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Office of the Medical Examiner

2014 Annual Report

Office of the Medical Examiner Commissioners Court (2014)

Commissioners Court (2015)

El Paso County Office of the Medical Examiner 4505 Alberta Drive El Paso, TX. 79905

Telephone: (915) 532-1447 Fax: (915) 532-6630 Website: http://www.epcounty.com/medicalexaminer/

Veronica Escobar County Judge Carlos Leon Commissioner Precinct 1 Sergio Lewis Commissioner Precinct 2 Vincent Perez Commissioner Precinct 3 Patrick Abeln Commissioner Precinct 4

Mario A Rascon, MD Chief Medical Examiner Juan U Contin, MD Janice Diaz-Cavalliery, MD Deputy Medical Examiners Irene Santiago Chief of Operations Annabel Salazar Chief Investigator Jennifer Contreras, D-ABMDI Deputy Chief Investigator Christina Enriquez Maricela Garcia Jose Labrado Carlos Lopez Jorge Ordaz Jose ”Louie” Romero, D-ABMDI Daniel Salas Investigators

Lorenzo Flores Forensic Photographer Angela Lawrence-Pusey Senior Administrative Assistant Shani Enriquez Transcriptionist Erick Vargas Gustavo Luevano Office Specialists Olga Chavez Morgue Manager Sal Tellez Morgue Supervisor Adrian Pineda Andrea Baca Morgue Attendants

Veronica Escobar County Judge Carlos Leon Commissioner Precinct 1 David Stout Commissioner Precinct 2 Vincent Perez Commissioner Precinct 3 Andrew Haggerty Commissioner Precinct 4

http://www.epcounty.com/medicalexaminer/

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2014 Annual Report

The information found in this annual report has been gathered from the case management system of the El Paso County Office of the Medical Examiner in El Paso, Texas (EPOME). Our staff strives to serve the citizens of El Paso with empathy, competency, integrity, and professionalism. The EPOME incorporates the scientific rigor of medicine and forensic science to investigate cases of sudden, unexpected deaths, or those that occur under violent or suspicious circumstances in El Paso County. We are acutely aware that, in many cases, the pursuit of civil or criminal proceedings is in part determined by our ability to determine the cause and manner of death. Thus, in an effort to provide thorough, honest investigations, the EPOME and its investigative medical staff, aside from the autopsy and ancillary testing, rely on witness accounts, law enforcement agencies, medical records review, first responders reports, and a wide variety of sources to certify the cause and manner of death. The EPOME is also very proud to function as an advocate for families by working with them to insure they are notified of the death, relaying preliminary findings, sharing the final autopsy report in a timely manner, assist families with funeral arrangements, and facilitating communication between the families and other agencies that will assist in the grieving process. Similarly, the EPOME works with organ and tissue procurement organizations whenever possible, to facilitate family wishes regarding postmortem donations. The public health role of the EPOME is to identify potential hazards in the community, to monitor trends in violence

and injury, to be adequately prepared for a potential emergency response, and to evaluate areas of concern

regarding health, safety, and welfare of the community. It is our hope that this report helps identify deadly trends

in the community that allow public health and policy efforts to enhance death prevention and surveillance efforts

and protect the lives of all El Pasoans.

Mario A Rascon, MD, D-ABP, D-ABMDI, F-CAP, F-NAME

Chief Medical Examiner

El Paso County Office of the Medical Examiner

The following individuals have contributed significantly to this document.

Irene Santiago Project Coordination, Database Administration, Proofreading Angela Lawrence-Pusey Data Coding, Database Administration, Database Maintenance, Statistical Data Olga Chavez Data Entry, Database Maintenance, Statistical Data Shani Enriquez Data Entry, Database Maintenance Erick Vargas Data Entry, Database Maintenance Gustavo Luevano Data Entry, Database Maintenance Lorenzo Flores Database Maintenance, Cover Photograph

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2014 Annual Report

TABLE OF CONTENTS

Introduction 4

Organizational Chart 5

Case Jurisdiction _______ 6

Executive Summary – 2014 7

EPOME Data (2011 – 2014) 7

Total cases handled by the EPOME

Exam Cases: Examination Type

Exam Cases: Manner of Death

Exam Cases: Toxicology and Histology Requests

EPOME Exam Cases: 2014 10

Manner of Death

Autopsy Status

Gender and Age Group

Natural Deaths 12

Accidents 14

Homicides 16

Suicides 18

Undetermined 20

Child Fatality ______________ 22

Fetal, Infant, and Child Deaths Summary Table

Infant Deaths: Cause of Death

Child Deaths: Cause of Death

Summary

Toxicology related deaths 25

Summary Table

Single vs. Multiple Drug

Single Drug-Related Deaths: Drug Involved

Multiple Drug-Related Deaths: Most Commonly Involved Drugs

Multiple Drug-Related Deaths: Number of Drugs Involved and Medication Key

Motor Vehicle Related Deaths 30

Summary Table

Manner of Death

Status of Decedent

Forensic Consultations 32

Neuropathology, Cardiovascular Pathology, Anthropology, and Entomology

Organ & Tissue Donation _______ 32

Cremation Authorizations 32

Unidentified Bodies 32

Unclaimed Bodies 33

Academic Outreach, Community Involvement, and Professional Development 33

Glossary 35

Epilogue 36

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2014 Annual Report

INTRODUCTION

This Annual Report would not be possible without the dedication and professionalism of the employees who

incessantly work for the El Paso County Office of the Medical Examiner (EPOME)

The EPOME provides medico-legal death investigation, including autopsy services and certification of cause and

manner of death in cases of homicides, suicides, accidents and sudden or unexpected natural deaths occurring in

the El Paso County. Exceptions to this disposition are areas within the County that arrange for their own death

investigations through their own governance bodies or with Federal assistance (Fort Bliss, Ysleta del Sur Pueblo).

