Post-mortem external examination: competence, education and accuracy of general practitioners in a metropolitan area

External post-mortem examination in virtual reality-scalability of a monocentric application

Conducting external post-mortem examinations is an essential skill required of physicians in various countries, regardless of their specialization. However, the quality of these examinations has been a subject of continuous debates, and notable errors were reviled. In response to these shortcomings, a virtual reality (VR) application was developed at Halle's medical department in Germany, focusing on the scene of discovery and the completion of death certificates. The initial trial of this VR application in 2020 involved 39 students and 15 early-career professionals. Based on the feedback, the application underwent improvements and was subsequently introduced to the medical department in Dresden, Germany, in 2022. Its primary objective was to showcase the VR training's adaptability and scalability across various educational structures and levels of medical expertise. Out of 73 students who participated, 63 completed the evaluation process. 93.1% (n = 58) of the evaluators reported increased confidence in conducting external post-mortem examinations, and 96.8% (n = 61) felt more assured in filling out death certificates, crediting this progress to the VR training. Additionally, 98.4% (n = 62) believed that repeating forensic medical aspects in their coursework was crucial, and 96.8% (n = 61) viewed the VR examination as a valuable addition to their academic program. Despite these positive responses, 91.6% (n = 55) of participants maintained that training with real corpses remains irreplaceable due to the insufficiency of haptic feedback in VR. Nevertheless, the potential for enhancing the VR content and expanding the training to additional locations or related disciplines warrants further exploration.

[Information on Death Certificates: Comparison Between Inpatient and Outpatient Sectors]

The death of a person and the circumstances of death are documented on the death certificate in Germany. The path of the corpse to burial as well as the quality of the cause of death statistics are significantly influenced by the information in the official death certificate. The quality of the information in the death certificates has been repeatedly criticized. The aim of the present study was to identify typical sources of error in death certificates and to obtain information on whether qualitative differences exist between death certificates completed in the outpatient and inpatient sectors. A retrospective evaluation was performed of 218 death certificates of deaths examined by the Institute of Legal Medicine as part of a second postmortem examination prior to cremation. Of these, 118 death certificates were issued in the hospital and 100 death certificates were issued on an outpatient basis by the family physician or a physician on duty in the outpatient sector. All but one of the death certificates issued on an outpatient basis were legible. The information on the underlying disease was plausible. More than one-third of the epicrises had no significant findings or were not completed at all. The entry on the immediate causes of death in the designated field on the death certificate (Ia in the causal chain) were inadequate in one third of the cases. The error rate in the entries was higher in outpatient than in inpatient deaths. In the future, therefore, it will be necessary to prepare for the special situation of a post-mortem examination by means of further and advanced training events and to convey the importance of the diagnoses determined in the process, in order to eliminate these avoidable sources of error.

Vaccine-induced or hybrid immunity and COVID-19-associated mortality during the Omicron wave

BACKGROUND

It is not yet entirely clear to what extent vaccine-induced or hybrid immunity protects individuals in Germany from death during the omicron wave of the COVID-19 pandemic.

METHODS

In this retrospective study, we evaluated 470 159 cases over age 59 in the German federal state of Bavaria who tested positive for SARS-CoV-2 between 1 January and 30 June 2022. Cox models were used to estimate adjusted hazard ratios (aHR) for dying within 60 days of the infection, depending on sex, age, time point of infection, and a range of immunity levels.

RESULTS

Over the period of observation, 3836 COVID-19-associated deaths were registered (case fatality rate 0.82 %). Risk of death was significantly lower in cases with a higher immunity level than in unvaccinated cases (aHR for a full primary immunity level, if reached less than six months before the time of the infection: 0.30, 95 %-confidence interval [0.23; 0.39]; if reached more than six months before: aHR 0.46 [0.35; 0.60]). A boosted immunity level lowered risk of death even further (if reached less than three months before the infection: aHR 0.17 [0.15; 0.20]; if reached more than three months before: aHR 0.25 [0.21; 0.29]).

CONCLUSION

Among elderly persons in Bavaria, a higher immunity level was associated with a substantial degree of protection against death during the Omicron wave; the strength of protection may have diminished somewhat over time.

