U.S. Fire Administration

Firefighter Autopsy
ProtocolMarch 2008

U.S. Fire Administration
Mission Statement
As an entity of the Federal Emergency
Management Agency (FEMA), the missionof the U.S. Fire Administration (USFA) isto reduce life and economic losses due
to ﬁre and related emergencies, throughleadership, advocacy, coordination, andsupport. We serve the Nation independently,
in coordination with other Federal agencies,
and in partnership with ﬁre protection andemergency service communities. With acommitment to excellence, we provide
public education, training, technology, anddata initiatives.

Firefighter
Autopsy Protocol■■■

Jeffrey O. Stull
International Personnel Protection, Inc.
Austin,Texas■■■

March 2008

Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of the
Department of Homeland Security or the U.S. Fire Administration.

■■
Table of Contents
Overview . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . vi
Acknowledgement. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . vii
I. BACKGROUND. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 1I.1 Scope of the Problem. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 1I.2 Rationale for the Protocol. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 3I.3 Description of the Protocol. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 4II. Medicolegal Autopsy Procedures in the United States. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 9II.1 When Is an Autopsy Required?. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 10
II.2 Definition of Manner, Cause, and Mechanism of Death. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 10
II.3 Chain of Custody and Documentation. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 11
II.4 Retention of Autopsy Specimens and Paperwork . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 12
III..Occupational Aspects of Firefighting of Specific Concern to Autopsy. .  .  .  .  .  .  .  .  .  .  .  . 13
III.1 Firefighter Death Classification. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 13
III.2 Trends in Line-of-Duty Deaths . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 14
III.3 Investigation of Line-of-Duty Deaths . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 18
III.4 Alcohol and Drugs . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 19
III.5 Fire Toxicology. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 20
III.6 Burns. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 24
III.7 Personal Protective Equipment. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 26
III.8 Non-Line-of-Duty Deaths. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 28
III.9 Firefighter Health. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 29
IV. PUBLIC SAFETY OFFICER BENEFITS (PSOB) PROGRAM. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 31
IV.1 Summary of the PSOB Law. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 31
IV.2 Summary of the Heart/Stroke Amendment. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 32
IV.3 Useful Web sites . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 33
Selected Bibliography . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 34
Determination of Alcohol Levels During Autopsy . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 34
Carbon Monoxide Determination During Autopsy . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 44
■ iv ■

■ Firefighter Autopsy Protocol■ v ■Table of Contents ■Appendix A: Death Investigation Systems In The United States And Territories. .  .  . 55
Appendix B: Niosh Firefighter Fatality Reports—Autopsy Information . .  .  .  .  .  .  .  .  . 93
Appendix C: Examination of Personal Protective Equipment. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 160
Protective Helmets. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 163
Protective Hoods. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Protective Garments (Coat and Pants). .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 163
Protective Gloves. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 164
Protective Footwear (Rubber). .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 165
Protective Footwear (Leather). .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 165

■■Overview

T

he Firefighter Autopsy Protocol has been extensively revised since its original 1994 edition. In thisnew protocol, a number of additional areas of information have been provided to take into accountemerging issues and new technologies as applied to the conduct of autopsies. As stated in the report, it
is recommended that autopsies be performed for all firefighter fatalities where a line-of-duty death has
occurred. It is further recommended that an autopsy be performed when a non-line-of-duty death may belinked to a line-of-duty exposure.
Specific sections have been provided in this report as background and areas of information as related to the
conducting of autopsies. General autopsy procedures must be supplemented with additional analyses andreviews in order to ascertain specific causes and mechanisms of death and to add to the body of knowledge
for understanding firefighter fatalities which, in turn, helps to prevent future firefighter fatalities. The protocol
gives specific attention to several areas, where current autopsy practice may be supplemented with additional
evaluations and considerations. Examples of these supplemental factors include■ evaluation of victim work history with specific attention to prior exposures;■ examination of personal protective equipment (PPE) for relating effects of clothing and equipment on
individual parts of the body, particularly in cases of trauma and burn injury;■ details in the physical examination for identifying signs of smoke asphyxiation and burn injury as
contributing causes of firefighter fatality;■ implementation of appropriate carbon monoxide and cyanide evaluation protocols as part of the
toxicological evaluation; and■ detailed toxicological evaluations where hazardous atmospheres have been encountered.
The utility of this specific firefighter autopsy protocol is intended to advance the analysis of the causesof firefighter deaths to aid in the development of improved firefighter health and safety equipment,
procedures, and standards. It also is critical in helping to determine eligibility for death benefits under
the Federal government’s Public Safety Officer Benefits (PSOB) Program, as well as State and local
programs. Lastly, implementation of this protocol will increase interest in the study of deaths as related tooccupational illnesses among firefighters, both active and retired.

■ vi ■

■■Acknowledgement
This project could not have been undertaken without the expertise of the following people who provided
invaluable guidance and input throughout this project:
Professor Vincent Brannigan, JD
Dept. of Fire Protection Engineering
University of MarylandCollege Park, MD 20742-3031

Ms. Valerie C. Neal*
PSOB (Senior Benefits Manager)
810 7th Street, NW
Washington, DC 20531

Dr. Merritt Birky
National Transportation Safety Board
2419 Childs Lane
Alexandria, VA 22308

Dr. Fredric Rieders
National Medical Services
2300 Stratford Avenue
Willow Grove, PA 19090

Richard Duffy
Int’l Association of Fire Fighters
1750 New York Avenue, NW
Washington, DC 20006

Kevin Roche
Phoenix Fire Department
2625 South 19th Street
Phoenix, AZ 85009

Ms. Rita Fahy
National Fire Protection Association
1 Batterymarch Park
Quincy, MA 02169-7471

Mary Ellis**
National Fallen Firefighters Foundation
16825 South Seton Avenue, Building O
P. O. Drawer 498
Emmitsburg, MD 21727

Captain Tom Hales, MD
Center for Disease Control
4676 Columbia Parkway
Cincinnati, OH 45226

Jim Monahan
Beebe Medical Center
424 Savannah Road
Lewes, DE 19958

Dr. James Melius
NY State Laborers
18 Corporate Woods Blvd.
Albany, NY 12211*No longer with PSOB at the time of publication.
**No longer with the NFFF at the time of publication.
■ vii ■

■■
I. BACKGROUNDThe U.S. Fire Administration (USFA) is committed to improving the health and safety of firefighters.
This mission has created an accompanying interest in learning about the causes of firefighter deaths
and injuries. In the process of researching firefighter deaths, it was determined that forensic medicine had
no standard protocol that would assist a coroner or medical examiner specifically in determining the causeof a firefighter death. Many purposes for firefighter autopsy are related to ensuring benefits in addition
to providing an improved understanding of fireground hazards and the effectiveness of firefighting
equipment.
In 1993, the USFA initiated a project to develop a standard firefighter autopsy protocol. Experts in forensic
pathology, toxicology, epidemiology, and medicolegal aspects of autopsy, as well as representatives ofseveral national fire service organizations, were selected to serve as a Technical Advisory Committee, toprovide expertise and guidance for development of the new autopsy protocol. The first firefighter autopsy
protocol was finalized in 1994 and disseminated in 1995. This protocol effectively served the forensic
professional and provided a basis for examining firefighter deaths more consistently.
In 2004, a revision of the firefighter autopsy protocol was undertaken to further refine and update
autopsy procedures to account for new types of analyses and concerns that have arisen with respect to the
conducting of firefighter autopsies. A second Technical Advisory Committee, with membership similar to
the first, was formed to help guide and review the modifications. The new changes and improvements inthe autopsy protocol are represented in this publication.
The consensus of the Technical Advisory Committee is reflected in the new protocol. This protocol isintended to provide guidance to medical examiners, coroners, and pathologists on uniform recommended
procedures for investigating the causes and contributing factors related to firefighter deaths. The protocol
recognizes and addresses those attributes of firefighter casualties which distinguish them from casualties
in the general population, as well as from civilian fire casualties. These differences include the use ofprotective clothing and equipment, prolonged exposures to the hazardous environment, and specialized
training and duties.
The accompanying documentation is intended to describe the need for a revised autopsy protocol, thesituations that led to its development, and the major issues that are related to it.

I.1 Scope of the Problem
Firefighting has been described as one of the Nation’s most hazardous occupations. The USFA estimatedthat the number of firefighters in 2005 was 1,136,650, comprising 313,300 career and 823,350■ 1 ■■ Firefighter Autopsy Protocol■ 2 ■I: Background ■volunteer firefighters.1This figure included only those career firefighters working for public municipalities
rather than for private fire brigades or for State or Federal government.
The NFPA defines on-duty fatalities as follows (Fahy, 2007):
On-duty fatalities include any injury sustained in the line of duty that proves fatal, any illness that wasincurred as a result of actions while on duty that proves fatal, and fatal mishaps involving non-emergency
occupational hazards that occur while on duty. The types of injuries included in the first category aremainly those that occur at a fire or other emergency incident scene, in training, or in crashes while
responding to or returning from alarms. Illnesses (including heart attacks) are included when the
exposure or onset of symptoms occurred during a specific incident or on-duty activity.
According to reports by the NFPA2, 3,723 firefighters have lost their lives while on duty in the UnitedStates over the past 30 years (1977 through 2006); this includes the 343* firefighters who died at theWorld Trade Center in 2001. Excluding the World Trade Center firefighter deaths, the average number offirefighter fatalities approaches 113 per year. However, from a yearly average of 151 firefighter line-ofduty deaths in the 1970s, the average death rate has declined to 99 deaths per year since 2000. While
the primary cause of line-of-duty fatalities remains sudden cardiac death, the number of such deaths
per year has declined by about one-third; however, since the early 1990s the number of cardiac-related
deaths has remained between 40 and 50 per year. Vehicular crashes remain the second-highest cause ofline-of-duty fatalities.
Improvements in firefighter health and safety standards and practices, particularly in the areas of PPE,
physical fitness, and training, are widely believed to be responsible for a significant downward trend
in line-of-duty deaths during the past 30 years. Between 1977 and 2006, the Nation experienced a43-percent drop in the annual number of firefighter line-of-duty deaths (see Figure 1). Notwithstanding
the significant drop in firefighter deaths, too many firefighters die needlessly each year.
The statistical analysis of firefighter fatalities accounts for how many firefighters have died and, to someextent, explains how they died, but the available data do not explain why firefighters die. Interpreting data
is made more complex by factors such as the declining number of structural fires and the year-to-year
variation in number and severity of wildland fires. Moreover, a dramatic downward shift in the total
number of firefighter deaths in certain years, such as 1992, 1993, and 2005, begs still more questions
about what is being done correctly to prevent line-of-duty deaths.
Epidemiological studies of firefighter mortality conducted in various years provide interesting insights
for comparing firefighter health and mortality rates to those of other population groups, but they, too, fallshort of explaining conclusively why firefighters die, and especially why any particular firefighter dies. Theinterest in occupational health factors relates to the frequency of sudden deaths due to heart attacks, aswell as chronic conditions which include respiratory disorders, heart disease, and cancer.

 USFA Web site—based on figures from the National Fire Protection Association’s (NFPA) U.S. Fire Department Profile through2005.
2 NFPA Journal, July/Aug 20071

 The USFA shows 344 firefighters died on duty and the National Fallen Firefighters Foundation have honored 347 firefightersfrom the World Trade Center.
*■ Firefighter Autopsy Protocol■ 3 ■I: Background ■Figure 1. On-Duty Firefighter Deaths (1977-2006)3

I.2 Rationale for the Protocol
The autopsy protocol was developed to give guidance to qualified professionals on the specific proceduresthat will be most appropriate in performing an autopsy on a deceased firefighter. The recommended
procedures are intended to address the complex relationship between the firefighter and the inherently
dangerous work environment where the duties of a firefighter must be performed. It has been assumed
that the user will be qualified, skilled, and experienced in performing autopsies, as the protocol isintended only to provide guidance on the special considerations that should apply to a firefighter*
autopsy that go beyond standard autopsy practice.
It is anticipated that the application of this firefighter autopsy protocol will lead to a more thoroughdocumentation of the causes of firefighter deaths and achieve three goals:
1.	It will advance the analysis of the causes of firefighter deaths to aid in the development of improved
firefighter health and safety equipment, procedures, and standards.
2.	It will help determine eligibility for death benefits under the Federal government’s PSOB, as well asState and local programs.
3.	It will address an increasing interest in the study of deaths that could be related to occupational
illnesses among firefighters, both active and retired.
fahy, Rita f ., Paul R . leBlanc, and Joseph l . Molis . Firefighter Fatalities in the U.S.—2006 . Quincy: national fire Protection
Association, June 2007 .

3

■ Firefighter Autopsy Protocol■ 4 ■I: Background ■The work environment of the firefighter is undoubtedly one of the most inherently dangerous workplaces.
To survive in that environment, the firefighter routinely uses protective clothing, respiratory protection,
safety equipment, and standard operating procedures (SOPs) intended to reduce the level of risk, butwhich cannot eliminate all risks. It is extremely important, in the event of a failure of those protective
systems, to fully and carefully determine what, if anything, may have gone wrong and how, if possible,
similar occurrences may be prevented from happening again. An autopsy may provide some of theessential evidence to make those determinations.
Several areas of interest in the study of chronic health issues are addressed in Part III of this document. The
specific issues relating to the determination of eligibility for death benefits are discussed in Part IV of thisdocument.
NFPA 1500, Standard on Fire Department Occupational Safety and Health Program,4 section 10.4.4 recommends, “If amember dies as a result of occupational injury or illness, autopsy results, if available, shall be recorded in
the health data base.” Appendix A-10.4.4 states, “The fire department should try to obtain autopsy or othermedical information for all deceased employees or former employees. This information could be useful inestablishing relationships between occupational factors and resulting fatalities at some time in the future.
Autopsies for fire fatalities should be conducted and recorded according to a standard protocol.” Annex B,
Monitoring Compliance with a Fire Safety Occupational Safety and Health Program, Section B-2, Figure
B-2 includes space for recording compliance with recording autopsy results in the health database.

I.3 Description of the Protocol
The Firefighter Autopsy Protocol is provided at the end of this section. The protocol is divided into thefollowing sections:
■
■
■
■
■
■
■
■

preliminary;
initial examination;
external examination;internal examination;
toxicological examination;
microscopic examination;summary of pathological findings; andconclusions.

The specific areas of procedures are described, but detailed step-by-step instructions are not provided as
autopsy practice varies and changes with the specific circumstances of death.

nfPA 1500, Standard on Fire Department Occupational Safety and Health Program . 2007 ed . Quincy: national fire Protection Association(617-770-3000; www.nfpa.org) .

4

■ 5 ■■ Firefighter Autopsy Protocol

I: Background ■S
PROTOCOLDISCUSSION

VIII. Preliminary
A. Circumstances of Death
1. Line-of-duty
a. Fire suppressionb. Special operations (e.g., hazmat, technical rescue)c. In transit to emergency
d. Other official activity
2. Non-line-of-duty
a. Active firefighter, unrelated activity
b. Former firefighter activity or exposure
B. Medical Records Review
1. Fire department injury/exposure records
a. Prior incidents
b. Prior injuries and treatments
2. Current medical conditions/medications
a. Prescribedb. Over-the-counterc. Administered by paramedics
C. Complete Work History
1. Length of fire suppression duty
2. Other jobs held during fire service
3. Jobs held after fire service
D. Scene Investigation
E. Scene Photography
1. The body as discovered
2. The site after the body is removed
3. The body clothed at autopsy
4. The body after removal of clothing
5. Specific shots of body depending on type of injury
F. Jurisdiction/Authority to Conduct Autopsy

Firefighters are subject to many uncommon occupational hazards,
including toxic and superheated atmospheres; explosions; falls;
crushing/penetrating forces; contact with fire, electricity, or hazardous
materials; and extremely strenuous and stressful physical activities.

VIII. Initial Examination
A. Identification of Victim
B. Document Condition of PPE
1. Refer to PPE diagram in Figure 8 and information in
Appendix C for standardized nomenclature.
Ppe description should include:a. Turnout coatb. Turnout pantsc. Helmet
d. Glovese. Boots
f. Self-contained breathing apparatus (SCBA)
g. Personal Alert Safety System (PASS)h. Protective hoodi. Clothing worn under turnouts
j. Other PPE not listed above
2. Use photographs to enhance documentation(see Appendix C)

Exercise caution when handling contaminated PPE, especially fromhazardous materials incidents, as residue may be harmful to those
involved in the autopsy. Gloves and other PPE should be used.

The autopsy results may be essential to determine why or how afirefighter was incapacitated, how the activity related to the cause ofdeath, and whether protective equipment performed properly. Having
a clear picture of the nature of firefighting operations that were taking
place (and to which the deceased was assigned) will assist in identifying possible mechanisms of injury. If the firefighter was reported
missing, try to determine the time of last contact or the length of time
between the initial report and the finding of the body.
The fire department should have an officer or internal Line-of-Duty
Death Investigation Team assigned to conduct a death investigation.
Other investigators may include the police, the State Fire Marshal(or other State officials), and/or Federal/State agencies responsible
for occupational safety and health, including the National Institute for
Occupational Safety and Health (NIOSH). Consult with these officials
as necessary.
In conducting the medical records review, obtain any documentsthat pertain to the incident. Document the occupational history ofthe deceased, including the number of years assigned as a “line”
firefighter, any history of unusual exposures (or changes in frequencyof exposure) to hazardous substances or diseases, and any relevant
occupational medical history. Finally, all recent medical history should
be reviewed, including documentation of any attempts at onscene
resuscitation.

Ppe should be sealed in a plastic bag if fire accelerants or other volatile/
toxic chemicals are suspected to be present; otherwise PPE should be
air-dried and preserved for examination. (Do not store clothing wet.)
Preservation of the original state of PPE, including clothing, is essential.
Ppe should be considered as evidence, and handled according to theSpecial Incident Procedures in NFPA 1851, Standard on Selection, Care,and Maintenance of Structural and Proximity Firefighting Protective
Ensembles (2008 edition). The Death Investigation Team should perform
or assist in the evaluation/documentation of PPE condition and performance. Documentation of the chain of custody of the PPE is required,especially as it may be examined by a number of individuals; however,examinations should be limited if the condition of the clothing is fragile
and will be further destroyed upon successive evaluations. Upon completion of any examination, PPE should be secured in an evidence storage
area. (International Association of Fire Fighters. Guide for Investigation of
a Line-of-Duty Death. Washington, DC, 2000).

continued on next page

■ Firefighter Autopsy Protocol■ 6 ■I: Background ■PROTOCOLDISCUSSION

C. Maintenance of Custody of Equipment
1. Appropriate storage conditions
2. Chain of custody
3. Limitation of handling if clothing and equipment
is fragile

Observations and photos recorded at the scene should indicate
whether the deceased was found wearing SCBA and/or other PPE.
If SCBA and PASS are user-controlled, were they properly activatedor working at the time of discovery of the deceased? A swab from theinside of the SCBA facepiece may help in determining operability.
A qualified specialist should inspect the PPE and note any damage.
NIOSH can assist in the determination of any contribution of thedeceased’s SCBA to the death. Ppe manufacturers may be able toassist in evaluating damage, but PPE should not be returned to the
manufacturer for examination (because of concerns about productliability).
Breathing apparatus filter cartridges, if any, should be retained.

VIII. External Examination
A. Document Condition of Body
1. Photograph
2. Radiograph
3. Record color of fingernails
4. Record appearance of blood
B. Document Evidence of Injury
C. Document Evidence of Medical Treatment
D. Collect Evidence from External Surfaces
1. Swabs of nasal/oral soot or other substances*
2. Hair*
3. Injection sites
E. Collect Vitreous Fluid
F. Document Burns*
1. Location
2. Degree
3. Etiology
4. Percentage of body surface area (BSA)
G. Biopsy Skin Lesions

A complete initial examination of the body is important prior to the full
autopsy, including X-rays, to help with identification, locate equipment, and look for nonobvious causes of death.
Firefighters are trained to provide emergency medical care for firecasualties. Of particular importance is that resuscitative efforts
for fellow firefighters are likely to be heroic and prolonged. This
fact should be taken into account when examining the body forevidence of medical intervention and when interpreting the resultsof blood gas assay.
Note the presence of soot or other unidentified substances on theskin and place samples (swabs) in a sealed container.
Certain internal samples (such as soot swabs and vitreous fluid) which
can be done before the body is opened are taken at this point because
collection can be accomplished in a more controlled manner, thus
reducing the potential for cross-contamination of the surfaces.
Hair samples should be about the thickness of a finger, pulled out
so as to include the roots, tied around the middle, with the proximaland distal ends marked, and stored in a plastic evidence bag.
Match burn injury locations to areas of heat/thermal damage on
clothing and equipment.
Vitreous fluid should be taken from both eyes. Vitreous fluid can beused to corroborate blood alcohol levels.

IIIV. Internal Examination
A. Document Evidence of Injury
B. Document Evidence of Medical Treatment
C. Describe Internal Organ System
D. Collect Samples for Toxicologic Analysis
1. Blood (2 x 20 cc red- and grey-top tubes)
2. Urine (20 to 30 cc) and/or trimmed bladder
3. Bile (all available) or gallbladder (if bile
unavailable)* May not be required for clear traumatic death

Soot swabs should be obtained from the upper and lower airways aswell as from the inside of the SCBA facepiece. These will assist in
the determination of SCBA usage and operability. Note any unusual
odors/colors of anything found during the internal examination.
Fresh-frozen samples of vital organs should be taken and retained aminimum of 90 days, preferably longer, as storage space permits.
An area of growing interest is the cancer rate of firefighters.
Potentially cancerous tissue should be biopsied and saved.
Additionally, histological type and the exact location of the tumor (ifsite-specific) within an organ should be documented in detail.

continued on next page

■ Firefighter Autopsy Protocol■ 7 ■I: Background ■PROTOCOLDISCUSSION

4. Cerebrospinal fluid (up to approx. 30 ml)
5. Soot swabs from airway*
a. Trachealb. Bronchial
6. Representative sampling of gastric and duodenal
contents (50 g; note total amount)
7. Take and retain fresh-frozen samples
a. Lung 100 gb. Kidney 100 gc. Liver 100 gd. Spleen 100 ge. Skeletal muscle (psoas or thigh) 20 g
f. Subcutaneous fat 20 g
g. Section of bone with marrow (3-4 cm)
h. Brain 100 g
8. Additional specific samples to be taken:
a. Tied-off lower lobe of right lung (store in arson
debris paint can)b. Peripheral blood from leg vein (fluoridated andred-top tubes)c. Any specimens taken in field or during hospital
resuscitationd. Sample hematomas
e. Any other sites should be labeled

In the case of incinerated remains, bone marrow or spleen may
be the only source of tissue for toxicological studies, especially for
those establishing carbon monoxide levels. Request determination ofcarbon monoxide content and of carbon monoxide-binding capacityof mixture from water extract of spleen, kidneys, or other organs.
Gastric and duodenal contents should be representative. Solid dosage forms should be removed, counted, and analyzed.

IIIV. Toxicological Examination
A. Urine Screen/Analysis
1. Volatile compounds (e.g., benzene, hydrocarbons
including accelerants, ethanol)
2. Psychoactive substances (e.g. opiate derivatives, marijuana metabolites, cocaine metabolites, stimulants,
phencyclidine)
B. Blood Analysis.
1. Carboxyhemoglobin, methemoglobin, sulfhemoglobin
2. Volatile compounds (see A.l. above)
3. Other (e.g., hydrocyanic acid, flouride)
4. Confirm results of positive urine screen
C. Subcutaneous Fat Analysis
1. Organic compounds, including:a. Herbicides
b. Pesticides
2. Polychlorinated biphenyls (PCBs)
D. Soot Screen (from swabs)*
1. Metals, including:a. Arsenicb. Antimonyc. Lead

The toxicologic analysis performed for firefighters should be of ahigher order than that performed for civilian fire casualties. In addition to ascertaining blood levels of various toxic products that arecommonly found in a fire environment, it is beneficial to know about
the presence of any judgment-impairing substances. This may be
important in the determination of eligibility for death benefits as well
as for determining causality.

When taking lung samples, use the right lung because aspirated
foreign materials have a greater propensity to lodge in the right lung.
Soot particles and other heat injuries indicate that the victim wasbreathing in fire. Absence of soot particles does not prove that thevictim was already dead when exposed to the fire.

Determinations of asphyxiation from carbon monoxide levels shouldtake into account victim medical history (i.e., smoking) in addition toother types of exposure. If victim survived carbon monoxide poisoning for several hours, portmortem samples usually will fail to showpresence of carboxyhemoglobin. Blood taken at time of admission tohospital still may be available and of particular value.
Determination of specific levels of metals, organic compounds, andgross particulate matter should be conducted because firefighter
exposure to these substances is believed to be greater than that forcivilians. Additionally, this information may yield important clues about
the cause, manner, and mechanism of firefighter death.
Use vitreous fluids or bile to confirm presence of ethanol in either
blood or urine.

* May not be required for clear traumatic deathcontinued on next page

■ Firefighter Autopsy Protocol■ 8 ■PROTOCOL
2. Organics, including:a. Pesticides
b. Herbicides
c. Vinyl chlorided. Acrylonitrilee. Acrolein
3. Particulate analysis (e.g., asbestos)

I: Background ■DISCUSSION
Use caution when noting the presence of hydrocyanic acid, as it canbe produced by bacterial decomposition within the tissues of thedeceased.
Check for the presence of PCBs and polynuclear aromatic compounds in the subcutaneous fat, as this will help in the determinationof a history of exposure.

IIVI. Microscopic Examination
A. Findings of Microscopic Examination

Representative samples of all organs and body systems should becollected. The sections should be microscopically examined for
malignant neoplasms and other abnormalities, including suggestive
premalignant changes

IVII. Summary of Pathological Findings
A. Medical Facts
1. Correlation

State objective findings related to gross and microscopic examinations. Correlate physical circumstances, toxicological analyses, andother investigative studies to pathological findings.

VIII. Conclusions
A. Discrepancies
1. Inconsistent observations
2. Differences between death certificate and subsequentfindings
B. Conclusions
1. List diagnoses on a separate page
2. Cause and manner of death

Include determination of cause, manner, and mechanism of death.
Describe discrepancies between evidence collected or observationsof eyewitnesses and the autopsy findings.

■■II. Medicolegal Autopsy Procedures in the
United StatesT

he need to investigate and understand the cause of death, particularly when it occurs under unusual,confusing, or ambiguous circumstances, is almost universal. Nearly every country has establishedrequirements for the medicolegal investigation of unforeseen, unnatural, or violent deaths, usually
including workplace accidents and job-related deaths. However, unlike some other industrialized nations,no national system of death investigation exists in the United States. Death investigation in the UnitedStates falls under the authority of State and local officials
Legal structures governing death investigation vary considerably among the 50 States, the District ofColumbia, and the territories. Depending on the jurisdiction, the official responsible for determining thecause, manner, and mechanism of death may be a coroner or medical examiner. Eleven States operate coroner
systems (either district or county coroners). Eighteen States use a State, district, or county medical examiner
system. Eighteen States operate under a mixed system of State or county medical examiners and county
coroners/medical examiners.5 Appendix A lists the specific practices used in each State.
Most firefighter deaths are investigated as unusual or unforeseen deaths according to State laws andregulations, and a high level of discretion is afforded to coroners and medical examiners in the mannerof fulfilling their duties and responsibilities. Only one State, Maryland, specifically requires a medicolegal
investigation of all firefighter deaths and, in fact, has a staff epidemiologist to study firefighter deaths.
Other States such as New Jersey have designated the Division of Fire Safety as the lead agency forinvestigating fire service accidents, but have established no autopsy requirements.
Three publications attempt to organize and describe medicolegal autopsy requirements in the United States:
1.	 Wecht, C.H. United States Medicolegal Autopsy Laws. 3rd ed. Arlington: Information Resources Press, 1989.
2.	 Combs, D.L., R.G. Parrish, R. Ing, et al. Death Investigation in the United States and Canada, 1995. Atlanta: Centers
for Disease Control, U.S. Health Services, 1995.
3.	Ludwig, Jurgen. Autopsy Practice. 3rd ed. Totowa: Humana Press, 2002.
Notwithstanding the differences among the various systems, all death investigation systems are intended torespond to questions of who died, how and why a death occurred, and (as applicable) who is responsible
for the occurrence. This information, in turn, may be used in legal proceedings; to compile vital statistics;
to evaluate medical care and treatment; and to compile factual information on clinical, anatomical,
pathological, physiological, and epidemiological subjects for research purposes.

5

www.cdc.gov/epo/dphsi/mecisp/death_investigation_in_the_united_states_and_canada.htm■ 9 ■■ Firefighter Autopsy Protocol■ 10 ■

I: Background ■II.1 When Is an Autopsy Required?
An autopsy is not performed as a part of every death investigation. In most cases, the determination of theneed to perform an autopsy is a discretionary responsibility of the coroner or medical examiner. The issuanceof a death certificate does not require an autopsy, and only a death certificate is needed to qualify for mostinsurance and death benefit programs. The coroner or medical examiner may determine that no autopsy
is required in any situation where there is sufficient other evidence to make conclusive determinations on
the cause and manner of death. In past years, an autopsy typically was omitted when the firefighter death
was believed to have been caused by natural causes, such as cardiac ischemia, even when it occurred on
the scene of, or en route to or from, a fire or emergency incident (see Goode, 1990).However, autopsies
are now recommended for all firefighter deaths, and the International Association of Fire Fighters (IAFF)
and other organizations encourage this practice. NIOSH’s Fire Fighter Fatality Investigation and Prevention
Program (FFFIPP) uses autopsy results in the analysis of firefighter fatalities and specifically recommends that
an autopsy be performed even if the cause of death is presumed to be natural. Section III.3, Investigation ofLine-of-Duty Deaths, provides additional details on this NIOSH program.
Many coroners and medical examiners have had to limit the number of autopsies performed because ofcost and time constraints. Fiscal pressures have increased as the number of death investigation cases has
increased, particularly those involving violent deaths. The cases in which an autopsy is most likely tobe omitted include those where there is a known and undisputed cause of death without suspicion of
criminal activity; line-of-duty deaths often fall within these parameters. Autopsies are sometimes omitted
because of the religious or personal preferences of the deceased and his or her family.
The failure to conduct autopsies appears to be of significant concern throughout the medicolegal
community. Performing autopsies, even in cases of prolonged illness or involving individuals withprior medical histories, would be valuable in conclusively determining the cause of death, gaining amore detailed understanding of injury and disease processes, and evaluating the quality of medical care.
According to some in the death investigation profession, a decline in the level of interest in pathology
and forensic pathology among medical students has led to a shortage of trained professionals to conduct
these procedures.
Autopsies usually are performed to establish or verify the cause of death, or to gather information orevidence that would be helpful in an investigation. Without an autopsy, specific causes, contributing
factors, and underlying conditions may go undiscovered and unreported. In the case of firefighter fatalities,
this lack of information may hamper industry and fire service understanding of the hazards of firefighting
significantly, and limit the ability to develop more effective ways to prevent firefighter deaths and injuries.

II.2 Definition of Manner, Cause, and Mechanism of Death
Because the firefighter death certificate and autopsy results have legal ramifications, it is important toclarify the differences among manner, cause, and mechanism of death, and especially to recognize thatvarious entities may use the terms “cause of death” or “nature of death” in ways quite different from theirappropriate use in the medicolegal autopsy.
■ Manner of death refers to classification of the death as natural, accidental, homicidal, or suicidal.6
The phrases “cause of death” and “mechanism of death” often are used interchangeably by clinicians andlaymen, but they are not synonymous: Ludwig, Jurgen. Autopsy Practice. 3rd ed. Totowa: Humana Press, 2002.

6

■ Firefighter Autopsy Protocol■ 11 ■

I: Background ■■ Cause of death is the “disease or injury that sets in motion the physiologic train of events culminating in
cerebral and cardiac electrical silence.”7■ Mechanism of death is the “physiological derangement set in motion by the causes of death that leads tocessation of life.”
Thus, for example, a firefighter who dies from a cardiac event at the scene of a fire may have “athero­sclerotic heart disease” as the “cause of death” and “ventricular arrhythmia” as the “mechanism of death.”II.3 Chain of Custody and Documentation
Careful documentation is essential both because of the legal ramifications, and the medical andepidemiological issues surrounding firefighter deaths. Documentation to maintain the chain of custody
is of particular importance in medicolegal cases. The following recommendations are made for the
information that is included with specimens that are submitted for toxicological studies:■ information that identifies each specimen, including the site where taken;■ specific details about the requested analytical test methods;■ relevant information about circumstances surrounding the specimen (e.g., emergency room measuresthat could affect certain drug levels); and■ signatures that document the chain of custody.
Shipping of autopsy specimens requires special consideration. Specimens must be packaged appropriately
to guard against breakage and to ensure the integrity of the samples. Tissues or body fluids submitted foranalysis for volatile substances should be packaged in glass rather than plastic, although plastic may be
acceptable for other samples. Any caps, lids, stoppers, or other loose parts of a container should be taped
into place. The materials used in shipping the specimens must not compromise the samples (e.g., paraffinblocks should be not be wrapped in cotton because cotton fibers could adhere to the paraffin). Containers
with wet or frozen samples must be packaged inside a second container that includes material sufficient
to absorb all liquid in case of leakage. Frozen samples require ice or dry ice around the sample and in thesecondary container; an insulated mailing container is necessary.
The Autopsy Handbook8 specifies that “medicolegal material is sent by messenger, registered mail, or air
express” and that specimen labels (inside the shipping container) include the following information:■ name and address of sender;■ name and address of recipient;■ description of container and source and nature of contents;■ tag stating that the shipment is evidence; and■ detailed requests for specific examinations.
Containers should be sealed with a tamper-proof method, such as with sealing wax imprinted with thesender’s thumbprint. The outer mailing container should have address labeling and also appropriate labels
such as: Ibid.
 Ludwig, op.cit.

78

■ 12 ■■ Firefighter Autopsy Protocol

I: Background ■■ Biohazard;■ Perishable Material;■	Fragile, Rush, Specimen; and/or■	Glass, Handle with Care.
Postal regulations must be followed. The publication “Domestic Mail Manual” is updated by the Postal
Service periodically. It is recommended that the receiving party be notified by telephone or electronic mailwhen a shipment is initiated.

II.4 Retention of Autopsy Specimens and Paperwork
Autopsy specimens should certainly be retained until the investigations into the firefighter’s death havebeen completed and any litigation surrounding the firefighter’s death has been resolved. After that point,
specimens and paperwork should be retained for a significant period of time. Recommended minimum
storage times, following the completion of the investigation, are listed in Table 1.

Table 1. Recommended Minimal Storage Times for
Autopsy Specimens and Paperwork9
Sample Type

Minimum Retention Time

Wet tissues

6 months

Accession records

1 yearQuality assurance documents

2 years

Paraffin blocks and photographs

5 years

Autopsy authorization forms

7 years

Autopsy reports and slides

20 years

It is important to recognize that each State or local medical examiner or coroner’s office may haveretention times that are very different from the recommendations provided above. In fact, these offices
may have procedures in place that require automatic disposal of certain records or samples that will
require extraordinary efforts on the part of fire departments or other individuals for continued storage andmaintenance. Of principal concern is the retention of samples until after any investigation is completed.
Further, certain statutes of limitation for potential litigation are likely to extend beyond the investigation
period. In these instances, it is important to file a request for extending the retention times for specificsamples with the State or local medical examiner or coroner. In certain circumstances, it may be necessary
to identify alternative storage locations that meet all the storage requirements for autopsy samples
complete with detailed chain of custody.

9 Ibid.

■■
III. Occupational Aspects of Firefighting ofSpecific Concern to AutopsyF

irefighter fatalities often result from complicated scenarios. Due to the nature of the occupation, afirefighter’s death could be caused by a wide variety of single factors or a combination of several
factors. For example, a firefighter could die from a stress-induced heart attack caused by simple overexertion; or a firefighter could die from asphyxiation which is actually caused by the failure of his or
her breathing apparatus; or a firefighter could die from hypothermia, resulting from being trapped in a
structural collapse while fighting a fire on an extremely cold day. A firefighter’s death could be caused by
the inhalation of toxic products of combustion, burns, traumatic injury, exposure to hazardous materials,
radiation, a variety of other singular causes, or a combination of factors.
A better understanding of the actual causes of firefighter deaths, including all of the causal factors, will
require a thorough examination of the protective clothing and equipment that are involved in the incident,
a detailed analysis of the situation, and the details, such as carboxy-hemoglobin levels and the presence of
toxic products in the respiratory and circulatory systems, that can be obtained only through an autopsy.

III.1 Firefighter Death Classification
The USFA and the NFPA separately publish annual analyses of firefighter line-of-duty deaths. Although
the two entities share information, they collect data independently. The NFPA identifies cases of firefighter
fatalities through sources including newspaper reports and Internet sites such as firehouse.com. The NFPA
then makes contact with the department (after the funeral) and collects information about the fatality.
To describe the mechanism of injury, the NFPA uses categories based on coding used in the 1981 edition
of NFPA 901, Uniform Coding for Fire Protection. The NFPA studies incident reports and witness accounts asavailable, and then determines which classification best describes that individual fatality. The nine causal
categories on which the system is based include
1 . fell/Slipped .
2 . Struck by .
3 . Overexertion/Strain .
4 . fire Department Apparatus Accident .
5 . Caught/trapped .

6 . Contact with/exposure to .
7 . exiting or escaping/Jumped .
8 . Assaulted .
9 . Other .

In any particular year, the categories used in summary reports do not include all of the above categories.
The NFPA analyst makes classifications based on the actual events for that year, and the reported causal
categories may vary from year to year. In certain years, some categories which had extremely few events
may be grouped into the “other” category.
While cardiac arrest and other stress-related fatalities are the leading cause of fireground deaths, thisclassification system does not differentiate the causes of cardiac and stress-related cases; all are classified■ 13 ■

■ Firefighter Autopsy Protocol■ 14 ■

I: Background ■as “Overexertion/Strain.” Although firefighting is widely recognized as a highly stressful occupation,
the physiological and psychological effects of job-related stress have not been clearly established ordifferentiated, particularly as they affect mortality and morbidity.
The annual reports also describe firefighter fatalities according to the nature of the death (i.e., the medical
cause of death), using the following categories:■ Sudden cardiac event■ internal trauma■ Asphyxiation■ Crushing■ Burns■ Drowning■ Stroke■ electrocution■ hemorrhage■ gunshot■ Aneurysm■ fracture■ heat stroke■ Pneumonia■ Other

Depending on the fatalities sustained for that year, the categories included in the report may not include allof those listed above. In addition, new categories may be created to reflect different circumstances.
Because the reported categories may vary from year to year, one must be careful when comparing resultsfrom year to year. For example, if there are several drowning deaths in one year, those would likely bereported as a separate category in the annual report;however, if there were only a single drowning in thenext year, then likely that death would be included as part of the “other” category in that year’s report.
Therefore, upon request, NFPA is willing to analyze data for particular situations.
It should be noted that these categories do not correspond with International Classification of Disease(ICD-10, released July 2007) or SNOMED (Standardized Nomenclature of Medicine) cause categories.
There are also new classifications of death and injury as the result of terrorism incidents that have been
established by the National Center for Health Statistics of the Department of Health and Human Services.

III.2 Trends in Line-of-Duty Deaths
The overall downward trend in line-of-duty deaths has been driven primarily by the downward trends indeaths attributed to cardiac arrest and in deaths during fireground operations or while at the fire scene.
Fireground deaths account for more than half of all firefighter duty deaths over the last 30 years; in 42.9
percent of the cardiac-related deaths, the firefighters’ cardiac symptoms appeared during fireground
operations. The downward trend in the number of fireground deaths has corresponded with a downward
trend in the number of structural fires, although in recent years the death rate has continued to decline
while the number of structural fires has held steady (see Figure 2). Death rates due to traumatic injuries(smoke inhalation, burns, and crushing or internal trauma) injuries remain a significant concern.
Other areas of concern for the period 1977 through 2006 include the following10:■ Wildland firefighting accounted for 338 fatalities, and aircraft crashes contribute significantly to thisnumber.
■ Road vehicle crashes accounted for 406 fatalities, mostly volunteer firefighters, and are the second
greatest cause of firefighter fatalities.

 Fahy, Rita, Paul LaBlanc, and Joseph Molis. “Firefighter Fatality Studies 1977-2006.” NFPA Journal, July/Aug. 2007.

10

■ Firefighter Autopsy Protocol■ 15 ■

I: Background ■■	Falls from apparatus while en route to or from alarms accounted for 41 deaths in the first 10 years, but
only 4 in the years 1999-2006 (and none in most of the 1990s).
■	Training deaths accounted for 247 fatalities, and the number of deaths in the most recent decade isnearly twice that of the first decade in this time period.

Figure 2. Trend for Firefighter Deaths at Structure Fires (courtesy of NFPA)

Figures 3 to 5 show these trends for the period 1977 to 2006.
Sudden cardiac death leads all categories of line-of-duty deaths. Between 1977 and 1991, 45 percent of
all firefighter deaths resulted from cardiac disorders, most from myocardial infarction. The proportion ofdeaths resulting from heart attacks has varied from 33.6 percent to 53.9 percent over the 15-year period.
Fahy (2007) reports that the number of deaths has remained between 40 and 50 per year for the period
since the early 1990s, although the year 2006 saw a record low of only 34 sudden cardiac deaths.

continued on next page

■ Firefighter Autopsy Protocol■ 16 ■

I: Background ■Figure 3. Firefighter Deaths in Aircraft Crashes Related to Wildland Fires (1977-2006)(courtesy of NFPA)

Figure 4. On-Duty Firefighter Deaths in Road Vehicle Crashes (1977-2006)(courtesy of NFPA)■ Firefighter Autopsy Protocol■ 17 ■

I: Background ■Figure 5. Deaths of U.S. Firefighters During Training (1977-2006)(courtesy of NFPA)

T

Kales, Stephanos, elpidoforos Soteriades, Costas Christophi, and David Christiani . “emergency Duties and Deaths from heart
Disease among firefighters in the united States .” New England Journal of Medicine, vol . 356 (12), 2007, pp . 1207-1215 .
11

■ Firefighter Autopsy Protocol■ 18 ■

I: Background ■complicated by the provisions of the Americans with Disabilities Act (ADA), which may restrict the abilityof fire departments to limit the duties of high risk individuals.

