HB 225-MEDICAL EXAMINERS & AUTOPSIES CHAIR DYSON announced HB 225 to be up for consideration. REPRESENTATIVE LESIL MCGUIRE, sponsor, explained that the understaffed condition of the Alaskan Medical Examiners office causes some unexplained deaths to go unexamined; it also diminishes the state's ability to acknowledge and react to the outbreak of communicable diseases. Last year over 1,100 cases were filed and the office has only one state medical examiner. His duties are multifaceted. One of the most important is performing autopsies, but he also has to testify in court in cases of a suspicious death. This becomes an important public issue because a lot of autopsies are suspicious and crimes cannot come to light and because deaths can be caused by contagious diseases. HB 225 requires the Medical Examiner's Office to be staffed with at least one medical examiner and one deputy medical examiner. CHAIR DYSON asked if staff to this office could be increased without this legislation. REPRESENTATIVE MCGUIRE replied that it could. CHAIR DYSON asked if the additional position mandated in this bill is reflected in the Governor's budget. REPRESENTATIVE MCGUIRE replied: It is reflected in the House version and I believe it will be reflected in the ultimate version that comes out of the conference committee. That is why there is a zero fiscal note. An additional $100,000 was put in for this position.... I think from conversations... with members of the your body it may well have been an oversight. She did not want to create more government, there are few very important areas that should be left to the state and this is one of those areas. She did not want to see this position contracted out or left unfilled. CHAIR DYSON asked Dr. Mandsager if the administration has taken a position on this bill. DR. RICHARD MANDSAGER, Director, Division of Public Health, Department of Health and Social Services (DHSS) testified that he supported the bill; however he clarified that the division's budget currently does have just enough money in it for minimal operation by two medical examiners and he has been recruiting for the other position for about six months now. He explained the reason for the $100,000 increment in the Governor's budget was to begin building the capacity of the Medical Examiner's Office to more fully meet its missions including attempting to answer questions from the bereaved as to why their loved one died. CHAIR DYSON said he understands that the administration supports the bill and the administration has established funding for the addition to the examiners office and the Division of Public Health is currently recruiting the additional staff. DR. MANDSAGER replied that that is correct. SENATOR ELTON said this bill not only provides for a deputy, but it also establishes his general duties and he asked if the department would establish his duties if it had one at this time rather than having those duties established in law as they would be doing under this bill. DR. MANDSAGER replied that he thought the department would establish those duties without this bill in that case. The only other difference this bill would make is that under current statute the department could recruit for a second person who might not be totally qualified to be a deputy. This bill requires recruiting someone who is qualified to serve as a deputy medical examiner. 1:43:29 PM SENATOR ELTON asked whether the department has looked at the possibility of having contract positions throughout the state to carry out some of the duties of the medical examiner. 1:44:43 PM DR. FRANK FALLICO, Chief Medical Examiner, Department of Health and Social Services (DHSS), replied that the department has considered that option and determined that it is too difficult to find enough staff who are qualified to perform forensic autopsies. CHAIR DYSON said he has heard that the Medical Examiner's Office misses the cause of some accidental deaths, particularly those involving carbon monoxide, because it does not have sufficient manpower to perform autopsies. DR. FALLICO, replied: As a matter of fact, we have investigated those deaths very thoroughly and when an autopsy is required we do it. I do not believe that we have missed any of those deaths. However, I will say that they are very difficult death determinations sometimes and they can be missed even under the best of circumstances. We have a problem with the transportation of bodies and doing this sort of work within our budget. However, we have special sensitivity to carbon monoxide deaths. As you know, there have been quite a few of them here under tragic circumstances and I do not believe that we have missed any of them. However, one sometimes does not know what one misses, if you will, and we certainly would have a better opportunity to pick up those accidental deaths to which I am now deferring if indeed we had one more medical examiner here. You know this office really can't run with one examiner because I am stretched to the point where I have to triage or turn away cases that would, perhaps, be done in other good jurisdictions. Once again, I do not believe that we have missed any carbon monoxide deaths that are of a level of suspicion such that others would disapprove of us having turned them down. CHAIR DYSON