Paramount to any investigation, evaluation, or inquiry is the knowledge of terminal events and pre-terminal characteristics of the victim. In most hospital deaths, this is readily provided by the medical record. In the world of forensic pathology, such history is often lacking, and reliance must be placed on an open mind with a conscious realization that drug abuse may have had a significant contribution to a person's death regardless of initial impressions. Infectious diseases such as hepatitis or endocarditis may be the result of intravenous drug abuse; cocaine may trigger convulsions or precipitate hypertensive crises and myocardial ischemia; CNS depressants may lead to positional asphyxia, etc.
There must also be an awareness that people with natural disease may, intentionally or not, abuse drugs which may exacerbate their underlying disease process and significantly contribute to their death. Drugs create pathological states, with or without death, by their immediate pharmacologic effects, the way in which the drug is taken, by the cumulative effects of chronic abuse, and by interaction with pre-existing pathologic conditions.1,2 Therefore, what once could have been discussed as a complication of hypertension (e.g., spontaneous aortic dissection) must now be evaluated as a possible effect of acute and chronic cocaine abuse.3,4
As noted previously, every death scene must be aproached with a conscious effort to evaluate the role of drugs and alcohol regardless of the apparent cause or manner of death. The scene investigator must therefore be ever cognizant of two possibilities: (1) because a person has a disease does not necessarily mean it is the cause of death; and (2) the scene of a drug overdose is frequently cleaned before investigators are even called. Consequently, it is important to evaluate all medication containers at the death scene, noting the identity of the drug and its purpose, the instructions for usage, and the number of pills remaining. Such a preliminary inventory (followed later by a more complete inventory and drug confirmation) often leads to a suspicion for drug overdose. However, since others may well have previously
Figure 18.104.22.168 Packets of drugs.
tampered with the scene, a search should be made for containers that may be concealed such as in waste baskets, beneath the bed, in a purse, etc.
All medication and medication containers should be confiscated for a more complete inventory and possible toxicologic evaluation.2 Likewise, all drug paraphernalia must be removed from the premises. Recognizing such paraphernalia requires that the investigator be aware of what illicit drugs prevail in a particular community and how they are used. Thus, a small spoon attached to the cap of a small vial, a gold- plated razor with a mirror, and a soda can with holes punched in the sides are all paraphernalia of cocaine abuse. Packets of drugs (often with a crude logo) (Figure 22.214.171.124) and used syringes are particularly important because these items may be the only way to determine the type of drug being abused, its purity, and its excipients. This is especially true for "designer drugs" which may be many thousand times more potent than heroin and therefore difficult to detect on routine toxicologic analysis of biological specimens.
Besides actual drug containers and paraphernalia, observation should be made which might reflect orientation toward a drug subculture: certain tattoos, evidence of gang affiliation (clothes, hair style, etc.), magazines, posters of drug-oriented music groups, etc. Periodicals and books of right-to-die organizations such as the Hemlock Society and its members should suggest the possibility of suicide or assisted suicide. This literature provides specific instructions about using drugs and plastic bags to commit suicide, and gives suggestions about avoiding (or cooperating) with a medical examiner's investigation.5-6
Following scrutiny of the environment, attention should turn to the victim. The exact position of the body when it was found2 is of particular importance to establish the possibility of postural or positional asphyxia.7 This is a situation where a person collapses in a position such that the airway (nose, mouth) is partially or completely obstructed. Because of the anesthetic effect of the drugs (with or without alcohol), the victim does not move to create an unobstructed airway, and death results from mechanical asphyxia. If the airway obstruction is partial, it may take some hours for death to actually occur from respiratory acidosis and carbon dioxide retention. During this time, the drugs and alcohol continue to be metabolized and eliminated in urine, sweat, or breath. Toxicologic analysis will then reveal a low level of drugs and, if the likelihood of positional asphyxia cannot be established, the cause of death may be a conundrum. At the scene of death it is important to interview the person who first discovered the body and ask specific questions to ascertain whether the airway could have been obstructed.
Examination of the victim at the scene should include a careful inspection of the hands and mouth for drug residue or pills, palpation for hyperthermia (or, better, a direct measurement with a plastic indicator strip or rectal thermometer) which could suggest death from a stimulant drug, tattoos which could suggest a drug culture, and fine parallel scars of the wrists or neck suggestive of a prior suicide attempt. A nearby plastic bag, particularly in the death of an elderly person with a chronic disease, suggests a death from the combination of asphyxia and drug overdose to terminate prolonged suffering (a method advocated by right-to-die organizations).
A fairly common mistake of some scene investigators is failure to turn the body over (which may reveal previously hidden drugs or drug paraphernalia), and failure to adequately examine the clothing. Pockets must be turned out or cut open, and underwear searched because they may contain packets or residue of drugs. Two death scenes have sufficient characteristics to suggest specific syndromes of cocaine abuse: cocaine-induced excited delirium and the cocaine body packer.
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