Appendix 1: Autopsy Protocol in Case of Gunshot Wounds and Intoxication HILLSBOROUGH COUNTY, FLORIDA MEDICAL EXAMINER DEPARTMENT1 401 SOUTH MORGAN STREET TAMPA,FLORIDA 33602 813-272-5342 Report of Diagnosis and Autopsy on [name of decedent] File 0x − 0xxxx 1 The county seal, contact information, decedent name and case number were brought out to a title page in order to provide more room on the diagnosis page. 101 102 Appendix 1 OPINION Final Diagnosis: Gunshot wound to chest, penetrating,2 indeterminate range. Perforation of heart and lungs. Pericardial and pleural hemorrhage3 Gunshot wound to left thigh, perforating, indeterminate range. Intoxication4 by ethyl alcohol Cause of Death: Gunshot Wound to Chest, with Perforation of Heart and Lungs Manner of Death: Homicide (Shot by other person with handgun) [name of pathologist], M.D. Date Signed Associate Medical Examiner 2 From the word “penetrating,” the reader can know that there is a bullet. 3 The more dynamic form, “pleural hemorrhage” is chosen over that static form, “hemothorax.” 4 “Intoxication” is an opinion that is independent of morphologic findings. Appendix 1 103 Death: [date] at 0104 hours Autopsy: [date] [street address] 401 S Morgan St, Tampa Age: 23 years Performed by: Length and Weight: 505, 124 pounds [name of pathologist], M.D. DESCRIPTION OF AUTOPSY FINDINGS Clothing: The body is received clothed in a white sleeveless T-shirt, black running pants, blue bikini underwear and blue and black flip-flops sandals. A gunshot defect is in the left pectoral region of the T-shirt, with no soot or gunpowder on the surrounding fabric. External Examination: 28 May 2003 at 1255 hours The body is that of a well-developed, well-nourished man who appears consis- tent with the above-stated length, weight, and age. The body length is personally measured at 65. Rigor mortis is fully developed. Livor mortis is posterior, partially blanches with digital pressure, and extends to the posterior axillary line. The body is cold from refrigeration. The anterior aspect of the left shoulder has a few small postmortem tan-yellow ant bites. The scalp is atraumatic and is covered by straight black hair in a full distribution. The skin is light brown. The irides are brown and the pupils are midsized.5 The conjunctivae have no petechiae. Facial hair comprises a mustache and chin whiskers. The nasal septum is intact. The oral mucosa has no injuries. The teeth are natural and in fair repair. The neck, back, chest, and abdomen have no masses or scars. The penis is uncir- cumcised and free of injuries. The testes are descended. The anus has no injuries. Adhesive cardiac monitors on are on torso.6 The upper and lower extremities have no masses. The lateral aspect of the right shoulder has a tattoo of a heart and an illegible word. 5 The decedent was ethnically Hispanic. No attempt to assign a race is made here. Rather, a few physical features are described. 6 Because the medical devices occupy only a single sentence, a special paragraph for medical devices and artifacts is not needed. 104 Appendix 1 Gunshot Wound of Chest7: 1. An entrance gunshot wound is in the left pectoral region of the chest, medial and superior to the left nipple, 14 1/2 inferior to the top of the head, 50 1/2 superior to the sole of the left foot, and 2 1/4 left of the anterior midline. The wound, including the abrasion collar, is round and 0.8 cm in diameter. The abrasion collar is circumferential, regular, and slightly wider along the lateral aspect. No soot deposition or gunpowder stippling is on the skin or in the soft tissues around this wound. 2. The wound path sequentially runs through the left third intercostal space anteri- orly, the anterior portion of the upper lobe of the left lung, the pericardial sac, the heart, the lower lobe of the right lung, and the right 8th intercostal space posteriorly, to end in the subcutaneous tissue on the right side of the back. The path through the heart is described in further detail8: The path through the heart begins as a circular perforation on the anterior aspect of the right ventricular outflow tract, then continues as a perforation of the base of the heart at the root of the aorta and pulmonary artery, and then passes through the posterior portion of the atrial septum. It leaves the heart at the origin of the right inferior pulmonary vein. 3. Recovered from the end of the wound path is a moderately deformed, non- jacketed, small-caliber lead bullet, located on the right side of the back 47 superior to the sole of the right foot, and 4 1/2 right of the posterior midline. The bullet is left uninscribed, and is photographed on a labeled evidence envelope before being sealed in the envelope. 