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Bar Journal - Spring 2004

The NH Office of Chief Medical Examiner: Medicolegal Death Investigation in the Granite State

By:
 

I. INTRODUCTION: GENERAL HISTORY OF DEATH INVESTIGATION

Systematic death investigation dates back to the 12th Century. In 1194 the British Parliament passed legislation establishing an elective office called "Keepers of the Pleas of the Crown." Three knights and one civilian were to be elected from each shire to serve as "Crowner." The focus of their investigation was not so much on cause of death as it was determining who was responsible for the death. The individual deemed responsible generally forfeited his money, land and livestock, or a large portion thereof to the King. Murder paid the crown twice; once by the perpetrator and a second hefty fine was assessed on the village that was so lax as to allow such a disturbance within its confines.

While the opportunities for corruption were both abundant and exuberantly exploited, this was the system transported to the colonies in the 17th century. Across the Atlantic, "Crowner" became "Coroner"; and death investigations in what was to become the United States were carried out primarily by elected coroners. It was not until after the Civil War that state legislatures began to consider the value of having death investigations conducted in a more scientific fashion; and in 1868 Maryland passed a law specifying that a physician shall serve as coroner. Massachusetts took the issue a step further in 1877, supplanting the coroner with a physician bestowed with the title of "Medical Examiner." The first modern, public health oriented system, and the model for all medical examiner systems since, was established in 1915 in New York City. Not only was the coroner replaced by a physician medical examiner, but the Medical Examiner was to be a non-political appointee and the scope of the Medical Examiner’s jurisdiction was expanded beyond deaths of a criminal nature to include deaths in the workplace, public health hazards stemming from overcrowding in the face of the burgeoning Industrial Revolution, transportation and product safety concerns and others.

This was the template applied as medical examiner systems were established around the nation. A National Research Council study published in 1932 referred to the superior functioning of the medical examiner system as "startling when compared with the poorly functioning coroner system." The NRC stated, "Dollar for dollar, the office of medical examiner does more work and better work for its community than does the office of coroner." Momentum gradually slowed in the latter half of the twentieth century; however, and the coroner’s system remains in place in 55% of medicolegal jurisdictions in the United States in 2004. Twenty-eight states are served exclusively by coroners. Of the states with a centralized state medical examiner’s office, six still have coroners serving in remote rural locales. Only 953 Of the 3,137 counties in the U.S (30%) are served by a medical examiner. Ten of those counties comprise the state of New Hampshire.

Formal medical examiner systems are typically headed by a board certified forensic pathologist appointed on the basis of his or her training and experience. Given that there are less than 400 full time, board certified forensic pathologists in the U.S, it is no mystery why coroner systems continue to flourish. At the current rate of 40 trainees in forensic pathology each year it would take over thirty years to fully meet the demographic need for forensic pathologists in this country. Even well functioning medical examiner systems remain resource-starved. Quoting once more from the National Research Council study published 71 years ago, ". . . the medical examiner system does not function as well as it should, because the same public indifference which retains the coroner system results in inadequate financial support that does not permit the well-trained medical examiner to use the scientific procedures which he knows to exist and which he knows how to employ." Given the impact that the quality of death investigation has on personal liberty and freedom, public health and safety, injury prevention and control, mortality analysis and objective assessment of medical care, the issue is neither small nor trivial.

Taking the long view, there are substantial fiscal advantages to be realized in a smoothly running medical examiner system. There are economies of scale in purchasing with less cost per capita. The state medical examiner is well positioned for federal contracts and grants to provide and support staff and activities of the office. The obstacle for the short-sighted is the start-up cost, however, once capitalized, maintenance is usually manageable and as the budget becomes institutionalized it becomes more predictable.

