MEDICOLEGAL AUTOPSY REPORT

Transcription

1 The North Carolina Baptist Hospitals, Inc. Wake Forest University School of Medicine Department of Pathology Medical Center Blvd Winston-Salem, NC Tel: (336) Fax: (336) MEDICOLEGAL AUTOPSY REPORT Prosector: C.J. Tape, M.D. Patient Name:: SANFORD, ROGER DALE Consultant: D. R. Jason, M. D. Medical Record #: Autopsy Assistant: Charles F Pagels, III DOB/Age:: Service: Race/Gender: W/M Admitted: Expired: 6/3/2009 Autopsied: 6/3/2009 Reported: 6/18/2009 Attending Physician: NCBH Path #: A Medical Examiner: Jeffrey B. Paysour Lincoln County Medical Examiner FINAL AUTOPSY DIAGNOSIS I. Medium caliber, non-exiting gunshot wound to left neck, indeterminate range A. Entrance: left neck C. Perforation: skin and subcutaneous tissue D. Perforation and fracture: C5, C6 E. Perforation: spinal cord, C5/C6 F. Perforation: musculature, subcutaneous tissue; right neck G. Bullet recovered in right neck; consistent with radiographic evidence 1. Moderately deformed lead, copper jacket, 10 mm (base), 25.4 grains H. Trajectory: left to right, front to back, slightly downward II. Medium caliber, non-exiting, gunshot wound to left arm and chest; indeterminate range A. Entrance: left arm (lateral) C. Perforation: skin, subcutaneous tissue, muscle D. Perforation: subcutaneous tissue, skin E. Exit: left arm (medial) at axilla F. Re-entrance: left chest at axilla G. Perforation: skin, subcutaneous tissue H. Perforation and fracture: 4th left rib/intercostal I. Perforation: left upper lobe 1. Hemothorax: 500 ml (left) J. Perforation: pericardium K. Perforation: left ventricle 1. Hemopericardium: 40 ml L. Perforation: AV septum, left M. Perforation: left atrium N. Perforation: right lower lobe O. Bullet recovered from right lower lobe, consistent with radiographic evidence 1. Moderately deformed, lead, copper jacket, 10 mm (base), grains P. Trajectory: left to right, downward, slightly front to back III. Medium caliber, non-exiting gunshot wound to left abdomen, indeterminate range A. Entrance: Left lower quadrant, abdomen C. Perforation: skin and subcutaneous tissue D. Perforation: small intestine x 2 E. Perforation: Psoas muscle, right F. Diffuse abdominal blood along wound tract G. Bullet recovered in right psoas muscle consistent with radiographic evidence 1. Moderately deformed lead, copper jacket, 10 mm (base), grains H. Trajectory: left to right, front to back and downward SANFORD, ROGER DALE Page 1 of 7 A09-789

2 IV. Medium caliber, exiting gunshot wound to right arm, indeterminate range (more superior) A. Entrance: Right upper arm, anterior/lateral C. Perforation: skin, subcutaneous tissue and muscle D. Perforation: fracture, right humerus E. Perforation: subcutaneous tissue and skin F. Copper jacket and lead fragments recovered in arm 1. Five pieces, 5-9 ml, 94.0 grains G. Exit: Right upper arm, dorsal H. Trajectory (anatomic position): front to back, downward and slightly right to left V. Medium caliber, exiting gunshot wound to right arm, indeterminate range (more inferior) A. Entrance: Right upper arm, anterior/medial C. Perforation: skin, subcutaneous tissue and muscle D. Perforation: fracture, right humerus E. Perforation: subcutaneous tissue and skin F. Copper jacket and lead fragments recovered in arm G. Exit: Right upper arm, dorsal H. Trajectory (anatomic position): front to back, downward and slightly right to left VI. Cholelithiasis VII. Cholesterolosis VIII. Hypertensive atherosclerotic cardiovascular disease A. Atherosclerosis, aorta and coronary arteries, minimal B. Cardiomegaly, 500 gm IX. Liver hemangioma X. Steatosis XI. Obesity, BMI = 36 ***Electronically Signed Out By: D. R. Jason, M. D.*** pkv Summary of Findings The autopsy of Roger Sanford, a 52-year-old man, was significant for multiple gunshot wounds to the neck, body and upper extremities (five total). All gunshot wounds were of indeterminate. A non-exiting gunshot wound was present on the left neck that severed the spinal cord. A non-exiting gunshot wound was present that went through the left arm, and entered the chest perforating the heart and both lungs. A non-exiting gunshot wound was present on the abdomen that perforated the small intestine. Two exiting gunshot wounds were present on the right arm. An abrasion was present on the left shoulder, aside from this and the gunshot wounds, no injuries were present. Evidence of natural disease included hypertensive atherosclerotic cardiovascular disease, cholelithiasis, cholesterolosis, steatosis, a liver hemangioma, and obesity with a BMI of 36. Toxicology revealed that the decedent had not consumed alcohol prior to death. According to investigative report, the decedent was shot by police after he threatened them with a weapon, reportedly a.22 caliber rifle. Police were responding to a domestic situation called in by the decedent's female acquaintance. The decedent had a history of depression, alcoholism and hypertension. The cause of death is gunshot wounds to the neck and body. The manner of death is homicide. SANFORD, ROGER DALE Page 2 of 7 A09-789