The cause of death is a disease, injury, toxic material, or combination of factors that causes a physiologic derangement severe enough to result in death. The manner of death refers to the circumstances surrounding how the death came about and is divided into five categories: natural, accident, suicide, homicide, and undetermined.

The Texas Code of Criminal Procedure (Chapter 49. Inquests Upon Dead Bodies), stipulates that the EPOME shall

conduct an inquest into the death of a person who dies in the County if:

(1) the person dies in jail or in prison (except under circumstances different than described by Section

501.055(b);

(2) the person dies an unnatural death from a cause other than a legal execution;

(3) the body or a body part of a person is found, the cause or circumstances of death are unknown,

whether the person is identified or unidentified;

(4) the circumstances of the death indicate the death may have been caused by unlawful means;

(5) the person commits suicide or the circumstances of the death indicate that the death may have been

caused by suicide;

(6) the person dies without having been attended by a physician;

(7) the person dies while attended by a physician who is unable to certify the cause of death and who

requests the justice of the peace to conduct an inquest; or

(8) the person is a child younger than six years of age (few exceptions are part of this provision)

Decisions about autopsies are not mandated and are left to the discretion of the medical examiner. Furthermore,

the laws are general enough that jurisdiction may be accepted in a wide variety of cases that are not otherwise

specified in law.

In addition, the EPOME services the community by assisting families with funeral arrangements, authorizing

cremations, signing death certificates, reporting viable candidates to the local tissue bank for postmortem

donation, positively identifying decedents, preparing for a mass disaster, teaching Medical Students (Paul L Foster

School of Medicine), and fostering community outreach through different institutions

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2014 Annual Report

ORGANIZATIONAL CHART

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2014 Annual Report

CASE JURISDICTION

The El Paso Metro area covers an area of 1,015 square miles, and has an estimated population (2013) of about

827,718. Countywide, the population is about 93% white (which includes 81% Hispanic and 12% white alone), 4%

black, 1% American Indian, 1% Asian, 1% two or more races.

When a local death (one that occurs within the boundaries of El Paso County) is reported to the EPOME, the case is either accepted or released. If a case is accepted, it means that the medical examiner will be signing the death certificate. A case is released (not accepted in the EPOME jurisdiction) when the death need not have been reported and there is a physician who is willing to sign the death certificate. A case is accepted if it meets the criteria specified by law as described above, and the death occurred in El Paso County Local deaths that fall under the EPOME jurisdiction are transported to the EPOME for examination by a contract body transport company. In the vast majority of cases, an EPOME investigator attends the death scene in person to perform a preliminary examination of the body as well a present a written field report to the medical examiner. EPOME investigators usually attend all homicides, suicides, and accidental deaths, and selected natural deaths. Investigators are on staff and available 24 hours/day, 365 days/year. EPOME investigators do not physically perform scene investigations on cases that are reported to them from outside of the physical boundaries of El Paso County.

On accepted cases, the medical examiner uses one of two approaches to obtain information to complete the death certificate: • Inquest. The death certificate is signed without examining the body (review of medical records and other

pertinent reports). • Exams: The body is physically transported to the EPOME, and a final written report is produced:

External Examination. Formal external examination, which may or may not include toxicology/chemical testing. Autopsy. Complete autopsy. A partial autopsy (dissection limited to specific anatomic sites) is sometimes performed if there is expressed objection to autopsy or significant health or safety risks exist for staff.

Area served by the EPOME is highlighted in red

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2014 Annual Report

EXECUTIVE SUMMARY – 2014

In 2014, the EPOME received a referral of 3798 cases. Every referral requires a preliminary screening by

EPOME investigative staff to determine if it falls under the jurisdiction of the EPOME. Of those calls, a

total of 2813 cases were released, with death certificates being signed by primary care physicians in the

community. Jurisdiction was accepted on a total of 985 cases (324 inquests and 661 exam cases). In all

the exam cases the bodies were physically examined at the EPOME and autopsies were conducted on 490

(476 complete autopsies; 14 partial autopsies) and 171 underwent an external examination only.

There were 2 cases of human bone remains in 2014, which required an anthropology consultation.

EPOME DATA (2011 – 2014)

TOTAL CASES HANDLED BY THE EPOME – 2011 to 2014

2467 2529 2634 2813

300 304 295

324 648 626

656

661

0

500

1000

1500

2000

2500

3000

3500

4000

2011 (3415)

2012 (3459)

2013 (3585)

2014 (3798)

Exam

Inquest

Release

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2014 Annual Report

EXAM CASES 2011 to 2014 – EXAMINATION TYPE

Autopsy examinations have increased from 55% of the exam cases in 2012 to 74% in 2014.

