The opioid epidemic that has claimed so many lives in Maryland is overwhelming the state medical examiner's office.
The agency has exceeded national caseload standards — the number of autopsies a single pathologist should perform in a year — in each of the past four years. The office now risks losing its accreditation.
"Everyone continues to add on work hours and work faster and hopefully not take short cuts," said Dr. David R. Fowler, Maryland's chief medical examiner. "They absorb this extra load. But there is a point where they can't continue to add to that and expect the system will function."
The challenge is not limited to Maryland. The combination of additional and more complex cases is overwhelming medical examiners' offices across the country, particularly along the East Coast, leaving many on the verge of losing accreditation.
"We view this as a national crisis," said Dr. Brian L. Peterson, president of the National Association of Medical Examiners.
The association categorizes the Maryland Office of the Chief Medical Examiner, traditionally well regarded by peers, as "deficient." It will re-evaluate the Baltimore-based agency in May.
The office can continue to operate without accreditation. But the association warns that performing too many autopsies can jeopardize quality and undermine confidence in the results.
The situation has troubling implications for the criminal justice and public health systems. Prosecutors rely on autopsy findings and medical examiners' testimony to bolster their cases, and public health officials use data from the agency to direct resources.
State pathologists are performing about 40 percent more autopsies than in 2010 — almost 100 more apiece — and the toxicology lab now runs nearly nonstop, officials say. But the office has not significantly boosted the ranks of examiners, and is struggling to hold on to support staff.
"Maryland is currently fully accredited," Peterson said. "But as is the case with many offices, it might be facing loss of that accreditation due to the intersection of caseload and staffing level."
The agency is part of the state Department of Health and Mental Hygiene. Medical examiners investigate deaths caused by injury, homicide or suicide, and those that are untimely, suspicious or not attended by a physician. In Maryland, that's about a third of all deaths. The office handled 14,385 cases in fiscal year 2016, and performed 5,439 autopsies.
The office began exceeding the national standard of 250 autopsies per examiner per year in fiscal 2013, according to the state health department. Its inability to meet that standard has led to its designation as deficient.
After the first quarter of fiscal 2017, the pathologists were on target to perform 328 autopsies — exceeding the limit of 325 for maintaining accreditation.
Baltimore County State's Attorney Scott Shellenberger, president of the Maryland State's Attorneys' Association, said a loss of accreditation would have an immediate effect on his cases. Prosecutors rely on medical examiners to provide solid autopsies and come to trial prepared to testify.
"In some cases there is a heightened need for forensic evidence to shed light on what actually happened," he said. "You want that to be the easy part of the case, the least challengeable and controversial. If they lose accreditation, it could create some doubt."
Dr. Leana Wen, the Baltimore health commissioner, said she relies on information from the medical examiner's office to develop policy and direct resources. But it isn't always available in a timely manner.
She noted, for example, that 2016 overdose death totals are not yet available from the state health department more than three months after the end of the year.
She said she has turned to hospital emergency rooms and emergency service providers for immediate information on "hot spots" of suspected fentanyl overdoses so officials can warn people in the community.
"Considering the number of overdoses, delays make sense in the medical examiner's office," she said. "But it also can impede our work."
Fowler lists 17 medical examiners on staff, up from 15 in 2015. He said six more examiners were needed to meet the standards. He requested three in the most recent state budget, out of consideration of the costs, about $171,000 each. He did not get them.
He reported that the office is completing only about three-quarters of the autopsies in 60 days. The standards call for 90 percent to be completed in that time.
In an interview, Fowler said the situation stings, even though he knows many other offices nationally face the same problems.
He said offices in some other states have racked up backlogs and scaled back services. He said that won't happen in Maryland.
Fowler's office was considered deficient once before, because it lacked proper space before a new building opened in 2010. That rating was not based on performance.
Fowler said overloaded workers are more likely to make mistakes. Delays mean families wait longer for answers and to claim the bodies of loved ones.
The state budget for fiscal 2018, which begins in July, does not include funding for more examiners. Instead, officials added $400,000 to boost salaries for examiners now working longer hours because they do not earn overtime.
The agency is also being permitted to fill five open support positions.
A health department spokesman said increasing salaries was the priority this year. Spokesman Christopher Garrett said officials are still exploring ways to shift more personnel to the agency.
A spokeswoman for Gov. Larry Hogan noted that the budget for the medical examiner's office has increased from $11.4 million in fiscal 2015 to $12.8 in the coming year.
"Funding for the Office of the Chief Medical Examiner has increased each year since the governor took office," spokeswoman Amelia Chasse said. "The [health] secretary is currently conducting an analysis of the office to determine additional personnel needs, and our administration is committed to meeting those needs."
Fowler said the office is handling a range of new cases, including those from the spike in homicides in Baltimore. The city has recorded more than 300 killings in each of the past two years, the first and second deadliest on record.
But there were far more deaths from overdose: 1,468 statewide in the first nine months of 2016, up from 1,259 for all of 2015, and more than twice as many as in 2010. Maryland was one of 30 states to report a large increase in overdose deaths.
More than 900 of the fatal overdoses in 2016 were related to heroin. More than 700 were related to fentanyl, a far more powerful opioid that is often mixed with heroin, unbeknownst to users.
Dr. Bruce Goldberger, a professor of toxicology at the University of Florida College of Medicine, said fentanyl has proved to be the greatest challenge for medical examiners. Illicit labs are constantly churning out new formulations, he said, and there are not always good testing methods to identify them.
Goldberger, a consultant for the U.S. Centers for Disease Control and Prevention, has studied the effects of fentanyl on medical examiner offices.
He called the combination of extra cases and more complex cases "unprecedented."
"These new emerging drugs, specifically fentanyl analogs, have a catastrophic effect," Goldberger said.
His lab performs toxicology testing for several Florida county medical examiners. He said he has seen a surge in requests.
"We are inundated," he said, "and we don't know how to dig out of it."
Fowler said he's still hoping for more examiners. He said his staff is extremely dedicated, and often works long hours without breaks. But many will qualify for retirement in the next five or six years.
Replacing them might not be easy, even with funding. The number of practicing pathologists who work as medical examiners dropped more than 11 percent from 2010 to 2015, according to the Association of American Medical Colleges. That was a steeper drop than in any other specialty.
Dr. Janis Orlowski is the group's chief health care officer.
"I think people go to medical school and then choose a specialty based on lifestyle as much as they choose based on what's interesting to them," she said. "Perhaps they see people in this area are overworked, as they likely are in the office in Baltimore."