3 Body Weight: 255 lb Body Length: 71 in BMI: 36 EXTERNAL EXAMINATION The body is that of a normally developed, obese, adult Hispanic man, who appears compatible with the stated age. Body identification includes an ID tag on the left wrist. The body is cool to touch. Rigor is full in all extremities and jaw. Diffuse, blanching, red livor extends over the surfaces of the body, except in areas subject to pressure. The scalp hair is gray and measures to 0.3 cm in length over the crown. The irides are brown; the pupils are bilaterally equal at 0.5 cm. The corneae are transparent. The sclerae and conjunctivae are unremarkable. The nose and ears are not unusual. The lips and gums are pale. The teeth are in fair repair. Facial hair consists of a brown/gray moustache. The neck is without masses, and the larynx is in the midline. The thorax is symmetrical with an anteroposterior/lateral ratio of about 1:2. The abdomen is protuberant. The penis is uncircumcised; the testes are bilaterally descended within the scrotum. The anus and back are unremarkable. The upper and lower extremities are well developed and symmetrical, without absence of digits. Identifying marks consist of tattoos. Evidence of emergency resuscitation and/or medical therapy consists of EKG leads on the chest and abdomen. The body is received clothed in a FedEx uniform, including shirt and pants; blue socks and black shoes. Personal items accompanying the body include 12 unspent Remington.22 cartridges and 58-cents in loose change. HEAD AND NECK EVIDENCE OF INJURY GUNSHOT WOUND (NECK) A medium caliber, non-exiting gunshot wound of indeterminate range is present above the clavicle on the left neck. No soot or stippling surrounds the wound. The perforation is regular, measuring 0.9 cm (diameter) with a 0.2 cm abrasion collar with a center that is 3¼ inches left of midline and 9 inches below the top of the head. The projectile perforated the skin, subcutaneous tissue, and musculature before perforating and fracturing C5 and C6 with underlying transection of the spinal cord. The projectile perforated the musculature and subcutaneous tissue of the right neck before coming to a stop. A moderately deformed lead copper jacket bullet is recovered, consistent with radiographic evidence, that is 10 mm (base) and weighs grains. The location of the bullet is 10 inches below the top of the head and 3½ inches right of midline. The trajectory is left to right, front to back, and slightly downward. CHEST AND ABDOMEN GUNSHOT WOUND (LEFT ARM + CHEST) SANFORD, ROGER DALE Page 3 of 7 A A medium caliber, non-exiting gunshot wound of indeterminate range to the left arm and chest is present. The entrance is on the left lateral arm with a vertically oriented regular perforation measuring 1 x 0.7 cm with a 0.15 cm abrasion collar and a center that is 6 inches below the top of the left shoulder and 13 inches left of midline with the arm approximated

