each others homicide reports. Pathologists are involved in the teaching of medical students and hospital residents who do rotations through the DCME Office. The Medical Examiners have faculty appointments with the University of Texas Southwestern Medical School, which also grants a fellowship certificate to the graduating Fellows. The residents perform autopsies on natural deaths and others with minimal litigation potential, and all are reviewed and cosigned by a medical examiner. A written and slide examination may be given at the end of the rotation. The medical examiners are also on staff at Parkland Memorial Hospital, and share in staffing the pathology residents there for the Parkland autopsy service. Pathologists, as well as experts in other specific departments of the Institute, provide testimony in court and at depositions. Medical examiner personnel are available to both the prosecuting and defense attorneys to discuss a case prior to trial, and are expected to be independent and impartial professional witnesses. Medical examiner scheduling for court cases is arranged by the administration secretary. Depositions on civil cases should be arranged to be held in our office during working hours. Most of the court cases are local, but a significant minority involves out-ofcounty trips. These are usually close enough to drive, and may be car-pooled with other witnesses from the Institute. Occasionally a flight will be necessary; the requesting agency will generally make all arrangements. A subpoena must be received in our office prior to going out of town to court. Criminal and civil trials, depositions, and meetings with attorneys are all part of the job, so all such time is on-the-job time, for which Dallas County will be paid by the requesting/summoning agency or attorney. In general, DCME will bill the criminal courts for the medical examiners time after the testimony or meeting, while civil matters or privately retained attorneys are required to pay in advance. Personal out-of-county travel expenses will be reimbursed, however, directly to the employee. In most cases a Witness Reimbursement form (for mileage and meals) is completed while still at the courthouse, filed either with the District Clerk or District Attorneys Office, and the money is sent later by the state. Any requests for reports or copies of our records, including photographs, are to be referred to the Records Custodian. Some of this material is public information, but our office must usually have a written request, sometimes a subpoena, and the appropriate fee payment. Reports should not be copied and handed to district attorneys or other visitors just because they are already in the office.
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CHAPTER 8 RECORDS / REPORTS / RELEASE OF INFORMATION I. Release of information
Under Texas law (Government Code, Chapter 552), the public has the right to access most Dallas County records. Dallas County officials and departments are expected to promptly release requested information that is not confidential by law, unless an exception to disclosure exits or an Attorney Generals Opinion is sought. See later sections in this chapter for specific types of reports and their availability. The information in these reports is clearly of interest and value to a variety of people (law enforcement, physicians, family, etc), but that value has to be weighed against the possible harm in releasing incorrect or premature information, and potentially damaging a criminal investigation. Confidential information should not be relayed out of curiosity by employees to friends or family members. No information of an investigative nature is ever released by this office except to the investigating agencies (for example, it is okay for an ME or field agent to tell police on a recent working homicide how many shots and if bullets were recovered, but not okay to tell friends or media the details of a death scene or findings). No information is released on out-ofcounty cases, except to the investigating agency, without prior approval by the referring JP (other than written reports as per policies in later sections of this chapter). No information is ever to be provided by autopsy technicians or transcriptionists. The records office staff is allowed to release or confirm decedent name, cause and manner of death, general area of the death scene, and age/race/sex of decedent. Field agents may also release cause and manner, as well as such information as additional autopsy findings to the investigating police, and preliminary information to media such as age, race, and sex of decedents, and a street block number where the death occurred. The decedents name is never released before notification of the family, and the home address is never to be released. MEs may release the same information as the field agents, and have the discretion to release more information as appropriate, such as toxicology results or information on a natural disease to investigators or family. Interviews will not be granted at death scenes or court. News media are allowed the following verbal information from the field agents: decedents name (only after nofification of next-of-kin), age and/or date of birth, sex, cause and manner of death, general place of incident (street block #, not exact address), place of death (if different, in hospital), and funeral home. Medical examiners are not allowed to discuss cases or grant interviews with the media regarding work without first checking with the chief medical examiner, who will obtain approval from the county commissioners prior to the interview. All records related to a case are placed in the case file. Case records and related inquest materials are stored using established protocols (see Appendix VIII). Requests for copies of parts of the file, including under the Open Records Act, will be handled by the Records Custodian (see Section VII for information on request and release of autopsy and external examination reports). The request should be written, and can be delivered by mail, fax, or in person to the Records personnel. The request should include enough description and detail about the request to enable DCME to accurately identify and locate the information requested. The person requesting records should cooperate with the countys reasonable efforts to clarify the type or amount of information requested, and should respond to written estimates of charges for reproducing records and make
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timely payment for all mutually agreed charges. Records not originating from the Medical Examiners office (such as hospital records and police reports) are never automatically released by us and must be requested from their original source, unless we are directed to do so by the District Attorney.. Only authorized persons, consisting of the medical examiners, and the toxicology supervisors, may release toxicology information over the telephone. If the caller is requesting interpretation or any information beyond a blood alcohol level, the call will be referred to the medical examiner. If a J.P. or investigating agency calls for a blood alcohol (often needed by statute quickly for their reports) on a case that is incomplete, the field agent taking the call will record the investigators name and contact information, and the decedents name and case #, and forward that information by e-mail to the designated toxicology supervisor. If the result is available, the toxicologist will make and document the verbal notification. If an emergency response person (EMS or Police) has a potential exposure to a blood-borne infectious disease, that person should follow the procedures described in the Safety Chapter, section on Occupational Injury and Exposure for follow-up testing, treatment, and/or counseling. The results (positive or negative) on any case tested for possible occupational CPR exposure are reported by our Chief Investigator to the Dallas County Exposure Nurse. She is responsible for making the notifications, as well as follow-up counseling and recommendations. Our office should not generally release infectious disease testing results directly to the potentially exposed person. HIV results may be included in the Autopsy Report at the discretion of the pathologist, with no legal requirements or restrictions currently in the State of Texas. In Texas, the decedent's medical records remain confidential but their autopsy reports are publicly available information. II. Photographs
Autopsy photographs have been excepted from public disclosure under Section 552.101 of the Govt. Code in conjunction with section 11 of article 49.25 of the Texas Code of Criminal Procedures. They are available by subpoena or other authority of law (e.g., court order). Scene photographs are available as public records. All requests for photographs are made through the Records Custodian. Photographs are never to be released directly to investigating agencies, attorneys, etc. without having them go through Records, except for photographs needed for identification of a decedent. One set is free on Dallas County cases and on out-of-county cases to the investigating or prosecuting agencies; telephone or written requests are acceptable. Fees are charged for additional sets and for most other requesting personnel, even with subpoenas. Photograph copies cannot be initiated until any required request or court affidavit and all monies are received unless authorized by an Institute supervisor. The request letter must state the case number, number of views, and number of prints per view. Two or three weeks is generally required to obtain prints. Photographs are permanently retained, either in the original form or another approved archive method. Refer to the chapter on photography for more information.
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Revised 1/03/08

III. Death Certificates
Death certificates on Dallas County cases are filed electronically with the state. For those funeral homes that are not yet on-line, DCME can print a paper copy for them to complete their part of the certificate. Our opinion as to cause and manner of death is provided on out-of-county cases to the JP, who is responsible for filing the medical part of the death certificate. Qualified persons including immediate family may obtain copies from the appropriate Bureau of Vital Statistics. The Medical Examiner's responsibility is to provide the information to the records secretary to complete the medical portion of the certificate. A Texas Medical License is required of any DCME physician signing a death certificate. Hospital residents, with or without a license, do not sign DCME case death certificates. DCME completes our part of the death certificate immediately after our investigation or examination (generally same or next day) so the funeral director can file it with vital statistics within ten days of the death. Any changes to the electronic death certificate record after the medical examiner has signed (electronically certified) the record will require decertification and recertification. These changes can be made only if the DC has not been filed and accepted by the local registrar; after that, an amendment to the death certificate would have to be completed. The funeral directors fill in most of the personal information about the decedent. The medical part includes several components:
Date and time of death - Be as specific as possible. If a death is witnessed, as in a hospital, the pronouncement time may be used. If the actual time of death is unknown, put "Found XX time". Always use a 12-hour system, and give a.m. or p.m. "Approximately X a.m." is also acceptable.
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Date and time of pronouncement - This is always known, whether a death occurs in a hospital or elsewhere with a pronouncement by a paramedic or a field agent, and whether the death was witnessed or the person was found dead. Signature, title, and medical license # of the signing physician. The signature is now electronic, confirmed at entry by a passcode. Cause of Death - The cause of death section is an opinion, derived from the investigation into the circumstances of the death and the findings of examination of the body. The requirement for certification is a statement of the general disease process or condition, which underlies, and is most likely responsible for death. The underlying cause of death is defined as the disease or injury, which initiated the train of events, however brief of prolonged, leading to death. Examples of causes of death include gunshot wound of the head, coronary artery atherosclerosis, and Acquired Immunodeficiency Syndrome (AIDS). The mechanisms of death, such as cardiac arrest, or shock, are non-specific final common pathways of death so general and meaningless that they should not be included on the certificate. The certificate contains lines for inclusion of the immediate cause, the antecedent causes, and the underlying cause, if desired, as well as the contributing causes of death. The immediate cause of death on line (a) may be the only entry if only one condition was present, e.g., "asthmatic bronchitis". If multiple conditions are listed in Part I, these should be listed so they represent a distinct sequence of events, with each condition a consequence of the condition entered immediately below it, and with the underlying cause of death entered on the lowest line used in Part I. Examples: 1. 2. a. Intracerebral hemorrhage due to b. Hypertension a. Hemopericardium with cardiac tamponade due to b. Rupture of myocardial infarct due to c. Coronary artery atherosclerosis
Traumatic deaths may also be certified as briefly as one line, e.g., "Blunt force injuries" in a motor vehicle accident case, or in several lines, e.g., Example: a. due to b. due to c. Aspiration pneumonia Quadriplegia with prolonged immobility Gunshot wound of the neck
It would also be acceptable to certify the previous case as simply, "sequelae of gunshot wound of neck".
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To the right of these four cause of death lines are spaces for the approximate time interval from onset to death. Broad terms may be used, such a minutes, hours, days, months, or years. If no time interval is provided, unknown will be used; this area cannot be left blank. The Part II space is for other significant conditions which were present at the time of death, and that contributed to death, but did not result in the underlying cause of death listed in Part I. For example, a patient who died of chronic alcoholism with ascites may have also had hypertensive heart disease entered in Part II as a contributory cause of death. If the cause of death (or manner of death) is unknown after performing the examination, and there is a reasonable expectation that the performance of certain tests (toxicology, microscopic, examination of the brain after fixation, etc) or further investigation will significantly change the diagnosis (or the manner), then the certificate may be reported as "pending" whatever tests are required. As soon as the additional information is received, the pathologist notifies the secretary to send an amended death certificate. Occasionally, even a thorough autopsy including additional studies such a bacteriology, toxicology, and histology, may fail to reveal the cause of death. These cases may be certified as Unknown, in one form or another, such as "Unknown natural causes", or even just "Undetermined causes". Manner of Death - The manner of death refers to the circumstances in which the cause of death occurred. The five possible manners are Natural, Accident, Suicide, Homicide, and Undetermined. As with causes of death, undetermined is only to be used after investigation has been pursued as far as possible. If the manner is unknown after performing the examination, but significant additional findings are expected, the certificate may be sent temporarily as "Pending investigation". How occurred - This line must be completed on all homicides, suicides, and accidents, but not generally on natural or undetermined causes or those cases still pending. It should be a brief clear statement of what happened without going into excessive detail. For example, a homicide might be "shot by another person", instead of "shot by Mr. Smith after a lover's quarrel". On motor vehicle accidents, there are several important points to include for statistical purposes, such as whether the decedent was the driver, a passenger, or pedestrian; single or multiple vehicles involved; ejected from vehicle or not; or whether a vehicle did not stop and render aid. Examples: "Driver ejected when motor vehicle left roadway and overturned", and "Pedestrian struck by motor vehicle which did not stop," or "Passenger in a collision of two motor vehicles". Non-vehicular accident examples include: "Burned using gasoline to light stove," or "slipped and fell while shoveling snow". This space may also be used on unexplained infant deaths, to include certain relevant stressors or gray-zone factors such as bedsharing with 2 adults, unsafe sleeping surface, or previous unexplained infant death of a sibling. Fetal death certificates are used for stillbirths. They are not electronic and are filed manually. By state statute, a stillborn fetus of less than 20 weeks gestational age does not need a birth or death certificate. The state now defines the 20 week line as a fetus weighing 350 grams or more; if the weight is unknown, 20 weeks is calculated from the start date of the last normal
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Revised 1/03/08

menstrual period. If there was any sign of life, however brief or premature the baby, a standard DC is used. IV.` Unpending/Amending Death Certificates
When a change or correction must be made on a certificate that is already released, one of two amendment forms is used. These are not electronic, but remain manual. The amended death certificate is an abbreviated version that basically includes only the changes. When a death certificate that was left pending certain tests is finalized or unpended, the pathologist submits an unpending form to the front office, which then complete a short amendment form to change the cause and/or manner of death. Another form (with a $15.00 fee) is submitted when amending/correcting such information as decedent's name, sex, or date of birth. V. Cause of Death Reports
This is a brief one-page report including the cause and manner of death with no additional examination findings. The front office secretary types the page from the death certificate information provided by the pathologist, obtains the pathologist's signature (medical examiner, fellow, or resident), and sends the report as soon as possible (generally the same day or next morning) to the investigating police agency on all cases and to the Justice of the Peace on out-ofcounty cases. A copy is also sent to the DAs office (Witness/Victims Section) on local homicide cases. If the death is from an airplane crash, a copy is also sent to the National Transportation Safety Board (NTSB); if at work, one is sent to OSHA; and if in water (other than something like a bathtub or private swimming pool), one is sent to the Texas Parks and Wildlife Department. A copy is also sent to any hospital when returning medical records. This information is used by the JP on out-ofcounty cases to complete their part of the death certificate, although the JP is not bound by DCMEs opinion. VI. Cremation Permits
Article 49, Subchapter B, Section 10, of the Texas Code of Criminal Procedures requires that before any dead body is cremated, the owner or operator of the crematory shall be furnished with a certificate signed by a medical examiner of the county in which the death occurred, showing that an autopsy was performed or was found unnecessary. The Medical Examiners Office will be provided a copy of the death certificate on all cases needing a cremation permit, unless the death certificate was completed by DCME. If not already assigned a DCME Case or No Case #, a No Case # will be assigned. The medical examiner (licensed medical examiner only, not fellows or residents) will review the certificate and make certain that the death was either certified by a medical examiner or was a natural death appropriately certified. If there is any problem requiring further review of a body by a medial examiner, the cremation may be delayed. This same section of the Medical Examiner law establishes a minimum 48 hour waiting period between the time of death and the cremation, unless the death certificate indicates the death was
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Revised 1/03/08

"caused by the pestilential diseases of Asiatic cholera, bubonic plague, typhus fever or smallpox", or unless the 48 hour waiting period is waived in writing by the county Medical Examiner. Our cremation permit also serves as this waiver. VII. Autopsy and External Examination Reports
The original signed autopsy and external examination reports are kept as part of the DCME case file. Files are kept on-site for approximately 2-3 years then kept permanently in one of two secure off-site storage areas. Files prior to 1987 were microfilmed then destroyed with the microfilm permanently kept on-site. The autopsy and external examination reports are considered public records in Texas and are available to anyone on request, unless an Attorney Generals Opinion is sought. Requests for reports on local homicide cases are all cleared first through the Dallas County District Attorneys Office before those reports are released. Requests on any out-of-county JP cases are cleared through the judge before release of the report; some have pre-arranged approval to release reports. Copies of these reports are provided on local cases as follows: Homicidesautomatically to the police agency; to others after clearance with DAs office, by written request and with payment. Accidents, traffic-related (includes all vehicular cars, trucks, motorcycles, bikes, ATVs) automatically to the Traffic Division of the local police agency and to DPS Accident Records Bureau; to family, insur. co., etc by written request and payment. Accidents, fire-relatedautomatically to the Fire Department; to others by written request and payment Suicides automatically to Dallas police; to others by written request and payment. Natural and Undetermined to police agencies by request; to family, insur. co., etc. by written request and payment. Child deaths 17 years old and under automatically to Dallas Child Death Review Team; to others depending on above manner of death category. They are provided on out-of county cases as follows: Homicidesautomatically to the J.P., police agency, and District Attorney; to others (family, insur. co., etc.) after clearance with J.P., by written request and with payment. Accidents, traffic and fire-related - automatically to J.P. and police agency; traffic
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Revised 1/03/08

