1. Less than lethal force: A Medical Examiner's View J.C. Upshaw Downs, M.D. Regional Medical Examiner Savannah, GA 912-921-5903 forensics@comcast.net

3. It’s all about customer service.

4. Autopsy Injuries Disease(s) Drug(s) Other(s) Evidence

5. Mandated Complete examination external clothes evidence wounds internal gross microscopic fluids (tox, chemistry, etc.) Medicolegal Autopsy aka Forensic Autopsy

6. Mandated Complete examination external clothes evidence wounds internal gross microscopic fluids (tox, chemistry, etc.) Medicolegal Autopsy aka Forensic Autopsy The Scene!

7. Cause of Death Proximate or underlying triggering event Determined by medical examination > other Multiple medical diagnoses heart attack (ASCVD) pulmonary embolus (PE) cancer Trauma GSW, blunt/sharp force, MVC, etc.

8. “It is a capital mistake to theorize before one has data. Insensibly one begins to twist facts to suit theories, instead of theories to suit facts.” A Scandal in Bohemia - Arthur Conan Doyle

9. Autopsy heart lungs liver spleen kidneys genitals endocrine GI tract CNS M/S clothing trauma toxicology odors personal effects foreign materials specialized testing microscopics History

10. Autopsy heart lungs liver spleen kidneys genitals endocrine GI tract CNS M/S clothing trauma toxicology odors personal effects foreign materials specialized testing microscopics History social medical terminal witnesses drug family medications symptoms activities changes scene EMTs History, history, history!

11. Autopsy heart lungs liver spleen kidneys genitals endocrine GI tract CNS M/S clothing trauma toxicology odors personal effects foreign materials specialized testing microscopics History social medical terminal witnesses drug family medications symptoms activities changes scene EMTs Questions who? what? when? where? how? why? other(s)? There’s no such thing as a silly question.

12. HistoryClinical Physical

13. Autopsy heart lungs liver spleen kidneys genitals endocrine GI tract CNS M/S clothing trauma toxicology odors personal effects foreign materials specialized testing microscopics History social medical terminal witnesses drug family medications symptoms activities changes scene EMTs Questions who? what? when? where? how? why? other(s)? COD Cause and manner are opinions.

14. Autopsy heart lungs liver spleen kidneys genitals endocrine GI tract CNS M/S clothing trauma toxicology odors personal effects foreign materials specialized testing microscopics History social medical terminal witnesses drug family medications symptoms activities changes scene EMTs Questions who? what? when? where? how? why? other(s)? COD MOD

15. Police gun down unarmed man The Daily Poop Nov 4, 2006 EMI! Pepper spray! Choke hold! Lawyers! Batons!

17. COD: He needed killin’ MOD: Natural (he had it comin’)

18. What is the relationship of events? Description of circumstances Is use of “sub-lethal” means not involved Relative import primary or underlying cause contributory/other significant condition disease toxicology environment

19. Levels of Certainty Certain Probable Equivocal Possible Coincidental Uncertain

20. 25 WM Partying downtown Bizarre behavior

21. Ofc. Cpl. Ofc. Area of arrest Government St. & George St.

22. Physical Combat 02:59:10 “We’ve got him surrounded Sarge, we’re waiting for you.” 03:01:27 “3S1, I’m out with 35.” Duration: 2 minutes 17 seconds. Witness: 1 minute 32 seconds

23. Right Costal Margin Right Elbow

24. Six oblique purple contusions

25. Guide Slot

26. Orange discoloration (OC)

27. Risk Indicators Bizarre/Violent Behavior Obesity -- especially “big bellies” Drug and/or alcohol involvement Apparent ineffectiveness of Spray OC DEATHS

28. R L R trachea larynx SCM

29. What happened? Who killed him? Why did they do it? How much will this cost?

30. Time up front is cheap, time on the back end is expensive.

31. How’s that investigation coming? Police – depends on ME investigation ME – pending for police investigation

32. Cause of Death strangulation with multiple blunt force injuries during arrest procedure (including prone restraint) while in an excited state Manner of Death?

33. Toxicology LSD: 1.5 ng/ml Alcohol: 0.235%

34. Good police work solves cases.

37. 9. Cases start and end at the scene.

38. ALL the evidence is important.

43. Status post law enforcement subdual Multiple BFI (contusions & abrasions) TASER burns, left breast Left occipital brain contusion Right occipital subarachnoid hemorrhage

44. Diagnoses Temperature core = 107 0 F Methamphetamine blood = 1100 ng/mL Amphetamine blood = 220 ng/mL Rhabdomyolysis Coagulopathy Centrilobular hepatic necrosis

45. COD: Sympathomimetic poisoning syndrome (malignant hyperthermia) Due to: Methamphetamine toxicity MOD: Accident

46. What happened? Excited delerium illicit drug use noncompliance perceived threat Restraint process… EMI handcuffing MBFI  coagulopathy (DIC)  hepatic necrosis  rhabdomyolysis

47. Excited State Excited delirium: acute mental disorder impaired thinking disorientation visual hallucinations Behavior consistent, purposeless often violent Potentially lethal medical emergency

48. Custody Deaths - Catecholamine Rush Fight-or-flight Sensitizes heart to dysrhythmia Psychological stress Sudden death without anatomic cause must exclude restraint/expgenous

49. Manner of Death Circumstances of cause Determined by investigation > other Natural Accident Suicide Homicide Undetermined

51. Homicide = Murder

52. The ME must remain impartial.

53. “Living is easy with eyes closed, Misunderstanding all you see.” - Winston O’Boogie