4 to the body. No soot or stippling surrounds the wound. The projectile perforated skin, subcutaneous tissue, and musculature while passing posteriorly to the humerus and then perforating subcutaneous tissue and skin before exiting from the left arm at the axilla. This initial exit measures 2 x 1.5 cm and is irregular with a center that is 4 inches below the top of the left shoulder and 9 inches left of midline. The projectile reentered the body along the left chest at the axilla, creating a slightly irregular 2.2 x 1.7 cm perforation with a 0.15 cm abrasion collar. The center of this perforation is 12 inches left of midline and 15 inches below the top of the head. After perforating the skin and subcutaneous tissue, the projectile perforated and fractured the 4th left rib and intercostal space. The anterior portion of the left upper lobe of the lung is grazed with a 1.5 x 1 cm perforation. There are 500 ml of blood present within the left thoracic cavity. The pericardium is perforated along the left aspect. The projectile also perforated the left ventricle, (creating a 1.5 x 1.3 cm defect), the left AV septum, and left atrium. 40 ml of blood are present within the pericardial sac. The projectile finally perforated the right lower lobe of the lung before coming to a stop. A moderately deformed lead bullet with a copper jacket is recovered from the right lung, consistent with the radiographic evidence, measuring 10 mm (base) and weighing grains. The approximate location of this bullet is 4½ inches right of midline and 17½ inches below the top of the head. The trajectory through the body is left to right, downward, and slightly front to back. GUNSHOT WOUND (LEFT ABDOMEN) A medium caliber, non-exiting gunshot wound of indeterminate range is present on the left lower quadrant of the abdomen. The entrance is regular and horizontally oriented, measuring 1 x 0.7 cm with a 0.1 cm abrasion collar and a center that is 1 inch left of midline and 29 inches below the top of the head. No soot or stippling surrounds the wound. The projectile perforated the skin and subcutaneous tissue before perforating the small intestine twice, and finally perforating the psoas muscle on the right and coming to a stop. There is profuse abdominal blood along the wound tract. A moderately deformed lead bullet with a copper jacket is recovered in the right psoas muscle, consistent with radiographic evidence. This projectile weighs grains and measures 10 mm (base). The approximate location of this bullet is 34 inches below the top of the head and 2½ inches right of midline. The trajectory through the body is left to right, front to back, and downward. UPPER EXTREMITIES A gunshot wound to the left arm with continuation into the body is described above. GUNSHOT WOUND (RIGHT ARM: MORE SUPERIOR) A medium caliber, exiting gunshot wound of indeterminate range is present on the right arm. The entrance is on the right upper arm along the anterolateral aspect with a regular entrance that measures 1 cm (diameter) with a 0.15 cm abrasion collar and a center that is 7 inches below the top of the right shoulder and 13 inches right of midline with the arm approximated to the body. No soot or stippling surrounds the wound. The projectile perforated the skin, subcutaneous tissue, and musculature before perforating and fracturing the right humerus. The projectile perforated the subcutaneous tissue and skin before exiting from the dorsal aspect of the right upper arm, creating an irregular perforation measuring 0.8 x 0.6 cm with a center that is 8 inches below the top of the right shoulder and 12 inches right of midline with the arm approximated to the body. There are 4 portions of copper jacket and a lead fragment, ranging in size from 5 to 9 mm and weighing 94.0 grains, recovered from the arm, consistent with the radiographic evidence and similar to the bullets recovered elsewhere. The trajectory in the SANFORD, ROGER DALE Page 4 of 7 A09-789

5 anatomic position is front to back, downward, and slightly right to left. GUNSHOT WOUND (RIGHT ARM: MORE INFERIOR) A medium caliber, exiting gunshot of indeterminate range is present on the right arm. The entrance is on the right upper arm along the anteromedial aspect, slightly inferior and medial to the gunshot wound n the right arm described above. The entrance is regular and horizontally oriented, measuring 0.9 x 0.7 cm with a 0.1 cm abrasion collar and a center that is 9 inches below the top of the right shoulder and 12 inches right of midline with the arm approximated to the body. No soot or stippling surrounds the wound. The projectile perforated the skin, subcutaneous tissue, and musculature before perforating and fracturing the right humerus. The projectile perforated the subcutaneous tissue and skin before exiting from the dorsal aspect of the right upper arm, just inferior to the exit described above, with an irregular perforation that measures 2.5 x 2.2 cm and a center that is 9 inches below the top of the right shoulder and 12.5 inches right of midline with the arm approximated to the body. The trajectory with the arm in anatomic position is front to back, downward, and slightly right to left. The trajectories of the 2 gunshot wounds to the right arm cross and the portions of copper and lead recovered may be from one or both of these projectiles. An 8 x 7 cm abrasion with scabbing is present on the left shoulder. LOWER EXTREMITIES None BODY CAVITIES Panniculus adiposus: 4 cm CENTRAL NERVOUS SYSTEM Brain weight: 1250 gm NECK INTERNAL EXAMINATION The right pleural cavity contains 500 ml of blood; the left pleural cavity contains 500 ml of blood. The abdominal contains diffuse blood along the wound tract. All body organs are present in normal and anatomical position. Injuries to the Central Nervous System (spinal cord) are described in the "Evidence of Injury" section. The dura mater and falx cerebri are intact. The leptomeninges are thin and delicate. The cerebral hemispheres are symmetrical. The structures at the base of the brain, including cranial nerves and blood vessels, are intact and free of abnormality. Sections through the cerebral hemispheres reveal no lesions within the cortex, subcortical white matter, or deep parenchyma of either hemisphere. The basal ganglia, thalami, and Ammon's horn are unremarkable. The cerebral ventricles are normal caliber. Sections through the brain stem and cerebellum are unremarkable. The spinal cord is unremarkable except for the injuries described above. Injuries to the neck are described in the "Evidence of Injury" section. Examination of the soft tissues of the neck, including strap muscles, thyroid gland, and large vessels, reveals no abnormalities. The hyoid bone and larynx are intact. The lingual mucosa is intact; the underlying firm red-brown musculature is devoid of hemorrhage. CARDIOVASCULAR SYSTEM Heart weight: 500 gm SANFORD, ROGER DALE Page 5 of 7 A Injuries to the heart are described in the "Evidence of Injury" section. The pericardial surfaces are smooth, glistening and unremarkable; the pericardial sac contains 40 ml of blood but no adhesions. The coronary