EXAM CASES 2011 to 2014 – MANNER OF DEATH

384

350

465 490

264 276

189 171

0

100

200

300

400

500

600

2011 2012 2013 2014

Autopsy

External

338

223

46 25 16

327

185

65

29 20

324

207

75

19 31

276

231

96

34 24

0

50

100

150

200

250

300

350

400

Natural Accident Suicide Homicide Undetermined

2011

2012

2013

2014

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2014 Annual Report

EXAM CASES 2011 to 2014 – TOXICOLOGY & HISTOLOGY REQUESTS

Ancillary procedures, such as toxicology testing and histological examination have increased since 2012, 197% and 481%,

respectively.

180

160

280

316

161

58

236

279

0

50

100

150

200

250

300

350

2011 2012 2013 2014

Toxicology

Histology

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2014 Annual Report

EPOME 2014: EXAM CASES

2014 TOTAL EXAM CASES (661) – MANNER OF DEATH

2014 TOTAL EXAM CASES (661) – AUTOPSY STATUS

MANNER OF DEATH

NATURAL ACCIDENT SUICIDE HOMICIDE UNDETERMINED TOTAL (%)

Full Autopsy (%) 200 (72.5%) 165 (71.4%) 59(61.4%) 34 (100) 18(75%) 476 (72.1%)

Partial Autopsy (%) 5 (1.8%) 3 (1.3%) 6(6.3%) 0 0 14 (2.1%)

External Exam (%) 71 (25.7%) 63 (27.3%) 31(32.3%) 0 *6(25%) 171 (25.8%)

TOTAL 276 231 96 34 24 661/100% *includes 3 abortions, 1 stillbirth and 2 skeletal remains

42%

35%

14%

5% 4%

Natural, 276

Accident, 231

Suicide, 96

Homicide, 34

Undetermined, 24

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2014 Annual Report

2014 TOTAL EXAM CASES (661) – GENDER AND AGE GROUP

M A N N E R O F D E A T H

NATURAL ACCIDENT HOMICIDE SUICIDE UNDETERMINED TOTAL

Age Group ♂ ♀ ♂ ♀ ♂ ♀ ♂ ♀ ♂ ♀ Unknown

<1 3 - 3 4 1 1 - - 3 3 3 21

1-5 - 1 2 3 - 1 - - - - - 8

6-10 - - - - - - - - - - - -

11-18 1 - 6 - 2 - 2 3 1 - - 15

19-25 1 3 21 6 7 1 10 2 3 - - 53

26-35 10 2 26 7 6 1 19 6 2 - - 79

36-45 15 8 32 7 2 2 10 4 1 - - 81

46-55 50 12 25 11 3 1 7 4 1 - - 114

56-65 64 20 28 17 1 2 11 3 2 1 - 149

66-75 28 12 10 4 2 1 4 - 2 - - 63

76-85 15 17 8 2 - - 9 - - - - 51

>85 10 4 6 3 - - - 1 - - - 24

Unknown - - - - - - 1 - 1 - 1 3

TOTAL 197 79 167 64 24 10 73 23 16 4 4 661

♂ : 477

♀ : 180

Unknown: 4

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2014 Annual Report

NATURAL DEATHS: 2011 – 2014

2014 NATURAL DEATHS (276) – GENDER AND AGE GROUP

Individuals aged 47 - 69 years comprised 47.9% of all people who succumbed to natural deaths.

336 327 323

276

0

50

100

150

200

250

300

350

400

2011 2012 2013 2014

3 1 10

15

50

64

28

1 3

2 8

12

20

12

0

10

20

30

40

50

60

70

80

90

Female

Male

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2014 Annual Report

2014 NATURAL DEATHS (276) – CAUSE OF DEATH

Cardiovascular Disease 169

Chronic Alcohol Abuse 21

Pulmonary Embolus 10

Diabetes Mellitus 9

Pneumonia 8

Seizure Disorder 7

Cancer 5

COPD 5

Hemorrhagic Stroke 5

Liver Cirrhosis 5

Morbid Obesity 5

Undetermined 5

Ruptured Berry Aneurism 3

Congenital Anomalies 2

Intestinal Ischemia 2

Mediastinitis 2

Asthma 1

AV Block 1

Cellulitis 1

Hepatic Abscesses 1

Intrauterine Fetal Demise 1

Ischemic Stroke 1

Necrotizing Fasciitis 1

Polycystic Kidney Disease 1

Pancreatitis 1

Peptic Ulcer Disease 1

Pyelonephritis 1

Sepsis 1

Starvation 1

TOTAL 276

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2014 Annual Report

ACCIDENTS: 2011 – 2014

2014 ACCIDENTS (231) – GENDER AND AGE GROUP

Accident victims were most frequently male (72%). Individuals between the ages of 22 – 52 years comprised 52% of

all accidental deaths. Accidents increased by 11.5% from 2013 to 2014.