said that he has heard that the department often gets requests to examine cases on behalf of family members whose recently deceased relatives had made suspicious changes to their will immediately before their deaths. DR. FALLICO responded: In forensic cases an autopsy is done if it will help solve the case; it is not done solely at the request of family members or even at the request of police or troopers unless we both agree to do it. I always work through the proper police or trooper agencies to see if the investigation really warrants an autopsy. In cases where autopsies are not warranted, I do not do them at the request of families because that is not the purpose of this office and it is certainly out of the question given our current staff level. CHAIR DYSON asked if he is correct in believing that the death of an elderly person does not trigger a police investigation and all that is required to close a case is a physician's signature on the death certificate. DR. FALLICO replied that if the death is a natural death that occurs in a hospital, it does not trigger an investigation from his office. If that same death occurs outside of the hospital, there are two ways in which it can be handled. The first is that the police will go to the home and investigate to determine whether or not it was a natural death. If so, that death is reported to him and he makes a determination of the cause of death and signs the death certificate. He said that in the great majority of cases, that does not require an autopsy and if the family asks him for one, he tells them that he is not able to do it. He refers them to a private pathologist who is able to perform the autopsy. 1:52:05 PM He said the second way involves what is called an expected home death where paper work is set up in advance. In these cases there is no real investigation by police and no autopsy is performed. Sometimes with these expected home deaths, however, the troopers disagree and they actually investigate the case, but nothing happens with his office except that the paper work is filled out. CHAIR DYSON asked if the police must respond to a death that has occurred in an assisted living home or a private home where hospice care was provided. DR. FALLICO responded that it depends on whether or not the death is reported and on the individual circumstances. Assisted living home deaths push a very sensitive button because of certain recent deaths and issues of elder abuse. The police certainly show up in some of those cases. He said that in every case he reviews the paper work and makes an independent determination about the cause and manner of death and he will require an autopsy in some of those cases - for example, if they die in certain nursing homes - because of the possible political and legal pressure that may arise from the deaths. CHAIR DYSON supposed: Here is a scenario that I have heard of, an 87-year old man who has been non ambulatory for six years and who is incompetent, miraculously decides to marry his 29 year-old personal care attendant whose boyfriend is the supervising physician and two weeks after the magic marriage, he ups and dies. But in the interim his will has been changed; but arguably he has died of natural causes and the supervising physician signs the death certificate. Is there anything in our process that looks at recent changes in status such as in marriages or in wills that may make you and the troopers decide that a case needs greater consideration? DR. FALLICO responded that his office is not a primary investigation agency and would refer such a case to the primary investigative agents and offer its assistance. 1:56:13 PM CHAIR DYSON asked if recent changes in a will or in marital status automatically trigger an investigation. DR. FALLICO replied he believes that the police or troopers would investigate such cases because that is part of their job. He believes that they would inform him of such changes before he made any decision regarding the case. He added that he must ultimately rely on the judgment of the police and troopers and if they are not willing to go forward on a case, he cannot perform an independent investigation. SENATOR WILKEN said he was puzzled about why this bill is necessary if the issue was already being taken care of. DR. MANDSAGER replied he thought the reason Representative McGuire introduced this bill was because she believes the department hasn't paid enough attention to making sure to has the two positions filled. Even, if the bill doesn't pass, he would continue to try and staff the office with two medical examiners with the current budgetary amount and it is a bit of an improvement over current practice in that it states very clearly that the state needs two medical examiners. He stated, "My personal opinion is that that's a correct statement and this bill would put it into statute rather than leaving it as an opinion." 