U.S. Fire Administration

Firefighter Autopsy 

Protocol

March 2008
U.S. Fire Administration

Mission Statement

As an entity of the Federal Emergency 

Management Agency (FEMA), the mission 

of the U.S. Fire Administration (USFA) is 

to reduce life and economic losses due 

to fi re and related emergencies, through 

leadership, advocacy, coordination, and 

support. We serve the Nation independently, 

in coordination with other Federal agencies, 

and in partnership with fi re protection and 

emergency service communities. With a 

commitment to excel lence, we provide 

public education, training, technology, and 

data 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.
■ iv ■

■ Table of Contents

Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi

Acknowledgement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

I. BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

I.1 Scope of the Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

I.2 Rationale for the Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

I.3 Description of the Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

II. Medicolegal Autopsy Procedures in the United States . . . . . . . . . . . . . . . . . . . . . . . . . 9

II.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
■ 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
■ vi ■

■ Overview

The Firefighter Autopsy Protocol has been extensively revised since its original 1994 edition. In this new protocol, a number of additional areas of information have been provided to take into account 

emerging 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 be 

linked 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 and 

reviews 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 causes 

of 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 to 

occupational illnesses among firefighters, both active and retired.
■ vii ■

■ 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 Maryland

College Park, MD 20742-3031

Dr. Merritt Birky

National Transportation Safety Board

2419 Childs Lane

Alexandria, VA 22308

Richard Duffy

Int’l Association of Fire Fighters

1750 New York Avenue, NW

Washington, DC 20006

Ms. Rita Fahy

National Fire Protection Association

1 Batterymarch Park

Quincy, MA 02169-7471

Captain Tom Hales, MD

Center for Disease Control

4676 Columbia Parkway

Cincinnati, OH 45226

Dr. James Melius

NY State Laborers

18 Corporate Woods Blvd.

Albany, NY 12211

Ms.Valerie C. Neal*

PSOB (Senior Benefits Manager)

810 7th Street, NW

Washington, DC 20531

Dr. Fredric Rieders

National Medical Services

2300 Stratford Avenue

Willow Grove, PA 19090

Kevin Roche

Phoenix Fire Department

2625 South 19th Street

Phoenix, AZ 85009

Mary Ellis**

National Fallen Firefighters Foundation

16825 South Seton Avenue, Building O

P. O. Drawer 498

Emmitsburg, MD 21727

Jim Monahan

Beebe Medical Center

424 Savannah Road

Lewes, DE 19958

 *No longer with PSOB at the time of publication.

**No longer with the NFFF at the time of publication.
■ 1 ■

■ I. BACKGROUND

The 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 cause 

of 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 of 

several national fire service organizations, were selected to serve as a Technical Advisory Committee, to 

provide 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 in 

the autopsy protocol are represented in this publication.

The consensus of the Technical Advisory Committee is reflected in the new protocol.This protocol is 

intended 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 of 

protective 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, the 

situations 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 estimated 

that the number of firefighters in 2005 was 1,136,650, comprising 313,300 career and 823,350 
■ Firefighter Autopsy Protocol ■ 2 ■ I: Background ■

volunteer firefighters.

1

This 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 was 

incurred 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 are 

mainly 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 United 

States over the past 30 years (1977 through 2006); this includes the 343* firefighters who died at the 

World Trade Center in 2001. Excluding the World Trade Center firefighter deaths, the average number of 

firefighter 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 of 

line-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 a 

43-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 some 

extent, 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, fall 

short of explaining conclusively why firefighters die, and especially why any particular firefighter dies.The 

interest in occupational health factors relates to the frequency of sudden deaths due to heart attacks, as 

well as chronic conditions which include respiratory disorders, heart disease, and cancer.

1

 USFA Web site—based on figures from the National Fire Protection Association’s (NFPA) U.S. Fire Department Profile through 

2005.

2

 NFPA Journal, July/Aug 2007

*

 The USFA shows 344 firefighters died on duty and the National Fallen Firefighters Foundation have honored 347 firefighters 

from 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 procedures 

that 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 is 

intended 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 thorough 

documentation 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 as 

State 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.

3 fahy, Rita f ., Paul R . leBlanc, and Joseph l . Molis . Firefighter Fatalities in the U.S.—2006 . Quincy: national fire Protection 

Association, June 2007 .
■ 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, but 

which 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 the 

essential 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 this 

document.

NFPA 1500, Standard on Fire Department Occupational Safety and Health Program,4 section 10.4.4 recommends, “If a 

member 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 other 

medical information for all deceased employees or former employees. This information could be useful in 

establishing 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 the 

following sections:

■ preliminary;

■ initial examination;

■ external examination;

■ internal examination;

■ toxicological examination;

■ microscopic examination;

■ summary of pathological findings; and

■ conclusions.

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.

4 nfPA 1500, Standard on Fire Department Occupational Safety and Health Program . 2007 ed . Quincy: national fire Protection Association 

(617-770-3000; www.nfpa.org) . 
■ Firefighter Autopsy Protocol ■ 5 ■ I: Background ■

S

PROTOCOL DISCUSSION

VIII. Preliminary 

A. Circumstances of Death 

1. Line-of-duty

a. Fire suppression

b. 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. Prescribed

b.	 Over-the-counter

c. 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.

The	autopsy	results	may	be	essential	to	determine	why	or	how	a	

firefighter	was	incapacitated,	how	the	activity	related	to	the	cause	of	

death,	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	documents	

that pertain to the incident. Document the occupational history of 

the deceased, including the number of years assigned as a “line” 

firefighter,	any	history	of	unusual	exposures	(or	changes	in	frequency	

of	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.

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 coat 

b. Turnout pants 

c. Helmet

d.	 Gloves	

e. Boots 

f. Self-contained breathing apparatus (SCBA)

g. Personal Alert Safety System (PASS) 

h.	 Protective	hood

i.	 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 from 

hazardous materials incidents, as residue may be harmful to those 

involved in the autopsy. Gloves and other PPE should be used.

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	the	

Special 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 ■

PROTOCOL DISCUSSION

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	activated	

or	working	at	the	time	of	discovery	of	the	deceased?	A	swab	from	the	

inside 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 the 

deceased’s SCBA to the death. Ppe manufacturers may be able to 

assist	in	evaluating	damage,	but	PPE	should	not	be	returned	to	the	

manufacturer	for	examination	(because	of	concerns	about	product	

liability).

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	fire	

casualties.	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	for	

evidence	of	medical	intervention	and	when	interpreting	the	results	

of blood gas assay.

Note	the	presence	of	soot	or	other	unidentified	substances	on	the	

skin	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	proximal	

and	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	be	

used	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)

Soot	swabs	should	be	obtained	from	the	upper	and	lower	airways	as	

well	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	a	

minimum 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	(if	

site-specific)	within	an	organ	should	be	documented	in	detail.

continued on next page *May not be required for clear traumatic death
■ Firefighter Autopsy Protocol ■ 7 ■ I: Background ■

PROTOCOL DISCUSSION

4.	 Cerebrospinal	fluid	(up	to	approx.	30	ml)

5.	 Soot	swabs	from	airway*

a. Tracheal

b. Bronchial

6.	 Representative	sampling	of	gastric	and	duodenal	

contents	(50	g;	note	total	amount)	

7. Take and retain fresh-frozen samples

a. Lung 100 g

b. Kidney 100 g

c.	 Liver	100	g

d. Spleen 100 g

e. 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	and	

red-top tubes)

c.	 Any	specimens	taken	in	field	or	during	hospital	

resuscitation

d. 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	of	

carbon	monoxide	content	and	of	carbon	monoxide-binding	capacity

of	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.

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	was	

breathing	in	fire.	Absence	of	soot	particles	does	not	prove	that	the	

victim	was	already	dead	when	exposed	to	the	fire.

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. Arsenic

b. Antimony

c. Lead

The	toxicologic	analysis	performed	for	firefighters	should	be	of	a	

higher	order	than	that	performed	for	civilian	fire	casualties.	In	addition	to	ascertaining	blood	levels	of	various	toxic	products	that	are	

commonly	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.

Determinations	of	asphyxiation	from	carbon	monoxide	levels	should	

take	into	account	victim	medical	history	(i.e.,	smoking)	in	addition	to	

other	types	of	exposure.	If	victim	survived	carbon	monoxide	poisoning	for	several	hours,	portmortem	samples	usually	will	fail	to	show	

presence	of	carboxyhemoglobin.	Blood	taken	at	time	of	admission	to	

hospital	still	may	be	available	and	of	particular	value.

Determination	of	specific	levels	of	metals,	organic	compounds,	and	

gross	particulate	matter	should	be	conducted	because	firefighter	

exposure	to	these	substances	is	believed	to	be	greater	than	that	for	

civilians.	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.

continued on next page

*May not be required for clear traumatic death
■ Firefighter Autopsy Protocol ■ 8 ■ I: Background ■

PROTOCOL DISCUSSION

2. 

3. 

Organics, including:

a. Pesticides

b. Herbicides

c.	 Vinyl	chloride

d. Acrylonitrile

e. Acrolein

Particulate analysis (e.g., asbestos)

Use	caution	when	noting	the	presence	of	hydrocyanic	acid,	as	it	can	

be	produced	by	bacterial	decomposition	within	the	tissues	of	the	

deceased.

Check for the presence of PCBs and polynuclear aromatic compounds	in	the	subcutaneous	fat,	as	this	will	help	in	the	determination	

of	a	history	of	exposure.

IIVI. Microscopic Examination

A.	 Findings	of	Microscopic	Examination

Representative	samples	of	all	organs	and	body	systems	should	be

collected.		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,	and	

other	investigative	studies	to	pathological	findings.

VIII. Conclusions

A. Discrepancies

1.	 Inconsistent	observations

2.	 Differences	between	death	certificate	and	subsequent	

findings

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	observations	

of	eyewitnesses	and	the	autopsy	findings.
■ 9 ■

■ II. Medicolegal Autopsy Procedures in the 

United States

The 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 established 

requirements 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 United 

States falls under the authority of State and local officials

Legal structures governing death investigation vary considerably among the 50 States, the District of 

Columbia, and the territories. Depending on the jurisdiction, the official responsible for determining the 

cause, 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 and 

regulations, and a high level of discretion is afforded to coroners and medical examiners in the manner 

of 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 for 

investigating 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 to 

respond 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
■ 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 the 

need to perform an autopsy is a discretionary responsibility of the coroner or medical examiner.The issuance 

of a death certificate does not require an autopsy, and only a death certificate is needed to qualify for most 

insurance 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 of 

Line-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 of 

cost 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 to 

be 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 with 

prior medical histories, would be valuable in conclusively determining the cause of death, gaining a 

more 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 or 

evidence 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 to 

clarify the differences among manner, cause, and mechanism of death, and especially to recognize that 

various entities may use the terms “cause of death” or “nature of death” in ways quite different from their 

appropriate 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 and 

laymen, but they are not synonymous: 

6

 Ludwig, Jurgen. Autopsy Practice. 3rd ed.Totowa: Humana Press, 2002.
■ 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 to 

cessation 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 and 

epidemiological 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 measures 

that 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 for 

analysis 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., paraffin 

blocks 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 the 

secondary 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 the 

sender’s thumbprint.The outer mailing container should have address labeling and also appropriate labels 

such as:

7

 Ibid.

8

 Ludwig, op.cit.
■ Firefighter Autopsy Protocol ■ 12 ■ 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 mail 

when 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 have 

been 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 year

Quality 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 have 

retention 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 and 

maintenance. 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 specific 

samples 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.
■ 13 ■

■ III. Occupational Aspects of Firefighting of 

Specific Concern to Autopsy

Firefighter fatalities often result from complicated scenarios. Due to the nature of the occupation, a firefighter’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 as 

available, and then determines which classification best describes that individual fatality.The nine causal 

categories on which the system is based include

1 . fell/Slipped . 6 . Contact with/exposure to .

2 . Struck by . 7 . exiting or escaping/Jumped .

3 . Overexertion/Strain . 8 . Assaulted .

4 . fire Department Apparatus Accident . 9 . Other .

5 . Caught/trapped .

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, this 

classification system does not differentiate the causes of cardiac and stress-related cases; all are classified 
■ 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 or 

differentiated, 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 ■ Drowning ■ Aneurysm

■ internal trauma ■ Stroke ■ fracture

■ Asphyxiation ■ electrocution ■ heat stroke

■ Crushing ■ hemorrhage ■ Pneumonia

■ Burns ■ gunshot ■ Other

Depending on the fatalities sustained for that year, the categories included in the report may not include all 

of 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 results 

from year to year. For example, if there are several drowning deaths in one year, those would likely be 

reported as a separate category in the annual report;however, if there were only a single drowning in the 

next 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 in 

deaths 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 this 

number.

■ Road vehicle crashes accounted for 406 fatalities, mostly volunteer firefighters, and are the second 

greatest cause of firefighter fatalities.

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

nearly twice that of the first decade in this time period.

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

continued on next page

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 of 

deaths 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.
■ 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

11 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 .
■ Firefighter Autopsy Protocol ■ 18 ■ I: Background ■

complicated by the provisions of the Americans with Disabilities Act (ADA), which may restrict the ability 

of fire departments to limit the duties of high risk individuals.

III.3 Investigation of Line-of-Duty Deaths

F

12 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).
■ 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. Each 

report 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 are 

provided as part of toxicology reports.Toxicology reports in most autopsies document the positive and 

negative 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. Blood 

tests 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 of 

blood 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 usually 

are 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 a 

preservative, 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 heart 

chambers and the femoral vessels, autopsy samples from pooled blood in the pericardial sac or pleural 

cavity 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

13 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.

14Caplan 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.
■ 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 coexisting 

illnesses/conditions, as well as of drugs used in emergency resuscitation attempts. Methods typically used 

in 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	detect	

and	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	of	

computerized	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	matching	

compound	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 and 

drug levels. A number of references are provided at the back of the protocol on the subject of alcohol and 

drug 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 have 

interacted 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 through 

dermal exposure, injection, or ingestion? 

■ Did protective clothing or SCBA fail to protect the user, or was the user’s air supply depleted or 

otherwise 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 diversity 

of chemical products found at fires.The increased use of plastics and other synthetic materials release 

different kinds of combustion products, many of them highly toxic or carcinogenic. Some examples of fire 

combustion 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); and

■ metals (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 from 

repeated or high concentration exposure to these chemicals.Table 4 shows chemicals identified in an 

analysis of fire smoke for several different fires.

Most protective clothing and equipment used by firefighters permits the ready penetration and permeation 

of toxic chemicals through protective fabrics and components. Since most firefighter protective clothing 

uses porous fabrics, the chemical vapors or liquids simply penetrate or pass through the pores of the 

material. Molecules of chemicals can also permeate into the fibers or coatings of clothing materials and 

can remain in the material for long periods of time, depending on the types of exposure chemical(s) and 

care 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 the 

absorption 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;
■ Firefighter Autopsy Protocol ■ 22 ■ 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 the 

helmet, 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 portion 

of smoke and is the primary cause of residue left on structures and clothing following fires. Soot and 

ash 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 the 

amount 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 resins 

or 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 penetrate 

easily into the inner layers of clothing, such as liner and barrier materials, contacting the firefighter's skin.

T

Contaminant 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	and	

ingestion.

•	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	inspired	

or 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	or	

ingestion.
■ Firefighter Autopsy Protocol ■ 23 ■ I: Background ■

T

Compound 1(K) 1(K) 2(K) 3(O) 4(O) 5(K) 6(K) 6(O)

Furan X X

C4

H8 isomers X X

Benzene X X X X X X X X

Dimethylfuran X X

Methyl methacrylane X X

Toluene X X X X

Furfural X X

Xylene X X X

Styrene X X X

Pinenes X X X

Limonene X X

Indane X X X X

Methylcyclopentane X X

2,4-Dimethyl-1-pentene X

Ethyl benzene X X

C3

-Alkyl benzene X

C4

-Alkyl benzene X X

n-Butane X

Freon 11 X

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 skin 

after 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, and 

Hepatitis B and C viruses.These viruses are extremely small in size and are transmitted by blood or other 

biological 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 and 

other incidents all involve the potential for this exposure. Even minute droplets of blood are capable of 

carrying thousands of virus that potentially can cause infection through mucous membrane contact or 

nonintact 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.

15 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.
■ 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 take 

the form of chemical warfare agents, toxic industrial chemicals, biological agents that are both liquid 

and 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 a 

terrorism 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 of 

rescue, 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 is 

characterized 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, are 

burning in a room.The thermal radiation and the air temperatures are virtually the same as those 

encountered on a hot summer day. As shown in Figure 1, Routine conditions are accompanied by a 

thermal 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, the 

thermal load exceeds 0.3 cal/cm2s and temperatures exceed 571 °F. In such conditions, the function 

of firefighters’ clothing and equipment is simply to provide protection during the short time needed 

for an escape without serious injury.

16Abbott, 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.
■ 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 shown 

in 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, burn 

injury 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 the 

entire skin thickness and are considered irreversible (complete healing is not possible). It is also important 

to 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 the 

performance 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 are 

worn together to provide protection against fireground hazards:

■ SCBA;

■ protective coat and pants;

■ protective helmet;

■ protective hood;

■ protective gloves;

■ protective footwear; and

■ PASS (may be integrated with SCBA)
■ Firefighter Autopsy Protocol ■ 27 ■ 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 for 

different 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

Protective coat

Protective gloves

Protective pants

Facepiece SCBA

Harness straps of SCBA 

(cylinder on back not shown)

Protective 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 when 

these 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 the 

firefighter’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 attributable 

to 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 these 

injuries. 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 the 

performance of the SCBA.This investigation can be conducted by the NIOSH, which is responsible for the 

certification 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 the 

service 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 the 

infiltration 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; and

■ the 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 are 

concerned 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 to 

be elevated as compared to other occupations.

■ A study of Seattle firefighters shows excess mortality from diseases of a priori concern, such as lung 

cancer, 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

18 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.

19Musk, 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.
■ 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 showed 

excesses of brain tumors, and lymphatic and hematopoietic cancers.

21

■ A detailed mortality study in Toronto showed firefighters to have statistically significant excesses of 

brain, 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 the 

relationship 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 of 

incidents 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 or 

occupational 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 premature 

20 lewis, 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 .

21 Demers, Paul A ., nicholas J . heyer, and linda Rosenstock . “Mortality Among firefighters from three northwestern united 

States Cities .” British Journal of Medicine, 1992, 49: 664-670 .

22 l’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 . 
■ 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 than 

just conjecture. Epidemiological studies have demonstrated that firefighters are much less likely than the 

general 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 population 

by their retirement age, which suggests that the so-called “healthy worker effect” diminishes with 

time, 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 health 

programs.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 and 

Wellness 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.

24Rubin, 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.
■ 31 ■

■ 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) and 

law 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 the 

coverage 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 the 

Federal 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 for 

death 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 and 

aspects of the history of its administration.

26 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
■ 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 officially 

recognized 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, this 

legislation amended certain provisions of the PSOB Act regarding designation of beneficiaries when the 

officer dies without a spouse or eligible children and removed the need for a 1-year waiting period to 

ensure 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, indicating 

where 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 to 

the 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 or 

strenuous 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.

27 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
■ 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 Public 

Service 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
■ 34 ■

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 in 

home 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 carried 

out. 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 

■ Selected Bibliography
■ 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 the 

usefulness 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 results 

in 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 for 

early absorption phase cases and B = 0.89 V for cases in subsequent phases.The former relationship 

would 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 fatal 

road traffic accidents and suicides by falling, in which 69% of the deceased sustained some form of 

head injury, were found to be similar to those of other postmortem cases.The observations reflect 

that vitreous humor, being reasonably protected, is likely to survive certain traumatic deaths and be 

available 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 the 

aim of this paper is to show the utilization of vitreous humor (VH) as the biological fluid for an 

unequivocal determination of ethanol origin in DB for forensic purposes. Alcohol was determined in 

VH, 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 of 

endogenous 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 to 

determine (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 collected 

following 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 for 

the large difference between the two results include diffusion of ethanol from the stomach into the 

chest cavity, contamination of the blood sample prior to collection, and ingestion of a large quantity 

of 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 (blood 

in 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 of 

death immediately following drinking, ethanol levels in the stomach contents are very high, and the 

following ratios of ethanol levels were observed: skeletal muscle to cardiac blood--less than 1; liver to 

cardiac 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 alcohol 

and 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 inVH 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% limits 

of 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 parametric 

estimates are in good agreement, with a median VH/FVB ratio of 1.18 and 2.5th and 97.5th centiles

of 0.63 and 1.92. Conclusions—The ethanol distribution ratios (VH/FVB) show wide variation and this 

calls for caution when results of analysingVH 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 the 

ethanol 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 blood 

level” 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 lead 

to 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 of 

many determinations, some of which show very wide ranges from the mean. Random specimens 

of 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 this 

instance, 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 most 

published reports, we find it hard to understand how so many investigators can conclude that it is 

satisfactory procedure to calculate the alcoholic content of blood, to the second decimal place, from a 

selected specimen of urine. Our data clearly confirm what other investigators2, 7 – 10 have claimed: that 

the 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 the 

assessment 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) and 

benzoylecgonine (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 of 

benzoylecgonine 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 the 

concentrations 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 at 

least 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 and 

urine samples in autopsy cases and in saliva from drunken drivers.The method gives instant and 

reliable semi-quantitative information on the presence of alcohol and is valuable when considering the 

necessity 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 by 

gas 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% is 

predicted 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 have 

provided 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 the 

raw 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 with 

the 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 this 

value 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 differences 

in 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 to 

predict a BAC, given pertinent data. In addition, it is possible to estimate from a given BAC the quantity 

of 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, and 

also 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 content 

of blood used for transfusion does not contribute significantly to the BAC of the recipient, since 

extensive 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 storing 

them under refrigeration. Should putrefaction be present, it is recommended that, in addition to 

blood, 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 time 

of 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 in 

which 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 validity 

of 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 and 

microbiology of decomposition. J Appl Bacteriol 1978;44:1-56.

4. Nanikawa R, Moriya F, Hashimoto Y. Experimental studies on the mechanism of ethanol formation in 

corpses. 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 by 

addition 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 the 

next 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 is 

believed 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 and 

vitreous 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 to 

analyse 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 die 

with their alcoholism rather than of it; 39% of males and 34% of females with histories of alcohol 

abuse 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 Death 

from 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 in 

home 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 carried 

out. 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 increase 

in 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 and 

hemoglobin 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 the 

study.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 exposure 

in 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 fire 

fighters. NIST’s Fire Dynamics Simulator (FDS) was employed to model the fire in order to estimate the 

concentration of carbon monoxide present in the dwelling, which was the immediate cause of death 

of 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, was 

plugged 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 been 

required to accumulate the concentrations of carboxyhemoglobin (49, 44, and 10%) measured on the 

fire 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 blood 

of 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 and 

then 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 made 

to 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 for 

the 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 the 

groups 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 patients 

with 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 areas 

in 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 neurologically 

intact. Awareness of the potential for basal ganglia lesions in CO poisoning should lead to more 

accurate 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 and 

carboxyhemoglobin (HbCO) levels in blood and body cavity fluids of cadavers which were not 

exposed 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 of 

hemoglobin (Hb) was measured as cyanmethemoglobin (CNmHb).The HbCO level was calculated 

by 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% and 

from 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 other 

substances during putrefaction.The significance of HbCO levels in body cavity fluids of cases with 

marked 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 conducted 

in 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 CO 

levels. 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. Cigarette 

smokers 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 specific 

environmental exposure.There were no differences between HbCO levels in ASHD sudden death 

patients and in living controls.There was also no relationship between cardiac pathologic findings and 

postmortem 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) level 

in 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 stability 

of 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 or 

without 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 from 

cadavers 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 fire 

with the exception of cases where no soot can be detected in the airways by the naked eye and the 

COHb 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 no 

accelerants 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 and 

n-decane were detected in the blood. In cases where the victim was found inside a gasoline-fuelled 

automobile 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 were 

also performed to evaluate the results of the blood analyses. Consequently, some compounds are 

proposed 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 by 

immunohistochemical and molecular-biological methods using the terminal deoxynucleotidyl 

transferase-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, the 

nuclei 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 cases 

of 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 areas 

of 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 methods 

of 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; evaluation 

of 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 addition 

of n-octanol, potassium ferricyanide and an internal standard (t-butanol), GC separation and 

determination 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 (GEYokogawa Medical Systems) equipped with an 

LH probe (linear, 7.5 MHz) was used and each lobe of the lungs was scanned on the anterior and 

posterior surfaces after resection.The US density showed a correlation between the left and right 

lobes, and also between the anterior and posterior surface scans of each lobe. Although there was a 

correlation 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 the 

survival 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 cases 

of 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%), independently 

of blood carboxyhemoglobin (COHb) levels. Age-dependent increase in Ub-positive % was observed 

in lower COHb (< 60%) cases.The intranuclear diffuse ubiquitin staining was not observed in cases 

of 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, or 

neighbors of the deceased and, obviously, macroscopic findings at the time of the autopsy. In order to 

evaluate 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 Medicine 

of 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 with 

analytical 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 this 

apparent 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 performance 

of 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 the 

bodies, spectrophotometric detection of the fatal carboxyhaemoglobin level in oedema fluid of the 

scalp.--Case 3: 23-year-old lorry driver, found dead in the tightly closed cab of his lorry, operation of 

a 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 pure 

carbon 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 in 

clothing, 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 spectral 

scans 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 loss 

of 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 degree 

of body burn, and in 25 severe charring and/or incineration was present at autopsy. In only one case 

was there a history of explosion or flash fire. Carboxyhemoglobin levels varied from 92% to values 

of < 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 this 

article 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 and 

spleen specimens were analyzed for CO by using a gas chromatographic method.Ten specimens with a 

spleen 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% were 

associated 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.
■ 55 ■

■ Appendix A: death investigation systems in the 

United states And territories

State/

Territory Type of System Title Deaths Investigated Contact Comment

Alabama Mixed:	State	

Medical	Examiner	

and County 

Coroners/Medical 

Examiners

County Coroner, 

State Medical 

Examiner

Coroner—All	deaths	where	the	

deceased	died	without	being	

attended	by	a	legally	qualified	

physician.

State	Medical	Examiner—

•	If	the	person	dies	by	violence	or	

homicide, 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.

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 death 

investigation	

in Jefferson 

County 

(Birmingham) 

from those in 

other counties.

Alaska State Medical 

Examiner

State Medical 

Examiner

•	Homicide.

•	Suspicion	of	criminal	means.