III.3 Investigation of Line-of-Duty Deaths
F

Fire Fighter Line-of-Duty Death and Injury Investigations Manual (updated in 2000). International Association of Fire Fighters (IAFF),
1750 New York Avenue, NW, Washington DC 2006. (202-737-8484; www.iaff.org).
12

■ Firefighter Autopsy Protocol■ 19 ■

I: Background ■Medical records, death certificates, and autopsy reports as well as interviews and evaluations of personal
protective equipment (PPE), particularly SCBA, are integral to the process of investigating fatalities. Eachreport includes a summary of the incident and specific recommendations for preventing similar events.
Reports omit department and individual identifiers, as the focus in not on determining fault or blame,
but rather on understanding the causes of firefighter fatalities and then developing and disseminating
recommendations for prevention of fatalities. An examination of each NIOSH firefighter fatality report was
conducted with the specific focus of discerning specific comments related to the conduct of autopsies.
These results are provided in Appendix C.

III
A relatively routine examination as part of any autopsy is an alcohol and drug screen. These analyses areprovided as part of toxicology reports. Toxicology reports in most autopsies document the positive andnegative findings of a series of tests conducted to detect specific substances that may have caused death.
Such tests commonly include tests for the presence of pharmacological agents and illegal drugs. Bloodtests for the presence of ethyl alcohol are conducted to determine whether the deceased was under the
influence of an intoxicating beverage at the time of death. In the case of fire victims, the toxicology report
should include analyses of blood, urine, other body fluids, and tissues for the presence of combustion
products and other toxicants and their biomarkers (see section below), as well as alcohol and drugs.
It is extremely important that, in the determination of alcohol levels, the effects of postmortem changes
and specimen storage be accounted for. Blood alcohol concentrations obtained at autopsy are valid until
putrefaction begins. This may vary from several hours to a few days, depending on the environment. Most
autopsy procedures recommend the addition of sodium fluoride at a concentration of 10 mg/mL ofblood to the sample and the storage of the sample in a refrigerator. Considerations for evaluation of blood
alcohol levels include■	If the blood is analyzed soon after withdrawal or if the blood is kept in the refrigerator, results usuallyare reliable, even if no sodium fluoride has been added.
■	If the air space about the blood sample is large, alcohol can evaporate and a falsely low blood alcohol
level can result.
■ Putrefaction changes before autopsy or during storage may cause a falsely high blood alcohol
concentration. Ethanol can be produced in the specimen container, usually in the absence of apreservative, as the fluoride inhibits bacteria far more effectively than fungi. Higher fluoride
concentrations are required for inhibiting fungal growth.13■ Although there is no major difference in alcohol concentrations of blood samples from the intact heartchambers and the femoral vessels, autopsy samples from pooled blood in the pericardial sac or pleuralcavity are unsatisfactory; blood should be withdrawn from peripheral vessels.
■ Blood alcohol concentrations vary from vitreous, urine, or tissue samples as compared to alcohol
determined through stomach contents. These variations depend on whether blood alcohol
concentrations were increasing or decreasing at the time of death.14 Harper D.R. and J.E.L. Correy. “Collection and storage of specimens for alcohol analysis.” In Medicolegal Aspects of Alcohol, J.C.
Garriott, ed. Phoenix: Lawyers and Judges Publishing Co., 1997, pp. 145-169.
14
Caplan Y.H., “Blood, urine and other tissue specimens for alcohol analysis.” In Medicolegal Aspects of Alcohol, J.C. Garriott, ed.
Phoenix: Lawyers and Judges Publishing Co., 1997, pp. 74-86.
13

■ Firefighter Autopsy Protocol■ 20 ■

I: Background ■The principal drugs for analysis include those for common narcotics, barbiturates, amphetamines,
hallucinogens, or cannabinoids. Tests for other prescription and nonprescription drugs are performed
occasionally to detect such compounds as common steroids, analgesics, and other indicators of coexistingillnesses/conditions, as well as of drugs used in emergency resuscitation attempts. Methods typically usedin these analyses are described in Table 2.

T
Technique

How Used

Volatiles by Gas Chromatography (GC)

Usually used for testing ethanol content; testing is applied as part of a general panel to detectand quantify numerous volatile compounds that include methyl, ethyl, and isopropyl alcohols
and ketones. t-Butyl alcohol is used as an internal standard because it does not occur naturally.

Specific drug screening by EnzymeMultiplied Immunoassay (EMIT)

EMIT can detect but not quantify dependence drugs of abuse. Specific test panels are available for cocaine metabolites, tricyclic antidepressants, barbiturates, cannabinoids, amphetamines, opiates, and propoxyphene. The technique does not detect drugs at parts per billion(ppb) levels.

Specific drug screening by EnzymeLinked Immunosorbent Assay (ELISA)ELISA uses antibodies as a more effective technique compared to EMIT (which it is supplanting). ELISA can detect drugs at ppb levels.

Drug screening by Thin-Layer
Chromatography (TLC)

TLC is used a general drug screen in lieu of EMIT and ELISA, which use panels for
specific drugs.

General drug screening, identification,and quantification by High-Performance
Liquid Chromatography (HPLC)

HPLC is used most commonly in place of TLC, given its greater sophistication and use ofcomputerized compound matching. HPLC can be used as a general screening technique,but also has been configured for specific drug or substance analyses. HPLC is preferred for
drugs that decompose in GC/MS injection procedures.

Specific drug identification and quantification by Gas Chromatography linked to
Mass Spectrometry (GC/MS)

GC/MS is now the preferred overall technique for analysis of specific drugs. Gas chromatography provides the separation of compounds in wet sample fluids while the mass spectrometry provides the identification and quantification of each analyte using computerized matchingcompound libraries. Specific separation techniques must be applied to identify specific drugs.

Advances are being made each year in progressively more capable and sensitive analytical equipment
and procedures that can be applied to the analysis of substances in autopsy tissues and fluid samples. It
is important to apply the most up-to-date techniques when conducting specific analyses for alcohol anddrug levels. A number of references are provided at the back of the protocol on the subject of alcohol anddrug testing.

III.5 Fire Toxicology
A complete understanding of the cause of a firefighter’s death must include some consideration of
emergency scene-specific toxicological agents that may have been involved and how they may haveinteracted with the deceased’s biological processes and systems to cause death.
■	For instance, did the inhalation of carbon monoxide result in cardiac ischemia and subsequent cardiac
arrest?
■ Did a toxin enter the body through some route other than the respiratory system, such as throughdermal exposure, injection, or ingestion?
■ Did protective clothing or SCBA fail to protect the user, or was the user’s air supply depleted orotherwise compromised?

■ Firefighter Autopsy Protocol■ 21 ■

I: Background ■These conditions are often accompanied by other injuries which may or may not themselves have caused
death, such as crushing forces (trauma) or prolonged exposure to high radiant heat levels (burns).
Firefighters respond to a variety of incidents, each presenting its own unique hazards. Traditionally,
most firefighting activity has centered around structural fires. The combustion of wood releases several
combustion products into the atmosphere, principally carbon monoxide and other simple hydrocarbons.
Structural fires have changed over the past several years because building materials have changed. Roofing,insulation, carpets, paints, and other construction materials all contribute to an ever-growing diversityof chemical products found at fires. The increased use of plastics and other synthetic materials releasedifferent kinds of combustion products, many of them highly toxic or carcinogenic. Some examples of firecombustion products:
■
■
■
■
■
■
■
■
■

carbon monoxide and carbon dioxide;
inorganic gases (hydrogen sulfide, hydrogen cyanide, nitrogen oxides);acid gases (hydrochloric acid, sulfuric acid, nitric acid);organic acids (formic acid, acetic acid);aldehydes (acrolein, formaldehyde);
chlorinated compounds (carbon tetrachloride and vinyl chloride);hydrocarbons (benzene);polynuclear aromatic compounds (PNA); andmetals (cadmium, chromium).

In addition, chemicals at the site of a fire further contribute to hazardous contaminants in fire smoke. A
classic example are PCBs, found in electrical transformers and other equipment, which, when burned,
may form dioxin, an acutely deadly substance. Even the normal household will contain cleaning supplies,
pesticides, pool chlorine, and other substances that contribute to release of toxic substances at fires. Table
3 lists some common fire smoke contaminants, the sources of these substances, and toxic effects fromrepeated or high concentration exposure to these chemicals. Table 4 shows chemicals identified in ananalysis of fire smoke for several different fires.
Most protective clothing and equipment used by firefighters permits the ready penetration and permeationof toxic chemicals through protective fabrics and components. Since most firefighter protective clothinguses porous fabrics, the chemical vapors or liquids simply penetrate or pass through the pores of thematerial. Molecules of chemicals can also permeate into the fibers or coatings of clothing materials andcan remain in the material for long periods of time, depending on the types of exposure chemical(s) andcare given to the clothing. Chemicals that get into the clothing from either means often directly contact the
firefighter's skin.
Different areas of the firefighter protective ensemble are likely to demonstrate varying propensities for theabsorption or adsorption of chemicals. Any porous fabric material found in the clothing or other items
may be contaminated, such as:■■■■

turnout clothing outer shells, moisture barriers, thermal liners, collars, and wristlets;
station/work uniforms;
glove shells and liners;
protective hoods;

■ 22 ■■ Firefighter Autopsy Protocol

I: Background ■■ boot linings;■ helmet straps; and■ SCBA straps.
Coated materials such as moisture liners, reflective trim, boot outer materials, a respirator masks are more
likely to be affected by permeation. The same is true for hard plastics or resins such as those used in thehelmet, SCBA components, and certain turnout clothing hardware.
In addition to liquid or vapor chemical contaminants, a tremendous amount of ash, soot, and other solid
matter is released during fires and firefighting activities. This solid matter provides the visible portionof smoke and is the primary cause of residue left on structures and clothing following fires. Soot andash represent incomplete products of combustion; that is, unburned fuel or agglomerated solids which
fail to burn completely during the fire. During combustion, synthetic materials create an increase in theamount of particulate matter, hence the "black" smoke from burning plastics. Since soot particles are very
porous, they tend to adsorb other hazardous chemicals. Ash, resins, and other particles from fire smoke
can become entrapped within the fibers of clothing or adhere to skin. Accumulation of soot on protective
clothing becomes visible as soiled or "dirty" areas. In some cases, these "soils" are made of melted resinsor plastics which, in the heat of the fire, become liquid and spread even further throughout the protective
clothing. In other cases, many of the particles are too small to see (less than 10 microns) and can penetrateeasily into the inner layers of clothing, such as liner and barrier materials, contacting the firefighter's skin.

TContaminant

Sources

Toxicology

Polychlorinated Biphenyl (PCBs)

Power transformers/capacitors
Televisions
Air conditioners
Carbonless copy paper
Hydraulic systems
Elevators• PCBs can produce dioxins that are toxic by inhalation andingestion.
• PCBs also absorb through the skin.
• PCBs cause cancer of the liver and pancreas.

Asbestos

Roofing and shingles
Acoustic ceiling tiles
Sprayed ceilings
Old pipe insulation
Old octopus-type furnaces
Pre-1975 drywall• Principal hazard is inhalation of fibers (<5 microns length)
causes cancer.
• Asbestos fibers can be aerosolized from clothing and inspiredor and ingested.

Creosote

Power poles
Railroad ties
Treated wood or buildings
Lumber yards
Piers and docks• Creosote is toxic through inhalation and skin absorption.
• Causes cancer of skin, prostate, and testicles.

Plastic Decomposition Products• Polycarbonates• Polystyrene• Polyurethane• (PVC)Electrical insulation
Plumbing
Furniture
Construction materials
Insulation and packaging
Tools/Toys
Automobiles• Variety of decomposition products including acrylonitrile,hydrogen cyanide, nitrogen oxides, hydrogen chloride,
benzene.
• Various routes of toxicity through skin absorption, inhalation oringestion.

■ 23 ■■ Firefighter Autopsy Protocol

I: Background ■T

Compound

1(K)

Furan

X

C4H8 isomers

X

Benzene

X

1(K)

2(K)

3(O)

4(O)

5(K)

6(K)

6(O)

X

X

X

X

X
X
X

X

Dimethylfuran

X

Methyl methacrylane

X

TolueneX

Furfural

X

X

XyleneX

X

StyreneX

X

Pinenes

X

X

LimoneneX

IndaneX

Methylcyclopentane

X

X

X
X
X

X

X
X
X
X
X

X

X
X

2,4-Dimethyl-1-pentene

X

Ethyl benzene

X

C3-Alkyl benzene

X

C4-Alkyl benzene

X

X

X
X

n-ButaneX

Freon 11X

t-Butyl anisole

X

X

Methyl naphthalene

X

X

K-knockdown; O-overhaul

Firefighters may be exposed to other particulate hazards. Chemical dusts, lead particles, and asbestos also
may be encountered at fires and other responses. For example, though asbestos is principally an inhalation
hazard, it can cling to protective clothing and be released when the responder is not wearing his or her
SCBA. Similarly, lead and other toxic dusts can fill clothing pores and contaminate the firefighter’s skinafter the incident.
Firefighters also are subject to exposure to blood or other body fluids containing pathogens, particularly
the Human Immunodeficiency Virus (HIV) or Acquired Immunodeficiency Syndrome (AIDS) virus, andHepatitis B and C viruses. These viruses are extremely small in size and are transmitted by blood or otherbiological fluids. The risk is high since emergency patient care is a major function of many responses.
The extrication of victims from automobile accidents and rescue of injured persons from fires andother incidents all involve the potential for this exposure. Even minute droplets of blood are capable ofcarrying thousands of virus that potentially can cause infection through mucous membrane contact ornonintact skin. Firefighters also face serious health threats from exposure to existing and nontraditional
airborne pathogens that can be encountered in providing medical care or general interface with the
public, including tuberculosis, sudden acquired respiratory syndrome (SARS), and more recently avian flu.
Though these exposures may not be fatal, they can contribute to firefighter fatalities.
Noonan, Gary P., Judith A. Stobbe, Paul Keane, Richard M. Ronk, Scott A. Hendricks, Laurence D. Reed, and Robert L.
McCarthy. Firesmoke: A Field Evaluation of Self-Contained Breathing Apparatus. NIOSH and U. S. Fire Administration, 1989.
15

■ Firefighter Autopsy Protocol■ 24 ■

I: Background ■An emerging concern for firefighters and other first responders is the potential lethality from exposure
to chemical, biological, radiological, nuclear, and explosive (CBRNE) hazards. These hazards may takethe form of chemical warfare agents, toxic industrial chemicals, biological agents that are both liquidand airborne, ionizing radiation, nuclear material, and explosives. Terrorism has become a real threat to
firefighters and is likely to cause multiple casualties, including firefighters. Under the circumstances of aterrorism event, special provisions will be needed for the handling of first responder and civilian deaths.

III.6 Burns
Firefighters encounter flames, high heat, physical obstacles, and a number of other hazards in carrying out
their response duties. Each hazard serves as an individual stressor on the firefighter that given its relative
intensity, length of exposure, and the degree to which protection is provided, creates specific risks of
injury, disease, or death.
Particularly relevant to this report is structural firefighting, which the NFPA defines as “the activities ofrescue, fire suppression, and property conservation in buildings, enclosed structures, vehicles, marine
vessels, or like properties that are involved in a fire or emergency situation.” Structural firefighting is likely
to expose firefighters to a range of thermal conditions when responding to a fire. While several researchers
have attempted to classify these conditions, one system is shown in Figure 1, where the fireground ischaracterized in terms of level of thermal radiation (expressed in cal/cm2s) and the air temperature(expressed in degrees Celsius and degrees Fahrenheit).16,17 Three possible structural firefighting situations
are illustrated in this figure and are described below:■	The Routine region describes conditions where one or two objects, such as a bed or waste basket, areburning in a room. The thermal radiation and the air temperatures are virtually the same as thoseencountered on a hot summer day. As shown in Figure 1, Routine conditions are accompanied by athermal radiation range of 0.025 to 0.05 cal/cm2s and by air temperatures ranging from 68 to 140 °F(20 to 60 °C). Protective clothing for firefighters typically provides protection under these conditions,but excessive exposure times may create a burn injury situation.
■	The Ordinary region describes temperatures encountered in fighting a more serious fire or being next
to a “flashover” room. Ordinary conditions are defined by a thermal range of 0.05 to 0.6 cal/cm2s,
representing an air temperature range of 140 to 571 °F (300 °C). Under these conditions, protective
clothing may allow sufficient time to extinguish the fire or to fight the fire until the nominal air supply
is exhausted (usually less than 30 minutes).
■	The Emergency region describes conditions in a severe and unusual exposure, such as those caused
inside a “flashover” room or the firefighter being next to a flame front. In Emergency conditions, thethermal load exceeds 0.3 cal/cm2s and temperatures exceed 571 °F. In such conditions, the functionof firefighters’ clothing and equipment is simply to provide protection during the short time needed
for an escape without serious injury.

Abbott, N. J. and S. Schulman. “Protection from Fire: Nonflammable Fabrics and Coatings.” Journal of Coated Fabrics, Vol. 6, July
1976, pp. 48-64.
17 Utech, H.P. “High Temperatures vs. Fire Equipment.” International Fire Chief, Vol. 39, 1973, pp. 26-27.
16

■ Firefighter Autopsy Protocol■ 25 ■

I: Background ■Figure 6. classification of Fireground conditions

Burns occur as the consequence of heat transfer to the skin at a rate greater than the body’s ability to dissipate
that heat. The occurrence of a burn injury can be predicted by plotting the heat energy versus time, as shownin Figure 7. This relationship shows that burns occur very quickly for high levels of heat energy exposure,while exposures to lower heat energies require a greater amount of time to cause a burn injury. Thus, burninjury is a function of both the intensity of heat exposure and the length of the exposure.
Increasing amounts of stored heat energy in the skin cause progressively greater damage. The defined
degrees of burn injury distinguish the levels (depth) of skin damage and how permanent the damage
becomes. For example, third-degree burns, also referred to as full-thickness burns, involve damage to theentire skin thickness and are considered irreversible (complete healing is not possible). It is also importantto point out that burn injuries may occur under portions of protective clothing and equipment that show
no damage.

■ Firefighter Autopsy Protocol■ 26 ■

I: Background ■Figure 7. relationship of heat energy and time to Burn injury

III.7 Personal Protective Equipment
Detailed knowledge of the manner of death requires, among other things, an evaluation of theperformance of the firefighter’s personal protective equipment (PPE), which includes protective clothing
and breathing apparatus. There is voluminous anecdotal evidence that failure to use proper protective
equipment has been responsible for many firefighter injuries, illnesses, and deaths.
Typically, firefighter protective ensembles consist of several elements of clothing and equipment that areworn together to provide protection against fireground hazards:
■
■
■
■
■
■
■

SCBA;
protective coat and pants;
protective helmet;
protective hood;protective gloves;protective footwear; andPASS (may be integrated with SCBA)

■ 27 ■■ Firefighter Autopsy Protocol

I: Background ■An example protective ensemble for structural firefighting is shown in Figure 8. Additional PPE
information is provided in Appendix C. Other types of specialized ensembles are worn by firefighters fordifferent applications. These include specialized ensembles for emergency medical operations, hazardous
materials incidents, and technical rescue events.

Figure 8. typical structural Firefighting ensemble(courtesy of morning pride manufacturing)
Protective helmet
Facepiece SCBA

Protective coat
Harness straps of SCBA
(cylinder on back not shown)

Protective gloves

Protective pantsProtective footwear

In order to provide intended protection, the ensemble elements must be chosen to work together without
interference and must be properly sized and worn consistent with manufacturer instructions. Even whenthese instructions are followed, it still is possible to overwhelm the protective qualities of the firefighter
PPE when fireground conditions exceed the designed capabilities of the clothing and equipment. In
addition, the burden of insulative clothing under hot working conditions also creates stressors on thefirefighter’s body that can contribute to illness and death.
The use of SCBA has reduced significantly the number of firefighter injuries and deaths that are attributableto smoke inhalation. While thermal and respiratory injuries remain a concern in cases of firefighter
autopsies, the widespread use of SCBA has introduced new considerations into the evaluation of theseinjuries. For example, knowing that a firefighter’s death was the result of inhalation of combustion
products, when the firefighter was using an SCBA, would indicate the need to fully evaluate theperformance of the SCBA. This investigation can be conducted by the NIOSH, which is responsible for thecertification of this equipment. Reviews are particularly important to ascertain the correct functioning of
the equipment and the amount of service air remaining in the cylinder. Obtaining this information may

■ Firefighter Autopsy Protocol■ 28 ■

I: Background ■not always be possible when the SCBA is destroyed in the fire. Regardless, it is important to check theservice life of the SCBA as part of any investigation, particularly where there is a question of asphyxiation.
The actual service life provided by an SCBA is always significantly less than the rated service life, since
firefighters can exhaust the air supply through more rapid breathing due to physical activity and stress.
Some instances also may be able to compromise the positive pressure of the facepiece, permitting theinfiltration of outside contaminants.
Experts may need to be consulted to determine how a firefighter’s protective clothing and equipment
performed or failed to perform. NIOSH has several independent consultants who are available to assist in
the evaluation of PPE. Checks of PPE include the following reviews:
■
■
■
■
■
■

the identification on each item of PPE that was worn;
the identification of each personal item of clothing that is worn underneath the protective clothing;
the manufacturer and date of manufacturing of each PPE item;the standard to which the specific item of PPE complies;
any specific options or attributes of the clothing item; andthe condition of the item as found on the injured or deceased firefighter.

Specific guidelines for the examination of PPE items are provided in Appendix C.

III.8 Non-Line-of-Duty Deaths
Because of their repetitive exposure to toxic environments and carcinogens, many firefighters areconcerned that they are at a higher risk to die prematurely, particularly as their longevity on the job
increases. The causes of firefighter deaths that occur off-duty (or non-line-of-duty) sometimes can be
attributed to one exposure or to a series of exposures to toxins. There have been some major, welldocumented exposures of firefighters to certain known carcinogens. It has been suggested, for instance,that fires in occupancies manufacturing or storing chemicals in Elizabeth, New Jersey, and Fort Lauderdale,
Florida, are responsible for increased incidence of cancer among the firefighters who fought these blazes.
In one of those examples, as many as 29 cases of cancer, including 19 cancer deaths, have occurred among
the approximately 100 firefighters who fought a fire in 1968 at the Everglades Fertilizer Plant in Fort
Lauderdale, Florida. All but one of these cases was diagnosed after the firefighter had retired or resigned
from the fire department. This case has prompted the NIOSH to initiate an epidemiological study of
firefighters involved in the Everglades fire.
More recently, additional medical and industry reviews have found the incidence of firefighter cancers tobe elevated as compared to other occupations.
■ A study of Seattle firefighters shows excess mortality from diseases of a priori concern, such as lungcancer, nonmalignant respiratory disease, and cardiovascular disease.18■ An analysis of firefighter deaths in the Boston area indicated a 3-to-1 increase in firefighter cancers
when compared to the general population.19 Heyer, Nicholas, Noel S. Weiss, Paul Demers, and Linda Rosentock. “Cohort Mortality Study of Seattle Fire Fighters:
1945-1983.” American Journal of Industrial Medicine, Vol. 17, 1990, pp. 493-504.
19
Musk, A. William, John M. Peters, and David H. Wegman. “Lung Function in Fire Fighters, I: A Three Year Follow-Up of Active
Subjects.” American Journal of Public Health, Vol. 67(7), 1977, pp. 86-89.
18

■ Firefighter Autopsy Protocol■ 29 ■

I: Background ■■	In Los Angeles, cancer mortality among surviving firefighters is elevated for all lung and circulatory
system cancers.20■ A study of firefighter mortality as compared to police officers in three northwestern U.S. cities showedexcesses of brain tumors, and lymphatic and hematopoietic cancers.21■ A detailed mortality study in Toronto showed firefighters to have statistically significant excesses ofbrain, central nervous system, and other cancers.22
A more recent study has documented the risk of increased rates of multiple myeloma, non-Hodgkin
lymphoma, and testicular cancer for firefighters based on a review of 32 different studies related to firefighter
cancer risks.23
It can be very difficult to directly attribute a non-line-of-duty death to a line-of-duty exposure, especially
if the exposure occurred years before the death. Comprehensive autopsies of firefighters whose death
may have been caused by a line-of-duty exposure could help establish a better understanding of therelationship between exposures and premature deaths; however, this will require much better data be
obtained and maintained than is currently the norm.
Many fire departments have mandated physical requirements and medical examinations for firefighters.
Regular medical exams and physical testing can track a firefighter’s physical and medical status from hire
to retirement, and can serve as a baseline against which to compare, especially after an incident or series ofincidents where a firefighter may be concerned that an exposure has jeopardized his or her health.
Records of exposures to particular toxins should be kept by the fire department along with the medical
records. Such documentation would be valuable in determining whether an exposure led to medical
problems, or whether a non-line-of-duty death is related to firefighting or other emergency oroccupational activities.
The firefighter autopsy protocol is primarily intended to be applicable to line-of-duty deaths; however,
it would also be appropriate for non-line-of-duty deaths where an occupational factor is suspected to be
involved in the cause of death. For most firefighter deaths that are not duty-related or that involve former
firefighters, existing clinical autopsy procedures consistent with the individual’s medical history should
be appropriate. The USFA Firefighter Autopsy Protocol has been designed to uncover pertinent forensic
information consistent with the distinct occupational aspects of firefighting.

III.9 Firefighter Health
Several studies have looked at the frequency of premature death rates among active and retired firefighters.
Rubin has described the relationships between the hazards of fire suppression and the risk of prematurelewis, S .S ., h .R . Bierman, and M .R . faith . “Cancer Mortality Among los Angeles City fire fighters .” Published Report
Submitted to the los Angeles fire Department, Dec ., 1982 .
21Demers, Paul A ., nicholas J . heyer, and linda Rosenstock . “Mortality Among firefighters from three northwestern unitedStates Cities .” British Journal of Medicine, 1992, 49: 664-670 .
22l’Abbe, Kristan A . and george A . tomlinson . “fire fighters in Metropolitan toronto: Summary of the Mortality Study .” Industrial
Standards Panel, toronto, Ontario, Canada, 1994 .
23
leMasters, grace K . et al . “Cancer Risk Among firefighters: A Review and Meta-Analysis of 32 Studies .” Journal of Environmental
Medicine, vol . 48, no . 11, november 2006, pp . 1189-1202 .
20

■ Firefighter Autopsy Protocol■ 30 ■

I: Background ■death from heart disease or cancer as “Firefighter’s Disease.”24 He notes that relatively little research has
been conducted on firefighter mortality and morbidity or the medical treatment of firefighters.
Rubin proposes that a concern for firefighter health should begin with prevention. He suggests that diet,lack of exercise, and lifestyle may be as responsible for premature firefighter deaths as any job-related
exposure. The relationships of lifestyle, exercise, and diet with firefighter mortality appear to be more thanjust conjecture. Epidemiological studies have demonstrated that firefighters are much less likely than thegeneral population to die from natural causes at a given age, early in their careers, because they must be
healthier than the average person to pass the rigorous health and fitness standards in order to be hired
or approved for volunteer duty. The death rate for firefighters catches up with the rest of the populationby their retirement age, which suggests that the so-called “healthy worker effect” diminishes withtime, especially if the individuals do not take care of themselves. This takes into account the factor that
firefighters tend to retire at a younger age than the general population.
The USFA25 describes a number of resources that address the implementation of firefighter healthprograms. These include the IAFF/International Association of Fire Chiefs (IAFC) “Fire Service Joint Labor
Management Wellness-Fitness Initiative;” the USFA/National Volunteer Fire Council (NVFC) “Health andWellness Guide for the Volunteer Fire Service”; the NVFC “Heart-Healthy Firefighter Program”; the IAFF/
IAFC “Candidate Physical Ability Test” for recruits; and the 16 Life Safety Initiatives from the National
Fallen Firefighter Foundatin’s (NFFF’s) “Everyone Goes Home” program.

Rubin, D.L. “Firefighters’ Disease.,” Firehouse Magazine, Jan. 1992, pp. 40-43. U.S. Bureau of the Census. 1991. Statistical Abstract of
the United States, 111th ed. Washington, D.C.: U.S. Government Printing Office.
25
Fire in the United States: 1992-2001, Chapter 5, p. 153.
24

■■
IV. PUBLIC SAFETY OFFICER BENEFITS(PSOB) PROGRAM
IV.1 Summary of the PSOB Law26
The Public Safety Officers Benefits Act, (42 USC 3796, Public Law 94-430) became law on September
29, 1976. The legislation provided for a $50,000 death benefit for firefighters (paid and volunteer) andlaw enforcement officers who died in the line of duty (emergency or non-emergency) from a traumatic
injury. On December 15, 2003, the Act was amended (Hometown Heroes Act) to cover deaths from heart
attack and stroke occurring in the line of duty. The Act does not cover deaths resulting from occupational
illness or pulmonary disease unless a traumatic injury is a substantial factor to the death. On August 10,
2006, new regulations for the PSOB were issued that incorporated all prior amendments to the original
regulations and adds the regulations for the Hometown Heroes Act.
On November 11, 1988, the benefit was increased from $50,000 to $100,000 and made retroactive
to June 1, 1988. The dependency test for parent(s) was eliminated. Additionally, it provided that, on
October 1, 1988, and every year thereafter, the benefit would be increased to reflect any increase in the
consumer price index. On October 26, 2001, as part of the Patriot Act of 2001, the benefit was increased
to $250,000 and made retroactive to January 1, 2001.
The Act did exclude Federal firefighters; however on October 12, 1984, the Act was amended to correct
this exclusion. Likewise, on October 15, 1986; public-sector EMS personnel also were amended into thecoverage of the Act. On June 25, 2002, the Act was amended by the enactment of the Mychal Judge Police
and Fire Chaplains Safety Officers Benefit Act, which now allows coverage of fire chaplains under the Act
and authorizes all beneficiaries of fallen firefighters, not just parents, spouses; or children to receive theFederal compensation. The legislation, named after the FDNY Chaplain Father Judge, was proposed after
it was discovered that 10 public safety officers who gave their lives on Sept. 11 would not be eligible fordeath benefits because they did not have any surviving immediate family.
On August 10, 2006, new regulations for administration of all PSOB benefits were issued that incorporated
all prior amendments to the original regulations and added the provisions of the Hometown Heroes Act(see below). These new regulations address the PSOB Act and regulations in five parts:
1.	The first part of this document describes the structure and background of the PSOB Program andaspects of the history of its administration.

from Summary of the federal (u .S .) Benefits for Public Safety Officers PSOB and PSOeA Programs, iAff Division of
Occupational health Safety and Medicine, www.iaff.org

26■ 31 ■

■ Firefighter Autopsy Protocol■ 32 ■

I: Background ■2.	The second part covers the recent changes to the PSOB Act contained in Public Law 109–162, which
provided a number of clarifying and conforming changes to the PSOB Act. New definitions included
the term “member of a rescue squad or ambulance crew,” which is now defined as “an officiallyrecognized or designated public employee member of a rescue squad or ambulance crew.” It also
amended the PSOB Act to ensure that the pre-existing statutory limitation on payments to noncivilians
referred to the individual who was injured or killed, and not to any potential beneficiaries. Finally, thislegislation amended certain provisions of the PSOB Act regarding designation of beneficiaries when theofficer dies without a spouse or eligible children and removed the need for a 1-year waiting period toensure payment to the beneficiary of the officer’s “most recently executed life insurance policy.”
3.	The third part addresses the comments received by the Bureau of Justice Assistance (BJA) that relate
to the proposed provisions implementing the Hometown Heroes Act, and explains the changes being
made in the final rule.
4.	The fourth part is a specific discussion of the terms “line of duty” and “authorized commuting.”
5.	The last part addresses the remainder of the comments in a section-by-section analysis, indicatingwhere changes to provisions were made, or where the BJA determined no changes were necessary.

IV.2 Summary of the Heart/Stroke Amendment27
The Hometown Heroes Survivors Benefits Act of 2003 (HHA) amends the PSOB Act and was signed into
Law on December 15, 2003. If a public safety officer dies as a direct and proximate result of a heart attack
or stroke, that officer shall be presumed to have died as the direct and proximate result of a personal injury
sustained in the line of duty unless such presumption is not overcome by competent medical evidence tothe contrary.
The law requires that the officer, while on duty engaged in a situation, and such engagement involved
nonroutine stressful or strenuous physical law enforcement, fire suppression, rescue, hazardous material
response, emergency medical services (EMS), prison security, disaster relief, or other emergency response
activity; or participated in a training exercise, and such participation involved nonroutine stressful orstrenuous physical activity. Any claim for nonroutine stressful or strenuous physical activities will be
excluded if such actions are of a clerical, administrative, or nonmanual nature.
Further, the law requires that the officer must have died as a result of a heart attack or stroke suffered■ while engaging or participating in such activity as described above;■ while still on that duty after so engaging or participating in such an activity; or■ not later than 24 hours after so engaging or participating in such an activity.
The HHA provision only covers deaths occurring on or after December 15, 2003. The HHA is not
retroactive, and therefore it does not apply to deaths that occurred before the aforementioned date.

from Summary of the federal (u .S .) Benefits for Public Safety Officers PSOB and PSOeA Programs,iAff Division of
Occupational health Safety and Medicine, www.iaff.org

27

■ Firefighter Autopsy Protocol■ 33 ■

I: Background ■IV.3 Useful Web sites
The following Web sites provide useful information either directly or indirectly related to the PublicService Officer Benefits Program:
Department of Justice Public Service Officer Benefits

https://www.psob.gov/

National Fallen Firefighters Foundation

http://www.firehero.org/

U.S. Fire Administration (firefighter fatality page)

http://www.usfa.dhs.gov/fireservice/fatalities/index.shtm

National Institute for Occupational Safety and Health(Fire Fighter Fatality Investigation and Prevention Program)

http://www.cdc.gov/niosh/fire/

International Association of Fire Fighters(line-of-duty deaths)

http://www.iaff.org/HS/LODD/index.html

International Association of Fire Chiefs(Near Miss reporting system)

http://www.iafc.org/displaycommon.cfm?an=1&subarticlenbr=328#nearmiss

National Volunteer Fire Council (in the line of duty)

http://nvfc.org/index.php?id=657

■■
Selected Bibliography
Determination of Alcohol Levels During Autopsy (abstract provided where available)
Barillo DJ, Rush BF Jr, Goode R, Lin RL, Freda A, Anderson EJ Jr
Am Surg.1986 Dec;52(12):641-5.
Is ethanol the unknown toxin in smoke inhalation injury?
Of the 12,000 fire-related deaths occurring annually in the United States, it is estimated that 60 to 80
per cent are due to smoke inhalation. Plastic and synthetic materials which have been introduced inhome construction and furnishings produce a more toxic smoke when burned. Efforts to identify a“supertoxin” in this smoke have been unsuccessful to date. An alternative approach is to examine why
victims are unable to escape, and become exposed to smoke for lethal periods of time. The authors
examined the circumstances of death in 39 fire victims (27 adults, 12 children) over a 25-month
period. Detailed examination of the fire scene, autopsy studies, and toxicologic analysis were carriedout. Position of the victim, and escape efforts were noted. Carbon monoxide was elevated in all
victims, with “lethal” levels (= greater than 50%) in 21/39 victims. Cyanide was detected in 24/29
victims, but none had lethal (3 mg/L) levels present. Ethanol was detected in 21/26 adults (80%) and
0/12 children (0%). 18/26 adult victims had ethanol levels above the statutory level of intoxication(10 mg%). Victims found in bed (no escape attempt) had a mean blood ethanol level of 268 mg%,compared with a mean level of 88 mg% in those victims found near an exit (P = .006). Ethanol
intoxication significantly impairs the ability to escape from fire and smoke and is a contributory factor
in smoke-related mortality.
Bonnichsen R, Moller M, Maehly AC.
Zacchia.1970 Apr-Jun;6(2):219-25.
How reliable are post-mortem alcohol determinations?
Brown GA, Neylan D, Reynolds WJ, Smalldon KW.
Anal Chim Acta.1973 Sep;66(2):271-83.
The stability of ethanol in stored blood. I. Important variables and interpretation of results.
Buchsbaum RM, Adelson L, Sunshine I.
Cuyahoga County Coroner’s Office, Cleveland, OH 44106.
Forensic Sci Int.1989 Jun;41(3):237-43.
A comparison of post-mortem ethanol levels obtained from blood and subdural specimens.
Post-mortem subdural ethanol levels have been proposed as a useful test in certain forensic cases
involving head trauma, particularly when the time interval from injury to death may have caused a■ 34 ■

■ Firefighter Autopsy Protocol■ 35 ■

I: Background ■lowering of the blood ethanol concentration to insignificant or undetectable levels. This study of 75
autopsied persons from whom both blood and subdural ethanol levels were obtained, shows theusefulness of the subdural ethanol level, especially where there is a prolonged or unknown posttraumatic time interval. Use of such a test is recommended in these situations.
Budd RD.
J Chromatogr.1982 Dec 3;252:315-8.
Ethanol levels in postmortem body fluids.
Chao TC, Lo DS.
Institute of Science and Forensic Medicine, Singapore.
Am J Forensic Med Pathol.1993 Dec;14(4):303-8.
Relationship between postmortem blood and vitreous humor ethanol levels.
	The relationship between the blood to vitreous humor ethanol ratios (B/V) and the corresponding
urine to blood ethanol ratios (U/B) of 200 postmortem cases were found to be bimodal in nature.
Using the U/B ratio of 1.20 as a demarcation below which early absorption prevails, the resultsin the early absorption phase gave an average B/V ratio of 1.29, a range from 0.71 to 3.71, and a
relatively large standard deviation of 0.57, whereas the results in the other phases (late absorption
and elimination) gave an average B/V ratio of 0.89, a spread from 0.32 to 1.28, and a standard
deviation of 0.19. It would appear that the blood ethanol levels can be estimated using B = 1.29 V forearly absorption phase cases and B = 0.89 V for cases in subsequent phases. The former relationshipwould underestimate the blood ethanol levels in cases of very early absorption phase and the later
overestimate the levels of late elimination cases. The ethanol distribution results in cases of fatalroad traffic accidents and suicides by falling, in which 69% of the deceased sustained some form ofhead injury, were found to be similar to those of other postmortem cases. The observations reflectthat vitreous humor, being reasonably protected, is likely to survive certain traumatic deaths and beavailable for postmortem ethanol investigation. The U/B ethanol ratios recorded in this work had an
average of 1.29, a range from 0.19 to 5.19, and a standard deviation of 0.48.
Coe JI, Sherman RE.
J Forensic Sci.1970 Apr;15(2):185-90.
Comparative study of postmortem vitreous humor and blood alcohol.
de Lima IV, Midio AF.
University of Sao Paulo, Medicolegal Institute, College of Pharmaceutical Sciences, Brazil.
Forensic Sci Int.1999 Dec 20;106(3):157-62.
Origin of blood ethanol in decomposed bodies.
Problems related to blood contamination by other postmortem fluids in decomposed bodies (DB)make the interpretation of medicolegal blood alcohol levels (B EtOH) a very difficult task. So theaim of this paper is to show the utilization of vitreous humor (VH) as the biological fluid for anunequivocal determination of ethanol origin in DB for forensic purposes. Alcohol was determined inVH, blood (chest fluid-CF) and urine (Ur) collected from 27 DB in different states of putrefaction. A
simple head-space gas-chromatographic method was used. In fifteen cases alcohol was found to be ofendogenous production due to its absence in VH. In the twelve remainders, alcohol was detected in■ Firefighter Autopsy Protocol■ 36 ■

I: Background ■VH and CF in an atypical distribution. Examining the reliable scene and historical information together
with the analytical data, ethanol origin in these cases was classified: endogenous production (3 cases),
ingested (2 cases), both (2 cases), contaminated plus endogenous production (3 cases) and unable todetermine (2 cases). According to the results obtained it was possible to conclude that alcohol analysis
in VH is fundamental for determining the origin of ethanol detected in CF of DB.
Hardin GG.
Forensic Science Laboratory, Minnesota Department of Public Safety Bureau of Criminal Apprehension, St.
Paul 55104, USA.
J Forensic Sci.2002 Mar;47(2):402-3.
Comment in:
J Forensic Sci. 2002 Nov;47(6):1405; author reply 1405.
Postmortem blood and vitreous humor ethanol concentrations in a victim of a fatal motor vehicle
crash.
A 20-year-old male was found on the passenger side of a small car after a collision with a semi-trailer
truck. Postmortem blood, collected from the chest cavity, and vitreous humor samples were collectedfollowing harvesting of the heart and bones. Gas chromatographic analysis revealed a blood ethanol
concentration of 0.32 g/dL and a vitreous humor ethanol concentration of 0.09 g/dL. The stomach
was intact and full of fluid and food, but its contents were not collected. Possible explanations forthe large difference between the two results include diffusion of ethanol from the stomach into thechest cavity, contamination of the blood sample prior to collection, and ingestion of a large quantityof ethanol shortly before death. This case demonstrates the importance of proper quality assurance
procedures in collecting postmortem specimens and of collecting a vitreous humor sample for ethanol
analysis in postmortem toxicology cases.
Heise HA.
Rocky Mt Med J.1968 Jun;65(6):39-44.
Alcohol and sudden death--importance of testing several body fluids.
Ito A, Moriya F, Ishizu H.
Department of Legal Medicine, Okayama University Medical School, Japan.
Acta Med Okayama.1998 Feb;52(1):1-8.
Estimating the time between drinking and death from tissue distribution patterns of ethanol.
	To establish a method for estimating the time between the last consumption of alcohol and death, we
examined the ethanol levels in body fluids and tissues of rats that had been orally administered 1 g/
kg ethanol. We observed the following relationships between ethanol levels in the cardiac blood (bloodin the heart itself), vitreous humor, and urine: cardiac blood > vitreous humor > urine at 10 min(early absorption stage); vitreous humor > cardiac blood > urine from 20 to 50 min (late absorption
stage); vitreous humor > urine > cardiac blood from 60 to 120 min (distribution stage); and urine> vitreous humor > cardiac blood at 180 min (excretion stage). It was also observed that, in cases ofdeath immediately following drinking, ethanol levels in the stomach contents are very high, and thefollowing ratios of ethanol levels were observed: skeletal muscle to cardiac blood--less than 1; liver tocardiac blood--around 1. buccal mucosa to cardiac blood-greater than 1. These ratios at equilibrium
after drinking were around 1, lower than 1 and around 1, respectively. We also measured alcohol■ Firefighter Autopsy Protocol■ 37 ■

