Role of the Medical Examiner
By: Dr Stephen Cohle, M.D.
The medical examiner is required to investigate the following types of death: All accidents, homicides, suicides, or apparent natural death in which the individual is not under medical supervision at the time of death or in whom a cause of death is not known at the time of pronouncement. In addition, deaths in police custody, jail or prison; death related to abortion; and, death investigations requested by the prosecutors or six voters in a county are undertaken by the medical examiner.
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The medical examiner undertakes the task of death investigation by obtaining history from police, medical personnel, family members or others who have knowledge about how the death occurred or pre-existing medical history. A death scene investigation should be performed if possible and can contribute much to the determination of the cause and manner of death (finding liquor or beer bottles, drugs or drug paraphernalia, etc. at the scene). The medical examiner has the authority to order an autopsy. If so, the pathologist should approach the death using the following four stages.
First the pathologist must obtain the death scene details and any available history from the medical examiner, police, medical personnel, family members, etc.
Secondly, the body is examined externally, then internally. Third, laboratory tests (X-rays, drug screens, etc. ) are ordered and, fourth, after a microscopic examination of the tissues, a ruling as to the cause and manner of death including contributing causes to the death such as (ethanol or other drug intoxication) are made. In alcohol or potential alcohol associated death (including all accidents, suicides, homicides and many apparent natural deaths), a detailed history of alcohol consumption both terminally and chronically by the deceased must be obtained. As mentioned above, any physical evidence relating to alcohol ingestion should be obtained and made available to the medical examiner and pathologist.
When certifying the cause and manner of death if, for example in the case of a fatal car accident, the medical examiner has determined that the cause of death is multiple blunt injuries, and if the deceased was the driver of the automobile, and a level of alcohol of 80 mg per 100 ml of blood or greater are identified, then generally acute ethanol intoxication will be listed as a contributing cause of the death. Our practice for obtaining toxicological specimens is to, at a minimum, collect blood, urine, and vitreous humor. The blood level of alcohol and other drugs indicates the level of these drugs in the person at the time of death. A level of alcohol in the vitreous humor will indicate the blood level 1-2 hours prior to death. This also serves as check on the accuracy of the blood level. The urine level, although not directly equal to the blood level, does roughly serve to confirm the accuracy of the blood level, i.e., a high amount of alcohol in the urine is almost always correlated with a high level of alcohol in the blood although the levels are not equal.
Forensic Aspects of Alcohol
Mechanism of action of alcohol
Alcohol is a depressant of brains cells. The degree of depression depends upon the concentration of alcohol in the blood. Alcohol depresses the activity of the brains cells. In lower concentrations only the cells in the brain that affect higher functions such as thinking and judgment are inhibited. The greater the level of alcohol, and thus, the greater the depression of the higher brain centers
the more the inhibitory functions of the cells are diminished allowing for more primitive and unrestrained behavior. With sufficiently high levels of alcohol even areas in the brain stem that control respiration, heart rate, and alertness are inhibited which can result in death. Nerve cells regulating blood vessels can be inhibited which can cause inappropriate dilatation of blood vessels with loss of heat from the body even incold weather (hypothermia).
The Effect
of Alcohol
| Concentration (mg/100 ml) |
Effect |
| < 30 |
Impairment of complex skills such as driving |
| 30-50 |
Definite deterioration of driving ability. |
| 50-100 |
Objective signs such as loquaciousness, progressive loss of inhibitions, laughter, and some sensory disturbance. |
| 100-150 |
Slurred speech, unsteadiness, possible nausea |
| 150-200 |
Obvious drunkenness, nausea, staggering gait. |
| 200-300 |
Stupor, vomiting, possible coma |
| 300-350 |
Stupor or coma, danger of aspirating vomit |
| >350 |
Progressive danger of death from respiratory center paralysis |
We reviewed cases of operators of vehicles, including automobiles, motorcycles and bicycles, over a one year period. Out of a total of 33 cases in which the operator of the vehicle was killed, we identified 16 cases in the driver/rider had a blood ethanol of greater than 80 mg/dl (0.08 mg%). Of these cases the ages ranged from 20-61 with a mean age of 36. There were 14 males and 2 females. The ethanol levels ranged from 91-300 with a mean of 187. There were 13 automobile drivers, one motorcycle rider, one bicyclist and one snowmobile driver. In six cases the vehicle struck a fixed object, in five cases the deceased’s vehicle was struck by another vehicle, and in five cases the driver’s vehicle was not struck by another vehicle nor did it hit a fixed object. In most of these cases the vehicle rolled after leaving the roadway. However, two motorcyclists were found dead and the terminal events were not witnessed.