221

185 207

231

0

50

100

150

200

250

2011 2012 2013 2014

3 2 6

21 26

32

25 28

10 8 6 4

3

6

7

7

11

17

4

2 3

0

5

10

15

20

25

30

35

40

45

50

Female

Male

<1

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2014 Annual Report

2014 ACCIDENTS (231) – MECHANISM

*note that the sum of all cases is >231 due to some cases involving multiple mechanisms, e.g., an intoxicated individual that

sustains a lethal head injury after a fall

Blunt Force Injuries 132

Acute Toxicity 67

Mixed Alcohol and Drug Toxicity 12

Drowning 9

Suffocation 5

Thermal Injuries 4

Hydrogen Sulfide Poisoning 2

Traumatic Asphyxia 2

Environmental Cold Exposure 2

Environmental Heat Exposure 2

Gunshot Wound 1

Choking 1

Wedging 1

Pericarditis 1

Dialysis Shunt Rupture 1

TOTAL 242*

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2014 Annual Report

HOMICIDES: 2011 – 2014

Homicide victims were most frequently male (70.5%). Individuals between the ages of 17 – 33 years comprised 47%

of all homicide victims.

Homicides increased by 78% from 2013 to 2014. Despite the increase, homicide rates in El Paso (4.1 per 100,000)

remain lower than the national rate of 4.5 per 100,000 (FBI Uniform Crime Report, 2014).

Furthermore, it should be noted that 6 of the homicide exam cases from the EPOME in 2014 (17.6% of the total

homicides), were cases in which the assault leading to the death took place outside of the El Paso County and, in

fact, outside of the State of Texas (5 cases from New Mexico and 1 case from Ciudad Juarez, Mexico). The corrected

homicide rate for homicides that took place in the El Paso County geographical circumscription (28 cases) equals 3.3

per 100,000, which ranks amongst the lowest homicide rate in the USA for a city with >500,000 population.

25

29

19

34

0

5

10

15

20

25

30

35

40

2011 2012 2013 2014

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2014 Annual Report

2014 HOMICIDES (34) – GENDER AND AGE GROUP

2014 HOMICIDES (34) – MODE OF INFLICTION

1

2

7

6

2

3

1

2

1

1

1

1

2

1

2

1

0

1

2

3

4

5

6

7

8

9

<1 1-5 6-10 11-18 19-25 26-35 36-45 46-55 56-65 66-75

Female

Male

27%

38%

26%

3% 3% 3%

Blunt Force, 9

Gunshot, 13

Sharp Force, 9

Ligature Strangulation, 1

Blunt and Sharp Force, 1

Unspecified Means, 1

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2014 Annual Report

SUICIDES: 2011 – 2014

2014 SUICIDES (96) – GENDER AND AGE GROUP

46

65 75

96

0

20

40

60

80

100

120

2011 2012 2013 2014

1 2

10

19

10

7

11

4

9 3

2

6

4

4

3

1

0

5

10

15

20

25

30

Female

Male

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2014 Annual Report

2014 SUICIDES (96) – METHOD

*includes: motor vehicle crash (1); jumped out of moving vehicle (1); ran into traffic (2); hit by train (1); descent from height (2);

thermal injuries (1).

Suicide victims were most frequently male (76%). Individuals between the ages of 21-39 years comprised 47.9% of

all suicides. The vast majority (84%) of suicidal gunshot wounds were located on the head, followed by the chest

(10%), neck (4%), and abdomen (2%).

Suicides increased by 28% from 2013 to 2014 and have more than doubled since 2011.

14%

24%

53%

1% 8%

Drug Toxicity, 13

Hanging, 23

Firearm, 51

Sharp Force, 1

Blunt Force*, 8

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2014 Annual Report

UNDETERMINED MANNER OF DEATH: 2011 – 2014

2014 UNDETERMINED MANNER OF DEATH (24): GENDER AND AGE GROUP

*includes: abortions (3), stillbirths (2), and Sudden Unexplained Infant Death (4).

16

20

31

24

0

5

10

15

20

25

30

35

2011 2012 2013 2014

1

3

1

3 2

1 1 2 2

3

1

1

3

0

1

2

3

4

5

6

7

8

9

10

Unknown

Female

Male

<1*

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2014 Annual Report

2014 UNDETERMINED MANNER OF DEATH: ASSOCIATED CAUSE OF DEATH

21%

17%

8%

50%

4%

Drug Toxicity, 5

Blunt Force Injury, 4

Skeletal Remains, 2

Undetermined Cause, 12

Hemoperitoneum, 1

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2014 Annual Report

CHILD FATALITY

In 2014, there were 36 deaths of children (individuals 18 years or age or younger), which included the deaths of 15

infants (a child in the first year of life). Additionally, 6 fetal deaths (3 abortions, 3 stillbirths) fell under the EPOME

jurisdiction in 2014.

