Welcome to the first day of your rotation at the Highland Medical Examiner’s Office. I hear you were assigned to work on Nick Herren’s case while you were at Highland Hospital . It can be hard to lose a patient and then make the transition to work on his autopsy – but you continue to do his family a great service by helping them understand what really went wrong. We think it’s helpful for your training to see a patient all the way through to an accurate diagnosis (in this case, cause of death), which is why we sometimes have our interns follow their patients across medical specializations, rather than staying in one area. By following this patient from the ICU to the medical examiner’s office, you will care for him from beginning to end.

Nick Herren was in such an unstable condition once he was admitted to the ICU that they weren’t able to conduct some common tests that might have helped us to determine why he collapsed on the basketball court. So, there’s still a lot of work for us to do to determine the cause of his death and any contributing circumstances. I’m going to ask you to look into the background of his case and to do some work on the autopsy itself – at the very least, interpret the findings. I have some other folks handling the cutting, weighing, etc. I’ll outline what I need you to do at each step in this process.

Review the case materials

I’m providing you with the case materials (attached to this email) from the police investigator, Tom Diaz. These include a video that Diaz put together of his findings, interviews, etc. as well as Nick Herren’s patient chart from the Highland Hospital ICU, which should look familiar to you. I want you to review the case details, make observations you think are related to the cause of death, and use the Research Notes template to record the decedent’s clinical findings and risk factors you think are relevant. Keep in mind that there are sometimes multiple factors at play when determining cause of death. For example, there can be a primary factor that ultimately explains the reason for someone’s death. But sometimes there may also be contributing factors that play a role (e.g., exacerbate existing poor health conditions), too.

In the template, you’ll see that I already put some thought into the various possible causes of Herren’s death (i.e., first column of the Diagnostic Research Table). Use my differential as a guide to get you started researching each possible cause of death.

Develop a Differential Diagnosis

Based on your research into the possible causes of death, start thinking about which diagnoses are more likely. Keep in mind that my differential diagnosis is only a starting point- - the list is not prioritized in any way. You’ll have to prioritize it (which I’ll explain in more detail below) and figure out if Herren had any particular signs and symptoms that match the possible causes of death. You can use that research template to help you keep your thinking straight. (By the way, the police have ruled out foul play, so I didn’t include it in my differential.)

Use the Diagnostic Report template to explain to me your prioritized list of diagnoses, which should be listed according to the most likely explanation for Nick’s illness. If you have a different metric for your prioritization, explain it. Be sure to provide evidence to support your prioritization (e.g., commonness of a disease or Nick’s medical history). (The findings you record in the Diagnostic Report now will later feed into your Autopsy Report.). The more you tell me about your thinking, the more I’ll know you’re headed in the right or wrong direction, and the more I’ll be able to teach you. My goal in my role here is to be accurate and helpful to the family, and to make sure you learn from the work you are doing.

I look forward to seeing your thoughts on the prioritized differential.

Regards,

Cameron Wood, M.D.

Chief Medical Examiner

Highland Medical Examiner’s Office