•	Suicide.

•	With	no	physician	in	attendance.

•	When	physician	is	unable	to	

execute	death	certificate.

•	When	cause	of	death	cannot	be	

determined.

Franc G. Fallico, MD

Acting State Medical 

Examiner

4500 South Boniface 

Pkwy.

Anchorage, AK 99507

(907) 269-5090 

Fax:	(907)	334-2216

Email: Franc_Fallico@

HEALTH.STATE.AK.US
■ Firefighter Autopsy Protocol ■ 56 ■ I: Background ■

State/

Territory Type of System Title Deaths Investigated Contact Comment

American 

Samoa

Territorial Coroner No	death	investigation	official.•	Where	any	dead	body	is	found.

•	By	accidental	means.

•	Allegedly	caused	by	unlawful	

means.

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 

Department 

of Medical 

Services’	local	

representative,	

who	is	authorized to act as 

Coroner and 

report	findings	

to the Attorney 

General.

Arizona County Medical 

Examiner

County Medical 

Examiner

•	When	not	under	current	care	of	

a physician for a potentially fatal 

illness.

•	When	the	attending	physician	

is	unavailable	to	sign	the	death	

certificate.

•	By	violence.

•	Of	a	prisoner	or	occurring	in	

prison.

•	Occurring	suddenly	to	a	person	

in apparent good health.

•	By	occupational	disease	or	

accident.

•	Where	a	public	health	hazard	is	

presented.

•	Occurring	during	anesthetic	or	

surgical procedures.

•	Occurring	in	a	suspicious,	

unusual, or unnatural manner.

Philip E. Keen, M.D.

Medical	Examiner

Maricopa County

120	South	Sixth	Avenue

Phoenix,	AZ	85003

(602) 506-3322 

Fax:	(602)	506-1546

Arkansas Mixed:	State	

Medical	Examiner	

and County 

Coroners/Medical 

Examiners

County Coroner, 

State Medical 

Examiner

•	Death	appears	to	be	caused	by	

violence,	homicide,	suicide,	or	

accident.

•	Death	appears	to	be	the	result	

of the presence of drugs or 

poisons.

•	Death	appears	to	be	the	result	

of	a	motor	vehicle	accident	or	

the	body	was	found	in	or	near	a	

roadway	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
■ Firefighter Autopsy Protocol ■ 57 ■ I: Background ■

State/

Territory Type of System Title Deaths Investigated Contact Comment

Arkansas 

(cont’d)

•	Death	appears	to	be	the	result	

of	a	motor	vehicle	accident	and	

there	is	no	obvious	trauma	to	the	

body.

•	Death	occurs	while	the	person	

is in a State mental institution or 

hospital	and	there	is	no	previous	

medical	history	to	explain	the	

death,	or	while	the	person	is	in	

police custody, a jail, or penal 

institution.

•	Death	appears	to	be	the	result	of	

a	fire	or	explosion.

•	Death	appears	to	be	the	result	of	

drowning.

•	Death	of	a	minor	child	appears	

to indicate child abuse.

•	Death	of	an	infant	or	minor	child	

without	previous	medical	history.

•	Human	skeletal	remains	are	

recovered.

•	Decomposition	of	the	body	

prohibits	external	examination	to	

rule out injury or circumstances 

of death cannot rule out the 

commission of a crime.

•	Manner	of	death	appears	to	be	

other than natural.

•	Death	is	sudden	and	

unexplained.

•	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.
■ Firefighter Autopsy Protocol ■ 58 ■ I: Background ■

State/

Territory Type of System Title Deaths Investigated Contact Comment

California Mixed:	County	 County Coroner, •	Violent,	sudden,	or	unusual. Scotty D. Hill 41 counties 

Medical 

Examiners/

Coroners

County 

Sheriff-Coroner, 

County Medical 

Examiner,	

Coroner 

•	Unattended.

•	Deaths	wherein	the	deceased	

has not been attended by a 

physician in the 20 days before 

death.

Executive	Secretary

California State Coroners 

Association

5925 Maybrook Circle

Riverside,	CA	

92506-4549

with	SheriffCoroners. 

In addition, 

many County 

Coroners also 

serve	as	Public	

•	Self-induced	or	criminal	abortion. (909) 788-2656 Administrator, 

•	Known	or	suspected	homicide,	

suicide, or accidental poisoning.

•	By	recent	or	old	injury	or	

accident.

Fax:	(909)	788-2934

Email: CSCA2000@aol.

com

Public 

Guardian, 

and Public 

Conservator.

•	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 a 

public hazard.

•	By	occupational	disease	or	

hazard.

•	Of	State	mental	hospital	patient.

•	Of	developmentally	disabled	

patient	in	State	developmental	

services	hospital.

•	In	prison	or	while	under	

sentence.

•	Under	other	suspicious	

circumstances.
■ Firefighter Autopsy Protocol ■ 59 ■ I: Background ■

State/

Territory Type of System Title Deaths Investigated Contact Comment

Colorado County Coroner County Coroner •	From	external	violence.

•	Unexplained	cause.

•	Under	suspicious	circumstances.

•	Suddenly,	when	in	good	health.

•	Where	no	physician	is	in	attendance,	or	where	the	attending	

physician is unable to certify the 

cause of death.

•	From	thermal,	chemical,	or	

radiation injury.

•	From	criminal	abortion.

•	From	disease	that	may	be	

hazardous or contagious or may 

constitute a hazard to the public 

health.

•	While	in	custody	of	law	enforcement	officials	or	while	incarcerated in a public institution.

•	From	industrial	accident.

James L. Kramer, P.A.C.

President

Colorado Coroner 

Association

517	Colorado	Avenue

Pueblo, CO 81004

(719) 543-4016 

Fax:	(719)	583-6077

Email:kramerpa@

co.pueblo.co.us

Thomas E. Henry, M.D.

Chief	Medical	Examiner/

Coroner

Denver	City	and	County

660 Bannock Street

Denver,	CO	80204-4507

(303) 436-7711 (303) 

436-7411

Fax:	(303)	436-7709

Connecticut State Medical 

Examiner

State Chief 

Medical 

Examiner

•	Due	to	criminal	abortion,	whether	

apparently self-induced or not.

•	Violent,	whether	apparently	

homicidal, suicidal, or accidental, including but not limited to 

deaths due to thermal, chemical, 

electrical, or radiation injury.

•	Sudden	or	unexpected	deaths	

not caused by readily recognizable disease.

•	Under	suspicious	circumstances.

•	Where	the	body	is	to	be	

cremated, buried at sea, or 

otherwise	disposed	of	so	as	to	

be	thereafter	unavailable	for	

examination.

•	Related	to	occupational	disease	

or accident.

•	Related	to	disease	which	might	

constitute a threat to public 

health.

H.	Wayne	Carver,	II,	M.D.

Chief	Medical	Examiner

Office	of	the	State	

Medical	Examiner	11	

Shuttle Road

Farmington, CT

06032-1939

(860) 679-3980 

Fax:	(860)	679-1257

Email:	H.Wayne.Carver@

po.state.ct.us
■ Firefighter Autopsy Protocol ■ 60 ■ I: Background ■

State/

Territory Type of System Title Deaths Investigated Contact Comment

Delaware State Medical 

Examiner

State Chief 

Medical 

Examiner

•	By	violence,	suicide,	or	casualty.

•	While	under	anesthesia.

•	By	abortion	or	suspected	

abortion.

•	By	poison	or	suspicion	of	poison.

•	Suddenly	when	in	apparent	

health.

•	When	unattended	by	a	

physician.

•	In	prison	or	penal	institution	or	

police custody.

•	Resulting	from	employment.

•	From	undiagnosed	cause	which	

may be related to a disease 

constituting a threat to public 

health.

•	In	any	suspicious	or	unusual	

manner.

•	If	the	body	is	unclaimed	or	to	be	

cremated.

Richard Callery, M.D.

State Chief Medical 

Examiner

Office	of	the	Chief	

Medical	Examiner

Department of Health and 

Social	Services

200 South Adam Street

Wilmington, DE 19801

(302) 577-3420 

Fax:	(302)	577-3416

Email: rcallery@state.

de.us

District of 

Columbia

Medical	Examiner Chief Medical 

Examiner

•	By	violence,	whether	apparently	

homicidal, suicidal, or accidental, 

including deaths due to thermal, 

chemical, electrical, or radiation 

injury.

•	Due	to	criminal	abortion,	whether	

apparently self-induced or not.

•	Under	suspicious	circumstances.

•	Of	persons	whose	bodies	are	to	

be cremated, dissected, buried 

at	sea,	or	otherwise	disposed	of	

so	as	to	be	thereafter	unavailable	for	examination.

•	Sudden	deaths	not	caused	by	

readily recognizable disease.

•	Related	to	disease	resulting	from	

employment	or	to	accident	while	

employed.

•	Related	to	disease	which	might	

constitute a threat to public 

health.

Johnathan L. Arden, M.D.

Chief	Medical	Examiner

Office	of	the	Chief	

Medical	Examiner

Building 27

1910 Massachusetts 

Avenue,	Southeast

Washington, DC 20003

(202) 698-9000

Fax:	(202)	698-9100
■ Firefighter Autopsy Protocol ■ 61 ■ I: Background ■

State/

Territory Type of System Title Deaths Investigated Contact Comment

Florida District Medical 

Examiner

District Medical 

Examiner

•	By	criminal	violence.

•	By	accident.

•	By	suicide.

•	Suddenly,	when	in	apparent	

good health.

•	Unattended	by	a	physician	or	

other 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	the	

State	without	proper	medical	

certification.

•	When	the	body	is	to	be	cremated, dissected, or buried at 

sea.

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

Georgia Mixed:	State	

Medical	Examiner	

and County 

Coroners/Medical 

Examiners

County Coroner, 

State Medical 

Examiner,	

Regional 

Medical 

Examiner,	

County Medical 

Examiner,	

Local Medical 

Examiner

•	By	violence,	suicide,	or	casualty.

•	Suddenly,	when	in	apparent	

good health.

•	When	unattended	by	a	

physician.

•	When	an	inmate	of	a	State	

hospital or State, county, or city 

penal institution.

•	When	ordered	by	a	court	having	

criminal jurisdiction.

•	After	birth	but	before	7	years	of	

age	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
■ Firefighter Autopsy Protocol ■ 62 ■ I: Background ■

State/

Territory Type of System Title Deaths Investigated Contact Comment

Georgia

(cont’d)

•	In	any	suspicious	or	unusual	

manner,	with	particular	attention	

to those persons 16 years of age 

and under.

•	As	a	result	of	an	execution	carried out pursuant to imposition of 

the death penalty.

Randy Hanzlick, M.D.

Chief	Medical	Examiner,	

Fulton County

Fulton County Medical 

Examiner	Center

430 Pryor Street SW

Atlanta, GA 30312

(404) 730-4400 

Fax:	(404)	730-4407

Email: RandyHanzlick@

mail.co.fulton.ga.us

Guam 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 a 

licensed physician.

3. unattended by a physician 

during a terminal illness, 

particularly if such death 

appears unrelated to a 

disease	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
■ Firefighter Autopsy Protocol ■ 63 ■ I: Background ■

State/

Territory Type of System Title Deaths Investigated Contact Comment

Guam (cont’d) 8. all hospital DOAs (dead 

on	arrival)	and	those	

dying	within	24	hours	after	

admission.

•	Bodies	to	be	cremated,	buried	at	

sea, or shipped off island.

Hawaii Mixed:	County	

Medical 

Examiners/

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	a	

physician.

•	In	prison.

•	In	a	suspicious	or	unusual	

manner.

•	Within	24	hours	after	admission	

to a hospital or institution.

Kanthi	Von	Guenthner,	

M.D.

Department of the 

Medical	Examiner

835	Iwilei	Road

Honolulu, HI 96817

(808) 527-6777 

Fax:	(808)	524-8797

Idaho County Coroner County Coroner •	As	a	result	of	violence	whether	

apparently homicidal, suicidal, or 

accidental.

•	Under	suspicious	or	unknown	

circumstances.

•	When	not	attended	by	a	physician during his/her last illness 

and the cause of death cannot 

be	certified	by	a	physician.

Erwin	Sonnenberg

Idaho Coroners 

Association

5550 Morrishill Road

Boise, ID 83706

(208) 364-2676

Fax:	(208)	364-2685

Email: CRSONNEL@

ADAWEB.NET  ̃

Illinois Mixed:	County	

Medical 

Examiners/

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 or 

radiation injury, or a complication 

of	any	of	them,	or	by	drowning,	

suffocation,	or	motor	vehicle	

accident.

•	Maternal	or	fetal	death	due	to	

abortion.

•	Due	to	sex	crime	or	crime	

against nature.

Jeff Lair

Secretary

Illinois Coroners and 

Medical	Examiners	

Association

P.O.	Box	1261

Jacksonville,	IL	62651

(217) 245-7423 

Fax:	(217)	479-4637

Email: coroner@

direcway.com
■ Firefighter Autopsy Protocol ■ 64 ■ I: Background ■

State/

Territory Type of System Title Deaths Investigated Contact Comment

Illinois

(cont’d)

•	Where	the	circumstances	are	

suspicious, obscure, mysterious, 

or	otherwise	unexplained;	and	

where,	in	the	written	opinion	

of the attending physician, the 

cause is not determined.

•	Where	addiction	to	alcohol	or	

to	any	drug	may	have	been	a	

contributory cause.

•	Where	the	decedent	was	

not attended by a licensed 

physician.

•	Occurring	in	State	institutions	or	

of	wards	of	the	State.

•	If	a	child	under	2	years	dies	

suddenly	or	unexpectedly	and	

circumstances concerning the 

death	are	unexplained.

•	While	being	pursued,	apprehended, or taken into custody by 

law	enforcement	officers	or	while	

in	custody	of	any	law	enforcement agency.

Indiana County Coroner County Coroner •	Has	died	from	violence.

•	Has	died	by	casualty.

•	Has	died	when	apparently	in	

good health.

•	Has	died	in	an	apparently	

suspicious, unusual, or unnatural 

manner.

•	Has	been	found	dead.

Lisa Barker

Executive	Director

Indiana Coroners 

Association

1643 West 800 South

Romney, IN 47981

(877) 692-7284 

Fax:	(765)	538-2880

Email: ISCABarker@aol.

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
■ Firefighter Autopsy Protocol ■ 65 ■ I: Background ■

State/

Territory Type of System Title Deaths Investigated Contact Comment

Iowa State Medical 

Examiner

State Medical 

Examiner,	

County Medical 

Examiner

•	Violent,	including	homicidal,	

suicidal, or accidental.

•	Caused	by	thermal,	chemical,	

electrical, or radiation injury.

•	Caused	by	criminal	abortion	

including those self-induced, or 

by	rape,	carnal	knowledge,	or	

crimes against nature.

•	Related	to	disease	thought	to	

be	virulent	or	contagious,	which	

might constitute a public hazard.

•	Occurring	unexpectedly	or	from	

unexplained	causes.

•	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,	with	

the	exception	of	pre-diagnosed	

terminal or bedfast cases for 

which	the	time	period	shall	be	

extended	to	20	days.

•	Where	the	body	is	not	claimed	

by	relatives	or	friends.

•	Where	the	identity	of	the	

deceased	is	unknown.

•	Of	a	child	under	the	age	of	2	

years	when	sudden	infant	death	

syndrome is suspected or cause 

of	death	is	unknown.

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 

Street

Des Moines, IA 50309

(515) 281-6726

Email: jgoodin@raccoon.

com

Kansas District Coroner District Coroner •	Death	is	suspected	to	have	been	

the	result	of	violence	caused	by	

unlawful	means,	or	by	suicide.

•	By	casualty.

•	Suddenly	when	the	decedent	

was	in	apparent	health.

•	When	the	decedent	was	not	

regularly attended by a licensed 

physician.

Alan Hancock, M.D.

President

Kansas Coroners 

Association

9201	Parallel	Parkway

Kansas City, KS 

66112-1598

(913) 299-1474 

Fax:	(913)	299-4931

Kansas

(cont’d)

•	In	any	suspicious	or	unusual	

manner,	or	when	in	police	

custody,	or	when	in	a	jail	or	

correctional institution.

•	When	the	determination	of	the	

cause of death is held to be in 

the public interest.
■ Firefighter Autopsy Protocol ■ 66 ■ I: Background ■

State/

Territory Type of System Title Deaths Investigated Contact Comment

Kentucky Mixed:	State	 County Coroner, •	Caused	by	homicide,	violence,	 Tracey S. Corey, MD

Medical	Examiner	 State Medical suicide, an accident, drugs, State Chief Medical 

and County Examiner,	 poison,	motor	vehicle,	train,	fire,	 Examiner

Coroners/Medical District Medical explosion,	drowning,	illegal	abor- Office	of	the	State	

Examiners Examiner tion, or unusual circumstances. Medical	Examiner

•	By	criminal	means.

•	Sudden	infant	death	syndrome.

Urban	Government	

Center

810	Barrett	Ave.

•	Child	abuse. Louisville,	KY	40204

•	Death	in	a	person	less	than	40	

years	of	age	with	no	past	medical	history	to	explain	the	death.

•	Death	occurring	at	a	worksite.

(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	

institution,	or	while	decedent	

was	in	police	custody.

•	When	the	death	was	sudden	

and	unexplained	or	the	decedent	

was	unattended	by	a	physician	

by more than 36 hours prior to 

death.

Director

Office	of	the	State	

Medical	Examiner

100	Sower	Blvd,	Suite	

202.	Frankfort,	KY	40601

(502) 564-4545 

Fax:	(502)	564-1699

Email:	dan.able@ky.gov

•	When	skeletonized	or	extensively	decomposed	human	

remains are found.

•	When	the	body	is	to	be	

cremated.

•	When	circumstances	of	death	

result	in	a	request	by	any	

responsible citizen for an 

investigation.
■ Firefighter Autopsy Protocol ■ 67 ■ I: Background ■

State/

Territory Type of System Title Deaths Investigated Contact Comment

Louisiana County Coroner Parish Coroner •	When	suspicious,	unexpected,	 Allen Herbert, M.D.

unusual or sudden. President

•	By	violence.

•	Due	to	unknown	or	obscure	

Louisiana Coroners’

Association

P.O.	Box	747

causes. Alexandria,	LA	71309

•	Where	the	body	is	found	dead. (318) 473-6831 

•	Without	attending	physician	

within	36	hours	prior	to	the	hour	

of death.

Fax:	(318)	473-6832

Email: LSCA@speedgate.net

•	When	abortion,	whether	

self-induced	or	otherwise,	is	

suspected.

•	Due	to	suspected	suicide	or	

homicide.

•	When	poison	is	suspected.

•	From	natural	causes	occurring	in	

a 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	whatever	

cause.

•	Stillborn	deaths.

•	Due	to	criminal	means.

•	If	victim	of	alleged	rape,	carnal	

knowledge,	or	crime	against	

nature.

•	By	casualty.

•	In	prison	or	while	serving	a	

sentence.

•	Due	to	virulent	contagious	

disease that might be caused by 

or cause a public hazard (AIDS 

cases included).
■ Firefighter Autopsy Protocol ■ 68 ■ I: Background ■

State/

Territory Type of System Title Deaths Investigated Contact Comment

Maine State Medical State Chief •	Violence	of	any	kind. Margaret	S.	Greenwald,	

Examiner Medical 

Examiner,	

Medical 

Examiner

•	Any	cause	where	the	death	

occurs	suddenly	while	the	person is in apparent good health.

•	Any	cause	where	there	is	no	

attending physician capable of 

certifying the death as due to 

natural causes.

MD

State Chief Medical 

Examiner

State House, Station #37

Augusta, ME 04333

(207) 624-7180 

Fax:	(207)	624-7178

Email: margaret.green-

•	Poisoning,	either	chronic	or	 wald@state.me.us

acute.

•	Diagnostic	or	therapeutic	

procedures under circumstances 

indicating gross negligence or 

unforeseen clearly traumatic 

causes.

•	Any	cause	while	the	person	is	in	

custody	or	confinement,	unless	

clearly	certifiable	by	an	attending physician as due to natural 

causes.

•	Disease	or	pathological	process	

constituting a threat to public 

health, if the authority of the 

medical	examiner	is	required	to	

study	the	death	adequately	to	

protect the public health.

•	Deaths	which	may	have	been	

improperly	certified	or	inadequately	examined,	including,	

but not limited to, bodies brought 

into the State under these 

circumstances.

•	In	the	case	of	a	child	under	the	

age of 3 years, from any cause, 

including sudden infant death 

syndrome, unless the death is 

clearly	due	to	a	specific	natural	

cause.
■ Firefighter Autopsy Protocol ■ 69 ■ I: Background ■

State/

Territory Type of System Title Deaths Investigated Contact Comment

Maryland State Medical 

Examiner

State Chief 

Medical 

Examiner

•	By	violence,	suicide,	or	casualty.

•	Suddenly	when	in	apparent	good	

health,	or	when	unattended	by	a	

physician.

•	In	any	suspicious	or	unusual	

manner.

•	Fetuses,	regardless	of	duration	

of pregnancy, if the mother is 

not attended by a physician at or 

after	the	delivery.

David	Fowler,	M.D.

Acting State Chief 

Medical	Examiner

State of Maryland

111 Penn Street

Baltimore, MD 21201

(410) 333-3226

Fax:	(410)	333-3063

Email: OCMEMD@aol.

com

Massachusetts State Medical 

Examiner

State Chief 

Medical 

Examiner,	

District Medical 

Examiner

•	Where	criminal	violence	appears	

to	have	taken	place,	regardless	

of	the	time	interval	between	

the incident and death, and 

regardless	of	whether	such	

violence	appears	to	have	been	

the immediate cause of death, or 

a contributory factor.

•	By	accident	or	unintentional	

injury, regardless of the time 

interval	between	the	incident	and	

death,	and	regardless	of	whether	

such	violence	appears	to	have	

been the immediate cause of 

death, or a contributory factor.

•	Suicide,	regardless	of	the	time	

interval	between	the	incident	and	

death.

•	Death	under	suspicious	or	

unusual circumstances.

•	Death	following	an	illegal	

abortion.

•	Death	related	to	occupational	

illness or injury.

•	Death	in	custody,	in	any	jail	or	

correctional facility, or in any 

mental health or mental retardation facility.

•	Death	where	suspicion	of	abuse	

of 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.

Richard	Evans,	M.D.

State Chief Medical 

Examiner

Commonwealth	of	

Massachusetts

720 Albany Street

Boston, MA 02118

(617) 267-6767 Toll free 

in Massachusetts (800) 

962-7877

Fax:	(617)	266-6763

Email:	richard.evans@

cme.state.ma.us
■ Firefighter Autopsy Protocol ■ 70 ■ I: Background ■

State/

Territory Type of System Title Deaths Investigated Contact Comment

Massachusetts 

(continued)

•	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	and	

including 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 under 

foster care.

•	Death	occurring	under	such	

circumstances as the chief medical	examiner	shall	prescribe	in	

regulations promulgated pursuant	to	the	provisions	of	Chapter	

30 A.

Michigan County Medical 

Examiner

County Medical 

Examiner

•	By	violence.

•	When	unexpected.

•	Without	medical	attendance	

during the 48 hours prior to the 

hour of death unless the attending physician, if any, is able to 

determine accurately the cause 

of death.

•	As	the	result	of	an	abortion,	whether	self-induced	or	

otherwise.

•	Of	any	prisoner	in	any	county	or	

city jail.

Dan Remick, M.D. 

President

Michigan Association for 

Medical	Examiners

M2210 Medical Science 

I, 1301 Catherine Road

Ann Arbor, MI 

48109-0602

(734) 763-6454

Fax:	(734)	763-6476

Email: remickd@umich.

edu
■ Firefighter Autopsy Protocol ■ 71 ■ I: Background ■

State/

Territory Type of System Title Deaths Investigated Contact Comment

Minnesota Mixed:	County	

Medical 

Examiners/

Coroners

County Coroner, 

Medical 

Examiner	

(Hennepin, 

Ramsey 

Counties)

•	Violent,	whether	apparently	

homicidal, suicidal, or accidental, including but not limited to 

deaths due to thermal, chemical, 

electrical, or radiation injuries.

•	Due	to	criminal	abortion,	whether	

apparently self-induced or not.

•	Under	unusual	or	mysterious	

circumstances.

•	Of	persons	whose	bodies	are	to	

be cremated, dissected, buried 

at	sea,	or	otherwise	disposed	of	

so	as	to	be	thereafter	unavailable	for	examination.

•	Of	inmates	of	public	institutions	

who	are	not	hospitalized	therein	

for organic diseases.

Andrew	M.	Baker,	M.D.

Medical	Examiner

Hennepin County

530	Chicago	Avenue

Minneapolis, MN 55415

(612) 215-6300 

Fax:	(612)	215-6330

Email:	andrew.baker@

co.hennepin.mn.us

Michael Rossman

Executive	Secretary

Minnesota Coroners’ 

and	Medical	Examiners’	

Association

530	Chicago	Avenue

Minneapolis, MN 55415

(612) 215-6300 

FAX (612) 215-6330

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.

•	Caused	by	thermal,	chemical,	

electrical, or radiation injury.

•	Caused	by	criminal	abortion,	

including self-induced, or 

abortion	related	to	or	by	sexual	

abuse.

•	Related	to	disease	thought	to	be	

virulent	or	contagious	which	may	

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	of	

the	deceased	is	unknown.

Sam	Howell

Administrator

Mississippi Crime 

Laboratory

1700	East	Woodrow	

Wilson	Avenue

Jackson, MS 39216

(601) 987-1440 

Fax:	(601)	987-1445

Email:	showell@mcl.

state.ms.usI
■ Firefighter Autopsy Protocol ■ 72 ■ I: Background ■

State/

Territory Type of System Title Deaths Investigated Contact Comment

Mississippi 

(continued)

•	Of	a	child	under	the	age	of	2	

years	where	death	results	from	

an	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	that	

the	death	was	not	investigated	

properly or that there is not an 

adequate	certification	of	death.

•	Where	a	person	is	admitted	to	a	

hospital emergency room unconscious	and/or	unresponsive,	with	

cardiopulmonary	resuscitative	

measures being performed, 

and	dies	within	24	hours	of	

admission	without	regaining	

consciousness	or	responsiveness,	unless	a	physician	was	

in	attendance	within	36	hours	

preceding presentation to the 

hospital,	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.
■ Firefighter Autopsy Protocol ■ 73 ■ I: Background ■

State/

Territory Type of System Title Deaths Investigated Contact Comment

Missouri Mixed:	County	 County Coroner, Coroner—In any city of 700,000 Michael A. Graham, M.D.