also to DPS Accident Records; to DA on request; to others after J.P. clearance on written request and with payment. Natural / Suicides / Undetermined automatically to the JP and police agency; to DA by request; to family, insur. co., etc. after J.P. clearance by written request and payment. Child death 17 years old and under automatically to Dallas Child Death Review Team; to others depending on above manner of death category. Free copies are available on request to the local District Attorneys, to Dallas County court appointed defense attorneys, and to the decedent's physician with written requests. Copies are also available on request for a processing fee to family members, privately retained defense or civil attorneys, and to anyone else. A $15 fee is assessed for a certified copy and a $5 fee for a non-certified copy. Reports are to be dictated the day in which the examination is performed, and completed in a timely manner, except where prolonged special testing or investigation is required. Reports are not sent in an incomplete state. There is no format which must be followed exactly, but certain features are standard, and most autopsy reports include an introductory section including the case number and name; age, race, and sex of the decedent; dates and times of the death and of the examination; place of pronouncement; and the internal organ weights. This is followed by the general external examination findings, identifying marks and scars, evidence of treatment, evidence of injury (usually external and internal together), and the internal examination (except for injuries). A section on microscopic is included if it is performed, At the end of the report is the findings summary, followed by the cause and manner of death, and the pathologist(s) signatures(s). Toxicology and other ancillary test results are usually included at the end, and the report may also include diagram(s). The signature section always has the performing pathologist listed first. Most natural, accident, and suicide cases include only this signature, if the examination was performed by a medical examiner. If the case was by a forensic fellow, the staffing medical examiner and the chief medical examiners signatures are added. If the case was by a pathology resident, only the staffing medical examiners name is added. On cases ruled as undetermined manner, the reports are also signed by the deputy chief and chief medical examiners. Homicides reports are reviewed and signed by all of the medical examiners. Autopsy / external examination reports should not be altered after they have been provided to anyone. Additional pages can be added with a title such as Supplement or Amendment to Autopsy Report. If a report has to be altered (for example, to correct an error while in court or too late to make an amendment page), it should be clearly documented with initials and the date of the change.
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VIII Autopsy (Level I and II) and External Examination Fees
Examinations performed by the pathologists on deaths occurring in Dallas County are done at no charge. There may be fees, however, on these cases for other services such as sending reports or photographs, or analyzing evidence. On JP cases, from other counties, there is a fee which is periodically evaluated and set by the Dallas County Commissioners Court. An inspection, or external examination, has a lower charge than an autopsy. Most autopsies are considered basic, or Level I, with the fee including routine toxicology and histology. A higher charge for complex, or Level II, autopsies is applied to all homicides and selected other autopsies that require extensive testing or other investigations. The decision of whether an autopsy is complex is made by the performing medical examiner, and may involve consultation with the chief medical examiner.. IX. Notifiable Diseases
Notifiable Diseases in Texas, in the Appendices, is a list of the communicable and occupational diseases, which are required to be reported in the State of Texas. Any pathologist in the Institute with a case having any of these diseases is obligated to report it, unless it is known to have been previously reported. The field agent supervisor makes the notification, and keeps a record of the reports.
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Revised 1/03/08
CHAPTER 9 DESCRIPTION OF INJURIES
The following is a general format of the features, which should routinely be described in cases involving traumatic injuries. Only the most commonly seen injuries are included here, and there will be frequent exceptions to these guidelines that will have to be considered on an individual case basis. For most homicides, suicides, and cases where firearms are involved, there should be a statement (usually at the beginning of the External Examination Section) as to whether or not there are bags on the hands on receipt of the body. At the end of the Evidence of Injury Section, a sentence such as "These injuries, having been described, will not be described again" may be included. The Internal Examination Section may then be limited to natural processes. I. Gunshot Wounds When there is more than one gunshot wound, a qualifying initial statement about numbering is necessary. An example is, "The gunshot wounds are arbitrarily numbered 1 through 3 for the purposes of identification without regard to possible chronological sequence or to severity of injury". The same is true for shotgun wounds and sharp force injuries. The description should include the following: A. Entrance Wound: Describe where it is located, and locate by measurements, usually from at least two standard reference points such as the anterior or posterior midline, and the top of the head or bottom of the heel. Other classic landmarks such as the center of the external auditory canal, nipple, or umbilicus, may be added as well. Give the shape and measurement of the defect. Describe any marginal abrasion, including its location and width. Describe if any gunshot residue (soot or stippling) is or is not present around or within the wound, and give its measurements in relation to the wound. B. Injury: The injuries are to be described sequentially: "After perforating the skin and subcutaneous tissue of the right side of the chest, the bullet sequentially perforates the underlying musculature, the fourth intercostal space, the middle lobe of the right lung, the pericardium and the heart, and penetrates into the lower lobe of the left lung." In a separate paragraph, list any associated injuries, such as hemothoraces,
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Revised 1/03/08

contusions of organs, orbital plate fractures, etc. C. Exit Wound (when present): As with the entrance wound, describe the exit wound, locate it in relation to standard landmarks, and measure the defect. Describe any additional characteristics such as contusion or abrasion (if a shored exit). D. Bullet Recovery (when present): Describe where the bullet is recovered and measure the location where possible. Describe the general appearance of the bullet (jacketed or not, deformed or not, and approximately what caliber it appears - small, medium, or large [small - less than .30 cal, medium - .30 cal to .40 cal, large - .40 cal or more]). State where and how the bullet is marked before submission to the Crime Lab. E. Pathway: Describe which way the bullet traveled, giving the major direction first, and using three planes: front vs. back, right vs. left, and upward vs. downward. When a path does not fit into one of these categories, describe it as such (e.g., "the bullet went from front to back, and left to right, without significant variation in its vertical axis"). F. Range of Fire: State the apparent range of fire based on examination of the skin using the following general guidelines: * Contact - soot on or in wound * Close - soot and gunpowder stippling * Medium or intermediate - stippling, without soot * Distant - no residue * Indeterminate - history of or physical evidence of interposed target other than clothing At the end of the report, in the Findings Section, these are summarized briefly as in this example: Gunshot Wound: 1. 2. 3. 4. Entrance wound: right upper back. Apparent range of fire: close-range, with soot and stippling on the skin, and soot on the clothing. Injuries: Perforations of right upper lobe of lung and of heart. Exit wound: Left lower anterior chest
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Revised 1/03/08

Or 4. 5. II. Bullet recovered: Medium caliber, copper jacketed, bullet recovered from muscle of left lower chest wall. Path: Back to front, downward, and right to left.
Shotgun Wounds A. Entrance wound: Give the general location on the body. If the wound is a single defect, then give the size of the defect, the measurement of the center of the defect from standard landmarks, whether the defect is round or oval, the description of the margins (smooth, irregular, scalloped, etc), whether satellite defects are present and where (by width from the entrance margin and in relation to the face of the clock), presence or absence of firearms residue, and any abrasions present (e.g. wad strike). If the wound is not a single central defect, then measure the overall pattern with regard to height and width, give the location of the center of the pattern in reference to standard landmarks, and count the number of shot pellet perforations. If there are ten or more birdshot perforations, count the total or simplify by saying "multiple birdshot perforations". If less than ten birdshot defects, or in any case of the larger buckshot perforations, count the total number of defects. Describe whether or not any firearms residue is present. B. Injuries: In shotgun wounds, describe in sequence similar to gunshot wounds - "After perforating the skin and subcutaneous tissue, the charge sequentially perforates... etc. C. Exit Wounds (uncommon unless a slug or buckshot): Measure the size of the defect and measure the location with regard to standard vertical and horizontal landmarks. D. Pellets: Describe if possible where the mean point of impact is and where the main body of the pellets are located. Most commonly you cannot measure where the pellets are recovered so you have to make statements such as, "multiple bird shot are recovered from the liver, right kidney, etc." Comment that representative birdshot are recovered and placed in an appropriately labeled envelope and submitted to the crime laboratory. If the wad is recovered, describe where it is located, when possible or practical measuring its location, and submit it with the pellets. Buckshot pellets are generally all recovered.
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Revised 1/03/08
E.
Path: As with bullets, describe the pathway of the charge in three directions, with the major direction first, e.g., front to back, left to right, and downward. If a path does not deviate in one of these directions, comment that there is no variation, such as, "front to back, with no variation in the vertical or left/right axes." At the end of the report, summarize these features in the Findings Section as in the previous example for gunshot wounds.
III.
Stab Wounds An introductory statement describing the total number of stab wounds and the general location on the body is necessary. Also make a statement regarding the numbering of the stab wounds for identification without regard to chronological sequence. A. Entrance: Give the general location of the wound, and give the measurements from the standard reference points (usually the top of the head and anterior or posterior midline). Describe the orientation of the wound (e.g., vertical, horizontal, or oblique, as right superior to left inferior), the length of the wound, the angles (sharp, blunt, or indeterminate), the width of any blunt angle, the margins (smooth or irregular), and any abrasion present (location and size). If an incised wound extends from one angle, describe how long it is and from which angle it extends. B. Injuries: Describe the injuries in sequence, e.g., "After perforating the skin and subcutaneous tissue, the stab wound sequentially perforates the ..." etc. Also add if the track tapers as it perforates the organs. In some cases, perforation of internal tissues such as pleura can help with characteristics of the weapon when the skin is indeterminate. Give any associated injuries such as hemothorax. C. Exit Wound (if present): Describe the location and appearance, as in entrance wound description. D. Path: A probe may be helpful in determining the direction. Give in three dimensions, as with gunshot wounds, with the primary direction given first. State the maximal depth of penetration, from the skin surface to the final termination point. When the track goes through bone or cartilage, such as the rib cage, this is a fairly accurate representation of a minimum blade length of the weapon. This is not true,
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Revised 1/03/08

however, if the blade goes through an easily compressible area such as the abdomen. This is why the term "maximal depth of penetration" is useful. E. Cluster of Stab Wounds: When there are multiple stab sounds in an area of the body, then these stab wounds can be clustered. Give the general location of the cluster on the body, the measurement of the cluster pattern with regard to height and width, the location of the center of the cluster in regard to standard reference points, and the range in lengths of the stab wounds, (e.g., "Wounds range in length from 1/2 to 1 inch"). Describe the wound margins (smooth or irregular) and the angles (sharp, blunt, indeterminate, or mixed). Describe the injuries (e.g., "The majority of the stab wounds penetrate into the subcutaneous fat, however, two stab wounds penetrate into the liver"). Give the maximal depths of penetration. State the direction of the stab wounds, including if they vary (e.g.," some of the wounds go from right to left and front to back, whereas some of the wounds go from front to back and left to right"). At the end of the report, summarize the findings as follows: 1. 2. 3. 4. Entrance wound location: The general location. Injuries: Perforations of major vessels or organs. Path of stab wound: Front vs. back, right vs. left, upward vs. downward. Maximal depth of penetration.
A comment may be added in the Conclusion regarding if the appearance of the wounds is consistent with a double or single-edged weapon such as a knife. IV. Blunt Force Injuries Cases involving blunt force have a wider range of etiologies and findings than do most cases involving firearms or sharp force. The circumstances may be as varied as motor vehicle accidents, falls, industrial accidents, child abuse, and homicidal beatings. The physical injuries, however, can basically be broken down to abrasions, contusions, lacerations, and fractures, which may occur individually or more often in combination. Abrasions are significant in that they show the point of impact, but the other injuries may occur both at impact sites or remote from them. Many times an injury may show a pattern suggesting the causative object, and may even be matched to a specific weapon. Some cases, such as homicides, deserve much more descriptive detail than a more routine motor vehicle accident. Because of this degree of variation in the significance of injuries, these cases require frequent consultation between new residents and fellows and the staff medical examiners. If there is any doubt, it is always better to document (by description, diagram, photography), than to possibly omit something significant. Blunt force injuries may be confined to the head and neck area, the trunk, or the extremities. In many cases all three areas are injured, but to prevent confusion, it is
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necessary to be systematic and record observations in an orderly fashion. The descriptions may be easily placed into an outline format broken down by area of body. A. Head and Neck: 1. 2. 3. External injuries: including abrasions, contusions, and lacerations. Subscalpular hemorrhages. Skull fractures: including such descriptors as open vs. closed (scalp defect vs. scalp intact), complete vs. incomplete, linear vs. comminuted, depressed vs. non-depressed, and contrecoup (such as in the anterior fossae, distant and unconnected to a fracture at an impact site). Epidural, subdural, and subarachnoid hemorrhages. Brain injuries. Internal neck injuries: including the anterior musculature, the underlying bony structures, and the posterior neck findings, if examined.
4. 5. 6.
B.
Trunk: 1. 2. 3. 4. External: Multiple blunt force injuries may often be enumerated in a general fashion. Fractures: including ribs, sternum, clavicles, vertebral column, and pelvis. Internal organ injuries: such as lacerations of liver, spleen, or heart. Body cavity hemorrhage: described and quantitated.
C.
Extremities: 1. 2. External injuries. Fractures: visible or palpable fractures.
V.
Strangulation Strangulation is death caused by external compression of the neck with obstruction of the blood vessels and/or airway of the neck. Homicidal strangulation is usually by ligature or manually, and rarely by hanging. Suicidal strangulation is generally by hanging which may or may not involve actual suspension of the body. Accidental strangulation may occur in a variety of ways, such as entanglement of a baby in a cord, or failure of a "safety" mechanism in an act of autoerotic asphyxia. History, scene investigation, and autopsy findings may all help in differentiating these manners of death. A. External injuries: Include all contusions, abrasions fingernail marks, facial livor, and petechiae (typically in bulbar and palpebral conjunctivae). Describe any ligature marks, with location, measurements, and its angle of orientation (most often near
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horizontal in homicidal strangulation; and above the thyroid cartilage in front and angled upward from there in hangings). B. Internal injuries: Include the findings from a layer-by-layer anterior neck dissection, including the strap muscles, thyroid cartilage, hyoid bone, and tongue, and from a posterior neck if performed.
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Revised 1/03/08
CHAPTER 10 ROUTINE HANDLING OF CASES I. Fingerprints
All medical examiner cases, whether autopsies or external examinations, have prints made. Two sets of fingerprints are made on identified bodies and four sets on unidentified bodies. Airplane pilots may get both fingerprints and footprints (the military keeps footprints on pilots). Homicides, suicides, and firearms-related cases also get palm prints. Children under twelve get footprints; if a child homicide, they may also get finger and palmprints. Additional sets of prints may be made on request for investigative agencies or identification problems. Prints are never to be made on any potential homicide or other case with bagged hands until the pathologist has seen the hands, and handwashings and other evidence has been collected, and possibly photographed as appropriate. Special procedures may have to be performed to obtain fingerprints on decomposing and mummifying bodies. If the skin of the hand is slipping off as a glove, the degloved skin may be printed by placing it over the gloved hand of the person taking the prints. If the fingers are dehydrated and wrinkled, they may be injected with warm water (or saline or glycerin). As they begin to soften, they can be re-injected. This process can be repeated but has to be monitored closely so they arent plumped too full, or oversoftened. Sometimes soaking alone of dried fingers will be enough. They should not be soaked in detergent, however, since many detergents have proteolytic enzymes and will erode the tissue. Each fingerprint card is labeled with a prepared gummed label, which is placed directly above the block FBI NO., next to the left edge of the card. The pathologist records the decedents initials, date of examination and pathologists initials on the label as specified. If there is any delay between printing and applying the label, the printing technician will write the case # in the spot to be labeled. Other areas on the cards are left blank for later use by the field agents and other agencies. One fingerprint card (no palm or footprint cards) is placed in the print basket for nightly pickup by the field agents. All other print cards are placed into clean clear sleeves and put in the case file. These procedures may vary on unidentified cases where print processing is needed immediately. Field agents will process fingerprint cards for distribution in the contaminated work area in the field agent office. One original fingerprint card for each case that has fingerprints will be recorded in the logbook, and batched and forwarded to the Dallas Sheriffs Office (usually daily). The Dallas Sheriffs Office (DSO) will send them on to the Texas Department of Public Safety (DPS), who may then send them on to the FBI. If DPS has an arrest record on the person, they send us a copy. The FBI sends us an arrest record and/or returns the prints to us. Some of the agencies may not routinely process the card if the decedent is under 18 or over 80 years of age. The records or cards returned from the FBI or DPS are first routed unopened to the chief field agent, who pulls any job applicant cards or reports and returns the rest to the field agents for disposition. Reports are identified by case number, prints are placed in individual plastic pouches,
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and all are forwarded to records to be filed. An original fingerprint card or a good copy must always remain in the case file. Any distribution of fingerprint cards from the case file requires: 1. within the institute, a supplemental investigation report reflecting the purpose of removal, and the location held, and an additional supplemental investigation report reflecting return of the card to the file, or, 2. outside the institute, a supplemental investigation report reflecting the purpose of the removal AND a receipt for evidence reflecting the person from the institute releasing the card(s), and the signature of the person receiving the card(s), the printed name of the person receiving the card, and the agency and agency telephone number of the person receiving the card; if the card is returned, a receipt will be prepared reflecting when the card was returned, by whom and to whom, and the card will be returned to the case file. II Autopsy / Inspection / Form 16 Guidelines
The following are guidelines on what cases should be autopsied versus given an externalonly examination (inspection). Even inspections cases still have the routine fingerprints, photographs, and collection and submission of toxicology specimens (whether they are tested or simply stored). If an autopsy is performed, it is to be a complete autopsy, including head, neck, chest, and abdomen; partial autopsies are not performed. Family permission is not needed for cases falling under M.E. jurisdiction, and autopsies may be performed, if needed, against known family objection. If, however, the case falls into one of the areas with medical examiner discretion, we can try to honor their wishes. Families will not be called to ask whether they want or object to an autopsy. Whenever a family requests an autopsy on a DCME case, it will be performed, unless there is a compelling reason not to (e.g., CJD). 1. Unnatural deaths: - Homicides and suicides autopsy - Accident, motor vehicle cases autopsy, whether brief or prolonged hospital course, unless significant infectious disease (e.g. Hep C, CJD, TB, etc.) and good documentation - Accident - elderly with subdural autopsy - Accident elderly with hip fracture medical examiner discretion - Accident prolonged hospitalization for aspiration of foreign body or food bolus, with good documentation and good reason why the individual aspirated (e.g., Parkinsons disease, previous stroke, etc) medical examiner discretion - Burn cases ME discretion to autopsy or inspect, and to leave at PMH for autopsy. - Drug overdose prolonged hospitalization try to recover original hospital blood for our toxicology ME discretion.
10.2
Revised 1/03/08
2. Natural deaths: - All individuals under 70 years of age without compelling medical history or only history of hypertension autopsy - Any age with good documentation explaining the cause of death medical examiner discretion 3. Form 16s: If a case fulfills the criteria for needing only an external inspection and a physician is interested in obtaining an autopsy, one may be performed at DCME if we deem that it is appropriate (unless there is a known family objection). If, however, we do not need to do the autopsy, then we may do an external inspection, complete a Form 16 and notify the secretary typing the Death Certificate. The Chaplains Office at the decedents hospital will then be notified and will work with the requesting physician to obtain family permission, transport the body, and have an autopsy performed there, if desired. This is done most often with Parkland and Childrens Hospitals due to their proximity and affiliation with UT Southwestern.. III. X-ray
Cases that require x-rays are up to the discretion of the pathologist. Many homicides, suicides and charred bodies are x-rayed. X-rays should be taken before the removal of clothing (which may contain projectiles) and are always taken of any body areas with firearms injuries, and on many stab wound cases. The chest may be x-rayed in cases with sharp force injuries to the neck (to check for cardiac air embolism). Charred bodies often get head, chest, and abdomen films. Babies that may have been abused receive whole body x-rays. Any unidentified body that is being released from the institution also gets whole-body x-rays and a complete dental series (for possible future comparisons). The autopsy technicians expose and process all the x-rays, according to the posted guidelines in the x-ray room. The technician must always wear his or her assigned x-ray exposure badge while working with the equipment. A marker with the case number must be included on the film cassette, on the decedent's left side, unless clearly labeled as some other orientation. When satisfactory xrays are completed, the x-ray machine is to be turned off, and the area cleaned as necessary. The autopsy technician is responsible for filing all x-rays after their use. The x-rays are kept for 2-3 years in a file in the autopsy area, then placed into permanent off-site storage. If duplicate ante mortem x-rays are received on a case, they should be labeled with the M.E. case number and filed with the rest of the x-rays. Original hospital x-rays are generally returned to the hospital unless they have been offered for our retention. If ante mortem x-rays show something interesting or important, and must be returned, they can be copied or photographed. Dental x-rays can be made on intact heads or skulls without removal of the jaws. The dental x-ray head and the special dental x-ray film are used, always placed with the small bump on the corner of the film towards the opening of the mouth (the labial or buccal side). If duplicate x-ray
10.3
Revised 1/03/08

