A Day In the Life of a Forensic Pathologist -The Toast

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url-1I’m running late this morning; I barely have time to print out a list of the day’s cases before rushing into morning report. The small conference room is packed with day shift investigators, autopsy assistants, the medical student rotating here this month, one of the two forensic pathologists doing autopsies today (I am the other one), and the file boxes, broken chairs, and assorted detritus permanently stored in the room. I slide into the last available chair just as the chief medical examiner begins the rundown. This half-hour meeting is when we discuss the day’s cases, decide what kind of examination is needed for each case, and assign the cases to the pathologists who will conduct the examinations. 

Some background: As deaths occur in our district, they are reported to one of the 12 investigators working in the medical examiner’s office. The investigator gathers preliminary information, including what the person may have died of and the circumstances surrounding the death, and makes a determination about whether the office needs to be involved in certifying the death. Although television makes it seem as though forensic pathologists spend all their time working on high-profile murders, the reality is that in a given year, only 15 to 20% of my cases are homicides, and of those only a few are unusual enough to be television-worthy. The majority of cases involve accidents, self-inflicted injuries, overdoses, and people who die unexpectedly at home, in sometimes murky circumstances. For deaths which occur because of a natural disease while the person is under the care of a physician or in a hospital, the doctor caring for the person can sign the death certificate, and the body can be transported directly to the funeral home for cremation or burial. Other deaths, including those occurring because of overdose or poisoning, in violent or suspicious or unclear circumstances, and in prison or police custody, are always considered to be under medical examiner jurisdiction, so these bodies are transported to the medical examiner’s office for examination before being released to the funeral home for cremation or burial.

Sometimes there are cases which fall into a gray area; for example, the death appears to be from natural disease but someone alleges that foul play was involved, or the death appears to be from natural disease but there is an underlying issue like an old injury that may have contributed to the death. If any such cases have been called in during the previous day, they can be discussed in the morning meeting, in order to determine whether the medical examiner’s office should accept jurisdiction and what needs to be done before certifying the death. 

Morning report is also a chance to preview the week’s schedule, hear about incoming cases, and organize the day’s workload. If plumbers are coming to fix the floor drain in the autopsy suite, law enforcement officers want to attend one or more of the examinations, or one of the duty pathologists has to go to court that day, this is the time to convey that information to the autopsy assistants, so we can figure out how to get all the cases done around these obligations. Once the meeting is over, the investigators return to their offices, and everyone else heads for the changing rooms.

url-2By the time I put on scrubs and gather my Dictaphone and camera, my first case is waiting at the autopsy station: a 70 year old woman found dead in her yard. She lived alone, and it’s not clear when she was last seen alive or if she had any medical problems. Across the room, my colleague is at a computer monitor, clicking through the x-rays on her first case, a 40 year old man shot at a party. The autopsy assistant waits for my nod, then opens the woman’s body bag so I can begin. I start by circling the body, examining the clothing to see if she is appropriately dressed for the weather, if the clothing is worn correctly and is in good repair, and if there is anything on the clothing (blood, paint, yard debris, broken glass, wood splinters) that might give me a clue as to what was happening around the time of her death. Next we undress the body and weigh, measure, and wash it. I examine the body surfaces now, assessing the skin for injuries, rashes, scars, and tattoos, and noting any lumps or bumps under the skin. Once the external examination is done, we don our masks and gowns, gloves and eye protection. The assistant loads scalpel blades onto handles, plugs in and tests the bone saw. While he is getting set up, I wander over to my colleague’s station, where she is now painstakingly documenting bullet wounds on a body diagram, muttering to herself about how in her day, people just got into fist fights at parties. I spend a few minutes insulting her drawing skills, then return to my table to make the incisions that allow the internal portion of my examination.

Rembrandt_Harmensz._van_Rijn_007As the internal organs are exposed, I can see something very wrong in the chest: a large collection of pus next to the right lung. The lung itself contains more pus. The rest of the organs show age-related changes, but nothing terribly abnormal. I collect specimens to send to the microbiology lab for infectious disease testing, to the histology lab to be made into microscope slides, and to the toxicology lab for drug testing. The cause of death for this woman is pneumonia with empyema (the medical name for the large collection of pus.) Since she has no injuries that could have played a role in her death, and pneumonia is a natural disease, the manner of her death will be certified as natural. I dictate the findings of the external and internal examinations, including organ weights and descriptions, and finish the dictation with a list of diagnoses and a statement about the cause and manner of death. In a week or so, one of the transcriptionists will convert this dictation into a typed autopsy report. In a couple of weeks I’ll get the results of the microbiology testing, telling me which bacteria (or virus, or fungus) caused the pneumonia; in a month or so I’ll get the histology slides and toxicology test results back. At that point, I’ll look at the slides under the microscope, correlating what I see in the tissues with what I already know from the physical exam. Putting all the findings together in the context of the microbiology and toxicology testing, I will then edit the report, adding to or expanding my diagnoses as needed. The final report will become a permanent part of the case file. 

If I were a television pathologist, I would now be striding about in front of my giant transparent touch-screen computer, charting and filling out the death certificate worksheet. Instead, since real-life medical examiner offices are chronically underfunded, I slink back to my office to fire up my trusty hand-me-down computer, received when another county department upgraded their office equipment and sent their old stuff to surplus. The operating system is slow enough that by the time I finish the last computer task, it’s time to start the next case.

