Signs of death

 

Fatalities on board ocean-going vessels present unique challenges to the crew. Although these events are not part of the shipboard routine, they must nevertheless be handled with maximum professionalism in the interests of everyone involved; this chapter should contribute towards achieving this goal. Since a physician will not be regularly available on the high seas and particularly not aboard container ships or freighters, this chapter is not just directed at physicians working on cruise ships, for example, but also aims at instructing medically qualified personnel aboard merchant ships (shipmaster, medical officer [7]) in the distinctive maritime medical features of adequate fatality management on board. There is a growing tendency for passengers to also be taken aboard container ships and freighters as “paying guests”. Thus older and even multi morbid patients are to be expected not only on commercial passenger vessels and cruise ships.

Like the determination of death made by paramedics on land (e.g., ambulance service emergency medical technicians), it is based on the four certain signs of death:

  • Livor mortis (lividity),
  • Rigor mortis,
  • Putrefaction,
  • Injuries incompatible with life.

Changes in the corpse like livor mortis and rigor mortis partly occur very soon after death and are reliable indicators of death. As soon as one of the four certain signs of death are present, resuscitation measures can be stopped without having to fear legal consequences. A provisional certificate of death at sea has been added to the chapter for the purpose of documenting the determination of death.

To confirm the findings, a post mortem examination must then be performed and documented; the chapter contains an algorithm designed to facilitate the provisional post mortem examination at sea by paramedics.

Although this chapter cannot and will not replace numerous studies on forensic post mortem examinations, fatalities on the high seas do have distinctive features that will be discussed at greater length in the following. Specific instructions should also enable medical laymen on board ocean-going vessels to make a definite determination of death, to perform a preliminary post mortem examination, and to store the corpse according to forensic and hygienic requirements until it can be handed over to the medical officer at the next port of call.

 

Determination of death aboard ships

 

Determining death is a physician’s task. Since a physician is not always present aboard ocean-going ships, however, and particularly not aboard container ships or freighters, the shipmaster and/or medical officer must take over this task. Guideline 9229 of the Council of the European Communities, Article 6, “Telemedical Services”, says that “Each member state [takes] the necessary measures for designating one or more centers that offer gratuitous telemedical services in order to ensure better emergency treatment of employees” [6]. Whenever technically possible, such telemedical services available to the shipmaster and/or medical officer should be utilized not only for accidents, injuries or diseases on board but also for fatalities. Even after receiving telemedical assistance, however, the shipmaster and/or medical officer must still take over the task of determining death and performing the subsequent post mortem examination on board if a physician is not available or could only be brought aboard by going to unjustifiable lengths. Thus the telemedical service does not release the shipmaster and/or medical officer from their responsibility on board! Moreover, in the presence of definitive signs of death, it is not necessarily useful to bring a physician on board only to determine death and take charge of the corpse. It is advisable, however, to report the fatality to the appropriate MRCC (Maritime Rescue Coordination Centre), which can then provide information regarding the further procedure. In any case, however, it must be reported as quickly as possible to the medical officer at the port of destination or at the next port of call, if the stop is justifiable and has been approved by the shipping company.

 

Certain signs of death

 

The determination of death can basically also be made by medical laymen on the basis of the four certain signs of death:

 

  • Livor mortis (lividity)
  • Rigor mortis
  • Putrefaction
  • Injuries incompatible with life

 

These certain signs of death can also occur separately (in relation to the time of death) [4,10] .Note: All changes in the corpse are extremely temperature dependent; the time periods specified here are only empirically derived reference values and can vary considerably depending on the environment and clothing.

 

Livor mortis (lividity)

 

After cardiac arrest, the blood sinks down into the dependent parts of the body – the formerly circulating blood volume is pulled downward by gravity. Thus lividity reflects the position of the corpse at death and is found, for example, on the shoulder blades and buttocks of a supine corpse while sparing areas with tight clothing and contact surfaces. It already appears as patches in the head and neck region 30 minutes after death; it becomes confluent after 1 – 4 hours and reaches its maximum after 3 – 16 hours. Livor mortis is usually bluish-violet due to the deoxygenated blood.