I: Background ■levels in the cardiac blood, urine, vitreous humor and stomach contents of nine cadavers who had
consumed alcohol prior to death. The relationships between the time since last consumption of alcoholand relative ethanol levels in these specimens were in good accordance with the results of the animal
experiments.
A W Jones and P Holmgren
J. Clin. Pathol., Sep 2001; 54: 699 - 702.
Uncertainty in estimating blood ethanol concentrations by analysis of vitreous humour
Aims—To determine the concentrations of ethanol in femoral venous blood (FVB) and vitreous
humour (VH) obtained during forensic necropsies. The ratios of ethanol concentrations in VH and
FVB, the reference interval, and the associated confidence limits were calculated to provide information
about the uncertainty in estimating FVB ethanol concentrations indirectly from that measured in VH.
Methods—Ethanol concentrations were determined in specimens of FVB and VH obtained from 706
forensic necropsies. The specimens were analysed in duplicate by headspace gas chromatography(HS-GC), with a precision (coefficient of variation) of 1.5% at a mean ethanol concentration of 500
mg/litre. The limit of detection of ethanol in body fluids by HS-GC in routine casework was 100 mg/
litre. Results—In 34 instances, ethanol was present in VH at a mean concentration of 154 mg/litre,
whereas the FVB ethanol concentration was reported as negative (< 100 mg/litre). These cases were
excluded from the statistical analysis. The concentration of ethanol in FVB was higher than in VH in 93
instances, with a mean difference of 160 mg/litre (range 0 to 900). The mean concentration of ethanol
in FVB (n = 672) was 1340 mg/litre (SD, 990) compared with 1580 mg/litre (SD, 1190) in VH. The
arithmetic mean VH/FVB ratio of ethanol was 1.19 (SD, 0.285) and the 95% range was 0.63 to 1.75.
The mean and SD of the differences (log VH - log FVB) was 0.063 (SD, 0.109), which gives 95% limitsof agreement (LOA) from -0.149 to 0.276. Transforming back to the original scale of measurement
gives a geometric mean VH/FVB ratio of 1.16 and 95% LOA from 0.71 to 1.89. These parametricestimates are in good agreement, with a median VH/FVB ratio of 1.18 and 2.5th and 97.5th centilesof 0.63 and 1.92. Conclusions—The ethanol distribution ratios (VH/FVB) show wide variation and thiscalls for caution when results of analysing VH at necropsy are used to estimate the concentration in
FVB. Dividing the ethanol concentration in VH by 2.0 would provide a very conservative estimate of theethanol content in FVB, being less than the true value, with a high degree of confidence.
Leahy MS, Farber ER, Meadows TR.
J Forensic Sci.1968 Oct;13(4):498-502.
Quantitation of ethyl alcohol in the postmortem vitreous humor.
Kaye S.
Am J Clin Pathol.1980 Nov;74(5):743-6.
The collection and handling of the blood alcohol specimen.
Text Available @ http://rcm-medicine.upr.clu.edu/publications/sidney_kaye/the-collection-and-handling-of-blood.htm
Proper collection, handling, and storage of the blood alcohol specimen are essential in medicolegal
cases involving the question of sobriety. A standard operating procedure is necessary to ensure
maximum reliability. Comments are offered on the advantages of using blood specimens in preference
to urine or tissue specimens. The use of a conversion factor to obtain a calculated “presumed bloodlevel” can be dangerous. Cautions and suggestions are offered regarding how and from where■ Firefighter Autopsy Protocol■ 38 ■

I: Background ■the blood should be obtained from a living person and during an autopsy. There are certain time
limitations for storage of these blood-alcohol specimens. Each laboratory must establish its own limits
for reliable storage, given the conditions in that laboratory. Unexpected and confusing results can leadto an erroneous interpretation if history, circumstances, type of injury, and survival time are not all
carefully considered. Several possibilities for error in judgment are discussed.
Kaye S, Cardona E.
Am J Clin Pathol.1969 Nov;52(5):577-84.
Errors of converting a urine alcohol value into a blood alcohol level.
Text Available @ http://rcm-medicine.upr.clu.edu/publications/sidney_kaye/Error-of-Converting.htm
A blood alcohol determination is one of the more frequently requested analyses in a toxicology or
forensic chemical laboratory. There are many reliable methods for determining the concentration of
alcohol in the blood. It is the purpose of this communication to show that it is, however, not reliable
to determine the concentration of alcohol in the urine and report as a blood alcohol level. This is
not reliable even using the best of average factors of equivalence. These factors used are an average ofmany determinations, some of which show very wide ranges from the mean. Random specimensof urine and blood were collected from 148 cases examined for alcohol content. An average urineblood alcohol ratio of 1.28: 1, with a range of 0.21 to 2.66, was obtained. The blood alcohol level was
calculated in each case from the corresponding urine alcohol determination by means of the average
ratio obtained from our data. In 32 (21.5%) of the cases, the blood figures calculated from the urine
value exceeded the actual level determined in blood. In 51 cases (34.5%) the calculated blood alcohol
concentration was below the determined value. In 65 cases (44%) the values corresponded. This
procedure was repeated using the conversion factor (1.25: 1) employed in some communities. In thisinstance, the calculated blood alcohol concentration exceeded the actual value in 39 cases (26.5%). In
49 cases (33%) the calculated value was below the observed level, and in 60 cases (40.5%) the values
corresponded. In view of the wide ranges in the individual urine-blood alcohol ratios found in mostpublished reports, we find it hard to understand how so many investigators can conclude that it issatisfactory procedure to calculate the alcoholic content of blood, to the second decimal place, from aselected specimen of urine. Our data clearly confirm what other investigators2, 7 – 10 have claimed: thatthe relationship (ratio-range) between the concentrations of alcohol in urine and in blood may vary
widely. This renders it unreliable to use an average conversion factor in medicolegal cases.
Kuroda N, Williams K, Pounder DJ.
Department of Legal Medicine, Keio University, Tokyo, Japan.
Am J Forensic Med Pathol.1995 Sep;16(3):219-22.
Estimating blood alcohol from urinary alcohol at autopsy.
	Urine alcohol concentration (UAC) and blood alcohol concentration (BAC) measured by gas
chromatography were available from 435 medicolegal autopsies. Simple linear regression with BAC
as outcome variable and UAC as predictor variable (range, 3-587 mg%) gave the regression equation
BAC = -5.6 + 0.811UAC with 95% prediction interval +/- 0.026 square root of [9465804 +(UAC-213.3)2] and 99% prediction interval +/- 0.034 square root of [9465804 + (UAC-213.3)2].
The standard error of the slope was 0.013 and the 95% confidence interval for the slope 0.785-0.837.
In practice, a BAC of 80 mg% is predicted with 95% certainty by a UAC of 204 mg% and similarly

■ Firefighter Autopsy Protocol■ 39 ■

I: Background ■a BAC of 150% by a UAC of 291 mg%. The prediction interval is too wide to be helpful in theassessment of an individual case fatality. The UAC is useful in corroborating but not in predicting BAC.
Mackey-Bojack S, Kloss J, Apple F.
Hennepin County Medical Center, Clinical Laboratories, Minneapolis, Minnesota 55415, USA.
J Anal Toxicol. 2000 Jan-Feb;24(1):59-65
Cocaine, cocaine metabolite, and ethanol concentrations in postmortem blood and vitreous humor.
	The use of postmortem cocaine and metabolite concentrations is a complex subject. This study was
undertaken to determine (1) the usefulness of vitreous humor as a specimen, compared with blood,to quantitate cocaine and cocaine metabolites; (2) whether there is a preferential site of disposition
for cocaethylene between vitreous humor and blood; and (3) if the presence of cocaethylene
influences the concentration of benzoylecgonine in postmortem specimens. Cocaine, benzoylecgonine,and cocaethylene were quantitated in blood and vitreous humor by gas chromatography-mass
spectrometry, and ethanol was quantitated by gas chromatography in 62 medical examiner cases.
No differences were found between mean concentrations of vitreous cocaine 0.613 mg/L (standard
deviation [SD] 0.994 mg/L), cocaethylene 0.027 mg/L (SD 0.59 mg/L), and ethanol 0.092 g/dL (SD
0.13 g/dL) compared to blood cocaine 0.489 mg/L (SD 1.204 mg/L), cocaethylene 0.022 mg/L (SD
0.055 mg/L), and ethanol 0.058 g/dL (SD 0.91 g/dL), respectively. However, a statistical difference
was found between mean benzoylecgonine concentrations in vitreous 0.989 mg/L (SD 1.597 mg/L)
and blood 1.941 mg/L (SD 2.912 mg/L) (p = 0.0004). Regression analysis demonstrated that linear
relationships were present between concentrations of vitreous and blood cocaine (r = 0.854) andbenzoylecgonine (r = 0.763). However, the correlation coefficients were lower for cocaethylene(r = 0.433) and ethanol (r = 0.343). There were variations between the concentrations of cocaine
and metabolites both in terms of magnitude and also direction of change. Mean concentrations ofbenzoylecgonine in blood and vitreous were higher in cases where ethanol was absent, 2.593 mg/L
(SD 3.195 mg/L) and 1.431 mg/L (SD 2.021 mg/L), compared to when ethanol was present,
1.199 mg/L (SD 2.396 mg/L) and 0.469 mg/L (SD 0.553 mg/L). This study demonstrates that
vitreous humor may be used to quantitate cocaine and cocaine metabolites; however, because theconcentrations of cocaethylene in vitreous humor and blood were not well correlated, vitreous humor
may not be a reliable specimen for measuring cocaine and cocaine metabolite concentrations.
Marks P.
Med Leg J.1996;64 ( Pt 4):186-93.
Comment in:
Med Leg J. 1997;65 ( Pt 3):151-2.
Blood alcohol level: the law and the medicine.
Marraccini JV, Carroll T, Grant S, Halleran S, Benz JA.
Office of the Medical Examiner, Palm Beach County, FL.
J Forensic Sci.1990 Nov;35(6):1360-6.
Differences between multisite postmortem ethanol concentrations as related to agonal events.
	In a study of postmortem ethanol concentrations, blood was withdrawn from the right atrium,
ascending aorta, and inferior vena cava. These samples, vitreous humor, and gastric fluid were analyzed
in 307 autopsies, where a minimum blood ethanol concentration of 0.05% weight/volume (w/v)
was present. Premortem, agonal, and postmortem events were reviewed in an attempt to account for■ Firefighter Autopsy Protocol■ 40 ■

I: Background ■differences in blood ethanol concentrations between sites. The agonal aspiration of vomitus having atleast 0.80% w/v ethanol appears to be associated with an increase in aortic ethanol concentrations. We
conclude that valid interpretation of postmortem ethanol concentrations must take into consideration
the possible entry of ethanol into the pulmonary venous circulation via the respiratory system.
McNeil AR, Gardner A, Stables S.
Department of Molecular Medicine, University of Aukland, New Zealand.
Alanmcn@ahsl.co.nz
Clin Chem.1999 Jan;45(1):135-6.
Simple method for improving the precision of electrolyte measurements in vitreous humor.
Text Available @ http://www.clinchem.org/cgi/content/full/45/1/135
Penttila A, Karhunen PJ, Pikkarainen J.
Department of Forensic Medicine, University of Helsinki, Finland.
Forensic Sci Int.1990 Jan;44(1):43-8.
Alcohol screening with the Alcoscan test strip in forensic praxis.
	The Alcoscan test strip was applied as an assay for the screening of alcohol in vitreous humor andurine samples in autopsy cases and in saliva from drunken drivers. The method gives instant andreliable semi-quantitative information on the presence of alcohol and is valuable when considering thenecessity of chemical sampling especially during autopsy.
Pleuckhahn VD, Ballard B.
Forensic Sci.1967 Oct;12(4):463-70.
Diffusion of stomach alcohol and heart blood alcohol concentration at autopsy.
Pounder DJ, Kuroda N.
Department of Forensic Medicine, University of Dundee, Scotland.
Forensic Sci Int.1994 Mar 25;65(2):73-80.
Comment in:
Forensic Sci Int. 1995 May 22;73(2):155; author reply 159-60.
Forensic Sci Int. 1995 May 22;73(2):157-8; author reply 159-60.
Vitreous alcohol is of limited value in predicting blood alcohol.
	Vitreous humour alcohol concentration (VHAC) and blood alcohol concentration (BAC) measured bygas chromatography were available from 345 medico-legal autopsies. Simple linear regression with
BAC as outcome variable and VHAC as predictor variable (range 1-705 mg%) gave the regression
equation BAC = 3.03 + 0.852 VHAC with 95% prediction interval +/- 0.019 square root of [7157272+ (VHAC - 189.7)2] and 99% prediction interval +/- 0.025 square root of [7157272 + (VHAC- 189.7)2]. The residual standard deviation of VHAC was 26 mg%, the standard error of the slope
0.0098 and the 95% confidence interval for the slope 0.833-0.871. In practice a BAC of 80 mg% ispredicted with 95% certainty by a VHAC of 150 mg% and similarly a BAC of 150 mg% by a VHAC
of 232 mg%. The prediction interval is too wide to be of real practical use. Previous authors haveprovided various formulae, including a simple conversion factor, to predict BAC from VHAC without
taking into account the uncertainty of the prediction for an individual subject. A re-analysis of theraw data from previous publications gave in most instances regression equations significantly different
from the authors’ own.

■ Firefighter Autopsy Protocol■ 41 ■

I: Background ■Riggs JE, Schochet SS Jr, Frost JL.
Department of Neurology, West Virginia University School of Medicine,
Morgantown, USA.
Mil Med.1998 Oct;163(10):722-4.
Ethanol level differential between postmortem blood and subdural hematoma.
Alcohol use is a major risk factor for accidental injury and death. However,when death occurs several
hours after injury, ethanol in the blood may be absent or low. Ethanol in sequestered hematomas has
been used to retrospectively implicate alcohol as a contributing factor at the time of injury. A 69-yearold man died from a large acute subdural hematoma. He had been seen in a hospital emergency
department 8 to 12 hours before his death for treatment of two lacerations (one on the head) that
occurred during a fall. Postmortem blood ethanol was 0.07%, and subdural hematoma ethanol was
0.04%. This ethanol level differential between the postmortem blood and the subdural hematoma
indicates that this man had consumed alcohol after being released from the hospital.
Semenov VA, Shaev AI.
Sud Med Ekspert.1967 Jan-Mar;10(1):8-10.
[On the possibility of photometric determination of alcohol in the blood and urine of cadavers withthe use of photoelectrocolorimetry][Article in Russian]Shepherd RT.
Med Leg J.1997;65 ( Pt 3):105-6.
Postmortem toxicology.
Sylvester PA, Wong NA, Warren BF, Ranson DL.
University Department of Surgery, University of Bristol, Bristol Royal
Infirmary, UK.
J Clin Pathol.1998 Mar;51(3):250-2.
Unacceptably high site variability in postmortem blood alcohol analysis.
Blood alcohol concentration is a frequently requested test in forensic pathology. The variability of thisvalue was studied by measuring the blood alcohol concentration from six sites in nine subjects at
necropsy in whom alcohol was the implicated cause of death. There were small consistent differencesin the blood alcohol concentrations between the sites in the nine subjects (p < 0.04). Calculation of
the mean blood:vitreous humour alcohol concentration ratio (B:V ratio) showed that vitreous humour
alcohol concentration most closely reflected the concentration at the femoral vein (B:V ratio = 0.94, r= 0.98), which is considered the optimal site for blood alcohol measurement. The correlation of left
heart blood with femoral blood was lower compared with the other sites. There is a potential for an
unacceptably large variation in the postmortem measurement of blood alcohol within each subject.
Trojanowska M.
Acta Pol Pharm.1967;24(3):331-4.
[The formation of endogenous ethanol in the blood and urine of cadavers][Article in Polish]■ Firefighter Autopsy Protocol■ 42 ■

I: Background ■Van den Oever R.
Arch Belg Med Soc.1977 Mar;35(3):181-91.
[Postmortem alcohol concentration in blood and vitreous humor][Article in Dutch]
Winek CL, Esposito FM.
Leg Med.1985;:34-61.
Blood alcohol concentrations: factors affecting predictions.
As a result of extensive alcohol research conducted on both humans and animals, it is possible topredict a BAC, given pertinent data. In addition, it is possible to estimate from a given BAC the quantityof alcohol consumed. Caution must be used in these predictions, for certain factors will affect the
final estimation. Absorption of alcohol is influenced by gastrointestinal contents and motility, andalso the composition and quantity of the alcoholic beverage. The vascularity of tissues influences the
distribution of alcohol, and their water content will determine the amount of alcohol present after
equilibrium. Elimination of alcohol begins immediately after absorption. The elimination rate varies
for individuals but falls between .015 percent to .020 percent per hour, with an average of .018
percent per hour. In addition to these factors, a BAC will depend on the subject’s weight, percentage
of alcohol in the beverage, and the rate of drinking. The principal effect of alcohol in the body is on
the central nervous system. Its depressant effect consists of impairment to sensory, motor and learned
functions. When combined with some other drugs, a more intoxicated state occurs. Although tolerance
to alcohol at low blood concentrations is possible, the tolerance most noted is a learned tolerance
among chronic drinkers. Contamination of antemortem blood samples collected for alcohol analysis
is minimal when swabbing with an ethanolic antiseptic is performed with routine clinical technique;sloppy swabbing has been shown to increase the BAC determination significantly. The alcoholic contentof blood used for transfusion does not contribute significantly to the BAC of the recipient, sinceextensive dilution occurs; nor does the alcohol present in injectable medication contribute significantly.
Although many factors may alter the concentration of alcohol present in autopsy specimens,
postmortem synthesis of alcohol receives the most attention. The microorganisms that cause
postmortem ethanol production can be inhibited by adding a preservative to the samples and storingthem under refrigeration. Should putrefaction be present, it is recommended that, in addition toblood, several different specimens be collected and analyzed for the presence of alcohol. Antemortem
blood samples containing ethanol, collected using sterile tubes and techniques, may be analyzed up to
14 days later with reasonable certainty that the ethanol level reflects that which was present at the timeof collection.
Winek CL, Murphy KL, Winek TA.
Forensic Sci Int.1984 Aug;25(4):277-81.
The unreliability of using a urine ethanol concentration to predict a blood ethanol concentration.
Of approximately 5,000 forensic cases with a positive ethanol result, over 1,000 were available inwhich both blood and urine were present for comparison of ethanol content. Data were examined for
calculation of the urine to blood ethanol concentration ratio, with the intent of evaluating the validityof predicting a blood ethanol level given a urine ethanol level. The overall urine to blood ethanol
concentration ratio was 1.57:1 with a range of 0.7 to 21.0:1. The extremely wide range of values
implies that a large degree of error would be introduced if a mean ratio was used when predicting a
blood ethanol level from a urine ethanol level.

■ Firefighter Autopsy Protocol■ 43 ■

I: Background ■Additional References
1.	Jones AW, Pounder DJ. Measuring blood alcohol concentration for clinical and forensic purposes. In:
Karch S, ed. Handbook of drug abuse. Boca Raton, Florida: CRC Press, 1997.
2.	Garriott JC. Analysis of alcohol in postmortem specimens. In: Garriott JC, ed. Medicolegal aspects of alcohol
determination in biological specimens. Littleton, Mass: PSG Publishing, 1988.
3.	Corry JE. Possible sources of ethanol ante- and post-mortem: its relationship to the biochemistry andmicrobiology of decomposition. J Appl Bacteriol 1978;44:1-56.
4.	Nanikawa R, Moriya F, Hashimoto Y. Experimental studies on the mechanism of ethanol formation incorpses. Z Rechtsmed 1988;101:21-6.
	Various in vitro experiments were performed for the purpose of clarifying the mechanism of
ethanol production in corpses. Whereas a negligible quantity of ethanol was produced in the
blood alone, which was left at room temperature, the quantity of ethanol was slightly increased byaddition of glucose to the blood. When saprogens were further added, the quantity was markedly
increased. Various materials were added to blood-liver homogenates as specimens, and the
mixtures were stored in an incubator at 37 degrees C. As a result of the addition of an antibiotic to
the mixture every day, there was hardly any production of ethanol. When alcohol dehydrogenase(ADH) and reduced nicotinamide adenine dinucleotide (NADH) were added, ethanol production
was slightly increased. When acetaldehyde was added first, ethanol production was inhibited thenext day, but on and after day 2, the quantity of ethanol was more than that in the control material.
When pyruvic acid was added first, the results were similar to the above. Pyrazole, cyanamide,
and disulfiram completely inhibited the production of ethanol. Ethanol production in corpses isbelieved to take place through a pathway opposite to that of ethanol metabolism in the living body,under the influence of ADH, ALDH, etc., in saprogens using carbohydrates as substrates.
5.	Zumwalt RE, Bost RO, Sunshine I. Evaluation of ethanol concentrations in decomposed bodies. J Forensic
Sci 1982;27:549-54.
6.	Canfield DV, Kupiec T, Huffine E. Postmortem alcohol production in fatal aircraft accidents. J Forens Sci
1993;38:914-7.
7.	Pounder DJ, Kuroda N. Vitreous alcohol is of limited value in predicting blood alcohol. Forens Sci Int
1994;65:73-80.
8.	Kuroda N, Williams K, Pounder DJ. Estimating blood alcohol from urinary alcohol at autopsy. Am J For
Med Path 1995;16:219-22.
9.	Harper DR. A comparative study of the microbiological contamination of postmortem blood andvitreous humour samples taken for ethanol determination. Forens Sci Int 1989;43:37-44.
10.	Levine B, Smith ML, Smialek JE, Caplan YH. Interpretation of low postmortem concentrations of
ethanol. J Forens Sci 1993;38:663-7.
11.	Mayes R, Levine B, Smith ML, Wagner GN, Froede R. Toxicological findings in the USS Iowa disaster. J
Forens Sci 1992;37:1352-7.
12.	Marraccini JV, Carroll T, Grant S, Halleran S, Benz JA. Differences between multisite postmortem
ethanol concentrations as related to agonal events. J Forens Sci 1990;35:1360-6.
13.	Pounder DJ, Smith DRW. Postmortem diffusion of alcohol from the stomach. Am J Forens Med Path
1995;16:89-96.

■ Firefighter Autopsy Protocol■ 44 ■

I: Background ■14.	Briglia EJ, Bidanset JH, Dal Cortivo LA. The distribution of ethanol in postmortem blood specimens. J
Forens Sci 1992;37:991-8.
15.	Knight B. Forensic pathology. London: Edward Arnold, 1991:493-4.
16.	Cox DE, Sadler DW, Pounder DJ. Alcohol estimation at necropsy. J Clin Pathol 1997;50:197-201.
AIMS: To gather data on blood alcohol concentrations in a forensic necropsy population and toanalyse the information on trends that may predict where alcohol testing is going to prove costeffective. METHODS: Alcohol assays were performed on blood, urine, and vitreous samples in
1620 consecutive medicolegal necropsy examinations. RESULTS: Alcohol was detected in only
7% of natural deaths from all causes and in four of 40 deaths categorised as unknown/obscure.
Alcohol concentrations > or = 350 mg/100 ml were found in nine drug/alcohol abuse deaths(range 362-506 mg/100 ml), five accidental deaths (356-504 mg/100 ml), and one homicide
victim (400 mg/100 ml). Those categorised as alcohol abusers were represented in all but one
category of death (unknown/obscure deaths in males), showing that many true alcoholics diewith their alcoholism rather than of it; 39% of males and 34% of females with histories of alcoholabuse had alcohol present in their blood at necropsy at concentrations > or = 50 mg/100 ml,
v only 9% (male) and 6% (female) without such history. CONCLUSIONS: The study highlights
the problems of elderly and “hidden” alcoholics and illustrates cases where routine assays would
provide additional significant information. Routine alcohol testing is useful in all cases of suspected
unnatural death but universal testing of forensic necropsies is not cost-effective.
Website Information
http://www.coheadquarters.com/coFire/cofire4.htm

Death from CO in Fire and Non-Fire Situations: Role of Alcohol (Ethanol, Ethyl Alcohol, ETOH) in Deathfrom CO
http://www.vv.se/traf_sak/t2000/POSTER7.pdf“Blood alcohol concentrations in an autopsy material in practice of the Institute of Forensic Research in
1990-1999”
Gubala, W.; Piekoszewski, W. (Poland)
http://bmj.bmjjournals.com/cgi/content/full/316/7125/87

BMJ 1998;316:87 (10 January)“Dead sober or dead drunk?May be hard to determine”

Carbon Monoxide Determination During Autopsy (abstracts provided where available)
Barillo DJ, Rush BF Jr, Goode R, Lin RL, Freda A, Anderson EJ Jr.
Am Surg.1986 Dec;52(12):641-5.
Is ethanol the unknown toxin in smoke inhalation injury?
Of the 12,000 fire-related deaths occurring annually in the United States, it is estimated that 60 to 80
per cent are due to smoke inhalation. Plastic and synthetic materials which have been introduced inhome construction and furnishings produce a more toxic smoke when burned. Efforts to identify a“supertoxin” in this smoke have been unsuccessful to date. An alternative approach is to examine why
victims are unable to escape, and become exposed to smoke for lethal periods of time. The authors

■ Firefighter Autopsy Protocol■ 45 ■

I: Background ■examined the circumstances of death in 39 fire victims (27 adults, 12 children) over a 25-month
period. Detailed examination of the fire scene, autopsy studies, and toxicologic analysis were carriedout. Position of the victim, and escape efforts were noted. Carbon monoxide was elevated in all
victims, with “lethal” levels (=greater than 50%) in 21/39 victims. Cyanide was detected in 24/29
victims, but none had lethal (3 mg/L) levels present. Ethanol was detected in 21/26 adults (80%) and
0/12 children (0%). 18/26 adult victims had ethanol levels above the statutory level of intoxication(10 mg%). Victims found in bed (no escape attempt) had a mean blood ethanol level of 268 mg%,compared with a mean level of 88 mg% in those victims found near an exit (P = .006). Ethanol
intoxication significantly impairs the ability to escape from fire and smoke and is a contributory factor
in smoke-related mortality.
Blackmore DJ.
Analyst.1970 May;95(130):439-58.
The determination of carbon monoxide in blood and tissue.
Chen KC, Lee EW, McGrath JJ.
J Appl Toxicol.1984 Jun;4(3):145-9.
Effect of intermittent carbon monoxide inhalation on erythropoiesis and organ weights in rats.
Sprague-Dawley rats were exposed to 450 ppm carbon monoxide (CO) for 6 h per day, 5 days per
week for 33 days. The effect of CO on reticulocyte count, hematocrit, hemoglobin concentration,body weight and selected organ weights was measured. Exposure to CO caused a three-fold increasein the youngest reticulocyte population, concomitant with an increase in the total reticulocyte count.
Despite continued CO exposure, reticulocyte number and distribution returned to normal by day
9, suggesting that reticulocyte response of the organism to CO had changed. Both hematocrit andhemoglobin concentrations began to increase 16 days after CO exposure and remained at the increased
level for the duration of the exposure period. There were no changes in kidney, liver and adrenal
weights throughout the course of study. However, spleen weight was increased after 5 days of CO
exposure. Left and right ventricular organ weight ratios increased equally at the same time during thestudy. These results indicate that the increase in the young reticulocyte population and the subsequent
increase in total reticulocyte count are the earliest erythropoietic responses to intermittent CO
exposure and that CO-induced polycythemia is associated with cardiac hypertrophy in rats.
Christensen AM, Icove DJ.
U.S. Tennessee Valley Authority Police, 400 W. Summit Hill Dr., WT-3D,
Knoxville, TN, USA
J Forensic Sci.2004 Jan;49(1):104-7.
The application of NIST’s Fire Dynamics Simulator to the investigation of carbon monoxide exposurein the deaths of three Pittsburgh fire fighters.
A case is reported in which computer fire modeling was used to reevaluate a fire that killed three firefighters. NIST’s Fire Dynamics Simulator (FDS) was employed to model the fire in order to estimate theconcentration of carbon monoxide present in the dwelling, which was the immediate cause of deathof two of the fire fighters, who appear to have removed their face pieces in order to share available air.
This estimate, along with an assumed respiration volume and known blood carboxyhemoglobin, wasplugged into a standard equation to estimate the time of exposure. The model indicated that 27 min
into the fire, the carbon monoxide concentration had already reached approximately 3600 ppm. At this

■ Firefighter Autopsy Protocol■ 46 ■

I: Background ■concentration, and a respiration of 70 L/min, an estimated 3 to 8 min of exposure would have beenrequired to accumulate the concentrations of carboxyhemoglobin (49, 44, and 10%) measured on thefire fighters at autopsy.
Freireich AW, Landau D.
J Forensic Sci.1971 Jan;16(1):112-9.
Carbon monoxide determination in postmortem clotted blood.
Grabowska T, Sybirska H, Malinski M.
Katedry Medycyny Sadowej Slaskiej AM w Katowicach
Arch Med Sadowej Kryminol.2003 Jan-Mar;53(1):9-17.
[Attempt to estimate risks of fatal poisoning on the basis of HCN and HbCO concentrations in bloodof fire victims][Article in Polish]
	Using the results of HCN and HbCO concentrations in the blood of 174 deceased found in different
burning spaces and 35 people with symptoms of poisoning evacuated from the scene of a fire andthen admitted to hospital. The correlation between blood concentration of both these xenobiotics
and death or chance of survival in a fire was estimated by statistical analysis. An attempt was madeto define a value of so-called “cut-off” points for HbCO and HCN by independence test chi 2 with
Yates’s correction. Point and interval estimations (95% Comfield’s confidence interval) were used forthe odds ratio (OR). The research showed that there was a strict statistical correlation between the
chance of survival and death risks dependent on blood concentrations of HCN and HbCO in all thegroups examined.
Hirsch CS, Adelson L.
JAMA.1969 Dec 22;210(12):2279-80.
Absence of carboxyhemoglobin in flash fire victims.
Iffland R, Sticht G.
Arch Toxikol.1972;29(4):325-30.
[Gas chromatographic method for determination of carbon monoxide in blood][Article in German]
Jones JS, Lagasse J, Zimmerman G.
Emergency Medicine Residency Program, Butterworth Hospital, Grand Rapids, MI.
Am J Emerg Med.1994 Jul;12(4):448-51.
Computed tomographic findings after acute carbon monoxide poisoning.
Selective necrosis and degeneration of the globus pallidus are characteristic autopsy findings in patientswith severe carbon monoxide (CO) poisoning. The objective of this study was to show that computed
tomography (CT) may demonstrate these morphological changes in the brain during life, and provide
a clue to prognosis. The authors reviewed the medical records of 19 consecutive patients with acute
CO poisoning who underwent CT examination during hospitalization. Abnormal CT findings were
found in 10 of the 19 patients (53%). The most common abnormal findings were low-density areasin the basal ganglia. These lesions were found in 7 of the 10 cases, and varied from small (limited to■ Firefighter Autopsy Protocol■ 47 ■

I: Background ■the globus pallidus) to large (extending to the internal capsule). Of the 10 patients with abnormal CT
scans, 9 survived to hospital discharge but all had some degree of functional neurological impairment.
Eighty-nine percent (8 of 9) of the patients with normal CT scans were discharged neurologicallyintact. Awareness of the potential for basal ganglia lesions in CO poisoning should lead to moreaccurate CT interpretation and may have significant prognostic implications
Kojima T, Nishiyama Y, Yashiki M, Une I.
Forensic Sci Int.1982 May-Jun;19(3):243-8.
Postmortem formation of carbon monoxide.
Since carbon monoxide (CO) production after death was suggested in a drowned body, CO andcarboxyhemoglobin (HbCO) levels in blood and body cavity fluids of cadavers which were notexposed to fire and CO hve been analyzed. CO released from the tissues was determined by gas
chromatography and gas chromatography-mass spectrometry, and the total concentration ofhemoglobin (Hb) was measured as cyanmethemoglobin (CNmHb). The HbCO level was calculatedby the ratio of CO content and CO-binding capacity. CO levels (ml/100 g at STP) of the seven cases
in which blood and body cavity fluids could be collected ranged from 0.13 to 0.87 in blood and 0.02
to 0.80 in body cavity fluids. HbCO levels in blood and body cavity fluids were from 0.3 to 6.0% andfrom 2.3 to 44.1%, respectively. In a typical case showing postmortem formation of CO, the CO levels
in body cavity fluids were higher than that in blood. It is suggested that CO in a putrefied body is due
to CO in blood prior to death and the CO formed by the decomposition of Hb, myoglobin and othersubstances during putrefaction. The significance of HbCO levels in body cavity fluids of cases withmarked postmortem decomposition seems difficult to interpret without the value of HbCO in blood.
Kuller LH, Radford EP, Swift D, Perper JA, Fisher R.
Arch Environ Health.1975 Oct;30(10):477-82.
Carbon monoxide and heart attacks.
A study of the relationship between carbon monoxide exposure and heart attacks was conductedin Baltimore. There was no evidence of clustering of either myocardial infarction or sudden ASHD
on a specific day, nor was there correlation between the number of cases per day and ambient COlevels. Postmortem HbCO levels were slightly higher in ASHD sudden deaths than in sudden deaths
due to other causes. Any differences were probably primarily due to cigarette smoking. Cigarettesmokers who died suddenly due to ASHD had substantially higher postmortem HbCO levels than
nonsmokers. Practically all of the elevated HbCO levels could be related to cigarette smoking or specificenvironmental exposure. There were no differences between HbCO levels in ASHD sudden deathpatients and in living controls. There was also no relationship between cardiac pathologic findings andpostmortem HbCO levels among patients dying suddenly of ASH.
Kunsman GW, Presses CL, Rodriguez P.
Forensic Toxicology Laboratory, Bexar County Medical Examiner’s Office, San
Antonio, Texas 78229, USA.
J Anal Toxicol.2000 Oct;24(7):572-8.
Carbon monoxide stability in stored postmortem blood samples.

■ Firefighter Autopsy Protocol■ 48 ■

I: Background ■Carbon monoxide (CO) poisoning remains a common cause of both suicidal and accidental deaths in
the United States. As a consequence, determination of the percent carboxyhemoglobin (%COHb) levelin postmortem blood is a common analysis performed in toxicology laboratories. The blood specimens
analyzed are generally preserved with either EDTA or sodium fluoride. Potentially problematic
scenarios that may arise in conjunction with CO analysis are a first analysis or a reanalysis requested
months or years after the initial toxicology testing is completed; both raise the issue of the stabilityof carboxyhemoglobin in stored postmortem blood specimens. A study was conducted at the Bexar
County Medical Examiner’s Office to evaluate the stability of CO in blood samples collected in red-,gray-, and purple-top tubes by comparing results obtained at the time of the autopsy and after two
years of storage at 3 degrees C using either an IL 282 or 682 CO-Oximeter. The results from this study
suggest that carboxyhemoglobin is stable in blood specimens collected in vacutainer tubes, with orwithout preservative, and stored refrigerated for up to two years.
Malik MO.
J Forensic Sci Soc.1971 Jan;11(1):21-8.
Problems in the diagnosis of the causes of death in burned bodies.
Mallach HJ, Mittmeyer HJ.
Beitr Gerichtl Med.1979;37:393-9.
[Effect of exposure, alcohol and body disposition on the carbon monoxideconcentration of fatal
poisonings][Article in German]
Mayes RW.
RAF Institute of Pathology and Tropical Medicine, Halton Aylesbury.
J Clin Pathol.1993 Nov;46(11):982-8.
ACP Broadsheet No 142: November 1993. Measurement of carbon monoxide and cyanide in blood.
Miyazaki T, Kojima T, Yashiki M, Chikasue F, Iwasaki Y.
Department of Legal Medicine, Hiroshima University School of Medicine, Japan.
Int J Legal Med.1992;105(2):65-8.
Interpretation of COHb concentrations in the left and right heart blood of cadavers.
Carbon monoxide hemoglobin (COHb) concentrations in left and right heart blood samples fromcadavers both exposed and not exposed to fire or CO gas were analyzed by the gas chromatographic
method. The COHb concentration ratio between samples of left and right heart blood (L/R ratio) does
not appear to be useful for establishing whether death has occurred before or after exposure to firewith the exception of cases where no soot can be detected in the airways by the naked eye and theCOHb concentration in the blood sample is within the level considered normal for tobacco smokers.
Morinaga M, Kashimura S, Hara K, Hieda Y, Kageura M.
Department of Forensic Medicine, Fukuoka University School of Medicine, Japan.
Int J Legal Med.1996;109(2):75-9.
The utility of volatile hydrocarbon analysis in cases of carbon monoxide poisoning.

■ Firefighter Autopsy Protocol■ 49 ■

I: Background ■A new approach to investigate the circumstances relating to carbon monoxide intoxication by
analysing volatile hydrocarbons in the blood of cadavers is reported. Headspace gas chromatography/
mass spectrometry was used to demonstrate the hydrocarbons. The results can be characterized
into four categories depending on the compounds detected. In construction fire cases where noaccelerants were found at the scene benzene, toluene and styrene were detected in the blood. In
cases where gasoline was found in the fire debris surrounding the victim, high levels of benzene,
toluene, ethylbenzene, xylene isomers, n-hexane and n-heptane were detected in the blood. In cases
where kerosene was found in the fire debris around the victim, benzene, toluene, ethylbenzene,
xylene isomers, C9-aromatics(n-propylbenzene, trimethyl-benzene isomers), n-octane, n-nonane andn-decane were detected in the blood. In cases where the victim was found inside a gasoline-fuelledautomobile filled with exhaust gas, benzene, toluene, ethylbenzene, xylene isomers, C9-aromatics
were found, but no aliphatic hydrocarbons such as components of petroleum. The analyses of the
combustion gases of inflammable materials, exhaust gas, gasoline vapours and kerosene vapours werealso performed to evaluate the results of the blood analyses. Consequently, some compounds areproposed as indicators to discriminate between inhaled gases i.e. styrene in common combustion gas,n-hexane and n-heptane as well as benzene, toluene and C9-aromatics in gasoline cases, n-nonane
and n-octane as well as benzene, toluene and C9-aromatics in kerosene cases, and benzene, toluene,
C9-aromatics but no aliphatic hydrocarbons in exhaust gas cases.
Nakatome M, Matoba R, Ogura Y, Tun Z, Iwasa M, Maeno Y, Koyama H, Nakamura Y, Inoue H.
Department of Legal Medicine, Course of Social Medicine, Osaka University Graduate School of Medicine,
Suita City, Japan. nakatome@legal.med.osaka-u.ac.jp
Int J Legal Med.2002 Feb;116(1):17-21.
Detection of cardiomyocyte apoptosis in forensic autopsy cases.
	The purpose of the present study was to determine reliable parameters for the detection of apoptotic
cells for use as a diagnostic marker during the early stage of acute myocardial infarction (AMI)
in forensic autopsy cases. Myocardial tissues taken from forensic autopsy cases were examined byimmunohistochemical and molecular-biological methods using the terminal deoxynucleotidyltransferase-mediated dUTP biotin nick end-labelling (TUNEL) and the DNA laddering methods. In
cases of AMI with a time period between 2 h from onset to death and 20 h post-mortem time, thenuclei of cardiomyocytes were stained positive with the TUNEL method and DNA fragmentation of
myocardial cells was detected by agarose gel electrophoresis. Similar findings were obtained in casesof carbon monoxide (CO) intoxication. However, no apoptotic cells were found in other cases such as
methamphetamine (MAP) intoxication, tetrodotoxin intoxication, alcohol intoxication, asphyxia, head
injury, heart injury or myocarditis. These findings suggested that it would be possible to apply TUNELpositive cells as a diagnostic marker during the early stages of AMI.
Perrigo BJ, Joynt BP.
Central Forensic Laboratory, Royal Canadian Mounted Police, Ottawa.
J Anal Toxicol.1989 Jan-Feb;13(1):37-46.
Evaluation of current derivative spectrophotometric methodology for the determination of percent
carboxyhemoglobin saturation in postmortem blood samples.
Carbon monoxide intoxication continues to be a commonly encountered cause of death in most areasof Canada. The forensic nature of the samples in these cases presents special problems that are not■ Firefighter Autopsy Protocol■ 50 ■

I: Background ■normally encountered in clinical determinations. A study was undertaken to assess various methodsof determining the percent carboxyhemoglobin saturation in blood, more specifically, those using
derivative spectrophotometric measurements in the Soret region of the UV spectrum. At the same time,other studies were carried out: the effects of storage time on the carboxyhemoglobin levels; evaluationof sample containers; comparison of percent carboxyhemoglobin saturation in blood samples taken
ante-mortem and post-mortem. Blood for the study was obtained from laboratory animals that were
exposed to carbon monoxide before death.
Oritani S, Zhu BL, Ishida K, Shimotouge K, Quan L, Fujita MQ, Maeda H.
Department of Legal Medicine, Osaka City University Medical School, Asahi-machi
1-4-3, Abeno, 545-8585, Osaka, Japan
Forensic Sci Int.2000 Sep 11;113(1-3):375-9.
Automated determination of carboxyhemoglobin contents in autopsy materials usinghead-space gas
chromatography/mass spectrometry.
	To establish a method for the routine analysis of carboxyhemoglobin (COHb) in autopsy materials
including those which have undergone postmortem changes, e.g. thermo coagulation, putrifaction
and contamination, an automated head-space gas chromatography/mass spectrometry (GC/MS)
analysis was utilized. The procedure consisted of preparation of the sample in a vial and a carbon
monoxide (CO) saturated sample, for estimation of hemoglobin content, in another vial, the additionof n-octanol, potassium ferricyanide and an internal standard (t-butanol), GC separation anddetermination of CO using a GC/MS system equipped with an automated head-space gas sampler. The
method was practical not only with the blood and bone marrow aspirates to confirm the findings on
the CO-oximeter system, but also with the thermo-coagulated and putrified blood.
Quan L, Zhu BL, Fujita MQ, Maeda H.
Department of Legal Medicine, Osaka City University Medical School, Asahi-machi
1-4-3, Abeno, 545-8585 Osaka, Japan. legalmed@med.osaka-cu.ac.jp
Leg Med (Tokyo).2003 Mar;5 Suppl 1:S335-7.
Ultrasonographic densitometry of the lungs at autopsy: a preliminary investigation for possible
application in forensic pathology.
	The aim of the present study was to examine the possible application of ultrasonographic (US)densitometry of the lungs to quantitative evaluation of pulmonary edema at autopsy (n=85). A
diagnostic ultrasound device LOGIQ alpha200 (GE Yokogawa Medical Systems) equipped with an
LH probe (linear, 7.5 MHz) was used and each lobe of the lungs was scanned on the anterior andposterior surfaces after resection. The US density showed a correlation between the left and rightlobes, and also between the anterior and posterior surface scans of each lobe. Although there was acorrelation between the US density and combined lung weight in total cases, the density ranged very
widely when lung weight was below about 1300 g, depending on the cause of death. The density
was high in drowning, asphyxia, poisoning and delayed traumatic death, whereas it was usually low
in fire death mainly due to burns, hemorrhagic shock and head injury. In the other causes of death,a considerable case-to-case difference was observed independent of the lung weight. These findings
suggested a possible contribution of pulmonary edema to high US density, possibly depending on thesurvival time and irrespective of the blood contents (congestion or postmortem hypostasis).

