Death Certificate

JACKSON — Wyoming is on pace to see nearly 400 more fatalities in 2020 than in 2019, but a lack of consistent rules for coroners and the dearth of testing at the beginning of the coronavirus pandemic make it difficult to know exactly how many of those will be from COVID-19.

Much of that increase can be explained by the coronavirus.

As of press time Tuesday, Wyoming had 202 reported deaths associated with COVID-19. It has averaged 29 deaths per month from the disease, though most have come in the past three months.

At 5,121, the death count in 2019 was the highest in the past 15 years. If current trends hold true, the state will have around 5,490 deaths this year, and at least 240 will be from COVID-19.

Categorizing COVID-19 deaths has become a hot-button political issue, with some arguing deaths are undercounted and others saying that because the vast majority of people who die from COVID-19 have comorbidities, the danger from the virus is overblown.

Coroners and medical providers who sign death certificates do have some leeway in determining cause of death. For instance, if a person dies with both heart disease and COVID-19, they can decide what the primary cause of death was and what was a contributing factor.

Epidemiologists, however, consider them to be COVID-19 deaths regardless of whether the disease was a primary or contributing cause.

“If a provider put COVID-19 on the death certificate as a cause of death, or contributing factor to that, that provider by his or her best clinical judgment said that person would not have died at the time they did in the way that they did if it were not for COVID-19,” State Health Officer Dr. Alexia Harrist said.

Categorizing deaths from other infectious diseases is similar, she said. If someone dies after contracting influenza, death certificates include conditions developed because of the disease like pneumonia, and ones that made fighting the disease difficult like heart disease.

Including everything that contributes to people’s deaths is important to help doctors and health officials understand why they died. Merely writing down the flu or COVID-19 wouldn’t give them a full picture of how comorbidities influence the trajectory of the disease.

“Very rarely are you ever going to see just COVID-19 on the death certificate,” Harrist said. “In fact, you could argue that's probably not a very complete death certificate.”

How those deaths are ascertained is often up to the coroner or medical provider. Though Wyoming has guidelines for coroners and provided some training on identifying COVID-19 deaths when the pandemic started, it is up to individual coroners to decide on things like postmortem coronavirus testing to see if an unattended death may have been due to COVID-19.

A self-proclaimed student of pandemics, Fremont County Coroner Mark Stratmoen stocked up on rapid tests, PPE and other supplies in February, he said.

“Anyone who thought it wasn’t going to get here eventually was a fool,” Stratmoen said. “We ordered extra body bags in the middle of March in anticipation.”

His office also ordered rapid tests and use them on corpses if “circumstances lead to a suspicion that COVID-19 is involved.”

Stratmoen’s office is on its second batch of 50 rapid tests, which cost $900 per batch.

“We need to spend and do what we need to do, and the county needs to figure out how to pay for it,” Stratmoen said.

So far they’ve come out of his regular budget with a chance of federal reimbursement.

Stratmoen thinks testing for COVID-19 is a best practice in death investigations during a pandemic because it’s one extra step that provides more information.

“It’s a finger poke blood draw, and we get the results in 10 minutes,” he said.

Stratmoen says the test will tell him if the deceased had the virus at the time of their death or had it prior or not at all.

Fremont County saw its first at-home COVID-19 death case Oct. 24.

“All the cases prior to that were in medical facilities,” he said. “Since the end of October we have had four that were coroner-case deaths. That represents a notable change in the dynamics of the community. People are dying that aren’t making it to medical care. It’s somewhat alarming.”

Stratmoen worries death statistics will become less accurate over the next few months as hospitals become more overwhelmed and more people die at home.

“We are probably missing a certain percentage of actual deaths from COVID but there is no way to define that definitively,” he said. “The numbers, in my opinion, are undercounted.”

Teton County Coroner Dr. Brent Blue’s opinion is the complete opposite.

“We don’t have good numbers, and that’s part of the problem,” Blue said. “I think the numbers are overcounted.”

Over the weekend and on Monday Blue pored over data he said he obtained from the state of Wyoming.

“Nobody has, so I thought it was time to do it,” he said.