 

 IntTextbookMaritMed_10-15_Fig_01

 

Fig.1: Livor mortis in its typical colour with level formation in the mid axillary line: typical spared areas at the contact surfaces of the left arm

 

Livor mortis is bright red in cases of carbon monoxide or hydrocyanide poisoning (or in cases where the corpse is kept in cold storage). Carbon monoxide is a colourless and odourless gas that arises, for example, from incomplete fuel combustion. Thus it is always necessary – primarily for self-protection – to consider or exclude carbon monoxide poisoning, particularly when bodies with bright red lividity are found in engine rooms, after engine room fires (automatic carbon dioxide fire extinguishing system!) or in boiler houses.

 

 

 

 IntTextbookMaritMed_10-15_Fig_02

Fig. 2: Bright red lividity on the dorsal side of the body as the expression of lethal carbon monoxide poisoning

 

Brown or green lividity occurs in cases of intoxication with poisons that form a modified version of hemoglobin (meth- or sulfhemoglobin formers). Livor mortis is mild or absent in cases of severe blood loss or anaemia. It can be completely shifted up to six hours after death: If the position of the corpse is changed, lividity also shifts according to the rules of gravity. If the corpse is repositioned between six and twelve hours after death, lividity appears on both the new and old dependent body parts; it is thus still “partly shift able”. In addition, the effect of gravity can cause point hemorrhages (vibices) in the livid areas when blood escapes from the vascular system into surrounding tissue after death.

 

 

 IntTextbookMaritMed_10-15_Fig_03

 

 

Fig. 3: Vibices in dependent body parts - here: lower legs after death by hanging – spared areas on the back of the foot due to tight shoes

 

Lividity can be completely blanched by finger pressure within the first twenty hours after death, since part of the blood can still move within the vascular system. This mechanism no longer functions 36 hours post mortem as the escape of serum from the vascular system increases blood viscosity, and the vessel walls become increasingly unstable and permeable.

 

Rigor mortis

 

At the microscopic level, the muscle fibers of the body consist of myosin and actin filaments (from the Latin “filamentum” = fiber) that slide into each other during energy utilization and thus cause shortening of the muscle (contraction). Energy is also needed to unlink the actin and myosin filaments; a living body has this energy available in the form of the molecule adenosine triphosphate (ATP). Since “fresh” ATP can no longer be synthesized by oxygen utilization after death, it is initially formed post mortem via alternative metabolic pathways like anaerobic glycolysis, where ATP is derived from glycogen. As soon as the muscle glycogen reserves are exhausted, the actin and myosin filaments become locked together and thus cause a “cramping” that becomes apparent as rigor mortis. Rigor mortis spreads according to Nysten’s law: starting in the masticatory muscles after 15 minutes to 3 hours, it moves downward to the lower limbs, and is complete after 6 – 10 hours. Up to 8 hours after death, rigor mortis can recur after being broken. Resolution of rigor mortis by dissociation of myosin and actin filaments at the molecular level follows the same downward progress and takes 2 – 4 (maximum 8) days.

 

 

 IntTextbookMaritMed_10-15_Fig_04

 

Fig.4: Fully developed rigor mortis

 

An exception to the spread of rigor mortis according to Nysten’s law can occur after hard physical labour, e.g. aboard ocean-going ships: the so-called “runner type” rigor mortis starts in the lower extremities due to muscle glycogen depletion. More precise knowledge of the biochemical processes can be gained from textbooks of physiology and forensic medicine [4,10,11]. The practical examination of rigor mortis is always performed in several large joints on both sides: the attempt is first made to open the mouth and then to move the upper and lower extremities.