film is used be certain the film is separated before processing. When the x-rays are completed, they are placed in a dental x-ray envelope labeled with the case number, pathologist's name, and decedent's name if known, and are kept in the decedents ME case file. If the consulting odontologist wants a set for their own storage, a duplicate set may be taken, but one set should always be retained in our file. Non-dental x-rays on unidentified bodies are kept in a separate file in the field agent area. See Chapter 12, Unidentified Bodies, for more information. IV. Autopsy Procedures / Evisceration
Autopsies are performed seven days a week, with a flexible "cut-off" time of 2:00 p.m. for not beginning new cases, to allow time for completion of the cases and clean up by the technicians. A routine autopsy includes a full external examination and internal examination of all organs in the abdominal, thoracic, and cranial cavities, with retention of any or all portions of those organs needed for future study. "Partial" or "limited" autopsies are not to be performed. A properly performed autopsy will not interfere with later viewing of a body or an open-casket funeral. The internal examination is generally performed in the Virchow method, where in-situ dissection is carried out and the organs are each removed individually. The autopsy technicians are all trained in this procedure, and can perform or assist with the dissection under the supervision of the pathologist. Routinely a Y-incision is made, extending from each acromio-clavicular process to the sternum, and down the midline to the symphysis pubis. The chest plate is removed by cutting through the ribs or costal cartilages. At this point the pericardial sac is opened, and the body cavities are all examined. Blood from the heart or great vessels may be obtained for toxicology or other purposes if peripheral blood was not already obtained. In traumatic or decomposing cases, it may be necessary to obtain chest fluid as a substitute. The fluids in the cavities are examined and their amounts recorded. The organs are removed individually, in a sequence as preferred by each prosector. On most cases the heart is lifted and cut across the great vessels, including the ascending aorta and the pulmonary artery (checking for thromboemboli while cutting). The lungs are each removed by lifting and cutting the hilum at the mediastinum. The intestines are often removed next, to allow more freedom in the abdomen, by transecting the duodenum near the ligament of Treitz, transecting the rectum, and cutting the mesentery at its root. The presence or absence of the appendix is noted and the appendix is removed and saved. Bile and urine are measured and collected. The liver and spleen are each dissected free and removed. The adrenal glands should now be easily located and removed. The stomach (unopened) is removed along with the duodenum, pancreas and lower portion of the esophagus. The kidneys are removed by incising the surrounding capsule, stripping it away from the renal surfaces, and transecting the renal vessels and ureter near the hilum. The ureters may be examined before this cut, if desired. The genitourinary organs (urinary bladder and prostate in males, or bladder, uterus, fallopian tubes, and ovaries in females) are now removed. The testes are not routinely removed, but may be removed at this point, if needed, by cutting the soft tissue in the inguinal regions on both sides of the pubic symphysis, and pushing the testes upward out of the scrotum through the inguinal canal. The breasts may be sectioned from the inside.
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Revised 1/03/08
To remove the brain, a posterior scalp incision is made behind the ears. The scalp is reflected both forward and behind from this incision, exposing the skull. The calvarium is cut using the electric saw, leaving a notch in the bone for repositioning, and trying to avoid cutting the dura or brain. The brain is eased out gently by cutting the dura, and cutting the cranial nerves and arteries at the sphenoid and temporal bones being careful to leave the olfactory bulbs intact. The brain is supported posteriorly as it falls back, and the final step is to transect the spinal cord by reaching into the foramen magnum. The neck and midline structures are usually removed after the head is done, especially on neck trauma cases, to allow for blood drainage. The pathologist may wish to perform this part of the dissection, and may follow different procedures than those described here (see Specific Types of Cases chapter, Strangulation section). On routine cases, the carotid arteries should be cut low in the neck, and the lower abdominal aorta cut near or above its bifurcation, to allow for the funeral home embalming procedures. Care must be taken on neck dissection to avoid creating visible skin defects or "button holes". Starting with a Y-incision very wide at the shoulders helps to more easily reflect the skin upward to the jaw line in front. The incision should not extend too far posteriorly or the body may leak after embalming. When the submandibular glands are visible, the skin is reflected high enough on each side, the larynx is pushed medially and a parasagittal cut made to the bone alongside the larynx just medial to the carotid sheath and its vessels. The vessels are transected in the lower neck at the clavicles. The parasagittal incisions are extended superiorly medial to the submandibular glands, then the two parasagittal cuts are connected by running the knife anteriorly around the neck structures, along the posterior edge of the mandible. The prosector can reach up through this new space under the mandible, pull the tongue down with the neck structures, and carefully sever its posterior and lateral connections. If the tongue is not being removed, this procedure is altered by simply cutting horizontally above the top of the hyoid bone medial to the submandibular glands. At this point, the neck and midline structures are easily removed by lifting them out and cutting the posterior soft tissue over the vertebral column. The pathologist is responsible for making certain the weights and volumes are recorded as well as any autopsy descriptions or findings. The removed organs are all examined and sectioned by a pathologist, who selects representative areas to save in the stock tissue bag, and to submit for histology if appropriate. In addition to the representative organ sections chosen by the pathologist to save, the technician will remove the appendix, a piece of the skeletal muscle and a piece of bone with marrow (rib or vertebral body) to place in the "save" bag. Specimen collection and retention is carried out as part of the mandated inquest, and next of kin permission for specimen collection is therefore not required, and the next of kin is not routinely notified .After autopsy, this fixative-filled bag is sealed and filed for storage. Other than this, and any organ saved for later examination (such as brain being fixed), all organs are placed in a large plastic bag, which is tied and returned to the trunk cavity of the decedent. The small representative pieces of tissue in formalin are placed into a labeled bag and sealed for storage. The formalin preserved specimens are disposed of after one year of storage unless a written request is received from authorized individuals (e.g., next of kin, legal representative) for longer retention or release to an appropriate place (e.g., a lab for further testing).
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Revised 1/03/08
V.
Toxicology
When feasible, specimens in each case are collected for toxicology. Specimens may be submitted for testing or for storage pending future need. On inspection-only cases, blood and vitreous are usually collected. On autopsy cases, blood, urine, vitreous, and bile are usually submitted if available; additionally, solid tissues and gastric contents may be submitted as applicable. Container Labeling: It is the responsibility of the pathologist to ascertain that all specimens are properly labeled. Labels are preprinted with the case number and unique specimen identification. Containers should be labeled prior to sample collection. Labels should be placed straight vertically on the tube so that the barcode may be read. Specimen containers should be marked with the decedent's initials, date of the examination, pathologist's initials, and specimen type and location. The appropriately printed label must be used. For example, do not use the printed muscle label on a liver or gastric specimen; write the specimen on other labels as needed. Specimen Collection: Typically four tubes of blood are drawn: 3 gray-top tubes and one red-top tube. Femoral blood is preferred and when available should be placed into the grey-top tubes. If femoral blood is unavailable, subclavian is the next choice, followed by heart, followed lastly by cavity blood. The source of blood (femoral, subclavian, heart, decomp fluid, etc.) should be noted on each tube. Bile, urine, and vitreous specimens are placed into red-top tubes. Vitreous must be collected using a clean, dry syringe. In adults, vitreous is collected from one eye and one eye is usually left intact. Vitreous fluid from babies should not be collected until the end of the autopsy in case injuries suggesting abuse are found and the eyes are needed for examination for retinal hemorrhage. In babies and children, vitreous volume may be low enough that both eyes must be used. When vitreous is collected after cornea harvest, write "corneas removed" at the top of the toxicology request form because these specimen may occasionally contain isopropyl alcohol. Tissues are collected in individual specimen cups. Muscle and liver are often useful in suspected overdose situations. Other tissues such as brain or injection sites should be collected as applicable. Spleen is sometimes useful for CO determination in burned bodies. Usually about 50 grams of tissue are collected. Specimen cups should not be over two-thirds full. Gastric contents should be submitted in a specimen cup. When the entire gastric content cannot be submitted, the contents should be well mixed, total volume measured, and a representative aliquot submitted in a specimen cup. The total volume of gastric contents should be noted on the Toxicology Request form because results are reported as mg per total volume of gastric. If metals analysis is requested, submit an extra gray top tube of blood if possible. If hair is submitted, for example in suspected arsenic cases, a pencil-thick section should be tied or banded together tightly down the length of the bundle. Then the entire tied bundle should be
10.6
Revised 1/03/08

pulled from the scalp. Repeat the process so there are at least two bundles of hair. Submit in a specimen cup. Pulled fingernails are often submitted in these types of cases. If volatile substances other than routine alcohols and acetone are suspected, blood specimens should be collected in special glass tubes with crimped metal caps provided by Toxicology. A box of the tubes, caps, crimping tool, and instructions are kept in the autopsy area. Three volatiles tubes should be collected: one tube filled with 1/8 blood, one tube filled with blood, and the third tube filled with blood. In rare cases, a toxicologist may be called down to the autopsy room to collect airway specimens from the body for volatiles. Toxicology Request Form - The pathologist should complete the toxicology request form, including enough details about the circumstances and any suspected drugs to help direct the toxicologists. Consultation with the Chief Toxicologist or Senior Toxicology Chemist may be appropriate in some cases to determine the proper specimens and any special handling. The pathologist indicates case priority at the top of the Toxicology Request Form. Most cases are routine priority. Routine cases with a manner of Homicide are prioritized over the nonhomicide routine cases. If the toxicology results are needed to determine the cause of death, the request is marked pending. A stat request used to obtain a quick result on a vitreous glucose, blood alcohol or carbon monoxide which will change the handling of a case. Full drug screens cannot be performed on a stat basis. On any stat request, the pathologist or technician must deliver the specimen and Toxicology Request Form promptly to the laboratory and inform the receiving clerk of the stat nature of the test and where to call the results. The remainder of the case will be handled in a routine manner. Expedite priority is used in urgent cases such as officer-involved and in-custody deaths. The pathologist selects the type of testing requested on the Toxicology Request Form: 1. 2. No tests requested General screen, includes: Alcohols and acetone screen Cannabinoid screen Drug screen: Alkaline drugs Acid/neutral drugs Opiates screen Electrolytes (vitreous humor panel) Carbon monoxide Metals: list metal Volatile screen Other, please list: Common tests are listed under "miscellaneous" in the appendix and include lithium, ethylene glycol, infectious disease testing, clinical chemistry tests, organic acid screen and any other send-outs.
3. 4. 5. 6. 7.
For a detailed list of substances detected in these testing panels, see Appendices-Toxicology Laboratory, Toxicology Testing Overview.
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Revised 1/03/08
Specimen Handling and Transport - After collection of the specimens or upon completion of the case, the labeled specimens are placed upright into a labeled, tamper-evident toxicology submission bag. The label is to be placed inside the bag, below the seal (easiest to apply the label before placing the specimens into the bag). All tubes for a single case are placed into one transport bag. Each specimen cup is placed into an individual, labeled transport bag. The bags are then sealed. During a working day, the toxicology specimens are stored in the autopsy room refrigerator, and the completed request forms are placed in a stack. Routinely (usually each afternoon), one of the autopsy technicians delivers specimens to the secured medical examiner toxicology refrigerator. Specimens are submitted using standard chain of custody protocol. The Evidence Registrar reviews the request forms and specimens and returns them or notifies the pathologist if corrections are needed, such as for mislabeled tubes or incomplete paperwork. Toxicology Results - Toxicology reports are returned to the submitting pathologist for review. The pathologist forwards the report to the transcriptionist to be included in the autopsy report. The toxicology report is included in the case file. Toxicology Specimen Retention - In the toxicology laboratory, liquids in glass tubes are usually stored refrigerated. Specimen cups are usually stored frozen. Toxicology specimens are stored for about 1 year (NAME requires 12 months after case completion) prior to routine disposal unless written notice is received from the medical examiner or another party to retain them. If the medical examiner has personal interest (research, etc.) in retaining specimens, a "Request to Hold Specimens" form is completed and submitted to the laboratory. Outside requests for toxicology specimens must be referred to Toxicology administration. Fees may apply for longer storage. VI. Referral Laboratory Analyses
Most referral laboratory testing is sent out through Toxicology. Exceptions include cultures and cytogenetics (following sections), which must be submitted to the testing labs as soon as possible after specimen collection. Referral tests may be ordered by writing them in the "other" section of the Toxicology Request Form. The date of the specimen collection should be entered onto any reference lab requisition completed by the pathologist. Tests for the blood-borne infectious diseases - HIV, hepatitis, and syphilis - are frequently requested either for diagnostic purposes or because of exposure of emergency response staff. The "routine" panel of tests for exposure includes a hepatitis B surface antigen, hepatitis B core antibody, hepatitis C antibody, RPR test for syphilis (with confirmatory tests if positive), and HIV-1/2 antibody screen by ELISA method (with confirmatory testing if positive). This panel is obtained by completing the pink Special Blood Test Request (kept in the autopsy area) and submitting the request form with the Toxicology Request Form. The Toxicology Laboratory will submit specimens for testing. The testing is often valid only within the first few days of death, so requesting the tests should be done as soon as it is indicated or suspected. For policies on reporting positive infectious disease results, see the chapter on Release of Information.
10.8
Revised 1/03/08
Metabolic screening is commonly performed on infant deaths to screen for inherited disorders in the metabolism of fatty and amino acids including the medium-chain and short-chain Acyl CoA Dehydrogenase deficiencies (MCAD and SCAD) occasionally found in suspected SIDS cases. This test is ordered as a send-out by writing metabolic or organic acid screen in the "other" section. The pathologist prepares the sample for submission by placing drops of blood on a special combination filter paper and request form kept in the autopsy area. Instructions are kept with the forms for drying specimens, placing in special envelopes, and submitting to the toxicology lab for send-out. The request form should be completed including the date of collection and date of birth. The lab may request that we obtain the newborn screening blood to help with evaluation of certain abnormalities. This card may be obtained by the field agents from the Texas Department of State Health Services. Examples of other referral lab tests include thyroid profiles, hemoglobin electrophoresis, lipid studies, cholinesterase levels (in suspected organophosphate insecticide poisonings), insulin levels, indicators of anaphylaxis (tryptase levels and specific IgE or RAST), and anabolic steroids. Most coagulation testing is invalid postmortem, but factor V Leiden and prothrombin may be performed. Appropriate specimens for these two tests include postmortem blood less than 5 days old, frozen tissue (liver, kidney, lung), and/or tissue in paraffin where the tissue was in formalin for only about one day. Contact Toxicology for assistance with special testing needs. In special cases the pathologist should consult with the toxicology laboratory staff prior to collecting specimens and requesting a test. VII. Histology
If microscopic examination is to be performed, small tissue sections are placed into labeled cassettes then into a fixative-filled histology jar kept ready for use in the autopsy area. The tissue sections should be the approximate size of a nickel or smaller. Brain and decomposed tissue are marked on the request form for special handling. Bone should also be marked in this way to notify the lab for special handling such as decalcification. A preprinted bar-coded histology label should be affixed to the jar. If the jar is a repeat submission, it should be noted on the request form. The request form is placed with the toxicology request, and the jar is placed in the designated spot for daily delivery to the toxicology lab, who handles the specimen send-out, billing, return of slides to the medical examiner, and storage of tissue blocks and slides. Any follow-up (recut, special stains, etc.) is requested on a second form given to toxicology Glass slides are stored permanently and the paraffin tissue blocks are kept for five years.
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Revised 1/03/08