2014 FETAL, INFANT, AND CHILD DEATHS – SUMMARY TABLE




Fetus 1 - - - - - - - - 2 3 6

<1 2 - 3 4 1 1 - - 3 1 - 15

1-3 - 1 2 3 - 1 - -

7

4-6 - - - - - - - - - - - -

7-10 - - - - - - - - - - - -

11-15 - - 1 - - - - 3 - - - 4

16-18 1 - 4 - 2 - 2 - 1 - - 10

TOTAL 4 1 10 7 3 2 2 3 4 3 3 42

♂ : 23

♀ : 16

Unknown: 3

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2014 Annual Report

2014 INFANT DEATHS (CHILDREN <1Y) – CAUSE OF DEATH

2014 CHILD DEATHS (CHILDREN 1-18) – CAUSE OF DEATH

Drowning 2

Drug Intoxication 1

Heat Exposure 1

Homicidal Blunt Force 1

Homicidal Gunshot 1

Homicidal Stabbing 1

Job-related Accident 1

Motor Vehicle Crash 3

Natural Causes 2

Run Over by Car 3

Suicidal Gunshot 1

Suicidal Hanging 4

TOTAL 21

Asphyxia - Suffocation 4

Asphyxia - Wedging 2

Congenital Anomalies 1

Drowning 1

Homicidal Blunt Force Injury 2

Undetermined (SUID) 4

Urinary Tract Infection 1

TOTAL 15

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2014 Annual Report

CHILD FATALITY – SUMMARY

Childhood deaths represented 6.3% all the exam cases investigated by the EPOME in 2014. Male decedents comprised 54% of the total deaths in children. The most common manner of death among children was accident (40%), followed by undetermined (23%). There were 4 suicides among children in 2014. Hanging (3 cases) and gunshot wound (1 case) were the methods of suicide in children. The total number of childhood homicides was 5. Blunt trauma (3 cases) was the most common mechanism of inflicted injury, followed by stabbing and gunshot wounds (1 case each). Of note is the relative high number of undetermined deaths in infants, which reflect the evolving nomenclature surrounding sudden unexplained infant deaths. Historically, many of these infant deaths were certified as Sudden Infant Death Syndrome (SIDS), which were then certified in manner as a natural (or sometimes and accidental) death. Currently, contemporary forensic pathologists have migrated from certifying infant deaths as SIDS, and replaced it with ‘undetermined’ cause and manner of death, which reflects a more honest admission of not knowing with certainty all the events that lead to an infant’s death. An excellent resource for additional information about the deaths of children in El Paso, their circumstances, risk

factors, and opportunities for prevention is the Child Fatality Review Team (CFTR) for El Paso County, which consists

of volunteers from many state and local agencies. The experts on this team review the circumstances of childhood

deaths in order to identify risk factors and develop prevention strategies, and their findings are presented in an

annual report

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2014 Annual Report

TOXICOLOGY-RELATED DEATHS

2014 TOXICOLOGY-RELATED DEATHS – SUMMARY TABLE

Individuals between the ages of 26-55 years comprised 71.6% of all toxicology-related deaths. Accidents comprised

82% of all toxicology-related deaths.

Regarding accidental toxicology-related deaths, the Male-to-Female ratio is 3.8:1; this ratio is nearly inverted in

suicidal toxicology-related deaths (F:M ratio 4:1).

The cases ruled undetermined in manner included cases in which a definite intention to self harm was not

established, but at least one aspect of the investigation suggested the death could have been a suicide.




0-17 - - - - - - - - - - - -

18-25 - - 2 1 - -

- 1 - - 4

26-35 - - 10 4 - - 1 3 1 - - 19

36-45 - - 14 2 - - - 2 1 - - 19

46-55 - - 15 4 - - - 1 - - - 20

56-65 - - 10 4 - - - 2 1 - - 17

66-75 - - 1 0 - - - - - - - 1

76-85 - - - - - - 1 - - - - 1

>85 - - - - - - - - - - - -

TOTAL - - 52 15 - - 2 8 4 - - 81

♂: 58

♀ : 23

Unknown: 0

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2014 Annual Report

2014 TOXICOLOGY-RELATED DEATHS – Manner of Death

2014 TOXICOLOGY-RELATED DEATHS – Single vs. Multiple Drugs

83%

12%

5%

Accident, 67

Suicide, 10

Undetermined, 4

36%

64%

Single Drug, 29

Multiple Drug, 52

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2014 Annual Report

2014 SINGLE DRUG-RELATED DEATHS – Drug Involved

More than half (51.7%) of the single-drug-related deaths were due to Heroin toxicity. There were three suicides via single drug

toxicity.

2014 MULTIPLE DRUG-RELATED DEATHS –Most Frequently Involved Drugs

Ethanol was present in 34.6% of all multiple drug-related deaths, as was heroin. Cocaine was present in 28.8% of all

multiple drug-related deaths. Opiates (heroin, morphine, oxycodone) were present in over half (52%) of the

multiple drug-related death cases. Overall, stimulants (cocaine, methamphetamine) were present in over a third

(36%) of the multiple drug-related death cases.

