The state’s chief medical examiner, whose office is responsible for investigating unexplained deaths statewide, has told staff members to cut their “workload to a bare minimum” and to no longer accept certain “flu-like” cases as the deadly coronavirus expands across Massachusetts.
The directives from Dr. Mindy J. Hull, detailed in internal e-mails obtained by the Globe, could scale back the type of cases the Office of the Chief Medical Examiner handles as she seeks to limit her staff’s exposure to COVID-19. It also offers a window into how it might juggle a potential spike in deaths from the rapidly spreading pandemic.
It remains to be seen which, if any, of the rising number of fatalities tied to COVID-19 will demand investigations from Hull’s office, which is responsible for probing unexplained deaths.
The chief medical examiner’s office routinely gets involved when deaths occur outside hospitals or other health care facilities. Those involving people with flu-like symptoms are also “very commonly reported” to her agency, Hull wrote in a set of COVID-19 protocols she released this month.
Her office has so far accepted what a spokesman Tuesday called “several cases” in which the person had flu-like symptoms before his or her death, though none tested positive for coronavirus.
But in girding for the pandemic, which has so far killed at least 15 people amid more than 1,800 confirmed cases statewide, Hull told her staff last week to accept only cases that “we absolutely have to.”
On Thursday, she followed with another directive, saying the office would no longer accept jurisdiction of “flu-like cases” if an attending physician is available to sign the death certificate.
Hull suggested in those cases, the physician classify the death broadly as “cardiopulmonary arrest in a person with flu-like symptoms during COVID-19 pandemic.”
“Obviously we are in uncharted territory,” Hull wrote in a March 16 e-mail to staff six days after Governor Charlie Baker declared a state of emergency. “During these strange times, my main goal is 1) to keep you all safe & 2) keep the OCME functioning.”
That includes a directive to “conserve everything right now,” including supplies and “human resources,” she said.
“Reduce our workload to a bare minimum,” Hull wrote. “Accept only cases we absolutely have to accept & view as many of our accepted cases as we can” instead of performing a more rigorous autopsy.
(A view is another term for an external examination, which can include inspecting the surface of the body, reviewing medical records, and doing minimally invasive testing, such as toxicology.)
In a statement to the Globe, Hull’s office said that when cause and manner of death are apparent for someone who died in a hospital or “when medical records are sufficient for a conclusion,” an in-person examination may not be necessary.
That also includes nursing homes. Hull told her staff that when possible, certain deaths, such as “falls, choking, etc.” in nursing homes, should be done by “document-review only” and that it would not go photograph the body or bring it to the medical examiner’s office in those cases.
“Like professionals in every discipline, Dr. Hull and her team are working to protect OCME staff and conserve resources,” spokesman Jake Wark said in a statement. The office “continues to fulfill its core medico-legal mission, investigating cases that fall under its jurisdiction while taking necessary steps to minimize the risk of COVID-19 exposure and ensure that final disposition remains safe, timely, and respectful.”
The rise of COVID-19 has upended daily life and normal functions across government for the last two weeks, prompting Baker to close schools, order “non-essential” businesses to close their doors, and urge people to stay home to slow the spread of infections.
That’s rippled into law enforcement as well. State Police Colonel Christopher Mason told his detectives responding to unattended deaths where the person had flu-like symptoms to defer any on-scene examinations “from close proximity” to Hull’s office, a State Police spokesman has said.
Hull created new protocols on March 7 for responding to deaths with potential COVID-19 infection, including creating a “special response team” that includes a medical examiner and up to two assistants. Hull or her deputy, Dr. Richard Atkinson, have also responded to each potential COVID-19 scene, her office said.
Hull intends to triage unattended deaths across four categories, and in cases where there’s low risk of infection, Hull said that “autopsies should be performed only when necessary.”
That approach aligns with the way other medical examiners are moving forward during the coronavirus crisis.
Dr. Sally S. Aiken, president of the National Association of Medical Examiners, said most coronavirus deaths are occurring in hospitalized patients who have already been diagnosed with COVID-19, meaning medical examiners would “ordinarily not need to do an autopsy.” The Occupational Safety and Health Administration also now recommends that COVID-19 deaths not be autopsied, she said.
Hull’s office was one of the first in the country to develop a COVID-19 specific plan, Aiken said, but given the patchwork of state laws governing examiners and coroners, she said there’s no “uniform response” across states.
“Every jurisdiction’s response will need to differ, as a practical matter,” Aiken said in an e-mail. “Depending how the pandemic develops, medical examiners will become involved in deaths that happen in private residences (just like now), and will need to determine if deaths are COVID-19 caused. That determination will be done by investigation and a variety of approaches.”
Hull’s office has already scaled back the number of autopsies it performs since she was tapped by the Baker administration to lead the agency in 2017. Autopsies accounted for 31 percent of the office’s 6,500-plus cases in 2019, according to its most recent annual report.
Danny McDonald of the Globe staff contributed to this report.