Medical County Medical or more inhabitants or in any Medical	Examiner

Examiners/ Examiner county	of	the	first	or	second	class	 City of St. Louis

Coroners in	which	a	Coroner	is	required,	 1300	Clark	Avenue

the	Coroner	must	investigate	all	 St. Louis, MO 

deaths	where	there	is	reason	to	 63103-2718

believe	that	death	was	caused	 (314) 622-4971

by	criminal	violence	or	following	 Fax:	(314)	622-4933

abortion. Email: GRAHAMMA@

•	By	violence	by	homicide,	 slu.edu

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 the 

death.

•	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	of	

a hazardous and contagious 

nature	or	which	might	constitute	

a 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.
■ Firefighter Autopsy Protocol ■ 74 ■ I: Background ■

State/

Territory Type of System Title Deaths Investigated Contact Comment

Montana Mixed:	State	 County Coroner— Gary Dale, M.D.

Medical	Examiner	

and County 

Coroners/Medical 

Examiners

Coroner, Chief 

State Medical 

Examiner,	

Associate 

Medical 

Examiner

•	Death	caused	or	suspected	to	

have	been	caused	by	an	injury,	

either recent or remote in origin.

•	Death	caused	or	suspected	

to	have	been	caused	by	the	

deceased or any other person 

that	was	the	result	of	an	act	

or omission, including, but not 

limited to, a criminal or suspected	criminal	act;	a	medically	

suspicious death, unusual death, 

or	death	of	unknown	circumstances, including any fetal 

death;	or	an	accidental	death.

State	Medical	Examiner

State	Crime	Lab	Division	

of Forensic Sciences

2679 Palmer Street

Missoula, MT 59808

(406) 728-4970 

Fax:	(406)	549-1067

Email: gdale@state.mt.us

Terry Bullis

Secretary-Treasurer

Montana Coroners’ 

Association

P.O.	Box	318

Hardin, MT 59034-0318

(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 Coroner

that poses a threat to public 228	Broadway	St.

health. Helena, MT 59601-4263

•	Death	occurring	while	the	

deceased	was	incarcerated	in	

a	prison	or	jail	or	confined	to	a	

correctional or detention facility 

(406) 442-7398 

Fax:	(406)	447-8298

Email: MNELSON@

co.lewis-clark.mt.us

owned	and	operated	by	the	

State	or	a	political	subdivision	of	

the State.

•	Death	occurring	while	the	

deceased	was	in	the	custody	

of,	or	was	being	taken	into	the	

custody	of,	a	law	enforcement	

agency	or	a	peace	officer.

•	Death	occurring	during	or	as	

a result of the deceased’s 

employment.

•	Death	occurring	less	than	24	

hours	after	the	deceased	was	

admitted to a medical facility or 

if	the	deceased	was	dead	upon	

arrival	at	a	medical	facility.

•	Death	occurring	in	a	manner	that	

was	unattended	or	unwitnessed	

and	the	deceased	was	not	

attended by a physician at any 

time in the 30-day period prior to 

death.
■ Firefighter Autopsy Protocol ■ 75 ■ I: Background ■

State/

Territory Type of System Title Deaths Investigated Contact Comment

Montana

(cont’d)

•	If	the	dead	body	is	to	be	

cremated or shipped into the 

State 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	no	

physician or surgeon licensed 

in	Montana	will	sign	a	death	

certificate.

ChiefState	Medical	Examiner—

provides	assistance	and	consultation to Coroners.

Nebraska County Coroner County Coroner, 

County 

Coroner’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	and	

unexplained	death	of	a	child	

between	the	ages	of	1	week	

and	3	years,	and	when	neglect,	

violence,	or	any	unlawful	means	

are possible.

•	When	death	is	not	certified	by	

attending physician.

•	When	an	individual	has	died	

while	being	apprehended	by	

or	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 Lancaster 

and Douglas 

Counties, 

physicians 

have	been	

appointed to 

assist in the 

investigations and the 

signing of the 

medical portion of death 

certificates.	

In Douglas 

County, 

the County 

Attorney has 

appointed 

a medical 

examiner	to	

investigate	

deaths by 

unnatural 

causes. 
■ Firefighter Autopsy Protocol ■ 76 ■ I: Background ■

State/

Territory Type of System Title Deaths Investigated Contact Comment

Nebraska

(cont’d)

Coroner’s 

physicians 

sign the death 

certificates.	

In Lancaster 

County, 

the County 

Attorney has 

retained a 

pathologist 

who	assists	

in	the	investigation by 

performing 

autopsies and 

signing the 

medical portion of death 

certificates.

Nevada District Coroner District Coroner •	Unattended	deaths.

•	Deaths	wherein	the	deceased	

has not been attended by a 

physician in the 10 days before 

death. The coroner shall issue 

the	certificate	of	death	following	

consultation	with	a	physician	

licensed to practice in the State.

•	Deaths	related	to	or	following	

known	or	suspected	self-induced	

or criminal abortion.

•	Known	or	suspected	homicide,	

suicide, or accidental death.

•	Deaths	known	or	suspected	as	

resulting	in	whole	or	in	part	from	

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	part	

occasioned by criminal means.

•	Deaths	in	prison.

Lary Simms, M.D.

Chief	Medical	Examiner

Clark County

1704 Pinto Lane

Las	Vegas,	NV	89106

(702) 455-3210 

Fax:	(702)	455-0416

Email: LSI@co.clark.

nv.us

Vernon	O.	McCarty

Washoe County Coroner

P.O.	Box	11130

Reno,	NV	89520

(702) 785-6114 

Fax:(775)	785-1468

Email:	VMCCARTY@

mail.co.washoe.nv.us

Although they 

have	coroner	

systems by 

ordinance, 

Washoe 

County (Reno) 

and Clark 

County (Las 

Vegas)	employ	

board-certified	

forensic 

pathologists 

who	provide	

medical 

examiner	

services	for	

their respective	counties,	

as	well	as	for	

other counties 

on a fee-forservice	basis.
■ Firefighter Autopsy Protocol ■ 77 ■ I: Background ■

State/

Territory Type of System Title Deaths Investigated Contact Comment

Nevada

(cont’d)

•	Deaths	under	such	circumstances as to afford reasonable 

ground to suspect that the death 

was	caused	by	the	criminal	

act of another, or any deaths 

reported by physicians or other 

persons	having	knowledge	of	

death	for	inquiry	by	the	coroner.

New	

Hampshire

State Medical 

Examiner

State Chief 

Medical 

Examiner,	

County Medical 

Examiner

•	By	violence	or	unlawful	act.

•	In	any	suspicious,	unusual,	or	

unnatural manner.

•	In	prison.

•	When	unattended	by	a	

physician.

•	Suddenly	when	in	apparent	

health, including those sudden	and	unexpected	deaths	of	

children under 3 years of age 

or	when	sudden	infant	death	

syndrome is suspected.

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

New	Jersey 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	part	

at	the	expense	of	the	State	or	

county	where	the	inmate	was	not	

hospitalized therein for organic 

disease.

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
■ Firefighter Autopsy Protocol ■ 78 ■ I: Background ■

State/

Territory Type of System Title Deaths Investigated Contact Comment

New	Jersey

(cont’d)

•	From	causes	which	might	constitute a threat to public health.

•	Related	to	disease	resulting	from	

employment	or	to	accident	while	

employed.

•	Sudden	or	unexpected	deaths	

of infants and children under 3 

years of age.

•	Fetal	deaths	occurring	without	

medical attendance.

New	Mexico State Medical 

Examiner

State Medical 

Investigator,	

District Medical 

Investigator

•	Sudden,	violent,	or	untimely.

•	Found	dead	and	the	cause	of	

death	is	unknown	or	obscure.

•	If	caused	by	criminal	act	or	

omission.

Ross	E.	Zumwalt,	M.D.

State Chief Medical 

Investigator

Office	of	the	Medical	

Investigator

State	of	New	Mexico

MSC11 6030

1	University	of	New	

Mexico

Albuquerque,	NM	

87131-0001

(505) 272-3053 

Fax:	(505)	272-0727

Email:RZumwalt@salud.

unm.edu

New	York Mixed:	County	

Medical 

Examiners/

Coroners

County Coroner, 

County 

Coroner’s 

Physician, 

County Medical 

Examiner	(in	

counties abolishing coroner 

system)

•	By	violence,	whether	criminal	

violence,	suicide,	or	casualty.

•	Caused	by	unlawful	act	or	

criminal neglect.

•	Occurring	in	a	suspicious,	

unusual,	or	unexplained	manner.

•	Caused	by	suspected	criminal	

abortion.

•	While	unattended	by	a	physician,	so	far	as	can	be	discovered,	or	where	no	physician	is	

able to certify the cause of death 

as	provided	in	public	health	law	

and in form as prescribed by the 

Commissioner of Health can be 

found.

•	Of	a	person	confined	in	a	public	

institution other than a hospital, 

infirmary,	or	nursing	home.

•	Death	occurring	to	an	inmate	of	

a correctional facility.

Charles S. Hirsch, M.D.

Chief	Medical	Examiner

City	of	New	York	(New	

York,	Bronx,	Kings,	

Queens, and Richmond 

Counties)

520	First	Avenue,	Room	

134

New	York,	NY	10016

(212) 447-2034 

Fax:	(212)	447-2744

In some 

counties, there 

are multiple 

coroners, each 

having	equal	

authority. 

In	Lewis,	

Madison, 

and	Oswego	

Counties, State 

law	requires	

that the District 

Attorney	serve	

as Coroner.
■ Firefighter Autopsy Protocol ■ 79 ■ I: Background ■

State/

Territory Type of System Title Deaths Investigated Contact Comment

North Carolina Mixed:	State	

Medical	Examiner	

and County 

Coroners/Medical 

Examiners

Chief Medical 

Examiner,	

County Medical 

Examiner,	

(Acting) Medical 

Examiner

•	Homicide.

•	Suicide.

•	Trauma-related.

•	Accidental.

•	Disaster	related.

•	Violence	related.

•	Unknown,	unnatural,	unusual,	or	

suspicious circumstances.

•	In	police	custody,	jail,	prison,	or	

correctional institution.

•	Poisoning	or	suspicion	of	

poisoning.

•	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.

John D. Butts, M.D.

Chief	Medical	Examiner

State Department of 

Health and Human 

Services

Office	of	the	Chief	

Medical	Examiner

Chapel Hill, NC 

27599-7580

(919) 966-2253 

Fax:	(919)	962-6263

Email: jbutts@ocme.unc.

edu

North Carolina 

has coroners in 

some counties	who	work	

closely	with	the	

State Medical 

Examiner.

North Dakota County Coroner County Coroner •	Generally,	deaths	occurring	by	

unlawful	means	or	without	medical attendance.

•	In	counties	with	more	than	8,000	

population.

•	As	a	result	of	criminal	or	violent	

means.

•	By	casualty	or	accident.

•	By	suicide.

•	Suddenly	when	in	apparent	good	

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.

Beverly	R.	Wittman

Deputy State Registrar 

and Director

Division	of	Vital	Records

North Dakota State 

Department of Health

600	East	Boulevard

Bismarck, ND 58505

(701) 328-4508

Fax:(701)	328-1850

Email: BWITTMAN@

state.nd.usNorth Dakota

The	office	of	

Coroner is 

abolished in 

counties adopting the County 

Manager form 

of	government,	with	

the County 

Manager or 

Sheriff assuming the duties 

of the Coroner. 

However,	if	

these duties 

conflict	with	

those performed by the 

Sheriff, the 

county State’s 

Attorney 

assumes the 

duties of the 

coroner.
■ Firefighter Autopsy Protocol ■ 80 ■ I: Background ■

State/

Territory Type of System Title Deaths Investigated Contact Comment

Northern 

Marina Islands

Not	available Not	Available •	Not	available. Orana Castro

Director

Office	of	Vital	Statistics

Commonwealth	Trial	

Courts

P.O.	Box	307

Saipan, MP 96950

(670) 234-6401

Ohio Mixed:	County	

Medical 

Examiners/

Coroners

County Coroner •	As	a	result	of	criminal	or	other	

violent	means.

•	By	casualty.

•	By	suicide.

•	Suddenly	when	in	apparent	

health.

•	In	any	suspicious	or	unusual	

manner.

•	Threat	to	public	health.

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

Coroners are 

not	allowed	

to	actively	

practice	law	

while	in	office.

Summit County 

has a County 

Medical 

Examiner	

system.

Oklahoma State Medical 

Examiner

State Chief 

Medical 

Examiner,	

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.

•	Due	to	criminal	abortion,	whether	

apparently self-induced or not.

•	Under	suspicious,	unusual,	or	

unnatural circumstances.

•	Related	to	disease	that	might	

constitute a threat to public 

health.

•	Unattended	by	a	licensed	medical or osteopathic physician for a 

fatal or potentially fatal illness.

•	Of	persons	after	unexplained	

coma.

•	That	are	medically	unexpected	

and occur in the course of a 

therapeutic procedure.

•	Of	any	inmates	occurring	in	any	

place of penal incarceration.

•	Of	persons	whose	bodies	are	

to be cremated, buried at sea, 

transported out of State, or otherwise	made	ultimately	unavailable for pathological study.

Fred B. Jordan, M.D.

Chief	Medical	Examiner

901	North	Stonewall

Oklahoma City, OK 

73117

(405) 239-7141

Fax:	(405)	239-2430

Email: Medical_

Examiner@ocmeokc.

state.ok.us
■ Firefighter Autopsy Protocol ■ 81 ■ I: Background ■

State/

Territory Type of System Title Deaths Investigated Contact Comment

Oregon State Medical 

Examiner

State Medical 

Examiner,	

County Medical 

Examiner

•	Apparently	homicidal,	suicidal,	

or occurring under suspicious or 

unknown	circumstances.

•	Resulting	from	the	unlawful	use	

of dangerous or narcotic drugs 

or the use or abuse of chemicals 

or	toxic	agents.

•	Occurring	while	incarcerated	in	

any jail, correction facility, or in 

police custody.

•	Apparently	accidental	or	following an injury.

•	By	disease,	injury,	or	toxic	agent	

exposure	during	or	arising	from	

employment.

•	While	not	under	the	care	of	

a physician during the period 

immediately	previous	to	death.

•	Related	to	disease	which	might	

constitute a threat to the public 

health.

Karen Gunson, M.D.

State	Medical	Examiner

Medical	Examiner	

Division

Oregon Department of 

State Police

301 Northeast Knott 

Street

Portland, OR 97212-3092

(503) 988-3746 

Fax:	(503)	280-6041

Email: karen.gunson@

state.or.us

Eugene Gray

Forensic Administrator

Medical	Examiner	

Division

Oregon Department of 

State Police

301 Northeast Knott 

Street

Portland, OR 97212-3092

(503) 280-6061 

Fax:	(503)	280-6041

Email: eugene.gray@

state.or.us

Pennsylvania Mixed:	County	

Medical 

Examiners/

Coroners

County Coroner, 

County Medical 

Examiner

•	Sudden	deaths	not	caused	by	

readily recognizable disease, 

or	wherein	the	cause	of	death	

cannot	be	properly	certified	by	

a 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	the	

outcome.

•	Deaths	occurring	as	a	result	

of	violence	or	trauma,	whether	

apparently homicidal, suicidal, 

or accidental (including, but not 

limited to, those due to mechanical, thermal, chemical, electrical 

or	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
■ Firefighter Autopsy Protocol ■ 82 ■ I: Background ■

State/

Territory Type of System Title Deaths Investigated Contact Comment

Pennsylvania

(cont’d)

•	Any	death	in	which	trauma,	

chemical	injury,	drug	overdose,	

or reaction to drugs or medication	or	medical	treatment	was	a	

primary or secondary, direct or 

indirect,	contributory,	aggravating, or precipitating cause of 

death.

•	Operative	and	perioperative	

deaths	in	which	the	death	is	not	

readily	explainable	on	the	basis	

of prior disease

•	Any	death	wherein	the	body	is	

unidentified	or	unclaimed.

•	Deaths	known	or	suspected	as	

due to contagious disease and 

constituting a public hazard.

•	Deaths	occurring	in	prison	or	a	

penal	institution	or	while	in	the	

custody of the police.

•	Deaths	of	persons	whose	bodies	

are to be cremated, buried at 

sea,	or	otherwise	disposed	of	so	

as	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.

•	As	a	result	of	any	accident	or	act	

of	violence	or	any	subsequent	

act, regardless of its nature or 

time	interval	between	said	acts	

and death, if there is a reasonable	doubt	that	there	might	have	

been	a	relation	between	said	

accident	or	act	of	violence	and	

death.

•	As	a	result	of	poisoning	or	

suspicion of poisoning.

•	Occurring	in	custody	of	the	

police	or	officers	of	the	law,	

while	in	prison,	or	as	a	result	of	

sickness	or	injury	occurring	while	

in prison, or suspicion thereof.

Lyvia	A.	Alvarez,	M.D.

Director

Institute of Forensic 

Sciences

Call	Box	11878

Caparra Height Station

San Juan, PR 00922

(809) 765-0615

(809) 765-4880
■ Firefighter Autopsy Protocol ■ 83 ■ I: Background ■

State/

Territory Type of System Title Deaths Investigated Contact Comment

Puerto Rico •	As	a	result	of	or	in	relation	to	the	

(cont’d) occupation of the deceased.

•	Due	to	acute	intoxication	with	

alcohol, narcotics, or any type of 

drug or controlled substance or 

suspicion of such.

•	Due	to	suicide	or	suspected	

suicide.

•	When	in	process	of	an	autopsy	

that	was	not	originally	considered medicolegal, the pathologist	discovers	any	clue,	or	any	

suspicion arises to indicate that 

such	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	an	

abortion or childbearing.

•	When	the	physician	who	

attended	said	person	while	living	

cannot reasonably establish that 

the	death	was	due	to	natural	

causes.

•	Occurring	during	or	after	

surgical, diagnostic, or therapeutic	procedures	or	where	the	

deceased	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	to	

the death.

•	Occurring	in	a	convalescent	

home, 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 public 

health.
■ Firefighter Autopsy Protocol ■ 84 ■ I: Background ■

State/

Territory Type of System Title Deaths Investigated Contact Comment

Puerto Rico

(cont’d)

•	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 to 

natural causes.

•	Occurring	during	hospitalization in a psychiatric institution, 

whether	it	be	commonwealth,	

municipal,	or	private,	except	in	

cases 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 of 

negligence.

•	When	the	corpse	is	to	be	

cremated, 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	death	

occurred.

•	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.

•	Due	to	a	criminal	abortion.

•	Due	to	an	accident	involving	

lack of due care on the part of a 

person other than the deceased.

•	Which	is	the	immediate	or	

remote	consequences	of	any	

physical	or	toxic	injury	incurred	

while	the	deceased	person	was	

employed.

Elizabeth A. Laposata, 

M.D.

State	Medical	Examiner

Office	of	State	Medical	

Examiner

Rhode Island Department 

of Health

48 Orms Street

Providence,	RI	02904

(401) 222-5500

Fax:	(401)	222-5517
■ Firefighter Autopsy Protocol ■ 85 ■ I: Background ■

State/ Type of System Title Deaths Investigated Contact Comment Territory

Rhode Island •	Due	to	the	use	of	addictive	or	

(cont’d) unidentifiable	chemical	agents.

•	Due	to	an	infectious	agent	

capable of spreading an 

epidemic	within	the	State.

•	When	unattended	by	a	

physician.

South Carolina Mixed:	County	 County Coroner, •	By	violence. Debbie Johnson In	counties	with	

Coroner and County Medical Executive	Director populations •	By	suicide. Medical	Examiner Examiner	 South Carolina Coroners of 100,000 •	When	in	apparent	good	health. Association or more, the 

•	When	unattended	by	a	 301	University	Ridge,	 governing	body	

physician. Suite 2300 of that county 

Greenville,	SC	29601 can chose to •	In	any	unusual	or	suspicious	 (864) 467-7446 have	a	Medical	 manner.

	Fax:	(864)	467-7469 Examiner	 •	While	an	inmate	in	a	penal	or	 system. correctional institution.

•	As	a	stillbirth,	medically	

unattended.

South Dakota County Coroner County Coroner •	By	unnatural	means,	including	 Kathlene A. Mueller

all deaths of accidental, homi- Manager,	Office	of	

cidal, suicidal, and undetermined Data,	Statistics	and	Vital	

manner, regardless of suspected Records

criminal	involvement	in	the	 State Department of 

death. Health

600	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 or state.sd.us

special school.

•	Those	believed	to	represent	a	

public health hazard.

•	Children	under	2	years	of	age	

resulting	from	unknown	cause	or	

if circumstances suggest sudden 

infant death syndrome as the 

cause.

•	Natural	deaths	if	the	decedent	is	

not under the care of a physician 

or the decedent’s physician does 

not	feel	qualified	to	sign	the	

death	certificate.
■ Firefighter Autopsy Protocol ■ 86 ■ I: Background ■

State/

Territory Type of System Title Deaths Investigated Contact Comment

Tennessee State Medical 

Examiner

State Chief 

Medical 

Examiner,	

Deputy Chief 

Medical 

Examiner,	

Assistant 

Chief Medical 

Examiner,	

County Medical 

Examiner

•	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	be	

cremated.

•	For	workers	compensation	

claims if cause of death is 

obscure or disputed.

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

Texas Mixed:	County	

Medical 

Examiners/

Coroners

County Justice 

of the Peace, 

County/

District Medical 

Examiner

Justice of the Peace—

•	In	prison	or	jail.

•	When	a	person	is	killed,	or	from	

any cause dies an unnatural 

death,	except	under	sentence	of	

the	law.

•	In	the	absence	of	one	or	more	

good	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	or	

registrar	required	to	report	the	

cause	of	death	does	not	know	

the cause of death.

•	When	the	attending	physician(s)	

cannot certify the cause of 

death.

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
■ Firefighter Autopsy Protocol ■ 87 ■ I: Background ■

State/

Territory Type of System Title Deaths Investigated Contact Comment

U.S.	Virgin	

Islands

Territorial Medical 

Examiner

Medical 

Examiner

•	Unnatural	deaths	as	prescribed	

by	law.

•	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	by	

law.

•	When	confined	to	a	public	

institution other than hospital, 

infirmary,	or	nursing	home.

•	As	prescribed	by	the	Governor	

or Attorney General.

James Glenn, M.D.

Medical	Examiner

Office	of	the	Medical	

Examiner

U.S.	Virgin	Islands	

Department of Justice

Toro 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 Justice

8050 Kronprindsens 

Gade

St.	Thomas,	VI	00802

(809)	744-5666	ext.	663	

(809) 776-8311

Utah State Medical 

Examiner

•	By	violence,	gunshot,	suicide,	

or	accident	(except	highway	

accidents).

•	Suddenly	when	in	apparent	

health.

•	When	unattended	(not	seen	by	a	

physician	within	30	days).

•	Under	suspicious	or	unusual	

circumstances.

•	Resulting	from	poisoning	or	

overdose	of	drugs.

•	Resulting	from	diseases	that	

may constitute a threat to public 

health.

•	Resulting	from	disease,	injury,	

toxic	effect,	or	unusual	exertion	

incurred	within	the	scope	of	the	

deceased’s employment.

•	Due	to	sudden	infant	death	

syndrome.

Todd C. Grey, M.D.

State	Medical	Examiner

Utah Department of 

Health

48	North	Medical	Drive

Salt Lake City, UT 84113

(801) 584-8410

Fax:	(801)	584-8435

Email:hldels.tgrey@state.

ut.usa
■ Firefighter Autopsy Protocol ■ 88 ■ I: Background ■

State/

Territory Type of System Title Deaths Investigated Contact Comment

•	Resulting	when	the	deceased	

was	in	prison,	jail,	police	

custody, the State hospital, or 

a detention or medical facility operated for the treatment 

of mentally ill or emotionally 

disturbed	or	delinquent	persons.

•	Associated	with	diagnostic	and	

therapeutic procedures.

•	Involving	questions	of	civil	liability,	in	accordance	with	provisions	

of the Worker’s Compensation 

Act.

Vermont State Medical 

Examiner

Chief Medical 

Examiner,	

Regional 

Medical 

Examiner

•	From	violence.

•	Suddenly	when	in	apparent	good	

health.

•	When	unattended	by	a	

physician.

•	By	casualty.

•	By	suicide.

•	As	a	result	of	injury.

•	When	in	jail,	prison,	or	any	

mental institution.

•	In	any	unusual,	unnatural,	or	

suspicious manner.

•	In	circumstances	involving	a	

hazard	to	public	health,	welfare,	

or safety.

Paul	L.	Morrow,	M.D.

State Chief Medical 

Examiner	Department	of	

Health

Baird 1 111 Colchester 

Ave.

Burlington,	VT	05401

(802) 863-7320 

Fax:	(802)	863-7265

Email:	pmorrow@vdh.

state.vt.us
■ Firefighter Autopsy Protocol ■ 89 ■ I: Background ■

State/ Type of System Title Deaths Investigated Contact Comment Territory

Virginia State Medical State Chief •	By	trauma,	injury,	violence,	 Marcella Farinelli Fierro, 

Examiner Medical poisoning, accident, suicide, or M.D.

Examiner,	 homicide. State Chief Medical 

County/ Examiner •	Suddenly	when	in	apparent	good	 City Medical Department of Health health.

Examiner 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

(804) 786-3174 •	Suddenly	as	an	apparent	result	 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	a	

physician.

Washington Mixed:	County	 County Coroner, •	Those	in	which	the	Coroner	 Richard Harruff, M.D., 

Medical County Medical suspects	that	the	death	was	 Ph.D.

Examiners/ Examiner unnatural,	or	violent,	or	resulted	 Chief	Medical	Examiner,	

Coroners from	unlawful	means,	or	from	 King County

suspicious circumstances, or 325	Ninth	Avenue	HMC	

was	of	such	a	nature	as	to	 Box	35792

indicate the possibility of death Seattle, WA 98104

by the hand of the deceased or (206) 731-3232

through the instrumentality of Fax:	(206)	731-8555

some other person. Email: richard.harruff@

metrokc.gov •	Those	occurring	suddenly	when	 Dan Blasdel, President in apparent good health and Washington Association without	medical	attendance	

of Coroners and Medical within	36	hours	preceding	death. 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,	

page (509) 530-6906 •	Those	as	a	result	of	any	violence	 Email: dblasdel@3-cities. whatsoever.

com

•	Those	resulting	from	a	known	

or	suspected	abortion,	whether	

self-induced	or	otherwise.
■ Firefighter Autopsy Protocol ■ 90 ■ I: Background ■

State/

Territory Type of System Title Deaths Investigated Contact Comment

Washington

(cont’d)

•	Those	apparently	resulting	from	

drowning,	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	or	

stillbirth.