VII. Cultures
Bacterial and viral cultures and gram stains are available through an outside laboratory. Supplies kept stocked in the autopsy area include aerobic and anaerobic blood culture bottle sets, pediatric blood culture single bottles, sterile tubes for cerebrospinal fluid or bits of tissue, aerobic and anaerobic culture swabs, tubes of liquid media for viral cultures (and cytogenetics), glass microscope slides, and sterile swabs. A Bunsen burner is available for flame-sterilizing tools. The specimens must be appropriately labeled and a laboratory request form completed, including the decedent's name and case number, date and time specimen collected, source of specimen, doctor's name, and test(s) requested. Requisition forms and instructions for the handling of the specimens are kept together in the autopsy area. On weekends and holidays, the laboratory must be called to make a specimen pick-up. IV. Chromosome Analysis
Chromosome analysis may be ordered through the Cytogenetics Laboratory in the Department of Pathology at UT Southwestern Medical School. The Cytogenetics lab is part of Veripath, phone 214-645-7000, fax 214-645-7001, at 2110 Research Row, Suite 110, Dallas, TX 75235, which also includes flow cytometry, immunohistochemistry, and a number of other diagnostic laboratory procedures. The test results take approximately one month (faster if blood is available), and may cost up into several hundred dollars (billed to the DCME office unless other arrangements are made). To order, collect whatever tissues appear most viable (kidney and lung are preferred, followed by skin), in as sterile a manner as possible, and place them in transport medium. Tubes of the labs own prepared RPMI with antibiotics and supplements are kept in the autopsy room freezer, and will thaw quickly for use (freezing is not necessary, but prolongs the storage life). If necessary, the viral culture RPMI tubes kept in the autopsy refrigerator may also be used. Blood is also an excellent specimen, but only if it is in a sodium-heparin tube. A Cytogenetics Laboratory request form including history should be completed by the Medical Examiner. The request form is available on-line at www.veripathlabs.com. A copy of the form is made and given to the accounting clerk in administration for billing/paying purposes. The lab is open and has a courier service 7 days a week, available by calling 214-645-7000.
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Revised 1/03/08
CHAPTER 11 EVIDENCE COLLECTION AND SUBMISSION I. General
Evidence is routinely collected on all homicides, firearms suicides and pedestrian "failure to stop and render assistance" (FSRA) traffic cases. Other cases may also require evidence collection, done under the direction of the pathologist. Special care must be taken in collecting evidence to avoid transfer of any contaminating materials, especially with the sensitivity of DNA analysis. All evidence is to be placed in containers, sealed, and labeled with at least the case number, date collected, name of deceased, description of item, and the names of the pathologist and person securing the specimen. The envelopes or bags are sealed with evidence tape, which must be initialed and dated by the person who seals it. If the evidence tape looks like it will tear, it may be overtaped with clear packing tape. On completion of the autopsy, it is the pathologist's responsibility to either immediately submit the evidence to the crime lab or to store it in a secure area until submission. Occasionally an investigator from an out-of county area may be present during the autopsy and may wish to take the evidence to his or her own local or the State Police Crime Lab. The DCME policy is to release all of the evidence together or none of it. A Receipt For Evidence (See Forms in Appendices) must be completed and the original top copy kept in the case file. A field agent should be notified to supplement the transfer into the computer if they were not initially involved in the transfer. On City of Dallas (DPD) cases, evidence is generally analyzed according to a standard agreement posted in the autopsy area. When submitting the evidence, the pathologist completes the DPD submission forms and the SWIFS Evidence Submittal Form. If the blood standard is not being analyzed, it should be marked stored even if other evidence is being released to DPD. On non-DPD cases, the MEs office must find out what the investigating agency wants analyzed, on a fee-for-service basis. After collecting the evidence, the pathologist completes the first part of the Evidence Testing Request Form, and gives it to a field agent who will contact the investigating officer and complete the second part of the form stating the officers request for the analysis versus release of the evidence items. When submitting the evidence, the pathologist submits both the Evidence Testing Request form and the SWIFS Evidence Submittal form, with the items marked analyze or release as per the investigating agencys request. If testing is being requested specifically by the pathologist to help in determination of cause or manner of death, the box Bill to Medical Examiner should be marked on the Evidence Submittal form. All other cases, including requests by investigating agencies or standard DPD procedures, should be marked Bill to Investigating Agency.
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Revised 1/03/08

II. Blood/DNA An FTA blood storage card is obtained on all homicides, all pedestrian failure to stop and render assistance(FSRA) cases, and other selected cases. The blood is used for DNA testing. DNA testing is performed in the crime lab most often at the request of the investigating agency when there is a suspect, often long after the autopsy is completed. It is imperative that we submit appropriate specimens, at the time of autopsy, which can be stored and used later for testing. Blood is routinely submitted on all homicide cases and is stored in a form usable for later testing. The head hair standards may also be used for DNA, if tissue is adherent. Seminal stains in clothing may be used if the lab was notified of that possibility and the clothing was submitted. Teeth and bone may be used if blood is not available on a skeletonized or decomposed body. Molar teeth are best, and may be extracted after any dental X-rays and charting are done. If the body does not have teeth, ribs work in moderate decomposition, and femurs work in severe decomposition. If questions, call the DNA lab supervisor. DNA testing my be useful in situations such as: A. B. C. D. Comparison of DNA obtained from a suspect with that in seminal fluid identified in a sexual activity kit or in the decedent's clothing. Typing of a decedent's blood with that found on the suspect's clothing. Paternity testing - a subpoena must be received by our office to send our evidentiary blood for this type of outside testing. Storage on unidentified bodies in case potential blood-related relatives are found for comparison.
If non-evidentiary tissue is to be stored at the pathologist's request, it may be frozen in the autopsy room freezer. III. Head Hair Standards Pulled head hair is kept as a comparison standard routinely on homicides and pedestrian FSRA cases. The hair should be pulled from several different areas of the head to include any different areas of color or character. It is best to pull at least 30-50 hairs with intact roots. These standards may be especially useful in matching hairs on suspected weapons to the decedent's body in cases of blunt force head injury. It is also a part of all rape kits. Head hair may also be useful in determining race in unrecognizable bodies, and may be used for DNA testing in cases such as decomposed bodies.
11.2
Revised 1/03/08

IV. Fingernail Clippings Fingernail clippings are collected routinely on homicide cases for possible blood or other trace evidence that may have been picked up during a struggle. A clean piece of paper is placed under each hand. Carefully inspect the hand for any visible trace evidence and collect it. Trim all overhanging fingernails with new clippers, being careful to avoid cutting into the skin of the fingers. Fold the paper around the clippings, and package the nails from each hand in a separately labeled envelope. Include the clippers in the final envelope on the case. V. Sexual Activity Kit The sexual activity kit includes blood and fingernail clippings as above, head and pubic hair, and swabs and smears from the oral, anal, and vaginal orifices as appropriate. Clothing is also submitted, with any suspicious spots circled. (Wet spots may dry and become invisible by the time of the lab examination.) The bodies are also carefully examined for any bite marks or spots suspicious of deposited semen. The kit routinely includes pulled head and pubic hair standards, and pubic hair combings. To collect combings, a clean piece of paper is placed under the area and the hair is combed with a clean plastic comb until hair stops coming out. The comb and hairs are wrapped together in the paper and placed in a labeled envelope. Head hair combings may be collected in the same manner and may be especially helpful if forced fellatio is suspected. Two swabs each are provided for oral and anal testing. The swabs are inserted and left for approximately five minutes. The oral swabs should be moved to reach all areas of the mouth. The anal swabs should be inserted completely into the anus, but only for a short distance to avoid excessive fecal contamination. A small amount of material is smeared onto a labeled glass slide for each of the two sources, and allowed to air dry. The swabs are then placed in the provided labeled cardboard boxes and also air-dried. After all are dry, the swab and glass slide containers are closed and placed in the rape kit box. Vaginal swabs and smears are performed in the same manner, with the swabs being inserted deep into the vaginal vault. Four swabs are provided for vaginal use to allow extras to be stored for DNA testing. Swabs of the penile urethra are not performed, but swabs may sometimes be indicated of the skin of the penis. In certain cases, involving sexual assault, vaginal washings with distilled water may be useful for DNA; contact the DNA laboratory if this is considered. Tampons may be submitted by first drying or by submitting immediately and bringing it to the evidence registrar for examination or proper storage which involves freezing. Tampons should not be placed into plastic containers. If a spot suspicious for deposited semen is found on the body, the area should be swabbed with a saline or water- moistened swab. The swab is then air-dried and submitted as above. During regular working hours a scientist from the forensic biology lab may be
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Revised 1/03/08