■ Firefighter Autopsy Protocol■ 51 ■

I: Background ■Quan L, Zhu BL, Oritani S, Ishida K, Fujita MQ, Maeda H.
Department of Legal Medicine, Osaka City University Medical School, Japan.
Int J Legal Med.2001;114(6):310-5.
Intranuclear ubiquitin immunoreactivity in the pigmented neurons of the substantia nigra in fire
fatalities.
	To evaluate the significance of immunohistochemical staining of ubiquitin (heat shock protein) in
the midbrain for medico-legal investigation of death in fires, we examined forensic autopsy casesof fire fatalities (n = 35) in comparison with controls (n = 27; brain stem injury, acute myocardial
infarction and carbon monoxide poisoning other than fire fatality). There were two intranuclear
staining patterns in the nuclei of pigmented substantia nigra neurons: a type of inclusion (possible
Marinesco bodies) and a diffuse staining. Percentage of nuclear ubiquitin positivity (Ub-positive %)in fire fatalities (2.7-44.7%; mean, 18.5%) was significantly higher than in brain stem injury (n = 9;0-10.4%; mean, 4.5%) and myocardial infarction (n = 14; 1.5-14.6%; mean, 6.9%), independentlyof blood carboxyhemoglobin (COHb) levels. Age-dependent increase in Ub-positive % was observedin lower COHb (< 60%) cases. The intranuclear diffuse ubiquitin staining was not observed in casesof high blood cyanide level (> 1.0 microg/ml). These observations showed that intranuclear ubiquitin
immunoreactivity of the pigmented substantia nigra neurons in the midbrain was induced by severe
stress in fires.
Reys LL, Santos JC.
Institute of Legal Medicine, University School of Medicine, Lisbon, Portugal.
Am J Forensic Med Pathol.1992 Mar;13(1):33-6.
Importance of information in forensic toxicology.
	Information in forensic toxicology plays a very important role. The forensic pathologist usually seeks
toxicologic analyses on basis of the information available at the time of the medicolegal autopsy.
Such information may be obtained from different sources: hospitals, authorities, relatives, friends, orneighbors of the deceased and, obviously, macroscopic findings at the time of the autopsy. In order toevaluate the relative importance of these different sources of information, the authors have studied,retrospectively, results of 580 postmortem examinations performed at the Institute of Legal Medicineof Lisbon, wherein toxicologic analyses had been requested. These cases pertain to the years 1987
and 1988, but do not include alcohol determination in the blood in cases of traffic accidents. In 274(47.4%) of the 580 cases, there were positive findings while in the remaining 306 (52.6%) findings
were negative. In cases with positive findings, circumstances and factors, which may have influenced
the pathologist’s decision to request toxicologic analysis, are discussed. In more than half the cases,
hospital information was the decisive factor, while in approximately 25% of the cases, autopsy findings
were the justification. In contrast, it is worth mentioning that in approximately 45% of the cases withanalytical negative results, requests were made, in cases of blank autopsies, for toxicologic analyses
in order to exclude the possibility of poisoning. It is interesting to note that in the same proportion
requests were justified on grounds of hospital information. Some of the factors that may explain thisapparent discrepancy are discussed. Finally, the relevance of background information is emphasized at
the level of the interpretation of analytical results, whether positive or negative.

■ Firefighter Autopsy Protocol■ 52 ■

I: Background ■Schmidt P, Musshoff F, Dettmeyer R, Madea B.
Institut fur Bechtsmedizin, Universitat Bonn.
Arch Kriminol.2001 Jul-Aug;208(1-2):10-23.
[Unusual carbon monoxide poisoning][Article in German]
Despite of indicative death scenes or characteristic findings of the external examination, about 40% of
the accidental fatal intoxications due to carbon monoxide are not recognized before the performanceof the autopsy. Six cases are reported which illustrate possible reasons for the delayed establishment of
the diagnosis: unusual circumstances of the intoxication or sources of carbon monoxide, only subtle
degree or lack of external signs of the intoxication or a competing cause of death at autopsy.--Cases
1 and 2: 53, respectively 54-year-old couple, found dead in a caravan, extreme putrefaction of thebodies, spectrophotometric detection of the fatal carboxyhaemoglobin level in oedema fluid of thescalp.--Case 3: 23-year-old lorry driver, found dead in the tightly closed cab of his lorry, operation ofa source of electricity with “environmentally friendly” fuel, carboxyhaemoglobin level 83%.--Case 4:
19-year-old man, found dead in the flat of friends, removal of the CO-source before alerting the police
forces, lack of the bright pink coloration of livor mortis, haemopericardium due to atrial rupture at
postmortem examination, carboxyhaemoglobin level 65%.--Case 5: 27-year-old man, found dead in
his flat, advanced decomposition of the body, residues of a charcoal fire in a metal bucket in the sink,carboxyhaemoglobin level 80%.--Case 6: 42-year-old woman, lying dead in the garage beside her car,engine switched-off, ignition key next to the body on the floor under the car, carboxyhaemoglobin
level 46%.
Shinomiya T, Shinomiya K.
Acta Med Leg Soc (Liege).1989;39(1):131-43.
[The variation in carbon monoxide release in the blood stain and in visceral tissues][Article in French]
Teige B, Lundevall J, Fleischer E.
Z Rechtsmed.1977 Jul 5;80(1):17-21.
Carboxyhemoglobin concentrations in fire victims and in cases of fatal carbon monoxide poisoning.
	The study comprises an eleven-year autopsy material of 141 cases from the Institute of Forensic
Medicine, Oslo. The fatal level of carboxyhemoglobin concentration is calculate from cases of purecarbon monoxide poisoning. Carboxyhemoglobin concentrations below this level are found in
approximately thirty percent of the fire victims. Alcohol intoxication, present in many fire victims, is
not related to low corboxyhemoglobin concentrations.
von Meyer L, Drasch G, Kauert G.
Z Rechtsmed.1979;84(1):69-73.
[Significance of hydrocyanic acid formation during fires][Article in German]
Cyanide concentrations of blood samples from fire victims autopsied in the Institute of Legal Medicine,
Munich, have been determined. In 25% of 48 analyzed cases cyanide concentrations from 0.52
microgram to 6.24 microgram Cyanide/ml blood have been detected. These results are compared
to former studies and the higher mean level in our collective is emphasized. The importance of■ Firefighter Autopsy Protocol■ 53 ■

I: Background ■hydrocyanid acid in the toxicity of fire gases is evidently greater, than assumed. Hydrocyanic acid may
be produced from nitrogen continaing polymers during combustion. The quote of these polymers inclothing, furniture, and also in equipment of cars is increasing. Therefore, it is necessary to take more
notice of the formation of hydrocyanic acid during combustion, even though carbon monoxide is in
general the main toxic agent in fire gases.
Winek CL, Prex DM.
Forensic Sci Int.1981 Sep-Oct;18(2):181-7.
A comparative study of analytical methods to determine postmortem changes in carbon monoxide
concentration.
	Twenty-one autopsy blood samples were analyzed using spectrophotometric and gas chromatographic
procedures after storage for 30 and 150 days. When carboxyhemoglobin was measured
spectrophotometrically at the absorbance ratio of 540 nm/555 nm, the observed average percent
losses were 8 +/- 9% and 35 +/- 27% after 30 and 150 days of storage, respectively. When measured
at the absorbance ratio of 540 nm/579 nm, the average percent losses of carboxyhemoglobin were 7+/- 8% and 34 +/- 25% after 30 and 150 days, respectively. Wavelength shifts and distorted spectralscans were observed at 150 days. When carbon monoxide was determined by gas chromatographic
methods based on combining capacity, the average percent loss was 15 +/- 24% and 37 +/- 36% after
30 days and 150 days, respectively. The average percent loss of calculated CO based on hemoglobin
concentration after 30 days was 31 +/- 14% and at 150 days, 40 +/- 24%. The average percent lossof calculated CO based on iron content was 23 +/- 13% and 37 +/- 23% after 30 and 150 days,
respectively.
Wirthwein DP, Pless JE.
Division of Forensic Pathology, Indiana University, Indianapolis 46202-5120, USA.
Am J Forensic Med Pathol.1996 Jun;17(2):117-23.
Carboxyhemoglobin levels in a series of automobile fires. Death due to crash or fire?
	The determination of death by trauma versus fire can be of major consideration, especially in civil
product liability litigation. Blood carboxyhemoglobin levels can be instrumental in that differentiation.
Twenty-eight fatalities involving fire in automobiles were reviewed. All subjects displayed some degreeof body burn, and in 25 severe charring and/or incineration was present at autopsy. In only one casewas there a history of explosion or flash fire. Carboxyhemoglobin levels varied from 92% to valuesof < 10%. In seven cases no collision occurred. In six of these subjects COHb values were > or =47%. In all 16 cases with carboxyhemoglobin levels of < or = 10% a collision occurred. In 12 of 16
of these subjects, blunt force injury sufficient to cause death was discovered. Data presented in thisarticle indicate that a carboxyhemoglobin level of > 30% strongly suggests inhalation of combustion
products as the cause of death. In contrast, a level of < 20% should prompt a search for other causes.
Wu SC, Levine B, Goodin JC, Caplan YH, Smith ML.
Office of the Chief Medical Examiner, State of Maryland.
J Anal Toxicol.1992 Jan-Feb;16(1):42-4.
Analysis of spleen specimens for carbon monoxide.
Crucial to the investigation of aircraft fatalities is the analysis of biological specimens for carbon
monoxide (CO). In many cases, blood specimens are unavailable or unsuitable for analysis, and the■ Firefighter Autopsy Protocol■ 54 ■

I: Background ■testing of an alternate specimen for CO becomes necessary. Spleen specimens provide a rich source of
red blood cells and hence can be a primary substitute for blood. To verify this, 40 paired blood andspleen specimens were analyzed for CO by using a gas chromatographic method. Ten specimens with aspleen CO saturation level (sat.) of less than 10% were associated with corresponding blood specimens
with CO sat. less than 10%. Fifteen of the 18 spleen specimens with CO sat. greater than 29% wereassociated with blood specimens with greater than 48% sat. Results were inconclusive when the spleen
CO sat. was between 10 and 29%. We concluded that spleen CO sat. can reflect blood CO sat. in certain
situations, particularly when spleen CO sat. is high.

■■Appendix A: death investigation systems in the
United states And territories
State/
Territory
Alabama

Type of System

Title

Deaths InvestigatedContact

Comment

Mixed: State
Medical Examiner
and County
Coroners/Medical
Examiners

County Coroner,
State Medical
Examiner

Coroner—All deaths where thedeceased died without being
attended by a legally qualified
physician.

Emily Ward, MD
Alabama Department of
Forensic Sciences
P.O. Box 240591
Montgomery, AL
36124-0591(334) 242-3093
Fax: (334) 260-8734

Slight differences in deathinvestigationin Jefferson
County(Birmingham)from those inother counties.

State Medical Examiner—• If the person dies by violence orhomicide, suicide, accidental, or
industrial.
• Criminal abortion.
• Sudden death, if in apparent
good health.
• In suspicious circumstances.
• When a public health hazard.
• If the body is to be cremated.

AlaskaState Medical
Examiner

State Medical
Examiner• Homicide.

Franc G. Fallico, MD
Acting State Medical• Suspicion of criminal means.
Examiner• Suicide.
4500 South Boniface• With no physician in attendance. Pkwy.
Anchorage, AK 99507• When physician is unable to(907)
269-5090
execute death certificate.
Fax: (907) 334-2216• When cause of death cannot be Email: Franc_Fallico@determined.
HEALTH.STATE.AK.US■ 55 ■

■ 56 ■■ Firefighter Autopsy Protocol

State/
Territory
American
Samoa

Type of System
Territorial Coroner

Title

Deaths InvestigatedNo death investi- • Where any dead body is found.
gation official.
• By accidental means.
• Allegedly caused by unlawfulmeans.

ArizonaCounty Medical
Examiner

County Medical
Examiner• When not under current care ofa physician for a potentially fatal
illness.
• When the attending physician
is unavailable to sign the deathcertificate.
• By violence.

I: Background ■Contact

Comment

Malaetasi M. Cogafau
Attorney General of
American Samoa
P.O. Box 7
Pago Pago, AS 96799(684) 633-4163

Pulenuu(village chief)reports deaths
to the Attorney
General,or, if necessary, to the
Departmentof Medical
Services’ local
representative,
who is authorized to act asCoroner andreport findings
to the Attorney
General.

Philip E. Keen, M.D.
Medical Examiner
Maricopa County
120 South Sixth Avenue
Phoenix, AZ 85003(602) 506-3322
Fax: (602) 506-1546• Of a prisoner or occurring inprison.
• Occurring suddenly to a person
in apparent good health.
• By occupational disease or
accident.
• Where a public health hazard ispresented.
• Occurring during anesthetic or
surgical procedures.
• Occurring in a suspicious,
unusual, or unnatural manner.
Arkansas

Mixed: State
Medical Examiner
and County
Coroners/Medical
Examiners

County Coroner,
State Medical
Examiner• Death appears to be caused byviolence, homicide, suicide, or
accident.
• Death appears to be the resultof the presence of drugs or
poisons.
• Death appears to be the resultof a motor vehicle accident or
the body was found in or near aroadway or railroad.

William Q. Sturner, M.D.
State Medical Examiner
P.O. Box 8500
Little Rock, AR 72215(501) 227-5936
Fax: (501) 221-1653
Email: William.Sturner@
ASCL.State.AR.US■ 57 ■■ Firefighter Autopsy Protocol

State/
Territory
Arkansas(cont’d)Type of System

Title

Deaths Investigated• Death appears to be the resultof a motor vehicle accident andthere is no obvious trauma to thebody.
• Death occurs while the person
is in a State mental institution or
hospital and there is no previous
medical history to explain thedeath, or while the person is inpolice custody, a jail, or penal
institution.
• Death appears to be the result ofa fire or explosion.
• Death appears to be the result ofdrowning.
• Death of a minor child appears
to indicate child abuse.
• Death of an infant or minor childwithout previous medical history.
• Human skeletal remains arerecovered.
• Decomposition of the bodyprohibits external examination torule out injury or circumstancesof death cannot rule out thecommission of a crime.
• Manner of death appears to beother than natural.
• Death is sudden andunexplained.
• Death occurs at a worksite.
• Death is due to criminal abortion.
• A physician was not in attendance within 36 hours preceding
death or, in pre-diagnosed
terminal or bedfast cases, within
30 days. This includes persons
admitted to an emergency room,
unconscious and unresponsive,
following cardiopulmonary
resuscitation, who die within
24 hours of admission without
regaining consciousness or
responsiveness.

I: Background ■Contact

Comment

■ 58 ■■ Firefighter Autopsy Protocol

State/
Territory
California

Type of System
Mixed: County
MedicalExaminers/
Coroners

Title
County Coroner,
CountySheriff-Coroner,
County Medical
Examiner,
CoronerDeaths Investigated• Violent, sudden, or unusual.

I: Background ■Contact

Scotty D. Hill
Executive
Secretary• Unattended.
California State Coroners• Deaths wherein the deceased
Association
has not been attended by a5925 Maybrook Circle
physician in the 20 days before Riverside, CA
death.
92506-4549• Self-induced or criminal abortion. (909) 788-2656
Fax: (909) 788-2934• Known or suspected homicide,suicide, or accidental poisoning. Email: CSCA2000@aol.
com• By recent or old injury or
accident.
• Drowning, fire, hanging, gunshot,
stabbing, cutting, exposure,
starvation, acute alcoholism,
drug addiction, strangulation,
aspiration.
• Suspected sudden infant death
syndrome.
• By criminal means.
• Associated with known or
alleged rape or crime against
nature.
• By known or suspected contagious disease constituting apublic hazard.
• By occupational disease or
hazard.
• Of State mental hospital patient.
• Of developmentally disabled
patient in State developmental
services hospital.
• In prison or while undersentence.
• Under other suspicious
circumstances.

Comment
41 counties
with SheriffCoroners.
In addition,
many County
Coroners also
serve as Public
Administrator,
PublicGuardian,and Public
Conservator.

■ 59 ■■ Firefighter Autopsy Protocol

State/
Territory
Colorado

Type of System

Title

County Coroner

County Coroner

Deaths Investigated

I: Background ■Contact• From external violence.

James L. Kramer, P.A.C.
President• Unexplained cause.
Colorado Coroner• Under suspicious circumstances. Association• Suddenly, when in good health. 517 Colorado Avenue
Pueblo, CO 81004• Where no physician is in atten(719) 543-4016
dance, or where the attending
physician is unable to certify the Fax: (719) 583-6077
Email:kramerpa@
cause of death.
co.pueblo.co.us• From thermal, chemical, orThomas E. Henry, M.D.
radiation injury.
Chief Medical Examiner/• From criminal abortion.
CoronerDenver City and County• From disease that may behazardous or contagious or may 660 Bannock Street
constitute a hazard to the public Denver, CO 80204-4507(303) 436-7711 (303)
health.
436-7411• While in custody of law enforce- Fax: (303) 436-7709
ment officials or while incarcerated in a public institution.
• From industrial accident.

Connecticut

State Medical
Examiner

State Chief
MedicalExaminer• Due to criminal abortion, whether H. Wayne Carver, II, M.D.
apparently self-induced or not.
Chief Medical Examiner
Office of the State• Violent, whether apparently
Medical Examiner 11
homicidal, suicidal, or accidenShuttle Roadtal, including but not limited todeaths due to thermal, chemical, Farmington, CT
06032-1939
electrical, or radiation injury.
(860) 679-3980• Sudden or unexpected deaths
Fax: (860) 679-1257
not caused by readily recogniz- Email: H.Wayne.Carver@
able disease.
po.state.ct.us• Under suspicious circumstances.
• Where the body is to becremated, buried at sea, orotherwise disposed of so as tobe thereafter unavailable for
examination.
• Related to occupational diseaseor accident.
• Related to disease which might
constitute a threat to publichealth.

Comment

■ 60 ■■ Firefighter Autopsy Protocol

State/
Territory
Delaware

Type of System
State Medical
Examiner

Title
State Chief
MedicalExaminer

Deaths Investigated

I: Background ■Contact• By violence, suicide, or casualty.

Richard Callery, M.D.
State Chief Medical• While under anesthesia.
Examiner• By abortion or suspected
Office of the Chiefabortion.
Medical Examiner• By poison or suspicion of poison. Department of Health andSocial Services• Suddenly when in apparent
200 South Adam Street
health.
Wilmington, DE 19801• When unattended by a(302) 577-3420
physician.
Fax: (302) 577-3416• In prison or penal institution or
Email: rcallery@state.
police custody.
de.us• Resulting from employment.
• From undiagnosed cause which
may be related to a disease
constituting a threat to publichealth.
• In any suspicious or unusual
manner.
• If the body is unclaimed or to becremated.

District ofColumbia

Medical Examiner

Chief Medical
Examiner• By violence, whether apparently
homicidal, suicidal, or accidental,
including deaths due to thermal,
chemical, electrical, or radiation
injury.

Johnathan L. Arden, M.D.
Chief Medical Examiner
Office of the Chief
Medical Examiner
Building 27• Due to criminal abortion, whether 1910 Massachusetts
Avenue, Southeast
apparently self-induced or not.
Washington, DC 20003• Under suspicious circumstances. (202) 698-9000• Of persons whose bodies are to Fax: (202) 698-9100
be cremated, dissected, buriedat sea, or otherwise disposed ofso as to be thereafter unavailable for examination.
• Sudden deaths not caused byreadily recognizable disease.
• Related to disease resulting from
employment or to accident while
employed.
• Related to disease which might
constitute a threat to publichealth.

Comment

■ 61 ■■ Firefighter Autopsy Protocol

State/
Territory
FloridaType of System
District Medical
Examiner

Title
District Medical
Examiner

Deaths Investigated• By criminal violence.
• By accident.
• By suicide.
• Suddenly, when in apparent
good health.
• Unattended by a physician orother recognized practitioner.
• In a prison or penal institution.
• In police custody.
• In any suspicious or unusual
circumstances.
• By criminal abortion.
• By poison.
• By disease constituting a threat
to public health.
• By disease, injury, or toxic
agent exposure resulting from
employment.
• When a body is brought into theState without proper medical
certification.

I: Background ■Contact
Stephen J. Nelson, M.D.,
M.A., F.C.A.P.
Chairman
Medical Examiners
Commission
Florida Department of
Law Enforcement
P.O. Box 1489
Tallahassee, FL
32302-1489(850) 410-8600
Fax: (850) 410-8621
Email:JNelsonMD@aol.
com
Vickie Marsey
Program Admin.
Medical Examiners
Commission
Same address as above(850) 410-8660
Fax: (850) 410-8621
Email: VickieMarsey@
fdle.state.fl.us• When the body is to be cremated, dissected, or buried atsea.
Georgia

Mixed: State
Medical Examiner
and County
Coroners/Medical
Examiners

County Coroner,
State Medical
Examiner,
Regional
MedicalExaminer,
County Medical
Examiner,
Local Medical
Examiner• By violence, suicide, or casualty.
• Suddenly, when in apparent
good health.
• When unattended by aphysician.
• When an inmate of a Statehospital or State, county, or city
penal institution.
• When ordered by a court having
criminal jurisdiction.
• After birth but before 7 years ofage if the death is unexpected or
unexplained.

Kris Sperry, M.D.
State Medical Examiner
Division of Forensic
Sciences
Georgia Bureau of
Investigation
P.O. Box 370808
Decatur, GA 30037-0808(404) 244-2709
Fax: (404) 212-3047
Email: kris.sperry@gbi.
state.ga.us

Comment

■ 62 ■■ Firefighter Autopsy Protocol

State/
Territory

Type of System

Title

Georgia(cont’d)Guam

Deaths Investigated

I: Background ■Contact• In any suspicious or unusual
manner, with particular attention
to those persons 16 years of age
and under.

Randy Hanzlick, M.D.
Chief Medical Examiner,
Fulton County
Fulton County Medical• As a result of an execution car- Examiner Center
ried out pursuant to imposition of 430 Pryor Street SW
Atlanta, GA 30312
the death penalty.
(404) 730-4400
Fax: (404) 730-4407
Email: RandyHanzlick@mail.co.fulton.ga.us
Territorial Medical
Examiner

Chief Medical
Examiner• Violent, unusual, or unnatural
deaths. This covers any death
attributed to accident, suicide,
homicide, criminal abortion,
physical, mechanical, electrical,
chemical, radiational, thermal, or
related means.
• All deaths under suspicious
circumstances.
• Sudden deaths in apparent
health without obvious cause.
• Deaths without medical
attendance:
1. found dead without obvious
or probable cause.
2. unattended at anytime by alicensed physician.
3. unattended by a physician
during a terminal illness,particularly if such deathappears unrelated to adisease previously diagnosed
and treated.
4. fetal death attended by
midwife.
5. deaths in prison, lock up,
penitentiary, or juvenile
justice facility.
6. deaths during or following
an acute or unexplained
syncope or coma.
7. during an acute or unexplained rapidly fatal illness
which may be contagious to
the public.

Aurelio A. Espinola, M.D.
Chief Medical Examiner
P.O. Box 7147
Tamuning, GU 96931(671) 646-9363h

Comment

■ 63 ■■ Firefighter Autopsy Protocol

State/
Territory

Type of System

Title

Guam (cont’d)Deaths Investigated

I: Background ■Contact

8. all hospital DOAs (deadon arrival) and thosedying within 24 hours after
admission.
• Bodies to be cremated, buried atsea, or shipped off island.

HawaiiMixed: County
MedicalExaminers/
Coroners

County Coroner,
Coroner
Physician(titled Medical
Examiner in
Honolulu)• As the result of violence.
• As the result of any accident.
• By suicide.
• Suddenly when in apparent
health.
• When unattended by aphysician.

Kanthi Von Guenthner,
M.D.
Department of theMedical Examiner
835 Iwilei Road
Honolulu, HI 96817(808) 527-6777
Fax: (808) 524-8797• In prison.
• In a suspicious or unusual
manner.
• Within 24 hours after admission
to a hospital or institution.
Idaho

County Coroner

County Coroner• As a result of violence whether
Erwin Sonnenberg
apparently homicidal, suicidal, or Idaho Coroners
accidental.
Association
5550 Morrishill Road
• Under suspicious or unknown
Boise, ID 83706
circumstances.
(208) 364-2676• When not attended by a physiFax: (208) 364-2685
cian during his/her last illness
Email: CRSONNEL@
and the cause of death cannot
ADAWEB.NET ˜
be certified by a physician.

Illinois

Mixed: County
MedicalExaminers/
Coroners

County Coroner,
County Medical
Examiner• Sudden or violent death, whether
apparently suicidal, homicidal, or
accidental, including but not limited to deaths apparently caused
or contributed to by thermal,
traumatic, chemical, electrical orradiation injury, or a complicationof any of them, or by drowning,
suffocation, or motor vehicle
accident.
• Maternal or fetal death due toabortion.
• Due to sex crime or crime
against nature.

Jeff Lair
Secretary
Illinois Coroners andMedical Examiners
Association
P.O. Box 1261
Jacksonville, IL 62651(217) 245-7423
Fax: (217) 479-4637
Email: coroner@
direcway.com

Comment

■ 64 ■■ Firefighter Autopsy Protocol

State/
Territory

Type of System

Title

Illinois(cont’d)Deaths Investigated

I: Background ■Contact• Where the circumstances are
suspicious, obscure, mysterious,or otherwise unexplained; andwhere, in the written opinionof the attending physician, thecause is not determined.
• Where addiction to alcohol orto any drug may have been acontributory cause.
• Where the decedent was
not attended by a licensed
physician.
• Occurring in State institutions orof wards of the State.
• If a child under 2 years diessuddenly or unexpectedly andcircumstances concerning thedeath are unexplained.
• While being pursued, apprehended, or taken into custody bylaw enforcement officers or whilein custody of any law enforcement agency.

IndianaCounty Coroner

County Coroner• Has died from violence.

Lisa Barker
Executive Director• Has died by casualty.
Indiana Coroners• Has died when apparently in
Association
good health.
1643 West 800 South• Has died in an apparently
Romney, IN 47981
suspicious, unusual, or unnatural (877) 692-7284
manner.
Fax: (765) 538-2880
Email: ISCABarker@aol.
• Has been found dead.
com
James St. Myer
President
Indiana Coroners
Association
4109 Janney Ave.
Muncie, IN 47305(765) 289-0865
Fax: (765) 284-4606
Email: JSTM1079@aol.
com

Comment

■ 65 ■■ Firefighter Autopsy Protocol

State/
Territory
Iowa

Type of System
State Medical
Examiner

Title
State Medical
Examiner,
County Medical
Examiner

Deaths Investigated• Violent, including homicidal,
suicidal, or accidental.
• Caused by thermal, chemical,
electrical, or radiation injury.
• Caused by criminal abortion
including those self-induced, orby rape, carnal knowledge, or
crimes against nature.
• Related to disease thought tobe virulent or contagious, whichmight constitute a public hazard.
• Occurring unexpectedly or from
unexplained causes.

I: Background ■Contact
Julia C. Goodin, M.D.,
State Medical Examiner
Office of the Iowa State
Medical Examiner,
Iowa Department of
Public Health Lucas State
Office Building,
5th Floor, 321 East 12th
StreetDes Moines, IA 50309(515) 281-6726
Email: jgoodin@raccoon.
com• Of a person confined in jail,prison, or correctional institution.
• Where a physician was not in
attendance at any time at least
36 hours preceding death, withthe exception of pre-diagnosed
terminal or bedfast cases forwhich the time period shall be
extended to 20 days.
• Where the body is not claimed
by relatives or friends.
• Where the identity of thedeceased is unknown.
• Of a child under the age of 2
years when sudden infant death
syndrome is suspected or causeof death is unknown.
KansasKansas(cont’d)District Coroner

District Coroner• Death is suspected to have been Alan Hancock, M.D.
the result of violence caused by President
unlawful means, or by suicide.
Kansas Coroners
Association• By casualty.
9201 Parallel Parkway• Suddenly when the decedent
Kansas City, KS
was in apparent health.
66112-1598• When the decedent was not(913) 299-1474
regularly attended by a licensed Fax: (913) 299-4931
physician.
• In any suspicious or unusual
manner, or when in police
custody, or when in a jail orcorrectional institution.
• When the determination of thecause of death is held to be in
the public interest.

Comment

■ 66 ■■ Firefighter Autopsy Protocol

State/
Territory
KentuckyType of System

Title

Deaths Investigated

Mixed: State
Medical Examiner
and County
Coroners/Medical
Examiners

County Coroner,
State Medical
Examiner,
District Medical
Examiner• Caused by homicide, violence,
suicide, an accident, drugs,
poison, motor vehicle, train, fire,
explosion, drowning, illegal abortion, or unusual circumstances.
• By criminal means.
• Sudden infant death syndrome.
• Child abuse.
• Death in a person less than 40
years of age with no past medical history to explain the death.

I: Background ■Contact
Tracey S. Corey, MD
State Chief Medical
Examiner
Office of the State
Medical Examiner
Urban Government
Center810 Barrett Ave.
Louisville, KY 40204(502) 588-5587
Fax: (502) 852-1767

Email: TraceySCorey@
aol.com• Death in any mental institution.
Dan Able Executive• Death in any prison, jail, or penal Director
Office of the Stateinstitution, or while decedent
Medical Examiner
was in police custody.
100 Sower Blvd, Suite• When the death was sudden202. Frankfort, KY 40601
and unexplained or the decedent (502) 564-4545
was unattended by a physician
Fax: (502) 564-1699
by more than 36 hours prior to
Email: dan.able@ky.gov
death.

• Death occurring at a worksite.

• When skeletonized or extensively decomposed humanremains are found.
• When the body is to becremated.
• When circumstances of death
result in a request by any
responsible citizen for aninvestigation.

Comment

■ 67 ■■ Firefighter Autopsy Protocol

State/
Territory
Louisiana

I: Background ■Type of System

Title

Deaths InvestigatedContact

County Coroner

Parish Coroner• When suspicious, unexpected,
unusual or sudden.

Allen Herbert, M.D.
President
Louisiana Coroners’
Association
P.O. Box 747
Alexandria, LA 71309(318) 473-6831
Fax: (318) 473-6832
Email: LSCA@speedgate.net• By violence.
• Due to unknown or obscurecauses.
• Where the body is found dead.
• Without attending physician
within 36 hours prior to the hourof death.
• When abortion, whether
self-induced or otherwise, issuspected.
• Due to suspected suicide or
homicide.
• When poison is suspected.
• From natural causes occurring ina hospital under 24 hours admission unless seen by a physician
in the past 36 hours.
• Following an injury or accident,
either old or recent.
• Due to drowning, hanging,burns, electrocution, gunshot
wounds, stabs or cutting,lightning, starvation, radiation,
exposure, alcoholism, addiction,
tetanus, strangulation, suffocation, or smothering.
• Due to trauma from whatevercause.
• Stillborn deaths.
• Due to criminal means.
• If victim of alleged rape, carnal
knowledge, or crime against
nature.
• By casualty.
• In prison or while serving asentence.
• Due to virulent contagious
disease that might be caused byor cause a public hazard (AIDS
cases included).

Comment

■ 68 ■■ Firefighter Autopsy Protocol

State/
Territory
Maine

Type of System
State Medical
Examiner

Title
State Chief
MedicalExaminer,
MedicalExaminer

Deaths Investigated• Violence of any kind.
• Any cause where the deathoccurs suddenly while the person is in apparent good health.
• Any cause where there is noattending physician capable ofcertifying the death as due tonatural causes.
• Poisoning, either chronic oracute.
• Diagnostic or therapeutic
procedures under circumstancesindicating gross negligence or
unforeseen clearly traumaticcauses.
• Any cause while the person is incustody or confinement, unlessclearly certifiable by an attending physician as due to naturalcauses.
• Disease or pathological process
constituting a threat to publichealth, if the authority of the
medical examiner is required to
study the death adequately toprotect the public health.
• Deaths which may have been
improperly certified or inadequately examined, including,but not limited to, bodies brought
into the State under thesecircumstances.
• In the case of a child under theage of 3 years, from any cause,
including sudden infant death
syndrome, unless the death isclearly due to a specific naturalcause.

I: Background ■Contact
Margaret S. Greenwald,
MD
State Chief Medical
Examiner
State House, Station #37
Augusta, ME 04333(207) 624-7180
Fax: (207) 624-7178
Email: margaret.greenwald@state.me.us

Comment

■ 69 ■■ Firefighter Autopsy Protocol

State/
Territory

Type of System

Title

Deaths Investigated

I: Background ■Contact

MarylandState Medical
Examiner

State Chief
MedicalExaminer• By violence, suicide, or casualty.

David Fowler, M.D.
• Suddenly when in apparent good Acting State Chief
health, or when unattended by a Medical Examiner
State of Maryland
physician.
111 Penn Street• In any suspicious or unusual
Baltimore, MD 21201
manner.
(410) 333-3226• Fetuses, regardless of duration Fax: (410) 333-3063
of pregnancy, if the mother is
Email: OCMEMD@aol.
not attended by a physician at or com
after the delivery.

Massachusetts

State Medical
Examiner

State Chief
MedicalExaminer,
District Medical
Examiner• Where criminal violence appears
to have taken place, regardlessof the time interval between
the incident and death, andregardless of whether such
violence appears to have been
the immediate cause of death, ora contributory factor.

Richard Evans, M.D.
State Chief Medical
Examiner
Commonwealth of
Massachusetts
720 Albany Street
Boston, MA 02118(617) 267-6767 Toll freein Massachusetts (800)• By accident or unintentional
962-7877
injury, regardless of the timeinterval between the incident and Fax: (617) 266-6763
death, and regardless of whether Email: richard.evans@
cme.state.ma.us
such violence appears to havebeen the immediate cause ofdeath, or a contributory factor.
• Suicide, regardless of the timeinterval between the incident anddeath.
• Death under suspicious or
unusual circumstances.
• Death following an illegal
abortion.
• Death related to occupational
illness or injury.
• Death in custody, in any jail orcorrectional facility, or in any
mental health or mental retardation facility.
• Death where suspicion of abuseof a child, family or household
member, elder person, or
disabled person exists.
• Death due to poison or acute or
chronic use of drugs or alcohol.

Comment

■ 70 ■■ Firefighter Autopsy Protocol

State/
Territory

Type of System

Title

Massachusetts(continued)

Deaths Investigated

I: Background ■Contact• Skeletal remains.
• Death associated with diagnostic
or therapeutic procedures.
• Sudden death when the
decedent was in apparent good
health.
• Death within 24 hours of admission to a hospital or nursing
home.
• Death in any public or private
conveyance.
• Fetal death as defined by
Section 202 of Chapter 111,
where the period of gestation
has been 20 weeks or more or
where fetal weight is 350 grams
or more.
• Pediatric deaths under andincluding the age of 18 years
from any cause.
• Any person found dead.
• Death in an emergency treatment facility, medical walk-in
center, day care center, or underfoster care.
• Death occurring under suchcircumstances as the chief medical examiner shall prescribe in
regulations promulgated pursuant to the provisions of Chapter
30 A.

MichiganCounty Medical
Examiner

County Medical
Examiner• By violence.
• When unexpected.
• Without medical attendance
during the 48 hours prior to thehour of death unless the attending physician, if any, is able todetermine accurately the causeof death.
• As the result of an abortion, whether self-induced orotherwise.
• Of any prisoner in any county orcity jail.

Dan Remick, M.D.
President
Michigan Association for
Medical Examiners
M2210 Medical ScienceI, 1301 Catherine RoadAnn Arbor, MI
48109-0602(734) 763-6454
Fax: (734) 763-6476
Email: remickd@umich.
edu

Comment

■ 71 ■■ Firefighter Autopsy Protocol

State/
Territory

Type of System

Title

Deaths Investigated• Violent, whether apparently
homicidal, suicidal, or accidental, including but not limited todeaths due to thermal, chemical,
electrical, or radiation injuries.

I: Background ■Contact

Minnesota

Mixed: County
MedicalExaminers/
Coroners

County Coroner,
MedicalExaminer(Hennepin,
RamseyCounties)

Andrew M. Baker, M.D.
Medical ExaminerHennepin County
530 Chicago Avenue
Minneapolis, MN 55415• Due to criminal abortion, whether (612) 215-6300
Fax: (612) 215-6330
apparently self-induced or not.
Email: andrew.baker@• Under unusual or mysterious
co.hennepin.mn.us
circumstances.
Michael Rossman• Of persons whose bodies are to Executive Secretary
be cremated, dissected, buried
Minnesota Coroners’at sea, or otherwise disposed of and Medical Examiners’
so as to be thereafter unavailAssociation
able for examination.
530 Chicago Avenue• Of inmates of public institutions Minneapolis, MN 55415
who are not hospitalized therein (612) 215-6300
FAX (612) 215-6330
for organic diseases.
Email: michael.rossman@co.hennepin.mn.us

Mississippi

Mixed: State
Medical Examiner
and County
Coroners/Medical
Examiners

State Medical
Examiner,
County Medical
Examiner(Coroner),
County Medical
Examiner
Investigator(Coroner)• Violent, including homicidal,
suicidal, or accidental.

Sam Howell
Administrator
Mississippi Crime• Caused by thermal, chemical,
Laboratory
electrical, or radiation injury.
1700 East Woodrow• Caused by criminal abortion,
Wilson Avenue
including self-induced, orJackson, MS 39216
abortion related to or by sexual(601) 987-1440
abuse.
Fax: (601) 987-1445• Related to disease thought to be Email: showell@mcl.
virulent or contagious which may state.ms.usI
constitute a public health hazard.
• Unexpected or from an unexplained cause.
• Of a person confined in a prison,
jail, or correction institution(autopsy mandatory if prisoner was in custody of State
Correctional System).
• Of a person where physician
was not in attendance within
36 hours preceding death, or in
prediagnosed terminal or bedfast
cases within 30 days.
• Of a person where the body
is not claimed by a relative or
friend.
• Of a person where the identity ofthe deceased is unknown.

Comment

■ 72 ■■ Firefighter Autopsy Protocol

State/
Territory
Mississippi(continued)

Type of System

Title

Deaths Investigated• Of a child under the age of 2
years where death results froman unknown cause or where
the circumstances surrounding
the death indicate that sudden
infant death syndrome may be
the cause of death (autopsy
mandatory).
• Where a body is brought into
this State for disposal and there
is reason to believe either thatthe death was not investigatedproperly or that there is not anadequate certification of death.
• Where a person is admitted to a
hospital emergency room unconscious and/or unresponsive, withcardiopulmonary resuscitative
measures being performed,
and dies within 24 hours ofadmission without regaining
consciousness or responsiveness, unless a physician was
in attendance within 36 hours
preceding presentation to thehospital, or in cases in which the
decedent had a prediagnosed
terminal or bedfast condition,
unless a physician was in attendance within 30 days preceding
presentation to the hospital.

I: Background ■Contact

Comment

■ 73 ■■ Firefighter Autopsy Protocol

State/
Territory
MissouriType of System
Mixed: County
MedicalExaminers/
Coroners

I: Background ■Title

Deaths InvestigatedContact

County Coroner,
County Medical
Examiner

Coroner—In any city of 700,000
or more inhabitants or in any
county of the first or second classin which a Coroner is required,
the Coroner must investigate alldeaths where there is reason tobelieve that death was causedby criminal violence or following
abortion.

Michael A. Graham, M.D.
Medical Examiner
City of St. Louis
1300 Clark Avenue
St. Louis, MO
63103-2718(314) 622-4971
Fax: (314) 622-4933
Email: GRAHAMMA@
slu.edu• By violence by homicide,suicide, or accident.
• By criminal abortion, including
those self- induced.
• By some unforeseen occurrence
and the deceased had not been
attended by a physician during
the 36-hour period preceding thedeath.
• Occurring in any unusual or
suspicious manner.
Medical Examiner—• By violence by homicide,suicide, or accident.
• By criminal abortion, including
those self-induced.
• By disease thought to be ofa hazardous and contagious
nature or which might constitutea threat to public health.
• Suddenly when in apparent good
health.
• When unattended by a physician, chiropractor, or accredited
Christian Science practitioner
during the 36-hour period
preceding the death.
• While in the custody of the law.
• While an inmate of a public
institution.
• Occurring in any unusual or
suspicious manner.