II. NEW HAMPSHIRE CENTRALIZES

New Hampshire did not have a centralized State Medical Examiner office until 1986 when late Roger Fossum was appointed New Hampshire’s first Chief Medical Examiner (NH RSA 611). Dr. Fossum essentially built a full service medical examiner system from the ground up. Legislation further defining the Office of Chief Medical Examiner (OCME), its scope, authority and responsibilities (NH RSA 611-A) was passed in 1996. Unfortunately, this was two years after Dr. Fossum’s untimely death at the age of 46. Then Deputy Chief, Dr. James Kaplan, served as Acting Chief Medical Examiner until September, 1997 when Dr. Thomas Andrew was named New Hampshire’s second Chief Medical Examiner. Dr. Thomas Gilson served as Deputy Chief from April 1998 through October 2001 and Dr. Jennie Duval, a New Hampshire native, began work as Deputy Chief in January 2002.

OCME’s place on the state’s organizational chart (Fig. 1) differs compared to other jurisdictions where the medical examiner’s office is within the Department of Health. Location in the Department of Justice is certainly not unusual and, in fact, may be the most common. A west coast phenomenon has some coroner’s offices within Safety.

OCME ORGANIZATIONAL CHART

Fig. 1

Despite the late arrival of a formal medical examiner system, New Hampshire is on the leading edge as far as the utilization of non-physician death investigators to perform field investigations. OCME has a talented and dedicated group of nurses, paramedics, physician assistants and others to respond to all "untimely deaths" as outlined in NH RSA 611-A. These individuals assess the scene and circumstances surrounding the death, confer with family members of the deceased and/or witnesses to the fatal event and other agency responders such as law enforcement and emergency medical personnel. They then present the case to the Chief or Deputy Chief Medical Examiner who makes one of the following dispositions: 1) jurisdiction declined 2) issuance of a death certificate based on history, circumstances of death and external examination of the body or 3) transfer of the remains to Concord for complete autopsy.

The importance of non-physician death investigators cannot be underestimated. Our current system of health care delivery has essentially eliminated the community physician’s role in forensic death investigation – the "Medical Referee" in the parlance of New Hampshire’s pre-medical examiner death investigation scheme. Today’s clinician, on a short leash held by a large HMO or other such entity, is loath to leave his or her office to attend a traffic fatality on SR101 that could tie him or her up for hours. Enter the specially trained ADME – a person with a background in science and medicine, trained in the area of forensic death investigation. New Hampshire ADME’s stack up favorably against any other system in the nation (Table 1) with 55 hours of didactic training plus a clinical component to learn the basis and rationale for certain autopsy procedures and to gain proficiency at obtaining postmortem samples for toxicological analysis. In addition, OCME conducts semi-annual, day-long continuing education seminars for working ADME’s.

STATE MANDATED DEATH INVESTIGATION
TRAINING IN THE UNITED STATES*

STATE

REQUIREMENT

Georgia

32 hours annually

Illinois

40 basic course

Kentucky

18 hours annually

Mississippi

40 hour basic course, 24 hours annually

Montana

40 hour basic course, 16 hours annually

Pennsylvania

32 hour basic course, 8 hours annually

Wyoming

40 hour basic course, 16 hours annually

*Arkansas, Michigan and Wisconsin have all considered mandatory
training and may have indeed instituted such by the time this is in print.

Table 1

III. WHO PAYS FOR THIS?

One may well ask how this is all funded. The answer is somewhat convoluted. When the medical examiner statute was written in 1984 and revised in 1996, at neither time was there any provision for funding forensic death investigation. What was left in place was the old system of having the county in which an "untimely death" occurred billed for the death investigation and assessed $500.00 if the County Attorney deemed an autopsy necessary. A brief glance at the kinds of deaths OCME is obliged to investigate will reveal the rather obvious fact that from a legal, and more specifically, prosecutorial standpoint, the county and OCME may be at odds as to whether or not an autopsy is "necessary."

As of January 1, 2003, the funding stream has been slightly altered. The legislature eliminated the $500.00 county assessment for autopsies, appropriated $140,000.00 for autopsy services and gave the Department of Justice authority to bill the counties for transportation and hospital charges associated with cases the County Attorneys have authorized. Time will tell if this is a permanent solution or a temporary remedy. A recent study of state medical examiner systems revealed per capita costs of $0.32 - $3.20 with a mean of $1.41. The mean translates into $1.7M annually to fund forensic medicine services in New Hampshire.