6 arteries arise normally, follow the usual distribution and are widely patent with evidence of minimal atherosclerosis but no thrombosis. The chambers and valves bear the usual size-position relationships and are unremarkable. The myocardium is dark red-brown, firm, and unremarkable; the atrial and ventricular septa are intact. The aorta and its major branches arise normally, follow the usual course and are widely patent with evidence of minimal atherosclerosis but no other abnormality. The vena cava and its major tributaries return to the heart in the usual distribution and are free of thrombi. RESPIRATORY SYSTEM Combined lung weight: 830 gm LIVER AND BILIARY SYSTEM Liver weight: 2080 gm Bile volume: 10 ml ALIMENTARY TRACT GENITOURINARY TRACT Right kidney: 180 gm Left kidney: 180 gm Urine volume: 50 ml Injuries to the lungs are described in the "Evidence of Injury" section. The upper airway is clear of debris and foreign material; the mucosal surfaces are smooth, yellow-tan and unremarkable. The pleural surfaces are smooth, glistening and unremarkable. Lobar divisions are of the usual configuration. The pulmonary parenchyma is dark red-purple, exuding slight to moderate amounts of blood and frothy fluid; no focal lesions are noted. The pulmonary arteries are normally developed, patent, and without thrombus or embolus. The hepatic capsule is smooth, glistening and intact, covering red-brown parenchyma with a red lesion that measures 1.5 x 1.5 x 1 cm, subcapsularly. The gallbladder contains yellow-green-brown, slightly mucoid bile with 2 mixed stones measuring 0.5 cm each; the mucosa is velvety with yellow streaks and specks. The extrahepatic biliary tree is patent, without evidence of calculi. The portal vein and its tributaries are unremarkable. Injuries to the small intestine are described in the "Evidence of Injury" section. The esophagus is lined by gray-white, smooth mucosa. The gastric mucosa is arranged in the usual rugal folds, and the lumen contains 500 ml of partially digested food. The small and large bowel are unremarkable. The appendix is present. The pancreas has a normal gray-white, lobulated appearance, and the ducts are clear. The renal capsules are smooth and thin, semi-transparent, and strip with ease from the underlying, smooth, red-brown, firm, cortical surface. The cortex is sharply delineated from the medullary pyramids, which are redpurple to tan and unremarkable. The calyces, pelves, and ureters are unremarkable. The relationships at the trigone are unremarkable. The mucosa of the urinary bladder is gray-tan and smooth. The testes, prostate and seminal vesicles are unremarkable. RETICULOENDOTHELIAL SYSTEM Spleen weight: 220 gm The spleen has a smooth, intact capsule covering red-purple, moderately firm parenchyma; the lymphoid follicles are unremarkable. The regional lymph nodes appear normal. The bone marrow is redpurple and homogeneous, without evidence of focal abnormality. ENDOCRINE SYSTEM MUSCULOSKELETAL SYSTEM The pituitary, thyroid, and adrenal glands are unremarkable. Injuries to the Musculoskeletal System are described in the "Evidence of Injury" section. The bony framework, supporting musculature, and soft tissues are otherwise not unusual. Tissue Examined: Heart 1 Uterus Spinal Cord Aorta Ovary Thymus SANFORD, ROGER DALE Page 6 of 7 A09-789

7 Lungs 2 Thyroid Seminal Vesicles Spleen Parathyroid Breast Liver 2 Esophagus Gallbladder Pancreas Stomach Skin Adrenals Small Intestine Muscle Kidney 1 Large Intestine Bone Marrow Bladder Lymph Node Vertebral Prostate Pituitary Femoral Testes Brain 1 Costal Coronary Arteries Trachea Sternal Appendix Diaphragm Microscopic Description: The liver section exhibits minimal macrovesicular steatosis as well as a neoplasm composed of multiple dilated blood vessels. With the exception of autolysis and congestion, the remaining sections exhibit no significant histopathological abnormalities TOXICOLOGY Toxicology Folder: T SPECIMENS received from Donald R. Jason on 08-jun-2009 S : 17.0 ml Blood Clot CONDITION: Postmortem SOURCE: Abdominal Cavity OBTAINED: 03-jun-2009 Ethanol None Detected 06/11/2009 COPY TO: Jeffrey B. Paysour, R.N. SANFORD, ROGER DALE Page 7 of 7 A09-789