Trim, Robert S. MBA, RN, CTBS*; Jentzen, Jeff MD, PhD†; Penn, Genevieve RN, ABMDI‡
From the *Operations, Midwest Division, RTI Biologics, Donor Services Division, Middleton, WI; †Autopsy and Forensic Services, University of Michigan, Ann Arbor, MI; and ‡Milwaukee County Medical Examiner’s Office, Milwaukee, WI.
Manuscript received May 5, 2011; accepted September 2, 2011.
The authors report no conflict of interest.
Reprints: Robert S. Trim, MBA, RN, CTBS, Operations, Midwest Division, RTI Biologics, Donor Services Division, 8120 Forsythia St, Suite 2, Middleton, WI 53562. E-mail: firstname.lastname@example.org.
Opinions based on toxicology results are dependent, in part, upon the quality of the specimen’s acquisition, storage, and chain of custody. The responsibility for these factors is often delegated to tissue and eye bank technicians. These technicians are not employees of the medical examiner (ME)’s office and may have no documented training related to the proper acquisition and handling of retained toxicology specimens. Medical examiners and coroners often request tissue recovery technicians to provide them with these toxicology samples when the tissue recovery is performed before autopsy. This practice helps facilitate donation and is convenient for the ME, but there may be unexpected implications for both the technicians and the ME that deserve further consideration. This article highlights the relevant issues in the postmortem recovery of biological samples for toxicology analysis and makes recommendations for the practice.
Medical examiners (MEs) and coroners are increasingly being asked to accommodate tissue and eye donations before autopsy. Tissue viability and postmortem microbial growth both impact tissue quality and drive the recovery agencies to procure tissues as soon as possible after death. Autopsies necessarily liberate enteric bacteria, increasing the risk of microbial contamination that could render the tissue unsuitable for transplantation.1 To minimize the bioburden on transplant tissues, tissue and eye procurement organizations (TPOs) prefer to perform their recoveries before autopsy.
When TPOs recover tissues before autopsy, toxicology samples necessary for a complete medicolegal investigation may experience postmortem alteration if they are not acquired before the recovery with the proper precautions. If the eyes are recovered, vitreous may be jeopardized. Similarly, adequate blood samples may not be available after bone recovery. To ensure that the necessary toxicology specimens are acquired in a timely fashion, the investigator may instruct the TPO technician to recover specimens on his/her behalf before the tissue recovery.
This process introduces 1 or more persons into the chain-of-custody for the acquired specimen. Some technicians may lack the necessary skills or knowledge to acquire the specimens. These factors could influence the specimen’s potential value to the investigation and any subsequent legal proceedings that rely on the results obtained from that specimen.2
To determine the manner and cause death, the forensic investigator must collect all relevant case information and draw conclusions that may require evidentiary support in a legal proceeding. This aggregation of evidence may involve the collection of toxicology specimens such as urine, blood, and vitreous fluid. It may also include taking postmortem photographs of the decedent and documenting physical examination findings before procurement. In some cases, to accommodate tissue and eye donation and the MEs workload, MEs are delegating these responsibilities to the TPO technicians performing the tissue recovery. The rapid recovery of tissue ensures that consented tissue is not lost due to the requirements of an autopsy. To this end, TPOs generally accept the responsibility for acquiring case information and procuring the necessary specimens for the MEs and coroners in cases before autopsy.
Evidence must be properly acquired, stored, and analyzed to ensure their evidentiary integrity. TPOs routinely collect donor blood samples to identify bloodborne diseases that may pose a risk to recipients. Technicians are familiar with many of the sample quality issues related to proper blood specimen collection (eg, hemolysis). However, TPOs may use some methods that may be inadvertently detrimental to toxicology specimens. Blood should be stored in the proper container and with the proper preservative for the integrity of the sample to be maintained for the relevant tests. TPOs use serum separator tubes and ethylenediaminetetraacetic acid tubes, which may not be adequate for most ME testing methods. For medicolegal cases, blood should also be recovered in sodium fluoride preservative (gray—topped tubes) because the anticoagulant inhibits microbial growth and serum enzymes that may adversely affect the detection of alcohol and other chemicals of interest to the ME. Any delay in preservation may allow degradation of the sample. Additionally, when a blood sample is difficult to acquire, the TPO’s technician may attempt to “milk” a limb or draw blood directly from the heart, which can influence the drug concentrations in the sample. Heart blood samples are not acceptable in that some drugs demonstrate significant postmortem redistribution. For this reason, it is essential that peripheral blood specimens (eg, femoral and subclavian) are submitted for testing and the site of the specimen draw is designated.3
TPOs may also be requested to obtain and secure vitreous fluid. Among TPOs, eye bank technicians, given their experience with eye anatomy, are more likely to acquire an adequate sample than technicians who are less familiar with the eye’s anatomy. Urine collection is not something TPOs perform as part of their recovery process, but MEs do request collection of these specimens. Eye technicians work almost exclusively with the structures of the eye. Tissue banks recover tissues (eg, long bones, tendons, and veins) from the extremities and from the thoracic cavity (ie, heart for valves and lung biopsies). The anatomy of the abdomen is usually not involved in the recovery process, unless research specimens from the abdomen are needed. In these cases, the abdomen is opened. The task of blindly puncturing the bladder to obtain a urine specimen may be difficult for technicians who do not have much experience in exposing the bladder. Technicians may also be reluctant to do it before recovery because opening the abdomen increases the risk of enteric bacterial contamination of the recovered tissues.