IV. OCME SERVICE TO NEW HAMPSHIRE

The primary mission of the Office is the investigation of sudden, unexpected or violent death. There are 25 categories of death reportable to OCME for inquiry. This inquiry includes an investigation into the circumstances of death and examination of the body, up to and perhaps including the performance of a complete autopsy. Goals and objectives of this process include determination of cause and manner of death as well as proffering, when scientifically defensible hypotheses regarding specific aspects of the fatal episode.

Over 50% of all medical examiner cases are the result of natural causes, thus OCME serves a vital public health function in monitoring the overall health of citizens of the State. In an age wherein the hospital autopsy has all but vanished, the impact of these examinations cannot be ignored. From a peak during the 1950’s and 60’s of 50-55%, the autopsy rates for hospital deaths at non-teaching hospitals nationally now average 9%, and many hospitals have autopsy rates at or near 0%. Dr. George Lundberg, pathologist and former editor of the Journal of the American Medical Association has said, "Autopsy is the one place where truth can be sought, found and told without conflict of interest." The public health is ill-served should OCME be forced to abdicate this very important duty.

The public health value of the forensic autopsy is evident and quantifiable. Accurate data on causes of death are critical for planning health care and allocating resources in a manner that is responsive to the needs of our citizens. Without knowing why (not generally, but specifically) people die; it is not possible to provide the facilities needed to care for the living. The Latin inscription over the portal of the Office of Chief Medical Examiner in New York City is translated in part as, "This is where death delights to serve the living." OCME is charged with the responsibility to accurately determine the cause of death. To accomplish this we must investigate thoroughly and not cut corners. The public expects nothing less from us than the excellence of thorough performance. The operating principle of any medical examiner office should be to autopsy unless there is a compelling reason not to.

Overall case work increases every year (Fig 2). In the most recent biennium a total of more than 9,000 cases required contact with a medical examiner at some level, a 33% increase over the prior biennium. Of these cases, approximately 6,000 required only a review, and/or amended death certificate while 3,265 required in-depth investigation, including a detailed scene investigation. Autopsies were performed on 665 cases (11% of those investigated). Kansas City, MO with a population of approximately 450,000 performs autopsies on 58% of investigated cases. Bexar County, TX (San Antonio) with a population of approximately 950,000, autopsies 65%. A 60% autopsy rate in NH would translate to over 1000 autopsies per year.

NH AUTOPSY TRENDS

Fig. 2

Autopsies generated nearly 7,000 specimens bringing the total volume of archived samples in frozen storage to over 15,000 (Fig. 3). In addition to frozen samples, 3,600 new formalin-fixed, paraffin embedded tissue blocks from which glass slides for microscopical examination are made further strain OCME’s limited storage capacity. OCME is currently in the process of upgrading it methods of handling and processing non-biological evidence generated by autopsy examinations. Institution of a computer-assisted bar coding system should streamline evidence tracking and vastly improve retrievability.

CASE MATERIALS IN STORAGE

Fig. 3

IV. BEYOND DEATH INVESTIGATION

OCME service to the state is not limited to death investigation. OCME consults on non-fatally injured persons for various agencies up to 20 times per year. The Chief, Deputy Chief and Chief Forensic Investigator, Kathrine Weider, all provide training to clinicians, first responders and students from middle school to the post-doctoral level on a broad range of forensic issues. The Chief and Deputy Chief Medical Examiners hold academic appointments at Dartmouth Medical School and the Massachusetts College of Pharmacy and Health Sciences at Manchester and are frequently utilized as conference, seminar and lecture speakers in New Hampshire and beyond.

Part of our role as educators is carried out on the stand as expert witnesses in legal proceedings of all types. In the many appearances made over the course of a given year, OCME staff view themselves as interpreters and translators of medicine and science for the lay jury rather than partisans in the adversarial process.