•	Those	due	to	virulent	or	

suspected. contagious disease 

which	may	be	a	public	health	

hazard.

•	Those	resulting	from	alleged	

rape,	carnal	knowledge,	or	

sodomy.

•	Those	occurring	in	a	jail	or	

prison.

•	Those	in	which	a	body	is	found	

dead or is not claimed by relatives	or	friends.

•	Industrial	deaths	when	cause	

of	death	is	unknown	and	

investigation	is	requested	by	

the Department of Labor and 

Industries.

West	Virginia State Medical 

Examiner

State Chief 

Medical 

Examiner,	

Deputy Chief 

Medical 

Examiner,	

County Medical 

Examiner

•	From	violence	or	suspected	violence,	or	where	natural	disease	

cannot be assumed.

•	When	unattended	by	a	

physician.

•	When	during	incarceration,	

protective	custody,	as	a	ward	

of	the	State,	or	associated	with	

police	intervention.

•	From	disease	or	environmental	

condition	which	might	constitute	

a threat to the public health.

•	When	in	any	suspicious,	

unusual, or unnatural manner.

•	In	deaths	thought	to	be	due	to,	

or	associated	with,	suspected	

abuse 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
■ Firefighter Autopsy Protocol ■ 91 ■ I: Background ■

State/

Territory Type of System Title Deaths Investigated Contact Comment

Wisconsin Mixed:	County	 County Coroner, •	If	circumstances	are	unex- Tom Terry, M.D. Counties	with	

Medical County Medical plained, unusual, or suspicious. President a Medical 

Examiners/

Coroners

Examiner •	By	homicide	or	manslaughter,	

including death resulting from 

reckless conduct, negligent 

control	of	a	vicious	animal,	or	

negligent	use	of	a	firearm.

•	By	suicide.

Wisconsin Coroner 

and	Medical	Examiner	

Association

730 Wisconsin St

Racine, WI 53403

(262) 636-3303

Fax:	(262)	636-3728

Examiner	

include those 

having	a	

population 

of 500,000 

or more, and 

those that 

•	Following	an	abortion. Email: TOMT@racineco. have	chosen	to	

•	By	poisoning,	whether	homicidal,	

suicidal, or accidental.

•	Following	accidents,	whether	

com have	a	Medical	

Examiner	

system.

the injury is or is not the primary 

cause.

•	When	a	physician	or	accredited	

practitioner	of	a	bona	fide	religious denomination relying upon 

prayer or spiritual means for 

healing	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	to	

sign	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.
■ Firefighter Autopsy Protocol ■ 92 ■ I: Background ■

State/

Territory Type of System Title Deaths Investigated Contact Comment

Wyoming County Coroner County Coroner •	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.

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 of 

Coroner 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
■ 93 ■

■ Appendix B: Niosh Firefighter Fatality 

Reports—Autopsy Information

The 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 for 

each 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, both 

are 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 the 

recommendation to “perform autopsies on all on-duty fire fighter fatalities.” This was noted on about two 

dozen 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 were 

artificially low in a case in which the victim had received oxygen therapy prior to death.
■ Firefighter Autopsy Protocol ■ 94 ■ I: Background ■ RTSNIOSH REP. # DATE OF INCIDENT Title CAUSE OF DEATH AUTOPSY AUTOPSY COMMENTS PDF LINK F2007-01 Dec 30, 2006 Career	firefighter	dies	and	 chief	is	injured	when	struck	 by	130-foot	awning	that	col- lapses during a commercial building	fire—Texas Blunt-force trauma Not mentioned None F2007- 01PD

F

F2006-26 Aug 13,

2006

Career engineer dies and firefighter	injured	after	falling	through	floor	while	conducting a primary search at a residential structure fire—Wisconsin

Smoke inhalation and thermal burns

Not mentioned None F2006-

26PD

F

F2006-22 Apr 8,

2006

Volunteer	firefighter	dies	after	being struck by a shackle on a	recoiling	tow	rope—South	Dakota

Blunt-force head trauma

Not mentioned None F2006-

22PD

F

F2006-19 May 14, 

2006

Career lieutenant dies in residential structure fire—Colorado

Complications from hypoxic	encephalopathy	(lack	of	oxygen	to the brain) due to apparent smoke inhalation

Not mentioned None F2006-

19PD

F

F2006-10 Mar 1, 

2006

Volunteer	firefighter	is	killed	and	another	volunteer	firefighter	is	injured	at	a	wildland/urban	interface	fire—Oklahoma

Complications from the burns	he	received	to	over	45%	of	his	body

Yes None F2006-

10PD

F

F2006-06 Nov	22,

2005

Volunteer	firefighter	dies	in	tanker	rollover	crash—Texas

Open skull fracture resulting from an automobile accident

Not mentioned None F2006-

06PD

F

F2005-28 Aug 6, 

2005

One	career	firefighter	dies	and	two	are	injured	in	apparatus crash—California

Multiple blunt-force trauma to the torso

Yes None F2005-

28PD

F
■ Firefighter Autopsy Protocol ■ 95 ■ I: Background ■ NIOSH REP. # DATE OF INCIDENT Title CAUSE OF DEATH AUTOPSY AUTOPSY COMMENTS PDF LINK F2006-25 Jul 26, 2006 Junior	volunteer	firefighter	 dies	and	three	volunteer	 firefighters	are	injured	in	a	 tanker crash—Alabama Blunt	force	trauma	with	 head and chest injuries Not mentioned None F2006-21 Mar 09, 2006 Career lieutenant suffers sudden cardiac death at his	home	after	finishing	his	 shift—Tennessee Hypertensive	heart	 disease Yes •	Cardiomegaly	(enlarged	heart):	heart	weight	of	441	grams	 (g)	(normal	weight	is	<400	g) •	LVH –	 left	ventricle	thickness	was	1.5-2.0	centimeters	(cm)	 (normal thickness is 0.6-1.1 cm)1 •	Myocardial	perivascular	and	patchy	interstitial	fibrosis •	Mild	bilateral	dilatation	of	left	and	right	ventricles	(no	 measurements	were	listed) •	Moderate	to	severe	coronary	artery	disease	(CAD)	with	 75%	narrowing	of	the	left	anterior	descending	(LAD)	 artery •	Mild	aortic	sclerosis •	No	evidence	of	thrombosis	(blood	clots)	in	his	coronary	 arteries •	No	evidence	of	a	pulmonary	embolus F2006-20 Apr 16, 2006 Career	airport	fire	apparatus	 operator suffers sudden cardiac death at his station after	exercising—Georgia Acute Respiratory Distress Syndrome due to an acute myocardial infarction (MI) Yes •	Acute	MIo	Massive	infarct	of	the	left	ventricle,	extending	 from	the	apex	to	the	base	of	the	heart –	 Focal	acute	extension	of	the	infarct	 –	 Stent	in	place,	proximal	left	anterior	descending	coro- nary	artery,	with	a	luminal	thrombus•	Atherosclerotic	 CADo	Moderate	to	severe	atherosclerosis	of	distal	left	 anterior descending artery – Moderate atherosclerosis of right coronary artery –	 Moderate	atherosclerosis	of	circumflex	artery •	Cardiomegaly	(enlarged	heart):	heart	weight	of	600	grams	 (g)	(the	normal	weight	given	in	the	autopsy	records	is	 250-350 g) •	No	pulmonary	embolus
■ Firefighter Autopsy Protocol ■ 96 ■ I: Background ■ NIOSH REP. # DATE OF INCIDENT Title CAUSE OF DEATH AUTOPSY AUTOPSY COMMENTS PDF LINK F2006-18 Mar 31, 2006 Firefighter/emergency	 medical technician (ff/emt) suffers	sudden	death	while	 on-duty—South Carolina Per	death	certificate:	 “probable cardiac arrhythmia,” due to “seizures,” due to “epilepsy.” Per	autopsy	findings:	 “sudden	unexplained	 ventricular	arrhythmia	 or possible seizure.” Yes •	Normal	sized	heart,	350	grams	(normal	<	400	grams)	 •	No	plaque,	atherosclerosis,	or	blockages	in	any	of	the	 coronary arteries •	Two	coronary	arteries	(the	left	anterior	descending	and	 the	right	coronary	artery)	had	“small	diameters	within	their	 distal distribution” •	No	microscopic	evidence	of	cardiomyopathy	(a	medical	 condition	that	is	associated	with	an	increased	risk	of	sud- den cardiac death) •	No	evidence	of	a	pulmonary	embolus	(blood	clot	in	the	 lung arteries) •	No	evidence	of	an	intra-cranial	hemorrhage	(stroke) •	Negative	blood	drug	test	for	illegal	 •	Positive	blood	drugs	test	for	methobarbitol	and	 phenobarbital. 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	cause	 of death, therefore the county coroner concluded the FF/ EMT	most	likely	died	of	a	“sudden	unexplained	ventricular	 arrhythmia or possible seizure.” F2006-17 May 03, 2006 Firefighter	suffers	heart	 attack	during	firefighting	 operation and dies 40 days later—Georgia “Hemodynamic failure” due to “healing and remote myocardial infarctions (mis)” due to “atherosclerotic coronary artery disease (CAD)” Yes •	Atherosclerotic	CAD – Normal-sized heart at 400 grams – Old (healed) MI in the lateral portion of the left ventricle – Recent MI in the anteroseptal portion of the left ventricle –	 Atherosclerotic	lesions	(50%—60%	blockage)	in	most	 of the coronary arteries –	 Recent	plaque	hemorrhage	and	rupture	of	the	proxi- mal portion of the LAD •	No	valve	abnormalities •	No	chamber	dilation	or	hypertrophy	
■ Firefighter Autopsy Protocol

■ 97

■ I: Background

■

NIOSH 

REP. #

DATE OF

 INCIDENT Title CAUSE OF DEATH AUTOPSY AUTOPSY COMMENTS

PDF 

LINK

F2006-16 Jul 07, 

2005

Fire apparatus operator suffers sudden cardiac death after responding to 12 calls—Georgia

“Cardiac dysrhythmia due to atherosclerotic coronary artery disease (CAD)”

Yes •	Atherosclerotic	CAD

–	 Variable	calcific	atherosclerosis	of	the	left	anterior	

descending	coronary	artery	with	a	90%	blockage

–	 Variable	calcific	atherosclerosis	of	the	right	coronary	

artery	with	a	40%	blockage

–	 Cardiomegaly	(enlarged	heart:	heart	weighed	660	

grams 

–	 Left	ventricular	hypertrophy

•	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.”

•	No	evidence	of	thromboemboli	in	the	pulmonary	arteries•	Negative	drug	and	alcohol	tests

F2006-15 Apr 03, 

2006

Assistant chief suffers a stroke during training and dies—Texas

Brain death due to brain aneurysm

No Perform	an	autopsy	on	all	duty-related	firefighter	fatalites

F2006-13 Jan 14, 

2006

Volunteer	firefighter	suffers	sudden cardiac death about 50	minutes	after	fighting	a	grass	fire—Kansas

Probable heritable cardiac arrhythmia (Brugada Syndrome)

Yes •	Probable	heritable	cardiac	arrhythmia	(Brugada	

Syndrome)

•	Cardiomegaly	(heart	weighed	478	grams	[g];	normal	

range is 261-455 g)

•	Coronary	arteries	free	of	significant	atherosclerosis	or	

thrombus

•	No	pulmonary	embolus
■ Firefighter Autopsy Protocol

■ 98

■ I: Background

■

NIOSH 

REP. #

DATE OF

 INCIDENT Title CAUSE OF DEATH AUTOPSY AUTOPSY COMMENTS

PDF 

LINK

F2006-12 Nov	15,	

2004

Career battalion chief suffers sudden cardiac death at his desk—Kansas

Atherosclerotic cardiovascular	disease	(CVD)

Yes •	Cardiomegaly	(enlarged	heart):	heart	weighed	534	grams

•	Left	ventricular	hypertrophy	(LVH)•	Essentially	normal	endocardium,	myocardium,	and	epicardium tissue.

•	Two	vessel	coronary	artery	disease	(CAD)	with	50%-75%	

narrowing	of	the	left	anterior	descending	and	right	coronary	arteries	by	atherosclerotic	plaque

•	No	evidence	of	thrombosis•	Mild	fibrous	thickening	of	the	cusps	of	the	aortic	valve•	No	evidence	of	a	pulmonary	embolus.

F2006-09 Jan 28, 

2006

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

“Arteriosclerotic cardiovascular	disease	(CVD)”	as	the	immediate cause of death and	“hypertensive	cardiomyopathy” as a significant	condition

Yes •	Cardiomegaly	(heart	weighing	450	grams	[g];	normal	

weight	is	<400	g)

•	Arteriosclerotic	CAD•	Mild	concentric	left	ventricular	hypertrophy	with	wall	

thickness	being	1.9	centimeters	[cm];	normal	thickness	is	0.6-1.1 cm

•	A	discrete	2	cm	x	1	cm	scar	in	the	subendocardial	and	

deep	myocardium	of	the	left	ventricular	wall	(proximal	medial posterior) suggesting a remote (old) heart attack (myocardial	infarction	[MI])

•	No	valvular	disease

•	No	sign	of	a	pulmonary	embolus	(blood	clot	in	the	lung)•	No	evidence	of	smoke	inhalation•	Carboxyhemoglobin	(COHb)	level	(measure	of	carbon	

monoxide	in	the	blood)	of	3.7%	(normal	for	smokers)
■ Firefighter Autopsy Protocol ■ 99 ■ I: Background ■ NIOSH REP. # DATE OF INCIDENT Title CAUSE OF DEATH AUTOPSY AUTOPSY COMMENTS PDF LINK F2006-08 Nov	21,	 2005 Firefighter/Emergency	 medical technician suf- fers an acute myocardial infarction and dies 3 days later—Pennsylvania Per	death	certificate:	 “atherosclerotic heart disease” due to “acute myocardial infarction” as the cause of death. Perautopsy: “arterio- sclerotic	cardiovascular	 disease	(CVD)	with	 acute myocardial infarction;	pulmonary	 emboli” as the cause of death.

Yes •	Arteriosclerotic	CVD

•	Extensive	left	ventricular	MI•	Cardiomegaly	(enlarged	heart:	heart	weighed	550	grams	

[g]

•	Biventricular	hypertrophy•	Microscopic	examination	revealed	an	“early	thrombus	at	

the	site	of	the	ventricular	infarction”

•	Microscopic	evidence	of	thromboemboli	in	the	pulmonary	

arteries	with	pulmonary	infarction

F2006-07 Feb 21, 

2006

Two	volunteer	firefighters	die	when	struck	by	exterior	wall	collapse	at	a	commercial	building	fire	overhaul—Alabama

Multiple blunt-force trauma

Yes None

F2006-05 Nov	28,	

2005

Career	firefighter	dies	after	engine	he	was	driving	collides	with	a	tractor	trailer—Alabama

Blunt-force injuries. Not mentioned None

F2006-04 Oct 24, 

2005

Career lieutenant suffers sudden cardiac death at his station after making multiple runs during the day—Tennessee

Cardiac arrhythmia as the immediate cause of death due to hypertensive	cardiovascular	disease

Yes •	Cardiomegaly	(enlarged	heart)	based	on	a	weight	of	700	

grams

•	Left	ventricular	hypertrophy•	Microscopic	examination	of	the	left	ventricular	myocardium	(three	sections)	showed	myocyte	hypertrophy	and	

small	foci	of	subendocardial	interstitial	fibrosis	(findings	consistent	with	hypertensive	heart	disease)

•	Patent	coronary	arteries	with	mild	atherosclerosis	and	no	

intracoronary thrombosis

•	Normal	heart	valves•	No	pulmonary	embolus
■ Firefighter Autopsy Protocol

■ 100

■ I: Background

■

NIOSH 

REP. #

DATE OF

 INCIDENT Title CAUSE OF DEATH AUTOPSY AUTOPSY COMMENTS

PDF 

LINK

F2006-03 Nov	05,	

2005

Firefighter	suffers	sudden cardiac death during	fire	fighting	operations—California

Atherosclerotic cardiovascular	disease	(CVD)

Yes •	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

•	Enlarged	heart	(cardiomegaly):	heart	weighed	450	grams	(g)•	No	evidence	of	a	premortem	pulmonary	thromboemboli	

(i.e., blood clots in the lungs)

•	Negative	carboxyhemoglobin	test•	Negative	drug	and	alcohol	tests

F2006-02 May 27, 

2005

Lieutenant suffers sudden cardiac death after scba training—Florida

Atherosclerotic cardiovascular	disease	(CVD)

Yes •	Atherosclerotic	CVD

•	Moderate	cardiomegaly	(enlarged	heart:	heart	weighed	

430 grams

•	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))

•	Acute	pulmonary	edema•	No	evidence	of	thromboemboli	in	the	pulmonary	arteries•	Negative	carboxyhemoglobin	test•	Negative	drug	and	alcohol	tests

F2006-01 May 13, 

2004

Fire chief suffers sudden death during training—Alabama

Accidental multiple drug	intoxication

Yes •	Enlarged	heart	(cardiomegaly):	heart	weighed	520	grams	

(g)

•	Mild	atherosclerosis•	Moderate	to	marked	pulmonary	edema•	No	evidence	of	thrombus	in	the	coronary	arteries•	No	evidence	of	thrombo-emboli	in	the	pulmonary	arteries•	Positive	blood	tests	for	diazepam	(Valium®),	morphine	

(MS	Contin®),	venlafaxine	(Effexor®)	and	methocarbamol	(Robaxin®)

•	Positive	urine	test	for	gabapentin	(Neurontin®)•	No	microscopic	examinations	were	performed.
■ Firefighter Autopsy Protocol

■ 101

■ I: Background

■

NIOSH 

REP. #

DATE OF

 INCIDENT Title CAUSE OF DEATH AUTOPSY AUTOPSY COMMENTS

PDF 

LINK

F2005-35 Dec 02, 

2005

Career captain dies and the driver/operator	and	a	firefighter	are	severely	injured	in	apparatus crash—Louisiana

Multiple blunt-force trauma and compressed	asphyxiation

Yes None

F2005-34 Nov	07,	

2005

Career	firefighter	killed	while	riding manlift to assess a silo fire—Missouri

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

Not mentioned None

F2005-33 Nov	04,	

2005

Captain suffers pulmonary embolism during response to a medical call and later dies—New	York

Pulmonary emboli (PE) due to probable deep vein	thrombosis	(DVT)

Yes •	Evidence	of	diffuse	PE	in	both	lungs

Swollen	right	lower	legMild	hypertensive	CVD:–	 No	significant	coronary	artery	atherosclerosis–	 Left	ventricle	walls	slightly	thickened/	hypertrophied	

(1.6	centimeters	[cm])	(normal	is	0.6	cm–1.1	cm)1

–	 Right	ventricle	walls	slightly	thickened/hypertrophied	

(0.6 cm)

•	Cardiomegaly	(enlarged	heart):	heart	weighed	540	grams	

(g)	(normal	is	<400	g)3

•	No	microscopic	examination	of	the	heart	muscle	was	

performed

•	Negative	drug	screen
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F2005-32 Mar 16, 

2005

Sergeant suffers sudden cardiac death during training—Kentucky

Per	death	certificate:	“acute myocardial infarction (MI)”Per autopsy: “hypertensive/ischemic	cardiovascular	disease	(CVD)”	as	the	cause	of	death

Yes •	Hypertensive/ischemic	CVD

•	Enlarged	heart	(cardiomegaly):	heart	weighed	500	grams	

(g)	(normal	is	<400	g)1

•	Biventricular	hypertrophy

–	 Right	ventricle	measured	1	centimeter	(cm)	(normal	is	

0.3-0.5 cm)2

–	 Left	ventricle	measured	3	cm	(normal	is	0.76–0.88	

cm)3 (normal echocardiographic measurement is 0.6–1.1 cm)4

•	Mitral	valve	showed	thickening	of	chordae	tendineae•	No	evidence	of	thrombus•	No	evidence	of	thrombo-emboli•	Negative	drug	and	alcohol	testsMicroscopic	examinations	revealed	the	following:•	Diffuse	myocardial	fibrosis•	Old	MI	of	lateral	wall	of	left	ventricular	free	wall,	posterior	

aspect	of	left	intraventricular	septum

•	Extensive	old	MI	of	left	ventricular	free	wall•	Acute	pulmonary	congestion

F2005-30 May 31, 

2005

Firefighter	suffers	sudden	cardiac death during physical fitness	training—New	Jersey

“Calcific	sclerosis	of	the	aortic	valve	with	aortic stenosis” as the cause	of	death,	with	“atherosclerotic coronary artery disease (CAD)”	as	a	significant	condition

Yes •	Calcific	sclerosis	of	the	aortic	valve	with	aortic	stenosis

•	Enlarged	heart	(cardiomegaly):	heart	weighed	580	grams	

(g)	(normal	is	<400	g)1

•	Atherosclerotic	CAD•	Severe	narrowing	(75%)	of	the	left	anterior	descending	

coronary artery

•	No	evidence	of	a	premortem	pulmonary	thromboemboli

Negative	drug	and	alcohol	tests	

F2005-29 Aug 27, 

2005

Volunteer	firefighter/rescue	diver	dies	in	training	incident	at	a	quarry—Pennsylvania

Drowning Not mentioned None
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F2005-27 Jun 21, 

2005

Volunteer	fire	chief	dies	from	injuries sustained during a tanker	rollover—Utah

Blunt force injuries to the head and torso

Not mentioned None

F2005-26 May 19, 

2005

Recruit	firefighter	suffers	heat	

stroke	during	physical	fitness	training and dies nine days later—Florida

Severe	heat	stroke	with	multisystem	organ	failure

No None

F2005-25 Feb 23, 

2005

Fire chief suffers sudden cardiac death at home after performing apparatus maintenance and conducting training—Texas

Severe	three	vessel	atherosclerotic coronary artery disease (CAD)

Yes •	Atherosclerotic	CAD:

•	Three	vessel	focal	severe	atherosclerotic	CAD•	Right	ventricle	chamber	mildly	dilated•	Cardiomegaly	(enlarged	heart):	heart	weighed	460	grams	

(normal	<	400	grams)1

•	No	pulmonary	embolism•	No	evidence	of	a	dissecting	aortic	aneurysm
■ Firefighter Autopsy Protocol ■ 104 ■ I: Background ■ NIOSH REP. # DATE OF INCIDENT Title CAUSE OF DEATH AUTOPSY AUTOPSY COMMENTS PDF LINK F2005-24 Feb 06, 2005 Firefighter	dies	after	respond- ing	to	a	call—New	York “Acute	intoxication	 by the combined effects	of	propoxy- phene	(Darvon®)	 and cyclobenzaprine (Flexeril®)”	as	the	 cause of death and “hypertension” as another condition. The	NIOSH	investiga- tor, like the medical examiner,	concluded	 the FF died due to a drug	intoxication,	but	 cannot rule out the possibility of a cardiac arrhythmia associated with	his	hypertensive	 heart disease and sub- sequent	left	ventricular	 hypertrophy	(LVH). Yes •	Acute	intoxication	by	the	combined	effects	of	propoxy- phene and cyclobenzaprine CAD: –	 Propoxyphene	(Darvon®)	blood	level	of	3.3	micro- grams	per	milliliter	(mcg/mL)	and	Norpropoxyphene	 blood	level	of	9.0	mcg/mL –	 Cyclobenzaprine	(Flexeril®)	blood	level	of	90	nano- grams per milliliter (ng/mL) and Norcyclobenzaprine with	a	positive	blood	level •	Hypertensive	cardiovascular	disease: –	 Left	ventricular	hypertrophy	(LVH)(left	ven- tricle	wall	thickness	1.5	centimeters	[cm])	[normal	 0.6cm–1.1cm])2 –	 Cardiomegaly	(heart	weight	500	grams	[normal	<	400	 grams])3 •	No	evidence	of	atherosclerotic	coronary	artery	disease	 (CAD) •	No	evidence	of	pulmonary	embolus Microscopic	examination	of	the	heart	revealed	myocyte	 hypertrophy	(consistent	with	mild	hypertensive	cardio- myopathy) but no infarcts or myocarditis. The autopsy did not	mention	“myocytes	in	disarray,”	which	is	diagnostic	of	 hypertrophic cardiomyopathy F2005-23 Mar 29, 2005 Firefighter/paramedic	suffers	 a dissection of his aorta while	participating	in	physical	 fitness	training—Texas “Aortic dissection and	its	sequelae”	 with	“Hypertensive	 cardiovascular	 disease” being another significant	condition Yes •	Extent	of	the	dissection:	from	proximal	left	and	right	 coronary artery at the aortic root to the right common iliac artery •	Cardiomegaly	(a	large	heart) •	Concentric	left	ventricular	hypertrophy •	No	atherosclerotic	coronary	artery	disease •	Negative	blood	tests	for	illicit	drugs	or	alcohol
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F2005-22 Jan 09, 

2005

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

Mitral	valve	failure Yes •	Mitral	valve	prolapse—undulating	leaflets	with	obvious	

hooding and thin, elongated chordae tendineae consistent with	prolapse

•	Cardiomegaly—(530	grams,	normal	<	400	grams)	with	

mild	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) 

•	Microscopic	examination	of	the	heart	muscle	showed	

widening	of	the	individual	myocytes	and	large,	irregular,	“boxcar”	nuclei;	focal	increased	interstitial	fibrosis	was	present	within	the	posterior	left	ventricle

•	Widely	patent	coronary	arteries	without	evidence	of	

significant	atherosclerosis	or	thrombosis

F2005-21 Feb 21, 

2005

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

Left anterior descending coronary artery thrombosis

Yes •	Attached	thrombus	(blood	clot)	with	complete	occlusion	

and focally a pinpoint lumen for about 1.5 cm in the proximal	left	anterior	descending	coronary	artery

•	Chronic	myocardial	ischemia

–	 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)

–	 Heart	weight	450	grams	(normal	<	400	grams)–	 Left	ventricular	walls	measure	1.4	centimeters	(cm)	in	

thickness (normal is 0.6 to 1.1 cm)

F2005-20 Jun 23, 

2005

Firefighter/Emergency	medical technician dies during the 

night	at	fire	station—Arizona

“Oxycodone	intoxication” as the cause of	death	with	“mild	thickening of the mitral valve”	and	“mild	diffuse	nephrosclerosis” as other conditions.

