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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
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Office of the Medical Examiner
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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Office of the Medical Examiner
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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Office of the Medical Examiner
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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Office of the Medical Examiner
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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Office of the Medical Examiner
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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Office of the Medical Examiner
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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Office of the Medical Examiner
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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Office of the Medical Examiner
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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Office of the Medical Examiner
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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Office of the Medical Examiner
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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Office of the Medical Examiner
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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Office of the Medical Examiner
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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Office of the Medical Examiner
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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Office of the Medical Examiner
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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Office of the Medical Examiner
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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Office of the Medical Examiner
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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Office of the Medical Examiner
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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Office of the Medical Examiner
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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Office of the Medical Examiner
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
M A N N E R O F D E A T H
NATURAL ACCIDENT HOMICIDE SUICIDE UNDETERMINED TOTAL
Age Group ♂ ♀ ♂ ♀ ♂ ♀ ♂ ♀ ♂ ♀ Unknown
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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Office of the Medical Examiner
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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Office of the Medical Examiner
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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Office of the Medical Examiner
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.
M A N N E R O F D E A T H
NATURAL ACCIDENT HOMICIDE SUICIDE UNDETERMINED TOTAL
Age Group ♂ ♀ ♂ ♀ ♂ ♀ ♂ ♀ ♂ ♀ Unknown
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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Office of the Medical Examiner
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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Office of the Medical Examiner
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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Office of the Medical Examiner
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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Office of the Medical Examiner
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
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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
M A N N E R O F D E A T H
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 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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Office of the Medical Examiner
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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Office of the Medical Examiner
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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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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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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Office of the Medical Examiner
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