Data generated in the study of sudden, unexpected or violent deaths, though occasionally critical in individual cases, is useless unless it is collated, disseminated and systematically analyzed. This is accomplished by the extensive reporting done on all such deaths by OCME. Toxicology reports for all vehicular fatalities are provided to the Department of Safety Division of Enforcement. All drug, poison and alcohol related deaths are reported to the New Hampshire Poison Information Center, NH Alcohol and Drug Abuse Prevention Program, the National Pediatric Toxicology Registry and/or the federal Drug Abuse Warning Network. OCME has recently agreed to participate in a federally funded, multi-site study of drug abuse in rural settings. Considering the dramatic upward trend in drug related deaths in all of New England (Fig. 4), this looms as a timely and very important study. Narcotic agents heroin, oxycodone and methadone are, by far the primary offenders in the increase in New Hampshire drug deaths. In fact, of the state’s 80 drug deaths in 2002, over half were related to opiates and 80% of these were heroin, methadone and/or oxycodone.

NH DRUG DEATHS 1995-2002

Fig. 4

Data reporting is not limited to drugs and alcohol. Long term care setting deaths under the Medical Examiner’s jurisdiction are reported to the State Office of the Ombudsman. OCME also completes reports to the United States Department of Labor on all work related fatalities and the U.S. Consumer Product Safety Commission is briefed on all deaths involving commercial products and residential buildings. Other reports go to the FDA, DEA, FAA, NHTSA, NTSB and OSHA as indicated.

Real time data sharing is central to the federal grant supported Med-X program (see below) in New Hampshire, a collaborative effort by OCME and the Public Health Laboratory aimed at surveillance by both clinical and autopsy means for clusters of emerging infectious diseases. Well publicized episodes regarding Ebola virus in Africa, Hantavirus in the American southwest, West Nile virus in New York and SARS in Asia emphasize the increased incidence of infectious disease emergence over the last twenty years.

VI. MASS FATALITY PLANNING AND HOMELAND SECURITY

Bioterrorism represents a subset of potential emerging infections. Autopsy-based surveillance for infectious disease offers a number of advantages, including enhanced diagnostic capacity with the use of tissues, accurate determination of the cause of death, providing insights into potential routes of infection and rapid notification of public health authorities. This is where the skills in evaluating infectious diseases pay dividends in the investigation of a potential criminal/terrorist act. The Med-X program of autopsy-based surveillance for clusters of infectious disease was developed in New Mexico. New Hampshire is one of only three other states to have implemented this program.

Any act of terrorism, "conventional", biological, chemical or radiological, leading to death is a homicide and therefore becomes the investigative responsibility of the medical examiner. Long before 9/11/2001, planning for mass fatality incidents was part of OCME’s charge. In addition to in-state planning, Kathrine Weider, OCME’s Chief Forensic Investigator, is a member of FEMA’s Disaster Mortuary Operational Response Team (D-MORT) system. Her reflections follow:

"It is the common expectation that the medical examiner takes charge and manages the remains of those who perish in a mass fatality situation. Medical examiner’s offices were expected to have a ‘plan’ but once in place, rarely were those plans ever revised, never mind tested. As recently as a few years ago, the basic philosophy of a typical medical examiner’s office regarding emergency response typically fell into one of three categories: (a.) Plan? What for? It won’t happen here. (b.) If it does happen here, we’ll call D-MORT to handle it. or (c.) Yes we took the time to write a plan but how can we justify expending scarce resources to further prepare for something that may never happen here when we can’t even afford basic equipment for the morgue for the cases we handle every day?

"Historically, levels of preparedness for a mass fatality event ranged from non-existent to written but for the most part, untested, plans. Many offices were shocked into reality only after they discovered that their belief that D-MORT was the panacea was mistaken. While D-MORT, is available on request to provide assistance to any medical examiner or coroner, unless the incident is a federally declared disaster, the cost of bringing in D-MORT assistance falls squarely on the jurisdiction requesting help. The cost of even a modest response can top $60,000 per day, not including the approximately $350,000 cost to transport and set up the portable morgue unit. An office’s operating budget could be completely exhausted before the first body was even recovered.