 

Putrefaction

 

The decomposition of a corpse occurs as a combination of bacterial putrefaction and enzyme-induced autolysis. The first visible sign is green skin discolouration that appears after 2 – 3 days, usually on the right lower abdomen – here the bowel lies close to the abdominal wall. Rigor mortis is completely resolved after 4 – 5 days; the eyeballs sink backwards, and the green skin discolouration increases and spreads over the entire body with venous marbling. After 10 – 14 days, putrefactive blisters form on the epidermis; the abdominal walls are distended, and reddish putrefactive fluid exudes from the mouth and nose. Two to three weeks after death, the skin falls off in shreds; the hair and nails can be pulled off; and fluid-filled putrefactive blisters also form in the soft tissues. The body is strongly distended.

 

 

 IntTextbookMaritMed_10-15_Fig_05

 

 

Fig.5: Venous marbling and green skin discolouration

 

Another late post mortem change that is also important in maritime medicine is ”adipocere formation”, also known as ”saponification”. Under certain climatic conditions (low oxygen environment, cold temperatures), all body tissue can transform into a waxy soap-like substance several weeks or months after death. This is primarily observed in corpses recovered from water – corpses thus altered are often incidentally recovered in nets of fishing vessels.

    A discussion of further post mortem changes due to feeding damage or mummification goes beyond the scope of a maritime medical textbook; more detailed information can be obtained from the relevant forensic literature [4,10].

 

Injuries incompatible with life

 

Injuries incompatible with life include obvious traumas such as decapitation or lacerations covering the entire body. However, injuries not visible externally may also cause the immediate of death of an individual, while those initially regarded as being incompatible with life may be survived with adequate treatment. The best possible medical care should always be delivered if there is any doubt.

Thus the presence of only one of the four certain signs of death is sufficient to determine a person’s death with adequate reliability regardless of the suspected cause of death – further diagnostic and therapeutic measures can then be stopped without incurring punishment for negligence or premeditation.

 

Uncertain signs of death

 

Apart from the certain signs of death, there are diverse so-called “uncertain” signs of death, which include:

 

  • Asystole (flatline) in the electrocardiogram (ECG),
  • Cardiac arrest,
  • Absence of pulse
  • Respiratory arrest
  • Absence of reflexes
  • Fixed dilated pupils
  • Pallor
  • Coldness

 

These conditions, whether taken singly or together, are not criteria for determining death but are reversible with adequate medical treatment. Thus it is not permissible for medical laymen to declare a person dead on the basis of these “uncertain” signs of death. As explained in previous chapters, it is in fact imperative in such cases to provide the best possible medical care available under the given conditions in order to enable the patient to survive. Accidental hypothermia – often seen at sea – is a special case (see previous chapters): A person with hypothermia and cardio circulatory arrest should be resuscitated for at least two hours or until certain signs of death occur. In general, it is only permissible to determine the death of hypothermic persons at sea after exhausting all medical possibilities and in the presence of certain signs of death. The following rule applies here: “Nobody is dead until he is warm and dead” [8].

 

Manners of death

 

Determining the manner of a person’s death (not to be confused with the cause of death!) means clarifying whether the death was natural or unnatural; this is done within the context of the post mortem examination (see below). The reader is again referred to detailed legal and medical textbooks, since different approaches are used to define the terms “natural death” and “unnatural death” in the specialist literature [4,9]. However, a distinction is generally made between three manners of death:

 

Natural death

 

Death from internal causes, e.g. diseases, malformations or reduced vitality, without any harmful outside influence in the development of the condition

 

Unnatural death

 

Death caused by external violence and other external events or their sequelae (even nonrecent ones): accident, criminal acts, suicide, neglect, physician’s act or omission; the majority of cases on board ocean-going vessels will involve unnatural manners of death, since these are young persons engaged in hazardous activities.

 

Indeterminate

 

Unclear whether the cause of death is internal or external – an autopsy is required to clarify the manner of death. When a medical layman makes the determination of death (only provisional on board), he will act correctly by certifying the manner of death as “indeterminate” in case of doubt. However, very careful documentation covering the circumstances of the person’s death and his past history is absolutely necessary to clarify the manner of death at a later time.