Heroin 15 Accident

Ethanol 3 Accident

Cocaine 3 Accident

Hydrocodone 2 Accident

Hydrocodone 1 Suicide

Diphenhydramine 2 Suicide

Diphenhydramine 1 Accident

Methadone 1 Accident

Doxylamine 1 Accident

TOTAL 29

Drug Mentioned N. of Cases

Ethanol 18

Heroin 18

Cocaine 15

Alprazolam 14

Hydrocodone 14

Zolpidem 7

Morphine 5

Clonazepam 5

Methamphetamine 4

Fluoxetine 4

Oxycodone 4

Quetiapine 4

Sertraline 4

Venlafaxine 3

Methadone 3

Carisoprodol 3

Diazepam 3

Doxylamine 3

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2014 Annual Report

2014 TOXICOLOGY-RELATED DEATHS – Multiple-Drug-Related Deaths: Number of Drugs Involved

Number of Drugs

MANNER 2 3 4 5 6 7 8

UNDETERMINED

1 38, 50

2 10, 12, 25

3 2, 20, 50

4 2, 18, 25, 27, 41

SUICIDE

1 3, 25, 50

2 8, 39

3 9, 25, 35

4 9, 25, 38, 50

5 20, 25, 37, 43

6 42, 48

7 6, 13, 20, 23, 27

ACCIDENT

1 2, 12, 25

2 16, 18, 41, 47

3 12, 25

4 20, 24

5 20, 25, 35, 41

6 2, 22, 25, 42, 50

7 2, 38

8 2, 12, 23, 32, 50

9 2, 15, 24, 25

10 12, 32, 35

11 24, 32

12 2, 6, 8, 12, 20

13 12, 20

14 2, 20, 22

15 2, 24

16 19, 25, 46

17 12, 24

18 20, 24

19 12, 24

20 20, 24

21 20, 24

22 32, 35

23 15, 20, 24

24 2, 23, 38

25 12, 25, 31

26 10, 15, 20

27 20, 31

28 31, 35

29 12, 24

30 2, 25, 41

31 20, 24

32 20, 24

33 20, 24

34 3, 7, 8, 10, 23, 27, 34, 50

35 47, 50

36 10, 45, 47, 49

37 12, 24, 42

38 12, 20, 24

39 2, 10, 24, 31

40 16, 18, 42

41 12, 24

TOTAL (52) 23 16 7 5 1

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2014 Annual Report

2014 TOXICOLOGY-RELATED DEATHS – Multiple-Drug-Related Deaths: Medication Key

ACETAMINOPHEN 1 ALPRAZOLAM 2 AMITRYPTILINE 3 AMPHETAMINE 4 BENZODIAZEPINE 5

BUPROPION 6

BUTALBITAL 7

CARISOPRODOL 8

CITALOPRAM 9

CLONAZEPAM 10

CLOZAPINE 11

COCAINE 12

CYCLOBENZAPRINE 13

DESIPRAMINE 14

DIAZEPAM 15

DIPHENHYDRAMINE 16

DIFLUORETHANE 17

MORPHINE 35

OPIATES 36

OXAZEPAM 37

OXYCODONE 38

PAROXETINE 39

PSEUDOEPHEDRINE 40

QUETIAPINE 41

SERTRALINE 42

TEMAZEPAM 43

TETRAFLUOROETHANE 44

TOPIRAMATE 45

TRAMADOL 46

VENLAFAXINE 47

VERAPAMIL 48

ZIPRASIDONE 49

ZOLPIDEM 50

ZOPICLONE 51

DULOXETINE 19

ETHANOL 20

ETHYLENE GLYCOL 21

FENTANYL 22

FLUOXETINE 23

HEROIN 24

HYDROCODONE 25

HYDROMORPHONE 26

HYDROXYZINE 27

INHALANTS 28

LORAZEPAM 29

MECLIZINE 30

METHADONE 31

METHAMPHETAMINE 32

METHANOL 33

MIRTAZAPINE 34

30


2014 Annual Report

MOTOR VEHICLE RELATED DEATHS

2014 MOTOR VEHICLE RELATED DEATHS – SUMMARY TABLE

There were 100 motor vehicle related fatalities in 2014, the vast majority of which were accidental deaths (91%).

The male:female ratio was 3:1


ACCIDENT HOMICIDE SUICIDE UNDETERMINED

Age Group ♂ ♀ ♂ ♀ ♂ ♀ ♂ ♀

>1 - - - - - - - - 0

1-5 2 1 - - - - - - 3

6-10 - - - - - - - - 0

11-18 4 - - - - - - - 4

19-25 18 5 - - 1 - 2 - 26

26-35 14 2 - - - 2 1 - 19

36-45 7 2 - 1 1 - - - 11

46-55 6 2 - - - - - - 8

56-65 9 8 - - - - - - 17

66-75 4 1 - - - - - - 5

76-85 2 - - - - - - - 2

>85 3 1 - - - - - - 4

Unknown - - - - 1 - - - 1

TOTAL 69 22 0 1 3 2 3 0 100

♂ : 75

♀ : 25

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2014 Annual Report

2014 MOTOR VEHICLE RELATED DEATHS – MANNER OF DEATH

2014 MOTOR VEHICLE RELATED DEATHS – STATUS OF DECEDENT

91%

5% 3% 1%

Accident, 91

Suicide, 5

Undetermined, 3

Homicide, 1

Hit by Train 3 Undetermined

Motor Vehicle – Front Passenger 1 Homicide

Jumped out of Running Motor Vehicle 1 Suicide

Motor Vehicle – Driver 1 Suicide

Hit by Train 1 Suicide

Ran into Traffic 2 Suicide

Motor Vehicle – Driver 32 Accident

Motor Vehicle – Front Passenger 4 Accident

Motor Vehicle – Back Passenger 4 Accident

Motor Vehicle, non-driver – position unknown 3 Accident

Motorcyclist 18 Accident

Pedestrian 28 Accident

Pinned Under Stationary Vehicle 2 Accident

TOTAL 100

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2014 Annual Report

FORENSIC CONSULTATIONS

On occasion, a detailed forensic neuropathology or forensic cardiovascular pathology is required to further