"Our office was fortunate to have been established by a Chief Medical Examiner who came to New Hampshire on the heels of having managed a major air disaster, the Delta Flight 191 Crash in Dallas in 1985. The lessons that Dr. Roger Fossum brought to New Hampshire from that experience were simple. It can happen. It will happen. It’s just a matter of time before it does happen. So get the office ready to deal with it. And he made that my job.

"As the designated mass fatality coordinator, I became a charter member of the Region 1 (New England) D-MORT team. This afforded me the opportunity to get invaluable training that would have been otherwise unavailable to me. It also gave the office access to a pool of trained and credentialed staff from which to obtain expert assistance and guidance both for help in developing our protocols and in the event that we might have such an emergency occur here. The trade-off was that team members were expected to respond to disasters in other areas when help was needed."

Response to an act of terrorism in New Hampshire has been examined and tested by the federal government. The May, 2000 drill known as "Top-Off," simulated simultaneous attacks on three American cities, a radiological event in Washington, DC, a biological event in Denver, Colorado and a chemical attack in Portsmouth, New Hampshire. Once again, Ms. Weider:

"Throughout the decade preceding "Top-Off", I wrote, rewrote, and revised a response plan for the office that collated the best advice I could glean from colleagues who had had the misfortune to play host to a major multiple fatality incident. At training updates, national conferences, and professional meetings we shared our plans and knowledge, discussed what had been found to have worked well, adequately, or not at all, and tried to learn from each other’s experiences. Over the years I attended nearly every table top and ‘live’ emergency response drill that was held throughout the state. I got to know most of the first responders and the key people from every state agency having any emergency response functions or responsibilities. With every drill and every meeting and sometimes even a casual conversation, changes were made, the plan was enhanced, and entire protocols were added, changed, and rewritten.

"With Top-Off approaching, I was remarkably confident. We knew that a mass fatality incident was going to be played out ‘real time’. I added an extra training program for the field staff. The directives they would be given were straightforward and would involve the same things they did every day, just on a broader scale. I rationalized that it was going to be like a regular day, only bigger, longer, and more involved, but certainly well within our ability to manage. Despite ten years of training and drilling, I had a lot to learn.

"From a training and experience point of view, Top-Off proved to be the closest thing to living through a disaster without actually being there. As the lead responder for the agency, I was trying to figure out what to do with an indeterminate number of dead people sitting in a chemical soup, and curve balls were flying at me from every direction. Problems I’d never even anticipated were erupting fast and furious. I had to think on my feet and problem solve in the moment. Without a doubt, I found my single most invaluable asset to be the relationships I had cultivated over the years with the key responders from the other state and local agencies. We all tapped into the knowledge that we collectively brought to the table and we provided each other with guidance, resources, and just as importantly, emotional support. Ten years of drills, meetings, and training culminated in a cohesive team effort that became the hallmark of that exercise. Had Top-Off been an actual emergency, we would have been able to manage it effectively.

"In the midst of Top-Off, I was ill- prepared for the biggest problem of all: the Top-Off drill included a hazardous materials emergency that involved over 60 human corpses. We quickly learned that our lack of even basic awareness of hazardous materials (HazMat) protocols paralyzed us. As we do following every drill, we looked at the issues that arose during Top-Off and modified our plan accordingly. I designated two members of the field staff to train for supervisory roles and initiated an orientation program for them immediately. Dr. Andrew designated me to become certified in HazMat Response. Over the subsequent year and a half I successfully completed the technician level certification program for HazMat Response. Additional training in Biologic Incidents, Weapons of Mass Destruction, and Incident Command to the level of instructor insure that we can not only respond appropriately to virtually any emergency but also can provide the requisite level of training to the field staff should such an emergency occur in New Hampshire."