called down to perform the swabbing. Because seminal stains are fluorescent, the body may be taken into a dark room (x-ray or photography) and viewed with the portable ultraviolet light to demonstrate the smears. VI. Bite Marks Human bite mark injuries found on victims of assault may provide crucial evidence in these cases. Bite mark analysis requires extensive expertise; an odontologist (see consultants appendix) is available to assist with these cases. Four procedures may be used to obtain and preserve evidence of a bite mark: A) Saliva swabbing for DNA typing, B) Photography of the bite marks, C) Impression of the bite marks, and D) Tissue sections of the bite marks. A. Swabbings of the Bite Mark: Varying amounts of saliva may be present at a bite, which may be usable for DNA typing. The fluid may dry or degenerate enough postmortem that the swabbings will not work, but the test may still be attempted in bite mark cases. The technique is to swab the involved area in a concentric fashion, using a sterile cotton swab moistened with sterile saline or sterile water (may obtain from the forensic biology lab). The swab is placed in a rape kit swab box for drying and submission to the forensic biology section of the crime lab. A control swab used in a similar fashion should be applied to an unbitten skin surface of the victim. A blood sample of the victim must also be submitted. B. Photography of the Bite Mark: Photographs are essential, and are most helpful close-up with a 1:1 ratio to life size. Both black and white and color photographs are taken both from a distance to show the bite mark in relation to anatomic landmarks and close-up. An L-shaped American Board of Forensic Odontology (ABFO#2) scale should be placed on the skin around the bite mark and parallel with it. The photographs are taken perpendicular to the bite mark. Close-ups of each arch pattern are helpful if the bite is on a curved surface. Oblique lighting may bring out surface indentations of the mark. Special ultraviolet and infrared techniques may also be helpful. C. Impressions of the Bite Mark: Rarely, a bite mark will actually leave visible three-dimensional characteristics, with indentations. The tooth mark depressions flatten out with the passage of time, so castings should be made as early as possible if they are being done. Making impressions is a skill requiring expertise with the materials, and is best left to the consulting odontologist, who will also testify if necessary. Impressions of the decedents own teeth may be taken if there is a possibility that the bite mark was self-inflicted.
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Revised 1/03/08
D.
Tissue Sections of the Bite Mark: If microscopic examination of a bite mark is being performed, the tissue section(s) should only be taken after completion of any of the previous procedures wanted.
VII.
Trace Evidence The Trace Evidence Unit at SWIFS is loosely divided into two types of analyses, chemical and microscopic. The chemical testing includes ignitable liquids (arson) examination and gunshot residues, both discussed in a later section on clothing. The microscopic examination may include any material that could be of evidentiary value in associating a victim to a suspect or scene and also includes gunshot reside evaluation on clothing. The most common forms of trace evidence are hairs and fibers found on a body or its accompanying clothing. Other types of trace evidence include metal fragments, paint chips, glass shards, plant material, etc. This examination is most helpful in "hit and run" pedestrian cases and bodies found dumped or murdered with no known suspect. To collect trace evidence, the body must be examined closely, and any of these materials collected and submitted, wrapped in paper or applied with clear tape to a clear sheet of flexible plastic. Use of obliquely oriented or ultraviolet light may help in visualizing any fibers. Carpet samples from crash bag buttons should also be submitted to exclude irrelevant textile fibers found on bodies. Bed sheets may be removed from under a body and carefully shaken out onto a large clean piece of paper, then wrapped as evidence, or submitted with the entire sheet and any evidence together in a large paper bag. Clothing may be entirely submitted after drying to the crime lab for examination. To test for oleoresin capsicum (OC) pepper spray, two methanol or ethanol moistened cotton swabs should be used to swab each area tested, usually the nasal and oral areas. The air-dried swabs are submitted in rape kit cardboard swab boxes to the crime lab for chemical analysis. Clothing may also be submitted but is not generally helpful. Many OC sprays also contain an ultraviolet sensitive visualizing agent, which may be demonstrated with an ultraviolet (Woods) lamp. When appropriate and available, a trace evidence analyst may be requested to examine the body and assist the pathologist in collecting the evidence. For more information, call the Trace Evidence Unit.
VIII.
Clothing Clothing may be submitted for evaluation of gunshot residue to aid in determining range of fire, for other trace evidence examination, for volatiles (accelerants) analysis in suspected arson cases, and for occasional other purposes such as blood typing (more often tested on suspect's clothing instead of the victim's).
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Revised 1/03/08
All clothing, except in arson cases, must be completely dried before submission, and must be submitted in paper bags (never plastic). Refer to the section on clothing in Chapter 4 for details on the storage and packaging of clothing. At the time of the autopsy, the pink copy of the Clothing List is placed in plastic with the clothing to be saved, and later submitted with the clothing to the crime lab. A body diagram including the injuries should be submitted with the request, especially before any examination of the clothing for firearms defects. Clothing or other materials being submitted for volatiles analysis must be placed as soon as possible in a metal paint can or non-permeable plastic bags and sealed. Use more than one can if the clothing does not easily fit into the can. A few cans are kept in the autopsy area, and more can be obtained from the Trace Evidence lab. Also available from the lab are rolls of tubular plastic that can be cut to the desired length to hold bulky or irregular clothing, then heat-sealed at both ends. Clothing with maggots and/or fly eggs may be treated to kill the insects before they become a pest problem in the morgue or laboratory. The clothing is placed in a plastic bag, a small amount of chloroform is added (splash a few ml directly into the clothing or onto a paper towel placed in the bag) and the bag is sealed and left at room temperature for a few hours (cooling appears to decrease the effectiveness of the chloroform). After the maggots are dead, the clothing is removed from the bag (carefully, if trace evidence is an issue), and dried as usual before submission. This does not interfere with either firearms residue or trace evidence testing. If there is any question about possible test interference, call the Trace Evidence Unit. IX. Head Hair for Gunshot Residue On occasions where a gunshot entrance wound is on the scalp, the bullet did not go through an interposed target such as a cap, and there is a question of the range of fire, the hair from around the entrance site may be submitted for examination for gunpowder. As the area is shaven, the hair should be collected onto a clean piece of paper. The hair (usually wet and bloody) is then placed in a clean plastic petri dish, taped closed, and placed in a labeled evidence envelope. If wet, it should be kept refrigerated until submission to the Crime Lab. X. Projectiles X-rays, to document and help with localization, are taken prior to starting the autopsy on all cases where the death involves projectiles. Projectiles should be removed carefully, using plastic forceps, and avoiding any scratches. Their locations should be noted in the autopsy record. Bullets are marked on the base, nose or deformed surface with some combination of the case number, decedent's initials, and pathologist's initials, depending on space. Multiple
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bullets from one case should be marked with individual variations. Markings should never be made on the side of a bullet where it will interfere with the firearms examination. Care should be taken to note if a bullet recovered has rifling marks or is a smooth bullet "core". The jacket should always be recovered if it has separated inside the body, as that is where the rifling marks will be. Aluminum jackets may not be observed in the x-ray, and will have to be searched for carefully. Shotgun pellets may be widely scattered in a body. A representative number (usually at least 10-15) of bird shot pellets should be recovered. In cases with larger buckshot, all of the pellets should be recoverable. Wads should be recovered, if present, and also submitted as evidence. Pellets and wads are not individually marked, but are placed together in a separate labeled evidence envelope for each shotgun wound, if individual wounds can be identified. All projectiles should be cleaned before submission, except in rare cases where trace evidence on the bullet may be probative to the investigation. They may be briefly placed in a detergent and dilute bleach solution (while performing the autopsy). Aluminum and steel jacketed bullets must be removed from bleach quickly, or the bleach will corrode the jacket, possibly damaging the external markings. XI. Gunshot Residue Kit Gunshot residue kits are submitted from the hands of all cases where firearms may have been involved, unless there has been prolonged survival such as a day or more in the hospital. They may be helpful, if positive, in associating the decedents hands with a firearm. SEM-EDX, or scanning electron microscopy with electron-dispersive x-ray, is the current and most specific method. It involves the use of small vials with a sticky end used to collect possible residues from the back of both hands. The material recovered on the vials is scanned with the electron microscope for particles of the appropriate shape and size, which are then subjected to x-ray analysis to determine the elemental composition of the particles. Collection of the samples is done according to the instructions included in the SEM kit. AA, or atomic absorption, is an older and less specific method that is offered by the laboratory for those agencies still requesting it. The test involves the use of five pairs of cotton-tipped swabs with plastic shafts (never wood, which may interfere with the testing), and dilute 5% nitric acid, which is kept in a plastic bottle. Four pairs of swabs are moistened with two or three drops of the acid and rolled for approximately 20 seconds over the backs and palms of both hands (one pair per site). They are then placed directly into small individually labeled plastic bags, which are then sealed. A fifth "solution control" swab is moistened with the acid and placed directly into the bag. The baggies are all placed in an evidence envelope and submitted together.
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XII. Tool Marks For most injuries, even when there is a pattern suggestive of a specific weapon, photography is adequate. On occasional cases, it may be useful to actually excise the injured area and submit it to the crime lab for comparison with a weapon. The prime example is sharp force injuries that have penetrated cartilage, generally the rib cage. In these cases, it may be possible to make an impression of the wound track, perform comparison microscopy, and see individual markings identical to those on a single specific weapon. The technique involves taking a photograph of the area to be excised, at enough distance to orient the injury with anatomic landmarks, then at least one close-up photograph showing the injured cartilage before excision. The same process is followed to photograph the excised specimen. A notch may be made and noted to help orient the specimen, for example, a notch in the rib above the injured rib, to mark the superior margin. The specimen is placed in formalin in a sealed plastic bag, which is then placed in a clean plastic container with a fitted lid. If there is a suspect weapon for matching, the specimen is submitted to the firearms and tool marks section of the crime lab. If there is no suspect weapon, the specimen may be stored for possible future comparison.
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CHAPTER 12 SPECIFIC TYPES OF CASES All cases autopsied at DCME receive complete autopsies, with the examination always including photographs, finger (or other) prints, toxicology specimens, external examination, and internal examination, including the head, neck, chest, and abdominal organs. Beyond these procedures, there is some variation in what steps are done on any given case. The pathologist determines what procedures will be done (and whether or not to do an autopsy), and may enlist the assistance of others (autopsy technicians and field agents) as necessary. Refer to precious chapters on evidence collection and toxicology for more specific information. In general, the following procedures are performed on these types of cases: I. Homicides A. General: 1. 2. 3. 4. 5. 6. Photograph body "as is". No processing is to be done without supervision of the pathologist responsible for the case. Obtain and develop x-rays, generally of the head and trunk, and of any area with a firearms injury. On cases where the neck is cut or stabbed, a chest xray may be done. (see special procedures - cardiac air embolism). If hands are bagged, cut away bag carefully and examine both bags and hands. Collect the "routine" homicide evidence: head hair, handwipings, and fingernail clippings, with trace evidence or other as indicated. Remove clothing, inventory, and bag (see Ch. 4 on clothing and personal effects). Homicide clothing is routinely retained for either evidence submission or storage. Homicide clothing is often inventoried in more descriptive detail than in other cases. There may be defects corresponding to the wounds, but measurements and details of any defects is usually not necessary in the autopsy report, as the crime lab will provide a clothing report if requested and testify as to their findings. Examine the body prior to cleaning, especially for gunshot residue or trace evidence. Clean body, then reexamine any areas previously obscured by blood or other material. Photograph full front views and close-ups of any injuries. Roll the body over, clean, and photograph the back if indicated. The body is ready for evisceration and recovery of projectiles, or any tissue being submitted tool mark analysis. In addition to routine toxicology samples, collect blood for DNA. Collect fingerprints, palm prints, and/or footprints as appropriate. This is often done before opening the body, both for cleaner prints and to help in quicker identification.
7. 8. 9. 10. 11. 12. 13.
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Revised 1/03/08
B.
Strangulation: Follow the general homicide protocol with special attention to documentation of all external and internal neck injuries. The pathologist should perform the neck dissection including a layer-by-layer examination of the anterior, and sometimes the posterior neck. The examination and evidence collection should be undertaken under the assumption that most strangulation victims are female and are also potentially sexual assault victims.
C.
Child Abuse: 1. 2. 3. 4. 5. 6. Infant and child abuse deaths are most often due to blunt force injuries, some of which may not be visible without extreme care and extra steps in the examination. All suspected child abuse cases receive full body x-rays, at settings to document recent and old healing fractures. A full external examination is performed, including the oral cavity and external genitalia with detailed description of any injuries, including measurements and any pattern present. Extensive photographic documentation is valuable. A full internal examination is performed, including submitting histology sections from various injured areas if desired to help document the varying ages of wounds in cases of chronic abuse. Vitreous fluid is not taken until after the brain is removed. If indicated, the eyes may be removed (see Special Procedures chapter), for fixation and later examination (with photography and histology) for hemorrhages in the retina and around the optic nerve. The subcutaneous surface of the back is examined to help demonstrate soft tissue hemorrhage, especially in dark skinned children. This is most easily done by marking a cross-shaped incision through the skin, with the vertical component from the occipital protuberance to the sacrum, and a horizontal intersecting incision below the scapulae. The incisions can be extended across the back of the arms, and down over the buttocks and thighs. Reflection of the skin away from the incision will allow for exposure of the entire back and for easy closure and suturing. Photographs are taken before and after the procedure.
7.
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II. Suicides
Suicide cases are handled similarly to homicides with generally less collection of potential evidence. If, at the time of autopsy, there is any question of a case being a suicide versus homicide, it is best to handle it as a homicide. As with homicides, all suicide cases receive photographs of the body "as is", full front views of the clean body, and close-ups of any injuries. A. Gunshot Cases: X-ray any areas involved with a firearm track. If bags are on the hands, remove them, examining the hands for soot, gunpowder, rust spots, etc. Document by photography before taking the handwipings. Undress the body, and clean it, being careful to avoid removing any firearms residue. Photograph the body and wounds. Autopsy, collecting any projectiles, and submitting them as for homicides. DPD cases get clothing and blood standard, as well as the GSR kit and any projectile submitted. Other cases may have evidence submitted at the discretion of the medical examiner and investigating agency. B. Hanging: If the ligature is still on the body, obtain close-up photographs with the ligature in place. Remove the ligature by cutting it at a point that will leave any knots intact, then reapproximating the cut ends. Obtain close-up photographs of the ligature furrow and of the ligature adjacent to the furrow. If the ligature is received with the body, obtain close-up photographs of the ligature furrow and of the ligature adjacent to the furrow. On DPD cases, the ligature is retained as per their standard chicklist. On others, the disposition of the ligature is at the discretion of the pathologist. Typically, the clothing and personal property may be returned with the body, but the ligature may be retained (most families would not want it back). The ligature can then be released to the local investigating agency. C. Carbon Monoxide, medication overdose, other: These cases are handled as routine autopsies, as per the responsible pathologist. Additional specimens for toxicology are often helpful, as in blood from multiple sites, liver tissue, or gastric contents (either in its entirety, or a representative mixed aliquot with the total volume recorded. Spleen may be helpful for CO testing.
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III. A. B. Traffic Autopsies Routine cases, or cases with victims who were inside vehicles which were either involved in a collision alone or with other vehicles: These are handled as routine autopsies. Pedestrian vs. Motor Vehicle Accidents: If the case is considered an accident, and the driver of the vehicle did not leave the scene, these cases may be handled routinely, with the addition of a measuring stick next to the lower extremities in the photograph. Evidence is not generally submitted. C. Pedestrianfailure-to-stop-and-render-assistance"(hit-and-run) cases: These cases are handled more like a typical homicide, with special care given to collecting any trace evidence (paint, glass, etc.), which could link the body to a vehicle. Head hair standards, blood, and clothing are submitted for evidence. The body is photographed with a measuring stick alongside the lower extremities. The pathologist may dissect the legs to document the presence and location of any injuries such as liquefied fat pockets or "bumper fractures" which might help localize the original point of impact. IV. Aircraft Accidents For large aircraft accidents, see Mass Fatalities Manual. For small aircraft accidents, with only one or a few deaths, the cases are handled in a routine manner, with the possible addition of a Federal Aviation Administration kit for toxicology evaluation. Tox kits are done on all pilots, but are generally done on passengers only if there is a fire. An NTSB investigator is assigned to each accident, and makes the decision regarding submittal of a toxicology kit. A few of the FAA toxicology kits are kept in the morgue cooler. Each kit contains the specimen containers, packing material, and instructions including a list of specimens, the quantities requested, and how to submit them. Be certain to follow the instructions carefully with regard to individual specimen collection and labeling, completion of the paperwork, and proper packing for transport. When completed, notify a Field Agent, who will notify the FAA contact person at 405-9544866 and arrange Federal Express shipping of the kit. The kit will be shipped to: FAA Toxicology and Accident Research Lab Mike Monroney Aeronautical Center 6500 S. Mac Arthur Blvd. Oklahoma City, OK 73169 A replacement kit will be provided by the FAA.
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Photographs and x-rays of the hands (A-P view) and ankles/feet (A-P and lateral views) may show characteristic injuries which can help in the determination of who was the pilot in control of the aircraft at the time of the accident. V. Other Accidents Most other accident cases will be handled in a routine manner. If an accident occurs at work, the Occupational Safety and Health Administration (OSHA) may be involved in the investigation, and may contact our office for our findings or other information. If a death may involve a fault in some type of equipment, electrical or otherwise, a consulting engineer (see Consultants in Appendices) may be called to evaluate the item. Depending upon the findings of the examination, the equipment may be held or released back to the family. X-rays of appliances may be helpful in demonstrating electrical shorts or miswiring. If the death appears to involve a consumer product, the pathologist may bring it to attention of the field agent who reports cases to the U.S. Consumer Product Safety Commission. VI. Fire Deaths X-rays are often performed on charred bodies due to the difficulty in visualizing external wounds on these cases. If the circumstances, x-rays, and external examination indicate the fire was accidental, a routine examination may be continued. If arson is suspected, the clothing must be removed, inventoried, and placed in a paint can and sealed for submission for analysis of volatiles including accelerant residues. On these cases, other evidence is submitted as appropriate. Stat carbon monoxide levels are available if that determination is needed immediately. The determination of whether a person was alive during the fire may be frequently visually made, by examination of the airways for soot deposits, and of the blood and viscera for the typical "cherry red" discoloration. Spleen may be tested for CO, and is sometimes preferable to blood. Bodies from fires are often tentative or unknown identifications. Further identification procedures can be followed as necessary as described later in this chapter in Unidentified Bodies section.
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Revised 1/03/08
VII.
Custody Deaths/Police Shootings All deaths in Dallas County which occur while in the custody of the law enforcement or judicial system and all police-related shooting deaths must be investigated by our office. The examinations must be performed by staff medical examiners. Some may be handled in a routine manner, as in a case with known natural disease where the person was transferred from jail and died in a hospital. Most cases, however, receive some special procedures, which may include, but are not restricted to: incisions of the wrists and feet, posterior neck dissection, reflection of the skin of the back, removal of the spinal cord, and special photography. The photography may include "as-is" photographs, clean overall views of the front, back, both lateral sides, and groin, and photos documenting the previous procedures. In some cases, swabbings may be tested for oleoresin capsicum pepper spray (see Trace Evidence section in the Evidence Collection chapter). Toxicology on all police-involved or in-custody deaths is marked expedite.
VIII.
Sudden Infant Death Syndrome (SIDS) SIDS, being a diagnosis of exclusion, requires a complete autopsy to exclude the possibilities of injuries or natural disease. Each case is handled on an individual basis at the discretion of the pathologist. If injuries are found, the case should be handled as described in the Homicide Section earlier in this chapter. In general, a SIDS examination includes an external and internal exam, with histology, toxicology, metabolic acid screening, and often, additional tests. Whole body X-rays will be performed. Vitreous fluid should never be taken from infants until after the organs and brain are removed, in case injuries are found and the eyes are needed intact for further examination. The external exam should include such observations as the state of hydration, status of the fontanelles, presence of petechiae, presence of any rash, developmental head features (shape and bossing, low-set ears, epicanthal folds, nasal bridge, micrognathia, cleft lip or palate, probe-patent choanae), umbilicus, hernias, numbers and configuration of fingers and toes, abnormalities of palmar creases, and any other deformities or anomalies. The internal examination consists of all the usual steps with special care taken to observe any congenital anomalies such as cardiovascular abnormalities, tracheo-esophageal fistula or tracheal stenosis, intestinal malrotation, renal agenesis or dysplasia, or reproductive abnormalities. Other significant natural findings include adrenal hemorrhages associated with sepsis, connective tissue or bone disorders, and petechiae of the thymus, heart, and lungs (frequently seen in SIDS deaths). The middle ears may be opened or removed, and examined for purulence. Cultures, most often of CSF and/or blood, may be submitted. Specimens will be submitted (see Chapter 10, Referral Laboratory Tests) for a panel of inborn errors in metabolism including fatty and amino acids.
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IX. Unidentified Bodies Most of our cases received initially as "unknowns" can be identified quickly, often within a day or two and often by photographs or fingerprints alone. If the identification takes longer than a couple of days, it will likely require more of these steps be taken. Before a body is released for county burial as an unknown, the field agents complete the DCME Unidentified Person Checklist to ensure that the following procedures, which are required by the state medical examiner law, have been performed. A. PHOTOGRAPHY - In addition to the regular face and overall photographs, all unidentified bodies (before release) get a lateral facial photograph with a scale, and photographs of any significant marks, scars, or tattoos, or any possibly identifying clothing, jewelry, or personal effects.. FINGERPRINTS - An extra two sets (4 sets total) of fingerprints are made and given as requested to the field agents, to speed up the identification process by law enforcement agencies. DENTAL COMPARISON - When ante mortem dental records are requested, the request should be for the entire record (which may be subpoenaed if necessary), i.e., charts, original x-rays, and the record of any subsequent work performed. The x-rays are kept in our office if an identification is made (with permission on JP cases). Films and records on any "non-match" are returned. An odontologist is available (see Consultants Appendix) to help with both the x-rays and the interpretations. Dental x-rays can be made on intact bodies or on skulls; the jaws should not be removed from the body. Before any unidentified body is released from our institution, full mouth x-rays must be taken. Dental x-rays on unidentified bodies are kept in the case file. A dental chart (Appendices, Dental Charting) should also be prepared before the release. Duplicate x-ray film can be used if an extra set is needed to send to a local investigative agency. Sometimes identification may be found inscribed directly into dentures. D. X-RAYS - Just as with dental, comparisons can be made between postmortem x-rays of the body and x-rays obtained during life on a suspected identification match. Hospital records may contain films including such useful areas as skull sinuses, extremities with old fractures or prosthetic devices, or skeletal areas included in routine chest or pelvic films. The consultant anthropologist or Parkland Hospital radiologists may be helpful in the interpretations. Before any unidentified body is released from our institution, whole body x-rays should be taken and filed for future comparisons. EXTERNAL EXAMINATION - Although external examinations including
B.
C.
E.
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Revised 1/03/08

clothing are always done, the pathologist should be extra careful on unknown cases to include in the notes all possible identifying marks and scars, and a complete clothing inventory. If the body is in such a state that evaluating physical characteristics is difficult, it is important to check the clothing carefully for tags with information such as sizes and brand names. Tattoos may be demonstrated more easily on decomposed bodies by using ultraviolet light and/or scraping away the superficial layers of skin. F. DNA Blood or other specimen(s) (see Evidence Collection chapter) should be saved on any body that remains unknown after the routine quick procedures, such as visual, prints, and dental. In addition to any submitted as evidence, some should be taken to submit to the Univ. of North Texas Health Science Centers Human Identification Laboratory. UNIDENTIFIED PERSON FORM - Except on those bodies received with a probable ID match being checked out, the pathologist should complete the description part of a DCME Unidentified Person Checklist after the autopsy. This form is usually already placed in the case folder by the field agents, and is to be kept in the file, with a copy given to the field agents for dispersal of information to investigative agencies. FORENSIC ARTISTRY - Both the Dallas Police Department and Texas Department of Public Safety have trained forensic artists who can draw faces for viewing and publishing purposes from bodies too damaged to publicly show. They can also do soft tissue facial reconstruction from cleaned skulls of very decomposed or skeletonized remains. The field agents may arrange the submission of the skull to the artist, who returns it after visage reconstruction and photography.
G.
X.
Skeletonized Remains The following procedures may be performed, depending on the case. If the skeleton is of an unidentified person, the preceding steps may also be taken. A. PHOTOGRAPHY - Photograph the body as received (in pieces, in boxes, etc.). Get full body photos in anatomic position and standard angles on the skull, both BEFORE CLEANING AND AFTER. Include any other photos as needed, e.g., of wounds or other details. ANTHROPOLOGIC CONSULTATION - Available on request (see Appendixes - Consultants). RADIOGRAPHY - X-rays may be needed for purposes of identification or age determination. They require different setting than the usual "hard" x-rays for locating bullets, etc. The objective is to capture as much detail in the
B. C.
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Revised 1/03/08

trabecular part of the bone as possible. Skull shots should be taken in the Frankfort plane, which is an A-P shot with the skull propped so that the beam will be in a plane parallel to a line between the floor of the orbit and the ear canal. D. INSECTS - The type of insects and their developmental stages may be important in determining postmortem interval and may be useful for toxicology analysis. Representative samples of each form and size should be collected, some kept alive for species identification, and some preserved for age determination. If diverse populations (different species or ages) are identified on various areas of the body, separate samples may be submitted, labeled as to their source. The live insects should be placed, with a small piece of liver and a folded wet paper towel, in a piece of foil which is then folded closed on top and placed in a vented container ("maggot motel"). Others should be boiled in water and then placed in a tube of 70% isopropyl or ethyl alcohol (not formalin). Refrigerate the living specimens until shipment. When submitting, include copies of any relevant information regarding the scene, information about the climate and environment of the body, and a note about the storage conditions of the specimens and time since the autopsy. Call the entomologists office (see Consultants appendix), and arrange to have the specimens shipped by Federal Express so they will arrive during their hours Monday through Friday. E. BOTANIC OR MYCOTIC EVIDENCE - Just as with insects, these may be collected for their potential value in determining postmortem interval and if the body has been moved. CLEANING - To clean skeletons after initial examination and photography, excess tissue can be cut away, making certain to note any marks artifactually made on the bones during this process. The best method is to place the bones in a combination of detergent with proteolytic enzyme (Biz, Tide, etc.) or you can add meat tenderizer containing chymopapain in warm water, preferably at 80oC (higher temperature will denature the enzyme). The process may require several hours, during which time repeat examinations may be done to detect any damage to the periosteum before this tissue is lysed. TAKING OSSEOUS SPECIMENS FOR ANALYSIS - Before osseous specimens are taken, the entire body should be x-rayed. Usually, the features are determined in the following order: sex, race, age, stature and physique, then any individualizing features for final identification. The following parts are needed: 1. 2. For sex: pelvis, humerus, radius, femur, or skull. For race: long bones, e.g. femur/tibia and humerus/radius, and the
F.
G.
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skull plus mandible. For age: medial clavicle, pubic symphysis, proximal fourth rib, and dental elements. For stature and physique: femur, tibia, clavicle and distal humerus (all same side if possible).
3. 4.
Every attempt should be made to remove these items without causing any tool damage to the bone. If facial reconstruction is contemplated, minimal cutting and sectioning should be done on the skull and jaw.
12.10
Revised 1/03/08