characterize important anatomic findings in selected cases. In the past, this was done through a forensic pathologist

consultant outside the State. In 2014, a forensic pathologist with subspecialty training in forensic cardiovascular

pathology and forensic neuropathology joined the EPOME as Deputy Medical Examiner and is currently in charge of

such consultations.

ORGAN AND TISSUE DONATION

In 2013 and 2014, 285 cases from the EPOME were referred to an organ procurement agency (OPO) for potential tissue donation. Of these, 138 families were approached and 54 consents were obtained. Subsequently, a total of 20 tissue procurements were conducted.

CREMATION AUTHORIZATIONS

In Texas, Medical Examiners and/or Justices of the Peace are required by law to sign cremation authorizations before a body is cremated. The forensic pathologists at the EPOME review each cremation authorization form and the respective death certificate before authorizing cremation. The table below shows the number of cremation authorizations signed by our forensic pathologists over the recent years.

UNIDENTIFIED BODIES The EPOME interacts with law enforcement agencies to positively identify individuals. By far, the most frequently

used technique is fingerprint comparison. Other scientific methods of identification (ID) include: radiograph

comparison (dental or body), medical devices, and DNA extraction.

Over the past 4 years, 94 decedents have been positively identified using this method. Additionally, in 2014, two decedents were positively identified via dental radiograph comparison; both cases involved decedents with thermal injuries.

YEAR Neuropathology Cardiovascular Anthropology Entomology

2013 5 4 1 0

2014 2 0 2 1

YEAR Cremations

2011 2823

2012 2585

2013 2717

2014 2839

YEAR Fingerprint ID

2011 9

2012 15

2013 22

2014 48

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2014 Annual Report

UNCLAIMED BODIES

El Paso County General Assistance Program provides financial assistance to help families who have lost a loved one pay for the funeral and cremation of the individual's remains. Over the past 4 years, 60 cases have been referred to this program.

YEAR Fingerprint ID

2011 17

2012 10

2013 14

2014 19

ACADEMIC OUTREACH, COMMUNITY INVOLVEMENT, AND PROFESSIONAL DEVELOPMENT The EPOME regularly interacts with the local community in a variety of ways such as academic outreach (lectures in academic institutions such as local High Schools, Colleges and Universities), inter-agency outreach (local Law enforcement agencies) and cooperative efforts (invited lectures, County Child Fatality Review Team) The EPOME also provides teaching in forensic pathology for students at the Paul L Foster School of Medicine, Texas

Tech University Health Sciences Center and fulfills, through courtroom testimony as expert witness, its legal obligations related to its involvement in medicolegal death investigation.

Academic Outreach and Community Involvement Lorenzo Flores – Forensic Photographer

2/27 San Elizario High School Career Day

3/7 Mountain View High School Career Day

3/19 Low light in-house photography

4/10 USBP Ysleta Station R.E.A.L Program

4/23 Low light in-house photography

5/1 SSG. M.R. Puentes Mid. School Career Day

5/2 Montwood High School Career Day

5/8 IBC West

6/6 Western Tech. Northeast

6/11 Excel Learning Center

6/27 USBP Mattox Station R.E.A.L. Program

7/1 USBP Ysleta Station R.E.A.L Program

10/29 USBP Ysleta Station Explorers Program

10/30 Magoffin Middle School Career Day

Janice Diaz-Cavalliery, MD

Texas criminal defense lawyers association. Forensic evidence and expert witness seminar. Medical forensics. September 19, 2014

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2014 Annual Report

Mario A Rascon, MD

Introduction to Forensic Pathology. Texas Tech University Health Sciences. Center, Paul L. Foster School of Medicine. Pathology interest group. March 27, 2014.

Medical Professionals Panel – Bioscience. University of Texas at El Paso. April 3rd, 2014

Introduction to Pathology. College High School Career Expo. Mission Early High School. May 2nd, 2014.

Internships

Investigative Intern, Summer. Mr. Miguel Aguirre (St. Mary’s University).

Morgue Intern, Winter. Ms Brianna Roghelia (EPCC)

Professional Development In 2014, the EPOME administrative, investigative, and morgue staff completed 396.55 hours of trainings, including:

Irene Santiago and Annabel Salazar:

July 2014. Mass Fatality workshop with the Health Department

October 2014. Hospice of El Paso training on death investigations/reportable deaths

October 2014. El Paso Fire Department Airport Exercise (Triennial)

November 2014. Suicide Coalition/Aliviane

Juan U Contin, MD

February 2014. Mid-Winter Medicine Update Conference in Ruidoso, NM. Presbyterian Healthcare Services

Janice Diaz-Cavalliery, MD

October 2014. El Paso Fire Department Airport Exercise (Triennial)

Mario A Rascon, MD

February 2014. Science, Law, and the Inferential Process. Workshop during the AAFS 66th Annual Scientific Meeting. Seattle, WA.