Yes •	Oxycodone	intoxication	(blood	level	of	0.85	milligrams	

per	liter	[mg/L])(therapeutic	blood	levels	are	less	than	0.1 mg/L)2

•	Mild	thickening	of	the	mitral	valve
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F2005-19 Jun 19, 

2004

Reserve	firefighter	suffers	sudden	cardiac	death	while	working	on	a	fuel	reduction	crew—Arizona

Atherosclerotic heart disease

Yes •	Atherosclerotic	heart	disease:

–	 99%	occlusion	of	left	anterior	descending	coronary	

artery

–	 99%	occlusion	of	right	coronary	artery–	 Left	ventricular	hypertrophy	(wall	thickness	1.4	centimeters	[cm]	[normal	0.6cm–1.1cm])1

•	Chronic	pyelonephritis,	left	kidney•	Negative	drug	and	alcohol	tests

F2005-18 Aug 16, 

2004

Airport	firefighter	suffers	sudden	cardiac	death	while	on duty—South Carolina

Acute myocardial ischemia secondary to a cardiac arrhythmia of unknown	etiology

Yes •	Enlarged	heart	(cardiomegaly)	weighing	460	grams	

(normal	<	400	grams)–	 Left	ventricular	hypertrophy	(wall	thickness	1.3	centimeters	[cm]	[normal	0.6	cm–1.1	cm])	–	 Interventricular	septum	hypertrophy	(wall	thickness	1.5	

cm	[normal	0.6	cm–1.1	cm])

•	Right	coronary	artery	bridging•	Right	ventricle	mildly	dilated•	Microscopic	findings

– Histological signs of ischemia–	 Scattered	myocytes	indicative	of	hypertrophy

F2005-17 Apr 20, 

2005

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

“Acute subarachnoid hemorrhage” due to “rupture of sacular cerebral aneurysm” as the	cause	of	death	with	“focal coronary artery atherosclerosis” as a significant	condition

Yes •	Sacular	aneurysm	with	rupture,	basilar	artery

– Acute subarachnoid hemorrhage, large amount, base 

of brain

•	Coronary	artery	atherosclerosis,	focal	and	severe

–	 Severe	narrowing	(90%)	of	the	left	anterior	descending	

coronary artery

•	Negative	drug	and	alcohol	tests
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F2005-16 Jan 21, 

2004

Captain suffers an acute aortic dissection after responding	to	two	alarms	and	subsequently	dies	due to hemopericardium—Pennsylvania

“Hemopericardium” due to an “aortic rupture” and “aortic dissection.”

Yes •	Hemopericardium	with	575	milliliters	(mL)	of	primarily	

unclotted blood in pericardium

•	Rupture	of	the	intrapericardial	portion	of	the	ascending	

thoracic aorta

•	Thoracoabdominal	aortic	dissection	extending	from	the	

ascending	aorta	to	the	distal	abdominal	aorta	(4	cm	above	

the iliac bifurcation

•	History	of	hypertension

–	 Cardiomegaly,	heart	weighing	560	grams	(normal	<	

400 grams)▪	Moderate	cardiac	left	ventricular	hypertrophy

•	Minimal	coronary	artery	disease	(25%	stenosis	of	the	left	

anterior descending and right coronary arteries)

•	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)

•	Morbid	obesity,	with	a	body	mass	index	of	51.9	kilograms/

meters2

F2005-15 Apr 23, 

2005

Career	firefighter	fatally	injured in fall from apparatus—Texas

Blunt-force head injuries

Yes None

F2005-14 Apr 22, 

2004

Lieutenant suffers sudden cardiac death at the scene of	a	structure	fire—South	Carolina

“Acute myocardial infarction”	due	to	“viral	endocarditis”

No Perform	an	autopsy	on	all	onduty	firefighter	fatalities

F2005-13 Apr 18, 

2005

A	volunteer	firefighter	and	volunteer	assistant	lieutenant die after a smoke explosion	at	a	townhouse	complex—Wyoming

Smoke inhalation and thermal	burns	to	over	50%	of	their	bodies

Not mentioned None

F2005-12 Aug 23, 

2004

Career	firefighter/EMT	dies	in	

ambulance crash—Florida

Blunt-force head trauma

Not mentioned None
■ Firefighter Autopsy Protocol ■ 108 ■ I: Background ■ NIOSH REP. # DATE OF INCIDENT Title CAUSE OF DEATH AUTOPSY AUTOPSY COMMENTS PDF LINK F2005-11 Dec 13, 2004 Fire chief suffers sudden cardiac	death	while	return- ing	to	the	fire	station	after	a	 structure	fire—Georgia “cardiorespiratory arrest”	due	to	“ASCVD”	 (atherosclerotic cardio- vascular	disease) No Perform	an	autopsy	on	all	onduty	firefighter	fatalities F2005-10 Feb 15, 2005 Lieutenant suffers a heart attack	while	driving	a	squad	 truck and dies four days later—Georgia 	“Anoxic	encephal- opathy” due to “sudden cardiac arrest” due to “atherosclerotic cardio- vascular	disease”	as	 the cause of death Yes •	Enlarged	heart	(cardiomegaly):	heart	weighed	450	grams	 •	Ischemic	heart	disease: –	 Moderate	narrowing	(40%-50%)	of	the	right	coronary	 artery –	 Mild	narrowing	(30%–40%)	of	the	left	anterior	 descending coronary artery •	No	evidence	of	pulmonary	thromboemboli •	Negative	drug	and	alcohol	tests F2005-09 Feb 19, 2005 Career	fire	captain	dies	 when	trapped	by	partial	roof	 collapse	in	a	vacant	house	 fire	–	Texas Smoke inhalation and thermal injuries Not mentioned, but postmortem carboxyhemo- globin	was	 reported	at	26% None F2005-08 Oct 20, 2004 Fire chief suffers sudden cardiac death after respond- ing	to	a	motor	vehicle	 crash—Texas “arrhythmia” as the cause of death due to “coronary artery disease”	(CAD)	with	 “atrial	fibrillation	and	 sleep apnea” as other significant	conditions No Perform	an	autopsy	on	all	onduty	firefighter	fatalities F2005-07 Feb 13, 2005 Career captain electrocuted at the scene of a residential structure	fire—California Electrocution Not mentioned None F2005-06 Jan 07, 2005 Fire	equipment	operator	 suffers a heart attack at the scene of a medical call and dies in the hospital thirteen days later—South Carolina “Myocardial infarction” due to “renal failure” due to “stroke” No Perform	an	autopsy	on	all	onduty	firefighter	fatalities F2005-05 Jan 20, 2005 Career captain dies after run- ning out of air at a residential structure	fire—Michigan Smoke and soot inhalation	with	a	 carboxyhemoglobin	 level	of	22.7% Not mentioned None
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F2005-04 Jan 23, 

2005

Career	firefighter	dies	while	exiting	residential	basement	fire—New	York

Smoke inhalation and burns of the head, torso and upper extremities	

Yes Note:	Carboxyhemoglobin	level	was	24%	saturation;	third	

degree	burns	on	approximately	63%	of	body	surface	area

F2005-03 Jan 23, 

2005

Career lieutenant and career firefighter	die	and	four	career	firefighters	are	seriously	injured during a three alarm apartment	fire—New	York

Mass trauma of the head, torso and extremities	with	multiple contusions of the	extremities.

Not mentioned None

F2005-02 Dec 20, 

2004

One probationary career firefighter	dies	and	four	career	firefighters	are	injured	at	a	two-alarm	residential	structure	fire—Texas

Thermal injuries and smoke inhalation

Not mentioned None

F2005-01 Aug 14, 

2004

Career	firefighter	dies	after falling from tailboard and	being	backed	over	by	engine—California

Multiple blunt-force injuries

Not mentioned None
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F2004-46 Feb 23, 

2004

Firefighter	collapses	and	dies	while	assisting	with	fire	suppression	efforts	at	a	residential	fire—Ohio

“Arteriosclerotic and hypertensive	heart	disease” as the immediate cause	of	death	with	“morbid obesity” as a contributory condition

Yes •	Coronary	artery	disease	(CAD)

–	 Atherosclerotic	occlusions	of	the	native	coronary	arteries (remote)–	 Two	vessel	coronary	artery	bypass	graft	procedure	

(remote)

–	 Occlusion	of	the	lower	coronary	artery	bypass	graft	

(remote)

–	 Open	upper	coronary	artery	bypass	graft	but	with	

moderate	calcific	atherosclerosis

–	 Myocardial	infarct	(heart	attack)	involving	the	anterior	

left	ventricle	and	interventricular	septum	(remote)

•	Cardiomegaly	(enlarged	heart)	weighing	780	grams	

(normal	<	400	grams)

•	Mild	narrowing	of	the	arteries	leading	to	the	kidneys	

(arteriolonephrosclerosis),	which	is	consistent	with	the	diagnosis of hypertension

•	Morbid	obesity;	at	72	inches	tall,	the	FF	weighed	300	

pounds	for	a	body	mass	index	(BMI)	of	40.7.

•	A	carboxyhemoglobin	(COHb)	measurement	of	<5%	

saturation. (Since the FF did not regain a heartbeat during resuscitation	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.)

•.	Negative	urine	drug	screen•	Skull	fractures

F2004-45 Feb 04, 

2004

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

Arteriosclerotic cardiovascular	disease(CAD) No Perform	an	autopsy	on	all	onduty	firefighter	fatalities
■ Firefighter Autopsy Protocol ■ 111 ■ I: Background ■ NIOSH REP. # DATE OF INCIDENT Title CAUSE OF DEATH AUTOPSY AUTOPSY COMMENTS PDF LINK F2004-43 Apr 27, 2004 One	part-time	firefighter	dies	 and another is seriously injured	when	two	fire	engines	 collide at an intersection while	responding	to	a	 fire—IIllinois Craniocerebral injuries with	aspiration	of	blood	 within	the	lungs Yes None F2004-42 Sep 26, 2004 Assistant chief suffers sudden cardiac death during response to boat fire—Wisconsin Per	death	certificate,	 “severe	arterioscle- rotic	cardiovascular	 disease” as the cause of	death	and	“previous	 myocardial infarction” as	other	significant	 condition. Perautopsy: “severe	coronary	artery	 disease due to arterio- sclerotic	cardiovascular	 disease” as the cause of death Yes •	Ischemic	heart	disease •	Heavily	calcified	coronary	arteries	with	severe	atheroscle- rotic	plaquing •	Total	occlusion	of	the	mid	right	coronary	artery •	Significant	narrowing	(60%-95%)	of	the	left	anterior	 descending coronary artery •	Mild	plaquing	in	the	left	circumflex	coronary	artery •	Cardiomegaly	(enlarged	heart)	–	heart	weighing	450	 grams (normal less than 400 grams) •	A	large	area	of	white	fibrosis	with	thinning	of	the	posterior	 wall	of	the	left	ventricle •	Severe	dilatation	of	the	heart	chambers •	No	evidence	of	pulmonary	thromboemboli •	Negative	drug	and	alcohol	tests •	Carboxyhemoglobin	(carbon	monoxide)	test	was	not	 performed F2004-41 Jun 08, 2004 Assistant chief suffers heart attack and dies after complet- ing	a	walk	test—Montana “Sudden arrhythmia” as the immediate cause of death and “acute coronary artery thrombosis” as a contributing factor Yes •	Enlarged	heart	(cardiomegaly):	heart	weighed	470	grams	 (normal	<	400	grams)	Ischemic	heart	disease: – Thrombus causing total occlusion in the right coronary artery –	 Significant	narrowing	(80%	to	90%)	of	the	left	anterior	 descending coronary artery –	 Minor	atherosclerosis	in	the	circumflex	artery •	No	evidence	of	pulmonary	thromboemboli •	Negative	drug	and	alcohol	tests
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F2004-40 Sep 12, 

2004

Career	helitack	firefighter	dies	in	burnover	during	an	initial	attack	at	a	wildland	fire	operation—California

Inhalation of products of combustion

Yes None

F2004-38 Mar 13, 

2004

Probationary	firefighter	suffers sudden cardiac death during maze drill—Connecticut

Sudden death associated	with	rheumatic	heart disease

Yes Valvular	heart	disease:

•	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)

•	Aortic	valve	fusion	of	the	right	and	left	cusps

Normal heart size (380 grams), yet mild left atrial enlargement and dilatation

•	No	significant	coronary	artery	disease	and	no	recent	or	

remote	evidence	of	a	heart	attack

•	Drug,	alcohol,	and	carbon	monoxide	tests	were	negative

F2004-37 Apr 08, 

2004

Volunteer	chief	dies	and	two	firefighters	are	injured	by a collapsing church facade—Tennessee

Multiple blunt-force trauma and thermal injuries

Not mentioned None

F2004-36 Mar 11, 

2004

Career	firefighter	drowns	while	conducting	training	dive—New	Hampshire

Drowning Not mentioned None
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F2004-35 Jun 17, 

2004

Firefighter	suffers	sudden	cardiac	death	at	his	fire	station—Georgia

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

Yes •	Hypertensive	heart	disease

–	 Severely	enlarged	heart	(cardiomegaly)	weighing	

840	grams	(normal	<	400	grams),	which	is	in	the	95th	percentile for body

–	 Markedly	severely	thickened	left	wall	of	the	heart	

(concentric	hypertrophy	of	the	left	ventricle)

– Moderate hardening of the kidney due to high 

blood pressure in the small arteries of the kidneys (arterionephrosclerosis)

•	Mild	to	moderate	heart	disease	(atherosclerotic	plaque	

blockage of three coronary arteries)–	 Approximately	40%–50%	blockages	(stenosis)	in	each	

of	the	left	anterior	descending,	circumflex,	and	right	coronary arteries.

•	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)

•	Microscopic	examination	of	the	kidney	showed	kidney	

cancer (papillary renal cell carcinoma)

His	blood	carboxyhemoglobin	level	(a	test	of	carbon	monoxide	exposure)	was	not	checked	due	to	no	exposure	to	fire	

smoke	during	his	shift.	No	drug	screen	was	performed

F2004-32 May 13, 

2004

Volunteer	firefighter	suffers	cardiac	arrest	while	battling	a	structure	fire—New	York

Acute myocardial infarction (heart attack) with	physical	exertion in a hot, humid environment	listed	as	a	contributing cause

No Perform	an	autopsy	on	all	on-duty	firefighter	fatalities

F2004-31 Aug 27, 

2003

Volunteer	firefighter	suffers	heart	attack	while	battling	structure	fire	and	dies	6	days	later—New	York

Acute myocardial infarction

No Perform	an	autopsy	on	all	onduty	firefighter	fatalities
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F2004-30 Mar 25, 

2004

Firefighter	collapses	and	suffers sudden cardiac death after	responding	to	a	vehicle	fire—Kentucky

A	cardiac	event	

(arrhythmia) due to hypertensive	and	atherosclerotic cardiovascular	disease

Yes •	Cardiomegaly	(an	enlarged	heart)	weighing	560	grams	

(normal is less than 400 grams)1

•	Dilated	right	ventricle•	Scar	of	white	fibrous	tissue	interlacing	with	brown	myocardium	(evidence	of	a	remote	[old]	myocardial	infarction	

[heart	attack])

•	Moderate	to	severe	coronary	artery	atherosclerosis	(left	

and right)

•	Possible	thrombus	in	the	right	coronary	artery

F2004-28 May 31, 

2002

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

Coronary atherosclerosis

Yes •	Atherosclerotic	coronary	artery	disease	(CAD)

•	Ischemic	heart	disease:

–	 Near	complete	occlusion	of	the	most	proximal	branch	

of the left anterior descending coronary artery

–	 90%	stenosis	in	the	left	circumflex	coronary	artery–	 70%	stenosis	in	the	right	coronary	artery– No superimposed acute thromboses or recent 

hemorrhages

–	 Enlarged	heart	(cardiomegaly)	weighing	510	grams	

(normal	<	400	grams)

–	 Left	ventricular	hypertrophy	(wall	thickness	1.7	centimeters	[cm]	[normal	0.6cm-1.1cm])–	 Interventricular	septum	hypertrophy	(wall	thickness	

1.9cm	[normal	0.6cm-1.1cm])

•	Mild	to	moderate	perivascular	fibrosis	of	the	heart	muscle	

on	microscopic	examination

•	No	evidence	of	a	pulmonary	embolus•	Vitreous	(eye)	chemistries	showed	elevations	in	sodium	

and	chlorine	consistent	with	dehydration

•	Negative	drug	and	alcohol	tests
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F2004-26 Feb 01, 

2003

Firefighter-engineer	suffers	sudden	cardiac	death	while	performing	strenuous	fire	station maintenance—California

“Atherosclerotic coronary artery disease” as the immediate cause	of	death	with	“hypertension”

Yes •	Cardiomegaly	(an	enlarged	heart)	weighing	510	grams	

(upper limit of normal is 400 grams)

•	Moderate	biventricular	dilatation	(LV—4	centimeters	(cm)	

internal	diameter;	RV-	4.0	X	4.5	cm	internal	diameter)

•	Atherosclerotic	coronary	artery	disease

–	 75%	stenosis	of	the	right	coronary	artery	with	a	right	

dominant coronary artery system

–	 75%	stenosis	in	the	left	main	artery–	 90%	stenosis	in	the	left	anterior	descending	artery–	 90%	stenosis	in	the	left	circumflex	artery– No coronary artery thrombus (blood clot)

•	No	pulmonary	emboli	(blood	clot	in	the	lung	vasculature)•	Negative	drug	screen

F2004-25 Mar 22, 

2003

Volunteer	firefighter	suffers sudden cardiac death 

during	fire	suppression	at	a	structural	fire—Indiana

Acute,	occlusive	thrombosis of the left circumflex	coronary	artery secondary to coronary artery atherosclerosis

Yes •	Moderate	to	severe	coronary	atherosclerosis	as	detailed	

below:–	 Acute	occlusive	thrombus	present	within	the	mid	to	

distal	portion	of	the	left	circumflex	coronary	artery

–	 80%-95%	stenosis	of	the	distal	left	anterior	descending coronary artery and the right posterior descending 

coronary artery

–	 Intraplaque	hemorrhage	at	the	mid	portion	of	the	left	

anterior descending coronary artery

–	 40%-60%	stenosis	of	the	mid	portions	of	left	anterior,	

left	circumflex,	and	right	coronary	arteries

–	 Cardiomegaly	(enlarged	heart	weighing	550	grams,	

normal is less than 400 grams)

–	 Extensive	biventricular	dilatation–	 Concentric	left	ventricular	hypertrophy	(LVH)

•	Negative	drug	and	alcohol	test	results•	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.
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F2004-24 Apr 15, 

2004

Acting	fire	chief	suffers	heart attack after shift and dies—Alaska

Cardiac	event No Perform	an	autopsy	on	all	onduty	firefighter	fatalities

F2004-23 May 06, 

2002

Firefighter	suffers	unwitnessed sudden cardiac death after responding to mobile home	fire—South	Carolina

“Cardiac arrhythmia” as the immediate cause of death due to “stress	of	fighting	fire”	and	“cardiomegaly	with	dilatation” as contributing factors

Yes •	Cardiomegaly	(enlarged	heart)—weighing	576	grams	

(normal less than 400 grams)

•	Mild	atherosclerotic	cardiovascular	disease

–	 50%	occlusion	in	the	right	coronary	artery–	 50%	occlusion	in	the	left	anterior	descending	artery

•	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)

•	No	evidence	of	thrombi,	emboli,	or	fibrosis	on	gross	

pathology

•	Drug	and	alcohol	tests	were	negative•	Carboxyhemoglobin	(carbon	monoxide)	test	was	negative	

(less	than	10%)

•	Hepatosplenomegaly
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F2004-22 Apr 10, 

2004

Career	firefighter/Emergency	medical technician suffers sudden death 5 hours after participating in emergency response—South Carolina

Per	death	certificate:“atherosclerotic coronary artery disease” Per autopsy:“acute cocaine intoxication”	as	the	immediate cause of death	with	hypertension and atherosclerotic coronary heart disease as contributing factors.

Yes •	Extensive	atherosclerotic	coronary	artery	disease	with	

near total occlusion of three coronary arteries (left anterior descending,	first	diagonal,	and	right	coronary	artery

•	Acute	thrombus	(“acute	organizing	occlusive	fibrin	

thrombi”)

•	Old	myocardial	infarction	of	the	posterior	left	ventricle•	Cardiomyopathy

–	 Cardiomegaly	(an	enlarged	heart)	weighing	680	grams	

(upper limit of normal is 400 grams

–	 Hypertensive	cardiovascular	disease–	 Biventricular	dilatation

•	Acute	Cocaine	Intoxication

– Cocaine, Blood: 0.48 mg/L– Ecgonine methyl ester, blood: 0.67 mg/L– Benzoylecgonine, blood: 0/76 mg/L– Benzoylecgonine, urine: 4.9 mg/L
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F2004-21 Apr 18, 

2004

District chief suffers sudden cardiac death at home after experiencing	symptoms	consistent	with	heart	disease	at his station—Illinois

“Cardiac arrhythmia” as the cause of death due to “ischemic heart disease.”

Yes •	Marked	atherosclerosis	with

–	 60%	narrowing	of	the	right	coronary	artery–	 60%	narrowing	of	the	left	main	coronary	artery–	 90%	narrowing	of	the	left	anterior	descending	coronary	

artery

–	 90%	narrowing	of	the	circumflex	coronary	artery

•	Recent	thrombus	in	the	circumflex	coronary	artery,	resulting in total occlusion•	No	evidence	of	remote	myocardial	infarction	or	myocardial	fibrosis•	Mild	left	ventricle	hypertrophy	with:

–	 Left	ventricle	thickness	1.6	cm	(normal	is	0.76-0.88	

cm)

–	 Interventricular	septum	thickness	1.5	cm	(normal	

echographic measurement is 0.6-1.1 cm)

•	Cardiomegaly	(enlarged	heart)	weighing	420	grams	

(normal is less than 400 grams)

F2004-20 Dec 25, 

2003

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

“Multi-organ system dysfunction” due to “cardiac arrest” as the immediate cause of death	with	“aortic	dissection”	as	a	significant	condition

No Perform	an	autopsy	on	all	onduty	firefighter	fatalities

F2004-19 Apr 30, 

2004

Career	firefighter	dies	from	injuries sustained in fall from apparatus—Massachusetts

Blunt-force head trauma

Not mentioned None
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F2004-18 Jan 14, 

2004

Volunteer	firefighter	suffers	sudden cardiac death after participating in emergency responses—Maryland

Acute myocardial infarction

Yes •	Cardiomegaly	(an	enlarged	heart)	weighing	670	grams	

(upper limit of normal is 400 grams)

•	Four	chamber	dilatation•	Biventricular	hypertrophy•	Atherosclerotic	CAD•	Acute	plaque	rupture	and	thrombosis,	left	obtuse	marginal	

artery (recent heart attack)

•	Total	occlusion	of	mid	left	circumflex	artery	by	healed	

plaque	rupture	with	organized	and	recanalized	thrombus	(old, healed heart attack)

•	Healed	transmural	infarction,	posterolateral	left	ventricle	

at base

•	Diffuse	50%-90%	narrowing	of	coronary	arteries•	Penetrating	organized	thrombus,	right	atrium;	undetermined etiology

F2004-17 Mar 13, 

2004

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

Victim	#1:	asphyxiation	due to compression of the body by building debris;	blunt-force	trauma of the head, neck,	pelvis,	and	extremities	were	contributory causes of death.Victim	#2:	asphyxiation	due to compression of the body by building debris	with	blunt	force	trauma of the head and extremities.