 

 Post mortem examination

 

Theoretical basics

 

A physician must inspect every corpse to determine death and to clarify the time, manner and cause of death (post mortem examination). Though, strictly speaking, the term “post mortem examination” refers to the inspection of a decedent by a physician, it will also be used in the following to describe the inspection of a decedent by a medical layman, in this case the shipmaster and/or medical officer. Before the determination of death by a physician, the body of a decedent may only be treated as a corpse when death is obvious from certain signs of death [5] as specified above. There is an inconsistency on board ocean-going vessels, since cargo ships on the high seas will not normally have a physician available. Thus the duty of determining death and documenting the post mortem examination (actually a physician’s responsibility!) must be assumed by the shipmaster and/or medical officer – with telemedical assistance, if necessary: it is by no means permissible to wait until the ship arrives at the port of destination – the post mortem examination must be performed as quickly as possible because even the slightest delay can reduce the reliability of the (physician’s) cause-of-death determination [5]. Special attention should be called here to the superficial skin and mucosa findings, which can yield important insights into the cause and manner of death but may be lost within a few days due to post mortem desiccation despite refrigeration of the corpse:

 

•          Congestive hemorrhages, pinpoint spots or so-called “petechiae” in the head and neck region, particularly in the mucosa (as the expression of upper  
           venous congestion from either an internal [e.g., cardiac disorder] or external cause [e.g., violence-related neck injury]),

•          Injection sites (as an indication of possible intoxications or addiction treatment),

•          Electricity marks (detection also for crew / passenger security!),

•          Small hematomas and swellings (for example, in the neck and throat after strangulation).

 

 IntTextbookMaritMed_10-15_Fig_08

 

Fig. 6: Pinpoint congestive hemorrhages (“petechiae”) in typical localization, here the ocular conjunctivae

 

 

Practical performance

 

A post mortem examination is basically performed in the same way as a physical examination in living persons: The examiner wears gloves, and the decedent is first completely undressed under good lighting conditions. A systematic head-to-foot procedure is then performed according to the described algorithm, and the following questions are precisely handled:

 

 IntTextbookMaritMed_10-15_Fig_10_A1

Fig. 7: Algorithm for post mortem examination

 

This procedure should always be consistently followed to ensure complete performance of the post mortem examination by laymen even under the special circumstances of death on board. The algorithm has been added as Appendix 1 for practical application on board.

 

 Documentation

 

The findings obtained during the post mortem examination must be comprehensibly documented by the inspecting shipmaster and/or medical officer. First the identity of the decedent is positively determined by the shipmaster, if possible. Then the death is entered in the log book, specifying the decedent’s personal data as well as the time or time range, place (longitude and latitude) and circumstances of death [5]. Moreover, a “Provisional Certificate of Death” should be issued by the shipmaster.

Such forms already exist for land-based rescue services so that emergency physicians do not have to completely fill out a Post mortem Examination Certificate and are ready for duty as quickly as possible.

The “Provisional Certificate of Death” provided in Appendix 2 has been modified for utilization in the special case of death on board.

 

 

 IntTextbookMaritMed_10-15_Fig_11_A2

Fig. 8: Provisional Certificate of Death

 

Issuing an official “Post mortem Examination Certificate” or “Death Certificate” on board after the post mortem examination would be a physician’s task that must not be delegated to laymen. It would surely be beyond their depth and should therefore be waived – also for legal reasons. On board ocean-going vessels, however, all post mortem examination findings should be promptly written down in the Algorithm for Post mortem Examination (Appendix 1) and signed by the shipmaster. In the age of digital media, photos of the corpse, its discovery site and the post mortem examination should be added to the Provisional Death Certificate – as explained above, even discrete findings can thus be secured and later confirmed.

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A so-called “Seaman’s Last Will and Testament” can be made in anticipation of the death of a person on board; it is written down by the shipmaster. Its validity expires if the testator is still alive three months later. An oral will can also be made in the presence of at least three uninvolved and uninterested witnesses.