Photographic documentation by TPOs, if done properly, can complement their written documentation and that of the ME, particularly when the ME is not present at the time the recovery takes place. As with any technology, however, the user needs to be familiar with the features and limitations inherent in the equipment. TPOs who recover tissues in multiple jurisdictions may be asked to use a variety of equipment that may be unfamiliar to them. Unless the needs of the ME have been conveyed to the technician taking the photographs, the composition and quality may not meet the ME’s specifications. It may be challenging to provide scaled photographs during the recovery of tissue due to the threat of contamination. If scaled photographs are required to document an anomaly in the surgical field (eg, aortic dissection found during cardiectomy), the technicians will need to ensure the surgical field is protected from contamination. There are multiple ways to accomplish this goal without compromising either the surgical field or the photographic evidence, and the preferred method may vary among TPOs. The growing presence of digital cameras in the morgue presents new issues such as the security of the photographs from an earlier case and accidental deletion or unauthorized access to and use of these photographs. “Custodial maintenance and chain of custody are legally required elements for documenting the handling of evidence.4” This is standard procedure within the MEs office, but issues may arise when evidence collection is delegated to persons outside the MEs office, particularly for those who are unfamiliar with chain of custody requirements.
MEs have procedure manuals that describe in some detail how different duties related within their departments are carried out. They also conduct formal and/or informal training events to teach these and other procedures to their staff. The ME staff who carry out these functions are therefore trained in the appropriate procedures and held accountable for their adherence to them. TPO technicians must be routinely trained on the ME’s procedures related to the evidence—collection practices and chain of custody functions that may be delegated to them.
When an ME grants a TPO access to the body of a decedent for donation, it is done with the assumption that the actions of the TPO will not interfere with any pending death investigation and that they are adequately trained to perform certain tasks on the ME’s behalf. The absence of identified errors does not indicate the absence of risk associated with this practice.
TPOs employ technicians whom they teach the anatomy and procedures related to the proper recovery and preservation of certain tissues used in transplantation. Education and experience requirements vary among TPOs.1 TPO technicians may be nurses, EMTs, medical students, police officers, etc. There is no formal program, like an associate’s degree, that teaches the skills needed to perform recoveries. The training program within each TPO is responsible for the quality of their staff’s performance in the field. With no expertise in the areas of forensic toxicology, evidence collection, or chain of custody requirements, the TPOs are not capable of properly instructing their staff on these issues without input from the ME.
MEs choose the TPOs with whom they work, if multiple TPOs are in their region. They have the right to expect TPOs to understand and adhere to their procedures as if they were ME employees. It is our recommendation that ME’s develop procedures related to each TPO’s access to their facility and the evidence that they may request of them and the training that would qualify the technicians for these procedures.
The following areas should be reviewed and appropriate procedures developed:
- Record TPO access to the ME’s morgue
- Document donor identification
- Develop criteria to allow a recovery before autopsy
- Instruct technicians in the proper documentation of physical findings
- Instruct technicians to adhere to specimen collection and labeling standards
- Provide supplies (eg, blood tubes, specimen jars, and cameras)
- Stipulate specimen storage requirements
- Inform technicians of the ME’s policy for camera use
- Document training requirements, including content and frequency
- Document training
The ME’s responsibility to the public is fundamental to the public’s confidence in decisions he/she makes. TPOs generally work well with MEs and provide usable evidence for the determination of the cause and manner of death. However, there are clear gaps where training and planning could help avoid unfortunate, yet avoidable, specimen contamination and deterioration related to a death investigation. Working together, TPOs and MEs can help each other avoid these foreseeable problems through increased communication, training, and cooperation. The ME’s confidence in the abilities of the TPOs and the TPOs recovery of donated tissue should both benefit from this collaborative effort. By following the recommendations for procedural clarity, training, and documentation, the ME will help protect the interests of the public with respect to both death investigations and transplantation.
1. Pearson K, Dock N, Brubaker S, et al. , eds. Standards for Tissue Banking. 12th ed. McLean, VA: American Association of Tissue Banks; 2008; : 87