Comment

■ 74 ■■ Firefighter Autopsy Protocol

State/
Territory
MontanaType of System

Title

Mixed: State
Medical Examiner
and County
Coroners/Medical
Examiners

CountyCoroner, Chief
State Medical
Examiner,
Associate
MedicalExaminer

Deaths InvestigatedCoroner—

I: Background ■Contact

Gary Dale, M.D.
State
Medical Examiner• Death caused or suspected to
State
Crime Lab Division
have been caused by an injury,ofForensic
Sciences
either recent or remote in origin.
2679 Palmer Street• Death caused or suspected
Missoula, MT 59808
to have been caused by the(406) 728-4970
deceased or any other person
Fax: (406) 549-1067
that was the result of an act
Email: gdale@state.mt.us
or omission, including, but not
Terry Bullis
limited to, a criminal or susSecretary-Treasurer
pected criminal act; a medically Montana Coroners’
suspicious death, unusual death, Association
or death of unknown circumP.O. Box 318
stances, including any fetal
Hardin, MT 59034-0318
death; or an accidental death.
(406) 665-1207• Death caused or suspected to
M.E. “Mickey” Nelson
have been caused by an agent, Lewis and Clark County
disease, or medical condition
Coronerthat poses a threat to public
228 Broadway St.
health.
Helena, MT 59601-4263(406) 442-7398• Death occurring while theFax: (406) 447-8298
deceased was incarcerated in
Email: MNELSON@a prison or jail or confined to aco.lewis-clark.mt.us
correctional or detention facility
owned and operated by theState or a political subdivision of
the State.
• Death occurring while thedeceased was in the custodyof, or was being taken into thecustody of, a law enforcement
agency or a peace officer.
• Death occurring during or asa result of the deceased’s
employment.
• Death occurring less than 24hours after the deceased wasadmitted to a medical facility orif the deceased was dead upon
arrival at a medical facility.
• Death occurring in a manner thatwas unattended or unwitnessed
and the deceased was notattended by a physician at any
time in the 30-day period prior todeath.

Comment

■ 75 ■■ Firefighter Autopsy Protocol

State/
Territory

Type of System

Title

Montana(cont’d)Deaths Investigated

I: Background ■Contact

Comment• If the dead body is to becremated or shipped into theState and lacks proper medical
certification or burial or transmit
permits.
• Death that occurred under suspicious circumstances.
• Death that is the result of a
judicial order.
• Death that has occurred and nophysician or surgeon licensed
in Montana will sign a deathcertificate.
ChiefState Medical Examiner—
provides assistance and consultation to Coroners.

Nebraska

County Coroner

County Coroner,
CountyCoroner’s
Physician• By criminal means or violence.
• Homicide or suicide.
• By drowning.
• If sudden or unusual.
• If drug-related.
• If sudden infant death syndrome
is suspected.
• When involving the sudden andunexplained death of a childbetween the ages of 1 weekand 3 years, and when neglect,
violence, or any unlawful meansare possible.
• When death is not certified byattending physician.
• When an individual has diedwhile being apprehended byor while in the custody of a law
enforcement officer or detention
personnel.
• Any suspicious, unexplained, or
unattended death.

DeMaris Johnson
Executive Director
Nebraska County
Attorneys Association
Suite 203
1233 Lincoln Mall
Lincoln, NE 68508(402) 476-6047
Fax: (402) 476-2469

In Lancasterand Douglas
Counties,
physicians
have been
appointed toassist in theinvestigations and thesigning of the
medical portion of deathcertificates.
In Douglas
County,the County
Attorney has
appointed
a medical
examiner toinvestigate
deaths byunnaturalcauses.

■ 76 ■■ Firefighter Autopsy Protocol

State/
Territory

Type of System

Title

Deaths Investigated

I: Background ■Contact

Nebraska(cont’d)

NevadaComment
Coroner’s
physicians
sign the deathcertificates.
In Lancaster
County,the County
Attorney hasretained apathologist
who assistsin the investigation by
performing
autopsies andsigning the
medical portion of deathcertificates.

District Coroner

District Coroner• Unattended deaths.

Lary Simms, M.D.
Chief Medical Examiner• Deaths wherein the deceased
Clark County
has not been attended by aphysician in the 10 days before 1704 Pinto Lane
Las Vegas, NV 89106
death. The coroner shall issue
the certificate of death following (702) 455-3210
Fax: (702) 455-0416
consultation with a physician
licensed to practice in the State. Email: LSI@co.clark.
nv.us• Deaths related to or following
Vernon O. McCarty
known or suspected self-induced Washoe County Coroneror criminal abortion.
P.O. Box 11130• Known or suspected homicide,Reno, NV 89520
suicide, or accidental death.
(702) 785-6114
Fax:(775) 785-1468• Deaths known or suspected as
resulting in whole or in part from Email: VMCCARTY@
mail.co.washoe.nv.us
or related to accident or injury.
• Deaths from drowning, fire,
hanging, gunshot, stabbing,cutting, exposure, starvation,
alcoholism, drug addiction,
strangulation, or aspiration.
• Deaths in whole or in partoccasioned by criminal means.
• Deaths in prison.

Although they
have coroner
systems byordinance,
WashoeCounty (Reno)
and ClarkCounty (Las
Vegas) employ
board-certified
forensic
pathologists
who provide
medicalexaminer
services fortheir respective counties,
as well as forother counties
on a fee-forservice basis.

■ 77 ■■ Firefighter Autopsy Protocol

State/
Territory

Type of System

Title

Nevada(cont’d)New
Hampshire

Deaths InvestigatedContact• Deaths under such circumstances as to afford reasonableground to suspect that the death
was caused by the criminal
act of another, or any deaths
reported by physicians or otherpersons having knowledge ofdeath for inquiry by the coroner.
State Medical
Examiner

State Chief
MedicalExaminer,
County Medical
Examiner• By violence or unlawful act.
• In any suspicious, unusual, or
unnatural manner.
• In prison.
• When unattended by aphysician.
• Suddenly when in apparent
health, including those sudden and unexpected deaths ofchildren under 3 years of age
or when sudden infant death
syndrome is suspected.

New Jersey

I: Background ■State Medical
Examiner

State Medical
Examiner,
County Medical
Examiner• By violence whether apparently
homicidal, suicidal, or accidental,
including, but not limited to,deaths due to thermal, chemical,
electrical, or radiation injury.
• Deaths due to criminal abortion,
whether apparently self-induced
or not.
• Not caused by readily recognizable disease, disability, or
infirmity.
• Under suspicious or unusual
circumstances.
• Within 24 hours after admission
to a hospital or institution.
• Of inmates in prison.
• Of inmates of institutions
maintained in whole or in partat the expense of the State or
county where the inmate was not
hospitalized therein for organic
disease.

Thomas Andrew
MD Chief Medical
Examiner
Office of State Chief
Medical Examiner Suite
218
246 Pleasant Street
Concord, NH 03301(603) 271-1235
Fax: (603) 271-6308

Faruk B. Presswalla, M.D.
State Medical Examiner
Office of the State
Medical Examiner
P.O. BOX 094
Trenton, NJ 08625-0094(609) 896-8900
Fax: (609) 896-8697
Email: presswallaf@dcj.
lps.state.nj.us

Comment

■ 78 ■■ Firefighter Autopsy Protocol

State/
Territory

Type of System

Title

New Jersey(cont’d)Deaths Investigated

I: Background ■Contact

Comment• From causes which might constitute a threat to public health.
• Related to disease resulting from
employment or to accident while
employed.
• Sudden or unexpected deathsof infants and children under 3
years of age.
• Fetal deaths occurring without
medical attendance.

New Mexico

New York

State Medical
Examiner

Mixed: County
MedicalExaminers/
Coroners

State Medical
Investigator,
District Medical
Investigator• Sudden, violent, or untimely.

County Coroner,
CountyCoroner’s
Physician,County Medical
Examiner (incounties abolishing coroner
system)Charles S. Hirsch, M.D.
Chief Medical Examiner
City of New York (New• Caused by unlawful act orYork,Bronx, Kings,
criminal neglect.
Queens, and Richmond• Occurring in a suspicious,
Counties)
unusual, or unexplained manner. 520 First Avenue, Room
• Caused by suspected criminal
134
abortion.
New York, NY 10016(212) 447-2034• While unattended by a physiFax: (212) 447-2744
cian, so far as can be discovered, or where no physician isable to certify the cause of deathas provided in public health law
and in form as prescribed by theCommissioner of Health can befound.

• Found dead and the cause ofdeath is unknown or obscure.
• If caused by criminal act oromission.

• By violence, whether criminal
violence, suicide, or casualty.

• Of a person confined in a public
institution other than a hospital,
infirmary, or nursing home.
• Death occurring to an inmate ofa correctional facility.

Ross E. Zumwalt, M.D.
State Chief Medical
Investigator
Office of the Medical
Investigator
State of New Mexico
MSC11 6030
1 University of New
MexicoAlbuquerque, NM
87131-0001(505) 272-3053
Fax: (505) 272-0727
Email:RZumwalt@salud.
unm.eduIn somecounties, there
are multiple
coroners, eachhaving equal
authority.
In Lewis,
Madison,and Oswego
Counties, Statelaw requiresthat the District
Attorney serveas Coroner.

■ 79 ■■ Firefighter Autopsy Protocol

State/
Territory
North Carolina

Type of System

Title

Mixed: State
Medical Examiner
and County
Coroners/Medical
Examiners

Chief Medical
Examiner,
County Medical
Examiner,(Acting) Medical
Examiner

Deaths Investigated

I: Background ■Contact• Homicide.

John D. Butts, M.D.
Chief Medical Examiner• Suicide.
State Department of• Trauma-related.
Health and Human• Accidental.
Services
Office of the Chief• Disaster related.
Medical Examiner• Violence related.
Chapel Hill, NC• Unknown, unnatural, unusual, or 27599-7580
suspicious circumstances.
(919) 966-2253• In police custody, jail, prison, or Fax: (919) 962-6263
Email: jbutts@ocme.unc.
correctional institution.
edu• Poisoning or suspicion of
poisoning.

Comment
North Carolina
has coroners insome counties who work
closely with theState Medical
Examiner.

• Possible public health hazard(such as acute contagious
disease or epidemic).
• Deaths during surgical or
anesthetic procedure.
• Sudden unexpected deaths
which are not reasonably related
to known previous disease.
• Deaths without medical attendance, as defined by statute.
North Dakota

County Coroner

County Coroner• Generally, deaths occurring by
unlawful means or without medical attendance.

Beverly R. Wittman
Deputy State Registrar
and Director• In counties with more than 8,000 Division of Vital Records
North Dakota State
population.
Department of Health• As a result of criminal or violent 600 East Boulevardmeans.
Bismarck, ND 58505• By casualty or accident.
(701) 328-4508
Fax:(701) 328-1850• By suicide.
Email: BWITTMAN@• Suddenly when in apparent good state.nd.usNorth Dakota
health.
• In a suspicious or unusual
manner.
• Occurring without medical
attendance.
• When the Workers’
Compensation Board deems
it necessary under the Crime
Victims Reparation Act.

The office ofCoroner isabolished incounties adopting the County
Manager formof government, with
the County
Manager or
Sheriff assuming the dutiesof the Coroner.
However, if
these duties
conflict withthose performed by theSheriff, thecounty State’sAttorney
assumes theduties of thecoroner.

■ 80 ■■ Firefighter Autopsy Protocol

State/
Territory

Type of System

Title

Deaths Investigated

I: Background ■Contact

NorthernMarina Islands

Not available

Not Available• Not available.

Orana Castro
Director
Office of Vital Statistics
Commonwealth Trial
CourtsP.O. Box 307
Saipan, MP 96950(670) 234-6401

Ohio

Mixed: County
MedicalExaminers/
Coroners

County Coroner• As a result of criminal or otherviolent means.

David P. Corey
Executive Director
Ohio State Coroners
Association
6161 Busch Blvd
Suite #87
Columbus, OH
43229-2508
614-262-OSCA
Fax: 614-888-9767
Email: info@osca.net• By casualty.
• By suicide.
• Suddenly when in apparent
health.
• In any suspicious or unusual
manner.
• Threat to public health.

OklahomaState Medical
Examiner

State Chief
MedicalExaminer,
County Medical
Examiner• By violence, whether apparently
homicidal, suicidal, or accidental,
including, but not limited to,death due to thermal, chemical,
electrical, or radiation injury.

Fred B. Jordan, M.D.
Chief Medical Examiner
901 North Stonewall
Oklahoma City, OK
73117
(405)
239-7141• Due to criminal abortion, whether
Fax:
(405)
239-2430
apparently self-induced or not.
Email: Medical_• Under suspicious, unusual, orExaminer@ocmeokc.
unnatural circumstances.
state.ok.us• Related to disease that might
constitute a threat to publichealth.
• Unattended by a licensed medical or osteopathic physician for afatal or potentially fatal illness.
• Of persons after unexplainedcoma.
• That are medically unexpected
and occur in the course of atherapeutic procedure.
• Of any inmates occurring in any
place of penal incarceration.
• Of persons whose bodies areto be cremated, buried at sea,transported out of State, or otherwise made ultimately unavailable for pathological study.

Comment

Coroners are
not allowed
to actively
practice law
while in office.
Summit County
has a County
MedicalExaminersystem.

■ 81 ■■ Firefighter Autopsy Protocol

State/
Territory

Type of System

Title

Deaths Investigated• Apparently homicidal, suicidal,
or occurring under suspicious or
unknown circumstances.

I: Background ■Contact

OregonState Medical
Examiner

State Medical
Examiner,
County Medical
Examiner

Karen Gunson, M.D.
State Medical Examiner
Medical Examiner• Resulting from the unlawful use Division
Oregon Department ofof dangerous or narcotic drugs
or the use or abuse of chemicals State Police
301 Northeast Knottor toxic agents.
Street• Occurring while incarcerated in
Portland, OR 97212-3092
any jail, correction facility, or in(503) 988-3746
police custody.
Fax: (503) 280-6041• Apparently accidental or follow- Email: karen.gunson@
ing an injury.
state.or.us• By disease, injury, or toxic agent Eugene Gray
exposure during or arising from Forensic Administrator
Medical Examiner
employment.
Division• While not under the care ofOregon Department ofa physician during the period
State Police
immediately previous to death.
301 Northeast Knott• Related to disease which might Street
constitute a threat to the public
Portland, OR 97212-3092
health.
(503) 280-6061
Fax: (503) 280-6041
Email: eugene.gray@state.or.us

Pennsylvania

Mixed: County
MedicalExaminers/
Coroners

County Coroner,
County Medical
Examiner• Sudden deaths not caused byreadily recognizable disease,or wherein the cause of deathcannot be properly certified bya physician on the basis of prior(recent) medical attendance.
• Deaths occurring under suspicious circumstances, including
those where alcohol, drugs,
or other toxic substances may
have had a direct bearing on theoutcome.
• Deaths occurring as a resultof violence or trauma, whether
apparently homicidal, suicidal,
or accidental (including, but notlimited to, those due to mechanical, thermal, chemical, electricalor radiational injury, drowning,cave-ins, and subsidences).

Dennis Kwiatkowski
Secretary Treasurer
Pennsylvania State
Coroners Association
110 Franklin Street
Suite 500
Johnstown, PA 15901(814) 535-622
Fax: (814) 539-9057
Email: coroner@co.cambria.pa.us

Comment

■ 82 ■■ Firefighter Autopsy Protocol

State/
Territory

Type of System

Title

Pennsylvania(cont’d)Deaths Investigated

I: Background ■Contact• Any death in which trauma,
chemical injury, drug overdose,or reaction to drugs or medication or medical treatment was a
primary or secondary, direct orindirect, contributory, aggravating, or precipitating cause ofdeath.
• Operative and perioperative
deaths in which the death is notreadily explainable on the basisof prior disease• Any death wherein the body isunidentified or unclaimed.
• Deaths known or suspected as
due to contagious disease andconstituting a public hazard.
• Deaths occurring in prison or apenal institution or while in thecustody of the police.
• Deaths of persons whose bodies
are to be cremated, buried atsea, or otherwise disposed of soas to be thereafter unavailable
for examination.
• Sudden infant death syndrome.
• Stillbirths.

Puerto Rico

Territorial Medical
Examiner

Director• As a result of criminal acts or
acts that are suspected as such.

Lyvia A. Alvarez, M.D.
Director• As a result of any accident or act Institute of Forensic
Sciencesof violence or any subsequentCall Box 11878
act, regardless of its nature or
Caparra Height Station
time interval between said acts
San Juan, PR 00922
and death, if there is a reasonable doubt that there might have (809) 765-0615(809) 765-4880
been a relation between said
accident or act of violence anddeath.
• As a result of poisoning or
suspicion of poisoning.
• Occurring in custody of thepolice or officers of the law,while in prison, or as a result ofsickness or injury occurring while
in prison, or suspicion thereof.

Comment

■ 83 ■■ Firefighter Autopsy Protocol

State/
Territory
Puerto Rico(cont’d)Type of System

Title

Deaths Investigated• As a result of or in relation to theoccupation of the deceased.
• Due to acute intoxication withalcohol, narcotics, or any type ofdrug or controlled substance orsuspicion of such.
• Due to suicide or suspectedsuicide.
• When in process of an autopsy
that was not originally considered medicolegal, the pathologist discovers any clue, or any
suspicion arises to indicate thatsuch death could have occurred
due to the commission of any
crime.
• Occurring suddenly or unexpectedly, while the person was
enjoying relative or apparent
good health.
• Occurring during or after anabortion or childbearing.
• When the physician who
attended said person while living
cannot reasonably establish thatthe death was due to naturalcauses.
• Occurring during or after
surgical, diagnostic, or therapeutic procedures or where thedeceased was under anesthesia
or recovering from it.
• Occurring during the course of
an illness, if there is a suspicion
that factors extraneous to said
illness could have contributed tothe death.
• Occurring in a convalescenthome, asylum, or similar institution, whether it be commonwealth, municipal, or private.
• Occurring to a person who has
had a contagious disease that
could constitute a threat to publichealth.

I: Background ■Contact

Comment

■ 84 ■■ Firefighter Autopsy Protocol

State/
Territory

Type of System

Title

Puerto Rico(cont’d)Deaths Investigated

I: Background ■Contact• Occurring within 24 hours after
the admission of the patient
to a hospital, clinic, or asylum,
whether it be commonwealth,municipal, or private, whenever
the death cannot be attributed tonatural causes.
• Occurring during hospitalization in a psychiatric institution,
whether it be commonwealth,municipal, or private, except incases of death due to childbirth,duly certified by a physician.
• Death caused by physical force
such as electricity, heat, cold,
radiation, or the effect of chemical products.
• Any death due to malnutrition,
abandonment, or exposure to
the elements, or as a result ofnegligence.
• When the corpse is to becremated, dissected, or it is
to be disposed of in such a
way that it will not be available
subsequently for examination,
regardless of how the deathoccurred.
• When the prosecutor or trial
judge investigating the death
requests an autopsy.

Rhode Island

State Medical
Examiner

State Medical
Examiner• By homicide, suicide or casualty. Elizabeth A. Laposata,M.D.
• Due to a criminal abortion.
State Medical Examiner• Due to an accident involving
Office of State Medicallack of due care on the part of a Examiner
person other than the deceased. Rhode Island Department• Which is the immediate orof Healthremote consequences of any
48 Orms Street
physical or toxic injury incurred
Providence, RI 02904
while the deceased person was (401) 222-5500
employed.
Fax: (401) 222-5517

Comment

■ 85 ■■ Firefighter Autopsy Protocol

State/
Territory

Type of System

Title

Rhode Island(cont’d)Deaths Investigated

I: Background ■Contact

Comment

Debbie Johnson
Executive Director
South Carolina Coroners
Association
301 University Ridge,
Suite 2300
Greenville, SC 29601(864) 467-7446
Fax: (864) 467-7469

In counties withpopulationsof 100,000
or more, thegoverning bodyof that county
can chose tohave a Medical
Examinersystem.

• Due to the use of addictive or
unidentifiable chemical agents.
• Due to an infectious agent
capable of spreading an
epidemic within the State.
• When unattended by aphysician.

South Carolina

Mixed: County
Coroner andMedical Examiner

County Coroner,
County Medical
Examiner• By violence.
• By suicide.
• When in apparent good health.
• When unattended by aphysician.
• In any unusual or suspicious
manner.
• While an inmate in a penal orcorrectional institution.
• As a stillbirth, medicallyunattended.

South Dakota

County Coroner

County Coroner• By unnatural means, including
all deaths of accidental, homicidal, suicidal, and undeterminedmanner, regardless of suspectedcriminal involvement in thedeath.

Kathlene A. Mueller
Manager, Office of
Data, Statistics and Vital
Records
State Department of
Health600 East Capitol Avenue• Identity of victim is unknown or
Pierre, SD 57501-3182
the body is unclaimed.
(605) 773-3361• Inmates of any state, county or
Fax: (605) 773-5683
municipally operated correctional Email: KATHIMU@doh.
facility, mental institution orstate.sd.us
special school.
• Those believed to represent a
public health hazard.
• Children under 2 years of age
resulting from unknown cause orif circumstances suggest sudden
infant death syndrome as thecause.
• Natural deaths if the decedent is
not under the care of a physician
or the decedent’s physician does
not feel qualified to sign thedeath certificate.

■ 86 ■■ Firefighter Autopsy Protocol

State/
Territory
Tennessee

Type of System
State Medical
Examiner

Title
State Chief
MedicalExaminer,
Deputy Chief
MedicalExaminer,
AssistantChief Medical
Examiner,
County Medical
Examiner

Deaths Investigated• From sudden violence.
• By casualty.
• By suicide.
• Suddenly when in apparent
health.
• When found dead.
• In prison.
• In any suspicious, unusual, or
unnatural manner.
• Where the body is to becremated.

I: Background ■Contact
Bruce Levy, M.D.
State Chief Medical
Examiner
State of Tennessee
Center for Forensic
Medicine
850 R.S. Gass Blvd.
Nashville, TN
37216-2640(615) 743-1800
Fax: (615) 743-1890
Email: blevy@forensicmed.com• For workers compensation
claims if cause of death is
obscure or disputed.
Texas

Mixed: County
MedicalExaminers/
Coroners

County Justiceof the Peace,
County/District Medical
Examiner

Justice of the Peace—• In prison or jail.
• When a person is killed, or fromany cause dies an unnatural
death, except under sentence ofthe law.
• In the absence of one or moregood witnesses.
• When found dead, the circumstances of death unknown.
• When the circumstances are
such as to lead to suspicion of
unlawful means.
• By suicide or suspected suicide.
• When unattended by a duly
licensed and practicing physician
and the local health officer orregistrar required to report thecause of death does not know
the cause of death.
• When the attending physician(s)cannot certify the cause ofdeath.
Medical Examiner—• Same as above, and in addition, any death within 24 hours
after admission to a hospital or
institution.

Vincent J.M. DiMaio,
M.D.
State Chief Medical
Examiner
Bexar County Forensic
Science Center
7337 Louis Pasteur
San Antonio, TX
78229-4565(210) 615-2100

Comment

■ 87 ■■ Firefighter Autopsy Protocol

State/
Territory

Type of System

Title

U.S. Virgin
Islands

Territorial Medical
Examiner

MedicalExaminer

Deaths InvestigatedContact• Unnatural deaths as prescribedby law.

James Glenn, M.D.
Medical Examiner
Office of the Medical
Examiner
U.S. Virgin Islands
Department of JusticeToro Building
3008 Golden Grove
Christiansted
St. Croix, VI 00820(809) 778-6311
Francisco Landron, M.D.
Medical Examiner
Office of the Medical
Examiner
U.S. Virgin Islands
Department of Justice8050 Kronprindsens
Gade
St. Thomas, VI 00802(809) 744-5666 ext. 663(809) 776-8311• From violence, whether criminal,suicide or casualty.
• Unlawful act or criminal neglect.
• Suspicious, unusual, or unexplained manner.
• Suspect criminal abortion.
• Death unattended by physician
or where cause of death unable
to be certified as provided bylaw.
• When confined to a public
institution other than hospital,
infirmary, or nursing home.
• As prescribed by the Governoror Attorney General.

Utah

State Medical
Examiner

I: Background ■• By violence, gunshot, suicide,or accident (except highway
accidents).

Todd C. Grey, M.D.
State Medical Examiner
Utah Department of
Health• Suddenly when in apparent
48 North Medical Drive
health.
Salt Lake City, UT 84113• When unattended (not seen by a (801) 584-8410
physician within 30 days).
Fax: (801) 584-8435• Under suspicious or unusual
Email:hldels.tgrey@state.
circumstances.
ut.usa• Resulting from poisoning or
overdose of drugs.
• Resulting from diseases that
may constitute a threat to publichealth.
• Resulting from disease, injury,
toxic effect, or unusual exertion
incurred within the scope of thedeceased’s employment.
• Due to sudden infant death
syndrome.

Comment

■ 88 ■■ Firefighter Autopsy Protocol

State/
Territory

Type of System

Title

Deaths Investigated

I: Background ■Contact• Resulting when the deceased
was in prison, jail, police
custody, the State hospital, ora detention or medical facility operated for the treatmentof mentally ill or emotionally
disturbed or delinquent persons.
• Associated with diagnostic andtherapeutic procedures.
• Involving questions of civil liability, in accordance with provisionsof the Worker’s Compensation
Act.
Vermont

State Medical
Examiner

Chief Medical
Examiner,
Regional
MedicalExaminerPaul L. Morrow, M.D.
• Suddenly when in apparent good State Chief Medical
Examiner Department ofhealth.
Health• When unattended by a
Baird 1 111 Colchester
physician.
Ave.
• By casualty.
Burlington, VT 05401(802) 863-7320• By suicide.
Fax: (802) 863-7265• As a result of injury.
Email: pmorrow@vdh.
• When in jail, prison, or any
state.vt.us
mental institution.
• From violence.

• In any unusual, unnatural, or
suspicious manner.
• In circumstances involving a
hazard to public health, welfare,or safety.

Comment

■ 89 ■■ Firefighter Autopsy Protocol

State/
Territory
Virginia

Type of System
State Medical
Examiner

Title
State Chief
MedicalExaminer,
County/City Medical
Examiner

Deaths Investigated

I: Background ■Contact• By trauma, injury, violence,poisoning, accident, suicide, or
homicide.

Marcella Farinelli Fierro,
M.D.
State Chief Medical• Suddenly when in apparent good Examiner
Department of Healthhealth.
Office of the State Chief• When unattended by a
Medical Examiner
physician.
400 East Jackson Street• In jail, prison, other correctional Richmond, VA
institution or in police custody.
23219-3694• Suddenly as an apparent result (804) 786-3174
Fax: (804) 371-8595
of fire.
Email: mfierro@vdh.
• In any suspicious, unusual, or
state.va.us
unnatural manner.
• The sudden death of any infant
less than 18 months of age
whose death is suspected as
due to SIDS.
• When the body shall be cremated or buried at sea.
• Fetal death not attended by aphysician.

Washington

Mixed: County
MedicalExaminers/
Coroners

County Coroner,
County Medical
Examiner• Those in which the Coroner
suspects that the death was
unnatural, or violent, or resulted
from unlawful means, or fromsuspicious circumstances, or
was of such a nature as toindicate the possibility of deathby the hand of the deceased or
through the instrumentality ofsome other person.

Richard Harruff, M.D.,
Ph.D.
Chief Medical Examiner,
King County
325 Ninth Avenue HMC
Box 35792
Seattle, WA 98104(206) 731-3232
Fax: (206) 731-8555
Email: richard.harruff@• Those occurring suddenly when metrokc.gov
Dan Blasdel, President
in apparent good health andWashington Association
without medical attendance
within 36 hours preceding death. of Coroners and Medical
Examiners• Those resulting from unknown or 1016 North 4th Avenue
obscure causes.
Pasco, WA99301• Those occurring within 1 year(509) 546-5885
following an accident.
Fax: (509)546-5812,• Those as a result of any violence page (509) 530-6906
Email: dblasdel@3-cities.
whatsoever.
com• Those resulting from a known
or suspected abortion, whether
self-induced or otherwise.

Comment

■ 90 ■■ Firefighter Autopsy Protocol

State/
Territory

Type of System

Title

Washington(cont’d)Deaths Investigated

I: Background ■Contact• Those apparently resulting fromdrowning, hanging, burns, electrocution, gunshot wounds, stabs
or cuts, lightning, starvation,
radiation, exposure, alcoholism,
narcotics or other addictions,tetanus, strangulation, suffocation, or smothering.
• Those due to premature birth orstillbirth.
• Those due to virulent orsuspected. contagious disease
which may be a public healthhazard.
• Those resulting from allegedrape, carnal knowledge, or
sodomy.
• Those occurring in a jail or
prison.
• Those in which a body is founddead or is not claimed by relatives or friends.
• Industrial deaths when causeof death is unknown andinvestigation is requested by
the Department of Labor andIndustries.

West Virginia

State Medical
Examiner

State Chief
MedicalExaminer,
Deputy Chief
MedicalExaminer,
County Medical
Examiner• From violence or suspected violence, or where natural diseasecannot be assumed.
• When unattended by aphysician.
• When during incarceration,
protective custody, as a wardof the State, or associated with
police intervention.
• From disease or environmental
condition which might constitutea threat to the public health.
• When in any suspicious,
unusual, or unnatural manner.
• In deaths thought to be due to,or associated with, suspectedabuse or neglect.

James Kaplan, M.D.
State Chief Medical
Examiner
State of West Virginia
Office of the Chief
Medical Examiner
701 Jefferson Road
South Charleston, WV
25309(304) 558-3920
Fax: (304) 558-7886
Email: jkaplan@wvdhhr.
org

Comment

■ 91 ■■ Firefighter Autopsy Protocol

State/
Territory
Wisconsin

Type of System
Mixed: County
MedicalExaminers/
Coroners

Title

Deaths InvestigatedCounty Coroner,
County Medical
Examiner• If circumstances are unexplained, unusual, or suspicious.

I: Background ■Contact

Tom Terry, M.D.
President
Wisconsin
Coroner• By homicide or manslaughter,andMedicalExaminer
including death resulting from
Association
reckless conduct, negligent
730 Wisconsin St
control of a vicious animal, orRacine, WI 53403
negligent use of a firearm.
(262) 636-3303• By suicide.
Fax: (262) 636-3728• Following an abortion.
Email: TOMT@racineco.
• By poisoning, whether homicidal, com
suicidal, or accidental.
• Following accidents, whether
the injury is or is not the primarycause.
• When a physician or accredited
practitioner of a bona fide religious denomination relying upon
prayer or spiritual means forhealing was not in attendance
within 30 days preceding death,or if the deceased was not being
treated for the condition causing
death.
• When a physician refuses tosign the death certificate.
• When a physician cannot be
obtained to sign the medical
certification of death.
• At the request of the Worker’s
Compensation Department.

Comment
Counties witha Medical
Examiner
include thosehaving a
populationof 500,000
or more, andthose thathave chosen tohave a Medical
Examinersystem.

■ 92 ■■ Firefighter Autopsy Protocol

State/
Territory
WyomingType of System

Title

County Coroner

County Coroner

Deaths Investigated• Violent or criminal action.
• Apparent suicide.
• Accident.
• Apparent drug or chemical
overdose or toxicity.
• The deceased was unattended
or had not seen a physician
within 6 months prior to death.
• Apparent child abuse causes.
• The deceased was a prisoner,
trustee, inmate, or patient of
any county or state corrections
facility or state hospital.
• If the cause is unknown.

I: Background ■Contact
Donald B. Pierson
Executive Director
Wyoming Peace Officers
Standards and Training
Commission
1710 Pacific Avenue
Cheyenne, WY 82002(307) 777-7718
Fax: (307) 638-9706
Email: wypost@sisna.com
James W. Thorpen, M.D.
Chairman
Wyoming Board ofCoroner Standards
County Building
200 North Center St,
Suite 10
Casper, WY 82601-1949(307) 235-9458
Fax: (307) 235-9608
Email: coroner@natrona.
net

SOURCE: all information was obtained from http://www.cdc.gov/epo/dphsi/mecisp/death_investigation.htm

Comment■■Appendix B: Niosh Firefighter Fatality
Reports—Autopsy InformationT

he NIOSH Fire Fighter Fatality Investigation and Prevention Program (FFFIPP) investigates firefighter
line-of-duty fatalities. The purpose of this investigative program is, according to the FFFIPP Web site(http://www.cdc.gov/niosh/fire/implweb.html), threefold:”Better define the magnitude and characteristics of line-of-duty deaths among fire fighters””Develop recommendations for the prevention of deaths and injuries””Disseminate prevention strategies to the fire service”
The FFFIPP reports include specific details about the circumstances surrounding the fatalities as well as
medical information including cause of death and pertinent autopsy results, when available.
This summary concentrates on investigations completed in the years 2000 through 2006; a few of
the year 2000 investigations related to incidents in 1998 and 1999. The following table includes foreach investigation the NIOSH Report Number, Date of Incident, Title, and Cause of Death, and includes
notations about whether an autopsy was performed and autopsy findings. A link to each report’s PDF file,available online, is provided. When the death certificate and autopsy listed differing causes of death, bothare included in the table.
Most reports specifically mention the autopsy (or lack thereof). However, about one-third of the reports
did not mention the autopsy outright. For some of those cases, postmortem toxicological specimen
analysis, typically for carboxyhemoglobin level, was noted; however, the specimen was not necessarily
obtained as part of an autopsy.
Approximately 280 FFFIPP reports were reviewed for recommendations or comments related to
autopsy procedures and protocols. The most common comment specific to autopsy protocols was therecommendation to “perform autopsies on all on-duty fire fighter fatalities.” This was noted on about twodozen cases involving cardiovascular deaths. No other recommendations were made for specific protocols
or procedures for the autopsy itself, or for the postautopsy storage of tissue samples, etc. However,carboxy-hemoglobin levels were mentioned numerous times with a comment that postmortem levels wereartificially low in a case in which the victim had received oxygen therapy prior to death.

■ 93 ■

Volunteer firefighter dies after Blunt-force headbeing struck by a shackle on trauma
a recoiling tow rope—South
DakotaCareer lieutenant diesin residential structure
fire—Colorado

Volunteer firefighter is killed
and another volunteer
firefighter is injured at awildland/urban interface
fire—Oklahoma
Volunteer firefighter dies intanker rollover crash—Texas
One career firefighter diesand two are injured in apparatus crash—California

Apr 8,
2006

May 14,2006

Mar 1,
2006

Nov 22,
2005

Aug 6,
2005

F2006-22

F2006-19

F2006-10

F2006-06

F2005-28

Yes

Not mentioned

Yes

Not mentioned

Not mentioned

Not mentioned

Not mentioned

AUTOPSY

None

None

None

None

None

None

None

AUTOPSY COMMENTS

F200528PDF

F200606PDF

F200610PDF

F200619PDF

F200622PDF

F200626PDF

F200701PDF

PDF
LINK

■ 94 ■

Multiple blunt-force
trauma to the torso

Open skull fracture
resulting from an
automobile accident

Complications from theburns he received toover 45% of his bodyComplications fromhypoxic encephalopathy (lack of oxygento the brain) due
to apparent smoke
inhalation

Smoke inhalation andthermal burns

Career engineer dies andfirefighter injured after
falling through floor while
conducting a primary searchat a residential structure
fire—Wisconsin

Aug 13,2006

F2006-26

Blunt-force trauma

CAUSE OF DEATH

Career firefighter dies andchief is injured when struckby 130-foot awning that collapses during a commercial
building fire—Texas

Title

Dec 30,2006

DATE OFINCIDENT

F2007-01

NIOSH
REP. #

RTS■ Firefighter Autopsy Protocol
I: Background ■Junior volunteer firefighter
dies and three volunteer
firefighters are injured in atanker crash—Alabama
Career lieutenant suffers
sudden cardiac death at
his home after finishing his
shift—Tennessee

Career airport fire apparatus
operator suffers sudden
cardiac death at his station
after exercising—Georgia

Mar 09,2006

Apr 16,2006

F2006-21

F2006-20

Title

Jul 26,
2006

DATE OFINCIDENT

F2006-25

NIOSH
REP. #

Acute Respiratory
Distress Syndrome due
to an acute myocardial
infarction (MI)Hypertensive heartdiseaseBlunt force trauma withhead and chest injuries

CAUSE OF DEATH

Yes

Yes

Not mentioned

AUTOPSY• No pulmonary embolus

PDF
LINK

■ 95 ■• Cardiomegaly (enlarged heart): heart weight of 600 grams(g) (the normal weight given in the autopsy records is
250-350 g)– Moderate atherosclerosis of circumflex artery– Moderate atherosclerosis of right coronary artery– Stent in place, proximal left anterior descending coronary artery, with a luminal thrombus• Atherosclerotic
CADo Moderate to severe atherosclerosis of distal left
anterior descending artery– Focal acute extension of the infarct• Acute MIo Massive infarct of the left ventricle, extending
from the apex to the base of the heart• No evidence of a pulmonary embolus• No evidence of thrombosis (blood clots) in his coronary
arteries• Mild aortic sclerosis• Moderate to severe coronary artery disease (CAD) with
75% narrowing of the left anterior descending (LAD)
artery• Mild bilateral dilatation of left and right ventricles (nomeasurements were listed)• Myocardial perivascular and patchy interstitial fibrosis– left ventricle thickness was 1.5-2.0 centimeters (cm)(normal thickness is 0.6-1.1 cm)1

• LVH

• Cardiomegaly (enlarged heart): heart weight of 441 grams(g) (normal weight is <400 g)

None

AUTOPSY COMMENTS■ Firefighter Autopsy Protocol
I: Background ■Firefighter/emergency
medical technician (ff/emt)
suffers sudden death while
on-duty—South Carolina

Firefighter suffers heart
attack during firefighting
operation and dies 40 days
later—Georgia

May 03,2006

F2006-17

Title

Mar 31,2006

DATE OFINCIDENT

F2006-18

NIOSH
REP. #“Hemodynamic failure”
due to “healing andremote myocardial
infarctions (mis)” due
to “atherosclerotic
coronary arterydisease (CAD)”

Per autopsy findings:“sudden unexplained
ventricular arrhythmia
or possible seizure.”

Per death certificate:“probable cardiac
arrhythmia,” due to“seizures,” due to“epilepsy.”

CAUSE OF DEATH

Yes

Yes

AUTOPSY• No chamber dilation or hypertrophy• No valve abnormalities

PDF
LINK

■ 96 ■– Recent plaque hemorrhage and rupture of the proximal portion of the LAD– Atherosclerotic lesions (50%—60% blockage) in mostof the coronary arteries– Recent MI in the anteroseptal portion of the left
ventricle– Old (healed) MI in the lateral portion of the left
ventricle– Normal-sized heart at 400 grams• Atherosclerotic CAD

The phenobarbital level of 8.9 micrograms per milliliter(µg/mL) was sub-therapeutic for a seizure disorder(10-30 µg/mL). A blood level for dilantin was not conducted.
These autopsy findings did not point to a definitive causeof death, therefore the county coroner concluded the FF/
EMT most likely died of a “sudden unexplained ventriculararrhythmia or possible seizure.”• Positive blood drugs test for methobarbitol andphenobarbital.

• Negative blood drug test for illegal• No evidence of an intra-cranial hemorrhage (stroke)• No evidence of a pulmonary embolus (blood clot in thelung arteries)• No microscopic evidence of cardiomyopathy (a medical
condition that is associated with an increased risk of sudden cardiac death)• Two coronary arteries (the left anterior descending andthe right coronary artery) had “small diameters within theirdistal distribution”• No plaque, atherosclerosis, or blockages in any of thecoronary arteries• Normal sized heart, 350 grams (normal < 400 grams)

AUTOPSY COMMENTS■ Firefighter Autopsy Protocol
I: Background ■Fire apparatus operator
suffers sudden cardiac
death after responding to 12
calls—Georgia

Assistant chief suffers astroke during training anddies—Texas
Volunteer firefighter suffers
sudden cardiac death about
50 minutes after fighting a
grass fire—Kansas

Apr 03,2006

Jan 14,2006

F2006-15

F2006-13

Title

Jul 07,
2005

DATE OFINCIDENT

F2006-16

NIOSH
REP. #

Probable heritablecardiac arrhythmia(Brugada Syndrome)

Brain death due tobrain aneurysm“Cardiac dysrhythmia
due to atherosclerotic
coronary arterydisease (CAD)”

CAUSE OF DEATH

Yes

No

Yes

AUTOPSY• No pulmonary embolus• Coronary arteries free of significant atherosclerosis or
thrombus• Cardiomegaly (heart weighed 478 grams [g]; normal
range is 261-455 g)• Probable heritable cardiac arrhythmia (Brugada
Syndrome)

Perform an autopsy on all duty-related firefighter fatalites• Negative drug and alcohol tests• No evidence of thromboemboli in the pulmonary arteries• Microscopic examination of the left ventricle revealed“patchy transmural myocardial fibrosis.” “Similar but lesser
changes were noted in the right ventricular myocardium,
where fibrosis was primarily perivascular.”– Left ventricular hypertrophy– Cardiomegaly (enlarged heart: heart weighed 660
grams– Variable calcific atherosclerosis of the right coronary
artery with a 40% blockage– Variable calcific atherosclerosis of the left anterior
descending coronary artery with a 90% blockage• Atherosclerotic CAD

AUTOPSY COMMENTS

PDF
LINK

■ Firefighter Autopsy Protocol■ 97 ■
I: Background ■TitleCareer battalion chief suffers
sudden cardiac death at his
desk—Kansas

Firefighter dies after
performing overhaul ata fire in a three-story
dwelling—Pennsylvania

DATE OFINCIDENT

Nov 15,2004

Jan 28,2006

F2006-12

F2006-09

NIOSH
REP. #“Arteriosclerotic
cardiovascular disease(CVD)” as the immediate cause of deathand “hypertensive
cardiomyopathy” as asignificant condition

Atherosclerotic
cardiovascular disease(CVD)

CAUSE OF DEATH

Yes

Yes

AUTOPSY• Carboxyhemoglobin (COHb) level (measure of carbon
monoxide in the blood) of 3.7% (normal for smokers)• No evidence of smoke inhalation• No sign of a pulmonary embolus (blood clot in the lung)• No valvular disease• A discrete 2 cm x 1 cm scar in the subendocardial anddeep myocardium of the left ventricular wall (proximal
medial posterior) suggesting a remote (old) heart attack(myocardial infarction [MI])• Mild concentric left ventricular hypertrophy with wall
thickness being 1.9 centimeters [cm]; normal thickness is0.6-1.1 cm• Arteriosclerotic CAD• Cardiomegaly (heart weighing 450 grams [g]; normal
weight is <400 g)• No evidence of a pulmonary embolus.

• Mild fibrous thickening of the cusps of the aortic valve• No evidence of thrombosis• Two vessel coronary artery disease (CAD) with 50%-75%
narrowing of the left anterior descending and right coronary arteries by atherosclerotic plaque• Essentially normal endocardium, myocardium, and epicardium tissue.