Adventure Legal Medicine: a free online serious game for supplementary use in undergraduate medical education

Serious games (computer-based learning games) are increasingly used in medical education at various levels, as user access is independent of location and time and promotes non-linear learning. In legal medicine, interactive digital media are still scarce. The freely accessible online serious game "Adventure Legal Medicine" was developed as part of the "Hamburg Open Online University". The goal was to teach the basics of forensic casework in a point-and-click adventure setting consisting of five cases. During development, 40 medical students were asked to evaluate the game anonymously. The System Usability Scale (SUS) resulted in a mean score of 86.7 (SD 8.3), which corresponds to above-average usability. Further specific evaluations revealed a good to very good rating of the game with no differences in terms of gender (p = 0.214), first-year versus advanced students (p = 0.393) and students who never/rarely or sometimes/often played computer games (p = 0.780). Since there are only a few digital media so far that allow curricular integration into undergraduate teaching in legal medicine, this serious game represents a possibility to integrate digital media into both face-to-face teaching and distance learning and to use it as a supplement to the medical school's own teaching offer, encouraging users to actively engage with the subject.

[Preliminary and Final Postmortem Examination and Death Certificate in the Emergency Medical Services in Germany: Heterogeneous Process Flows and Inadequate Standards]

BACKGROUND

Inconsistent regulations and laws can lead to misunderstandings and incorrect procedures. In this study we would like to evaluate the heterogeneity of the different processes of postmortem examination and death certification in the German emergency medical services.

METHODS

An e-mail with a survey link was sent to 212 medical directors of emergency services. The questions were answered online.

RESULTS

The response rate was 47%. Regulated procedures were evident in 58% of the cases. Issue of provisional death certificate comprised 64%, postmortem examination 45%; 19.4% of emergency physicians were required to do the final post-mortem. In 41% of the cases, the application protocol was considered sufficient as a form of documentation. 45% of the participants evaluated the respective legal regulation as sufficient. Questions and concerns arose, especially when medical directors of EMS believed that the state-specific regulations were not sufficient (p<0.001).

CONCLUSION

The results show that the obligatory post-mortem examination in Germany is heterogeneous in its processing procedures. More than half of the participants rate the existing legal regulations as inadequate. As a result, it is not uncommon for queries and complaints to arise, but above all for uncertainties to arise in everyday practice. Our results suggest that uniform legislation and clearly defined processes are desirable.

Autopsy-Based Learning is Essential But Underutilized in Medical Education: A Questionnaire Study

To this day, autopsies and dissections have been essential in medical education, but declining autopsy numbers have endangered this long-standing tradition. Students' perceptions of these teaching methods should be constantly updated to help educators understand how to achieve their teaching goals. The purpose of this study was to explore the state of autopsy- and dissection-based teaching in two Finnish universities based on the experiences of the students, survey their perceptions of such teaching, and to compare the Finnish situation with students' perceptions in other countries as it emerges from medical literature. A questionnaire went to 859 second-, fourth-, and sixth-year medical students. The questions concerned dissection and autopsy classes these students had attended, the views of the students in regard to the number of classes, and the benefits of and attitudes towards autopsy teaching. An open question of how to improve autopsy teaching was included. The response rate was 19.4%. Most respondents requested more autopsy and dissection classes, especially practical education. They found autopsies most beneficial in learning anatomy and dealing with one's own emotions related to death. Their experiences proved least beneficial for interaction with the relatives of a deceased patient and for people skills. Integrational methods and focusing on the main learning outcomes were suggested as improvements. Overall, students found dissection and autopsy teaching important, but felt concerned about the diminishing autopsy numbers. Focusing on main learning objectives and better integration of autopsies in the teaching of different specialties could help to utilize autopsies to a greater extent.

Consistent acting, legal knowledge and competence of external postmortem examination in Dutch hospital settings

