Timeliness

The postmortem medical examination, conducted only rarely, produces data about an event that is inherently late (death), using methods that are time consuming (establishing with certainty the cause of death). This implies an inherent limitation to the timeliness of medical examiner data.

The medical examiner can make available the results of the physical examination soon after its completion, thanks to the use of electronic record systems. A biosurveillance system could access the data regarding the deceased, as would be the case with any electronic medical record, as soon as the medical examiner enters them into a database (assuming that technical integration and administrative barriers have been addressed). However, some data, such as laboratory values or pathologic examination, might not be available until later. Additionally, while live patients can usually supply a past medical history immediately, the medical examiner may have to wait longer to collect such information; in some unfortunate cases, there is no one to supply it.

As a result, the time lag between time of death and a medical examiner's reporting of data regarding the deceased can be protracted.The postmortem examination takes time. If only body parts are available for autopsy, the true cause of death may take longer to establish. A heavy caseload can delay completion of autopsy reports. A mass-casualty incident, which is a rare event, can cause delays measured in days or even weeks. Unless special assistance is requested for a mass casualty incident (and such help may itself be delayed by days), the medical examiner's office must deal with whatever the daily demand is with a fixed staff. This means that, on a given day, some bodies, without obvious law enforcement or immediately discernible public health priority (higher than other bodies involved in the same mass casualty incident) may be placed in a freezer compartment until attention can be paid to them. The same may occur in cases of unrelated deaths if the medical examiner's staff is diverted to a mass casualty incident. In a recent example, an efficient and experienced mortuary team was deployed by the National Disaster Medical System to augment a county medical examiner's response to a commuter plane crash. The team required three days to complete the autopsies of 19 air-crash victims; their reporting did not include all laboratory test results, which were reported later. In another example, a county medical examiner reporting a jumbo jet crash off Long Island, New York, in 1996 did not complete the bulk of the required work for weeks; DNA-based identification of the last two victims was finally accomplished 13 months after the plane fell into the sea (New York Times, 1997). A caveat here, however, is that such data can usually be recorded and released sooner to law enforcement or governmental public health than to families.

Given an average workload, significant delays are the exception rather than the rule. Whether a medical examiner can maintain efficient operation in the face of an epidemic, or bioterrorist attack, depends on the incident's effect on the medical examiner's workload and the medical examiner's ability to quickly deploy additional staff.

The utility of medical examiner data in the context of an epidemic, whether organic or a case of bioterrorism, also depends on the degree to which the medical examiner has integrated the department's information systems and linked them to a biosurveillance system, and the degree to which the medical examiner's personnel can continue functioning efficiently.

Thus, medical examiner data seems most helpful in outbreaks that have a long window of opportunity for intervention, are fatal, and are distinctive enough or large enough to come to postmortem examination. There are many pathogens and outbreaks, for example, which have this characteristic, including Hantavirus (where there is a continuous source of exposure that will continue to produce death until it is identified), or person-to-person contagious diseases, or vector-borne illness, such as West Nile. At the other extreme, an extremely rapidly progressing outbreak, such as one caused by a terrorist's point bioaerosol release, would benefit from data that are inherently earlier.

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