“Exposure to hazardous conditions, including body fluids, infectious diseases, unsafe structures, and radiation. Working environment may include fumes, noxious odors, and toxic waste. Able to lift and maneuver decedents at least 100 lbs. Exposure to high job stress…” (excerpt from a death investigator job description)
Working conditions for medicolegal death investigators (MDIs), transporters, and autopsy staff are always rough. But a 2021 FrontLine article highlighted how health and safety in the Coroner’s Office have become a bigger concern since the pandemic.
Safety Oversight Lacking for Last Responders
Researchers and regulators have published little about health problems, injuries, or fatalities associated with conducting death investigations, so no one really knows how dangerous it is to be an MDI. A patchwork of plans regulates the occupational safety of those who work with the dead. In Pennsylvania, for example, the state’s General Safety Law, not OSHA (the federal Occupational Safety and Health Administration), covers public sector employees. That category includes most C/ME workers. State worker safety regulations must be at least as effective as OSHA’s.
OSHA and state agencies rarely conduct safety inspections of their facilities or working conditions. A 2022 literature review found only one article that specifically looked at MDI workplace safety hazards. CDC’s new resource site for coroners and medical examiners includes a Health and Safety resources section, but has little data available at this time. Coroner and medical examiner offices can request Health Hazard Evaluations through this site, but it appears few have done so.
Dangers: The Big Four
Manual Lifting
Obesity (BMI > 30, severe obesity > 35) has become epidemic in the United States. Because it’s a risk factor for cardiovascular disease, diabetes, and COVID-19, people with obesity are more susceptible to deaths that fall under the jurisdiction of a C/ME. As a result, it’s not unusual for MDIs and transporters to recover a body weighing more than 250 lbs or even 300 lbs. Chester County (PA) recovered one body weighing over 700 lbs in recent years. The risk of musculoskeletal injuries, especially back injuries, during manual body removal from homes and other out-of-hospital locations is high. Power-operated stretchers help, but at more than $15,000 each, many offices can’t afford one — and they aren’t useful on stairs, tight spaces, or rough outdoor terrain.
Maneuvering oversize bodies at autopsy is also risky. In 2021, after a safety incident, the Chester County (PA) Coroner set a cutoff of 250 lbs for autopsies because its antiquated autopsy space did not allow for safe handling of larger bodies. The office began referring autopsies on heavier bodies to a private out-of-county facility with bariatric equipment.
How much is too much to lift, carry, or turn? The National Institute for Occupational Safety and Health (NIOSH) publishes a technical manual for calculating recommended weight limits. But the math doesn’t work for restricted spaces, unfavorable environmental conditions, or “unstable loads.” So, no one really knows how much is “too much” for those who work with the dead. There is currently no scientific basis for the common MDI job requirement of being able to lift “at least 100 lbs.”
Biohazards
Exposure to infectious diseases like COVID-19, tuberculosis, and Hepatitis B/C happens. Workers have to assume every dead body is contagious, because they don’t always know the medical history. Autopsy workers are especially at risk because of sharps injuries. Due to the forensic pathologist shortage, pathologists are performing more than the recommended number of autopsies. The increased workload likely increases errors and accidents. Universal Precautions and Blood-borne Pathogens training modules are widely available online and should be required for C/ME staff.
“Exposure to hazardous conditions, including body fluids, infectious diseases, unsafe structures, and radiation…”
Concern about aerosol-generating procedures during autopsies, especially use of bone saws, increased dramatically during the COVID-19 pandemic. CDC guidance calls for ” appropriate engineering controls and personal protective equipment (PPE)” if aerosol generation is likely. A 2020 survey of Pennsylvania’s C/ME offices found that only two of the eight offices with their own autopsy facilities had negative pressure units. None had a BioSafety Level 3 facility.
Chemicals
Drugs like fentanyl and carfentanil pose a risk when investigating drug deaths, but MDIs can also be exposed to carbon monoxide, cyanide, and other chemicals. CDC’s new website for coroners and medical examiners provides references on drug exposure. The take-home from the limited available research seems to be that the risk is low if standard operating procedures are followed and personal protective equipment (PPE) is used correctly.
Mental Health Risks
This is currently a big concern. Daily exposure to horrific murders, mutilating accidents, suicides, infant deaths, and decomposed bodies takes its toll. So does interaction with grieving, distraught, and sometimes hostile families and friends. There is so much new work going on in this area since the pandemic that it will be covered in a future blog post.
The COVID-19 Pandemic: New Dangers for the Medicolegal Death Investigation Community
Death investigators are essential employees; like other essential employees, they didn’t have the option of working from home during the pandemic. Quite the opposite: the more deaths, the greater the workload and risk of virus exposure for C/ME workers. A study in the Journal of Occupational and Environmental Hygiene evaluated the impact of COVID-19 on Pennsylvania C/ME operations in 2020. Workers reported greater use of PPE, including Tyvek suits, N95 masks, face shields, and sometimes respirators – if they could get them. Fewer than two-thirds of the offices used N95 masks to handle COVID-19 cases and less than one-third used Tyvek suits. C/ME offices did not have adequate access to PPE. Only 18% were able to fit-test staff for masks.
Home deaths were the most dangerous. Often investigators and transporters knew little about the circumstances of the death when going to the scene. Therefore, they had to consider COVID-19 infection a possibility in every out-of-hospital death. The risk was aggravated because C/MEs had little or no access to COVID-19 tests early in the pandemic. According to the Pennsylvania study , about 71% of C/ME offices were testing decedents by late in the year. But most only did so if the decedent was known to have been symptomatic.
Mitigating the Dangers of Medicolegal Death Investigation
First, C/MEs can take action by request a Health Hazard Evaluation from NIOSH. CDC provides information about this on its new resource site for coroners and medical examiners. The site has examples of previous evaluations. If more C/ME offices request evaluations, more data on health and safety in the Coroner’s Office will be available. That information could help protect those who take care of the dead.
Second, OSHA and state agencies should start doing more inspections and reporting on C/ME office working conditions and injuries.
Third, national accreditation by the International Association of Coroners and Medical Examiners or the National Association of Medical Examiners would mitigate the considerable risks of being a last responder. That’s because accreditation requires standard operating procedures, equipment, and infrastructure that address safety. Because of the cost and effort required, very few offices are accredited.
Conclusion
In summary, more data is needed on the dangers of medicolegal death investigation and how they affect the health and safety of those who work in coroner and medical examiner offices. Local, state, and federal agencies can take action to safeguard last responders.