Not mentioned None
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F2004-16 Dec 18, 

2003

Firefighter	dies	at	home	after	shift—Maryland

Arteriosclerotic cardiovascular	disease Yes The	carboxyhemoglobin	level	(a	measure	of	exposure	to	 carbon	monoxide)	was	not	measured

•	Severe	arteriosclerotic	cardiovascular	disease•	Old	subendocardial	infarct	of	left	ventricle•	Biventricular	dilatation•	Cardiomegaly	(heart	weighing	550	grams	with	normal	less	

than 400 grams4)

•	Aortic	atherosclerosis•	Cardiac	valves	were	unremarkable•	No	thrombi	were	found•	Drug	and	alcohol	tests	were	negative

F2004-15 Mar 03, 

2004

Forest	ranger/Firefighter	drowned	after	catastrophic	blow-out	of	right	front	tire—Florida

Drowning	with	no	evidence	of	traumarelated injuries

Not mentioned Postcrash blood alcohol content (BAC) and drug screening 

tests	were	negative

F2004-14 Apr 04, 

2004

Career	firefighter	dies	and	two	career	captains	are	injured	while	fighting	night	club	arson	fire—Texas

High	thermal	exposure Yes None

F2004-13 Apr 18, 

2003

Firefighters	suffers	fatal	pulmonary embolism after knee surgery	for	a	work-related	injury—North Carolina

Massive	pulmonary	embolism (PE) due to a	deep	vein	thrombus	(DVT)	due	to	knee	injury	that	was	treated	surgically

Yes •	Acute	pulmonary	embolus

•	Remote	pulmonary	emboli	(at	least	two	weeks	old)•	Deep	vein	thrombosis	in	the	right	leg•	Evidence	of	hypertensive	cardiovascular	disease•	Severe	focal	atherosclerotic	coronary	artery	disease•	No	ethanol	(alcohol)	or	salicylates	(aspirin)	detected

F2004-12 Jan 27, 

2004

Firefighter/Paramedic	dies	after performing physical fitness	training—Florida

Aortic	valve	stenosis Yes •	Aortic	valve	stenosis

•	Cardiomegaly	(heart	weighing	440	grams	with	normal	less	

than 400 grams)

•	Mild,	patchy,	interstitial	fibrosis	[as	determined	by	microscopic	examination]•	No	evidence	of	thromboemboli•	No	evidence	of	atherosclerosis
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F2004-11 Feb 13, 

2004

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

Multiple gunshot wounds

Not mentioned None

F2004-10 Feb 18, 

2004

Career	firefighter	dies	searching	for	fire	in	a	restaurant/lounge—Missouri

Smoke inhalation Not mentioned An	independent	toxicology	report	listed	the	victim’s	carbon	

monoxide	level	at	51%	saturation.	There	was	no	notable	trauma

F2004-09 Apr 02, 

2001

Firefighter/Driver/Engineer	suffers heart attack and dies at the end of his 24-hour shift—Hawaii

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

Yes •	Blood	clot	(thrombus)	in	one	of	the	coronary	arteries	(midleft anterior descending artery)

•	Moderate	to	severe	coronary	atherosclerosis•	A	large	heart	weighing	470	grams	(normal	<	400	grams)•	Thickened	left	wall	of	the	heart	(left	ventricular	

hypertrophy)

•	A	negative	drug	screen

F2004-08 Jan 21, 

2004

Firefighter	suffers	sudden	cardiac death after emergency recall—Massachusetts

“Acute sudden cardiac death syndrome” due to “acute myocardial infarction” as the immediate cause of death and “obesity” as	another	significant	condition

No Perform	an	autopsy	on	all	onduty	firefighter	fatalities

F2004-07 Nov	18,	

2002

Fire chief dies after performing	service	call—Connecticut “ASCVD”	(athero- sclerotic coronary 

vascular	disease)	as	the immediate cause of	death,	with	hyperlipidemia and smoking as contributing factors

Yes •	Arteriosclerosis,	with	95%	occlusion	of	the	left	main	

coronary	artery	and	90%	occlusion	of	the	right	coronary	artery

•	No	CO	level	taken
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F2004-06 Nov	17,	

2003

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

Occlusive	atherosclerotic	cardiovascular	disease

Yes •	Heart	weighing	400	grams

•	Atherosclerotic	cardiovascular	disease•	0.7	centimeter	area	of	increased	consistency	which	is	

slightly grayer than adjacent areas in the posterior lateral aspect	of	the	left	ventricular	wall	in	the	apical	third

•	No	thrombi	or	emboli•	No	fibrosis•	Drug	and	alcohol	tests	were	negative	

F2004-05 Jan 09, 

2004

Residential	basement	fire	claims the life of career lieutenant—Pennsylvania

Smoke and soot inhalation and thermal burns

Not mentioned None

F2004-04 Dec 16, 

2003

Career	firefighter	dies	of	carbon	monoxide	poisoning	after	becoming	lost	while	searching for the seat of a fire	in	warehouse—New	York

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

Yes None

F2004-03 Nov	17,	

2003

Career	captain/safety	officer	dies	in	a	single	motor	vehicle	crash	while	responding	to	a	call—Kansas

Probable positional asphyxia

Not mentioned None

F2004-02 Nov	29,	

2003

Basement	fire	claims	the	life	of	volunteer	firefighter	– Massachusetts

Smoke and soot inhalation

Not mentioned None

F2004-01 Oct 24, 

2003

District chief dies after suffering	a	heart	attack—Texas Myocardial infarction No Perform	an	autopsy	on	all	onduty	firefighter	fatalities

F2003-41 Oct 17, 

2003

Live-fire	exercise	in	mobile	flashover	training	simulator	injures	five	career	firefighters—Maine

No deaths None

F2003-40 Feb 26, 

2003

Airport	firefighter	suffers	sudden	cardiac	death	at	fire	station—ArKansas

Myocardial infarction No Perform	an	autopsy	on	all	onduty	firefighter	fatalities

F2003-39 Jul 21, 

2003

Firefighter	suffers	sudden	cardiac death in parking lot of fire	station—Tennessee

Myocardial infarction No Perform	an	autopsy	on	all	onduty	firefighter	fatalities
■ Firefighter Autopsy Protocol ■ 123 ■ I: Background ■ NIOSH REP. # DATE OF INCIDENT Title CAUSE OF DEATH AUTOPSY AUTOPSY COMMENTS PDF LINK F2003-38 Oct 07, 2003 Firefighter	dies	after	 performing	ventilation	 at	a	fire	in	a	two-story	 dwelling—Pennsylvania “Ischemic heart dis- ease” as the immediate cause of death and “smoke inhalation” as a significant	condition Yes •	Cardiomegaly	(heart	weighing	552	grams,	with	normal	 less than 400 grams) •	Mild	atherosclerotic	coronary	artery	disease	involving	the	 left main coronary artery •	Remote	(old)	myocardial	infarction	involving	the	apex	and	 left	posterior	ventricular	wall •	Fibrosis	within	the	apex	and	left	posterior	ventricular	wall	 (as	determined	by	microscopic	examination) •	Evidence	of	smoke	inhalation	(moderate	amount	of	soot	 in	the	trachea	and	large	airways	of	both	lungs) •	Carboxyhemoglobin	(measure	of	carbon	monoxide	in	the	 blood)	level	negative F2003-37 Oct 27, 2003 Volunteer	assistant	chief	 is struck and killed at road construction site—Minnesota Craniocerebral injuries and closed head trauma Yes None F2003-36 Oct 29, 2003 A	career	firefighter	was	 killed and a career captain was	severely	injured	during	 a	wildland/urban	interface	 operation—California Thermal injuries

Yes Extensive	burns	over	the	entire	body,	no	evidence	of	

underlying	cardiovascular	or	pulmonary	disease,	and	a	carboxyhemoglobin	level	of	27%	(confirming	significant	exposure	to	carbon	monoxide	prior	to	his	death)

F2003-35 Sep 27, 

2003

Firefighter	suffers	a	heart	attack after responding to a	rubbish	fire	at	a	two-story	apartment	building—New	York

“Acute myocardial infarction” as the immediate cause of death and “diabetes mellitus” and “hypertension” as other significant	conditions

No None

F2003-34 Jul 10, 

2003

Volunteer	firefighter/fire	service	products	salesman	dies after being struck by dislodged rescue airbag—South Dakota

Closed	head	wound Not mentioned None
■ Firefighter Autopsy Protocol ■ 124 ■ I: Background ■ NIOSH REP. # DATE OF INCIDENT Title CAUSE OF DEATH AUTOPSY AUTOPSY COMMENTS PDF LINK F2003-33 Aug 06, 2003 Career	firefighter/emer- gency medical technician dies and paramedic is injured	in	a	three-vehicle	 collision—Nebraska Blunt-force trauma due	to	a	motor	vehicle	 accident Not mentioned None F2003-32 Oct 01, 2003 Two	firefighters	die	and	eight	 firefighters	are	injured	from	 a	silo	explosion	at	a	lumber	 company—Ohio Multiple blunt-force injuries Not mentioned None F2003-31 Apr 14, 2003 Lieutenant suffers sud- den cardiac death after performing forcible entry requiring	heavy	physical	 exertion—Georgia “Cardiac dysrhythmia” due to “atherosclerotic coronary artery dis- ease” as the immedi- ate cause of death and “superimposed physical	exertion”	as	a	 contributing factor Yes •	Cardiomegaly	(heart	weighing	530	grams,	with	normal	 less than 400 grams1) •	Atherosclerotic	coronary	artery	disease •	Left	ventricular	hypertrophy	(15	millimeters	(mm)	thick;	 normal	between	7.6-8.8	mm •	Interventricular	septal	hypertrophy	(16mm	thick;	normal	is	 6 to 11 mm) •	No	thromboemboli	are	recovered	from	the	main,	right,	or	 left pulmonary arteries or their segmental branches •	No	obvious	soot	in	the	nares	or	oral	cavity •	Microscopic	sections	of	the	right	ventricle,	left	ventricle,	 and	interventricular	septum	do	not	reveal	significant	 myocardial	inflammation,	infarct,	hemorrhage,	fibrosis,	or	 neoplasia •	Drug	and	alcohol	tests	were	negative	 F2003-30 Jul 28, 2003 One	volunteer	lieutenant	dies	 and	a	volunteer	firefighter	is	 seriously injured in a motor vehicle	rollover	incident	while	 enroute	to	a	trailer	fire— North Carolina Acute intracranial injuries Not mentioned None
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F2003-29 Dec 15, 

2002

Firefighter	suffers	heart	attack at the scene of a structure	fire	and	dies	2	months later—Indiana

“Acute myocardial infarction” due to “atherosclerotic cardiovascular	disease”	as	the immediate cause of death and “chronic obstructive	pulmonary	disease (COPD)” as a contributing factor

No Perform	an	autopsy	on	all	onduty	firefighter	fatalities

F2003-28 Aug 08, 

2003

Live-fire	training	exercise	claims the life of one recruit firefighter	and	injures	four	others—Florida

Atherosclerotic cardiovascular	disease”	due	to “COPD”

No Perform	an	autopsy	on	all	onduty	firefighter	fatalities

F2003-27 Jan 25, 

2003

Fire captain suffers sudden cardiac	death	during	a	livefire	training	exercise—North	Carolina

“Acute myocardial infarction” (heart attack) as the cause of death due to “coronary atherosclerosis”	with	a “prior myocardial infarction” being a significant	contributing	factor

Yes Severe	atherosclerotic	coronary	artery	disease

•	100%	blockage	of	the	right	coronary	artery,	the	circumflex	

coronary	artery,	and	the	first	diagonal	coronary	artery	in	the area of the stent

•	A	seven	centimeter	scar	(due	to	his	heart	attack	in	1999)	

in	the	posterior	and	lateral	left	ventricular	wall

•	A	two	centimeter	hyperemic	area	near	the	first	diagonal	

coronary	artery	which	probably	represented	the	early	signs of a recent (acute) heart attack (myocardioal infarction)

Carboxyhemoglobin	level	was	less	than	5%	suggesting	carbon	monoxide	exposure	was	not	a	significant	factor	in	the Captain’s sudden death 
■ Firefighter Autopsy Protocol ■ 126 ■ I: Background ■ NIOSH REP. # DATE OF INCIDENT Title CAUSE OF DEATH AUTOPSY AUTOPSY COMMENTS PDF LINK F2003-26 Feb 20, 2003 Firefighter	suffers	sudden	 cardiac	death	at	his	fire	 station—Oregon Per	death	certificate:	 “ischemic heart dis- ease” as the immediate cause of death due to “atherosclerotic coro- nary heart disease.” Per autopsy: “arteriosclerotic cardio- vascular	disease”	as	 the cause of death Yes •	Moderate	calcification	and	atherosclerotic	narrowing	of	 the coronary arteries •	Softening	and	dark	discoloration	of	the	left	ventricle,	more	 toward	the	apex”	[a	finding	suggestive	of	a	recent	myocar- dial	infarct	(MI)	(otherwise	known	as	a	heart	attack)] •	No	scars	suggestive	of	old/remote	heart	attacks •	No	evidence	of	a	blood	clot	(embolus)	in	the	pulmonary	 arteries •	Microscopic	examination	of	the	heart	muscle	showed	no	 inflammation,	necrosis,	or	scarring •	Blood	carboxyhemoglobin	level	(a	test	of	carbon	monox- ide	exposure)	was	not	checked	due	to	no	exposure	to	fire	 smoke	during	his	shift,	and	no	drug	screen	was	performed F2003-25 May 14, 2003 Career	Federal	firefighter	 dies from injuries sustained at prescribed burn—Arizona Adult Respiratory Distress Syndrome secondary	to	severe	 inhalation injury with	cardiovascular	 compromise. None mentioned Note:	Thirty-six	%	of	the	victim’s	body	surface	area	had	 second- and third-degree burn injuries and he had a significant	inhalation	injury F2003-24 Jan 21, 2003 Firefighter	suffers	fatal	heart	 attack	while	performing	phys- ical	fitness	training—Missouri Per	death	certificate:	 “acute myocardial infarction” due to “ath- erosclerotic coronary artery disease” Per autopsy: “coronary atheroscle- rosis”	followed	by	 “stenosis, thrombosis, chronic myocardial infarct, subacute myocardial infarcts, acute myocardial infarct, and acute ischemic change” as the cause(s) of death. Yes •	A	large	heart	(435	grams	with	normal	less	than	400	 grams) •	Significant	coronary	atherosclerosis •	Stent	placement	in	three	coronary	arteries	[left	anterior	 descending	(LAD),	left	circumflex,	right	coronary	artery] •	Evidence	of	old	heart	attacks	(myocardial	infarcts	or	MIs) •	Subacute	MIs •	Acute	(recent)	MI	in	the	interventricular	septum	and	left	 ventricular	free	wall 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
■ Firefighter Autopsy Protocol ■ 127 ■ I: Background ■ NIOSH REP. # DATE OF INCIDENT Title CAUSE OF DEATH AUTOPSY AUTOPSY COMMENTS PDF LINK F2003-23 Jun 26, 2003 Volunteer	assistant	chief	 dies	in	tanker	rollover—New	 Mexico Multiple injuries con- sistent	with	a	rollover	 motor	vehicle	crash Not mentioned None F2003-22 Dec 13, 2002 Volunteer	firefighter	suffers	 sudden cardiac death after completing emergency medi- cal	technician	(emt)	written	 examination—Texas Acute myocardial infarction No Perform	autopsies	on	all	on-duty	firefighter	fatalities F2003-21 Feb 12, 2003 Firefighter	recruit	suffers	 sudden cardiac death during physical ability training—Texas Cardiac hypertrophy, “biventricular	dilatation	 and cardiomegaly Yes •	Cardiac	hypertrophy •	Biventricular	and	right	atrial	dilatation •	Cardiomegaly	(an	enlarged	heart)	weighing	440	grams •	The	coronary	arteries	are	free	of	atherosclerosis •	The	cardiac	valves	are	unremarkable •	No	blood	clots	in	the	pulmonary	vessels,	therefore	no	 evidence	of	a	pulmonary	embolus	 F2003-20 May 22, 2003 Junior	volunteer	firefighter	is	 killed	while	responding	to	a	 brush	fire	with	an	intoxicated	 driver—Wyoming Massive	trauma Not mentioned None F2003-19 Jun 16, 2003 Volunteer	firefighter	killed	 after	his	privately	owned	 vehicle	hydroplaned	 and struck a billboard signpost—kentucky Massive	head	and	 chest trauma Not mentioned None F2003-18 Jun 15, 2003 Partial roof collapse in commercial	structure	fire	 claims	the	lives	of	two	career	 firefighters—Tennessee Victim	#1:	thermal	 burns. Victim	#2:	thermal	 inhalation injury Not mentioned None F2003-17 May 18, 2003 Volunteer	training/Safety	 officer	dies	from	injuries	 received	in	fall	from	pick- up	truck	following	training	 exercise—Tennessee Blunt-force injury to the head Not mentioned None
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F2003-16 Feb 23, 

2003

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

Severe	pneumonia	as	a	consequence	of	complications due to a pedestrian motor vehicle	accident

Not mentioned None

F2003-15 Apr 03, 

2003

Volunteer	firefighter	dies	in	tanker	rollover—Ohio

Compressive	asphyxia Not mentioned None

F2003-14 Mar 19, 

2003

Volunteer	captain	killed	in	fire	apparatus	crash	while	responding to a training exercise—Oregon

Positional	asphyxiation Not mentioned None

F2003-13 Mar 18, 

2003

Volunteer	firefighter	killed	while	walking	across	an	interstate	highway	responding	to	a	motor	vehicle	incident—Texas

Severe	craniocerebal	injuries

Yes None

F2003-12 Mar 31, 

2003

Career	firefighter	dies	and	two	career	firefighters	injured	in	a	flashover	during	a	house	fire—Ohio

Severe	third	degree	burns

Not mentioned None

F2003-11 Feb 07, 

2001

Firefighter	collapses	and	dies	at the scene of residential fire—Florida

Hypertensive	and	arteriosclerotic heart disease

Yes •	Enlarged	heart	(concentric	left	ventricular	hypertrophy)

•	Coronary	atherosclerosis•	Four-vessel	bypass•	Pulmonary	edema•	Cerebral	edemaHis	blood	carboxyhemoglobin	level	was	not	checked
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F2003-10 May 22, 

2002

Firefighter	suffers	sudden cardiac death during 

a medical emergency response—California

Complication of hypertrophic cardiomyopathy Yes •	An	enlarged	heart	weighing	565	grams	(normal	less	than	 400 grams)

•	Thickened	left	ventricle	of	2.0	centimeters	(cm)	in	diameter	(normal	<1.3)•	Thickened	right	ventricle	of	1.0	centimeters	(cm)	in	

diameter	(normal	<0.8)

•	Minimal	atherosclerosis	in	the	coronary	arteries•	surgical	patch	and	scar	at	the	apex	of	the	heart’s	left	

ventricle	consistent	with	a	well	healed	surgical	repair	of	an	old	knife	wound	to	the	chest

•	Bilateral	fibrous	pleural	adhesions	and	pericardial	sac	

adhesions	also	consistent	with	his	old	knife	wound	to	the	chest

•	No	evidence	of	a	blood	clot	(embolus)	in	the	pulmonary	

arteries

•	A	negative	drug	screen	of	illicit	drugs	(e.g.	cocaine)

•	Histology	(microscopic)	examination	of	the	heart	tissue	

was	not	performed
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F2003-09 Jan 14, 

2003

Firefighter	suffers	fatal	heart	arrhythmia at structure fire—Illinois

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

Yes •	Atherosclerotic	cardiovascular	disease

•	Coronary	artery	atherosclerosis•	Remote	myocardial	infarct	(heart	attack),	posterior/inferior	

wall	of	left	ventricle	with	moderate	thinning	of	the	wall

•	Diffuse	mild	and	focal	moderate	aortic	atherosclerosis•	Clinical	history	of	hypercholesterolemia•	Hypertensive	cardiovascular	disease•	Cardiac	hypertrophy	(490	grams)•	Clinical	history	of	hypertension•	Tobacco	pneumonitis	with	early	pulmonary	emphysema	

and chronic bronchitis

•	History	of	cigarette	smoking•	No	ethanol	or	illicit	drugs	were	detected	Carboxyhemoglobin	level	was	2.2%,	indicating	the	captain	had	inhaled	some	but	not	an	excessive	amount	of	carbon	monoxide;	possibly	due	to	his	cigarette	smoking

F2003-08 Nov	12,	

2002

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

Myocardial sarcoidosis Yes •	Myocardial	sarcoidosis	(noncaseating	granulomas)	of	the	

heart,	lung,	lymph	nodes,	and	liver

•	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	and	interventricular	septum	(all	findings	consistent	with	sarcoidosis	involving	the	heart)

•	Cardiomegaly	(an	enlarged	heart)	weighing	640	grams

•	No	atherosclerotic	disease	of	the	coronary	arteries

F2003-07 Jan 13, 

2003

Career	firefighter/emergency	medical technician dies from injuries sustained in fall from apparatus—California

Multiple traumatic injuries

Not mentioned None
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F2003-06 Sep 19, 

2002

Firefighter	dies	from	progressive	respiratory	failure—Massachusetts

Progressive	respiratory failure and clinical history of adult respiratory distress syndrome due to inhalational injuries

•	Pulmonary	congestion•	Tracheobronchial	tree	is	diffusely	obstructed	by	mucoidtype material•	Areas	of	squamous	metaplasia	in	the	midtrachea•	Chronic	inflammatory	infiltrate	within	the	mucosa	and	

submucosa of the lungs

•	Diffuse	alveolar	damage	in	the	reparative	phase•	Interstitial	fibrosis	of	the	lungs•	No	significant	narrowing	of	the	coronary	arteries•	Cardiomegaly	(enlarged	heart)	(466	grams)

F2003-05 Jan 19, 

2003

Career	firefighter/emergency	medical technician dies in ambulance	crash—Texas

Blunt-force injuries Not mentioned None

F2003-04 Jan 20, 

2003

Career	firefighter	dies	from	injuries	received	during	a chimney and structural collapse after a house fire—Pennsylvania

Compressional asphyxia	as	a	result	of being trapped from falling debris

Not mentioned None

F2003-03 Jan 19, 

2003

Volunteer	firefighter	dies	following	nitrous	oxide	cylinder	explosion	while	fighting	a commercial structure fire—Texas

Thermal	injuries,	with	smoke inhalation and blast effect

Yes 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

F2003-02 Dec 05, 

2002

Firefighter	suffers	fatal	heart	attack	at	two-alarm	structure	fire—Texas

Atherosclerotic and hypertensive	cardiovascular	disease

Yes •	Severe	occlusive	coronary	artery	disease

•	Remote	infarct	of	the	posterior	wall	of	the	left	ventricle	

and	the	posterior	aspect	of	the	interventricular	septum

•	Cardiomegaly	(an	enlarged	heart)	weighing	560	grams	

(normal is less than 400 grams)

•	Concentric	left	ventricular	hypertrophy	(free	wall	width	1.5	

centimeters thick)

Carboxyhemoglobin	level	was	less	than	one	percent,	indicating	inhaled	carbon	monoxide	was	not	a	factor	in	his	death
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F2003-01 May 29, 

2002

Firefighter	dies	during	night	at	fire	station—Mississippi

“Sudden cardiac death” secondary to hypertensive	heart	disease	and coronary artery disease

Yes •	Coronary	artery	disease	(CAD)

•	An	enlarged	heart	(460	grams).•	Histologic	and	visual	inspection	of	the	heart	failed	to	

reveal	evidence	of	acute	or	remotein	farction

•	Microscopic	analysis	reveals	ischemic	change	manifested	

by nuclear hyperchromatism, nuclear outline irregularity, and	nuclear	enlargement	of	the	nuclei	of	the	individual	rhabdomycytes

F2002-50 Nov	25,	

2002

Structural collapse at an auto	parts	store	fire	claims	the	lives	of	one	career	lieutenant	and	two	volunteer	firefighters—Oregon

Asphyxiation Not mentioned None

F2002-49 Nov	01,	

2002

Volunteer	lieutenant	dies	following	structure	collapse at residential house fire—Pennsylvania

Traumatic compressional	asphyxia Not mentioned None
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F2002-48 Aug 28, 

2001

Firefighter	suffers	sudden	cardiac death at a structural fire—New	York

“Hypertrophic cardiomyopathy	with	myocardial arteriolarsclerosis” as the immediate cause	of	death	with	a	“myxomatous	mitral	value”

Yes •	Widely	patent	(open)	coronary	arteries

•	An	enlarged	heart	weighing	440	grams•	Slightly	thickened	left	ventricle	of	1.4	centimeters	(cm)	in	

diameter

•	Microscopic	changes	of	the	heart	muscle•	Myocyte	bundles	arranged	in	a	sinusoidal	and	other	

irregular patterns

•	Focal	myocyte	hypertrophy	with	occasional	multipolarity•	Widened	interstitium	with	fibrosis	in	irregular	patterns•	Arterioles	with	thickened	intima•	No	inflammatory	infiltrates,	contraction	banding,	or	

hypereosinophilia

•	Marked	billowing	of	both	leaflets	of	the	mitral	valve•	No	evidence	of	a	blood	clot	(embolus)	in	the	pulmonary	

arteries

•	Blood	carboxyhemoglobin	level	was	less	than	3%,	suggesting	the	victim	was	not	exposed	to	excessive	carbon	

monoxide	levels
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F2002-47 Jan 13, 

2001

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

“Hypertensive	and	arteriosclerotic heart disease” as the immediate cause of death and “smoke inhalation” as	an	other	significant	condition

Yes •	Hypertensive	and	arteriosclerotic	cardiovascular	disease

•	60%	calcific	atherosclerotic	stenosis	in	left	main	stem	

coronary artery

•	30%	stenosis	in	proximal	right	coronary	artery•	Valves	have	focal	atherosclerosis•	Cardiomegaly	(heart	weighed	560	grams)	with	concentric	

left	ventricular	hypertrophy

•	Coronary	arteriosclerosis,	multifocal,	moderate,	with	

superimposed coronary thrombosis in the left main stem and right coronary artery

•	Generalized	visceral	congestion	with	pulmonary	edema•	Smoke	inhalation•	Scant	soot	in	nares•	Soot	in	upper	airway•	Blood	carboxyhemoglobin	level	was	less	than	3%,	suggesting	the	victim	was	not	exposed	to	excessive	carbon	

monoxide	levels

F2002-46 Jan 04, 

2001

Firefighter	suffers	a	heart	attack	and	dies	while	exercising	in	firehouse—New	York

Atherosclerotic cardiovascular	disease Yes •	Atherosclerotic	cardiovascular	disease •	Coronary	artery	with	marked	atherosclerotic	stenosis	

(80%)	of	the	proximal	left	anterior	descending	artery

•	Myocardial	infarct,	remote	(at	least	3	months	old),	septum	

(microscopic),	focal	fibrosis	of	septum	adjacent	to	conduction	fibers

•	Myxoid	mitral	valve•	No	evidence	of	a	blood	clot	(embolus)

F2002-44 Sep 30, 

2002

Parapet	wall	collapse	at	auto body shop claims life of career captain and injures career lieutenant and emergency medical technician—Indiana

Extensive	blunt-force	trauma

Yes None
■ Firefighter Autopsy Protocol ■ 135 ■ I: Background ■ NIOSH REP. # DATE OF INCIDENT Title CAUSE OF DEATH AUTOPSY AUTOPSY COMMENTS PDF LINK F2002-43 Oct 09, 2002 Firefighter	dies	after	col- lapse at apartment building fire—kentucky Ventricular	 tachyarrhythmia No Perform	an	autopsy	on	all	onduty	firefighter	fatalities F2002-42 Jun 13, 2002 Emergency medical techni- cian	killed	in	single-vehicle	 crash	while	responding	to	 structure	fire—North	Carolina Blunt-force trauma to the head and neck Not mentioned None F2002-41 Sep 23, 2002 Career	firefighter	dies	in	 tanker	rollover—North	 Carolina Fractured neck due to motor-vehicle	incident Not mentioned None F2002-40 Sep 14, 2002 Career	firefighter	dies	after	 roof	collapse	following	roof	 ventilation—Iowa Smoke inhalation, intra-alveolar	hemor- rhage, and carbon monoxide	intoxication Yes Carboxyhemoglobin	level,	30.3% F2002-39 Sep 05, 2002 Junior	volunteer	fire- fighter	dies	in	tanker	 rollover—Tennessee Massive	head	and	 chest trauma Not mentioned None F2002-38 Jul 01, 2002 Volunteer	captain	killed,	 two	firefighters	and	police	 officer	injured	when	struck	 by	motor	vehicle	at	highway	 incident—Minnesota Multiple blunt-force trauma Not mentioned None F2002-37 Aug 01, 2002 Volunteer	firefighter	dies	 during	wildland	fire	suppres- sion—South Dakota Second- and third- degree	burns	over	70	 percent of the body Not mentioned None F2002-36 Aug 08, 2002 Volunteer	firefighter	dies	 after	being	run	over	by	 brush	truck	during	grass	fire	 attack—Texas Craniofacial crush inju- ries due to a fall from moving	vehicle	with	a	 secondary	run-over Not mentioned None F2002-35 Jun 08, 2002 Offduty	career	firefighter	dies	 and another offduty career firefighter	is	injured	after	 being	struck	by	a	truck	while	 assisting	at	a	highway	traffic	 incident—Florida Multiple blunt-force injuries	with	compound	 fractures of the skull Not mentioned None
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F2002-34 Jul 30, 