 

 

 Storage of body

 

In case of fatalities at sea, it is necessary to not only determine death and perform the post mortem examination but to also hand over the decedent’s body to the competent authorities when the ship arrives at the port of destination, and it must be stored on board until that time. After a person dies, the decomposition processes can be largely delayed by putting the corpse into cold storage as soon as possible; the optimal storage temperature is 4°C. Storing the body at temperatures below 0°C causes considerable tissue damage, and important findings may thus be lost. Reference should be made here to the “International Agreement Concerning the Conveyance of Corpses of February 10, 1937” and the “Council of Europe Agreement on the Transfer of Corpses of October 26, 1973” [1,2]: Originally laid down for the plannable transport of persons who die on land from one port to another, these legal provisions can also be applied for those who unexpectedly die on board ocean-going vessels if appropriate arrangements have already been made beforehand: After the post mortem examination, the undressed “corpse is wrapped in a shroud and placed in a metal coffin whose floor must be covered by a 5 cm layer of an antacid substance (peat, sawdust, powdered charcoal, etc.) with an antiseptic agent added. The metal coffin is closed air-tight (soldered) and fixed in a wooden coffin so that even the motion of the sea cannot move it. The wooden coffin must be at least 3 cm thick with watertight seams and must be closed by screws not more than 20 cm apart; it is secured by metal bands. The wooden coffin is then put into a crate in such a way it cannot be shifted. If the death occurs less than 48 hours before the ship arrives in the port where the funeral is to take place and if the necessary materials are not present on board, the corpse may be wrapped in a shroud soaked in an antiseptic solution and placed in a sturdy wooden coffin.” However, this procedure requires the availability of all suitable materials on board, which will rarely be the case due to logistic and financial considerations on the part of the shipping company. For practical purposes, it is advisable to use body bags. They are inexpensive, commercially available and should be carried along on all ocean-going ships. These plastic bags are provided with zip closure to prevent body fluids from escaping into the environment.

 

 

 

 IntTextbookMaritMed_10-15_Fig_12

 

 

Fig 9: Commercially available body bag

Alternatively, the decedent’s body may be wrapped in tarpaulin, lined sailcloth, or some similar material. It is also advisable to place absorbent material like cellulose in the body bag or tarpaulin. The corpse is then stored in the ship’s cold room. Care must always be taken to “exclude any contact of the corpse with food or luxury articles and any disturbance of passengers or crew.” [1,2] For this purpose, the body bag must be stored in the cold room as far away as possible from food provisions and secured against slipping due to the motion of the sea; in addition, the corpse should be surrounded by absorbent material (see above) to prevent body fluids from contaminating the environment. The corpse need not be cold-stored if it is brought to the port of destination in less than 24 hours and handed over to the port medical officer immediately after arrival. Obviously, it is necessary to keep not only the corpse itself but also objects that may be connected with the person’s death (e.g., clothing, drugs, weapons or strangulation tools).

 

Death after suspected infectious diseases

 

If the death of a person on board might be due to a contagious disease, the corpse must additionally be wrapped in a shroud soaked in an antiseptic solution. For hygienic reasons, it should by no means be cold-stored near food. It may generally be assumed, however, that a person’s death will have deprived particularly viral germs of their sustenance. Especially in cases of suspected infectious diseases, it is imperative to consult with the medical officer at the port of destination as soon as possible and to clarify whether the ship can call at that port with the corpse on board. In individual cases, the decision can be made – only in agreement with the medical officer at the port of destination! – to give the corpse a seaman’s burial for epidemic hygienic reasons. The shipmaster should perform the burial in a dignified manner and document the ceremony.