A crucial role in the external postmortem examination system of the Netherlands is that of the attending physicians, who are either general practitioners or physicians in hospitals. They perform 85% of all external postmortem examinations and must immediately report to forensic physicians all unnatural deaths and deaths that they are not convinced to be natural. These attending physicians need therefore to be properly qualified and need to be competent, by acting consistently and by having knowledge of the appropriate laws surrounding external postmortem examination. The aim of this study is to analyse the competence of the attending physicians in hospital settings. This research studied whether they regard themselves as competent, whether they had knowledge of and acted according to the appropriate laws, and whether they acted consistently in following the procedures around external postmortem examinations. A survey was conducted among clinicians. After discarding 23 questionnaires for various reasons, 326 datasets remained on which the research was based. There was no significant difference between the medical specialists (79%) and the residents and fellows (86%) in their feeling of being competent in undertaking external postmortem examinations. The answers of the respondents showed at least one inconsistency in 54%. Of the respondents 34% were considered as to have knowledge of relevant laws. Of the respondents 21% felt competent, was consistent in all their answers and scored a 100% on legal knowledge. The study showed that though a physician might feel competent, this does not mean he actually is competent in performing an external postmortem examination. Furthermore, the extent of a respondents' ignorance of the appropriate laws and the inconsistency in acts and thoughts is undermining the system of postmortem examination.

Using simulation mannequins and actors in training for external post-mortem examinations -experiences from use in medical students and police officers

In the daily practice of external post-mortem examinations and dealing with surviving dependents, striking failures can be observed regularly, pointing to an increased demand for training of the various professional groups involved. In this study, the experience gained from using simulation mannequins and actors for post-mortem examination training in medical students and police officers are presented. Since 2017, a training station has been offered at the Medical Faculty of the Technical University of Dresden (Germany) for practicing examinations in death scene and establishing communication with grieving relatives. It is conducted in small groups of up to 5 people, both for medical students and for police officers and police recruits. These courses are evaluated by means of questionnaires including 3 and 11 items respectively for the different groups. The questionnaires have been completed by 679 medical students and 67 police participants. Both groups of participants evaluated their previous experience as average. They assessed the course as having a high degree of practical and professional relevance. The didactic transfer of the teaching contents and its competent support were rated remarkably positive by the participants. Additionally, the police group reported high rates of approval for the use of feedback, the learning effect, and the appropriateness of the group size. The establishment and continuation of the simulation-based external post-mortem examination in the form of small-group teaching is associated with a considerable expenditure of equipment, material and personnel. In addition, its implementation requires sound cooperation structures. On the other hand, introduction and continuation of these types of additional teaching and learning methods, with a large practical component, can increase confidence in daily practice, and thus improve the quality of external post-mortem examination. Ultimately, this can also improve the cooperation between forensic medicine and the investigating authorities.

Study on death certificates and postmortem examination certificates written by Korean emergency physicians

INTRODUCTION

Statistics on death are the basis of a country's health, safety, and welfare policies. Emergency physicians issue a postmortem examination certificate (PEC) for death outside the hospital as well as a death certificate (DC) for death in the hospital. This study investigated the actual conditions and criteria for writing a DC and PEC, writing environment, and doctor's experience.

MATERIAL AND METHODS

The physicians' DC and PEC writing experience and demographic data were analyzed. The questions focused on CPR, patient's medical certificate, time and place of death, difficulty in writing the PEC and DC, and education in certificate writing.

RESULTS

229 emergency physicians were included. Physicians' opinions differed for CPR patients in terms of time of death, location, and whether or not to issue DC/PEC. The causes of death were also different. Further, 76.9% of the doctors did not have enough time to write a medical certificate and about 45% of them wrote it within 30 min; 76% had DC-related complaints, and 7.0% faced legal problems due to the DC; 93.3% of the emergency physicians stated that a coroner system is needed in South Korea.

CONCLUSION

Emergency physicians are responsible for writing DCs and PECs. The standards vary from physician to physician at the time of writing. Writing DCs and PECs is also burdensome. In South Korea, it is necessary to separate the DC and PEC, to develop national data management networks, and to introduce a postmortem examination system.

The postmortem examination prior to cremation: Still a necessary safety measure?

BACKGROUND

The postmortem external examination has repeatedly been the subject of political and medicolegal disputes. This study was performed to examine whether the postmortem external examination at the crematory provides additional benefits and to determine whether any differences in the quality of medical death certificates exist between hospital and non-hospital postmortem external examinations.

MATERIAL AND METHODS

All cases of death that had been examined within the context of a second postmortem external examination at crematories performed by medicolegal specialists from the Hamburg Department of Legal Medicine were analyzed during a 6-month investigation period.

RESULTS

A second postmortem external examination was carried out on 9981 decedents prior to cremation during the investigation period. In the interim, the second postmortem medical examiner did not release 474 bodies (4.7%) for cremation. Suspicion of death caused by trauma was the most frequent cause for delaying the release of the body. The quality of information stated on the medical death certificate was good in 112 certificates issued by clinicians (48.9%, n = 229) and in 51 issued by general practitioners (31.3%, n = 163).