CHAPTER 13 HOSPITAL / PRIVATE CASES I. Hospital Cases- General info
Occasional cases that would not normally be brought into DCME for a county autopsy may be brought in for an autopsy to be performed by a Parkland pathology resident under the supervision of a DCME medical examiner due to the affiliation of the office and the medical examiners with the UT Southwestern Medical System. Although performed in the facility, these autopsies are not performed at Dallas County expense, and do not fall under county jurisdiction. Limited documentation on these cases is available in the DCME database system, and their autopsy reports are not available through DCME. The autopsies are initiated by St. Paul and Zale-Lipshy University Hospitals (Parklands and Childrens are done at their own hospitals), who get the autopsy permission and funeral home information, if available, from the appropriate next-of-kin, arrange transportation of the body to our office, and make notification. During weekdays, they call the Parkland/UT Autopsy Coordinator, Pamela, at 214-590-0362 and fax her the autopsy permit and funeral home information. She brings it to the DCME field agent to initiate our involvement, and brings with her an autopsy case folder containing the permit, DCME billing form, the histology submission form, and Parklands autopsy forms and diagrams for the resident. On weekends and if Pamela is unavailable, the hospital is to call the pathology resident-on-call, who performs those duties. Another type of case that falls into this group is Neuropathology brain only cases such as where a brain is being removed with family permission as part of a study of Alzheimers disease. II. Field agents
When we are notified of a case, the field agent assigns the decedent a DCME case number. Parkland/UT may also have assigned their own autopsy number, which may be mentioned in our records. If the decedents death was already reported to us and already has a number as a No Case, Non-Reportable, or Absentia case, it is to keep that number. If it does not already have a DCME number, it is to be assigned a PC number, and entered into the DCME system. The field agent prepares the toe tags and Body Disposition form (including the funeral home information if already provided by the hospital). The field agent logs the case into the funeral home book, and places the toe tags in the box in the elevator as with any other body arriving to DCME. The Body Disposition form, DCME case report, and any case folder from the Parkland / UT autopsy office (Pamela) is placed into the case file tray with the routine DCME cases. On the Neuropathology brain cases, the field agent includes a DCME Charge Sheet in the paperwork. The Clothing and Toxicology forms done on Dallas County cases are not needed on these cases. The medical examiner assigned to Parkland autopsy duty (7 days a week) will generally be the staff pathologist. Transportation of the body is arranged by the hospital; the field agent does not call transport. The hospital chart may arrive with the initial notification or later with the body. Either way, it should be placed with the other case paperwork or given to the medical examiner assigned to
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Revised 1/03/08

Parkland duty. If funeral home information is initially unknown, Bed Control at the hospital will follow up with the family and later call us with the funeral home. When the medical examiner tells the field agent that the body is ready for release, the field agent calls the funeral home, notes that in the funeral home book and on the Disposition form, and places the Disposition form in the blue notebook the same as other bodies being released from DCME. III. Body Receiving and Release
The body should be checked in as any other body arriving at DCME, with the usual DCME procedures followed such as checking toe tags against all paperwork, completing a Body In page, and entering the case into the logbook and computer. They should generally arrive with a copy of the hospital chart which is to be taken up to the field agents as usual. The usual DCME release procedures are followed. There will usually be no clothing; a Clothing List will not be present unless clothing was with the body. IV Pathology Resident / Medical Examiners
The pathologists should follow standard UT procedures regarding checking patient identification and proper autopsy permit status, and autopsy performance. If a Parkland autopsy folder is not provided by the Parkland Autopsy Coordinator, they are available on weekends in the black box in the Parkland autopsy area. Photographs are taken using the Parkland/UT autopsy number (not the DCME #) and are later downloaded into the Parkland autopsy case system. Camera disks are available at Parkland autopsy, but DCME disks may also be used if needed. Clothing is not generally present. If it is, a DCME Clothing List is to be completed and the clothing may be released with the body. Tissue sections are saved following UT procedures with the save jar stored at the PMH morgue. Containers and tackleboxes can be brought over from PMH prior to the autopsy. The brain does not necessarily need to be saved, but if it is, it should be stored at PMH. Histology is submitted to the immunohistochemistry lab (F2.212) using the IHC lab histology form (provided in the PMH autopsy folder). If cultures are obtained, they are to be taken by the resident to Zale-Lipshy Lab Central (third floor). Do not take them to Parklands lab or use the DCMEs contract lab. If it is a St. Paul case, a courier will transport the cultures from Zale to St. Paul.
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Revised 1/03/08
Toxicology is not generally performed. If the medical examiner decides that it is needed, it probably also means that the case has become suspicious of something other than natural causes, which would then necessitate the case being converted to a DCME case anyway. However, if the case is not converted to a DCME case, the pathologist should note that it is a hospital case on the tox request form and DCME Toxicology will subsequently bill the university hospital. After completion of the case, the medical examiner completes the portion of the Disposition form allowing release of the body, and gives it to the field agent. The medical examiner also completes the bottom part of the DCME billing form (the amounts and hospital to be billed are preprinted) and submits it to the DCME accounting clerk (Mr. Ali). This ensures that the ordering hospital pays Dallas County for the use of the autopsy facility and the technicians time; the medical examiners time is not billed for as staffing the Parkland pathology residents is part of their duty as faculty at UTSMS. Completion of the autopsy report is between the resident, the supervising medical examiner, and the Parkland/UT Autopsy Coordinator. The reports are kept in the PMH autopsy database, and are sent by the Coordinator to the hospitals transcription departments for distribution within the hospitals. On Neuropathology brain cases, the medical examiner should notify the contact person listed in the field agent case report when the body arrives. UTs Neuropathology department arranges obtaining the brain here, and transporting it to their study location. After the removal is completed, it is the responsibility of the medical examiner covering hospital autopsies to complete the Body Disposition Form and the Charge form as with hospital cases. However, the medical examiner is not responsible for the autopsy itself. V. Autopsy Technicians
The DCME autopsy technicians assist the pathologists in the performance of the St Paul and Zale hospital cases. These cases do not require fingerprinting, or the collection of toxicology specimens (rare exceptions, and that usually involves the case also being converted to a DCME case). They also assist the Neuropathology department personnel in removing the brain on the Neuropathology cases. VI. Records/Reports
DCME keeps records of all bodies arriving here, including at least the record of body receiving and release, and the field agent report (may be minimal on NC or NR cases). In addition, if the case is an AB case, has a cremation permit, or becomes a county disposal, records will be kept regarding those activities. There will be no autopsy report, however, at DCME or available to the public through us, on these hospital/private cases. Any person asking for information on a report should be
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referred to Pamela, the Parkland/UT Autopsy Coordinator (214-590-0362). They may also try to go directly through the medical records department at the hospital of the decedents death. VII. Private Cases
Private cases that are not under DCME jurisdiction or due to their affiliation with the UT medical school complex are uncommon, but may be performed by a DCME medical examiner. These cases are not done at any expense to the county or on county time of any employees. The performing medical examiner will pay at least for the facility use, and will pay any employee services or for any materials/services provided by the county. They are done after-hours only, and involve no county record keeping, except for the records maintained on all bodies received / released by DCME.
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Revised 1/03/08
CHAPTER 14 SPECIAL PROCEDURES
I.
Demonstration of Thrombi in the Calves To demonstrate the presence of deep leg vein thrombi in a case with pulmonary embolism, incise the skin posteriorly from the thigh to the ankle, and reflect the skin laterally. The tendon of Achilles is divided, and the calf musculature is separated from the bones and reflected upward. Serial transverse sections are made through the musculature including in the popliteal fossa. Ante mortem thrombi will extrude from the vein as firm structures, which cannot be mistaken for the soft gelatinous postmortem artifacts. The major arteries of the calf pass between the tibia and the fibula. They remain intact if this procedure is properly performed, avoiding any interference with subsequent embalming of the leg.
From Spitz and Fisher, Medicolegal Investigation of Death, Third Edition, 1993. Courtesy of Charles C. Thomas, Publisher, Springfield, Illinois.
14.1
Revised 1/03/08
II.
Demonstration of Pneumothorax To check for pneumothorax, particularly tension pneumothorax with mediastinal shift, chest x-rays should be taken. A large water-filled syringe with a large needle can be introduced anteriorly into each pleural cavity through the intercostal space. In infants the baby can be totally submerged under water before the chest cavity is incised. Another method is to incise the chest skin, leaving the bones of the chest plate intact (see the following diagrams). The skin and muscles are reflected back on the injured side of the chest to form a pocket, which is then filled with water. To measure any air present, an inverted and water-filled graduated cylinder may be held over the pocket. A scalpel is introduced under the cylinder in the water through an intercostal space into the costodiaphragmatic sinus, and is twisted a few times to ensure creating an open defect.
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Revised 1/03/08
III.
Demonstration of Air Embolism The presence of air in the heart should be suspected in cases with open wounds in the neck area, and occasionally other cases (e.g., introduction of air through a vascular catheter in a "medical misadventure", and oral intercourse in pregnant women). Air in the right side of the heart may be visible in a routine chest X-ray. If not, and it is suspected, an X-ray taken with the body propped on its left side (right side up) may help in visualizing any air. Air can be demonstrated and measured by making an H-shaped skin incision (later expanded for the autopsy), reflecting back the skin and muscle, and removing the lower portion of the chest plate (See following diagrams). The upper portion of the chest plate is left intact until after this procedure to avoid the accidental introduction of air during its manipulation and cutting. The pericardial sac is incised anteriorly, held open with hemostats by an assistant, and filled with water submerging the heart. A large graduated cylinder filled with water and carefully inverted is placed over the heart, with the mouth of the cylinder in the pericardial water. The right side of the heart is then perforated with a scalpel under the water level, twisting the scalpel a few times to ensure an open defect. If air is present, bubbles will rise into the cylinder displacing water. The absence of any demonstrable air does not totally exclude that possibility. For example, the air may have moved on through the heart into the lungs, where it may not be detected.
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Revised 1/03/08

IV. Removal of the Spinal Cord The spinal cord may be easily retrieved intact, suitable for subsequent gross and microscopic examination, or fixation and neuropathologic consultation, using either the anterior or posterior approach. The autopsy is performed in the usual way. The brain is removed and the nerve roots in the cervical area are severed through the foramen magnum. In the anterior approach after the trunk has been eviscerated, a series of cuts are made on the left and right sides of all of the vertebral bodies into the spinal canal. Prying with a chisel may be necessary to remove the bony wedges of vertebrae, exposing the spinal cord in the dural encasement. This approach allows removal of the cord without the necessity of turning over the body, but it can be difficult to expose the upper cervical portion and can generate more bone dust from sawing through the vertebral bodies than the posterior method. In the posterior approach, the evisceration, removal of the brain, and severance of the upper cervical nerve roots through the foramen magnum are performed in the same manner. The body is then turned over, and a skin incision is made from the occiput to the lower lumbar region. The skin is reflected for a short distance bilaterally, and a series of saw cuts are made through the lamina on both sides of the spinous processes of all of the vertebrae. The entire strip of spinous processes and interconnecting soft tissue is dissected away, exposing the cord within the dura. The dura can be longitudinally opened to remove the cord, or the cord and the dura can be removed as a single unit; either way the nerve roots should be cut as distal to the cord as possible, as the cord is lifted out.
Posterior Cuts: Anterior Cuts:
An alternative method involves the removal of the anterior aspect of the lumbosacral vertebrae, tying off the cauda equina, severing the cauda distal to the tied portion then pulling the spinal cord down through the column following ligation of nerves at the C-1 level through intracranial cavity. This is most useful when the
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Revised 1/03/08

cord is being removed for either a more thorough exam or natural disease rather than when a spinal cord injury is suspected. This method results in less recovery of the nerve roots than in the previously described posterior approach. V. Fixation Of The Brain The brain may be fixed either for neuropathologic consultation or for later examination by the case pathologist. A supply of buckets and 20% formalin is kept for this purpose. The bucket should be labeled with the case name and number, date of examination, and pathologist's name. If it is for personal sectioning, it should be labeled as such and kept away from those saved for conference. The brain may be suspended by a string through the Circle of Willis, which is tied to the bucket handle. Salt is not used to aid in flotation of the brain due to the possible osmotic-induced artifacts. The lids should be closed tightly. The brains are kept in fixative for at least 10 days, and are washed in water overnight or longer before examination. VI. Removal and Examination of Eyes The eyes are most often removed in cases of suspected infant abuse to examine for hemorrhage in the retina and around the optic nerve. After removal of the brain, the eyes can be removed through the orbital plates without damage to the eyelids. The eyes can be replaced with plastic shapers by the funeral homes with no disfiguration of the face. For each eye, two cuts are made in the paramedian (anterior-posterior) plane, as far as possible medially and laterally through the lesser wing of the sphenoid bone and through the orbital plate. The cuts are connected anteriorly by a coronally oriented cut through the orbital plate. They are connected posteriorly and inferiorly by a transverse cut through the sphenoid bone. The resulting bony wedge including most of the posterior wall of the orbit can now be easily removed. Using forceps, carefully chip away the thin bone of the orbital plate, exposing the orbital contents. The fat in the posterior portion of the orbit can be gently pulled and dissected out, exposing the optic nerve and the globe. The nerve should be cut as far posteriorly as possible. The posterior soft tissue of the globe can be gently pulled back, and the six nerves attached to the globe cut, being careful to avoid the eyelids. The conjunctiva around the cornea can be safely cut with small scissors. The removed eyes and attached optic nerves are placed in 10 or 20% formalin for at least a week before sectioning. During the examination, photographs are generally made, at the direction of or by the pathologist, of the intact eyes, the nerve and the opened globe. The nerves may be serially cross-sectioned, or longitudinally cut with the eye. A transverse cut is made through the iris about 1 mm from its edge and extended posteriorly to a point immediately adjacent to the nerve. A parallel cut is made through the opposite edge of the iris and to the other side of the nerve. It is important to make the cuts in this area of the iris to include the entire lens in the resulting middle section, and to better
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Revised 1/03/08

open the anterior chamber to prevent bubble formation during processing. Incisions made moving from anterior to posterior help prevent detachment of the retina. For the same reason, a large single-edged razor blade with no central hole works best. The transverse mid section of the eye can be submitted for histology in the extra deep histology cassettes kept in the autopsy room. Nerve cross-sections may be submitted in a regular cassette.
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Revised 1/03/08
CHAPTER 15 ORGAN AND TISSUE DONATION I. Transplantation In medical examiner cases where tissue and/or organ donation is being considered, one of the medical examiners must generally be contacted for approval before anything is removed (see exceptions later on some JP cases). This is true both of decedents already in the Institute and of those on life support in a hospital. Hospitals are required by law to approach the families of all dying patients regarding the possibility of organ and tissue donation, unless the patient is already known to be ineligible for donation (due to reasons such as age, infectious disease, etc.). If the next of kin does not give consent, the medical examiner does NOT have the authority to overrule the family's decision. It is the responsibility of the transplant authority, not the DCME, to obtain the necessary next-of-kin consent for donation. Two separate transplantation organizations are involved in this process Transplant Services Center, a state agency affiliated with the UT Southwestern Medical Center at Dallas and Southwest Transplant Alliance (the Organ Bank), a private non-profit organization. Out-of-county cases may use another organization. Typically, if the patient is in the hospital and visceral organs are being requested, Southwest Transplant Alliance will contact us. If the patient is already deceased and at the Institute, the Transplant Services Center is the one to contact us. The two groups cooperate, however, and we are generally called only once even if both groups are involved. Transplant Services is involved in removal of tissues (corneas, skin, bone, cartilage, and the heart for the valves) which can be removed either while the decedent is still at the hospital or in the Institute (see Appendices Transplantable Tissues for a list of these tissues and their restrictions regarding donor age and time since death). Southwest Transplant Alliance is involved in the removal of visceral organs (heart, kidney, liver, or other organs or tissues requiring a patient support system to maintain the viability of the organ), which are harvested in the hospital operating room prior to our receiving the body. They also sometimes do skin and bone. The medical examiner's decision is based upon whether the removal of the tissues would impair the autopsy findings or interpretation, interfere with the determination of the cause or manner of death, or interfere with subsequent court trials. There is almost no reason to deny M.E. permission. In general, if an organ is useful for transplantation, it can be expected to have appeared normal to the harvesting surgeon or technician. If the decedent is taken into surgery for donation, a multi-page form is completed and sent to the medical examiner including such information as abnormal findings and what was removed.
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Revised 1/03/08