2002

Career lieutenant and firefighter	die	in	a	flashover	during	a	live-fire	training	evolution—Florida

Smoke inhalation and thermal injuries

Not mentioned None

F2002-33 Jan 31, 

2002

Firefighter	dies	during	night	at	fire	station—North	Carolina

Ischemic heart disease Yes •	Severe	three-vessel	atherosclerotic	disease

•	Microscopic	examination	of	one	section	of	the	heart	

reveals	multiple	small	areas	of	fibrosis.	But	there	is	otherwise	no	evidence	of	acute	or	old	infarction

•	A	normal	sized	heart

F2002-32 Jul 04, 

2002

Structural collapse at residential	fire	claims	lives	of	two	volunteer	fire	chiefs	and	one	career	firefighter—New	Jersey

Fixed	compression Yes None

F2002-31 Jul 05, 

2002

Volunteer	firefighter	dies	due	to	inadvertent	fireworks	discharge—North Dakota

Blunt-force injuries of the chest and left upper	extremity	due	to	fireworks	discharge

Not mentioned None

F2002-30 Jan 21, 

2002

Firefighter	suffers	probable	heart attack at condominium fire—South	Carolina

Arteriosclerotic cardiovascular	disease Yes •	Ischemic	fibrosis	with	scarring,	consistent	with	an	remote,	 healed heart attack (infarct)

•	Coronary	atherosclerosis•	Aortic	atherosclerosis	with	ulcerating	plaques•	A	large	heart	(500	grams)

F2002-28 Apr 27, 

2002

Firefighter	dies	after	leaving	fire	station—Pennsylvania

Sudden cardiac death No Perform	autopsies	on	all	on-duty	firefighter	fatalities

F2002-27 May 16, 

2001

Firefighter	dies	during	the	night	at	fire	station—Missouri

Asphyxiation	due	to	probable seizure

No Perform	an	autopsy	on	all	deceased	firefighters
■ Firefighter Autopsy Protocol ■ 137 ■ I: Background ■ NIOSH REP. # DATE OF INCIDENT Title CAUSE OF DEATH AUTOPSY AUTOPSY COMMENTS PDF LINK F2002-24 Nov	02,	 2001 Firefighter	suffers	fatal	 heart	attack	at	fire	 scene—Wisconsin Per autopsy: acute coronary thrombo- sis	with	ischemic	 arrhythmia Per	death	certificate:	 “cardiac arrhythmia” as the immediate cause of death and “CAD” (coro- nary artery disease) as the underlying cause Yes •	Severe	three-vessel	coronary	atherosclerosis •	Multiple	90-98%	stenosis	of	LAD	[left	anterior	descending]	 and	left	circumflex	[coronary	arteries] •	Acute	thrombosis,	left	circumflex	artery •	Interstitial	and	perivascular	fibrosis,	myocardium •	Cardiomegaly	due	to	left	ventricular	hypertrophy •	A	blood	specimen	obtained	at	autopsy	contained	“<1%”	 COHb F2002-23 Mar 11, 2001 Firefighter	suffers	fatal	heart	 attack	during	training—New	 Mexico Per autopsy: “myocardial infarction” with	“severe	hypoxic	brain injury” resulting from the cardiac arrest. 	Per	death	certificate:	 “cardiac arrest” as the immediate cause of death, due to “myocardial infarction,”	with	“coronary	 artery disease” as the underlying cause Yes •	Acute	myocardial	infarction,	extensive,	left	ventricle	 and	intraventricular	[sic]	septum	with	cardiac	arrest	and	 resuscitation •	Coronary	artery	stenosis,	bilateral,	95%	left	coronary	and	 90%	right	coronary •	Brain	death	secondary	to	cardiac	arrest	(The	last	finding	 was	based	on	the	hospital	record;	the	autopsy	did	not	 include	an	examination	of	the	brain.) F2002-22 Sep 26, 2001 Firefighter	suffers	fatal	 heart	attack	at	fire	at	his	 residence—Florida “Acute thrombosis of coronary artery” due to “arteriosclerotic cardio- vascular	disease” Yes Atherosclerotic	cardiovascular	disease	to	include •	Cardiomegaly	(445	grams)	with	left	and	right	ventricular	 hypertrophy •	Mild	to	severe	calcific	atherosclerosis	of	the	coronary	 arteries •	Acute	thrombosis	of	the	left	anterior	descending	coronary	 artery Carboxyhemoglobin	(COHb)	concentration	(a	measure	of	 carbon	monoxide	exposure)	in	blood	obtained	at	autopsy	 was	1.4%	(a	medically	insignificant	level).	There	was	no	 soot in the lungs
■ Firefighter Autopsy Protocol ■ 138 ■ I: Background ■ NIOSH REP. # DATE OF INCIDENT Title CAUSE OF DEATH AUTOPSY AUTOPSY COMMENTS PDF LINK F2002-21 May 04, 2002 Junior	firefighter	killed	while	 responding	to	fire	alarm	on	 his	bicycle—Pennsylvania Multiple injuries Not mentioned None F2002-20 May 03, 2002 Two	career	firefighters	die	in	 four-alarm	fire	at	two-story	 brick structure—Missouri Smoke inhalation Not mentioned 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. F2002-19 Apr 10, 2002 Firefighter	dies	during	live	 fire	training—North	Carolina Per	death	certificate:	 “ischemic heart dis- ease due to coronary artery disease” Per autopsy: “probable cardiac arrhythmia secondary to ischemic heart disease caused by	severe	coronary	 artery atherosclerosis” Yes •	Carboxyhemoglobin	level	was	measured	at	less	than	5%. •	Severe	coronary	atherosclerosis	of	the	left	anterior	 descending and right coronary arteries •	Proximal	to	mid	left	anterior	descending	diffuse	lesions	 causing a pinpoint lumen •	80%	stenosis	of	right	coronary	alternating	to	minimal	 throughout length of lumen •	Obesity	(height	of	67	inches	and	weight	of	195	pounds)	 (Body	Mass	Index	of	30.5	kilograms	per	square	meter	(kg/ m2) F2002-18 Apr 11, 2002 Career	fire	chief	dies	after	 being	struck	by	a	fire	 truck	at	a	motor-vehicle	 incident—Kansas Chest, abdomen, and skull trauma Not mentioned None F2002-17 Apr 05, 2002 Firefighter	dies	during	the	night	 at	fire	station—Kansas Cardiac arrhythmia due to	mitral	valve	prolapse Yes •	Carboxyhemoglobin	level	was	less	than	10%,	suggesting	 that	carbon	monoxide	poisoning	was	not	responsible	for	 his demise •	Urine	and	blood	drug	screen	was	negative	for	illicit	drugs	 and alcohol •	Normal	sized	heart	of	360	grams •	Moderate	myxomatous	degeneration,	mitral	valve	with	 endocardial friction lesions •	Foci	of	myofiber	bundle	disorder	and	myocyte	disarray	of	 the	left	ventricle	on	microscopic	examination •	Normal	coronary	arteries •	Possible	acutely	dilated	right	ventricle
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F2002-16 Apr 07, 

2002

Volunteer	firefighter	dies	and	two	are	injured	in	engine	rollover—Alabama

Mechanical	asphyxia	due to blunt head trauma

Not mentioned None

F2002-15 Jun 14, 

2002

Career	firefighter	drowns	during	final	dive	of	training	course—Indiana

Drowning Yes None

F2002-14 Jan 10, 

2002

Civilian	jumps	from	fourth-story	window	of	burning apartment building and strikes career firefighter—Michigan

County	medical	examiner listed the cause of death as natural due to a ruptured berry aneurysm;	independent	review	concluded	that	the	firefighter’s	death	was	work-related	

Yes The	independent	review	concluded	that	the	firefighter’s	

death	was	work-related.	The	report	described	the	cause	of	death	as	“...job	related,	caused	by	stress	and	exertion	in	the	performance	of	his	duties.	The	timeliness	of	the	events	

on	January	10,	2002,	and	subsequent	developments	are	unquestionably	the	direct	result	of	the	victim’s	blood	pressure	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.”

F2002-13 Mar 20, 

2002

Volunteer	firefighter	dies	after being struck by motor	vehicle	on	interstate	highway—Mississippi

Craniocerebral trauma Not mentioned None

F2002-12 Mar 01, 

2002

Volunteer	firefighter	killed	and career chief injured during residential house fire—Tennessee

Asphyxiation Not mentioned Carboxyhemoglobin	level	was	listed	at	31.8%

F2002-11 Mar 04, 

2002

One	career	firefighter	dies	and a captain is hospitalized after	floor	collapses	in	residential	fire—North	Carolina

Multiorgan	failure;	80%	total	body	surface	burns

Not mentioned None

F2002-10 Mar 02, 

2002

Volunteer	firefighter	dies	after tanker truck is struck by freight train—kentucky

Multiple blunt-force injuries

Not mentioned None
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F2002-09 Aug 29, 

2001

Firefighter	dies	while	exercising—Florida

Arteriosclerotic and hypertensive	heart	disease

Yes •	Cardiomegaly	(an	enlarged	heart	weighing	700	grams

•	Biventricular	dilatation•	Left	ventricular	hypertrophy	with	patchy	fibrosis•	Scarring	consistent	with	a	remote	(old)	heart	attack	

(myocardial infarction)

•	Moderate	to	severe	occlusive	coronary	artery	disease	

(CAD)

•	Moderate	obesity	(Body	Mass	Index	of	43	kilograms	per	

square	meter	[kg/m2]

F2002-08 Aug 09, 

2000

Firefighter	dies	at	kitchen	fire—North	Carolina

Hypoxia	due	to	pulmonary edema due to cardiomyopathy

Yes •	Dilated	cardiomyopathy

•	Status	postmitral	valve	replacement•	Severe	pulmonary	edema•	History	of	rheumatic	heart	disease•	Cardiomegaly	(an	enlarged	heart	weighing	475	grams)•	Evidence	of	chronic	ischemia•	Morbid	obesity	(Body	Mass	Index	of	43	kg/m2)•	Mild	occlusive	coronary	artery	disease	(CAD)

F2002-07 Feb 11, 

2002

One	career	firefighter	dies	and another is injured after partial structural collapse—Texas

Multiple blunt-force injuries

Not mentioned None

F2002-06 Mar 07, 

2002

First-floor	collapse	during residential basement 

fire	claims	the	lives	of	two	firefighters	(career	and	volunteer) and injures a career firefighter	captain—New	York

Asphyxia	due	to	the	inhalation of smoke and soot

Not mentioned None
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F2002-05 Dec 14, 

2001

Firefighter	suffers	sudden	cardiac death and crashes tanker	while	responding	to	a	chimney	fire—Colorado

Heart failure as the immediate cause of death due to arteriosclerotic heart disease

Yes •	Cardiomegaly

•	Old	healed	myocardial	infarct	[heart	attack]	involving	the	

interventricular	septum	and	the	anterior	wall	left	ventricle

•	Atherosclerotic	coronary	artery	disease,	severe	poststent	

replacement coronary arteries

•	Atherosclerotic	degeneration	abdominal	portion	of	the	

aorta

•	Small	old	infarct	right	cerebral	hemisphere	[stroke],	

internal capsule, brain

•	No	evidence	for	any	of	the	following:	epidural,	subdural,	

or	subarachnoid	[skull]	hemorrhage,	recent	stroke,	pulmonary embolus

•	Blood	screen	for	illicit	drug	use	or	alcohol	was	negative

F2002-04 Jan 21, 

2002

Motor-vehicle	incident	claims	life	of	volunteer	firefighter—Ohio

Laceration of the brain secondary to blunt impacts to the head

Not mentioned None

F2002-03 Dec 24, 

2001

Firefighter	suffers	cardiac	arrest	while	responding	to	a	structure	fire—Texas

Arteriosclerotic cardiovascular	disease Yes •	Atherosclerosis	of	the	coronary	arteries •	Cardiomegaly	(enlarged	heart	weighing	600	grams)

•	Old	posterolateral	myocardial	infarction	(prior	heart	

attack)

•	Bilateral	ventricular	dilatation•	Drug	screen	was	negative	for	alcohol,	illicit	drug	use,	and	

carbon	monoxide

F2002-02 Dec 15, 

2001

Firefighter	dies	during	fire	department	standby—Arizona

“Probable acute myocardial ischemia” due to “coronary atherosclerosis” due to “diabetes mellitus” as the immediate cause of death and a “history of	previous	myocardial	infarction” as an other significant	contributing	condition

No Perform	an	autopsy	on	all	onduty	firefighter	fatalities
■ Firefighter Autopsy Protocol ■ 142 ■ I: Background ■ NIOSH REP. # DATE OF INCIDENT Title CAUSE OF DEATH AUTOPSY AUTOPSY COMMENTS PDF LINK F2001-40 Mar 06, 2000 Firefighter	suffers	car- diac arrest at structure fire—Illinois Cardiac arrhythmia Yes •	Atherosclerosis	of	the	coronary	arteries •	50%	to	75%	narrowing	of	the	proximal	left	anterior	 descending coronary artery •	Cardiomegaly	due	to	left	ventricular	hypertrophy •	Ischemic	heart	disease	 F2001-39 Nov	19,	 2001 Volunteer	firefighter	killed	 and an assistant chief injured in	tanker	truck	crash—west	 Virginia Blunt-force traumatic head injury Not mentioned None F2001-38 Sep 25, 2001 Volunteer	firefighter	dies	and	 two	others	are	injured	during	 live-burn	training—New	York Asphyxia	due	to	smoke	 inhalation Not mentioned None F2001-37 Jun 18, 2001 Firefighter	suffers	heart	 arrhythmia and dies at wildland	fire—Washington Probable cardiac dysrhythmia due to fibrosis	of	the	conduc- tion system of the heart Yes •	Fibrosis	of	the	conduction	system	of	the	heart •	Focal	moderate	to	severe	atherosclerosis	of	the	proxi- mate left anterior descending (LAD) coronary artery •	Mild	perivascular	fibrosis	with	adjacent	areas	of	myocyte	 hypertrophy	of	the	left	ventricle	and	interventricular	 septum •	Possible	dilated	right	ventricle F2001-36 Aug 19, 2001 Volunteer	firefighter	dies	 when	tanker	crashes	into	 boulder and tree—Oregon Blunt-force head trauma Not mentioned None F2001-35 Oct 13, 2001 Volunteer	firefighter	drowns	 during	multiagency	dive- rescue	exercise	–	Illinois Drowning Not mentioned None F2001-34 Aug 12, 2000 Firefighter	suffers	prob- able	heart	attack	at	fire	 station—kentucky Acute myocardial infarction No Perform	an	autopsy	on	all	firefighters	who	were	fatally	 injured	while	on	duty F2001-33 Oct 13, 2001 High-rise	apartment	fire	 claims the life of one career firefighter	(captain)	and	 injures another career firefighter	(captain)—Texas Asphyxia	due	to	a	lack	 of	oxygen.	 Not mentioned The	victim’s	blood	level	of	carboxyhemoglobin	measured	 18%	saturation
■ Firefighter Autopsy Protocol ■ 143 ■ I: Background ■ NIOSH REP. # DATE OF INCIDENT Title CAUSE OF DEATH AUTOPSY AUTOPSY COMMENTS PDF LINK F2001-32 Aug 13, 2001 Firefighter	dies	at	three-alarm	 structure	fire—New	York Hypertrophic and arteriosclerotic cardiac disease Yes •	A	carboxyhemoglobin	level	(to	assess	the	victim’s	carbon	 monoxide	exposure)	was	not	performed. •	“To	assist	the	investigation	of	fire-related	deaths,	we	 [NIOSH]recommend	performing	carboxyhemoglobin	 levels	to	rule	out	carbon	monoxide	poisoning.” •	Borderline	cardiomegaly	(an	enlarged	heart	weighing	400	 grams) •	Dilated	cardiac	chambers •	Pulmonary	congestion	and	edema •	Fatty	liver •	Hepatosplenomegaly	 F2001-31 Apr 23, 2001 Firefighter	suffers	a	fatal	 heart attack during a training exercise—Michigan “Acute myocardial infarction” as the immediate cause of death and “arterio- sclerotic	cardiovas- cular disease” as the underlying cause Yes •	Acute	myocardial	infarction	due	to	arteriosclerotic	cardio- vascular	disease	with	acute	subepicardial	antero-lateral	 myocardial infarction •	Coronary	atherocalcinosis	with	maximal	manifestation	 and	75%	luminal	stenosis	in	left	mid	descending	coronary	 artery •	Cardiomegaly	with	dilated	cardiomegaly	and	left	ventricu- lar hypertrophy F2001-30 Apr 02, 2001 Firefighter	suffers	fatal	heart	 attack after returning home from	fire—Iowa “Acute myocardial infarction” as the immediate cause of death	and	“severe	arte- riosclerotic coronary vascular	disease—right	 coronary artery” as the underlying cause Yes •	Severe	atherosclerotic	coronary	artery	disease—distal	 right coronary artery •	Remote	myocardial	infarctions.	.	.	.	One	probably	 occurred months ago, and another is at least 7 days in age •	Respiratory	congestion	and	edema,	severe •	The	result	of	a	blood	test	for	carboxyhemoglobin	(an	 indicator	of	carbon	monoxide	exposure)	was	reported	 as	“0.0%,”	but	the	blood	was	drawn	almost	2	hours	after	 Engine	1	departed	the	fire	scene	and	after	50	minutes	of	 oxygen	(which	accelerates	the	clearing	of	carboxyhemo- globin)	administered	via	endotracheal	tube.	(At	autopsy,	 the	result	of	another	carboxyhemoglobin	test	was	also	 reported	as	“0.0%.”)
■ Firefighter Autopsy Protocol ■ 144 ■ I: Background ■ NIOSH REP. # DATE OF INCIDENT Title CAUSE OF DEATH AUTOPSY AUTOPSY COMMENTS PDF LINK F2001-29 Feb 12, 2001 Firefighter	dies	of	complica- tions of heart failure suffered at	fire	scene—Wisconsin Hypoxia/Ischemia,	 Acute	[of	the	brain	 and	spinal	cord]”	as	 the immediate cause of	death,	various	 autopsy	findings	as	 intermediate causes, and	“Overexertion	from	 responding	to	a	fire	call	 with	Fire	Dept”	as	the	 underlying cause Yes •	Congestive	heart	failure •	Arteriosclerotic	coronary	artery	disease	with	luminal	 occlusion	of	over	95%	in	the	proximal	circumflex	which	 arises	aberrantly	from	the	right	sinus	of	Valsalva	[and]	up	 to	50%	occlusion	in	anterior	interventricular	artery,	distal	 circumflex,	and	posterior	intraventricular	artery,	heart •	Anomalous	coronary	artery	distribution •	Bronchopneumonia,	focal,	mild,	acute,	lungs •	Hypoxia/ischemia,	acute,	varying	severity,	semiglobal,	 (cerebral, cerebellar, and spinal cord) •	Infarct,	acute/recent,	middle	and	inferior	temporal	gyrus	 and occipital lobes, bilateral) •	Atherosclerosis,	moderate	to	severe,	right	vertebral	artery,	 basilar artery, temporal branch of right middle cerebral artery •	Status	postcardiac	arrest	(pulseless	time	6-8	minutes) F2001-28 Dec 23, 1995 Firefighter	receives	severe	 electrical shock causing cardiac complications, forcing his retirement, and eventually	causing	his	 death—Massachusetts “Arteriosclerotic coro- nary heart disease” as the immediate cause of death,	with	“hyperten- sive	heart	disease”	as	 a contributing, but not an underlying, cause of death Yes •	An	enlarged	heart	(cardiomegaly)	of	500	grams •	All	four	chambers	of	the	heart	were	dilated •	Thickened	left	ventricle	wall	of	1.8	centimeters	(normal	 <1.2	centimeters) •	Severe	arteriosclerosis	with	diffuse	calcification •	Contusion	and	laceration	on	the	left	side	of	the	head	 without	internal	injury	 F2001-27 Jun 16, 2001 Career	firefighter	dies	after	 single-family-residence house	fire—South	Carolina Complications due to second- and third- degree burns Not mentioned None F2001-26 Jul 26, 2001 Career	firefighter	dies	from	 injuries	when	stationary	fill	 tank	becomes	over-pressur- ized and suffers catastrophic failure—California Head injury due to blunt impact Not mentioned None
■ Firefighter Autopsy Protocol ■ 145 ■ I: Background ■ NIOSH REP. # DATE OF INCIDENT Title CAUSE OF DEATH AUTOPSY AUTOPSY COMMENTS PDF LINK F2001-25 Jun 15, 2001 Firefighter	dies	after	 completing job task evaluation—Alabama Per	death	certificate: “cardiac arrest” as the immediate cause of death. Per autopsy: “cardiac arrhythmia” due to “myocardial ischemia” due to “coro- nary artery disease” Yes •	Moderate	coronary	atherosclerosis	with	50%	narrowing	 of	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	descend- ing coronary artery thrombosis •	Acute	myocardial	ischemia •	Severe	concentric	left	ventricular	hypertrophy F2001-24 Feb 05, 2001 Firefighter	suffers	sud- den	cardiac	death	while	 exercising	during	his	 shift—California Cardiac dysrhythmia associated	with	 exertion	due	to	dilated	 cardiomyopathy Yes •	The	heart	had	a	rounded	“globoid”	configuration	rather	 than the normal pyramidal shape •	The	heart	was	enlarged	(weighing	480	grams) •	All	four	chambers	of	the	heart	were	moderately	dilated	 (enlarged) •	Both	heart	ventricles	were	hypertrophied	(thick). •	No	evidence	indicated	old	or	recent	myocardial	infarctions	 (heart attacks) •	No	atherosclerotic	changes	were	evident	in	the	coronary	 arteries (no blockage in the coronary arteries) •	Microscopic	examination	of	the	left	ventricle,	the	right	 ventricle,	and	the	interventricular	tissue	showed	myocyte	 hypertrophy (muscle cell thickening) characterized by enlarged	“box	car”	nuclei	and	some	patchy	interstitial	 fibrosis	(scar	tissue	between	some	of	the	muscle	cells)	 •	There	was	no	evidence	of	vasculitis,	myocarditis,	sarcoi- dosis, Fabry’s disease, amyloidosis, or hemochromatosis •	No	illicit	drugs,	alcohol,	or	steroids	were	found •	Blood	lead	level,	the	urine	arsenic	level,	and	the	urine	 mercury	level	were	below	the	laboratory’s	level	of	detec- tion	(<3	micrograms	(mcg)	per	deciliter,	<15	mcg	per	 liter	(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)
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F2001-23 Jun 17, 

2001

Hardware	store	explosion	claims	the	lives	of	three	career	firefighters—New	York

Victims	#1	&	#3:	massive	blunt	force	trauma	Victim	#2:Asphyxia	due	to	smoke	inhalation.

Not mentioned None

F2001-22 Mar 10, 

2001

Firefighter	dies	while	on	duty—Texas

Hypertensive	and	arteriosclerotic cardiovascular	disease

Yes •	Severe	occlusive	coronary	artery	disease	with	75%	

narrowing	of	the	right	coronary	artery	and	the	diagonal	branch;	50%	narrowing	of	the	left	anterior	descending	coronary	artery	and	the	left	circumflex

•	Cardiomegaly	(enlarged	heart)•	Left	ventricular	hypertrophy•	Pulmonary	congestion	and	edema

F2001-21 Jan 18, 

2001

Firefighter	dies	in	sleep	during	his	work	shift—Michigan Arteriosclerotic cardio- vascular	disease Yes •	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	the	right coronary artery

•	Enlarged	heart•	Left	ventricular	hypertrophy•	Pulmonary	congestion	and	edema	

F2001-20 Dec 02, 

1998

Firefighter	has	sudden	cardiac death during training—Texas

Atherosclerotic cardiovascular	disease Yes •	Carboxyhemoglobin	level	was	1%,	suggesting	the	 firefighter	was	not	exposed	to	excessive	concentrations	of	

carbon	monoxide	(CO).