This is a 20 year old man, known to use heroin, found dead in a public restroom at a park. Based on the investigative report, this case should be a simple drug overdose. But when I open the body bag, I discover that things are somewhat more complicated. The clothes are muddy and there are twigs and dried grass in the hair; there is a large laceration on the scalp and there are scrapes and bruises over the face and encircling the neck. This appearance doesn’t fit with someone who simply sat down on a concrete bathroom floor and died after injecting heroin. Although I can’t yet see the parts of the body that are covered with clothing and mud, the injuries I can see make me worried that he was assaulted prior to death. 

imagesAt this point a television pathologist would change into designer shoes and jet off to the park, where she would interview bystanders, collect their DNA, and process it in her mobile DNA lab to find the assailant in just under 20 minutes. I, on the other hand, pull the shoe covers off my sensible clogs and clomp across the building to track down an investigator and ask him to call law enforcement. Usually case detectives like to attend autopsies in suspicious deaths, to gather information that may aid in their search for a perpetrator. In this case they did not suspect foul play, and therefore didn’t arrange to attend the exam. Since I now believe this death could be a homicide, I want to alert them to my suspicions and give them the opportunity to come now if they wish to. While we wait to hear back from the investigator, I pull out the stepladder to take photos of the clothing and visible injuries, then examine the skin and clothing for hair or other debris that can be collected as evidence. I find some scraps of material stuck to the man’s hand, and what looks like rope fibers stuck to his neck, so I take some additional photos of these areas. The intercom squawks: the investigating agency is sending a homicide detective and a crime scene photographer, who should arrive in 10 minutes or so. 

While waiting, I return to my office. There’s a tray of histology slides on my chair. One third of my desk is now occupied by piles of hospital and clinic records, topped by a note from one of the investigators indicating which case they belong to and ending with a cheery “Enjoy!” I shift everything to the guest chair and sit down to check email and phone messages. I return a call to the county attorney, who has some questions about a case of mine that is going to trial next week and also wants to let me know that they will need me to testify on Tuesday, probably in the afternoon. Next I call the case detective for an examination I did a couple of days ago; he has some new information he wants to pass on to me. The third message is from the mother of an infant I autopsied last week, who has more questions for me about how her baby died. I decide to call her later, as I don’t wish to rush the conversation. 

I cross back to the other side of the building, stopping at the reception area to pick up the detective and crime scene photographer. In the autopsy suite, my colleague has finally started the internal examination on her case, and the room is quiet except for her occasional commentary to the medical student. The detectives attending her case have retreated to the far wall, staring at their phones. One of them is asleep standing up. They perk up briefly to greet the detective on my case and exchange some banter, while the photographer gets set up and takes preliminary pictures. As she photographs the areas of trace evidence, I move along, collecting the specimens while the assistant packages and labels them. Next, we photograph the hands, then swab them and scrape under the fingernails. Because of the injuries on the neck, I make additional swabs from this area. Once the evidence has been collected, we undress the body, laying out the clothing on a gurney so it can be photographed. The assistant wheels the autopsy table over to the sink and locks it into place. He dribbles dishwashing liquid over the body and turns on the sink hose, handing me a sponge and keeping one for himself. As we clean the mud and dried blood from the body surfaces, more and more injuries emerge. The detective moves closer to the body and whistles in surprise. “Is that a boot print?” I nod, pointing out similar patterned injuries on the back and right arm. It’s now apparent that this case is indeed a homicide. It takes the rest of the morning to finish the external examination, conduct the internal examination, and document and photograph all the injuries. When the exam is finally finished and I have dictated my findings, I fill out the paperwork required to send specimens to the toxicology lab and make sure the evidence is signed over to the detective before retreating to my office for lunch.

images-1I work on leftovers from last night’s dinner as various investigators come by to ask about new cases or follow up on old ones. Colleagues drift in and out, wanting to show histology slides for a second opinion or vent about this morning’s interview with that defense attorney. The autopsy assistant pops in to say he just finished cleaning up from the morning, and can we start the afternoon session 30 minutes later than usual? Between interruptions, I sift through the contents of my inbox, signing off on requests to send autopsy reports to family members and news media and glancing through medical records and police reports before placing them into the appropriate case files. 

A calendar reminder pops up: Crime Lab, 3:00 p.m. I remember that I have an appointment to watch the test fire of a weapon used to shoot a woman whose autopsy I did a few weeks ago. There are conflicting stories about how the shooting occurred: she shot herself, someone else shot her while showing her how to use the gun, someone else shot her while cleaning the gun across the room. The physical exam excludes one of these scenarios; I am hoping that the test fire will help me exclude another one, or at least make it much less likely. If this were TV, the firearms examiner would be working in a sunlit laboratory down the hall, and I could visit between cases to watch a holographic re-enactment of the shooting while admiring the view over downtown. Alas, reality intrudes again: the firearms lab is 20 minutes away by car, in the basement of a dingy building near the airport. They don’t do holograms. And due to the unexpected turn of events this morning, I still have three cases to do this afternoon. Even if all three go as planned, there’s no way I’ll make it to the crime lab in time. I call my contact to reschedule the appointment and make sure it’s OK to bring the medical student along. After updating my calendar, I head back across the building. I find the autopsy assistants in their break room, eating cake out of Styrofoam cups. “Better have some, Doc. You might need some extra energy this afternoon.” We laugh, shake our heads. I can’t find any plates either, so I scoop some cake into a cup and join them. 

We slump in mismatched chairs and eat mostly in silence, enjoying a moment of peace in a hectic day. Then a commotion in the hall heralds the arrival of law enforcement, here to attend my colleague’s afternoon case. We toss the cups, wipe our hands, sweep the crumbs from our scrub tops. Time to get back to work and see what surprises the afternoon will bring. 

Veena Singh is a forensic pathologist.

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