• Left ventricular hypertrophy (LVH)• Cardiomegaly (enlarged heart): heart weighed 534 grams

AUTOPSY COMMENTS

PDF
LINK

■ Firefighter Autopsy Protocol■ 98 ■
I: Background ■Firefighter/Emergency
medical technician suffers an acute myocardial
infarction and dies 3 days
later—Pennsylvania

Two volunteer firefighters die when struck by
exterior wall collapse at acommercial building fire
overhaul—Alabama
Career firefighter dies afterengine he was driving
collides with a tractor
trailer—Alabama
Career lieutenant suffers
sudden cardiac death at
his station after making
multiple runs during the
day—Tennessee

Feb 21,
2006

Nov 28,2005

Oct 24,2005

F2006-07

F2006-05

F2006-04

Title

Nov 21,2005

DATE OFINCIDENT

F2006-08

NIOSH
REP. #

Cardiac arrhythmia as
the immediate cause ofdeath due to hypertensive cardiovasculardiseaseBlunt-force injuries.

Multiple blunt-force
traumaPer death certificate:“atherosclerotic heartdisease” due to “acute
myocardial infarction”
as the cause of death.
Perautopsy: “arteriosclerotic cardiovasculardisease (CVD) withacute myocardial
infarction; pulmonary
emboli” as the cause ofdeath.

CAUSE OF DEATH

Yes

Not mentioned

Yes

Yes

AUTOPSY• No pulmonary embolus• Normal heart valves• Patent coronary arteries with mild atherosclerosis and no
intracoronary thrombosis• Microscopic examination of the left ventricular myocardium (three sections) showed myocyte hypertrophy andsmall foci of subendocardial interstitial fibrosis (findings
consistent with hypertensive heart disease)• Left ventricular hypertrophy• Cardiomegaly (enlarged heart) based on a weight of 700
grams

None

None

• Microscopic evidence of thromboemboli in the pulmonary
arteries with pulmonary infarction• Microscopic examination revealed an “early thrombus at
the site of the ventricular infarction”• Biventricular hypertrophy• Cardiomegaly (enlarged heart: heart weighed 550 grams[g]• Extensive left ventricular MI• Arteriosclerotic CVD

AUTOPSY COMMENTS

PDF
LINK

■ Firefighter Autopsy Protocol■ 99 ■
I: Background ■Firefighter suffers sudden cardiac death
during fire fighting
operations—California

Lieutenant suffers sudden
cardiac death after scba
training—Florida

Fire chief suffers sudden death
during training—Alabama

May 27,2005

May 13,
2004

F2006-02

F2006-01

Title

Nov 05,2005

DATE OFINCIDENT

F2006-03

NIOSH
REP. #

Accidental multiple
drug intoxication

Atherosclerotic
cardiovascular disease(CVD)

Atherosclerotic
cardiovascular disease(CVD)

CAUSE OF DEATH

Yes

Yes

Yes

AUTOPSY• No microscopic examinations were performed.

• Positive urine test for gabapentin (Neurontin®)

PDF
LINK

■ 100 ■• Positive blood tests for diazepam (Valium®), morphine(MS Contin®), venlafaxine (Effexor®) and methocarbamol(Robaxin®)• No evidence of thrombo-emboli in the pulmonary arteries• No evidence of thrombus in the coronary arteries• Moderate to marked pulmonary edema• Mild atherosclerosis• Enlarged heart (cardiomegaly): heart weighed 520 grams(g)• Negative drug and alcohol tests• Negative carboxyhemoglobin test

• No evidence of thromboemboli in the pulmonary arteries• Acute pulmonary edema• Microscopic examination of the coronary arteries revealed
an “apparent thrombus material identified in the lumen”
with “evidence of re-canalization” (suggestive of a remote[old] myocardial infarction))• Moderate cardiomegaly (enlarged heart: heart weighed
430 grams• Atherosclerotic CVD• Negative drug and alcohol tests• Negative carboxyhemoglobin test

• No evidence of a premortem pulmonary thromboemboli(i.e., blood clots in the lungs)• Enlarged heart (cardiomegaly): heart weighed 450 grams (g)• Atherosclerotic CVD with complete narrowing (100%) of
the right coronary artery and severe narrowing (75%) of
the left main coronary artery and the left anterior descending coronary artery; no evidence of an intra-coronary
blood clot (thrombus), but thrombolytic medications were
given in the ED

AUTOPSY COMMENTS■ Firefighter Autopsy Protocol
I: Background ■Career captain dies and thedriver/operator and a firefighter are severely injured inapparatus crash—Louisiana
Career firefighter killed whileriding manlift to assess a silo
fire—Missouri

Captain suffers pulmonary
embolism during response
to a medical call and later
dies—New YorkNov 07,2005

Nov 04,2005

F2005-34

F2005-33

Title

Dec 02,
2005

DATE OFINCIDENT

F2005-35

NIOSH
REP. #

Pulmonary emboli (PE)due to probable deepvein thrombosis (DVT)

Positional asphyxia
due to entrapment
between the manlift
and floor access
opening

Multiple blunt-force
trauma and compressed asphyxiation

CAUSE OF DEATH

Yes

Not mentioned

Yes

AUTOPSY• Negative drug screen• No microscopic examination of the heart muscle was
performed• Cardiomegaly (enlarged heart): heart weighed 540 grams(g) (normal is <400 g)3– Right ventricle walls slightly thickened/hypertrophied(0.6 cm)– Left ventricle walls slightly thickened/ hypertrophied(1.6 centimeters [cm]) (normal is 0.6 cm–1.1 cm)1

– No significant coronary artery atherosclerosis• Evidence of diffuse PE in both lungs
Swollen right lower leg
Mild hypertensive CVD:

None

None

AUTOPSY COMMENTS

PDF
LINK

■ Firefighter Autopsy Protocol■ 101 ■
I: Background ■Firefighter suffers sudden“Calcific sclerosis ofcardiac death during physical the aortic valve withfitness training—New Jersey aortic stenosis” as thecause of death, with“atherosclerotic coronary artery disease(CAD)” as a significant
condition
Volunteer firefighter/rescue
diver dies in training incident
at a quarry—Pennsylvania

May 31,
2005

Aug 27,
2005

F2005-30

F2005-29

Drowning

Per autopsy: “hypertensive/ischemic
cardiovascular disease(CVD)” as the cause ofdeath

Per death certificate:“acute myocardial
infarction (MI)”CAUSE OF DEATH

Sergeant suffers sudden cardiac death during
training—Kentucky

Title

Mar 16,2005

DATE OFINCIDENT

F2005-32

NIOSH
REP. #

Not mentioned

Yes

Yes

AUTOPSY

None• No evidence of a premortem pulmonary thromboemboli
Negative drug and alcohol tests• Severe narrowing (75%) of the left anterior descending
coronary artery• Atherosclerotic CAD• Enlarged heart (cardiomegaly): heart weighed 580 grams(g) (normal is <400 g)1• Calcific sclerosis of the aortic valve with aortic stenosis• Acute pulmonary congestion• Extensive old MI of left ventricular free wall

• Old MI of lateral wall of left ventricular free wall, posterior
aspect of left intraventricular septum• Diffuse myocardial fibrosis

Microscopic examinations revealed the following:• Negative drug and alcohol tests• No evidence of thrombo-emboli• No evidence of thrombus• Mitral valve showed thickening of chordae tendineae– Left ventricle measured 3 cm (normal is 0.76–0.88cm)3 (normal echocardiographic measurement is
0.6–1.1 cm)4

– Right ventricle measured 1 centimeter (cm) (normal is0.3-0.5 cm)2

• Biventricular hypertrophy• Enlarged heart (cardiomegaly): heart weighed 500 grams(g) (normal is <400 g)1• Hypertensive/ischemic CVD

AUTOPSY COMMENTS

PDF
LINK

■ Firefighter Autopsy Protocol■ 102 ■
I: Background ■Recruit firefighter suffers heat Severe heat stroke
stroke during physical fitness with multisystem organ
training and dies nine days
failurelater—Florida
Fire chief suffers sudden
cardiac death at home
after performing apparatus
maintenance and conducting
training—Texas

May 19,2005

Feb 23,2005

F2005-26

F2005-25

Severe three vessel
atherosclerotic coronary artery disease(CAD)

Blunt force injuries tothe head and torso

Volunteer fire chief dies frominjuries sustained during atanker rollover—Utah

Jun 21,
2005

F2005-27

CAUSE OF DEATH

Title

DATE OFINCIDENT

NIOSH
REP. #YesNo

Not mentioned

AUTOPSY• No evidence of a dissecting aortic aneurysm• No pulmonary embolism• Cardiomegaly (enlarged heart): heart weighed 460 grams(normal < 400 grams)1• Right ventricle chamber mildly dilated• Three vessel focal severe atherosclerotic CAD• Atherosclerotic CAD:

None

None

AUTOPSY COMMENTS

PDF
LINK

■ Firefighter Autopsy Protocol■ 103 ■
I: Background ■“Aortic dissection
and its sequelae”
with “Hypertensive
cardiovasculardisease” being anothersignificant condition

Firefighter/paramedic suffers
a dissection of his aorta
while participating in physicalfitness training—Texas

Mar 29,2005

F2005-23

CAUSE OF DEATH

Firefighter dies after respond- “Acute intoxication
ing to a call—New Yorkby the combined
effects of propoxyphene (Darvon®)and cyclobenzaprine(Flexeril®)” as thecause of death and“hypertension” asanother condition.
The NIOSH investigator, like the medical
examiner, concluded
the FF died due to adrug intoxication, butcannot rule out thepossibility of a cardiac
arrhythmia associatedwith his hypertensive
heart disease and subsequent left ventricular
hypertrophy (LVH).

Title

Feb 06,2005

DATE OFINCIDENT

F2005-24

NIOSH
REP. #Yes

Yes

AUTOPSY• Negative blood tests for illicit drugs or alcohol• No atherosclerotic coronary artery disease• Concentric left ventricular hypertrophy• Cardiomegaly (a large heart)• Extent of the dissection: from proximal left and rightcoronary artery at the aortic root to the right common iliac
arteryMicroscopic examination of the heart revealed myocyte
hypertrophy (consistent with mild hypertensive cardiomyopathy) but no infarcts or myocarditis. The autopsy did
not mention “myocytes in disarray,” which is diagnostic ofhypertrophic cardiomyopathy• No evidence of pulmonary embolus• No evidence of atherosclerotic coronary artery disease(CAD)– Cardiomegaly (heart weight 500 grams [normal < 400grams])3– Left ventricular hypertrophy (LVH)(left ventricle wall thickness 1.5 centimeters [cm]) [normal
0.6cm–1.1cm])2• Hypertensive cardiovascular disease:– Cyclobenzaprine (Flexeril®) blood level of 90 nanograms per milliliter (ng/mL) and Norcyclobenzaprinewith a positive blood level– Propoxyphene (Darvon®) blood level of 3.3 micrograms per milliliter (mcg/mL) and Norpropoxyphene
blood level of 9.0 mcg/mL• Acute intoxication by the combined effects of propoxyphene and cyclobenzaprine CAD:AUTOPSY COMMENTS

PDF
LINK

■ Firefighter Autopsy Protocol■ 104 ■
I: Background ■Firefighter/Emergency medi- “Oxycodone intoxicacal technician dies during the tion” as the causenight at fire station—Arizona of death with “mildthickening of the mitralvalve” and “mild diffuse
nephrosclerosis” asother conditions.

Jun 23,2005

F2005-20

Left anterior descending coronary artery
thrombosis

Wildland firefighter suffers
sudden cardiac death after
performing mop-up/overhaul
operations at two wildland
fires—Florida

Feb 21,
2005

F2005-21

Mitral valve failure

CAUSE OF DEATH

Volunteer firefighter suffers
cardiac death the morning
after emergency medical
technician training—North
Carolina

Title

Jan 09,2005

DATE OFINCIDENT

F2005-22

NIOSH
REP. #

Yes

Yes

Yes

AUTOPSY• Mild thickening of the mitral valve• Oxycodone intoxication (blood level of 0.85 milligrams
per liter [mg/L])(therapeutic blood levels are less than
0.1 mg/L)2– Left ventricular walls measure 1.4 centimeters (cm) inthickness (normal is 0.6 to 1.1 cm)– Heart weight 450 grams (normal < 400 grams)– Fibrosis in the mid septum, just below the right aortic
cusp, and near the apex of the heart (strongly suggestive of a remote heart attack)• Chronic myocardial ischemia• Attached thrombus (blood clot) with complete occlusionand focally a pinpoint lumen for about 1.5 cm in theproximal left anterior descending coronary artery• Widely patent coronary arteries without evidence ofsignificant atherosclerosis or thrombosis• Microscopic examination of the heart muscle showedwidening of the individual myocytes and large, irregular,“boxcar” nuclei; focal increased interstitial fibrosis waspresent within the posterior left ventricle• Cardiomegaly—(530 grams, normal < 400 grams) withmild left ventricular hypertrophy – left ventricle thickness
1.4 cm (normal 0.6 to 1.1 cm), interventricular septum
1.6 cm (normal 0.6 to 1.1 cm)• Mitral valve prolapse—undulating leaflets with obvious
hooding and thin, elongated chordae tendineae consistent
with prolapse

AUTOPSY COMMENTS

PDF
LINK

■ Firefighter Autopsy Protocol■ 105 ■
I: Background ■Reserve firefighter suffers
sudden cardiac death whileworking on a fuel reduction
crew—Arizona

Airport firefighter suffers
sudden cardiac death whileon duty—South Carolina

Driver/operator dies due
to a stroke while driving a fire engine to an
alarm—Tennessee

Aug 16,2004

Apr 20,2005

F2005-18

F2005-17

Title

Jun 19,2004

DATE OFINCIDENT

F2005-19

NIOSH
REP. #“Acute subarachnoid
hemorrhage” due to“rupture of sacular
cerebral aneurysm” as
the cause of death with“focal coronary arteryatherosclerosis” as asignificant condition

Acute myocardialischemia secondary toa cardiac arrhythmia of
unknown etiology

Atherosclerotic heartdiseaseCAUSE OF DEATH

Yes

Yes

Yes

AUTOPSY• Negative drug and alcohol tests– Severe narrowing (90%) of the left anterior descending
coronary artery• Coronary artery atherosclerosis, focal and severe– Acute subarachnoid hemorrhage, large amount, baseof brain• Sacular aneurysm with rupture, basilar artery– Scattered myocytes indicative of hypertrophy– Histological signs of ischemia• Microscopic findings• Right ventricle mildly dilated• Right coronary artery bridging– Interventricular septum hypertrophy (wall thickness 1.5
cm [normal 0.6 cm–1.1 cm])

– Left ventricular hypertrophy (wall thickness 1.3 centimeters [cm] [normal 0.6 cm–1.1 cm])

• Enlarged heart (cardiomegaly) weighing 460 grams(normal < 400 grams)• Negative drug and alcohol tests• Chronic pyelonephritis, left kidney– Left ventricular hypertrophy (wall thickness 1.4 centimeters [cm] [normal 0.6cm–1.1cm])1– 99% occlusion of right coronary artery– 99% occlusion of left anterior descending coronary
artery• Atherosclerotic heart disease:

AUTOPSY COMMENTS

PDF
LINK

■ Firefighter Autopsy Protocol■ 106 ■
I: Background ■Lieutenant suffers sudden
cardiac death at the sceneof a structure fire—South
Carolina
A volunteer firefighter andvolunteer assistant lieutenant die after a smoke
explosion at a townhousecomplex—Wyoming

Career firefighter/EMT dies in Blunt-force head
ambulance crash—Florida
traumaApr 22,
2004

Apr 18,2005

Aug 23,
2004

F2005-14

F2005-13

F2005-12

Smoke inhalation andthermal burns to over
50% of their bodies“Acute myocardial
infarction” due to “viralendocarditis”

Blunt-force head
injuries

Career firefighter fatally
injured in fall fromapparatus—Texas

Apr 23,2005

F2005-15“Hemopericardium”
due to an “aortic
rupture” and “aortic
dissection.”

CAUSE OF DEATH

Captain suffers an acuteaortic dissection after
responding to two alarms
and subsequently diesdue to hemopericardium—
Pennsylvania

Title

Jan 21,
2004

DATE OFINCIDENT

F2005-16

NIOSH
REP. #

None

None

Perform an autopsy on all onduty firefighter fatalities

None• Morbid obesity, with a body mass index of 51.9 kilograms/
meters2• No evidence of infection in his left or right lung fields(pneumonia), although there were bilateral serosanguinous pleural effusions (200 mL on the left, 150 mL on
the right)• Minimal coronary artery disease (25% stenosis of the left
anterior descending and right coronary arteries)▪ Moderate cardiac left ventricular hypertrophy– Cardiomegaly, heart weighing 560 grams (normal <400 grams)• History of hypertension• Thoracoabdominal aortic dissection extending from theascending aorta to the distal abdominal aorta (4 cm above
the iliac bifurcation• Rupture of the intrapericardial portion of the ascending
thoracic aorta• Hemopericardium with 575 milliliters (mL) of primarily
unclotted blood in pericardium

AUTOPSY COMMENTS

PDF
LINK

■ 107 ■

Not mentioned

Not mentioned

No

Yes

Yes

AUTOPSY■ Firefighter Autopsy Protocol
I: Background ■Career fire captain dieswhen trapped by partial roof
collapse in a vacant housefire – Texas
Fire chief suffers sudden
cardiac death after responding to a motor vehicle
crash—Texas

Career captain electrocutedat the scene of a residential
structure fire—California
Fire equipment operator
suffers a heart attack at thescene of a medical call anddies in the hospital thirteendays later—South Carolina

Career captain dies after run- Smoke and sootning out of air at a residential inhalation with astructure fire—Michigan
carboxyhemoglobin
level of 22.7%

Feb 19,2005

Oct 20,2004

Feb 13,2005

Jan 07,2005

Jan 20,2005

F2005-09

F2005-08

F2005-07

F2005-06

F2005-05“Myocardial infarction”
due to “renal failure”
due to “stroke”

Electrocution“arrhythmia” as thecause of death due
to “coronary arterydisease” (CAD) with“atrial fibrillation andsleep apnea” as othersignificant conditions

Smoke inhalation andthermal injuries“Anoxic encephalopathy” due to “sudden
cardiac arrest” due to“atherosclerotic cardiovascular disease” asthe cause of death

Lieutenant suffers a heart
attack while driving a squadtruck and dies four days
later—Georgia

Feb 15,2005

F2005-10“cardiorespiratoryarrest” due to “ASCVD”(atherosclerotic cardiovascular disease)

CAUSE OF DEATH

Fire chief suffers sudden
cardiac death while returning to the fire station after astructure fire—Georgia

Title

Dec 13,
2004

DATE OFINCIDENT

F2005-11

NIOSH
REP. #

None

Perform an autopsy on all onduty firefighter fatalities

None

Perform an autopsy on all onduty firefighter fatalities

None• Negative drug and alcohol tests• No evidence of pulmonary thromboemboli– Mild narrowing (30%–40%) of the left anterior
descending coronary artery– Moderate narrowing (40%-50%) of the right coronary
artery• Ischemic heart disease:• Enlarged heart (cardiomegaly): heart weighed 450 grams

Perform an autopsy on all onduty firefighter fatalities

AUTOPSY COMMENTS

PDF
LINK

■ 108 ■

Not mentionedNo

Not mentionedNo

Not mentioned,
but postmortem
carboxyhemoglobin wasreported at 26%

Yes

No

AUTOPSY■ Firefighter Autopsy Protocol
I: Background ■TitleCareer firefighter dies while
exiting residential basement
fire—New York
Career lieutenant and career
firefighter die and four career
firefighters are seriously
injured during a three alarmapartment fire—New YorkOne probationary career
firefighter dies and four
career firefighters are injured
at a two-alarm residential
structure fire—Texas
Career firefighter diesafter falling from tailboard
and being backed over byengine—California

DATE OFINCIDENT

Jan 23,2005

Jan 23,2005

Dec 20,2004

Aug 14,
2004

F2005-04

F2005-03

F2005-02

F2005-01

NIOSH
REP. #

Multiple blunt-force
injuries

Thermal injuries andsmoke inhalation

Mass trauma of thehead, torso andextremities withmultiple contusions of
the extremities.

Smoke inhalation andburns of the head,torso and upper
extremities

CAUSE OF DEATH

Not mentioned

Not mentioned

Not mentioned

Yes

AUTOPSY

None

None

None

Note: Carboxyhemoglobin level was 24% saturation; third
degree burns on approximately 63% of body surface area

AUTOPSY COMMENTS

PDF
LINK

■ Firefighter Autopsy Protocol■ 109 ■
I: Background ■Firefighter collapses anddies while assisting withfire suppression efforts at aresidential fire—Ohio

Firefighter suffers sudden
cardiac death after repacking a hose load on a fireengine—New Jersey

Feb 04,
2004

F2004-45

Title

Feb 23,
2004

DATE OFINCIDENT

F2004-46

NIOSH
REP. #

Arteriosclerotic cardiovascular disease(CAD)“Arteriosclerotic andhypertensive heart disease” as the immediate
cause of death with“morbid obesity” as acontributory condition

CAUSE OF DEATH

No

Yes

AUTOPSY

Perform an autopsy on all onduty firefighter fatalities• Skull fractures•. Negative urine drug screen• A carboxyhemoglobin (COHb) measurement of <5%saturation. (Since the FF did not regain a heartbeat duringresuscitation efforts, the 100% oxygen delivered via
the endotracheal tube was unlikely to have significantly
reduced the half-time of his COHb level. Thus, a level of<5% is unlikely to have contributed to his sudden death.)• Morbid obesity; at 72 inches tall, the FF weighed 300
pounds for a body mass index (BMI) of 40.7.

• Mild narrowing of the arteries leading to the kidneys(arteriolonephrosclerosis), which is consistent with thediagnosis of hypertension• Cardiomegaly (enlarged heart) weighing 780 grams(normal < 400 grams)– Myocardial infarct (heart attack) involving the anterior
left ventricle and interventricular septum (remote)– Open upper coronary artery bypass graft but withmoderate calcific atherosclerosis– Occlusion of the lower coronary artery bypass graft(remote)– Two vessel coronary artery bypass graft procedure(remote)– Atherosclerotic occlusions of the native coronary arteries (remote)• Coronary artery disease (CAD)

AUTOPSY COMMENTS

PDF
LINK

■ Firefighter Autopsy Protocol■ 110 ■
I: Background ■Assistant chief suffers heart “Sudden arrhythmia”
attack and dies after complet- as the immediate
ing a walk test—Montana
cause of death and“acute coronary artery
thrombosis” as acontributing factor

Jun 08,
2004

F2004-41“severe coronary arterydisease due to arteriosclerotic cardiovasculardisease” as the causeof death

Perautopsy:

Per death certificate,“severe arteriosclerotic cardiovasculardisease” as the causeof death and “previous
myocardial infarction”
as other significant
condition.

Assistant chief suffers
sudden cardiac death
during response to boat
fire—Wisconsin

Sep 26,
2004

F2004-42

CAUSE OF DEATH

One part-time firefighter dies Craniocerebral injuries
and another is seriouslywith aspiration of blood
injured when two fire engines within the lungs
collide at an intersection
while responding to afire—IIllinois

Title

Apr 27,
2004

DATE OFINCIDENT

F2004-43

NIOSH
REP. #

Yes

Yes

Yes

AUTOPSY• Negative drug and alcohol tests

PDF
LINK

■ 111 ■

• No evidence of pulmonary thromboemboli– Minor atherosclerosis in the circumflex artery– Significant narrowing (80% to 90%) of the left anterior
descending coronary artery– Thrombus causing total occlusion in the right coronary
artery• Enlarged heart (cardiomegaly): heart weighed 470 grams(normal < 400 grams) Ischemic heart disease:• Carboxyhemoglobin (carbon monoxide) test was not
performed• Negative drug and alcohol tests• No evidence of pulmonary thromboemboli• Severe dilatation of the heart chambers• A large area of white fibrosis with thinning of the posteriorwall of the left ventricle• Cardiomegaly (enlarged heart) – heart weighing 450
grams (normal less than 400 grams)• Mild plaquing in the left circumflex coronary artery• Significant narrowing (60%-95%) of the left anterior
descending coronary artery• Total occlusion of the mid right coronary artery• Heavily calcified coronary arteries with severe atherosclerotic plaquing• Ischemic heart disease

None

AUTOPSY COMMENTS■ Firefighter Autopsy Protocol
I: Background ■Career helitack firefighter
dies in burnover during an
initial attack at a wildland fire
operation—California
Probationary firefighter
suffers sudden cardiac
death during maze
drill—Connecticut

Volunteer chief dies andtwo firefighters are injured
by a collapsing church
facade—Tennessee
Career firefighter drowns
while conducting training
dive—New Hampshire

Mar 13,2004

Apr 08,2004

Mar 11,
2004

F2004-38

F2004-37

F2004-36

Title

Sep 12,
2004

DATE OFINCIDENT

F2004-40

NIOSH
REP. #

Drowning

Multiple blunt-force
trauma and thermal
injuries

Sudden death associated with rheumaticheart disease

Inhalation of productsof combustion

CAUSE OF DEATH

Not mentioned

Not mentioned

Yes

Yes

AUTOPSY

None

None

• Drug, alcohol, and carbon monoxide tests were negative• No significant coronary artery disease and no recent or
remote evidence of a heart attack• Aortic valve fusion of the right and left cusps
Normal heart size (380 grams), yet mild left atrial enlargement and dilatation• Mitral valves thickened and fusion of the chordae
tendineae” (strong cords of fibrous tissue fused together
resulting in thickening and shortening of the mitral valve
cusps)

Valvular heart disease:

None

AUTOPSY COMMENTS

PDF
LINK

■ Firefighter Autopsy Protocol■ 112 ■
I: Background ■Volunteer firefighter suffers
heart attack while battling
structure fire and dies 6 days
later—New YorkAug 27,
2003

F2004-31

Acute myocardial
infarction

Volunteer firefighter suffers
Acute myocardial
cardiac arrest while battling a infarction (heart attack)structure fire—New Yorkwith physical exertion in a hot, humid
environment listed as acontributing cause

May 13,
2004

F2004-32“Cardiac dysrhythmia”
as the immediate
cause of death due to“massive cardiomegaly” due to “hypertensive heart disease.”

CAUSE OF DEATH

Firefighter suffers sudden
cardiac death at his firestation—Georgia

Title

Jun 17,
2004

DATE OFINCIDENT

F2004-35

NIOSH
REP. #

No

No

Yes

AUTOPSY

Perform an autopsy on all onduty firefighter fatalities

Perform an autopsy on all on-duty firefighter fatalities

His blood carboxyhemoglobin level (a test of carbon monoxide exposure) was not checked due to no exposure to firesmoke during his shift. No drug screen was performed• Microscopic examination of the kidney showed kidneycancer (papillary renal cell carcinoma)• Mild thickening (myocytic hypertrophy) and mild to moderate scarring of the heart muscle (interstitial fibrosis), but
no evidence of heart attack (acute or remote infarct)– Approximately 40%–50% blockages (stenosis) in eachof the left anterior descending, circumflex, and rightcoronary arteries.

• Mild to moderate heart disease (atherosclerotic plaqueblockage of three coronary arteries)– Moderate hardening of the kidney due to highblood pressure in the small arteries of the kidneys(arterionephrosclerosis)– Markedly severely thickened left wall of the heart(concentric hypertrophy of the left ventricle)– Severely enlarged heart (cardiomegaly) weighing
840 grams (normal < 400 grams), which is in the 95th
percentile for body

• Hypertensive heart disease

AUTOPSY COMMENTS

PDF
LINK

■ Firefighter Autopsy Protocol■ 113 ■
I: Background ■Firefighter collapses andsuffers sudden cardiac death
after responding to a vehicle
fire—Kentucky

Firefighter suffers sudden cardiac death while
performing work capacity
test—California

May 31,
2002

F2004-28

Title

Mar 25,
2004

DATE OFINCIDENT

F2004-30

NIOSH
REP. #

Coronary
atherosclerosis

A cardiac event(arrhythmia) due tohypertensive andatherosclerotic cardiovascular disease

CAUSE OF DEATH

Yes

Yes

AUTOPSY

PDF
LINK■ 114 ■• Negative drug and alcohol tests• Vitreous (eye) chemistries showed elevations in sodium
and chlorine consistent with dehydration• No evidence of a pulmonary embolus• Mild to moderate perivascular fibrosis of the heart muscle
on microscopic examination– Interventricular septum hypertrophy (wall thickness
1.9cm [normal 0.6cm-1.1cm])– Left ventricular hypertrophy (wall thickness 1.7 centimeters [cm] [normal 0.6cm-1.1cm])– Enlarged heart (cardiomegaly) weighing 510 grams(normal < 400 grams)– No superimposed acute thromboses or recent
hemorrhages– 70% stenosis in the right coronary artery– 90% stenosis in the left circumflex coronary artery– Near complete occlusion of the most proximal branchof the left anterior descending coronary artery• Ischemic heart disease:• Atherosclerotic coronary artery disease (CAD)• Possible thrombus in the right coronary artery• Moderate to severe coronary artery atherosclerosis (leftand right)• Scar of white fibrous tissue interlacing with brown myocardium (evidence of a remote [old] myocardial infarction[heart attack])• Dilated right ventricle• Cardiomegaly (an enlarged heart) weighing 560 grams(normal is less than 400 grams)1

AUTOPSY COMMENTS■ Firefighter Autopsy Protocol
I: Background ■Firefighter-engineer suffers
sudden cardiac death while
performing strenuous fire station maintenance—California

Volunteer firefighter suffers sudden cardiac death
during fire suppression at astructural fire—Indiana

Mar 22,
2003

F2004-25

Title

Feb 01,
2003

DATE OFINCIDENT

F2004-26

NIOSH
REP. #

Acute, occlusive
thrombosis of the left
circumflex coronary
artery secondary
to coronary arteryatherosclerosis“Atherosclerotic coronary artery disease”
as the immediate
cause of death with“hypertension”

CAUSE OF DEATH

Yes

Yes

AUTOPSY• Carboxyhemoglobin level (a measure of carbon monoxide
exposure) of 2.2% (10 hours after the initiation of oxygen).
The normal lab value for moderate to heavy smokers is
4-15%. The FF did have a history of smoking.

PDF
LINK

■ 115 ■• Negative drug and alcohol test results– Concentric left ventricular hypertrophy (LVH)– Extensive biventricular dilatation– Cardiomegaly (enlarged heart weighing 550 grams,
normal is less than 400 grams)– 40%-60% stenosis of the mid portions of left anterior,left circumflex, and right coronary arteries– Intraplaque hemorrhage at the mid portion of the left
anterior descending coronary artery– 80%-95% stenosis of the distal left anterior descending coronary artery and the right posterior descending
coronary artery– Acute occlusive thrombus present within the mid todistal portion of the left circumflex coronary artery• Moderate to severe coronary atherosclerosis as detailed
below:• Negative drug screen• No pulmonary emboli (blood clot in the lung vasculature)– No coronary artery thrombus (blood clot)– 90% stenosis in the left circumflex artery– 90% stenosis in the left anterior descending artery– 75% stenosis in the left main artery– 75% stenosis of the right coronary artery with a rightdominant coronary artery system• Atherosclerotic coronary artery disease• Moderate biventricular dilatation (LV—4 centimeters (cm)internal diameter; RV- 4.0 X 4.5 cm internal diameter)• Cardiomegaly (an enlarged heart) weighing 510 grams(upper limit of normal is 400 grams)

AUTOPSY COMMENTS■ Firefighter Autopsy Protocol
I: Background ■Acting fire chief suffers
heart attack after shift anddies—Alaska
Firefighter suffers unwitnessed sudden cardiac death
after responding to mobile
home fire—South Carolina

May 06,
2002

F2004-23

Title

Apr 15,
2004

DATE OFINCIDENT

F2004-24

NIOSH
REP. #“Cardiac arrhythmia”
as the immediate
cause of death due to“stress of fighting fire”
and “cardiomegaly withdilatation” as contributing factors

Cardiac event

CAUSE OF DEATH

Yes

No

AUTOPSY• Hepatosplenomegaly• Carboxyhemoglobin (carbon monoxide) test was negative(less than 10%)• Drug and alcohol tests were negative• No evidence of thrombi, emboli, or fibrosis on grosspathology• Biventricular hypertrophy with dilatation (left ventricle
thickness of 1.5 cm at the anterior papillary muscle)• Biventricular hypertrophy with dilatation (left ventricle
thickness of 1.5 cm at the anterior papillary muscle)– 50% occlusion in the left anterior descending artery– 50% occlusion in the right coronary artery• Mild atherosclerotic cardiovascular disease• Cardiomegaly (enlarged heart)—weighing 576 grams(normal less than 400 grams)

Perform an autopsy on all onduty firefighter fatalities

AUTOPSY COMMENTS

PDF
LINK

■ Firefighter Autopsy Protocol■ 116 ■
I: Background ■F2004-22

NIOSH
REP. #

Apr 10,2004

DATE OFINCIDENT
Career firefighter/Emergency
medical technician suffers
sudden death 5 hours afterparticipating in emergency
response—South Carolina

Title“acute cocaine
intoxication” as theimmediate cause ofdeath with hypertension and atherosclerotic coronary heartdisease as contributing
factors.

Per autopsy:“atherosclerotic coronary artery disease”

Per death certificate:

CAUSE OF DEATH• Extensive atherosclerotic coronary artery disease withnear total occlusion of three coronary arteries (left anterior
descending, first diagonal, and right coronary arteryYes– Benzoylecgonine, urine: 4.9 mg/L

– Benzoylecgonine, blood: 0/76 mg/L

– Ecgonine methyl ester, blood: 0.67 mg/L

– Cocaine, Blood: 0.48 mg/L

• Acute Cocaine Intoxication– Biventricular dilatation– Hypertensive cardiovascular disease– Cardiomegaly (an enlarged heart) weighing 680 grams(upper limit of normal is 400 grams• Cardiomyopathy• Old myocardial infarction of the posterior left ventricle• Acute thrombus (“acute organizing occlusive fibrin
thrombi”)

AUTOPSY COMMENTS

AUTOPSY

PDF
LINK■ Firefighter Autopsy Protocol■ 117 ■
I: Background ■District chief suffers sudden
cardiac death at home after
experiencing symptoms
consistent with heart diseaseat his station—Illinois

Assistant chief dies after
suffering aortic dissection during a fire alarm
response—Connecticut

Career firefighter dies frominjuries sustained in fall fromapparatus—Massachusetts

Dec 25,2003

Apr 30,2004

F2004-20

F2004-19

Title

Apr 18,
2004

DATE OFINCIDENT

F2004-21

NIOSH
REP. #

Blunt-force headtrauma“Multi-organ systemdysfunction” due to“cardiac arrest” as theimmediate cause ofdeath with “aortic dissection” as a significant
condition“Cardiac arrhythmia”
as the cause of death
due to “ischemic heartdisease.”CAUSE OF DEATH

Not mentioned

No

Yes

AUTOPSY

None

Perform an autopsy on all onduty firefighter fatalities• Cardiomegaly (enlarged heart) weighing 420 grams(normal is less than 400 grams)– Interventricular septum thickness 1.5 cm (normal
echographic measurement is 0.6-1.1 cm)– Left ventricle thickness 1.6 cm (normal is 0.76-0.88
cm)• Mild left ventricle hypertrophy with:• No evidence of remote myocardial infarction or myocardial fibrosis• Recent thrombus in the circumflex coronary artery, resulting in total occlusion– 90% narrowing of the circumflex coronary artery– 90% narrowing of the left anterior descending coronary
artery– 60% narrowing of the left main coronary artery– 60% narrowing of the right coronary artery• Marked atherosclerosis with

AUTOPSY COMMENTS

PDF
LINK

■ Firefighter Autopsy Protocol■ 118 ■
I: Background ■Volunteer firefighter suffers
sudden cardiac death afterparticipating in emergency
responses—Maryland

Career battalion chief andcareer master firefighter die
and 29 career firefighters are
injured during a five alarm
church fire—Pennsylvania

Mar 13,
2004

F2004-17

Title

Jan 14,
2004

DATE OFINCIDENT

F2004-18

NIOSH
REP. #

Victim #2: asphyxiation
due to compression of
the body by building
debris with blunt force
trauma of the head andextremities.

Victim #1: asphyxiation
due to compression of
the body by building
debris; blunt-force
trauma of the head,neck, pelvis, andextremities were
contributory causes ofdeath.