DISCUSSION

This study verified deficiencies in the initial postmortem external examination. A postmortem external examination prior to cremation by a medical professional specialized in this field is currently an indispensable component for quality assurance.

Implementation of an algorithm for the identification of breast cancer deaths in German health insurance claims data: a validation study based on a record linkage with administrative mortality data

OBJECTIVE

To adapt a Canadian algorithm for the identification of female cases of breast cancer (BC) deaths to German health insurance claims data and to test and validate the algorithm by comparing results with official cause of death (CoD) data on the individual and the population level.

DESIGN

Validation study, secondary data, medical claims.

SETTING

Claims data of two statutory health insurance providers (SHIs) for inpatient and outpatient care, CoD added via record linkage with epidemiological cancer registry (ECR).ParticipantsAll women insured with the two SHIs and who deceased in the period 2006-2013, were residents of North Rhine Westphalia (NRW) and were linked with ECR data: n=22 413.

MAIN OUTCOME MEASURES

Based on inpatient and outpatient diagnoses in the year before death, six algorithms were derived and the accordance of the algorithm-based CoD with the official CoD was evaluated calculating specificity, sensitivity, negative and positive predictive values (NPV, PPV). Furthermore, algorithm-based age-specific BC mortality rates covering several calendar years were calculated for the entire insured female population and compared with official national rates.

RESULTS

Our final algorithm, derived from the NRW subsample, comprised codes indicating the presence of BC, metastases, a terminal illness phase and the absence of codes for other tumours. Overall, specificity, sensitivity, NPV and PPV of this algorithm were 97.4%, 91.3%, 98.9% and 81.7%, respectively. In the age range 40-80 years, sensitivity and PPV slightly decreased with increasing age. Algorithm-based age-specific BC mortality rates agreed well with official rates except for the age group 85 years and older.

CONCLUSIONS

The algorithm-based identification of BC deaths in German claims data is feasible and valid, except for higher ages. The algorithm to ascertain BC mortality rates in an epidemiological study seems applicable when information on the official CoD is not available in the original database.

Knowledge, competencies and attitudes regarding external post-mortem physical examination: A survey among German post-graduate trainees in general practice

Background: The external post-mortem examination (EPME) is an important medical, legal and socio-economic task with far-reaching relevance; however, due to discrepancies between findings from EPMEs and actual cause of death, improvements in accuracy and quality are needed.

Objectives: To investigate knowledge, competencies and attitudes regarding EPME in general practitioner (GP) post-graduate trainees.

Methods: Before four post-graduate training courses on the EPME for general practitioner trainees, organized in 2014 in the German federal state of Baden-Wuerttemberg, a questionnaire on the EPME was distributed by the lecturer, completed by the GP post-graduate trainees and returned to the lecturer. The questionnaire consisted of 19 items related to three main categories: knowledge, competencies and attitudes.

Results: Out of 380 GP post-graduate trainees, 128 completed and returned the questionnaire (response rate 33.7%). Less than 18% felt adequately confident in identifying a natural cause of death and less than 5% felt adequately confident in identifying an unnatural cause of death. Only 33% consistently fully uncover the corpse for the EPME.

Conclusion: We found an important uncertainty in GP post-graduate trainees regarding their EPME knowledge and competencies.

An unusual exit wound as a result of a shotgun suicide to the head

The location of a gunshot entrance wound as well as the wound path trajectory are the main findings that help to determine the position from which a weapon was fired and thus distinguish firearm suicides from homicides and accidents. We present a case of a 28-year old man, who was found dead in his car. Because of an unusual position of the firearm, which was clamped into the steering wheel, and an unclear entrance/exit wound, an autopsy was performed. The deceased showed typical signs of a contact shotgun wound to the head with an entrance wound in the right temporal region and an exit wound in the midface. With the help of gunpowder attachments and a muzzle imprint at the entrance site, a wound channel from the right lower posterior part of the temporal region to the left anterior part of the mid-facial region could be reconstructed. The stellate wound in the midface was assessed as an atypical exit wound. The cause of death was a contact shotgun shot to the right temple with a consequent central regulatory failure due to extensive brain injury. The manner of death was concluded to be a suicide.