ABSTRACT: When assaying for postmortem morphine concentration, significant site sampling variability exists between central and peripheral sampling sites and even within sampling regions of the body. To study the variation, 76 suspected heroin overdoses were identified. Each had femoral artery (FA) and vein (FV), left and right ventricle and pooled heart blood samples obtained at autopsy. Forty‐four tested positive for morphine. Morphine concentrations were determined by gas chromatography/mass spectrometry, with sampling site differences reported as log‐transformed ratios and compared by signed rank test.The mean FA to FV ratio for total morphine was 1.2 (range 0–4.5). The ratio for left heart to right heart total morphine was 1.1 (range 0.4–3.2). Left ventricular to FV total morphine ratio was 2.0 (range 0.6–6.9). In these opioid overdose deaths, FA and FV morphine concentrations are usually similar, although up to 4.5‐fold differences were noted. Centrally obtained morphine concentrations are on average twice as high compared with peripheral morphine concentrations. Left and right ventricular morphine concentrations were usually similar, although up to 3.2‐fold differences were noted (left side higher).

Occupational deaths due to projectiles from hand tools are rare. We report 2 unusual cases of individuals killed by metallic projectiles produced by the fragmentation of the head of a sledgehammer. At initial examination, these wounds appear similar to atypical gunshot or stab wounds. Proper evaluation requires radiographic examination, scene correlation, and, when possible, comparison of metallic fragments retrieved at autopsy and tools from the scene.

BACKGROUND:Forensic pathologists face difficult moral questions in their practices each day. Consistent ethical and legal guidelines for autopsy tissue use extending beyond usual clinical and legal imperatives have not been developed in this country.OBJECTIVE:To obtain the perceptions of medical examiners regarding the ethical acceptability of autopsy tissue use for research and education.METHOD:A written, self-report questionnaire was developed and piloted by a multidisciplinary team at the University of New Mexico, Albuquerque. All individuals who attended a platform presentation at the National Association of Medical Examiners Annual Meeting in September 1997 were invited to participate.RESULTS:Ninety-one individuals completed the survey (40% of all conference registrants and approximately 75% of presentation attendees). Sixty-three percent of respondents had encountered an ethical dilemma surrounding autopsy tissue use, and one third reported some professional ethics experience. Perspectives varied greatly concerning the ethical acceptability of using autopsy tissues to demonstrate or practice techniques (eg, intubation, brachial plexus dissection) and of fulfilling requests to supply varying kinds and quantities of tissues for research and education. Most respondents indicated that consent by family members was important in tissue use decisions. Respondents agreed on the importance of basic values in education and research, such as integrity, scientific or educational merit, and formal institutional approval of a project. Characteristics of the decedent did not influence decisions to release tissues, except when the individual had died from a mysterious or very rare illness. Attributes of medical examiners, with the exception of sex, also did not consistently predict responses.CONCLUSION:Significant diversity exists in beliefs among medical examiners regarding perceptions of the appropriate use of autopsy tissues for education and research. There is need for further inquiry and dialogue so that enduring policy solutions regarding human tissue use for education and research may be developed.

Suicide is among the leading causes of death in the United States, and in women the second leading cause of injury death overall. Previous studies have suggested links between intimate partner violence and suicide in women. We examined female suicide deaths to identify and describe associated risk factors. We reviewed all reports from the New Mexico Office of the Medical Investigator for female suicide deaths occurring in New Mexico from 1990 to 1994. Information abstracted included demographics, mechanism of death, presence of alcohol/drugs, clinical depression, intimate partner violence, health problems, and other variables. Annual rates were calculated based on the 1990 census. The New Mexico female suicide death rate was 8.2/100,000 persons per year (n = 313), nearly twice the U. S. rate of 4.5/100,000. Non-Hispanic whites were overrepresented compared to Hispanics and American Indians. Decedents ranged in age from 14 to 93 years (median = 43 years). Firearms accounted for 45.7% of the suicide deaths, followed by ingested poisons (29.1%), hanging (10.5%), other (7.7%), and inhaled poisons (7.0%). Intimate partner violence was documented in 5.1% of female suicide deaths; in an additional 22.1% of cases, a male intimate partner fought with or separated from the decedent immediately preceding the suicide. Nearly two-thirds (65.5%) of the decedents had alcohol or drugs present in their blood at autopsy. Among decedents who had alcohol present (34.5%), blood alcohol levels were far higher among American Indians compared to Hispanics and non-Hispanic Whites (p = .01). Interpersonal conflict was documented in over 25% of cases, indicating that studies of the mortality of intimate partner violence should include victims of both suicide and homicide deaths to fully characterize the mortality patterns of intimate partner violence.