He shared a summary of what he found with the News&Guide, where he stated there have been 168 Wyoming death certificates with COVID-19 listed in some form since Jan. 1.

“This is high variability in the way death certificates are made out from county to county, doctor to doctor,” Blue stated in his notes. “Estimated margin of error is 10% due to lack of standardization. Most death certificates were made out by physicians and were NOT coroner cases.”

In unattended death investigations Blue feels there is no reason to test the deceased because “we usually have a pretty firm cause of death.”

“We had a 41-year-old woman die at home,” he said. “She had a massive heart attack. There is no reason to do a COVID test.”

Though Wyoming’s Vital Statistics Services will ask coroners and providers follow up questions if something seems off with their death certificates, the department generally defers to them because they are the ones working with the deceased.

“What we try to do is just give them guidance in completing the certificate and if something looks irregular, the law provides the authority for our office to ask them to do a consult,” said Guy Beaudoin, deputy state registrar at Vital Statistics.

Because of that deference, it’s theoretically possible some coroners could be labeling deaths caused by COVID-19 as heart disease, or adding COVID-19 to the list of contributing factors to someone who died in a car crash. However, state officials say the process of checking with coroners, as well as the requirement that any coroner who isn’t a medical doctor consult with one during a death investigation, prevent that from happening.

“We're able to work with those providers to really confirm, was COVID really a cause or contributor to that, or was it not,” Harrist said.

Stratmoen confirmed that, saying the “Department of Vital Statistics will call if they don’t like how it’s filled out.”

Being that Wyoming is on track to have roughly 370 more deaths than last year, it’d be easy to chalk them up to the virus. However, the state could have a gap of more than 100 deaths between that 370 and the eventual number of COVID-19 fatalities.

Wyoming’s aging population may contribute to some of the excess deaths, but Harrist said the state likely undercounted COVID-19 fatalities. Though she thinks the systems in place now are catching the majority, if not all, deaths from the virus, testing shortages early in the pandemic likely prevented providers from identifying many early cases.

“My opinion as an epidemiologist is that COVID deaths, especially at the beginning of the pandemic, were undercounted,” she said. “Being in a global pandemic we have to look at that as a likely cause of at least some of the excess deaths, especially early on.”

Excepting the testing problems from the spring, not every state has a coroner system like Wyoming’s, meaning they might have a better handle on catching COVID-19 deaths.

The state of Montana has a hybrid system that includes 56 county coroners and a state medical examiner’s office with several forensic pathologists on staff.

“Death investigation and death certification around the United States varies considerably and is hardly uniform,” Montana Chief Medical Examiner and Forensic Pathologist Dr. Robert Kurtzman said.

In states like Wyoming, coroners are elected or appointed and are not required to have any medical training, though they have the statutory power to make their own decisions in death investigations.

“In optimal practice they should both be equal but that’s not always the case,” Kurtzman said.

In March Montana came up with protocol that was distributed to its county coroners.

If a decedent was hospitalized and had recently been tested for COVID-19 no additional testing is required.

If a decedent was not in the hospital and has no medical history expected to cause death an autopsy is performed and COVID-19 testing should be included.

If a decedent had a significant pre-existing condition and the death was expected a virus test might not be necessary —but if they were experiencing COVID-19 related symptoms then they will get tested.

Finally, anyone who died while incarcerated or in a nursing home should be tested no matter what due to the risks associated with congregant settings.

Kurtzman said 100% testing might not be realistic at this point in the pandemic, but focused testing is practical, based on the availability of tests.

In the absence of a strict protocol like that in Wyoming, Beaudoin from the Vital Statistics Services, said the state’s coroners are doing a good job managing COVID-19 deaths. However, if the recent exponential growth in Wyoming’s death total continues, it could overburden them, in particular making it more difficult for them to have the supplies and time to do postmortem testing when needed.

Stratmoen, the Fremont County coroner, sees the people around the state to blame for the situation he and his colleagues find themselves in. As the death count in Wyoming creeps toward eclipsing last year, he thinks much of it could have been prevented.

“I am really sorry, but if everyone had paid attention and done the proper precautions we would not be where we are now,” Stratmoen said. “We are stuck with where our behavior has put us.”

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