•	Atherosclerotic	cardiovascular	disease•	Moderate	to	severe	narrowing	of	the	coronary	arteries•	Mild	to	moderate	narrowing	of	the	aorta•	Mild	narrowing	of	the	cerebral	arteries•	Remote	myocardial	infarction,	multiple,	left	ventricle
■ Firefighter Autopsy Protocol ■ 147 ■ I: Background ■ NIOSH REP. # DATE OF INCIDENT Title CAUSE OF DEATH AUTOPSY AUTOPSY COMMENTS PDF LINK F2001-19 Feb 19, 2000 Firefighter	dies	after	assisting	 an injured person—Ohio Severe	occlusive	coro- nary artery disease Yes •	Severe	occlusive	coronary	artery	disease	with	calcifica- tion;	70-80%	narrowing	of	the	left	anterior	descending	 coronary	artery	and	the	right	coronary	artery;	Recent	 thrombus right coronary artery •	Left	ventricular	hypertrophy •	Pulmonary	congestion	and	edema •	Congestion	of	viscera	 F2001-18 May 09, 2001 Career	firefighter	dies	after	 becoming	trapped	by	fire	in	 apartment	building—New	 Jersey Asphyxiation Not mentioned None F2001-17 Mar 06, 2001 Motor-vehicle	incident	 claims	the	life	of	a	volunteer	 assistant chief—Alaska Multiple blunt-force injuries Not mentioned None F2001-16 Mar 08, 2001 Career	firefighter	dies	after	 falling	through	the	floor	fight- ing	a	structure	fire	at	a	local	 residence—Ohio Complications of thermal	burns	to	60%	 of total body surface Not mentioned None F2001-15 Mar 18, 2001 Residential	fire	claims	the	 lives	of	two	volunteer	fire- fighters	and	seriously	injures	 an assistant chief—Missouri Asphyxiation	due	to	 smoke inhalation Not mentioned None F2001-14; Grant Number R43-OH-004173 Feb 18, 2001 Firefighter	dies	after	return- ing	from	mutual-aid	fire	 call—Connecticut “Cardiac arrest” is listed as the immediate cause of death, and “hyperlipidemia” and “diabetes mellitus” are listed as contributing factors No None F2001-13 Mar 14, 2001 Supermarket	fire	claims	the	 life	of	one	career	firefighter	 and critically injures another career	firefighter—Arizona Thermal burns and smoke inhalation Not mentioned The	victim’s	carboxyhemoglobin	level	was	listed	at	61%	at	 the time of death
■ Firefighter Autopsy Protocol ■ 148 ■ I: Background ■ NIOSH REP. # DATE OF INCIDENT Title CAUSE OF DEATH AUTOPSY AUTOPSY COMMENTS PDF LINK F2001-11 Nov	16,	 2000 Driver/Operator	suffers	a	car- diac	arrest	during	a	wildland	 fire	exercise—Georgia Per	death	certificate: atherosclerotic cardio- vascular	disease Per autopsy: “heart rhythm distur- bance (arrhythmia)” as the cause of death and atherosclerotic cardiovascular	disease	 as the contributing factor. 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 •	Vascular	congestion,	all	internal	organs	 F2001-10; Purchase Order 0000136411 Dec 23, 2000 Firefighter	dies	at	house	 fire—New	Hampshire Atherosclerotic and hypertensive	cardio- vascular	disease	with	 cardiac arrhythmia following	stress	 and	exertion	during	 firefighting Yes •	A	nontoxic	carbon	monoxide	level •	Detectable	blood	ethyl	alcohol	 •	Pulmonary	emphysema •	Atherosclerosis	of	the	coronary	arteries.	Specifically,	the	 artery	supplying	the	anterior	wall	of	the	heart	was	focally	 occluded,	and	two	other	major	arteries	were	40-50%	 occluded –	 Acute	thrombi	(blood	clots)	were	noted F2001-09 Feb 25, 2001 Volunteer	firefighter	dies	and	 another	firefighter	is	injured	 during	wall	collapse	at	fire	at	 local business—Wisconsin Anoxic	encephalopathy	 and chest compression asphyxia Not mentioned None F2001-08 Feb 17, 2001 Two	volunteer	firefighters	 die	fighting	a	basement	 fire—Illinois Asphyxiation	caused	 by inhalation of prod- ucts of combustion Yes None F2001-07 Jan 09, 2001 A	volunteer	firefighter	died	 after being struck by a motor	vehicle	while	directing	 traffic—New	York Multiple injuries consisting	of	a	massive	 closed head injury, pulmonary contusion, and chest injury Not mentioned None
■ Firefighter Autopsy Protocol ■ 149 ■ I: Background ■ NIOSH REP. # DATE OF INCIDENT Title CAUSE OF DEATH AUTOPSY AUTOPSY COMMENTS PDF LINK F2001-06 Jan 12, 2001 Firefighter	dies	after	the	 tanker	truck	he	was	driving	 strikes a utility pole and overturns	while	responding	to	 a	grass	fire—kentucky Blunt-force injuries Not mentioned None F2001-05 Oct 13, 2000 Driver/Operator	dies	at	 his station after respond- ing to three emergency incidents—Massachusetts Cerebral	event	as	the	 immediate cause of death, due to cere- bral hypoperfusion and coronary artery disease No Autopsies	should	be	performed	on	all	onduty	firefighters	 whose	death	may	be	cardiovascular-related F2001-04 Jan 11, 2001 Volunteer	firefighter	(lieuten- ant)	killed	and	one	firefighter	 injured during mobile home fire—Pennsylvania Asphyxiation Not mentioned None F2001-03 Dec 28, 2000 Roof collapse injures four career	firefighters	at	a	church	 fire—ArKansas No deaths NA NA F2001-02 Aug 17, 2000 A	firefighter	drowns	after	 attempting to rescue a civilian	stranded	in	flood	 water—Colorado Apparent	drowning Not mentioned None F2001-01 Nov	16,	 2000 Volunteer	firefighter	dies	 and	junior	firefighter	is	 injured	after	tanker	rollover	 during	water	shuttle	training	 exercise—kentucky Massive	internal	 injuries Not mentioned None F2000-45 Jun 23, 2000 Firefighter	suffers	a	heart	 attack	after	expressing	 symptoms	while	on	duty— New	Jersey Arteriosclerotic cardio- vascular	disease Yes •	Three	arteries	are	calcified	with	10%	to	50%	obstruction	 multifocally •	Nonadherent	thrombus	in	the	right	coronary	artery •	Mild	atherosclerosis	of	the	mitral	and	aortic	valves •	A	1	cm	scar	in	the	posterior	wall	of	the	left	ventricle,	 inferiorly F2000-44 Nov	25,	 2000 Residential	house	fire	 claims the life of one career firefighter—Florida Asphyxia	due	to	smoke	 inhalation and carbon monoxide	poisoning Yes Positive	carbon	monoxide	reading	of	69.5%	was	recorded
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F2000-43 Oct 29, 

2000

A	volunteer	assistant	chief	

was	seriously	injured	and	two	volunteer	firefighters	were	injured	while	fighting	a	townhouse	fire—Delaware

No deaths NA NA

F2000-42 Feb 13, 

2000

Lieutenant suffers a cardiac arrest during a structural drill—kentucky

“Hypertensive	atherosclerotic	cardiovascular	disease” as the cause of death and “diabetes, hyperlipidemia, tobacco use, and hypertension” as contributing factors

Yes •	Hypertensive	atherosclerotic	cardiovascular	disease

•	Cardiomegaly

•	High-grade	stenosis	(80%)	of	the	circumflex	and	proximal	

left anterior descending arteries

•	Total	occlusion	of	the	mid-left	anterior	descending	artery•	Stent	within	the	right	coronary	artery•	Acute	thrombus	of	the	right	coronary	artery•	Circumferential	scarring	of	the	left	ventricular	free	wall	

and septum

•	Peripheral	vascular	disease	of	the	abdominal	aorta•	Nephrosclerosis•	Diabetes	mellitus•	Hyperlipidemia•	Documented	history	of	inferior	wall	infarction	in	1997•	“Documented	history	of	tobacco	use”•	“Documented	history	of	hypertension”	

F2000-41 Sep 27, 

2000

Firefighter	dies	after	being	run	over	by	ladder	truck	while	attempting	to	board—Alabama

Multiple blunt-force injuries

Not mentioned None
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F2000-40 Aug 06, 

2000

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

Arteriosclerotic heart disease

Yes •	No	weight	taken	at	the	time	of	his	autopsy

•	An	enlarged	heart	weighing	570	grams•	Left	and	right	ventricular	dilatation•	Scar	formation	in	the	left	ventricle	(superior	aspect	of	the	

posterior	wall)

•	Arteriosclerotic	heart	disease•	Fresh	clot	(thrombus)	in	the	right	coronary	artery	2	cm	

from its origin

–	80%	narrowing	of	the	distal	right	coronary	artery–	60%	narrowing	of	the	circumflex	artery–	80%	narrowing	of	the	left	anterior	descending	artery•	Illicit	drug	and	alcohol	tests	were	negative•	Presence	of	a	prescription	heart	medication	(Papaverine)•	Large	white	layer	of	lipid	(fat)	material	[suggesting	a	

recent meal or a lipid disorder

F2000-39 Apr 29, 

2000

A lieutenant dies and three firefighters	of	a	career	department	were	injured	when	the	truck	they	were	responding	in	was	struck	by	another	vehicle—Illinois

Multiple injuries sustained due to a motor-vehicle	crash

Not mentioned None

F2000-38 Aug 13, 

2000

Firefighter/scuba	diver	dies during training evolution—Indiana

[Pulmonary]	barotrauma

Yes •	Extensive	air	emboli	(air	bubbles	in	lung,	brain,	and	heart	

blood	vessels)

•	Subcutaneous	emphysema	(air	under	the	skin)	and	

alveolar	hemorrhage,	as	well	as	pulmonary	edema	with	pink	foam	in	the	airways

•	No	pneumothorax.	•	Toxicology	reports	listed	no	finding	which	contributed	to	

his death
■ Firefighter Autopsy Protocol ■ 152 ■ I: Background ■ NIOSH REP. # DATE OF INCIDENT Title CAUSE OF DEATH AUTOPSY AUTOPSY COMMENTS PDF LINK F2000-37 Jul 18, 2000 Arson	investigator	dies	 from injuries sustained from a fall during an arson investigation—Illinois “Multiple organ system failure” due to, or as a	consequence	of,	(b)	 “peritonitis	with	severe	 hypotension, ischemic necrosis	of	the	liver	 and kidneys” due to, or as	a	consequence	of,	 (c) “blunt force trauma of	the	left	chest	wall	 with	splenic	hemato- mas and a perforated stress ulcer.” Yes	-two “Blunt	force	trauma	of	the	left	chest	wall	resulted	in	a	 massive	intrasplenic	hematoma	and	the	development	of	a	 stress	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 organ system	failure,	specifically	generalized	ischemic	necrosis	of	 the	liver	(superimposed	upon	hepatitis	C-induced	micronod- ular cirrhosis), acute tubular necrosis of the kidneys and infarction of the rectosigmoid colon. The combination of liver	failure	and	renal	failure	constitutes	so-called	‘multiple organ	system	failure’	and	was	the	immediate	cause	of	 death.	The	underlying	cause	of	death	was	blunt-force	 trauma	of	the	left	chest	wall.”

Two	days	later,	a	second	autopsy	was	performed	by	a	forensic	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

F2000-36 Jul 23, 

1998

Captain suffers a heart attack at	a	structure	fire	and	dies	12	days later—Illinois

Myocardial infarction (otherwise	known	as	a heart attack) as the immediate cause of death,	due	to	severe	atherosclerotic cardiovascular	disease

Yes •	A	large	heart	(cardiomegaly)	weighing	535	grams

•	An	old	posterior	MI

•	A	recent	anterior	septal	MI•	Severe	coronary	artery	disease	(CAD)•	Stent	in	the	LAD	with	60-75%	focal	occlusion	proximally•	70-80%	occlusion	proximally	of	the	circumflex	artery•	50-60%	occlusion	of	the	right	coronary	artery

F2000-35 Jul 02, 

2000

Junior	firefighter	killed	responding to call in his privately	owned	vehicle	(pov)—Pennsylvania

Blunt-force trauma to the head and trunk

Not mentioned None
■ Firefighter Autopsy Protocol ■ 153 ■ I: Background ■ NIOSH REP. # DATE OF INCIDENT Title CAUSE OF DEATH AUTOPSY AUTOPSY COMMENTS PDF LINK F2000-34 Apr 26, 2000 Lieutenant	dies	at	a	fire	in	 a one-and-one-half story dwelling—west	Virginia Atherosclerotic coro- nary disease No A	visual	inspection,	rather	than	an	autopsy,	was	also	com- pleted	by	the	Assistant	Medical	Examiner.	Based	on	this	 inspection,	the	following	“pathologic	diagnosis”	was	listed: •	“Myocardial	infarct	(based	on	circumstances,	EKG	 changes, and serologic testing)” •	“Mild	chronic	obstructive	pulmonary	disease	and	hepatitis	 per history.” F2000-33 May 27, 2000 Pumper	truck	rollover	 claims	the	life	of	a	volunteer	 firefighter—Missouri Cerebral laceration, due to an open skull fracture Not mentioned None F2000-32 Apr 29, 1998 Driver/Operator/Firefighter	 suffers a heart attack and dies	while	supporting	fire	 suppression	activities—New	 York Hypertensive	and	 atherosclerotic cardio- vascular	disease Yes •	Marked	coronary	artery	atherosclerosis –	 Near	occlusive	mid-right	CAD –	 Near	occlusive	proximal	left	anterior	descending	CAD •	Small	circumscribed	area	(0.5	by	1.2	by	1.0	centimeter)	of	 subepicardial	fibrosis	in	the	mid-posterior	left	ventricular	 wall	(nontransmural).	This	finding	is	consistent	with	a	 remote (at least 3 months) heart attack in the distribution of	the	right	coronary	artery	lesion	mentioned	previously •	Left	ventricular	hypertrophy •	No	evidence	of	a	blood	clot	(embolus)	in	the	pulmonary	 arteries; •	His	blood	carboxyhemoglobin	level	was	less	than	3%,	 suggesting	the	victim	was	not	exposed	to	excessive	 carbon	monoxide	levels F2000-31 Nov	16,	 1999 Firefighter	collapses	at	the	 fire	house	and	subsequently	 dies due to heart arrhythmia secondary to myocardial sarcoidosis—New	Jersey Granulomatous myocarditis due to sar- coidosis, generalized Yes •	Cardiac	hypertrophy	and	cardiomegaly	(a	large	heart) •	No	significant	atherosclerotic	disease	of	the	coronary	 arteries •	Sarcoidosis	(noncaseating	granulomas)	of	the	heart,	lung,	 lymph	nodes,	liver,	and	spleen
■ Firefighter Autopsy Protocol ■ 154 ■ I: Background ■ NIOSH REP. # DATE OF INCIDENT Title CAUSE OF DEATH AUTOPSY AUTOPSY COMMENTS PDF LINK F2000-30 Sep 28, 1998 District chief dies of a stroke after	serving	as	the	Incident	 Commander at a structure fire—Tennessee Intracerebral hemor- rhage due to hyper- tension, essential (otherwise	known	as	a	 “stroke”) No Perform	an	autopsy	on	all	onduty	firefighter	fatalities F2000-29 Jan 12, 2000 Firefighter	dies	as	a	result	of	 a cardiac arrest at the scene of	a	structure	fire—Maine Cardiac arrest Yes An	autopsy	was	performed;	however,	medical	records	were	 not	available	to	NIOSH	personnel	at	the	time	of	this	report F2000-28 Aug 20, 1998 Firefighter	dies	on	 duty—Tennessee “acute myocardial infarction due to coro- nary artery disease” as the immediate cause of death and “diabetes mellitus Type II and renal failure” as other significant	conditions No Perform	an	autopsy	on	all	onduty	firefighter	fatalities F2000-27 Apr 30, 2000 Volunteer	assistant	chief	 dies during a controlled-burn training	evolution—Delaware Asphyxiation	and	 thermal burns Not mentioned Carbon	monoxide	level	was	listed	at	41% F2000-26 Apr 20, 2000 Residential	structure	fire	 claims the life of one career firefighter—Alabama Thermal injuries (full-thickness burns to roughly one-third of body surface area) Not mentioned None F2000-25 Apr 07, 2000 A	volunteer	firefighter	died	 and	a	second	was	seri- ously injured after fuel tank explosion—Iowa Multiple blunt-force injuries to the head, neck, torso, and extremities

Yes None

F2000-24 Apr 11, 

2000

Firefighter	dies	during search-and-rescue training—Ohio

Cardiomegaly—acute cardiac arrhythmia

Yes •	Cardiomegaly	(enlarged	heart)

–	 A	weight	of	690	grams

•	Moderate	coronary	atherosclerosis

•	50-60%	blockage	of	the	midpoint	of	his	left	anterior	

descending coronary artery

•	Chronic	and	acute	lung	congestion

F2000-23 Mar 31, 

2000

Career	firefighter	dies	and	three are injured in a residential	garage	fire—Utah

Smoke and soot inhalation and acute carbon monoxide	intoxication

Not mentioned •	CO	levels	were	at	25%	saturation	but	may	not	accurately	

reflect	his	level	due	to	intubation	and	resuscitation	efforts)
■ Firefighter Autopsy Protocol

■ 155

■ I: Background

■

NIOSH 

REP. #

DATE OF

 INCIDENT Title CAUSE OF DEATH AUTOPSY AUTOPSY COMMENTS

PDF 

LINK

F2000-22 Mar 15, 

2000

Wildland	fire	claims	the	life	of	one	volunteer	firefighter	and	injures	another	firefighter—South Dakota

Sepsis as a result of	extensive	thermal	burns due to a grass fire

Not mentioned None

F2000-21 Jun 02, 

1998

On-duty	driver/operator	dies	in sleep—Indiana

Probable arrhythmia due to hypertrophic cardiomyopathy,	fibrosis of sinoatrial node

Yes •	Since	the	driver/operator	was	not	engaged	in	fire	suppression	activities,	his	blood	was	not	tested	for	carbon	

monoxide	poisoning	(carboxyhemoglobin	levels)

•	Moderate	coronary	artery	disease

–	 Up	to	50%	stenosis	of	the	proximal	circumflex	artery–	 Up	to	50%	stenosis	of	the	mid	left	anterior	descending	

coronary artery

– Intramyocardial tunneling of coronary artery– Fibrosis of the sinoatrial node

•	Concentric	hypertrophic	cardiomyopathy

–	 Diminished	left	ventricular	cavity–	 Dilated	right	ventricle–	 Significant	myocyte	hypertrophy	with	nuclear	enlargement	and	fiber	disarray	involving	the	septum	of	both	

ventricles

•	Biventricular	and	ventricular	septum	hypertrophy•	Severely	congested	lungs	bilaterally	with	edema•	Hepatosplenomegaly	with	passive	congestion•	Hashimoto’s	thyroiditis

F2000-20 Feb 10, 

1998

Driver/Operator	dies	at	a	motor	vehicle	fire—Wisconsin

“Myocardial infarction” as the immediate cause of death, due to	“severe	atherosclerotic	cardiovascular	disease.”

Yes •	Severe	arteriosclerotic	heart	disease

–	 High-grade	atheromatous	plaques	of	up	to	100%	

occlusion of the left anterior descending and the right coronary arteries

•	Large	remote	myocardial	infarct	in	the	lateral	wall	of	the	

left	ventricle

•	Three	graft	vessels•	Cardiomegaly	(enlarged	heart)	(750	gms)
■ Firefighter Autopsy Protocol ■ 156 ■ I: Background ■ NIOSH REP. # DATE OF INCIDENT Title CAUSE OF DEATH AUTOPSY AUTOPSY COMMENTS PDF LINK F2000-19 Mar 17, 2000 Motor-vehicle	incident	involv- ing amtrak train claims life of career	firefighter/engineer— North Carolina Multiple blunt-force injury	from	the	fire	 truck/train collision Not mentioned None F2000-18 Jan 17, 2000 Tanker	rollover	claims	life	of	 volunteer	fire	chief—Missouri Massive	neck	trauma	 and upper chest trauma Not mentioned None F2000-17 Feb 11, 2000 A	volunteer	firefighter/driver	 was	killed	and	another	 volunteer	firefighter	was	 injured	while	responding	to	 a	motor	vehicle	incident	with	 injuries—California Adult respiratory dis- tress	syndrome	[lung	 failure]/ischemia	and	 encephalopathy due to motor	vehicle	crash Not mentioned None F2000-16 Mar 03, 2000 Arson	fire	claims	the	life	of	 one	volunteer	firefighter	and	 one	civilian	and	severely	 injures	another	volunteer	 firefighter—Michigan Asphyxiation Not mentioned None F2000-15 Oct 15, 1997 Battalion chief suffers a heart attack	and	eventually	dies	 while	participating	in	a	fitness	 program—California Cardiogenic shock due to enterobacter sepsis due to multiorgan failure due to ischemic cardiomyopathy No Perform	autopsies	on	all	onduty	firefighter	fatalities F2000-14 Feb 06, 2000 Firefighter	dies	at	a	single- family	dwelling	fire—Iowa “Occlusive	coronary	 artery disease” as the immediate cause of death due to “ath- erosclerotic	vascular	 disease” Yes •	Atherosclerotic	vascular	disease –	 Severe	coronary	artery	disease –	 Right	coronary	artery,	75%	stenotic –	 Left	circumflex	artery,	80%	stenotic –	 Left	anterior	descending	artery	unavailable	due	to	 organ	harvesting	for	donation •	Focal	contraction	band	necrosis	in	the	right	ventricle •	Acute	pulmonary	congestion,	agonal •	Pulmonary	anthracosis	without	emphysema •	Carbon	monoxide	level	of	4%
■ Firefighter Autopsy Protocol

■ 157

■ I: Background

■

NIOSH 

REP. #

DATE OF

 INCIDENT Title CAUSE OF DEATH AUTOPSY AUTOPSY COMMENTS

PDF 

LINK

F2000-13 Feb 14, 

2000

Restaurant	fire	claims	the	life	of	two	career	firefighters—Texas

Asphyxia	due	to	smoke	inhalation

Yes None

F2000-12 Jan 17, 

2000

Sector captain suffers fatal heart	attack—Texas

“Myocardial infarction” (heart attack) as the immediate cause of death, and “diabetes”	as	a	significant	condition

No None

F2000-11 Jan 15, 

2000

Volunteer	firefighter	drowns	during	dry-suit	training	dive—North Carolina

Severe	metabolic	acidosis as the result of	near	drowning

Not mentioned None

F2000-10 Oct 28, 

1999

A	captain	and	a	firefighter	die from injuries in a tanker rollover—Indiana

Victim	#1:	Cardiac	

arrhythmiaVictim	#2:	Sepsis

Not mentioned None

F2000-09 Jan 27, 

2000

Volunteer	firefighter	dies	fighting	a	structure	fire	at	a	local	residence—Texas

Smoke inhalation Yes None

F2000-07 Jan 17, 

2000

Volunteer	firefighter	dies after 9-foot fall from ladder—Pennsylvania

Blunt-force trauma to the head

Not mentioned None

F2000-06 Nov	14,	

1999

Tanker	rollover	results	in	the	death	of	one	volunteer	firefighter—Texas

Blunt trauma Yes None
■ Firefighter Autopsy Protocol ■ 158 ■ I: Background ■ NIOSH REP. # DATE OF INCIDENT Title CAUSE OF DEATH AUTOPSY AUTOPSY COMMENTS PDF LINK F2000-05 Dec 13, 1999 Firefighter	dies	at	a	barn	 fire—Ohio “Fatal cardiac arrhyth- mia” as the immediate cause of death due to “acute thrombotic occlusion of the right coronary artery” (heart attack),	“80-90%	 narrowing	of	the	left	 anterior descending coronary artery, and severe	coronary	 atherosclerosis.” Yes •	Coronary	artery	disease –	 Severe	coronary	atherosclerosis – Complete acute thrombotic occlusion of the right coronary artery –	 Narrowing	of	the	left	coronary	artery –	 Proximal	and	middle	left	anterior	descending	branch,	 near complete occlusion – Generalized moderate atherosclerosis •	Hypertrophy	and	dilatation	of	the	heart •	Acute	and	chronic	marked	congestion	of	the	lungs •	Splenomegaly The	victim’s	blood	was	not	tested	for	carbon	monoxide	 poisoning	(carboxyhemoglobin	levels)	although	the	depart- ment	requested	this	be	done F2000-04 Dec 22, 1999 Structure	fire	claims	the	lives	 of	three	career	firefighters	 and	three	children—Iowa Victim	#1:	Smoke	 inhalation and sudden exposure	to	intense	 heat Victim	#2:	Smoke	 inhalation and sudden	exposure	 to	an	extremely	hot	 environment Victim	#3:	Sudden	 exposure	to	intense	 heat Not mentioned Victim	#1:	15%	Carboxyhemoglobin	level	 Victim	#2:	25%	Carboxyhemoglobin	level	 Victim	#3:	1.0%	Carboxyhemoglobin	level F2000-03 Jul 04, 1999 Captain dies as a result of a cardiac arrest at the scene of a	structure	fire—Alabama Myocardial infarction No Note:	No	blood	was	sent	for	laboratory	analysis	during	 resuscitative	efforts.	According	to	post-mortem	toxicology	 forensic	specimen	analysis,	the	victim’s	carboxyhemoglobin	 level	was	“negative.”	An	autopsy	was	not	performed Perform	an	autopsy	on	all	onduty	firefighter	fatalities
■ Firefighter Autopsy Protocol

■ 159

■ Appendix B

■

NIOSH 

REP. #

DATE OF

 INCIDENT Title CAUSE OF DEATH AUTOPSY AUTOPSY COMMENTS

PDF 

LINK

F2000-02 Jul 06, 

1998

Forestry	worker	dies	while	bulldozing	a	fire	line	at	a	wildland	fire—Alabama

Per	death	certificate:	“cardiac arrest” as the immediate cause of death and “respiratory failure” as the underlying causePer autopsy: “acute myocardial infarction” (heart attack)

lYes •	Atherosclerotic	cardiovascular	disease,	trivessel,	very	

severe	(Ninety-%	occlusion	of	each	of	the	following	arteries:	left	anterior	descending,	right,	and	circumflex	arteries)

•	Myocardial	infarctions,	old,	remote,	multiple•	Myocardial	infarction,	recent,	acuteToxicological	analysis	reported	a	10-percent	carboxyhemoglobin	level.	In	an	interview,	the	head	of	the	Toxicology	

Section	who	performed	this	analysis	communicated	that	the	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	not	indicative	of	a	toxic	exposure

F2000-01 Dec 18, 

1999

Motor-vehicle	incident	claims	the	life	of	a	volunteer	firefighter	and	injures	a	volunteer	chief—Virginia

Atlanto-occipital dislocation	(severe	neck	spinal cord damage) resulting from motorvehicle	violence

Not mentioned None
■ 160 ■

■ Appendix C: Examination of Personal 

Protective Equipment

I

n 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 as 

part 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 and 

descriptive notes of all observations. It is as important to note that something was functional or in good 

condition 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 in 

advance 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; and

■ the deposition of any samples that are tested.

Evaluation of SCBA is critical to the investigation. Do not make any adjustments to the SCBA unless 

absolutely necessary.The positions of straps and knobs should be photographed, and then marked with 

an indelible marker or grease pencil.Valves should not be opened or shut under any circumstances. If the 

investigators wish to test breathing air, a SCBA that was filled from the same source at approximately the 

same time should be used. Several observations should be made at the incident scene: 
■ 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 the 

firefighter)?

■ 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 have 

and 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 of 

damage may cause loss of fabric strength or protective properties. It is particularly important to 

check 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 areas 

of 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, position 

of collar, ear covers, etc.) and whether parts of the ensemble were wet when worn (including wet from 

an 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 the 

investigation 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 to 

compare 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 (as 

listed 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; and

■ signs 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 ■ 164 ■ 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 be 

necessary to open the liner to determine the condition of the film or coated side of the moisture 

barrier.);

■ 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

■ 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 and 

interior).

Protective Footwear (Rubber)

■ loss of elasticity;

■ delamination of seam seals;

■ material damage;

■ steel toe or shank damage;

■ sole tread wear; and

■ loss 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; and

■ signs 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 to 

determine whether the item in question was operating properly and, if not, whether it contributed to the 

incident.

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 and 

temperature 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 item 

in 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 Minimum Recommended Photographs

Self-contained breathing apparatus (SCBA) •	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,	or	

accessory 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 ■ I: Background ■

Clothing or Equipment Item Minimum Recommended Photographs

Protective	hood •	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	other	

items	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	of	

footwear