4. Associated findings comprise extravasation of blood into tissue along the wound pathway, a measured 400 milliliters of blood in the right pleural cavity, a mea- sured 100 milliliters of blood in the pericardial sac, and a measured 1 liter of blood in the left pleural cavity. The hemothoraces are associated with partial collapse of both lungs. 5. The direction of the wound path, with respect to the standard anatomic position, is left to right, front to back, and downward. Gunshot Wound of Left Thigh: 1. The entrance wound is on the anterior aspect of the left thigh proximally, just inferior to the left groin fold, 34 inferior to the top of the head, 31 superior to the sole of the left foot, and 3 1/4 left of the anterior midline. The wound, including the abrasion collar,9 is round and 0.6 cm in diameter. The enclosed entrance perforation is 0.4 cm in diameter. The abrasion collar is thin, crescen- 7 Most of the paragraphs in this section begin with a key word or phrase that indicates what the paragraph is about. 8 The pathologist has opted to use two paragraphs for the wound path. The first names all the organs perforated. The second gives detail that would be of interest only to a physician. 9 The pathologist has chosen to take the outside dimensions of the abrasion collar as the main measurement. Appendix 1 105 tic, and is at the superior edge of the wound from 11 to 1 o clock. No soot deposition or gunpowder stippling is on the skin or in the soft tissues around this wound. 2. The wound path runs through the musculature of the anterior and lateral aspects of the left thigh, without perforation of the neurovascular structures, to exit at the lateral aspect of the thigh. There is no bullet. Blood is extravasated into the tissues along the wound pathway.10 3. The exit perforation is on the lateral aspect of the thigh, 30 superior to the sole of the left foot. It is a 0.5 × 0.3 cm perforation with no marginal abrasion and no apparent tissue deficit. 4. The direction of the wound path, with respect to the standard anatomic position, is right to left, front to back, and downward. Blunt Impact Wounds: 1. The left eyebrow laterally has a 0.8 centimeter in-greatest-dimension purple con- tusion. 2. The upper central portion of the back has a 0.9 centimeter in-greatest-dimension red-brown abrasion. 3. The left shoulder laterally has a 2 × 0.7 centimeter red-brown abrasion. 4. The left elbow laterally has a 2 × 1.5 centimeter red-brown abrasion. 5. The left wrist dorsally has two punctate red-brown abrasions. 6. The left shin anteriorly has two pink contusions measuring 1.0 and 1.6 centimeters. Internal Examination11: 28 May 2003 at 1330 hours Head: The scalp, skull, and meninges have no injuries. The epidural and subdural spaces have no liquid accumulations. The brain weighs 1350 grams. It has translu- cent leptomeninges and clear cerebrospinal fluid. The hemispheres are symmetric. The cranial nerves, cerebral arteries, and external and cut surfaces of the brain are unremarkable. Neck: The strap muscles, hyoid bone, and laryngeal cartilages have no injuries. The tongue has no bite marks or contusions. The pharynx, larynx, and trachea have smooth mucosal linings, without masses or obstruction. Body Cavities: The pneumothorax test is negative bilaterally. The pericardial, pleu- ral, and peritoneal cavities have smooth linings. The peritoneal cavity contains no blood or excess liquid.12 The viscera are normally situated, are generally pale, and have no abnormal odors. 10 Because this was the only item that would be suitable for a separate paragraph of associated findings, the item was conveniently placed here. 11 The internal findings pertinent to the wounds have all been described in the special wound sections and are not repeated here. 12 The pericardial and pleural cavity contents have already been described. 106 Appendix 1 Cardiovascular: The heart weighs 270 grams. It has a smooth epicardial surface. The coronary ostia arise normally from the sinuses of Valsalva. The epicardial coro- nary arteries have normal distributions. The posterior descending artery arises from the right coronary artery.13 The arteries are patent and of normal caliber. The cardiac chambers are neither hypertrophied nor dilated. The atrial and ventricular septa are intact, with the exception of the bullet perforation of the atrial septum. The myocar- dial cut surfaces are red-brown and have no infarcts. The endocardial surfaces are smooth. The aortic and pulmonic valve cusps are disrupted by the gunshot wound described above, but the valve cusps and leaflets are otherwise unremark able. The great vessels connect to the heart in a normal fashion and are empty of blood.14 The great vessels contain no thrombi.