April 2014. Texas Mortuary Operations Response Team Structure Development Meeting. The Harris County Institute of Forensic Sciences. Houston, TX.

August 2014. 41st Annual New England Seminar in Forensic Sciences. Colby College. Waterville, ME

Christina Enriquez

Medicolegal Death Investigators Training Course. August 2014. Saint Louis University School of Medicine. St. Louis, MO.

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2014 Annual Report

GLOSSARY

Abortion - the premature exit of the products of conception (fetus, fetal membranes, or placenta) from the uterus. Accident – the manner of death used when, in other than natural deaths, there is no evidence of intent Autopsy – a detailed postmortem external and internal examination of a body to determine cause of death, collect evidence, determine the presence or absence of injury. The autopsy includes examination of the internal organs and structures after dissection. Cause of Death – a disease, injury, or poison resulting in a physiological derangement or biochemical disturbance that is incompatible with life. The result of post-mortem examination, including autopsy and toxicological findings, combined with information about the medical history of the decedent serves to establish the cause of death. The cause of death can result from different circumstances and manner of death. For example, the same cause of death, gunshot wound, can result under suicidal, homicidal, or accidental manners. Children – individuals 18 years of age and younger. Ethanol – an alcohol, which is the principal intoxicant in beer, liquor, and wine. External Examination– a detailed postmortem external examination of a body, conducted when a full autopsy is determined to not be required. Homicide – the manner of death in which death results from the intentional harm of one person by another. Infant - a child in the first year of life Inquest - an investigation into the cause and circumstances of the death of a person, and a determination, made with or without a formal court hearing, as to whether the death was caused by an unlawful act or omission. Physician: a practicing doctor of medicine or doctor of osteopathic medicine who is licensed by the Texas State Board of Medical Examiners under Subtitle B, Title 3, Occupations Code. Jurisdiction – the extent of the Office of the Medical Examiner’s authority over deaths. The EPOME authority covers every death which is due or which might reasonably have been due to a violent or traumatic injury or accident, or is of public health interest and will be investigated by the Medical Examiner. Manner of Death – the general category of the circumstances of the event which causes the death. The categories are accident, homicide, natural, suicide, and undetermined. Method of Death – the means, fatal agency or item causing death, present at the time of injury or death. Natural – the manner of death used when solely a disease causes death. If death is hastened by an injury, the manner of death is not considered natural. Office of the Medical Examiner – the office within the El Paso County that is responsible for the investigation of sudden, violent, or unexpected death. Opiate – a class of drugs, including morphine, codeine, and heroin, derived from the opium poppy plant (Papaver somniferum). Pending – the cause of death and manner of death are to be determined pending further investigation (such as toxicological, histological and/or neuropathological testing). Stillbirth – the death of a fetus after the 20th week of pregnancy. Also known as Intrauterine Fetal Demise (IUFD) Stimulant: a class of drugs, including cocaine and oral amphetamines, whose principal action is the stimulation of the central nervous system. Sudden and Unexpected Infant Death - the death of an infant less than one year of age in which investigation, autopsy, medical history review and appropriate laboratory testing fail to identify a specific cause of death. Sudden Infant Death Syndrome – (SIDS) a broad, heterogeneous group of unknown causes of death in infants which, since its creation in 1969, evolved from a descriptor into a diagnosis as if it were a singular disease or disorder. Forensic pathologist are migrating away and abandoning the use of SIDS as a diagnostic phrase. Suicide – the manner of death in which death results from the purposeful attempt to end one’s life. Undetermined – the manner of death for deaths in which there is insufficient information to assign another manner. An undetermined death may have an undetermined cause and manner of death; an undetermined cause of death and a known manner; or a known cause of death and an undetermined manner.

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2014 Annual Report

EPILOGUE

On behalf of the EPOME I would like to thank the Commissioners Court for offering continued support of the EPOME, an agency that fulfills an irreplaceable duty and a necessary service for the citizens of El Paso. I also wish to express my deepest gratitude to the EPOME staff: our investigators, a group of professional, committed individuals who are permanently available to reach any scene in any corner of the County and tend to our families’ needs in an effort to provide them with answers after the tragic loss of a loved one; our administrative staff members, who competently keep this program running, and our morgue staff, whose skillful and diligent work allow proper documentation of autopsy findings. This report is dedicated with the utmost respect and gratitude to Dr. Juan U. Contin, a discerning man tirelessly dedicated to giving voice to those no longer with us.

Mario A Rascon, MD, D-ABP, D-ABMDI, F-CAP, F-NAME

Chief Medical Examiner

El Paso County Office of the Medical Examiner

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2014 Annual Report

2014 El Paso County Office of the Medical Examiner Annual Report This publication may be reproduced, in whole or in part, without permission. Digital copies of this publication can be requested at [email protected] Created by: Mario A Rascon

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