Despite the planning, the multidisciplinary meetings and all the drills, an actual event literally re-writes the manual as it unfolds. There are no better examples than the terrorist attacks on our nation on September 11, 2001 and the nightclub fire at The Station in Providence Rhode Island last year. The "interconnectedness" of the forensic family is brought into sharp focus by tragic events such as these. Kathrine Weider relates her experiences in these two horrific events.

"When the Twin Towers fell on September 11th, 2001, the Region 1 DMORT team was activated and I was ordered by FEMA to go immediately to assist with the mortuary response. After three weeks in New York, I returned to New Hampshire with logarithmically more insight, training and expertise in disaster management than I’d been able to acquire in over ten years of drills, training, and even the Top-Off experience.

"The drills and training gave me the necessary skills to function effectively within the framework of a formal incident response in a neighboring jurisdiction. And my experience in New York reinforced for me the value and necessity of such ‘mutual aid’. As valuable as the first hand experience was, even more valuable is the knowledge that if we find ourselves the unfortunate hosts of such a catastrophe, we will have a pool of trained, credentialed staff readily available to supplement our own. There is a system and it works.

"When the call came once again for the D-MORT Region 1 team to respond to Rhode Island in February, 2003, the benefit of experience was again brought to bear. Working with the same members I’d served with in New York gave an element of familiarity in an otherwise uniquely stressful time. The response was set up and operated out of the main office of the Rhode Island Medical Examiner. We worked quickly and efficiently and the direct examinations and identifications were completed accurately and ahead of schedule. Up to this point, it had been widely held that such an operation was best moved off site and segregated from regular office work. The Rhode Island experience had many applications for our own plan and sparked yet another major revision. I doubt that we would have attempted such a drastic departure from the long held and widely accepted practice of utilizing a portable temporary morgue. Yet Rhode Island’s previous experience – the Egypt Air disaster – enabled them to break with tradition and the resulting successful operation became a premier learning opportunity for all of us who were called in to assist.

"Worldwide, earthquakes, hurricanes, building collapses, train, bus and plane crashes, and other natural and engineering disasters take more of a toll in human lives than terrorism. And while such incidents don’t inspire the feelings of fear and vulnerability that a suicide bomber does, they kill scores of people nonetheless. That being said, there is no substitute for the years of training, drilling, attendance at conferences and meetings, and the wide array of experiences that can only be gotten by assisting other jurisdictions, all of which will serve us well when eventually it is our turn to manage such a profoundly difficult situation. In the event that a catastrophic event does occur and the medical examiner’s staff is called upon to manage it to, our office will be equal to the task."

Ms. Wieder’s recent recognition by Secretary Tom Ridge as a Founding Member of the United States Homeland Security team is evidence that we are in good hands.

VII. OCME SERVICE TO THE NATION AND INTERNATIONALLY

OCME personnel also participate in a wide array of state and national committees, task forces and work groups including; the Child Fatality Review Committee, Domestic Violence Fatality Review Committee, Youth Suicide Prevention Assembly, Teen Motor Vehicle Legislative Task Force, NH Coalition to Prevent Shaken Baby Syndrome, Vital Records Improvement Fund Advisory Committee, National Domestic Violence Advisory Committee, the College of American Pathologists’ Ad Hoc Committee on Tissue and Organ Procurement. This September Dr. Andrew was appointed to the NAME Board of Directors as well as NAME’s newly formed Working Group on the establishment of uniform medical examiner office standards.

Research is another goal of the agency. Papers have been presented by the NH-OCME at national conferences on sudden infant death, use of DNA/RNA probes in the diagnosis of myocarditis, use of molecular biology techniques in the diagnosis of genetic conditions predisposing to pulmonary thromboembolism and the use of biochemical testing in the evaluation of range of fire in firearms injuries. Dr. Andrew has recently been appointed by the Association of Sudden Infant Death Programs to be the lead author in their forthcoming paper regarding current recommendations for the investigation of sudden, unexpected deaths in infancy.