2:00:50 PM REPRESENTATIVE MCGUIRE commented that it's not uncommon for the legislature to set out in statute a series of standards in areas if wants to - even within the departments of the Executive Branch there is precedent for it. She said further: And then secondly, I would just say that I do respect what you have to say and as I have said earlier I tread lightly in this area, but I do think it's a matter of such importance that it should be in statute. The concern that I have, Senator Wilken is that when you look back at the history, it's been an interesting one. There was a point in time where the Medical Examiner Office had as many as five physicians throughout the state that were doing autopsies. We were rated in the top tier of medical examiner offices in the United States. And over the years we have simply have eliminated those positions or they have fallen off and we have not filled them.... 2:03:22 PM SENATOR ELTON asked if the word "or" should be placed between "Medical Examiner" and "Deputy Medical Examiner" on page 3, line 19, to form the phrase "Medical Examiner or Deputy Medical Examiner." REPRESENTATIVE MCGUIRE thanked Senator Elton for pointing out the drafting error and said that the suggested corrections would be made. SENATOR ELTON moved on page 3, line 19, to insert "or" after "Examiner". There were no objections and Amendment 1 was adopted. 2:04:46 PM DR. DON ROGERS, former State Medical Examiner, supported HB 225 saying that autopsies should be performed on all the coroner's cases because if one solely relies on police departments and witnesses, one will often be mislead. Accurate determination of the cause of death is a requirement on the death certificate and if one does not do the examination and signs the certificate without looking at the body, one is going to be wrong in a substantial number of cases. Medical examiners also have a duty to alleviate the concerns of the families of the deceased. 2:07:11 PM DR. ROGERS stated that the Medical Examiner's Office lab needs a toxicology component because it currently is not able to perform carbon monoxide tests. SENATOR ELTON asked if the Office of the Medical Examiner generally provides autopsies on the bodies of people who die in hospital. DR. ROGERS replied that the Medical Examiner does not perform autopsies for natural deaths that occur in the hospital. He explained that the law requires an autopsy for deaths that occur under anesthesia or that occur shortly after admission to a hospital. SENATOR OLSON asked whether the investigation of those deaths is a matter of the Medical Examiners discretion or if they automatically fall under the purview of the Medical Examiner by law. 2:09:42 PM DR. ROGERS replied that when he worked for the Medical Examiners Office, it performed autopsies for all deaths involving anesthesia or a possible medical error because most of the time the physicians and the families wanted someone besides the hospital personnel performing the investigation. He said that in a state as small as ours with as few deaths as we have, it is possible to perform most, if not all, autopsies. 2:11:35 PM SENATOR OLSON asked what level of education and experience is required to perform the duties of the Medical Examiner and the Deputy Medical Examiner. DR. FALLICO replied: The answer is to be fully qualified as a forensic pathologist certified in the sub-specialty of forensic pathology, one must go to medical school, obtain an MD or a DO degree, followed by at least certification in anatomic pathology, which is a branch of pathology and that takes two to three years, followed then by certification in forensic pathology and that's an additional year of training. Now, another way to do it would be to become certified in anatomic pathology and clinical pathology, like I am, followed by another year of forensic pathology. So you know there's a long arduous course for getting there - many years. And for a variety of reasons that I won't get into, very very few people go into this field. There are about 300 fully qualified forensic pathologists practicing in the country full time. Those are the numbers. So, with these great shortages and so forth, we are not talking about top-rated people. It is possible that people with lesser training could do this work, but we've all read about the disasters across the country in medical examiner's offices where less-than-well-qualified people perform the work. What we have done is set the highest standards here no matter what, because we don't want to go back to the old ways of doing partial autopsies, of not weighing certain organs and having my reports reflect that certain things in the past that may have been acceptable, but today I would be criticized for. When I get up on the stand - you probably all know me - you read about what I do. I was just down there in Juneau earlier this week and I'm under very, very detailed cross examination with experts that are flown up here by the defense and others to certify my work and try and attack defense. So, I feel what we need are fully qualified people as I've described in those qualifications. SENATOR OLSON asked how this bill would apply to foreign graduates and that, "Obviously, there are pathologists there." DR. FALLICO answered that he is a foreign medical graduate from the University of Bologna. As long as the graduate passes the qualification to practice medicine in the United States, and specifically holds a valid bona fide state license, he is just as qualified as anyone else. SENATOR WILKEN moved to report SCS HB 225(HES) out of committee with individual recommendations. There were no objections and it was so ordered.