Acute myocardial
infarction

CAUSE OF DEATH

Not mentioned

Yes

AUTOPSY

None• Penetrating organized thrombus, right atrium; undetermined etiology• Diffuse 50%-90% narrowing of coronary arteries• Healed transmural infarction, posterolateral left ventricle
at base• Total occlusion of mid left circumflex artery by healed
plaque rupture with organized and recanalized thrombus(old, healed heart attack)• Acute plaque rupture and thrombosis, left obtuse marginalartery (recent heart attack)• Atherosclerotic CAD• Biventricular hypertrophy• Four chamber dilatation• Cardiomegaly (an enlarged heart) weighing 670 grams(upper limit of normal is 400 grams)

AUTOPSY COMMENTS

PDF
LINK

■ Firefighter Autopsy Protocol■ 119 ■
I: Background ■TitleFirefighter dies at home after
shift—Maryland

Forest ranger/Firefighter
drowned after catastrophic
blow-out of right front
tire—Florida
Career firefighter dies andtwo career captains are
injured while fighting nightclub arson fire—Texas
Firefighters suffers fatal pulmonary embolism after knee
surgery for a work-related
injury—North Carolina

Firefighter/Paramedic diesafter performing physicalfitness training—Florida

DATE OFINCIDENT

Dec 18,2003

Mar 03,2004

Apr 04,2004

Apr 18,2003

Jan 27,
2004

F2004-16

F2004-15

F2004-14

F2004-13

F2004-12

NIOSH
REP. #

Aortic valve stenosis

Massive pulmonary
embolism (PE) due toa deep vein thrombus(DVT) due to knee
injury that was treatedsurgicallyHigh thermal exposure

Drowning with noevidence of traumarelated injuries

Arteriosclerotic cardiovascular disease

CAUSE OF DEATH

Yes

Yes

Yes

Not mentioned

Yes

AUTOPSY• No evidence of atherosclerosis• No evidence of thromboemboli

PDF
LINK

■ 120 ■• Mild, patchy, interstitial fibrosis [as determined by microscopic examination]• Cardiomegaly (heart weighing 440 grams with normal lessthan 400 grams)• Aortic valve stenosis• No ethanol (alcohol) or salicylates (aspirin) detected• Severe focal atherosclerotic coronary artery disease• Evidence of hypertensive cardiovascular disease• Deep vein thrombosis in the right leg• Remote pulmonary emboli (at least two weeks old)

• Acute pulmonary embolus

None

Postcrash blood alcohol content (BAC) and drug screening
tests were negative• Drug and alcohol tests were negative• No thrombi were found• Cardiac valves were unremarkable• Aortic atherosclerosis• Cardiomegaly (heart weighing 550 grams with normal lessthan 400 grams4)• Biventricular dilatation• Old subendocardial infarct of left ventricle• Severe arteriosclerotic cardiovascular disease

The carboxyhemoglobin level (a measure of exposure tocarbon monoxide) was not measured

AUTOPSY COMMENTS■ Firefighter Autopsy Protocol
I: Background ■Firefighter/Driver/Engineer
suffers heart attack and diesat the end of his 24-hour
shift—Hawaii

Firefighter suffers sudden“Acute sudden cardiac
cardiac death after emerdeath syndrome” duegency recall—Massachusetts to “acute myocardial
infarction” as theimmediate cause ofdeath and “obesity”
as another significant
condition
Fire chief dies after performing service call—Connecticut

Apr 02,
2001

Jan 21,
2004

Nov 18,
2002

F2004-09

F2004-08

F2004-07“ASCVD” (atherosclerotic coronary
vascular disease) as
the immediate causeof death, with hyperlipidemia and smoking as
contributing factors

Acute myocardial
infarction and coronary
artery thrombosis
due to atherosclerotic
cardiovascular disease

Smoke inhalation

Career firefighter diessearching for fire in a
restaurant/lounge—Missouri

Feb 18,
2004

F2004-10

Multiple gunshot
woundsCAUSE OF DEATH

Career lieutenant killed andfirefighter injured by gunfire
while responding to medical
assistance call—Kentucky

Title

Feb 13,
2004

DATE OFINCIDENT

F2004-11

NIOSH
REP. #

Yes

No

Yes

Not mentioned

Not mentioned

AUTOPSY• No CO level taken• Arteriosclerosis, with 95% occlusion of the left main
coronary artery and 90% occlusion of the right coronary
arteryPerform an autopsy on all onduty firefighter fatalities• A negative drug screen• Thickened left wall of the heart (left ventricular
hypertrophy)• A large heart weighing 470 grams (normal < 400 grams)• Moderate to severe coronary atherosclerosis• Blood clot (thrombus) in one of the coronary arteries (midleft anterior descending artery)An independent toxicology report listed the victim’s carbon
monoxide level at 51% saturation. There was no notable
traumaNone

AUTOPSY COMMENTS

PDF
LINK

■ Firefighter Autopsy Protocol■ 121 ■
I: Background ■Career firefighter dies ofcarbon monoxide poisoning
after becoming lost while
searching for the seat of afire in warehouse—New York
Career captain/safety officer
dies in a single motor vehicle
crash while responding to acall—Kansas
Basement fire claims thelife of volunteer firefighter– Massachusetts
District chief dies after suffer- Myocardial infarction
ing a heart attack—Texas
Live-fire exercise inmobile flashover training
simulator injures five career
firefighters—Maine
Airport firefighter suffers
sudden cardiac death at firestation—ArKansas

Firefighter suffers sudden
Myocardial infarction
cardiac death in parking lot offire station—Tennessee

Dec 16,2003

Nov 17,2003

Nov 29,2003

Oct 24,2003

Oct 17,2003

Feb 26,2003

Jul 21,
2003

F2004-04

F2004-03

F2004-02

F2004-01

F2003-41

F2003-40

F2003-39

Myocardial infarction

No deaths

Smoke and sootinhalation

Probable positional
asphyxia

Smoke inhalation witha carboxyhemoglobin(cohb) level of 74.8%
in the emergency
department

Smoke and sootinhalation and thermalburns

Residential basement fireclaims the life of career
lieutenant—Pennsylvania

Jan 09,2004

F2004-05

Occlusive atherosclerotic cardiovasculardiseaseCAUSE OF DEATH

Firefighter/Paramedic suffers
sudden cardiac death while
performing physical fitnesstraining—Washington

Title

Nov 17,
2003

DATE OFINCIDENT

F2004-06

NIOSH
REP. #

Perform an autopsy on all onduty firefighter fatalities

Perform an autopsy on all onduty firefighter fatalities

None

Perform an autopsy on all onduty firefighter fatalities

None

None

None

None

• Drug and alcohol tests were negative• No fibrosis• No thrombi or emboli• 0.7 centimeter area of increased consistency which isslightly grayer than adjacent areas in the posterior lateral
aspect of the left ventricular wall in the apical third• Atherosclerotic cardiovascular disease• Heart weighing 400 grams

AUTOPSY COMMENTS

PDF
LINK

■ 122 ■

No

No

No

Not mentioned

Not mentioned

Yes

Not mentioned

Yes

AUTOPSY■ Firefighter Autopsy Protocol
I: Background ■Firefighter dies after
performing ventilation
at a fire in a two-story
dwelling—Pennsylvania

Volunteer assistant chiefis struck and killed at road
construction site—Minnesota
A career firefighter was
killed and a career captainwas severely injured during
a wildland/urban interface
operation—California
Firefighter suffers a heart
attack after responding toa rubbish fire at a two-story
apartment building—New
York

Volunteer firefighter/fireservice products salesmandies after being struck by
dislodged rescue airbag—
South Dakota

Oct 27,2003

Oct 29,2003

Sep 27,2003

Jul 10,2003

F2003-37

F2003-36

F2003-35

F2003-34

Title

Oct 07,
2003

DATE OFINCIDENT

F2003-38

NIOSH
REP. #

Closed head wound“Acute myocardial
infarction” as theimmediate cause ofdeath and “diabetes
mellitus” and “hypertension” as othersignificant conditions

Thermal injuries

Craniocerebral injuries
and closed headtrauma“Ischemic heart disease” as the immediate
cause of death and“smoke inhalation” as asignificant condition

CAUSE OF DEATH

Not mentioned

No

Yes

Yes

Yes

AUTOPSY

None

None

Extensive burns over the entire body, no evidence ofunderlying cardiovascular or pulmonary disease, and acarboxyhemoglobin level of 27% (confirming significant
exposure to carbon monoxide prior to his death)

None• Carboxyhemoglobin (measure of carbon monoxide in the
blood) level negative• Evidence of smoke inhalation (moderate amount of sootin the trachea and large airways of both lungs)• Fibrosis within the apex and left posterior ventricular wall(as determined by microscopic examination)• Remote (old) myocardial infarction involving the apex andleft posterior ventricular wall

• Mild atherosclerotic coronary artery disease involving theleft main coronary artery• Cardiomegaly (heart weighing 552 grams, with normal
less than 400 grams)

AUTOPSY COMMENTS

PDF
LINK

■ Firefighter Autopsy Protocol■ 123 ■
I: Background ■Lieutenant suffers sudden cardiac death after
performing forcible entry
requiring heavy physicalexertion—Georgia

One volunteer lieutenant dies Acute intracranial
and a volunteer firefighter is injuries
seriously injured in a motor
vehicle rollover incident while
enroute to a trailer fire—North Carolina

Apr 14,
2003

Jul 28,2003

F2003-31

F2003-30“Cardiac dysrhythmia”
due to “atherosclerotic
coronary artery disease” as the immediate cause of deathand “superimposed
physical exertion” as acontributing factor

Multiple blunt-force
injuries

Two firefighters die and eightfirefighters are injured froma silo explosion at a lumber
company—Ohio

Oct 01,
2003

F2003-32

Blunt-force trauma
due to a motor vehicle
accident

CAUSE OF DEATH

Career firefighter/emergency medical technician
dies and paramedic isinjured in a three-vehicle
collision—Nebraska

Title

Aug 06,
2003

DATE OFINCIDENT

F2003-33

NIOSH
REP. #

Not mentioned

Yes

Not mentioned

Not mentioned

AUTOPSY

None• Drug and alcohol tests were negative• Microscopic sections of the right ventricle, left ventricle,
and interventricular septum do not reveal significant
myocardial inflammation, infarct, hemorrhage, fibrosis, or
neoplasia• No obvious soot in the nares or oral cavity• No thromboemboli are recovered from the main, right, orleft pulmonary arteries or their segmental branches• Interventricular septal hypertrophy (16mm thick; normal is
6 to 11 mm)• Left ventricular hypertrophy (15 millimeters (mm) thick;normal between 7.6-8.8 mm• Atherosclerotic coronary artery disease• Cardiomegaly (heart weighing 530 grams, with normal
less than 400 grams1)

None

None

AUTOPSY COMMENTS

PDF
LINK

■ Firefighter Autopsy Protocol■ 124 ■
I: Background ■Firefighter suffers heart
attack at the scene of astructure fire and dies 2
months later—Indiana

Live-fire training exercise
claims the life of one recruit
firefighter and injures fourothers—Florida
Fire captain suffers sudden
cardiac death during a livefire training exercise—North
Carolina

Aug 08,2003

Jan 25,2003

F2003-28

F2003-27

Title

Dec 15,
2002

DATE OFINCIDENT

F2003-29

NIOSH
REP. #“Acute myocardial
infarction” (heart
attack) as the cause ofdeath due to “coronary
atherosclerosis” witha “prior myocardial
infarction” being asignificant contributing
factorAtherosclerotic cardiovascular disease” due
to “COPD”“Acute myocardial
infarction” due to“atherosclerotic cardiovascular disease” asthe immediate causeof death and “chronic
obstructive pulmonary
disease (COPD)” as acontributing factor

CAUSE OF DEATH

Yes

Carboxyhemoglobin level was less than 5% suggesting
carbon monoxide exposure was not a significant factor in
the Captain’s sudden death• A two centimeter hyperemic area near the first diagonalcoronary artery which probably represented the earlysigns of a recent (acute) heart attack (myocardioal
infarction)• A seven centimeter scar (due to his heart attack in 1999)
in the posterior and lateral left ventricular wall

• 100% blockage of the right coronary artery, the circumflex
coronary artery, and the first diagonal coronary artery in
the area of the stent

Severe atherosclerotic coronary artery disease

Perform an autopsy on all onduty firefighter fatalities

Perform an autopsy on all onduty firefighter fatalities

No

No

AUTOPSY COMMENTS

AUTOPSY

PDF
LINK■ Firefighter Autopsy Protocol■ 125 ■
I: Background ■Career Federal firefighter
dies from injuries sustainedat prescribed burn—Arizona

Firefighter suffers fatal heart Per death certificate:attack while performing phys- “acute myocardial
ical fitness training—Missouri infarction” due to “atherosclerotic coronary
artery disease”

May 14,2003

Jan 21,
2003

F2003-25

F2003-24“coronary atherosclerosis” followed by“stenosis, thrombosis,
chronic myocardial
infarct, subacute
myocardial infarcts,
acute myocardial
infarct, and acuteischemic change” asthe cause(s) of death.

Per autopsy:

Adult Respiratory
Distress Syndrome
secondary to severe
inhalation injury
with cardiovascularcompromise.

“arteriosclerotic cardiovascular disease” asthe cause of death

Per death certificate:“ischemic heart disease” as the immediate
cause of death due to“atherosclerotic coronary heart disease.”
Per autopsy:

CAUSE OF DEATH

Firefighter suffers sudden
cardiac death at his firestation—Oregon

Title

Feb 20,2003

DATE OFINCIDENT

F2003-26

NIOSH
REP. #• A large heart (435 grams with normal less than 400
grams)

Yes

PDF
LINK

■ 126 ■

Since the captain was not involved in any fire suppression
duties that day, a carboxyhemoglobin level (a measure of
exposure to carbon monoxide) was not checked• Acute (recent) MI in the interventricular septum and left
ventricular free wall

• Subacute MIs• Evidence of old heart attacks (myocardial infarcts or MIs)

• Stent placement in three coronary arteries [left anterior
descending (LAD), left circumflex, right coronary artery]• Significant coronary atherosclerosis

Note: Thirty-six % of the victim’s body surface area hadsecond- and third-degree burn injuries and he had asignificant inhalation injury• Blood carboxyhemoglobin level (a test of carbon monoxide exposure) was not checked due to no exposure to firesmoke during his shift, and no drug screen was performed• Microscopic examination of the heart muscle showed no
inflammation, necrosis, or scarring• No evidence of a blood clot (embolus) in the pulmonary
arteries• No scars suggestive of old/remote heart attacks• Softening and dark discoloration of the left ventricle, more
toward the apex” [a finding suggestive of a recent myocardial infarct (MI) (otherwise known as a heart attack)]• Moderate calcification and atherosclerotic narrowing of
the coronary arteries

AUTOPSY COMMENTS

None
mentioned

Yes

AUTOPSY■ Firefighter Autopsy Protocol
I: Background ■Volunteer firefighter suffers
Acute myocardial
sudden cardiac death after
infarction
completing emergency medical technician (emt) written
examination—Texas
Firefighter recruit suffers
sudden cardiac death
during physical ability
training—Texas

Junior volunteer firefighter iskilled while responding to abrush fire with an intoxicateddriver—Wyoming
Volunteer firefighter killed
after his privately owned
vehicle hydroplanedand struck a billboard
signpost—kentucky
Partial roof collapse incommercial structure fireclaims the lives of two career
firefighters—Tennessee
Volunteer training/Safety
officer dies from injuries
received in fall from pickup truck following training
exercise—Tennessee

Dec 13,
2002

Feb 12,
2003

May 22,
2003

Jun 16,2003

Jun 15,2003

May 18,2003

F2003-22

F2003-21

F2003-20

F2003-19

F2003-18

F2003-17

Blunt-force injury to theheadVictim #2: thermal
inhalation injury

Victim #1: thermalburns.

Massive head andchest trauma

Massive trauma

Cardiac hypertrophy,“biventricular dilatationand cardiomegaly

Multiple injuries consistent with a rollover
motor vehicle crash

Volunteer assistant chiefdies in tanker rollover—New
MexicoJun 26,2003

F2003-23

CAUSE OF DEATH

Title

DATE OFINCIDENT

NIOSH
REP. #

Not mentioned

Not mentioned

Not mentioned

Not mentioned

Yes

No

Not mentioned

AUTOPSY

None

None

None

None

• No blood clots in the pulmonary vessels, therefore noevidence of a pulmonary embolus• The cardiac valves are unremarkable• The coronary arteries are free of atherosclerosis• Cardiomegaly (an enlarged heart) weighing 440 grams• Biventricular and right atrial dilatation• Cardiac hypertrophy

Perform autopsies on all on-duty firefighter fatalities

None

AUTOPSY COMMENTS

PDF
LINK

■ Firefighter Autopsy Protocol■ 127 ■
I: Background ■Volunteer captain killed infire apparatus crash while
responding to a training
exercise—Oregon
Volunteer firefighter killed
while walking across aninterstate highway responding to a motor vehicle
incident—Texas
Career firefighter dies andSevere third degree
two career firefighters injured burns
in a flashover during a house
fire—Ohio
Firefighter collapses and dies Hypertensive andat the scene of residential
arteriosclerotic heart
fire—FloridadiseaseMar 19,2003

Mar 18,2003

Mar 31,
2003

Feb 07,
2001

F2003-14

F2003-13

F2003-12

F2003-11

Severe craniocerebal
injuries

Positional asphyxiation

Compressive asphyxia

Volunteer firefighter dies intanker rollover—Ohio

Apr 03,2003

F2003-15

Severe pneumonia
as a consequence ofcomplications due toa pedestrian motor
vehicle accident

CAUSE OF DEATH

Volunteer fire police captaindies from injury-related
complications after being
struck by motor vehicle while
directing traffic—New Jersey

Title

Feb 23,
2003

DATE OFINCIDENT

F2003-16

NIOSH
REP. #Yes

Not mentioned

Yes

Not mentioned

Not mentioned

Not mentioned

AUTOPSY

His blood carboxyhemoglobin level was not checked• Cerebral edema• Pulmonary edema• Four-vessel bypass• Coronary atherosclerosis• Enlarged heart (concentric left ventricular hypertrophy)

None

None

None

None

None

AUTOPSY COMMENTS

PDF
LINK

■ Firefighter Autopsy Protocol■ 128 ■
I: Background ■F2003-10

NIOSH
REP. #

May 22,
2002

DATE OFINCIDENT
Firefighter suffers sudden cardiac death during
a medical emergency
response—California

Title
Complication of hypertrophic cardiomyopathy

CAUSE OF DEATH
Yes

AUTOPSY• Histology (microscopic) examination of the heart tissue
was not performed• A negative drug screen of illicit drugs (e.g. cocaine)• No evidence of a blood clot (embolus) in the pulmonary
arteries• Bilateral fibrous pleural adhesions and pericardial sac
adhesions also consistent with his old knife wound to thechest• surgical patch and scar at the apex of the heart’s left
ventricle consistent with a well healed surgical repair ofan old knife wound to the chest• Minimal atherosclerosis in the coronary arteries• Thickened right ventricle of 1.0 centimeters (cm) indiameter (normal <0.8)• Thickened left ventricle of 2.0 centimeters (cm) in diameter (normal <1.3)• An enlarged heart weighing 565 grams (normal less than
400 grams)

AUTOPSY COMMENTS

PDF
LINK

■ Firefighter Autopsy Protocol■ 129 ■
I: Background ■TitleFirefighter suffers fatal heartarrhythmia at structure
fire—Illinois

Sudden cardiac death due
to myocardial sarcoidosis
claims the life of an onduty
firefighter—Connecticut

Career firefighter/emergency
medical technician dies frominjuries sustained in fall fromapparatus—California

DATE OFINCIDENT

Jan 14,2003

Nov 12,
2002

Jan 13,2003

F2003-09

F2003-08

F2003-07

NIOSH
REP. #

Multiple traumatic
injuries

Myocardial sarcoidosis“Cardiac arrhythmia”
due to “heart disease”
as the immediate
cause of death and“exertion while fighting
a house fire” as acontributing factor

CAUSE OF DEATH

Not mentioned

Yes

Yes

AUTOPSY

None• No atherosclerotic disease of the coronary arteries• Cardiomegaly (an enlarged heart) weighing 640 grams• The right heart ventricle revealed lymphocytic infiltrates
and noncaseating granulomas that are confluent, with
dense fibrosis between the granulomas. There is also
some nodule involvement of the papillary muscles andinterventricular septum (all findings consistent withsarcoidosis involving the heart)• Myocardial sarcoidosis (noncaseating granulomas) of theheart, lung, lymph nodes, and liver

Carboxyhemoglobin level was 2.2%, indicating the captainhad inhaled some but not an excessive amount of carbon
monoxide; possibly due to his cigarette smoking• No ethanol or illicit drugs were detected• History of cigarette smoking• Tobacco pneumonitis with early pulmonary emphysema
and chronic bronchitis• Clinical history of hypertension• Cardiac hypertrophy (490 grams)• Hypertensive cardiovascular disease• Clinical history of hypercholesterolemia• Diffuse mild and focal moderate aortic atherosclerosis• Remote myocardial infarct (heart attack), posterior/inferiorwall of left ventricle with moderate thinning of the wall

• Coronary artery atherosclerosis• Atherosclerotic cardiovascular disease

AUTOPSY COMMENTS

PDF
LINK

■ Firefighter Autopsy Protocol■ 130 ■
I: Background ■Firefighter dies fromprogressive respiratory
failure—Massachusetts

Career firefighter/emergency
medical technician dies inambulance crash—Texas
Career firefighter dies frominjuries received duringa chimney and structural
collapse after a house
fire—Pennsylvania
Volunteer firefighter dies following nitrous oxide cylinder
explosion while fighting
a commercial structure
fire—Texas
Firefighter suffers fatal heart
attack at two-alarm structure
fire—Texas

Jan 19,2003

Jan 20,2003

Jan 19,2003

Dec 05,2002

F2003-05

F2003-04

F2003-03

F2003-02

Title

Sep 19,2002

DATE OFINCIDENT

F2003-06

NIOSH
REP. #

Atherosclerotic andhypertensive cardiovascular disease

Thermal injuries, withsmoke inhalation andblast effectCompressional
asphyxia as a resultof being trapped fromfalling debris

Blunt-force injuries

Progressive respiratory failure and clinicalhistory of adult respiratory
distress syndrome due toinhalational injuries

CAUSE OF DEATH

Yes

Yes

Not mentioned

Not mentioned

AUTOPSY

PDF
LINK■ 131 ■

Carboxyhemoglobin level was less than one percent,indicating inhaled carbon monoxide was not a factor in his
death• Concentric left ventricular hypertrophy (free wall width 1.5
centimeters thick)• Cardiomegaly (an enlarged heart) weighing 560 grams(normal is less than 400 grams)• Remote infarct of the posterior wall of the left ventricle
and the posterior aspect of the interventricular septum• Severe occlusive coronary artery disease

Preliminary autopsy findings indicated that he had received
significant blast injuries, i.e., both eardrums were ruptured
and there was concussive damage to his lungs

None

None

• Cardiomegaly (enlarged heart) (466 grams)• No significant narrowing of the coronary arteries• Interstitial fibrosis of the lungs• Diffuse alveolar damage in the reparative phase• Chronic inflammatory infiltrate within the mucosa andsubmucosa of the lungs• Areas of squamous metaplasia in the midtrachea• Tracheobronchial tree is diffusely obstructed by mucoidtype material• Pulmonary congestion

AUTOPSY COMMENTS■ Firefighter Autopsy Protocol
I: Background ■TitleFirefighter dies during nightat fire station—Mississippi

Structural collapse at an
auto parts store fire claims
the lives of one career
lieutenant and two volunteer
firefighters—Oregon
Volunteer lieutenant dies
following structure collapse at residential house
fire—Pennsylvania

DATE OFINCIDENT

May 29,2002

Nov 25,2002

Nov 01,
2002

F2003-01

F2002-50

F2002-49

NIOSH
REP. #

Traumatic compressional asphyxia

Asphyxiation“Sudden cardiac death”
secondary to hypertensive heart diseaseand coronary arterydiseaseCAUSE OF DEATH

Not mentioned

Not mentioned

Yes

AUTOPSY

None

None

• Microscopic analysis reveals ischemic change manifested
by nuclear hyperchromatism, nuclear outline irregularity,and nuclear enlargement of the nuclei of the individual
rhabdomycytes• Histologic and visual inspection of the heart failed toreveal evidence of acute or remotein farction• An enlarged heart (460 grams).

• Coronary artery disease (CAD)

AUTOPSY COMMENTS

PDF
LINK

■ Firefighter Autopsy Protocol■ 132 ■
I: Background ■F2002-48

NIOSH
REP. #
Title
Firefighter suffers sudden
cardiac death at a structural
fire—New YorkDATE OFINCIDENT

Aug 28,2001“Hypertrophic cardiomyopathy with myocardial arteriolarsclerosis”
as the immediate
cause of death with a“myxomatous mitralvalue”

CAUSE OF DEATH
Yes

AUTOPSY• Blood carboxyhemoglobin level was less than 3%, suggesting the victim was not exposed to excessive carbon
monoxide levels• No evidence of a blood clot (embolus) in the pulmonary
arteries• Marked billowing of both leaflets of the mitral valve• No inflammatory infiltrates, contraction banding, or
hypereosinophilia• Arterioles with thickened intima• Widened interstitium with fibrosis in irregular patterns• Focal myocyte hypertrophy with occasional multipolarity• Myocyte bundles arranged in a sinusoidal and otherirregular patterns• Microscopic changes of the heart muscle• Slightly thickened left ventricle of 1.4 centimeters (cm) indiameter• An enlarged heart weighing 440 grams• Widely patent (open) coronary arteries

AUTOPSY COMMENTS

PDF
LINK

■ Firefighter Autopsy Protocol■ 133 ■
I: Background ■Parapet wall collapse at
auto body shop claims
life of career captain andinjures career lieutenantand emergency medical
technician—Indiana

Sep 30,2002

F2002-44

Extensive blunt-force
traumaFirefighter suffers a heart
Atherosclerotic cardioattack and dies while exercis- vascular disease
ing in firehouse—New YorkJan 04,2001

F2002-46“Hypertensive andarteriosclerotic heartdisease” as the immediate cause of deathand “smoke inhalation”
as an other significant
condition

CAUSE OF DEATH

Firefighter suffers a heart
attack and dies after performing “ventilation-entry-search”
activities in a five-story
apartment building fire—New
York

Title

Jan 13,
2001

DATE OFINCIDENT

F2002-47

NIOSH
REP. #Yes

Yes• Hypertensive and arteriosclerotic cardiovascular disease

Yes

None

• No evidence of a blood clot (embolus)• Myxoid mitral valve• Myocardial infarct, remote (at least 3 months old), septum(microscopic), focal fibrosis of septum adjacent to conduction fibers• Coronary artery with marked atherosclerotic stenosis(80%) of the proximal left anterior descending artery• Atherosclerotic cardiovascular disease• Blood carboxyhemoglobin level was less than 3%, suggesting the victim was not exposed to excessive carbon
monoxide levels• Soot in upper airway• Scant soot in nares• Smoke inhalation• Generalized visceral congestion with pulmonary edema• Coronary arteriosclerosis, multifocal, moderate, withsuperimposed coronary thrombosis in the left main stem
and right coronary artery• Cardiomegaly (heart weighed 560 grams) with concentricleft ventricular hypertrophy• Valves have focal atherosclerosis• 30% stenosis in proximal right coronary artery• 60% calcific atherosclerotic stenosis in left main stem
coronary artery

AUTOPSY COMMENTS

AUTOPSY

PDF
LINK■ Firefighter Autopsy Protocol■ 134 ■
I: Background ■Emergency medical techniBlunt-force trauma tocian killed in single-vehicle
the head and neckcrash while responding tostructure fire—North Carolina
Career firefighter dies intanker rollover—North
Carolina
Career firefighter dies afterroof collapse following roof
ventilation—Iowa
Junior volunteer firefighter dies in tanker
rollover—Tennessee
Volunteer captain killed,
two firefighters and police
officer injured when struckby motor vehicle at highway
incident—Minnesota
Volunteer firefighter dies
during wildland fire suppression—South Dakota
Volunteer firefighter diesafter being run over bybrush truck during grass fireattack—Texas
Offduty career firefighter dies Multiple blunt-force
and another offduty career
injuries with compound
firefighter is injured after
fractures of the skull
being struck by a truck while
assisting at a highway traffic
incident—Florida

Jun 13,2002

Sep 23,2002

Sep 14,2002

Sep 05,2002

Jul 01,
2002

Aug 01,
2002

Aug 08,2002

Jun 08,2002

F2002-42

F2002-41

F2002-40

F2002-39

F2002-38

F2002-37

F2002-36

F2002-35

Craniofacial crush injuries due to a fall frommoving vehicle with asecondary run-overSecond- and thirddegree burns over 70
percent of the bodyMultiple blunt-force
traumaMassive head andchest trauma

Smoke inhalation,
intra-alveolar hemorrhage, and carbon
monoxide intoxication

Fractured neck due tomotor-vehicle incident

Ventriculartachyarrhythmia

Firefighter dies after collapse at apartment building
fire—kentucky

Oct 09,2002

F2002-43

CAUSE OF DEATH

Title

DATE OFINCIDENT

NIOSH
REP. #

Not mentioned

Not mentioned

Not mentioned

Not mentioned

Not mentioned

Yes

Not mentioned

Not mentioned

No

AUTOPSY

None

None

None

None

None

Carboxyhemoglobin level, 30.3%

None

None

Perform an autopsy on all onduty firefighter fatalities

AUTOPSY COMMENTS

PDF
LINK

■ Firefighter Autopsy Protocol■ 135 ■
I: Background ■Structural collapse atresidential fire claims lives of
two volunteer fire chiefs andone career firefighter—New
JerseyVolunteer firefighter diesdue to inadvertent fireworks
discharge—North Dakota
Firefighter suffers probableheart attack at condominium
fire—South Carolina

Firefighter dies after leaving
fire station—Pennsylvania
Firefighter dies during theAsphyxiation due tonight at fire station—Missouri probable seizure

Jul 04,2002

Jul 05,2002

Jan 21,
2002

Apr 27,2002

May 16,2001

F2002-32

F2002-31

F2002-30

F2002-28

F2002-27

Sudden cardiac death

Arteriosclerotic cardiovascular disease

Blunt-force injuriesof the chest and left
upper extremity due tofireworks discharge

Fixed compression

Ischemic heart disease

Firefighter dies during
night at fire station—North
Carolina

Jan 31,
2002

F2002-33

Smoke inhalation andthermal injuries

CAUSE OF DEATH

Career lieutenant andfirefighter die in a flashoverduring a live-fire training
evolution—Florida

Title

Jul 30,2002

DATE OFINCIDENT

F2002-34

NIOSH
REP. #

No

No

Yes

Not mentioned

Yes

Yes

Not mentioned

AUTOPSY

None

None

Perform an autopsy on all deceased firefighters

Perform autopsies on all on-duty firefighter fatalities• A large heart (500 grams)• Aortic atherosclerosis with ulcerating plaques• Coronary atherosclerosis• Ischemic fibrosis with scarring, consistent with an remote,healed heart attack (infarct)• A normal sized heart• Microscopic examination of one section of the heart
reveals multiple small areas of fibrosis. But there isotherwise no evidence of acute or old infarction• Severe three-vessel atherosclerotic disease

None

AUTOPSY COMMENTS

PDF
LINK

■ Firefighter Autopsy Protocol■ 136 ■
I: Background ■Firefighter suffers fatal
heart attack at fire
scene—Wisconsin

Firefighter suffers fatal heart
attack during training—New
MexicoFirefighter suffers fatal
heart attack at fire at his
residence—Florida

Mar 11,
2001

Sep 26,2001

F2002-23

F2002-22

Title

Nov 02,
2001

DATE OFINCIDENT

F2002-24

NIOSH
REP. #“Acute thrombosis ofcoronary artery” due to“arteriosclerotic cardiovascular disease”“cardiac arrest” as theimmediate cause ofdeath, due to “myocardial
infarction,” with “coronary
artery disease” as theunderlying cause

Per death certificate:“myocardial infarction”
with “severe hypoxic brain
injury” resulting from thecardiac arrest.

Per autopsy:

Per death certificate:“cardiac arrhythmia” as
the immediate cause ofdeath and “CAD” (coronary artery disease) as
the underlying cause

Per autopsy: acutecoronary thrombosis with ischemic
arrhythmia

CAUSE OF DEATH

Yes

Yes

Yes

AUTOPSY

PDF
LINK■ 137 ■

Carboxyhemoglobin (COHb) concentration (a measure ofcarbon monoxide exposure) in blood obtained at autopsy
was 1.4% (a medically insignificant level). There was nosoot in the lungs• Acute thrombosis of the left anterior descending coronary
artery• Mild to severe calcific atherosclerosis of the coronary
arteries• Cardiomegaly (445 grams) with left and right ventricular
hypertrophy

Atherosclerotic cardiovascular disease to include• Brain death secondary to cardiac arrest (The last finding
was based on the hospital record; the autopsy did notinclude an examination of the brain.)• Coronary artery stenosis, bilateral, 95% left coronary and
90% right coronary• Acute myocardial infarction, extensive, left ventricle
and intraventricular [sic] septum with cardiac arrest andresuscitation• A blood specimen obtained at autopsy contained “<1%”
COHb• Cardiomegaly due to left ventricular hypertrophy• Interstitial and perivascular fibrosis, myocardium• Acute thrombosis, left circumflex artery• Multiple 90-98% stenosis of LAD [left anterior descending]and left circumflex [coronary arteries]• Severe three-vessel coronary atherosclerosis

AUTOPSY COMMENTS■ Firefighter Autopsy Protocol
I: Background ■TitleJunior firefighter killed while
responding to fire alarm on
his bicycle—Pennsylvania
Two career firefighters die infour-alarm fire at two-story
brick structure—Missouri

Firefighter dies during live
fire training—North Carolina

Career fire chief dies after
being struck by a fire
truck at a motor-vehicle
incident—Kansas
Firefighter dies during the nightat fire station—Kansas

DATE OFINCIDENT

May 04,2002

May 03,2002

Apr 10,2002

Apr 11,
2002

Apr 05,2002

F2002-21

F2002-20

F2002-19

F2002-18

F2002-17

NIOSH
REP. #

Cardiac arrhythmia due
to mitral valve prolapse

Chest, abdomen, andskull trauma

Per autopsy: “probablecardiac arrhythmia
secondary to ischemic
heart disease causedby severe coronary
artery atherosclerosis”

Per death certificate:“ischemic heart disease due to coronary
artery disease”

Smoke inhalation

Multiple injuries

CAUSE OF DEATH

Yes

Not mentioned• Carboxyhemoglobin level was measured at less than 5%.

Yes• Possible acutely dilated right ventricle• Normal coronary arteries

PDF
LINK

■ 138 ■

• Foci of myofiber bundle disorder and myocyte disarray ofthe left ventricle on microscopic examination• Moderate myxomatous degeneration, mitral valve withendocardial friction lesions• Normal sized heart of 360 grams• Urine and blood drug screen was negative for illicit drugs
and alcohol• Carboxyhemoglobin level was less than 10%, suggestingthat carbon monoxide poisoning was not responsible forhis demiseNone• Obesity (height of 67 inches and weight of 195 pounds)(Body Mass Index of 30.5 kilograms per square meter (kg/m2)

• 80% stenosis of right coronary alternating to minimalthroughout length of lumen• Proximal to mid left anterior descending diffuse lesions
causing a pinpoint lumen• Severe coronary atherosclerosis of the left anterior
descending and right coronary arteries

Note: The carbon monoxide level in the blood was noted
to be less that 10% in Victim #1, and 47.9% in Victim #2.
Victim #1 had third-degree thermal injury over 40% of his
body, and Victim #2 had third-degree thermal injury over
18% of his body surface area.

None

AUTOPSY COMMENTS

Not mentioned

Not mentioned

AUTOPSY■ Firefighter Autopsy Protocol
I: Background ■TitleVolunteer firefighter dies andtwo are injured in engine
rollover—Alabama
Career firefighter drowns
during final dive of training
course—Indiana
Civilian jumps fromfourth-story window ofburning apartment building and strikes career
firefighter—Michigan

Volunteer firefighter diesafter being struck by
motor vehicle on interstate
highway—Mississippi
Volunteer firefighter killed
and career chief injured
during residential house
fire—Tennessee
One career firefighter diesand a captain is hospitalized
after floor collapses in residential fire—North Carolina
Volunteer firefighter diesafter tanker truck is struck by
freight train—kentucky

DATE OFINCIDENT

Apr 07,2002

Jun 14,2002

Jan 10,2002

Mar 20,2002

Mar 01,2002

Mar 04,2002

Mar 02,
2002

F2002-16

F2002-15

F2002-14

F2002-13

F2002-12

F2002-11

F2002-10

NIOSH
REP. #

Multiple blunt-force
injuries

Multiorgan failure;
80% total body surface
burns

Asphyxiation

Craniocerebral trauma

County medical examiner listed the cause ofdeath as natural due toa ruptured berry aneurysm; independent
review concluded thatthe firefighter’s death
was work-related

Drowning

Mechanical asphyxia
due to blunt headtraumaCAUSE OF DEATH

Not mentioned

Not mentioned

Not mentioned

Not mentioned

Yes

Yes

Not mentioned

AUTOPSY

None

None

Carboxyhemoglobin level was listed at 31.8%

None

The independent review concluded that the firefighter’s
death was work-related. The report described the cause ofdeath as “...job related, caused by stress and exertion in
the performance of his duties. The timeliness of the eventson January 10, 2002, and subsequent developments
are unquestionably the direct result of the victim’s bloodpressure which brought on leakage from a pre-existing
aneurysm, (sentinel bleed) and ultimately the rupture of
the aneurysm, profuse subarachnoid hemorrhage, brain
swelling, coma, and death.”

None

None

AUTOPSY COMMENTS

PDF
LINK

■ Firefighter Autopsy Protocol■ 139 ■
I: Background ■One career firefighter diesand another is injured
after partial structural
collapse—Texas
First-floor collapse durAsphyxia due to theing residential basement
inhalation of smoke
fire claims the lives of two
and soot
firefighters (career and volunteer) and injures a career
firefighter captain—New YorkFeb 11,2002

Mar 07,
2002

F2002-07

F2002-06

Multiple blunt-force
injuries

Hypoxia due topulmonary edema due
to cardiomyopathy

Firefighter dies at kitchen
fire—North Carolina

Aug 09,2000

F2002-08

Arteriosclerotic andhypertensive heartdiseaseCAUSE OF DEATH

Firefighter dies while
exercising—Florida

Title

Aug 29,2001

DATE OFINCIDENT

F2002-09

NIOSH
REP. #

Not mentioned

Not mentioned

Yes

Yes

AUTOPSY

None

None

• Mild occlusive coronary artery disease (CAD)• Morbid obesity (Body Mass Index of 43 kg/m2)• Evidence of chronic ischemia• Cardiomegaly (an enlarged heart weighing 475 grams)• History of rheumatic heart disease• Severe pulmonary edema• Status postmitral valve replacement• Dilated cardiomyopathy• Moderate obesity (Body Mass Index of 43 kilograms per
square meter [kg/m2]• Moderate to severe occlusive coronary artery disease(CAD)• Scarring consistent with a remote (old) heart attack(myocardial infarction)• Left ventricular hypertrophy with patchy fibrosis• Biventricular dilatation• Cardiomegaly (an enlarged heart weighing 700 grams

AUTOPSY COMMENTS

PDF
LINK

■ Firefighter Autopsy Protocol■ 140 ■
I: Background ■Firefighter suffers sudden
cardiac death and crashes
tanker while responding to achimney fire—Colorado

Motor-vehicle incident
claims life of volunteer
firefighter—Ohio
Firefighter suffers cardiac
arrest while responding to a
structure fire—Texas

Firefighter dies during fire department
standby—Arizona

Jan 21,
2002

Dec 24,2001

Dec 15,2001

F2002-04

F2002-03

F2002-02

Title

Dec 14,
2001

DATE OFINCIDENT

F2002-05

NIOSH
REP. #“Probable acute
myocardial ischemia”
due to “coronary
atherosclerosis” due to“diabetes mellitus” as
the immediate causeof death and a “historyof previous myocardial
infarction” as an othersignificant contributing
condition

Arteriosclerotic cardiovascular disease

Laceration of the brain
secondary to blunt
impacts to the headHeart failure as theimmediate cause ofdeath due to arteriosclerotic heart disease

CAUSE OF DEATH

No

Yes

Not mentioned

Yes

AUTOPSY

Perform an autopsy on all onduty firefighter fatalities• Drug screen was negative for alcohol, illicit drug use, andcarbon monoxide• Bilateral ventricular dilatation• Old posterolateral myocardial infarction (prior heart
attack)• Cardiomegaly (enlarged heart weighing 600 grams)• Atherosclerosis of the coronary arteries

None• Blood screen for illicit drug use or alcohol was negative• No evidence for any of the following: epidural, subdural,or subarachnoid [skull] hemorrhage, recent stroke,
pulmonary embolus• Small old infarct right cerebral hemisphere [stroke],internal capsule, brain• Atherosclerotic degeneration abdominal portion of theaorta• Atherosclerotic coronary artery disease, severe poststent
replacement coronary arteries• Old healed myocardial infarct [heart attack] involving theinterventricular septum and the anterior wall left ventricle• Cardiomegaly

AUTOPSY COMMENTS

PDF
LINK

■ Firefighter Autopsy Protocol■ 141 ■
I: Background ■Volunteer firefighter dies andtwo others are injured during
live-burn training—New York
Firefighter suffers heartarrhythmia and dies atwildland fire—Washington

Volunteer firefighter dieswhen tanker crashes into
boulder and tree—Oregon
Volunteer firefighter drowns
during multiagency diverescue exercise – Illinois
Firefighter suffers probable heart attack at firestation—kentucky
High-rise apartment fireclaims the life of one career
firefighter (captain) andinjures another career
firefighter (captain)—Texas

Sep 25,2001

Jun 18,2001

Aug 19,2001

Oct 13,2001

Aug 12,2000

Oct 13,2001

F2001-38

F2001-37

F2001-36

F2001-35

F2001-34

F2001-33

Asphyxia due to a lackof oxygen.

Acute myocardial
infarction

Drowning

Blunt-force headtraumaProbable cardiac
dysrhythmia due tofibrosis of the conduction system of the heart

Asphyxia due to smoke
inhalation

Volunteer firefighter killed
Blunt-force traumaticand an assistant chief injured head injury
in tanker truck crash—west
Virginia

Nov 19,2001

F2001-39

Cardiac arrhythmia

CAUSE OF DEATH

Firefighter suffers cardiac arrest at structure
fire—Illinois

Title

Mar 06,
2000

DATE OFINCIDENT

F2001-40

NIOSH
REP. #

Not mentionedNo

Not mentioned

Not mentioned

Yes

Not mentioned

Not mentioned

Yes

AUTOPSY

None

None

The victim’s blood level of carboxyhemoglobin measured
18% saturation

Perform an autopsy on all firefighters who were fatally
injured while on duty

None

None

• Possible dilated right ventricle• Mild perivascular fibrosis with adjacent areas of myocyte
hypertrophy of the left ventricle and interventricular
septum• Focal moderate to severe atherosclerosis of the proximate left anterior descending (LAD) coronary artery• Fibrosis of the conduction system of the heart• Ischemic heart disease• Cardiomegaly due to left ventricular hypertrophy• 50% to 75% narrowing of the proximal left anterior
descending coronary artery• Atherosclerosis of the coronary arteries

AUTOPSY COMMENTS

PDF
LINK

■ Firefighter Autopsy Protocol■ 142 ■
I: Background ■Firefighter suffers fatal heart
attack after returning homefrom fire—Iowa

Apr 02,
2001

F2001-30“Acute myocardial
infarction” as theimmediate cause ofdeath and “severe arteriosclerotic coronary
vascular disease—rightcoronary artery” as theunderlying cause“Acute myocardial
infarction” as theimmediate cause ofdeath and “arteriosclerotic cardiovascular disease” as theunderlying cause

Firefighter suffers a fatal
heart attack during a training
exercise—Michigan

Apr 23,2001

F2001-31

CAUSE OF DEATH

Firefighter dies at three-alarm Hypertrophic andstructure fire—New Yorkarteriosclerotic cardiac
diseaseTitle

Aug 13,
2001

DATE OFINCIDENT

F2001-32

NIOSH
REP. #

Yes

Yes

Yes

AUTOPSY• The result of a blood test for carboxyhemoglobin (anindicator of carbon monoxide exposure) was reported
as “0.0%,” but the blood was drawn almost 2 hours afterEngine 1 departed the fire scene and after 50 minutes ofoxygen (which accelerates the clearing of carboxyhemoglobin) administered via endotracheal tube. (At autopsy,
the result of another carboxyhemoglobin test was also
reported as “0.0%.”)• Respiratory congestion and edema, severe• Remote myocardial infarctions. . . . One probably
occurred months ago, and another is at least 7 days inage• Severe atherosclerotic coronary artery disease—distalright coronary artery• Cardiomegaly with dilated cardiomegaly and left ventricular hypertrophy• Coronary atherocalcinosis with maximal manifestation
and 75% luminal stenosis in left mid descending coronary
artery• Acute myocardial infarction due to arteriosclerotic cardiovascular disease with acute subepicardial antero-lateral
myocardial infarction• Hepatosplenomegaly• Fatty liver• Pulmonary congestion and edema• Dilated cardiac chambers• Borderline cardiomegaly (an enlarged heart weighing 400
grams)• “To assist the investigation of fire-related deaths, we[NIOSH]recommend performing carboxyhemoglobin
levels to rule out carbon monoxide poisoning.”• A carboxyhemoglobin level (to assess the victim’s carbon
monoxide exposure) was not performed.

AUTOPSY COMMENTS

PDF
LINK

■ Firefighter Autopsy Protocol■ 143 ■
I: Background ■TitleFirefighter dies of complications of heart failure sufferedat fire scene—Wisconsin

Firefighter receives severe
electrical shock causing
cardiac complications,
forcing his retirement, andeventually causing his
death—Massachusetts

Career firefighter dies after
single-family-residence
house fire—South Carolina
Career firefighter dies frominjuries when stationary filltank becomes over-pressurized and suffers catastrophic
failure—California

DATE OFINCIDENT

Feb 12,2001

Dec 23,
1995

Jun 16,2001

Jul 26,2001

F2001-29

F2001-28

F2001-27

F2001-26

NIOSH
REP. #

Head injury due toblunt impact

Complications due tosecond- and thirddegree burns“Arteriosclerotic coronary heart disease” asthe immediate cause ofdeath, with “hypertensive heart disease” asa contributing, but notan underlying, causeof death

Hypoxia/Ischemia,
Acute [of the brain
and spinal cord]” as
the immediate causeof death, various
autopsy findings asintermediate causes,and “Overexertion from
responding to a fire callwith Fire Dept” as theunderlying cause

CAUSE OF DEATH

Not mentioned

Not mentioned

Yes

Yes

AUTOPSY

None

None

• Contusion and laceration on the left side of the head
without internal injury• Severe arteriosclerosis with diffuse calcification• Thickened left ventricle wall of 1.8 centimeters (normal<1.2 centimeters)• All four chambers of the heart were dilated• An enlarged heart (cardiomegaly) of 500 grams• Status postcardiac arrest (pulseless time 6-8 minutes)• Atherosclerosis, moderate to severe, right vertebral artery,basilar artery, temporal branch of right middle cerebral
artery• Infarct, acute/recent, middle and inferior temporal gyrus
and occipital lobes, bilateral)• Hypoxia/ischemia, acute, varying severity, semiglobal,(cerebral, cerebellar, and spinal cord)• Bronchopneumonia, focal, mild, acute, lungs• Anomalous coronary artery distribution• Arteriosclerotic coronary artery disease with luminal
occlusion of over 95% in the proximal circumflex whicharises aberrantly from the right sinus of Valsalva [and] up
to 50% occlusion in anterior interventricular artery, distal
circumflex, and posterior intraventricular artery, heart• Congestive heart failure

AUTOPSY COMMENTS

PDF
LINK

■ Firefighter Autopsy Protocol■ 144 ■
I: Background ■Firefighter dies after
completing job task
evaluation—Alabama

Firefighter suffers sudden cardiac death while
exercising during his
shift—California

Feb 05,2001

F2001-24

Title

Jun 15,
2001

DATE OFINCIDENT

F2001-25

NIOSH
REP. #

Cardiac dysrhythmia
associated withexertion due to dilated
cardiomyopathy“cardiac arrhythmia”
due to “myocardialischemia” due to “coronary artery disease”“cardiac arrest” as theimmediate cause ofdeath. Per autopsy:

Per death certificate:

CAUSE OF DEATH

Yes

Yes

AUTOPSY

PDF
LINK■ 145 ■

• Blood lead level, the urine arsenic level, and the urine
mercury level were below the laboratory’s level of detection (<3 micrograms (mcg) per deciliter, <15 mcg perliter (mcg/l), <5 mcg/l, respectively). The urine lead level
was elevated at 76 mcg/l and when corrected for urine
creatinine was 165 mcg per gram creatinine (reference
range <50)

• No illicit drugs, alcohol, or steroids were found• There was no evidence of vasculitis, myocarditis, sarcoidosis, Fabry’s disease, amyloidosis, or hemochromatosis• Microscopic examination of the left ventricle, the rightventricle, and the interventricular tissue showed myocyte
hypertrophy (muscle cell thickening) characterized byenlarged “box car” nuclei and some patchy interstitial
fibrosis (scar tissue between some of the muscle cells)• No atherosclerotic changes were evident in the coronary
arteries (no blockage in the coronary arteries)• No evidence indicated old or recent myocardial infarctions(heart attacks)• Both heart ventricles were hypertrophied (thick).