This article expands on several key points about collaboration between emergency physicians and other researchers. Nontraditional areas of collaboration are important in broadening the scope of emergency medicine research.

To compare the epidemiology of farm with non-farm occupational injury deaths, we reviewed state medical examiner data for all occupational injury deaths in New Mexico from 1980 to 1991. We identified 53 farm-related injury deaths for a rate of 21.3 per 100,000 worker-years. Farm workers were four times more likely than non-farm workers to die from occupational injury. American Indians had the highest farm injury death rate. Farm decedents were older than non-farm decedents (t498 = 6.29, p < 0.0001). Half of the farm decedents were 50 years of age or older; one-third were 60 years of age or older. Crush injuries accounted for half of all farm injury deaths including 18 of 23 motor vehicle deaths, half of these involving a tractor rollover. One in six farm injury deaths were from electrocution; one in five involved alcohol. Our study indicates that New Mexico has high farm-related injury mortality related to tractor use, alcohol intoxication, farm animals, and exposure to electricity. American Indians and older males are especially susceptible to these factors.

OBJECTIVE To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data. METHODS The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978-1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults. RESULTS Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased. CONCLUSIONS Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.

The purpose of this study was to determine if the exchange resin sodium polystyrene sulfonate increases the clearance of lithium in a healthy volunteer. A single healthy volunteer received 900 mg lithium for each of three study phases. A sodium polystyrene sulfonate dose of either 0, 20, or 40 grams was administered one half hour after each lithium dose to assess the effect on lithium clearance. Multiple blood samples were obtained for serum lithium concentrations over a 36- to 48-hour time period. Pharmacokinetic parameter estimates were calculated and compared. Sodium polystyrene sulfonate was found to increase the clearance of lithium in a single volunteer. Sodium polystyrene sulfonate may be useful in the treatment of lithium intoxication by increasing the clearance of lithium.

Study objective: To examine specific risks for occupational injury deaths in New Mexico.Design: Retrospective review of slate medical investigator reports from 1980 through 1991 with regard to industry, agent of death, gender, ethnicity, location, and alcohol and other drug involvement.Participants: New Mexico residents who were fatally injured while on the job.Results: We identified 613 deaths: 87.1% unintentional, 10.6% homicides, and 2.3% suicides. Industries with the most fatalities were construction(11.8%), oil/gas (10.6%), and farming (8.6%). The primary agents of death were motor vehicles (41.7%), firearms (10.1%), and falling objects (10.0%). Almost all (95.6%) oi the decedents were male. However, females were overrepresented among homicide deaths (P<.0001). Most unintentional injuries occurred in rural areas (69.1%), whereas most homicides (73.4%) and suicides (71.4%)occurred in urban areas. Drug or alcohol use was evident in 19.4% of cases.Conclusion: New Mexico has a high rate of occupational injury death, which appears to be associated with rural location and use of motor vehicles and alcohol.

BACKGROUNDIn May 1993 an outbreak of severe respiratory illness occurred in the southwestern United States. A previously unknown hantavirus was identified as the cause. In Asia hantaviruses are associated with hemorrhagic fever and renal disease. They have not been known as a cause of human disease in North America.METHODSWe analyzed clinical, laboratory, and autopsy data on the first 17 persons with confirmed infection from this newly recognized strain of hantavirus.RESULTSThe mean age of the patients was 32.2 years (range, 13 to 64); 61 percent were women, 72 percent were Native American, 22 percent white, and 6 percent Hispanic. The most common prodromal symptoms were fever and myalgia (100 percent), cough or dyspnea (76 percent), gastrointestinal symptoms (76 percent), and headache (71 percent). The most common physical findings were tachypnea (100 percent), tachycardia (94 percent), and hypotension (50 percent). The laboratory findings included leukocytosis (median peak cell count, 26,000 per cubic millimeter), often with myeloid precursors, an increased hematocrit, thrombocytopenia (median lowest platelet count, 64,000 per cubic millimeter), prolonged prothrombin and partial-thromboplastin times, an elevated serum lactate dehydrogenase concentration, decreased serum protein concentrations, and proteinuria. Rapidly progressive acute pulmonary edema developed in 15 of the 17 patients (88 percent), and 13 patients, all of whom had profound hypotension, died (case fatality rate, 76 percent). Increases in the hematocrit and partial-thromboplastin time were predictive of death.CONCLUSIONSInfection with a newly described hantavirus causes the hantavirus pulmonary syndrome, which is characterized by a brief prodromal illness followed by rapidly progressive, noncardiogenic pulmonary edema.