The field agents intermediate between the requesting transplant authority and the medical examiner, and document the approval or denial in the computer and case file. The ME may ask the field agent to relay certain requests to the transplant group such as taking photographs of the body before skin harvest or to have the pathology reports and/or remains of a heart returned to DCME after removal of valves. If a delay in obtaining medical examiner approval will preclude procurement of an organ or tissue, the medical examiner may be called at any hour. However, if organ/tissue time limits allow, or no action will be taken by transplant until morning, there would be no need to call a medical examiner late at night if one will be arriving soon at the office. On Dallas County Cases, a medical examiner must always be consulted: - In those non-homicide cases where family has given consent, the approval is usually granted and the tissue and organs may be harvested prior to the medical examiner seeing the case. - In those homicide cases where family has given consent, the medical examiner will usually grant approval using the above guidelines. If visceral organs are being donated they will be removed in the hospital prior to the medical examiner seeing the body. On Out-of County Cases, the Justice of the Peace acts in the same function as the medical examiner and must grant or deny approval for donation. DCME may not be involved in the process at all if donation is done before we are notified or the body arrives at SWIFS. If we are involved, it is up to the transplant authority to obtain the JP approval, as well as that of the family, and report it to us. It is suggested that they follow the same guidelines regarding what time to call the JP as the field agents use for the medical examiners. - In most natural and accident cases, where the JP has approved, there is no need to also call a medical examiner. - In homicide, suicide, or firearm cases, or others where there are likely subsequent court issues, the decision is made by the JP, but the judge may sometimes want to consult the ME regarding concerns such as evidence preservation. If a medical examiner withholds approval for removal of one or more organs of a potential donor for any reason, and the surgeons still want to use them, the medical examiner must be present during the initial phase of organ removal. After observing the condition of the internal organs, a denial can still be made, but a written explanation must be provided to the transplant agency and to the consenting next of kin citing the reason(s) for denial. On an evening or night case where timing is a problem, corneas and other tissues may be removed prior to the medical examiner seeing the body. On most
15.2
Revised 1/03/08

homicides, however, photographs of the body and collection of trace evidence are important, and permission will not be granted for skin or bone harvest until after the medical examiner has examined the body and these procedures are completed. If no family is available to consent or object to donation, the medical examiner may be asked by the transplant organizations to give permission do donate a non-visceral organ or tissue, excluding corneal tissue, under what is commonly called the M.E. Law (see following excerpts). Note that this state law refers to donation when family is unavailable, NOT against the wishes of family with known objection to donation. In cases where this law is to be invoked, it is the responsibility of the transplant groups to make diligent attempts to contact the next of kin, including documentation of multiple phone calls with no response to their residence, or of the fact that no next of kin can be found. Although the law allows this donation, in practice it is not done due to potential complications from lack of medical history or later finding family objections. Previous laws allowed for the same type of consent by a medical examiner for donation of corneal tissue and visceral organs in the absence of family, but those laws have since been revoked. In any case where corneas are removed and vitreous fluid is submitted for toxicology, a note should be made on the top of the Toxicology Request Form that the corneas were removed. This will aid in later interpretation of the lab results, as these cases may have artifactual elevations of isopropyl alcohol. II. Research / Other Donation No organs or tissue are released from the medical examiners office for any type of research purpose without the consent of the next of kin. The brain is the organ most often donated. Occasionally the family will have prearranged donation if the decedent was participating in a study of patients with Alzheimers disease or schizophrenia. The Alzheimer cases are usually local donations involving the Neuropathology Department at UT Southwestern. The schizophrenia cases are sometimes long-distance; the research facility (usually in Massachusetts) will arrange and pay for shipping. The Department of Psychiatry at UT Southwestern Medical Center has an ongoing collection of human brain tissue (Dallas Brain Collection) for studies of mental illness. They request permission from next-of-kin to donate the whole brain in cases where the decedent has a history of mental illness: reported psychiatric diagnoses, reported psychiatric medications, history of substance abuse, and death due to suicide. They are also obtaining consent and collecting brains as normal controls from decedents who did not have any of the previously listed histories. These studies of brains from people with mental illnesses that currently have no known physiological characteristics will help to understand more about the disease processes and possibly help with future treatment. The main criteria for the brains is a post-mortem interval of 24 hours or less, less than 24 hours of prolonged agonal state, no brain diseases (like Alzheimers of other dementias),
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Revised 1/03/08

and that the cause of death does not involve head injury. After the brain is removed at autopsy, the research collector takes it in the fresh state to their medical school laboratory where it is examined and a report is generated for DCME. If the case is not going to be autopsied by DCME, they can arrange for UTs Willed Body program to come to DCME and remove the brain for them. III. Related Laws The following are excerpts from Texas laws regarding medical examiners and donation / transplantation in the TEXAS HEALTH and SAFETY CODE. Chapter 692 Texas Anatomical Gift Act, and Chapter 693 "Removal of Body Parts, Body Tissue, and Corneal Tissue", refer to the removal of organs and tissues from decedents whose deaths are within medical examiner/justice of the peace jurisdictions. Chapter 692.004. (a) The following persons, in the following priority, may give all or any part of a decedents body for a purpose specified by Section 692.005: (1) the decedents spouse; (2) the decedents adult child; (3) either of the decedents parents; (4) the decedents adult brother or sister; (5) the guardian of the person of the decedent at the time of death; or (6) any other person authorized or under an obligation to dispose of the body. Chapter 693, Subchapter A, Section 002 (a), paragraph (4): If the medical examiner is considering withholding one or more organs of a potential donor for any reason, the medical examiner shall be present during the removal of the organs. In such case, the medical examiner may request a biopsy of those organs or deny removal of the anatomical gift. If the medical examiner denies removal of the anatomical gift, the medical examiner shall explain in writing the reasons for the denial. The medical examiner shall provide the explanation to: (A) the qualified organ procurement organization, and (B) any person listed in Section 693.004 who consented to the removal. Chapter 693, Subchapter A, Section 003 (b): "If a person listed in Section 693.004 is known and available within four hours after death is pronounced, a medical examiner or a person acting on the authority of a medical examiner may not remove a non-visceral organ or tissue unless the medical examiner or person obtains that person's consent." See later House Bill revision. 693.003 (c): "If a person listed in Section 693.004 cannot be identified and contacted within four hours after death is pronounced and the medical examiner determines that no reasonable likelihood exists that a person can be identified and contacted during the four-hour period, the medical examiner may permit the removal of a non-visceral organ or tissue."
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693.004 "Persons Who May Consent or Object to Removal. The following persons may consent or object to the removal of tissue or a body part: 1) the decedent's spouse; 2) the decedent's adult children, if there is no spouse; 3) the decedent's parents, if there is no spouse or adult child; or 4) the decedent's brothers or sisters, if there is no spouse, adult children or parent." House Bill No. 1544, effective September 1, 2005, added Section 692.017. CIVIL PENALTY. (a) A person who removes corneal tissue from a decedent knowing that a gift authorizing the removal has not been made in accordance with Section 692.003 or 692.004 is liable to the state for a civil penalty. (c) A civil penalty under this section may not exceed $500 for each violation. In assessing a penalty under this section, the court shall consider the seriousness of the violation.
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Revised 1/03/08
CHAPTER 16 SAFETY Safety of DCME employees and visitors is of utmost importance. The SWIFS Safety Officer, Dr. Elizabeth Todd, is responsible for the oversight and documentation of safety training of employees and safety equipment maintenance. Each work area has readily available safety equipment such as fire extinguishers, eyewashes, first aid kits, emergency showers, formaldehyde spill kits, and emergency lights strategically located as appropriate for the area. These are periodically checked and the records kept by the safety officer or her designated employees, Jack Trout and Justin Schwane. Individual copies of the institutes Safety Manual are available from the Safety Officer. I. General Infection Transmission Information Occupational exposure to infection can occur in many ways. All specimens and all cases should be considered potentially infectious. For the purposes of infection control, OSHA has defined body fluids as those fluids which have been directly linked to the transmission of HIV and/or Hepatits and/or to which universal precautions apply: blood, semen, blood products, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, and amniotic fluid. Only blood has been actually implicated in the occupational transmission of HIV from patients to health care workers. The other body fluids, however, remain a theoretical hazard. The blood-borne infections of primary concern to health-care workers include the Human Immunodeficiency Viruses (HIV) causing AIDS, the Hepatitis Viruses (especially Hepatitis Viruses B [HBV], C, and D), and syphilis. Syphilis and HIV are relatively fragile, but Hepatitis B may be stable in dried blood on a counter top for several days. Airborne transmission, or transmission of infectious particles less than 5 microns by aerosol inhalation, may be a problem, especially with Tuberculosis and the fungal infections Histoplasmosis and Coccidiomycosis. Even blood-borne infections may be transmitted in this route through direct droplet contact from splashes, spatter, removal of stoppers from tubes of blood, etc. In addition to the infections already listed, examiners should always be aware of the risks of infection by the more "routine" organisms, such as staph or strep bacteria into a cut or an open wound. The means of transmission of microorganisms include: A. Direct contact 1. Percutaneous - parenteral inoculation of blood or other body fluids, as occurs by accidental needle sticks, scalpel cuts, etc., and by transfusion of infected blood products. 2. Non-intact skin - transfer of infectious fluids through the
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Revised 1/03/08

contamination of preexisting minute cuts, scratches, abrasions, burns, weeping skin lesions, etc. 3. B. Mucous membranes - contamination of mucosal surfaces by splashes, spattering, or other means of mouth, nose, or eye contact.
Indirect contact - transmission of infectious blood or body fluids to the skin or mucous membranes by hand contact with common environmental surfaces such as telephones, test tubes, writing pens, or other surfaces. This is known to occur with Hepatitis B Virus, but has not been documented with HIV. This is also the primary method of transmitting colds and flu. Fecal-oral transmission - this poses a significant risk for Hepatitis A and the enteric viruses (which are not, fortunately, generally significant health hazards). It does not appear likely to be a transmission route for Hepatitis B or HIV, unless blood is present. Airborne transmission - either "true" airborne tiny particles or larger droplets carrying blood-borne particles.
C.
D.
Anyone, anywhere, will have some risk of exposure to infectious disease, but some jobs will obviously have higher or lower levels of risk. All SWIFS employees should be aware of their own level of risk and be aware of the necessary precautions and available protective steps and apparel to minimize this risk. If questions, check with the supervisor, the Safety Officer, or a medical examiner. II. Universal Precautions The term "universal precautions" refers to a system of infectious disease control, which assumes that every direct contact with body fluids is infectious. Every case should be performed following universal precautions, as though they all have HIV or hepatitis virus. This means the employee protects himself during all laboratory work from parenteral, mucous membrane, and non-intact skin exposure. The same precautions are protective against many chemical exposures. Gloves should be worn at all times for handling blood, body fluids, bodies, tissues, and items possibly soiled with blood or body fluids. Double gloves may be worn, usually a thick outer pair and an inner disposable pair. Cut-resistant steel mesh or Kevlar gloves may be worn between these layers, usually on the nondominant hand more at risk of being cut. Mesh gloves protect the wearer against knife cuts, but not against punctures. Some puncture-resistant gloves are available, but they may limit flexibility. Shoe covers are worn in the autopsy area. They are to be disposed of before leaving the area to enter the locker rooms or to go upstairs.
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Revised 1/03/08
Eye protection and masks should be worn for autopsy activities, clean up, and any time there is a risk of splashing infectious agents or chemicals. When performing an autopsy or within proximity of an autopsy (within splash/spray range), shoe covers, scrub clothes, a water-repellant layer (apron, gown, etc.), gloves, mask and eye covers must by worn. Other optional protective apparel available includes safety gloves, hats, arm covers, and various types of masks and face shields. In other laboratory areas, a lesser degree of protection is required, but will generally include availability of at least gloves and face protection. Laundering is provided if scrubs are worn Take care to avoid aerosolization of blood, etc. When opening blood tubes, place gauze over cap and tube opening. Procedures that have high potential for creating aerosols (centrifuging, vigorous mixing, etc.) should be carried out in biological safety cabinets or under hoods. Wash hands following completion of laboratory activities, after removal of protective clothing and before leaving the laboratory, even though gloves had been worn. Take great care to avoid injuries with needles, scalpels, knives, or other sharp instruments. Needle, blade, and contaminated glass disposal is into punctureresistant containers labeled as biohazard. Needles should not be manually recapped or removed from syringes or other holders; they should be discarded into the special biohazard containers that accept the entire unit or provide a means of safely disconnecting them. Scalpels are not to be passed from one prosector to another. They should be placed down on a firm surface, and then picked up by the second person. Bone dust and blood spatter may be minimized by prudent use of the electrical Stryker saws (e.g., cutting through ribs or costal cartilage with shears or a knife). To reduce spray generated by the saw, damp towels may be placed around the field, and the area irrigated with a slow water drip. Dilute bleach may also be used. Eating, drinking, and smoking are prohibited in the autopsy and specimen handling areas. These activities, as well as nail biting or any other hand-to-mouth, nose, or eye actions, may contribute to indirect transmission of infection. All biological spills are to be cleaned up and disinfected with an agent effective against HIV, Tuberculosis, and other pathogens. The autopsy stations and tools must be cleaned between cases. Generally, detergent and a 1:10 to 1:100 dilution of household bleach are used. A brief exposure of 10 minutes is adequate; longer may corrode instruments. The bodies, carts, and head blocks are also cleaned with detergent and dilute bleach. The autopsy stands, clean paperwork areas, and
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Revised 1/03/08

floors are cleaned daily, or more often if spills occur. Walls and ancillary areas such as the coolers and x-ray rooms are cleaned regularly. Place all tissues being fixed and saved in at least 10% formalin (3.7% formaldehyde), present in at least ten times the volume of tissue, which should be thinly sectioned if possible. This will inactivate all the important infectious agents except the agent of Creutzfeldt-Jakob Disease (CJD). Embalming fluid containing glutaraldehyde is similarly effective. Decontamination of the very rare CJD requires prolonged autoclaving at higher temperature or pressure, or immersion in 1 N sodium hydroxide. Care must be taken to not transfer blood or other fluids to papers or other objects that will then be carried around to different clean parts of the building. Both the autopsy and field agent areas have clean and dirty workspaces. The clean areas (most of the field agent room and one counter in the autopsy rooms) are reserved for papers, case files, empty unused specimen containers, etc. No blood, specimens, used fingerprint equipment, decedent medications, etc. are allowed. The dirty areas (one counter in the field agent room, and most of the autopsy area) are for these other materials. Only necessary papers (autopsy diagrams, weights page, etc.) should be placed on the autopsy room stands, and if they become visibly contaminated with blood, they should be disposed of and replaced with a clean copy for the file. See later section, Hazardous Waste Disposal, in this chapter regarding disposal of biological or chemical wastes. III. Known Infectious and Hazardous Cases Although universal precautions are taken on all cases due to their potential risk, certain hazardous cases may deserve extra precautions. Autopsy will be avoided completely in cases with known communicable disease unless it is necessary (see Chapter 10 section on Autopsy vs. Inspection). Cases known or suspected to have HIV or Hepatitis infections are relatively common, and should be safely performed using universal precautions, which protect the employee mainly from blood-borne diseases. It is wise, however, to perform these examinations last, and in an area with the least traffic. Cases known or suspected to have been victims of bio-terrorism attacks (Anthrax, Small Pox or Plague), tuberculosis, plague, Hantavirus, SARS, Creutzfeldt-Jakob Disease or encephalopathy of unknown cause, or other unusual infections should be discussed with the Chief or Deputy Chief Medical Examiner regarding both the necessity of performing an autopsy and any special precautions which should be taken. These bodies are to be placed in two body bags. See protocol for processing of bodies known or suspected of having highly infection agents (HIA) in the appendices. Extra steps may include using the specially ventilated Isolation
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Room, using Parklands isolation room, wearing additional protective gear, avoiding the use of an electrical saw, having a clean "circulator" to assist (e.g. recording observations, handling uncontaminated equipment, etc.), adding extra disinfecting procedures, and limiting the examination to only the necessary areas. The special Communicable DiseaseBlood/Body Fluid Precautions toetags should be placed on the cases known or suspected to have any of the following diseases (according to the Texas Administrative Code, Communicable Diseases, Ch 97, Rule 97.12): acquired immune deficiency syndrome (AIDS), anthrax, brucellosis, cholera, Creutzfeldt-Jakob disease, viral hepatitis, HIV infection, plague, Q fever, rabies, relapsing fever, Rocky Mountain Spotted Fever, syphilis, tuberculosis, tularemia, and viral hemorrhagic fevers. The individual disease should not be noted on the tag. Any suspicion should be based on good medical or historical information, and not on something as vague as a decedent's lifestyle or appearance. The use of special labels may create a false sense of security that non-labeled blood is not infectious. Special labeling is therefore not encouraged for in-house use on specimens from the more routine infections such as AIDS and hepatitis, which are adequately handled using Universal Precautions. IV. Occupational Injury and Exposure When a splash or injury to an employee occurs, the blood or body fluid should immediately be washed off with antimicrobial soap, while encouraging bleeding. The skin should be washed thoroughly, but not scrubbed, as this may damage the skin and increase the risk of infection. In the case of a mucous membrane exposure (eye, nose, or mouth), gently flush the exposed area with copious amounts of water. Sinks, eyewashes, and emergency showers are located throughout the autopsy and laboratory areas, and there are sinks and showers in the locker rooms. All DCME employee injuries, including cuts, needle sticks, and mucous membrane exposures, should be reported immediately to the employees supervisor. A notebook labeled Blood / Body Fluid Exposure Protocol, kept in the field agent area, contains further directions for the steps to be taken following exposure. Blood from the decedent must be collected for infectious disease testing when appropriate. Parklands Occupational Health Services (across Harry Hines) handles the follow-up testing, prophylaxis treatment, and/or counseling. After hours and on weekends/holidays, the employee may be seen in the PMH Emergency Room. In addition to the infections discussed earlier in this chapter, remember to cover for tetanus and bacterial infections as needed. If a Dallas County public service emergency response worker has a possible exposure, they should call the Dallas County Health, Communicable Diseases Section, Nurse for EMS and Public Safety Exposure (currently Sally Colwell) at 214819-2009, or fax 214-819-6095. If shes unavailable, the nurse-on-call can be
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reached through the main number 214-819-2004. DCME will provide blood or test results on the decedent as appropriate, but all testing, follow-up, treatment, and/or counseling of the exposed worker is through the countys Public Safety Exposure nurse. If a public service worker from another county has a possible exposure from a DCME case, they can work through their own countys occupational exposure system, or can also call the Dallas County nurse above, where they can be helped with referral information if not directly assisted. We will provide blood and/or test results to the appropriate nurse/physician as needed, but should not give the results directly to the exposed person. To reduce the risk of infection, all Institute personnel who may be exposed to blood or body fluids are offered the Hepatitis B vaccine at no cost, at any time from the beginning of employment. The vaccine consists of a series of injections given in the deltoid muscle once, one month later, and six months after the first dose. Annual tuberculosis testing is also provided by the county at no cost to the employee. V. Chemicals A. General Chemical exposure should be kept to a minimum, and appropriate protective apparel should always be worn. All chemicals are to be stored as per the manufacturer's instructions in properly labeled containers. Current MSDS's (Manufacturers Safety Data Sheets) are kept on all chemicals used in the Institute, and are readily available in each work area. B. Formalin Formalin (formaldehyde gas in water) has both short-term and long-term exposure limits. The formaldehyde levels in the autopsy area are regularly monitored by the Institute's Environmental Laboratory. Minor spills are to be cleaned up immediately with water and absorbent material or mop. Spill kits are available with an absorbent cloth for small puddles of formalin or hydrocarbons. Larger containers of absorbing/neutralizing material to pour over the spill are also kept near the chemical storage area. For any major spill, the area should be evacuated and the Environmental Laboratory in the Institute, or the Dallas County Hazardous Materials
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Revised 1/03/08