• All four chambers of the heart were moderately dilated(enlarged)• The heart was enlarged (weighing 480 grams)• The heart had a rounded “globoid” configuration rather
than the normal pyramidal shape• Severe concentric left ventricular hypertrophy• Acute myocardial ischemia• Moderate coronary atherosclerosis with 50% narrowingof the right coronary artery and the left main artery; 75%
narrowing of the left circumflex; 80% narrowing of the left
anterior descending coronary artery; left anterior descending coronary artery thrombosis

AUTOPSY COMMENTS■ Firefighter Autopsy Protocol
I: Background ■Firefighter dies while on
duty—Texas

Firefighter dies in sleep during his work shift—Michigan

Firefighter has sudden
cardiac death during
training—Texas

Mar 10,2001

Jan 18,2001

Dec 02,
1998

F2001-22

F2001-21

F2001-20

CAUSE OF DEATH

Atherosclerotic cardiovascular disease

Arteriosclerotic cardiovascular disease

Hypertensive andarteriosclerotic cardiovascular disease

Asphyxia due to smoke
inhalation.

Hardware store explosion
Victims #1 & #3: masclaims the lives of three
sive blunt force trauma
career firefighters—New York Victim #2:

Title

Jun 17,
2001

DATE OFINCIDENT

F2001-23

NIOSH
REP. #

Yes

Yes

Yes

Not mentioned

AUTOPSY• Remote myocardial infarction, multiple, left ventricle• Mild narrowing of the cerebral arteries• Mild to moderate narrowing of the aorta• Moderate to severe narrowing of the coronary arteries• Atherosclerotic cardiovascular disease• Carboxyhemoglobin level was 1%, suggesting thefirefighter was not exposed to excessive concentrations ofcarbon monoxide (CO).

• Pulmonary congestion and edema• Left ventricular hypertrophy• Enlarged heart• Significant occlusive coronary artery disease with 85%
narrowing of the left main coronary artery, 60% narrowing of the left anterior descending coronary artery, 30%
narrowing of the left circumflex, and 25% narrowing of theright coronary artery• Pulmonary congestion and edema• Left ventricular hypertrophy• Cardiomegaly (enlarged heart)• Severe occlusive coronary artery disease with 75%
narrowing of the right coronary artery and the diagonalbranch; 50% narrowing of the left anterior descending
coronary artery and the left circumflex

None

AUTOPSY COMMENTS

PDF
LINK

■ Firefighter Autopsy Protocol■ 146 ■
I: Background ■Career firefighter dies after
falling through the floor fighting a structure fire at a local
residence—Ohio
Residential fire claims the
lives of two volunteer firefighters and seriously injures
an assistant chief—Missouri
Firefighter dies after returning from mutual-aid firecall—Connecticut

Supermarket fire claims thelife of one career firefighterand critically injures anothercareer firefighter—Arizona

Mar 08,2001

Mar 18,2001

F2001-15

F2001-14;
Feb 18,Grant Number
2001
R43-OH-004173

Mar 14,2001

F2001-16

F2001-13

Motor-vehicle incident
claims the life of a volunteer
assistant chief—Alaska

Mar 06,2001

F2001-17

Thermal burns andsmoke inhalation“Cardiac arrest” islisted as the immediate
cause of death, and“hyperlipidemia” and“diabetes mellitus” arelisted as contributing
factors

Asphyxiation due tosmoke inhalation

Complications ofthermal burns to 60%
of total body surface

Multiple blunt-force
injuries

Asphyxiation

Career firefighter dies after
becoming trapped by fire inapartment building—New
JerseyMay 09,2001

F2001-18

CAUSE OF DEATH

Firefighter dies after assisting Severe occlusive coroan injured person—Ohionary artery disease

Title

Feb 19,2000

DATE OFINCIDENT

F2001-19

NIOSH
REP. #

Not mentionedNo

Not mentioned

Not mentioned

Not mentioned

Not mentioned

Yes

AUTOPSY

None

None

None

None

None

The victim’s carboxyhemoglobin level was listed at 61% at
the time of death• Congestion of viscera• Pulmonary congestion and edema• Left ventricular hypertrophy• Severe occlusive coronary artery disease with calcification; 70-80% narrowing of the left anterior descending
coronary artery and the right coronary artery; Recent
thrombus right coronary artery

AUTOPSY COMMENTS

PDF
LINK

■ Firefighter Autopsy Protocol■ 147 ■
I: Background ■Firefighter dies at house
fire—New Hampshire

Volunteer firefighter dies andanother firefighter is injured
during wall collapse at fire at
local business—Wisconsin
Two volunteer firefighters
die fighting a basement
fire—Illinois
A volunteer firefighter diedafter being struck by a
motor vehicle while directing
traffic—New YorkDec 23,2000

Feb 25,2001

Feb 17,2001

Jan 09,2001

F2001-10;
Purchase Order
0000136411

F2001-09

F2001-08

F2001-07

CAUSE OF DEATH

Multiple injuries
consisting of a massive
closed head injury,
pulmonary contusion,and chest injury

Asphyxiation caused
by inhalation of products of combustion

Anoxic encephalopathy
and chest compression
asphyxia

Atherosclerotic andhypertensive cardiovascular disease withcardiac arrhythmia
following stressand exertion during
firefighting“heart rhythm disturbance (arrhythmia)”as the cause of death
and atherosclerotic
cardiovascular disease
as the contributing
factor.

Per autopsy:

Driver/Operator suffers a car- Per death certificate:diac arrest during a wildland
atherosclerotic cardiofire exercise—Georgia
vascular disease

Title

Nov 16,
2000

DATE OFINCIDENT

F2001-11

NIOSH
REP. #

Not mentioned

Yes

Not mentioned

Yes• Atherosclerotic cardiovascular disease with 70% stenosis,
left main coronary artery; 70-90% stenosis, multifocal, left
anterior descending coronary artery; complete occlusion,
circumflex coronary artery

Yes

None

None

None

– Acute thrombi (blood clots) were noted• Atherosclerosis of the coronary arteries. Specifically, theartery supplying the anterior wall of the heart was focallyoccluded, and two other major arteries were 40-50%
occluded• Pulmonary emphysema• Detectable blood ethyl alcohol• A nontoxic carbon monoxide level• Vascular congestion, all internal organs

AUTOPSY COMMENTS

AUTOPSY

PDF
LINK■ Firefighter Autopsy Protocol■ 148 ■
I: Background ■Volunteer firefighter (lieutenant) killed and one firefighter
injured during mobile home
fire—Pennsylvania
Roof collapse injures four
No deaths
career firefighters at a church
fire—ArKansas
A firefighter drowns after
attempting to rescue a
civilian stranded in flood
water—Colorado
Volunteer firefighter diesand junior firefighter isinjured after tanker rollover
during water shuttle training
exercise—kentucky
Firefighter suffers a heart
attack after expressing
symptoms while on duty—
New Jersey

Residential house fireclaims the life of one career
firefighter—Florida

Jan 11,
2001

Dec 28,2000

Aug 17,2000

Nov 16,2000

Jun 23,
2000

Nov 25,
2000

F2001-04

F2001-03

F2001-02

F2001-01

F2000-45

F2000-44

Yes

Yes

Not mentioned

Not mentioned

NA

Not mentionedNo

Not mentioned

AUTOPSY

Positive carbon monoxide reading of 69.5% was recorded• A 1 cm scar in the posterior wall of the left ventricle,
inferiorly• Mild atherosclerosis of the mitral and aortic valves• Nonadherent thrombus in the right coronary artery• Three arteries are calcified with 10% to 50% obstruction
multifocally

None

None

NA

None

Autopsies should be performed on all onduty firefighters
whose death may be cardiovascular-related

None

AUTOPSY COMMENTS

PDF
LINK

■ 149 ■

Asphyxia due to smoke
inhalation and carbon
monoxide poisoning

Arteriosclerotic cardiovascular disease

Massive internal
injuries

Apparent drowning

Asphyxiation

Cerebral event as theimmediate cause ofdeath, due to cerebral hypoperfusionand coronary arterydiseaseDriver/Operator dies at
his station after responding to three emergency
incidents—Massachusetts

Oct 13,
2000

F2001-05

CAUSE OF DEATH

Firefighter dies after the
Blunt-force injuries
tanker truck he was driving
strikes a utility pole andoverturns while responding toa grass fire—kentucky

Title

Jan 12,
2001

DATE OFINCIDENT

F2001-06

NIOSH
REP. #■ Firefighter Autopsy Protocol
I: Background ■A volunteer assistant chief
was seriously injured andtwo volunteer firefighters
were injured while fighting atownhouse fire—Delaware
Lieutenant suffers a cardiac
arrest during a structural
drill—kentucky

Firefighter dies after
being run over by laddertruck while attempting toboard—Alabama

Feb 13,2000

Sep 27,2000

F2000-42

F2000-41

Title

Oct 29,2000

DATE OFINCIDENT

F2000-43

NIOSH
REP. #

Multiple blunt-force
injuries“Hypertensive atherosclerotic cardiovasculardisease” as the causeof death and “diabetes, hyperlipidemia,
tobacco use, andhypertension” ascontributing factors

No deaths

CAUSE OF DEATH

Not mentioned

Yes

NA

AUTOPSY

None• “Documented history of hypertension”• “Documented history of tobacco use”

• Documented history of inferior wall infarction in 1997

• Hyperlipidemia• Diabetes mellitus• Nephrosclerosis• Peripheral vascular disease of the abdominal aorta• Circumferential scarring of the left ventricular free walland septum• Acute thrombus of the right coronary artery• Stent within the right coronary artery• Total occlusion of the mid-left anterior descending artery• High-grade stenosis (80%) of the circumflex and proximal
left anterior descending arteries• Cardiomegaly• Hypertensive atherosclerotic cardiovascular diseaseNA

AUTOPSY COMMENTS

PDF
LINK

■ Firefighter Autopsy Protocol■ 150 ■
I: Background ■Firefighter/scuba diverdies during training
evolution—Indiana

Aug 13,2000

F2000-38[Pulmonary]barotrauma

Multiple injuries
sustained due to a
motor-vehicle crash

A lieutenant dies and threefirefighters of a career
department were injured
when the truck they were
responding in was struck byanother vehicle—Illinois

Apr 29,2000

F2000-39

CAUSE OF DEATH

Firefighter collapses and dies Arteriosclerotic heart
during exercise training at his disease
fire station—Missouri

Title

Aug 06,
2000

DATE OFINCIDENT

F2000-40

NIOSH
REP. #Yes

Not mentioned

Yes

AUTOPSY• Toxicology reports listed no finding which contributed tohis death• No pneumothorax.

• Subcutaneous emphysema (air under the skin) andalveolar hemorrhage, as well as pulmonary edema withpink foam in the airways• Extensive air emboli (air bubbles in lung, brain, and heart
blood vessels)

None• Large white layer of lipid (fat) material [suggesting a
recent meal or a lipid disorder• Presence of a prescription heart medication (Papaverine)• Illicit drug and alcohol tests were negative– 80% narrowing of the left anterior descending artery– 60% narrowing of the circumflex artery– 80% narrowing of the distal right coronary artery• Fresh clot (thrombus) in the right coronary artery 2 cmfrom its origin• Arteriosclerotic heart disease• Scar formation in the left ventricle (superior aspect of theposterior wall)• Left and right ventricular dilatation• An enlarged heart weighing 570 grams• No weight taken at the time of his autopsy

AUTOPSY COMMENTS

PDF
LINK

■ Firefighter Autopsy Protocol■ 151 ■
I: Background ■Junior firefighter killed
responding to call in his
privately owned vehicle(pov)—Pennsylvania

Jul 02,
2000

F2000-35

Not mentioned

Yes“Blunt force trauma of the left chest wall resulted in a
massive intrasplenic hematoma and the development of astress ulcer. The spleen was not ruptured. The stress ulcer
perforated, releasing bowel contents into the peritoneal
cavity, which resulted in fibrinous peritonitis. Hypotensive
episodes secondary to the peritonitis led to multiple organsystem failure, specifically generalized ischemic necrosis of
the liver (superimposed upon hepatitis C-induced micronodular cirrhosis), acute tubular necrosis of the kidneys andinfarction of the rectosigmoid colon. The combination ofliver failure and renal failure constitutes so-called ‘multiple
organ system failure’ and was the immediate cause ofdeath. The underlying cause of death was blunt-force
trauma of the left chest wall.”Yes -twoNone• 50-60% occlusion of the right coronary artery• 70-80% occlusion proximally of the circumflex artery• Stent in the LAD with 60-75% focal occlusion proximally• Severe coronary artery disease (CAD)• A recent anterior septal MI• An old posterior MI• A large heart (cardiomegaly) weighing 535 gramsTwo days later, a second autopsy was performed by aforensic pathologist hired by the victim’s widow. This
autopsy essentially confirmed the findings of the first
autopsy with two additional points mentioned. A left-arm
contusion (bruise), a left-trunk contusion, and a left-10th-rib
fracture were noted, suggesting the initial fall on July 18
was quite severe. A second point in this autopsy was that
postinjury medications, in addition to chronic hepatitis C
virus (HCV) infection and cirrhosis due to HCV, contributed
to his liver failure

AUTOPSY COMMENTS

AUTOPSY

PDF
LINK■ 152 ■

Blunt-force trauma to
the head and trunk

Captain suffers a heart attack Myocardial infarction
at a structure fire and dies 12 (otherwise known asdays later—Illinois
a heart attack) as theimmediate cause ofdeath, due to severe
atherosclerotic cardiovascular disease

Jul 23,
1998

F2000-36“Multiple organ system
failure” due to, or asa consequence of, (b)“peritonitis with severe
hypotension, ischemic
necrosis of the liverand kidneys” due to, or
as a consequence of,(c) “blunt force traumaof the left chest wallwith splenic hematomas and a perforated
stress ulcer.”

CAUSE OF DEATH

Arson investigator diesfrom injuries sustained
from a fall during an arson
investigation—Illinois

Title

Jul 18,
2000

DATE OFINCIDENT

F2000-37

NIOSH
REP. #■ Firefighter Autopsy Protocol
I: Background ■Lieutenant dies at a fire ina one-and-one-half story
dwelling—west Virginia

Pumper truck rollover
claims the life of a volunteer
firefighter—Missouri
Driver/Operator/Firefighter
suffers a heart attack anddies while supporting fire
suppression activities—New
York

Firefighter collapses at thefire house and subsequently
dies due to heart arrhythmia
secondary to myocardial
sarcoidosis—New Jersey

May 27,2000

Apr 29,1998

Nov 16,1999

F2000-33

F2000-32

F2000-31

Title

Apr 26,
2000

DATE OFINCIDENT

F2000-34

NIOSH
REP. #

Granulomatous
myocarditis due to sarcoidosis, generalized

Hypertensive andatherosclerotic cardiovascular disease

Cerebral laceration,
due to an open skull
fracture

Atherosclerotic coronary disease

CAUSE OF DEATH

Yes

Yes

Not mentioned

No

AUTOPSY• Sarcoidosis (noncaseating granulomas) of the heart, lung,
lymph nodes, liver, and spleen• No significant atherosclerotic disease of the coronary
arteries• Cardiac hypertrophy and cardiomegaly (a large heart)• His blood carboxyhemoglobin level was less than 3%,
suggesting the victim was not exposed to excessive
carbon monoxide levels• No evidence of a blood clot (embolus) in the pulmonary
arteries;• Left ventricular hypertrophy• Small circumscribed area (0.5 by 1.2 by 1.0 centimeter) of
subepicardial fibrosis in the mid-posterior left ventricularwall (nontransmural). This finding is consistent with aremote (at least 3 months) heart attack in the distributionof the right coronary artery lesion mentioned previously– Near occlusive proximal left anterior descending CAD– Near occlusive mid-right CAD• Marked coronary artery atherosclerosis

None• “Mild chronic obstructive pulmonary disease and hepatitis
per history.”• “Myocardial infarct (based on circumstances, EKG
changes, and serologic testing)”

A visual inspection, rather than an autopsy, was also completed by the Assistant Medical Examiner. Based on thisinspection, the following “pathologic diagnosis” was listed:

AUTOPSY COMMENTS

PDF
LINK

■ Firefighter Autopsy Protocol■ 153 ■
I: Background ■Firefighter dies on
duty—Tennessee

Volunteer assistant chiefdies during a controlled-burn
training evolution—Delaware
Residential structure fireclaims the life of one career
firefighter—Alabama
A volunteer firefighter diedand a second was seriously injured after fuel tank
explosion—Iowa
Firefighter dies during search-and-rescue
training—Ohio

Career firefighter dies andSmoke and soot inhathree are injured in a residen- lation and acute carbon
tial garage fire—Utahmonoxide intoxication

Aug 20,1998

Apr 30,2000

Apr 20,2000

Apr 07,2000

Apr 11,
2000

Mar 31,
2000

F2000-28

F2000-27

F2000-26

F2000-25

F2000-24

F2000-23

Cardiomegaly—acutecardiac arrhythmia

Multiple blunt-force
injuries to the head,neck, torso, andextremities

Thermal injuries(full-thickness burns
to roughly one-third ofbody surface area)

Asphyxiation andthermal burns“acute myocardial
infarction due to coronary artery disease” asthe immediate causeof death and “diabetes
mellitus Type II andrenal failure” as othersignificant conditions

Cardiac arrest

Firefighter dies as a result ofa cardiac arrest at the sceneof a structure fire—Maine

Jan 12,
2000

F2000-29

Intracerebral hemorrhage due to hypertension, essential(otherwise known as a“stroke”)

CAUSE OF DEATH

District chief dies of a stroke
after serving as the Incident
Commander at a structure
fire—Tennessee

Title

Sep 28,
1998

DATE OFINCIDENT

F2000-30

NIOSH
REP. #• CO levels were at 25% saturation but may not accuratelyreflect his level due to intubation and resuscitation efforts)• Chronic and acute lung congestion• 50-60% blockage of the midpoint of his left anterior
descending coronary artery• Moderate coronary atherosclerosis– A weight of 690 grams• Cardiomegaly (enlarged heart)

None

None

Carbon monoxide level was listed at 41%

Perform an autopsy on all onduty firefighter fatalities

An autopsy was performed; however, medical records were
not available to NIOSH personnel at the time of this report

Perform an autopsy on all onduty firefighter fatalities

AUTOPSY COMMENTS

PDF
LINK

■ 154 ■

Not mentioned

Yes

Yes

Not mentioned

Not mentioned

No

Yes

No

AUTOPSY■ Firefighter Autopsy Protocol
I: Background ■Wildland fire claims the life of
one volunteer firefighter andinjures another firefighter—
South Dakota
On-duty driver/operator diesin sleep—Indiana

Driver/Operator diesat a motor vehicle
fire—Wisconsin

Jun 02,
1998

Feb 10,1998

F2000-21

F2000-20

Title

Mar 15,
2000

DATE OFINCIDENT

F2000-22

NIOSH
REP. #“Myocardial infarction”
as the immediate
cause of death, due
to “severe atherosclerotic cardiovasculardisease.”Probable arrhythmia
due to hypertrophic
cardiomyopathy, fibrosis of sinoatrial node

Sepsis as a resultof extensive thermalburns due to a grass
fire

CAUSE OF DEATH

Yes

Yes

Not mentioned

AUTOPSY• Cardiomegaly (enlarged heart) (750 gms)

• Three graft vessels

PDF
LINK

■ 155 ■• Large remote myocardial infarct in the lateral wall of theleft ventricle– High-grade atheromatous plaques of up to 100%
occlusion of the left anterior descending and the rightcoronary arteries• Severe arteriosclerotic heart disease• Hashimoto’s thyroiditis• Hepatosplenomegaly with passive congestion• Severely congested lungs bilaterally with edema• Biventricular and ventricular septum hypertrophy– Significant myocyte hypertrophy with nuclear enlargement and fiber disarray involving the septum of both
ventricles– Dilated right ventricle– Diminished left ventricular cavity• Concentric hypertrophic cardiomyopathy– Fibrosis of the sinoatrial node

– Intramyocardial tunneling of coronary artery– Up to 50% stenosis of the mid left anterior descending
coronary artery– Up to 50% stenosis of the proximal circumflex artery• Moderate coronary artery disease• Since the driver/operator was not engaged in fire suppression activities, his blood was not tested for carbon
monoxide poisoning (carboxyhemoglobin levels)

None

AUTOPSY COMMENTS■ Firefighter Autopsy Protocol
I: Background ■A volunteer firefighter/driver
was killed and anothervolunteer firefighter was
injured while responding toa motor vehicle incident withinjuries—California
Arson fire claims the life of
one volunteer firefighter andone civilian and severely
injures another volunteer
firefighter—Michigan
Battalion chief suffers a heart
attack and eventually dieswhile participating in a fitness
program—California
Firefighter dies at a singlefamily dwelling fire—Iowa

Feb 11,2000

Mar 03,2000

Oct 15,1997

Feb 06,2000

F2000-17

F2000-16

F2000-15

F2000-14“Occlusive coronary
artery disease” as theimmediate cause ofdeath due to “atherosclerotic vasculardisease”

Cardiogenic shock due
to enterobacter sepsis
due to multiorgan
failure due to ischemic
cardiomyopathy

Asphyxiation

Adult respiratory distress syndrome [lungfailure]/ischemia andencephalopathy due tomotor vehicle crash

Tanker rollover claims life of Massive neck trauma
volunteer fire chief—Missouri and upper chest
traumaJan 17,2000

F2000-18

CAUSE OF DEATH

Motor-vehicle incident involv- Multiple blunt-force
ing amtrak train claims life of injury from the fire
career firefighter/engineer— truck/train collision
North Carolina

Title

Mar 17,
2000

DATE OFINCIDENT

F2000-19

NIOSH
REP. #YesNo

Not mentioned

Not mentioned

Not mentioned

Not mentioned

AUTOPSY• Carbon monoxide level of 4%

PDF
LINK

■ 156 ■• Pulmonary anthracosis without emphysema• Acute pulmonary congestion, agonal• Focal contraction band necrosis in the right ventricle– Left anterior descending artery unavailable due toorgan harvesting for donation– Left circumflex artery, 80% stenotic– Right coronary artery, 75% stenotic– Severe coronary artery disease• Atherosclerotic vascular disease

Perform autopsies on all onduty firefighter fatalities

None

None

None

None

AUTOPSY COMMENTS■ Firefighter Autopsy Protocol
I: Background ■Volunteer firefighter drowns
Severe metabolic
during dry-suit training dive— acidosis as the result
North Carolinaof near drowning
A captain and a firefighter
die from injuries in a tanker
rollover—Indiana
Volunteer firefighter diesfighting a structure fire at a
local residence—Texas
Volunteer firefighter
dies after 9-foot fall fromladder—Pennsylvania
Tanker rollover results inthe death of one volunteer
firefighter—Texas

Jan 15,2000

Oct 28,1999

Jan 27,2000

Jan 17,2000

Nov 14,1999

F2000-11

F2000-10

F2000-09

F2000-07

F2000-06

Blunt trauma

Blunt-force trauma to
the head

Smoke inhalation

Victim #2: Sepsis

Victim #1: Cardiac
arrhythmia“Myocardial infarction”(heart attack) as theimmediate cause ofdeath, and “diabetes” as a significant
condition

Sector captain suffers fatal
heart attack—Texas

Jan 17,2000

F2000-12

Asphyxia due to smoke
inhalation

CAUSE OF DEATH

Restaurant fire claims
the life of two career
firefighters—Texas

Title

Feb 14,
2000

DATE OFINCIDENT

F2000-13

NIOSH
REP. #Yes

Not mentioned

Yes

Not mentioned

Not mentioned

No

Yes

AUTOPSY

None

None

None

None

None

None

None

AUTOPSY COMMENTS

PDF
LINK

■ Firefighter Autopsy Protocol■ 157 ■
I: Background ■Captain dies as a result of a Myocardial infarction
cardiac arrest at the scene ofa structure fire—Alabama

Jul 04,1999

F2000-03

Victim #3: Sudden
exposure to intense
heat

Victim #2: Smoke
inhalation andsudden exposure
to an extremely hot
environment

Victim #1: Smoke
inhalation and sudden
exposure to intense
heat

Structure fire claims the livesof three career firefightersand three children—Iowa

Dec 22,
1999

F2000-04“Fatal cardiac arrhythmia” as the immediate
cause of death due
to “acute thrombotic
occlusion of the rightcoronary artery” (heart
attack), “80-90%
narrowing of the left
anterior descending
coronary artery, andsevere coronary
atherosclerosis.”

CAUSE OF DEATH

Firefighter dies at a barn
fire—Ohio

Title

Dec 13,
1999

DATE OFINCIDENT

F2000-05

NIOSH
REP. #

No

Not mentioned

Yes

AUTOPSY

PDF
LINK■ 158 ■

Perform an autopsy on all onduty firefighter fatalities

Note: No blood was sent for laboratory analysis duringresuscitative efforts. According to post-mortem toxicology
forensic specimen analysis, the victim’s carboxyhemoglobin
level was “negative.” An autopsy was not performed

Victim #3: 1.0% Carboxyhemoglobin level

Victim #2: 25% Carboxyhemoglobin level

Victim #1: 15% Carboxyhemoglobin level

The victim’s blood was not tested for carbon monoxide
poisoning (carboxyhemoglobin levels) although the department requested this be done

• Splenomegaly• Acute and chronic marked congestion of the lungs• Hypertrophy and dilatation of the heart– Generalized moderate atherosclerosis– Proximal and middle left anterior descending branch,near complete occlusion– Narrowing of the left coronary artery– Complete acute thrombotic occlusion of the rightcoronary artery– Severe coronary atherosclerosis• Coronary artery disease

AUTOPSY COMMENTS■ Firefighter Autopsy Protocol
I: Background ■Forestry worker dies whilebulldozing a fire line at awildland fire—AlabamaMotor-vehicle incident
claims the life of a volunteer
firefighter and injures a
volunteer chief—Virginia

Dec 18,1999

F2000-01

Title

Jul 06,
1998

DATE OFINCIDENT

F2000-02

NIOSH
REP. #

Atlanto-occipital dislocation (severe neckspinal cord damage)resulting from motorvehicle violence“acute myocardial
infarction” (heart
attack)Per autopsy:

Per death certificate:“cardiac arrest” as theimmediate cause ofdeath and “respiratory
failure” as the underlying cause

CAUSE OF DEATH

Not mentioned

lYes

AUTOPSY

None

Toxicological analysis reported a 10-percent carboxyhemoglobin level. In an interview, the head of the Toxicology
Section who performed this analysis communicated thatthe victim’s actual carboxyhemoglobin range was within 5
to 10 percent, a range he considered indicative of carbon
monoxide exposure during this fire suppression but notindicative of a toxic exposure• Myocardial infarction, recent, acute• Myocardial infarctions, old, remote, multiple• Atherosclerotic cardiovascular disease, trivessel, very
severe (Ninety-% occlusion of each of the following arteries: left anterior descending, right, and circumflex arteries)

AUTOPSY COMMENTS

PDF
LINK

■ Firefighter Autopsy Protocol■ 159 ■
Appendix B ■■■Appendix C: Examination of PersonalProtective EquipmentIn some cases, performance of protective clothing and equipment will be a factor in the incident
outcome. The condition of all protective clothing and equipment must be properly documented aspart of the investigation and can have an impact on a determination for the cause of death during an
autopsy. The impounded equipment should be examined at the scene if possible, and again after it has
been secured. While at the scene, it is important to note the condition of the equipment in addition to its
operational status. Closer examination of equipment may be done following impoundment.
Each item of protective clothing and equipment should be examined carefully. The clothing and equipment
always should be photographed. Begin the series of photographs with an overview picture of the item
(both front and back). Additional pictures should be taken of every significant component or feature of
the clothing and equipment. Pay particular attention to valves, knobs, buttons, and hoses of self-contained
breathing apparatus (SCBA) and interface areas for clothing, such as the front closure and collar of pants,
ear covers, and visor or goggles of helmets. Table C-1 provides a list of photographs that should be taken
for each item of protective clothing and equipment.
Areas of damage or charring also should be photographed. Schematic drawings of protective clothing
and equipment should indicate location and extent of the damage. Investigators should take detailed anddescriptive notes of all observations. It is as important to note that something was functional or in goodcondition as it is to note failure or damage. Most performance tests of clothing is destructive. Therefore,
it is important to document the condition of the clothing and equipment properly through a detailed
written description and photographs/video before any testing is conducted. Note testing always must
be authorized by the department before the testing is conducted. Any testing should be identified inadvance by:
■
■
■
■
■

the type of test;
the laboratory where the test will be conducted;
a description of any samples or specimens removed from the clothing or equipment;
the purpose of the test; andthe deposition of any samples that are tested.

Evaluation of SCBA is critical to the investigation. Do not make any adjustments to the SCBA unlessabsolutely necessary. The positions of straps and knobs should be photographed, and then marked withan indelible marker or grease pencil. Valves should not be opened or shut under any circumstances. If theinvestigators wish to test breathing air, a SCBA that was filled from the same source at approximately thesame time should be used. Several observations should be made at the incident scene:■ 160 ■

■ Firefighter Autopsy Protocol■ 161 ■

I: Background ■■ Was the victim wearing SCBA?
■	If not, where was SCBA found in relation to the victim?
■ Was the face piece intact and in place on the victim?
■ Was there pressure remaining in the air cylinder?
■	If so, what were the gauge readings?
■ Did all gauge readings agree?
■ Were valves and regulators in their proper positions?
■ Were support straps and apparatus in their proper configuration, and were they attached as would be
expected for normal use?
■ Was there any visible damage to the SCBA (tank, hoses, straps, regulators, mask)?
■ Was there any signs of icing on the regulator (or freeze burns on the face or respiratory tract of thefirefighter)?
■ Was any recent maintenance done on the unit?
■ What maintenance records are available on the unit?
■ What were the qualifications of the technician completing the necessary repairs or modifications?
■ Were there any reported problems with this specific unit or with the model?
■ Did the SCBA meet the NFPA 1981 standard in effect at the time of its manufacture?
If investigators have any concerns that the SCBA may have been a factor in the death or injury of
firefighters, then the SCBA should be sent to the National Institute for Occupational Safety and Health(NIOSH), in Morgantown, West Virginia. Upon written request, NIOSH investigators will conduct an
independent inspection and evaluation of the SCBA. This letter should be sent to NIOSH along with the
SCBA to be inspected.
Each member of the fire department who is involved in fire suppression activities is required to haveand activate a personal alert safety system (PASS) before entering the hazard area. In some cases, PASS
may be integrated with the SCBA and will be activated automatically when the SCBA is worn and used.
Investigators should include the following in their observations.
■ Was the victim wearing a PASS device when he or she entered the hazard area?
■ Was it turned on?
■	Is the device capable of being activated with a single gloved hand?
■ Was it functioning when the victim was found?
■	How did the audible alert signal strength compare with a new PASS device with a new battery?
■ Was the victim carrying any other communications equipment (e.g., radio)?
■ Was there any visible damage to the PASS device?
■ Where was it found in relation to the victim?
■	Is it possible that the PASS may have been submerged in water or had the seals to the interior
compartment compromised to cause leakage?
■ Was the PASS functional immediately after the incident?
■ When were the PASS batteries last changed?

■ Firefighter Autopsy Protocol■ 162 ■

I: Background ■■ When was the PASS last tested?
■ Was any recent maintenance done on the unit?
■ Did a certified technician complete the necessary repairs or modifications?
■ Were there any previously reported problems with this specific unit or with the model?
■ Did the PASS device meet the NFPA 1982 Standard in effect at the time of its manufacture?
Before beginning the inspection of protective clothing it is important to note the presence and position of
the clothing. The following questions, after such documentation, should be addressed:■ What items of protective clothing was the firefighter wearing (e.g., turnout coat, turnout pants,
helmet, gloves, boots, hood, goggles/face shield)?
■ Were all items of protective clothing donned properly?
■	Had the protective clothing been removed?
− Purposely, by firefighter?
− Accidently (knocked off)?
−	If so, where was the garment found in relation to the firefighter’s body?
■ Were any items of protective clothing removed during rescue efforts?
■ Were any rips, cuts, or tears made during rescue efforts?
■ Did protective clothing meet the appropriate NFPA standard at the time it was manufactured?
■	Every item of protective clothing should be inspected for the following types of wear or damage:− Cleanliness, or lack thereof, indicates smoke or chemical exposure.
− Char, heat damage, and burned areas indicate exposure to excessive heat and/or flame. Areas ofdamage may cause loss of fabric strength or protective properties. It is particularly important tocheck all layers of the protective garment.
−	The garment also should be checked for worn or abraded areas, rips, tears, cuts, and fraying.
All seams should be checked for broken or missing stitching indicative of seam failure. Signs of
discoloration or dye loss also may indicate heat or chemical exposure. Reflective trim should be
inspected with a flashlight to ensure that it has not lost its reflective properties.
■	If injuries have occurred, it is especially important to match injury areas on the victim with the areasof the clothing under which the injuries occurred.
Important areas for examination include the following:■ any gaps in the liner system under the outer shell;■ types of reinforcements over any injury area; and■ overall integrity of clothing when worn.
It is important also to ascertain the configuration of clothing as worn (e.g., fastening of closures, positionof collar, ear covers, etc.) and whether parts of the ensemble were wet when worn (including wet froman earlier response). It is useful to compare how the clothing was worn by the deceased firefighter during
the fatal event, if possible. The sizing of protective clothing and equipment should also be noted in theinvestigation of personal protective equipment (PPE) performance. Investigation of possible clothing
failures must account for differences in clothing performance that occur through wear. It may be useful tocompare clothing performance with new or unused items.

■ Firefighter Autopsy Protocol■ 163 ■

I: Background ■Investigation of personal protective clothing and equipment should include the following assessments (aslisted by each item):Protective Helmets■ helmet outer shell:− bubbling of shell material,− delamination of material or soft spots,− dents, cracks, nicks, gouges, or flaking, and− loss of surface gloss;■ helmet inner shell and impact liner:− warping,− wear (excessive or unusual),− broken or missing components, and− improper installation/attachment of components;■ suspension system:− cracked or missing suspension system components,− torn head band or size-adjustment slots,− stripped size adjustment ratchet knob,− signs of excessive wear;■ crown straps and ear covers:− improper installation and fit, and− signs of wear, damage, and excessive heat;■ damaged chin straps fasteners, slides, and closures; and■ faceshield/goggles:− signs of wear, damage, and excessive heat,− deformation, scratches obscuring vision, and− damaged fasteners, straps, and closures.

Protective Hoods
■
■
■
■
■

hood integrity;
signs of shrinkage;loss of elasticity;
seam integrity; andsigns of wear, damage, and charring.

Protective Garments (Coat and Pants)■ outer shell− signs of wear, damage, excessive heat, discoloration, or char on fabric,

■ Firefighter Autopsy Protocol

■

■

■

■

■

I: Background ■− seam integrity,− reinforcement integrity,− closure system integrity,− condition of hardware, and− damage to pockets; items in pockets and their respective condition;
moisture barrier and thermal barrier:− delamination of seams or seals,− seam integrity/quilt stitching,− attachment system to the outer shell, and− signs of wear, damage, excessive heat, discoloration, or char on fabric? (In many cases, it may benecessary to open the liner to determine the condition of the film or coated side of the moisturebarrier.);reflective trim
− signs of wear, damage, excessive heat, melt, discoloration, or char on trim,− seam/stitching integrity, and− loss of reflectivity; fluorescence;
reinforcements (shoulders, elbows, knees, sleeve ends, pant cuffs):− signs of wear, damage, excessive heat, melt, discoloration, or char on exterior or interior layers,− seam/stitching and attachment integrity integrity,− permanent compression;
protective wristlets:− shrinkage,− loss of elasticity,− seam integrity, and− thumbhole elongation;suspenders:− melting or other heat damage,− shrinkage,− loss of elasticity,− seam integrity, and− condition of hardware;

Protective Gloves■■■■■ 164 ■

glove integrity;
shrinkage;loss of elasticity/flexibility;
seam integrity;

■ Firefighter Autopsy Protocol■ 165 ■

I: Background ■■ liner pullout; and■ signs of wear, damage, excessive heat, discoloration, or char on leather/fabric (both exterior andinterior).

Protective Footwear (Rubber)
■
■
■
■
■
■

loss of elasticity;
delamination of seam seals;
material damage;steel toe or shank damage;sole tread wear; andloss of liquid-tight integrity (waterproofness).

Protective Footwear (Leather)
■
■
■
■
■
■
■
■
■
■
■

seam integrity;material damage (rips, tears, holes);steel toe or shank damage;sole tread wear;
loss of liquid-tight integrity (waterproofness);closure system;
uniform integrity;
seam integrity;material damage (rips, tears, holes);closure system; andsigns of wear, damage, excessive heat, discoloration, or char on fabric.

Protective clothing and equipment experts may be required. On occasion, certain garments and equipment
may need to be sent out to testing labs for verification that it meets the current set of applicable standards
to which the item was certified; however, judgment must be applied if the specific property being
measured would be a contributory factor to the firefighter fatality. Other reasons for testing would be todetermine whether the item in question was operating properly and, if not, whether it contributed to theincident.
Once the items have been impounded by the investigation team and their condition documented,
outside assistance should be requested. All issues involving SCBA testing should be handled by NIOSH.
Other protective clothing and equipment testing may be conducted by appropriately qualified experts
or independent testing laboratories. Impounded items should be transferred to the testing laboratory
following strict chain-of-custody procedures. The testing laboratory should be asked to compare the item
performance at the time of the incident with the performance requirements of the appropriate NFPA
standard. The independent expert or laboratory may be asked further to determine the range of heat andtemperature conditions to which the item may have been exposed. The testing laboratory’s report should
be summarized in the body of the investigation report and attached as an appendix to the report.

■ Firefighter Autopsy Protocol■ 166 ■

I: Background ■Manufacturer’s technical experts may have useful information and should be invited to examine the itemin the presence of investigation team members. The manufacturer’s written comments should be requested
for inclusion in the report. At no time should a manufacturer’s representative be given custody of an
impounded item or left alone with impounded items.

T
Clothing or Equipment Item
Self-contained breathing apparatus (SCBA)

Minimum Recommended Photographs• Complete SCBA resting on back plate with cylinder shown in front and facepiece off to
side• Complete SCBA show harness side
• Base of cylinder showing cylinder valve and position• Closeup of manufacturer product label and certification mark• Closeup of cylinder valve and first-stage regulator• Closeup of pressure gauge• Closeup of second-stage regulator• Front of facepiece• Interior of facepiece• Closeup of facepiece exhalation valve• Integrated PASS (if present)• Any specific areas of damage to valves, harness, backplate, hoses, facepiece straps, oraccessory items

Personal alert safety system (PASS)• Complete PASS (top view)• Complete PASS (bottom view)• Closeup of manufacturer product label and certification mark• Closeup of battery panel• Any specific area of damage, particularly for condition of seals in PASS case (if PASS
can be opened, the condition of interior components, if warranted by investigation)

Protective helmet• Front top of helmet (showing shield and emblem)• Left top of helmet• Right top of helmet• Back top of helmet• Interior of helmet showing ear covers (two photographs may be needed to adequately
show both sides)• Closeup of product label and certification mark (if possible)• Any specific area of damage such as shell, edge beading, straps, suspension, and ear
covers)■ Firefighter Autopsy Protocol■ 167 ■

Clothing or Equipment Item
Protective hood

I: Background ■Minimum Recommended Photographs• Left side of hood (lying flat)• Right side of hood (lying flat)• Closeup of product label and certification mark• Any specific area of damage to material or face opening

Protective garments• Front of garment with closures secured• Back of garment with closures secured• Interior of garment shell (liner removed and shell turned inside out)—both front and back• Removed liner—moisture barrier side—both front and back• Removed liner, turned inside out—thermal barrier side—both front and back• Closeups of all product labels and certification marks on both shell and liner• Any specific area of damage to shell, liner, hardware, trim, reinforcements, and otheritems on garments (where damage occurs on one side, attempt to photograph other,
especially in case of thermal damage)Protective gloves• Back side of gloves• Palm side of gloves• Closeup of product label and certification mark• Any specific areas of damage to glove exterior, lining, gauntlet, or wristlet

Protective footwear• Left side of footwear (standing upright)• Right side of footwear (standing upright)• Footwear soles• Closeup of product label and certification mark (if possible)• Any specific areas of damage to exterior, lining, sole, hardware, or other features offootwear