Four Corners hantavirus (FCV) is the tentative name of the suspected etiologic agent of the newly identified hantavirus-associated respiratory distress syndrome (HARDS). The identification in HARDS patients of serum immunoglobulin M and immunoglobulin G antibodies that cross-reacted with Hantaan, Seoul, and Puumala virus antigens first suggested that FCV is a hantavirus. Limited nucleotide sequence data from the FCV glycoprotein-2 (G2) confirmed that FCV is a hantavirus and showed that it is most closely related to Prospect Hill and Puumala viruses. We have molecularly cloned approximately 95% of the sequences of the M and S segments of the FCV genome encoding the envelope glycoproteins and nucleocapsid protein N from the lungs of a patient with HARDS. The nucleotide sequence has been determined for 2,632 bases. The nucleotide sequence data show that FCV is a new member of the Puumala virus and Prospect Hill virus division of the hantavirus genus. Phylogenetic tree analyses indicate that the M and S segments have evolved in parallel. Therefore, the novel pathogenic activity of FCV is not likely to be the result of recent reassortment of segments from less pathogenic viruses.

Study objective: To determine if the mechanism of fatal childhood pedestrian injuries correlated with location, injury pattern, and age of the pedestrian and to determine ethnic differences in fatality rates.Design: Retrospective review of state medical investigator reports and autopsies from 1986 to 1990. Logistic regression and chi2 were used to test for statistically significant differences between the groups in our data set.Type of participants: New Mexican children, 0 to 14 years old fatally injured by moving vehicles.Results: Sixty-four children died for an overall fatality rate of 3.8 (per 100,000). Native American children and children younger than 5 years experienced the highest fatality rates. Children younger than 5 years were more likely to be crushed under the wheels of a slow-moving vehicle in both a nontraffic and a traffic location, whereas older children were found more often to have died from injuries from a high-speed impact event in a traffic location (P<.001). Leg fractures (P=.001) and spinal fractures (P=.02) occurred more frequently in impact than crush injuries.Conclusion: Young children are at risk for a crush injury in both the traffic and nontraffic environment.

Three cases involving overdoses of carisoprodol are presented. Concentrations of carisoprodol and its major metabolite meprobamate, were determined in urine, vitreous humor, heart, and femoral blood. All drugs were quantified by gas chromatography/mass spectrometry (GC/MS).

A case of bile duct adenomas in association with heterozygous (MZ) deficiency of alpha 1-proteinase inhibitor (API) is presented. The salient features were the presence of large API-containing globules in the adenomatous tissue and only minimally, in granular form, in hepatocytes. alpha 1-Proteinase inhibitor was not demonstrated in portal bile ducts entrapped in the adenomatous tissue or in bile ducts present in the liver parenchyma. Bile duct markers such as cytokeratin and carcinoembryonic antigens were present in the adenomatous tissue and also in the normal bile ducts, but not in the hepatocytes, suggesting that the adenomatous structures are ductular in origin, and probably not from ductular metaplasia of liver cells. Accumulation of API is postulated to be a triggering factor in neoplastic transformation.

A portable emergency bypass system using a membrane oxygenator device (CPS) was evaluated. The ability of the CPS to supply the oxygen transfer needs of five anesthetized dogs consistently over six hours and the system's effects on hemoglobin concentration, platelet count, and degree of hemolysis were assessed. The animals maintained spontaneous heart beats, pump flows averaged 100 ml/kg/min; mean arterial pressures were maintained at from 114 to 144 mm Hg. Immediate dilution of hemoglobin and platelet levels occurred in the first 30 minutes. Further hemodilution was limited during the first two hours, although three of the animals required transfusions during the six-hour period to maintain their hematocrits. Plasma free hemoglobin did not significantly increase during the six hours. Baseline oxygen consumption data obtained in three animals ranged from 44.5 to 96 (ml oxygen/min/m2). Oxygen and carbon dioxide transfer measurements during the first hour of bypass were not significantly different from measurements during the last hour of perfusion. The study suggests that optimal use of the CPS could supply much if not all of a patient's basal oxygen transfer requirements for at least six hours.