Memories of 2020 – An Interview with the Medical Examiner

Dr. Monika Pitzele

During recent weeks the news included multiple recollections of the beginning of the pandemic and reflections of the year behind us. As a member of our forensic section and a person with a strong interest in forensic pathology, I followed the trend and decided to talk to someone with the most fascinating job, the Cook County Chief Medical Examiner (ME), Dr. Ponni Arunkumar. Below are excerpts from our conversation supplemented with some additional statistics. Cook County consists of the city of Chicago and surrounding suburbs. With its population of about 5.2 million, it is the second largest county in the US, after Los Angeles County. However, Los Angeles has about twice the population with four times the surface area, so I am not sure if us being in second place is completely fair… Anyway, it does sound like the pandemic significantly increased the workload of our ME’s office. In 2020 the case load reached a record high of 16,049 cases, compared to 6,274 cases in 2019. According to the released statistics, Cook County ME’s office reported 8,192 Covid related deaths. The following is our conversation:

Q: What changes have you observed during the pandemic?

A: We did take jurisdiction of the Covid deaths, but if you look at non-Covid, the numbers also went up.  We usually get about 6,200 cases. In 2020 we got almost 8000 non-Covid cases. If people were found at home and the cause of death is uncertain, we would swab them for Covid in addition to the autopsy. But the majority of the differences are the opioid overdoses and the homicides, mainly gunshot wounds, both of which went up by about 50 percent.

Q: Did any of the criteria regarding choosing ME cases change during the pandemic? As a working ER doc, it seemed to me that the ME’s office has become more selective.

A: We did get significantly busier, but the criteria have not changed. But it is possible we have become a little bit stricter. If, for example, a person has some natural disease and they were in the hospital, in those cases we asked the physician to sign the death certificate. It is possible that prior to the pandemic, we would just take these cases if they're younger. But if there was natural disease and the evaluating physician did not suspect drugs or foul play, then we were okay with the physician signing the death certificate. So maybe we got stricter with the criteria for what we take jurisdiction on just because there was such a huge caseload.

Q: What criteria did you use to determine a Covid death? Was it always a PCR? Was it done in the hospital or here at the office?

A: We took jurisdiction of all the Covid deaths. Even if we did not bring the body here, we did record reviews and signed the death certificate, so we would review all the medical records and put in the cause of death. For patients diagnosed and tested at the hospital the cases were well documented and it was not an issue at all. We did the testing for patients who were found at home, or, if they were homeless and found with no history – we did the swabs and quite a few of them came back positive. There were cases where people were positive for Covid PCR but per family had no symptoms, so they did not have clinical infection. In those cases, we could not just go with a positive PCR. We would do X-rays and CT scans here at the office. If they had infiltrates and history of symptoms but a negative PCR, we would still call it probable Covid infection. With the post-mortem swabs the PCR can be negative, but the person still had an infection.

Q: But you were not doing routine swabs on every patient?

A: We were not doing it routinely. If they were shot, we didn't swab, but we had to do the autopsy. If we saw something, we would document. But there are some offices where they would swab everyone who comes to the medical examiner's office. Our caseload is just way too high to do it.

Q: What would you say were the most common findings in the Covid patients that you did autopsies on?

A: Based on our autopsy findings, we were seeing pulmonary thromboemboli most often. I think when it comes to the symptoms of pneumonia, people are going to the hospital. For these cases we just reviewed the records.  But the ones we did the autopsies on, pulmonary thromboemboli, is what we were seeing a lot of. I remember one case with myocarditis from Covid, young kid.

Q: How many pediatric deaths from Covid have you seen during the pandemic?

A: Not too many, I would say. I haven't done the count, but it would be less than 10 for sure.

Q: Have you seen any changes in presentation over the course of the year with different variants and changes in the treatment in the hospitals?

A: Presentation of patients we do autopsies on have not changed. The main difference I see in the hospitalized patients is that initially the people would be in a hospital for a long time. Now there is this tendency, and I don't know what the exact criteria would be, but they often go into a hospice. We weren't seeing all of that in the beginning.

It is always fascinating for me to get a glimpse into the functioning of the medical examiner’s office. But there was another aspect of this conversation that I found striking -- the Medical Examiner’s caseload increased not only due to Covid-19 cases. There was an almost 25% increase in non-Covid deaths during the pandemic year. The main reasons identified by Dr. Arunkumar are opioid deaths and homicides.

Opioid deaths have been significantly increasing in Cook County over the last few years. In 2020 there were 1599 confirmed cases, but during the release of the data there were 450-500 cases pending toxicology, making the potential number of opioid related deaths close to 2000. For comparison, the reported number of opioid deaths in 2019 was 1277, much increased from 647 in 2015. Per Dr. Arunkumar, the main opioid responsible for the lethal overdoses is fentanyl, which is consistent with nationwide data. A good example of its danger is the fact that in suburban Cook County out of people misusing opioids only 8% use heroin and fentanyl analogs, fentanyl is responsible for 50-70% of fatal overdoses. Comparing strengths, heroin is about 7 times as potent as morphine, while fentanyl has more than 100 times morphine’s potency.

Another significant increase of mortality was seen in homicides – in 2020 there were 970 homicides compared to 675 in 2019. Out of 970 homicides, 875 people died of gunshot wounds. Of the total number of homicides 78% of deaths were Black people, 16% Latino, 9/10 male. Looking at Covid deaths, about half of the reported deaths were in the Black and Latino population. According to US census data, Cook County’s population is about 24% Black and 25% Latino. These statistics are very sobering, and further emphasize the disparities present in our society and worsened by the pandemic.

References:

1. https://www.cookcountyil.gov/content/about-cook-county

2. Cook County Medical Examiner Reports Record Number of Deaths in 2020, wttw news, by Kristen Thomas,  January 4, 2021, 11:40am

https://news.wttw.com/2021/01/04/cook-county-medical-examiner-reports-record-number-deaths-2020

3. Cook County Medical Examiner Handled Record Number of Deaths in 2020, WBEZ Chicago, by Alex Keefe, Michael Puente, January 2, 2021, 11:52am

https://www.wbez.org/stories/cook-county-gun-murders-broke-record-in-2020/505c1aa7-9bf7-4a3e-bbde-eb88c618d6f5

4. Cook County Registers Record Number of Opioid Deaths in 2020, NBC Chicago, January 2, 2021, 1:19pm,

https://www.wbez.org/stories/cook-county-gun-murders-broke-record-in-2020/505c1aa7-9bf7-4a3e-bbde-eb88c618d6f5

5. Opioid Epidemic in Suburban Cook County, Cook County Department of Public Health, Epidemiology Unit, Alfreda Holloway-Beth, Nhan Nguyen, February 2021

https://cookcountypublichealth.org/wp-content/uploads/2021/02/CCDPH-Opioid-Epidemic-Report-2.18.21.pdf