(Hazmat) Response Unit, should be called. Used formalin is reclaimed by one of the autopsy technicians wearing a chemical-protective mask (one kept in each of the two main autopsy areas). The small containers are poured into 55-gallon drums, which are removed by a disposal service on contract to the county. VI. Fire/Emergency Evacuation Employees should be aware of the locations of fire extinguishers and exits. In the autopsy area, extinguishers are located near the main sink, in the hallway, and by the loading dock. On most floors, they are in the hallways. The extinguishers are provided and maintained by the County Fire Marshall's office. Extinguishers may be tried if there is a small and contained fire (as in a wastebasket), and the floor safety warden is also notified. If the fire becomes out of control, the warden may make the decision to evacuate. Each floor of the building has two designated Safety Wardensand the entire building has a Lead Emergency Warden. Current lists of these wardens are kept posted in the hall on each floor. If there is an emergency situation (i.e., fire, chemical spill, bomb threat), immediately notify the areas Safety Warden. Should the decision be made to evacuate, including any time the fire alarm sounds, all employees must immediately leave the building and assemble across the parking lot in the courtyard of the medical school. Do not use the elevators during an emergency. To assist with roll call, please stay grouped with others in your department. Do not re-enter the building until instructed by a warden to do so. The wardens have the responsibility of coordinating the evacuation of all employees and visitors from the building, directing emergency personnel to our facility, conducting roll call of employees at the staging area, and instructing the employees when it is safe to re-enter the building. Should the emergency be severe weather, the stairwells have been designated as our storm shelter. If you receive information of imminent severe weather, notify a warden and proceed to the nearest stairwell. Again, do not use the elevators during an emergency situation. Do not leave the shelter until the severe weather has passed, and the lead warden had determined it safe for you to return to your work areas. Severe weather is defined as confirmed reports of the following: a. b. c. d. e. Wall cloud, funnel cloud, or tornado Hail, or greater Damaging winds, 50 MPH or more Flash floods Rain, 1 inch per hour or more
If you have any questions regarding these emergency procedures, please contact one
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of the safety wardens on your floor. PLEASE NOTE: The fire alarm installed in this building is a local alarm only!!! In case of fire, the Dallas Fire Department must be notified in a manner separate from the alarm stations in the hallways!! Dial Dallas emergency number 911 to report a fire!!! VII. Electrical Safety All electrical instrumentation must be operated according to manufacturer's specifications. No employee will operate any equipment before being instructed in its safe operation. Any defects observed and reported will be promptly repaired. Before performing routine repairs on electrical equipment, be sure the equipment is unplugged. Repairs other than routine will be performed by qualified personnel, i.e., licensed Dallas County electrician or equipment service person. All outlets in the autopsy area where water may be present are protected by ground fault circuit interrupters, which should be regularly tested. VIII. Radiation Safety Anyone taking x-rays must be trained in the use of the equipment, and must be provided with and wearing a radiation-exposure badge. The badges are monitored bi-monthly. Monitoring records are posted in the autopsy area and are available for review in the Safety Officers office. Setting instructions for the x-ray machine are posted at the machine. No person is allowed in the x-ray area during x-ray exposure. In no case may a body be held in position by a person while x-rays are taken. Various instruments in the laboratories may also pose a radiation danger to skin and eyes. Protective glasses should be worn to guard against ultraviolet, infrared, or laser exposure if working with these light sources. The radiation regulations and protocol are available from the Safety Officer. Individual copies are available. IX. Biological and Hazardous Waste Disposal Biological and chemical waste cannot be disposed in the regular trash, and must be placed into specially marked biological and chemical waste handling containers. Biologically contaminated sharps (such a needles, scalpel blades, and broken glass or
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pipettes) must be collected in hard-sided containers and disposed in Biohazard containers. These wastes are disposed through a commercial service. X. Security In a situation where security personnel are needed, first call Parkland Hospital Security at 214-590-8104. If they cannot respond, call UTHSCD Security at 214-648-2081, (214-6488911 for emergencies). The Dallas County Emergency Services at 214-653-7000 or 2146553-2990 cannot respond as quickly as the first two, due to their proximity, but is to be called to report the situation afterwards. In any true emergency or life-threatening situation, call 911. Refer to the SWIFS Facility Security Manual for information on the various types of system alarms in SWIFS, and for instructions on the appropriate staff response to the various system alarms.
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CHAPTER 17 PERSONNEL I. General All employees of the Institute of Forensic Sciences will comply with the rules and regulations as outlined in the Dallas County Personnel Manual. In addition, Dallas County operates within the rules and regulations of the Civil Service Rules and Regulations, copies of which can be obtained from the Human Resources Department or on-line. The County is an Equal Opportunity Employer, and also works to make reasonable accommodations for applicants and employees in compliance with the Americans with Disabilities Act. It is the policy of Dallas County to provide all employees a work environment that is free from any form of unlawful harassment. The Institute is a limited access department to help ensure the proper safekeeping of evidentiary items, department records, and other critical materials. Only employees and authorized visitors are allowed access to the building. All employees are issued photoidentification cards, which must be worn at all times while in the building. Refer to the SWIFS Facility Security Manual for more information on the visitors policies. The Institute, as a county building, is a Smoke and Tobacco Free Facility. No smoking or tobacco use is allowed in the building or within 25 feet of any public entrance to the Institute. Employees are expected to inform any visitors of this policy. Outdoor smoking areas are designated as follows: a. Near the fence in the parking lot at the back dock. b. On the back porches. (This area is covered. However, due to security measures, this area cannot be reached through the porch exit doors; staff will be required to walk around the building to reach this site. c. Designated areas at UT-Southwestern: E Dock (between Aston and the cafeteria) d. Designated areas at Parkland: ER Garage, near Staff Residence, near MRI building Recycling is encouraged in the workplace. The Institute participates in a voluntary recycling program. II. Payroll/Compensation Detailed information on benefits is available from County Personnel or from the Forensic Coordinator or Administrative Secretary. In general, all employees have health insurance coverage through the County (multiple plans available), unless they "opt-out" after proving current health insurance coverage elsewhere. If "opt-out" is chosen, the County's contribution may be used for other available benefits, but may not be collected as
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additional salary. Optional insurance and related benefits include life, disability, dental, dependent care, and flexible medical/dental reimbursement. All employees participate in a mandatory county-managed retirement program, for which a percentage of the paycheck is routinely withdrawn. In addition, employees may choose to participate in a Deferred Compensation Plan, for which money is withdrawn "tax-deferred" from the salary and deposited into a program with some employee-chosen options for its investment. Sick leave is accrued from the beginning of employment. Refer to the Dallas County Personnel Manual for details on the sick leave policy and on the countys policies regarding the Family and Medical Leave Act. Employees who abuse sick leave may be subject to disciplinary action, reduced evaluation scores, and decreased merit increases. Vacation time is also accrued from the onset of employment, but may not be taken during the first six months. Vacation schedules must be worked out among the employees of each section with their supervisor to provide for adequate coverage. County holidays are to be taken on the official holiday whenever possible. If the employee must work the holiday, or if the holiday falls on an employees regular day off, a substitute holiday is taken as soon as possible. A single Personal Day is also granted to each employee per calendar year, to be taken on a day of their choice as convenient for the office. Dallas County employees use an automated time accounting system. All employees receive two 10-minute breaks during the day, which do not have to be entered into the time records. Non-exempt employees must use the electronic time clock at the building entrance when starting and ending their work shift to track their working hours. A 30-minute lunch must be taken, and is automatically deducted from their work time. Any exceptions/corrections to the schedules (long lunch, vacation time, sick time, missed time punches, etc.) will be entered by the supervisors. It is the employees responsibility to ensure that any variances from the employees standard work schedule are communicated to the supervisor prior to the end of the shift on Friday. Non-exempt employees (employees who can be paid overtime pay) are prohibited from working more than 40 hours per week without supervisory authorization, in advance and in writing. Exempt employees must use the computer web timesheet to enter their actual time worked and any type of leave that is taken. Supervisors will review and approve all time accounting. Exempt employees must account for all time including start time, lunch-out, lunch-in, end time, vacation, sick, personal business, etc. Each day must add up to 8 hours or more. If less than 8 hours is worked, the balance must be accounted for from one of the other areas such as approved time off (ATO) or sick time. The times should be entered on a daily basis, and must be entered prior to the end of the shift on Friday. County paydays are every two weeks, and are distributed by direct deposit into the employees chosen bank account. Contact Administration regarding requests for special handling of paychecks.
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Overtime payments and other "adjustments" to your normal salary typically will be made in the next pay period following the event requiring the adjustment (e.g., overtime worked, leave without pay). III. University of Texas Personnel The Medical Examiners are faculty of the University of Texas Southwestern Medical School, and along with the Fellows, obtain University of Texas photo-identification cards. These cards then provide access for use of UT facilities such as the library and Student Union Building (fee may be required). The library may actually be used by anyone, but for medical-literature-search and check-out privileges, a card is necessary. IV. Ethics The Institute of Forensic Sciences is a governmental agency. The integrity of its employees reflects not only on the Institute, but also on the county and government in general. Ethical behavior is based on the principles that government be honest, fair, and accurate. Employees should have no conflict of interest, which exists when private motives or financial dealings have the potential to undermine the independent or professional judgment of the employee. Examples include, but are not limited to: A. B. Use of county-owned property for personal convenience or profit, including vehicles, office equipment, and long-distance calls. Seeking economic gain through privileged knowledge or official position. Because of the potential for this abuse, Institute employees are not allowed to recommend funeral homes. Acceptance of gifts from any person doing business or seeking to do business with the County, in an area in which the employee may participate. A County employee also being an employee, agent, partner, consultant, etc., of any person doing business or seeking to do business with the County.
C. D.
Much of the information to which we have access is confidential knowledge. Employees are not to discuss details of cases with people outside of the Institute, except where the discussion is appropriate to the case. See Chapter 8, Release of Information. All laws against criminal behavior apply, of course, to employees of the Institute. Stealing (e.g., money or jewelry from decedents) is grounds for immediate dismissal, as well as any appropriate criminal penalties. The Institute of Forensic Sciences is a drug-free workplace, with rules concerning the
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possession, use, and abuse of alcohol and drugs, including inhalants, on county premises or while representing the county off premises. Any employee convicted of a criminal drug or alcohol statute infraction shall notify the employees supervisor and department head in writing within five days after the conviction. Depending upon the conviction and the employees job position, the employee may be subjected to disciplinary action under the Dallas County Personnel procedures up to and including termination, or may be required to participate in an approved rehabilitation program.
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CHAPTER 18 QUALITY ASSURANCE SWIFS and the Dallas County Medical Examiners Office are committed to ensuring a high quality forensic investigation and examination service. The institutes Quality Manager is responsible for the oversight and documentation of the quality management program. Continuous quality performance of the forensic autopsy service is ensured by the following means: I. Equipment
Part of quality assurance involves the use of properly functioning equipment. The general building facilities are maintained by Dallas County facilities, which keep their own records. The institutes scientific equipment has periodic checks, with most records maintained by the Quality Manager, except as noted below for DCME. -Scales and balances calibrated annually; coordinated by and records kept by the Quality Manager. -X-ray equipment maintained by contract with UT Southwestern Medical School, and processing chemicals are routinely maintained by the autopsy technicians. -Coolers and freezer Temperatures checked regularly as below by DCME employees and recorded on the posted appropriate temperature logs, with their initials. Older log pages are stored by the autopsy supervisor. Temperatures also checked by Dallas County Maintenance, who keep their own records. If DCME finds temperatures out-of-range, or if a rising trend appears dangerous, the duty field agent is to call county maintenance. -Body cooler temperature range 33-45F. Checked early morning (@2-4am) by a field agent or designee and by the evening autopsy tech (@6pm). Local alarm sound at a higher temperature. -Autopsy room specimen refrigerator temperature range 2-10C or 35-50F. Checked once daily by the evening autopsy technician (@6pm). If temperature is out-ofrange, the duty field agent is to call county maintenance. The contents of the refrigerator should be removed and placed into the body cooler temporarily, and the refrigerator cleaned and disinfected before maintenance arrives. -Decomp refrigerator temperature range 35-50F or 2-10C. Checked once daily by the evening autopsy technician (@6pm). -Decomp freezer- temperature range -5 to +7F. Checked once daily by the evening autopsy technician (@6pm).
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II.
Staff
Medical examiners are required to be Board Certified in anatomic and forensic pathology within two years of their hire-date, and are required to have, or be in the process of obtaining a valid Texas medical license. Annual renewal of the Texas Medical License requires a minimum of 24 hours of continuing medical education, including at least 12 AMA approved category 1 formal hours, at least one of which is ethics. Pathologists attend multiple conferences (see Appendices Conference Schedule). These include case photography review, heart and brain cutting conferences with consultants, and pending case conference, where difficult or unusual cases are reviewed together before their completion. Pathologists, other SWIFS staff, and people from outside agencies such as district attorneys and police attend the SWIFS Lecture Series, a regular forum for continuing education and updates. Pathologists participate in the ASCP Forensic Pathology Checksample series. The results of these proficiency tests are maintained by the Quality Manager. All homicide case reports are reviewed and cosigned by all of the medical examiners. If questions or disagreements arise, the reports may be changed before being finalized. Signatures by the other medical examiners indicate their peer review and agreement with the report. All reports on examinations performed by forensic fellows or residents are reviewed and cosigned by the supervising medical examiner, and by the Chief Medical Examiner on fellows cases. Selected completed autopsy reports (with photographs and microscope slices as appropriate) are reviewed in detail by a rotating assigned medical examiner, with completion of a written evaluation form. Problems detected are reported to the Chief Medical Examiner (or Deputy Chief on the Chiefs cases), who will investigate the noted issues, discuss them with the case pathologist, and determine and document any necessary action. The documentation will be maintained by the Quality Manager. Cases performed by residents or fellows will be excluded. The completed Body In/Body Out packets on all cases are reviewed regularly by the autopsy supervisor for any errors made in body receiving or release. Field agents are encouraged to become registered or board certified investigators by the American Board of Medicolegal Death Investigators. Continuing education is required for maintenance of certification, which can be obtained by attending the SWIFS lecture series. Field agents case reports are reviewed by the chief field agent and appropriate actions (corrections, additional training, etc.) are taken if problems are found with the quality of the reports. Outside continuing education is encouraged at all levels of employment.
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SWIFS Office of The Medical Examiner General Policy and Procedures, 128 Pages (01.03.2008)

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SOUTHWESTERN INSTITUTE OF FORENSIC SCIENCES (SWIFS)

OFFICE OF THE DALLAS COUNTY MEDICAL EXAMINER (DCME)

GENERAL POLICIES AND PROCEDURES

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Reviewed and approved: __________________________________ Chief Medical Examiner

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CHAPTER 3 BODY RECEIVING AND RELEASE

CHAPTER 4 PERSONAL EFFECTS

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CHAPTER 10 ROUTINE HANDLING OF CASES

CHAPTER 13 HOSPITAL / PRIVATE CASES

CHAPTER 14 SPECIAL PROCEDURES

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CHAPTER 15 ORGAN AND TISSUE DONATION

CHAPTER 18 QUALITY ASSURANCE

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CHAPTER 2 FIELD AGENTS I. General Policy

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