Data generated in the medicolegal investigation of death has far-reaching consequences. Forensic pathology, by nature a population based field, and as the last stronghold of autopsy pathology offering a window on all violent and many natural deaths, is a data-rich, epidemiological treasure trove that can serve the living. Many of the safety features in vehicles on the road today such as active and passive restraints, collapsible steering columns, padded dashes and recessed knobs and buttons come from the collated findings of autopsies around the nation. Modifications in a broad range of consumer products from Venetian blind cords to power tools to infant swings have had the same origins. This is public service at its finest.

Through the unique relationship that exists between Dartmouth Medical School and the medical school at the University of Pristina in Kosovo, Drs. Andrew and Duval are in the embryonic stages of the implementation of an exchange program designed to provide much needed training and technical advice to the Medical Examiner’s Office struggling to emerge in the violent wake of the dissolution of Yugoslavia. Kosovo, a United Nations protectorate at present, is trying to rebuild their economic, administrative and educational infrastructure. Dartmouth exchanges medical students as well as veteran physicians with Kosovo and the NH-OCME may eventually be part of that effort.

VIII. THE FUTURE

OCME is actively working toward achieving accreditation by NAME. Accreditation is, at present, voluntary and only 42 offices (23% of the nation’s medical examiner offices) are NAME accredited. Taken as a whole, the nation’s forensic infrastructure is in dire need of upgrading. Facilities are inadequate in number, modernization, capacity and compliance with safety standards. It was this indisputable set of facts that brought forth the Paul Coverdell National Forensic Sciences Improvement Act of 2000 (Pub. Law 106-561) which unanimously passed the Senate and the House and was signed by then President Clinton. The stated goal of the Coverdell Act is "to improve the quality, timeliness and credibility of forensic science services" and remains the only federal bill that identifies medical examiner/coroner offices specifically as eligible for funding.

Originally slated for an appropriation of $84 million, the legislative meat grinder took this to $35 million with $29.5 million earmarked. The remaining $5.5 million was distributed on the basis of population. Funds made available to New Hampshire have been used to hire a part-time staffer who will assist in moving the agency closer to NAME accreditation. An unfortunate recent development is the federal Justice Department decision to place all its financial support for forensic sciences, $177 million, behind reduction of the current DNA testing backlog and the zeroing out of all Coverdell funds to medical examiner’s offices. Unfortunate in that DNA comprises less than 5% of the work generated by a typical medical examiner’s office.

Despite those who perpetuate the myth of "doing more with less," the truth is that we do less with less, and the casualties of that truth are public health, safety and ultimately justice, in both the legal and social senses. Meanwhile in the Granite State, with adequate support in both personnel and financial resources, neither of which seem a wasteful or frivolous expenditure, accreditation can be accomplished, putting New Hampshire among the nation’s elite medicolegal offices, offering the best and most comprehensive forensic medical service possible to its citizens. Members of the Bar are stakeholders in this process. Referring yet again to the 1932 NRC study, the following statement rings true today, ". . . the legal profession [should] become educated to a realization of the aid that it should and must receive from medicine." The Bar’s much needed support of OCME will be crucial in the lean financial times ahead.

The author gratefully acknowledges the Institute of Medicine, host of a recent workshop on the state of medicolegal death investigation in the United States. Proceedings of this workshop have been published and are available at www.nap.edu. Thanks also to the following colleagues in forensic medicine for their insights: Charles Hirsch, MD (New York, New York), Marcella Fierro, MD (Richmond, Virginia), Randy Hanzlick, MD (Atlanta, Georgia), Kurt Nolte, MD and Ross Zumwalt, MD (Albuquerque, New Mexico), Carl Parrott (Cincinnati, Ohio), Garry Peterson, MD, JD (Minneapolis, Minnesota), Victor Weedn (Pittsburgh, Pennsylvania) and Jamie Downs, MD (Savannah, Georgia).

Author

Dr. Thomas A. AndrewBy Dr. Thomas A. Andrew, Chief Medical Examiner, Department of Justice, Concord, New Hampshire.

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