Spectrum Forensics Accidents
| Case Number |
Age/Sex/Driver-passenger/Circumstance/Cause of death/Alcohol level |
| A-08-349 |
30 yo/f/passenger/motorcycle drive lost control on curve, operator intoxicated/multiple blunt injuries/270mg/dl |
| A-08-365 |
25 yo/m/driver/head on collision automobile accident/multiple blunt injuries/160 mg/dl |
| A-08-379 |
31 yo/m/neither/fell asleep on railroad tracks consuming alcohol previous
evening/multiple blunt injuries/250 mg/d |
| A-08-381 |
31 yo/m/driver/rider of bicycle/hit by car while crossing road on bike/multiple blunt
injuries/130 mg/dl |
| A-08-419 |
45 yo/w/m/driver/left roadway, rolled/multiple injuries/280 mg/dl |
| A-08-437 |
74 yo/m/not applicable/passed out drunk in car/asphyxia by aspiration of gastric contents/200 mg/dl |
| A-08-452 |
37 yo/w/m/driver/left roadway, rolled/multiple force injuries/160 mg/dl |
| A-08-466 |
22 yo/w/m/driver/ car vs telephone pole at 100 mph/multiple blunt injuries/110
mg/dl |
| A-08-469 |
51 yo/w/m/driver not applicable/pedestrian hit by car/multiple blunt injuries/310
mg/dl |
| A-09-007 |
30 yo/m/driver/lost control on ice, hit tree/multiple blunt injuries/91 mg/dl |
| A-09-033 |
28 yo/m/driver/snowmobile hit by other snowmobile/multiple blunt injuries/220
mg/dl |
| A-09-051 |
49 yo/m/driver not applicable/pedestrian hit by car, dark clothing, dark
night/multiple blunt injuries/290 mg/dl |
| A-09-082 |
36 yo/f/driver/lost control, T-boned/craniocerebral trauma/170 mg/dl |
| A-09-158 |
59 yo/m/driver/lost control, went into ditch/multiple blunt chest injuries/190 mg |
| A-09-165 |
20 yo/m/driver/lost control, hit trees/multiple chest and abdominal injuries/110
mg/dl |
| A-09-180 |
24 yo/m/driver/car vs tree/craniocerebral trauma/200 mg/dl |
| A-09-222 |
61 yo/m/driver/ran stop sign, hit by SUV/multiple blunt force injuries/300 mg/dl |
| A-09-262 |
27 yo/m/pedestrian hit by truck, dark clothing, dark night/multiple blunt injuries/89
mg/d |
| A-09-279 |
47 yo/m/driver of motorcycle/found crashed/multiple blunt injuries/190 mg/dl |
Surprisingly, no teenagers or elderly individuals were killed in this series of cases. This suggests that an important factor in fatal crashes in teenagers and the very old drivers is lack of attention rather than ethanol intoxication. As expected, the vast preponderance of victims was males. The mean level of alcohol (187 mg/ dl) would be expected to be manifest as obvious drunkenness, nausea and a staggering gait, if walking. The highest level in our study (300 mg/ dl) would induce stupor and coma in most individuals.
In summary, a significant number of victims of motor vehicle crashes had a high level of ethanol at the time of the crash. Furthermore, even riding a bicycle while intoxicated can be fatal.
Editor’s Note: Dr. Stephen Cohle, M.D. is the Chief Medical Examiner for Kent County and Deputy Chief Medical Examiner for Ottawa County. He is a board certified forensic pathologist who has a special interest in cardiac pathology.