 

Further procedure on land

 

In case of a fatality on board, the journey can be continued without forensic or hygienic scruples if the following has been accomplished: unequivocal determination of death based on its certain signs, a provisional post mortem examination including documentation (with telemedical assistance, if possible), and correct storage of the corpse under the above-mentioned conditions. When the ship arrives, the medical officer at the port of destination, who is always notified in advance, takes charge of the corpse and performs the further medical procedures; an autopsy will generally be required to unequivocally determine the cause of death. If the decedent is a passenger, the shipmaster’s responsibility ends when the ship has reached the port of destination and the corpse has been handed over to the competent port medical officer together with the documented findings. If, however, a crew member has died on board in international waters, the shipmaster must arrange the burial or return the corpse to the home port in agreement with the medical officer at the port of destination and the will of the decedent or his family. The following points should be considered here:

 

•          If the corpse cannot be brought to the port of destination (no storage facilities on board, for example) but can be taken to another port within 24 hours  
          after the fatality without health-related transport scruples, the burial must always be performed on land. The historic seaman’s burial remains the     
           exception as mentioned above!

•          The ship owner pays the expenses if the burial is performed outside the jurisdiction of the country under whose flag the ship sails.

•           The “International Agreement Concerning the Conveyance of Corpses of February 10, 1937” again takes effect [1,2] if the corpse is planned to be returned to the home country [3] after completion of the formalities and determination of the cause and manner of death. Apart from these specific regulations for transporting corpses, there are also administrative provisions. Any transport of corpses, by whatever means, requires a special mortuary passport that must in all cases contain the decedent’s surname, first name and age as well as the place, day and cause of death; this passport is issued by the authority competent for the place of death. For fatalities on board in international waters, this may be the authority of the home port or the port of destination or the next port of call. Care should be taken here to ascertain any differences in the regulations. It is advisable to formulate the mortuary passport not only in the language of the country where it was issued but also in at least one of the languages most commonly used for international communication. The necessary documents and certificates must be issued according to the laws of the country whose flag the ship bears.

 

•           Finally, the shipmaster must entrust the personal belongings of a deceased crew member to the competent Marine Office or, with its consent, to another one. The ship owner must transfer wages due to a deceased crew member to the competent Marine Office, which delivers the belongings and wages to the heirs of the deceased crew member at their expense.

 

Death after suspected infectious diseases

 

If the death of a person on board might be due to a contagious disease, all persons on board are considered to be potential contact persons even if they did not come into contact with the decedent. The crew and passengers must be examined by a physician. The entire ship must be disinfected if there is evidence that the decedent had a contagious disease. The personal gear of the decedent must be destroyed if it cannot be disinfected.

 

 References

 

  1. Council of Europe Agreement on the Transfer of Corpses of October 26, 1973, p 515
  2. International Agreement Concerning the Conveyance of Corpses of February 10, 1937, p199
  3. International Labour Organisation, Convention No. 164 concerning Health Protection and Medical Care for Seafarers (Geneva, October 8th, 1987)
  4. Madea B (ed.): Die ärztliche Leichenschau (2nd Edition). Springer Publishing House, Heidelberg / Germany
  5. Richtlinien für das Strafverfahren und das Bußgeldverfahren (RiStBV) vom 01.01.1977 in der Fassung vom 01.10.1988
  6. Guideline 9229 of the Council of the European Communities, Article 6 (ABl. L 113, April 30th, 1992, p 19)
  7. Standards of Training, Certification and Watchkeeping for Seafarers (STCW), 1995
  8. www.sarrrah.de, Version from January 07th, 2009
  9. Tröndle H, Fischer T (eds.): Strafgesetzbuch und Nebengesetze (52nd Edition). C. H. Beck Publishing House, Munich / Germany
  10. Tsokos M (2005): Post mortem Changes. In: Payne-James J, Byard RW, Cores TS, Henderson C: Encyclopaedia of Forensic and Legal Medicine, Volume 3 (1st Edition), pp 456 – 476. Elsevier Academic Press, Amsterdam / Boston / Heidelberg / London / New York / Oxford / Paris / San Diego / San Francisco / Singapore / Sydney / Tokyo
  11. Schmidt R, Thews G (eds.): Physiologie des Menschen (29th Edition). Springer Publishing House, Heidelberg / Germany