This is an incredible clip. I've come to love this guy. There are so many frighteningly brilliant quotes, you will need to watch it several times to catch them all. Watch.
He introduces himself as a website, then as the governor of Tennessee (he is, of course, neither).
"I chose this location because I like it a lot." Compelling reason.
"Many people have died from gun control." Oh really? How's that?
What exactly is a "nut cake"?
"I want us all, in a group of 25 or more, to come to Nashville with your guns and tell me I'm doing wrong and then we'll sit down at the table and discuss it." Speechless.
"I'm basilmarceaux.com"
"I'll see you at the polls.....Amen."
Dumpster fires like this don't come along all that often. Looks like a walrus, only slightly more articulate, running for the highest office in the state of Tennessee. I hope he wins.
Saturday, August 28, 2010
Tuesday, July 27, 2010
Hippies
Recently wrapped up a lovely 30-hour shift (I was asleep for one of those hours) during which I was paged about every 20 minutes, and called on to take care of 2 seizures and one stroke in patients I was cross covering on (which means they’re patients I’ve never seen before and know nothing about). It’s frightening, but fortunately I have back-up from more experienced residents. But it’s stressful and in order to unwind, you have to force yourself to get out and do stuff when you’re not at the hospital, even though the only thing you usually feel like doing is sleeping and loafing.
So Ash and I went to the lake today. The UW campus is right on Lake Washington and they rent canoes there for cheap. So we went out for a little paddle today. There’s a floating freeway that connects Seattle to it’s posh suburb, Bellevue. You can paddle under the overpass and there are some little marshy areas with tons of birds, shrubs, and tons of little banks with people relaxing on the grass, drifting on blow-up rafts, or swimming with their dogs.
Ash and I made a little lap around these areas and were on our way back under the freeway toward the university. We’re paddling along and look off to our left to one of the little areas where people were swimming and we see about 6 people, with gray hair—more of it on their chests than their heads—and they’re butt ass naked. It was about 2 p.m. This is about 200 yards from a very busy freeway and along a route well-trafficked by canoes, kayakers, and lots of boats—many with children in them.
Never seen that at Utah Lake. I didn’t actually see one, but I have to believe there was a decent sized water bong hiding up in the weeds somewhere, or some massive hand-rolled splithes, or maybe some peyote. I also have to believe some of these same folks were, many years ago, free lovin’ and dropping acid and following Jimi Hendrix and Janis Joplin across the country in sweaty VW buses packed with other people who looked like they would smell bad. I was tempted to snap a picture. I can’t imagine they would have minded. There they were, standing in the water, just ankle deep, in all their glory. Pretty awesome. Seattle is different.
So Ash and I went to the lake today. The UW campus is right on Lake Washington and they rent canoes there for cheap. So we went out for a little paddle today. There’s a floating freeway that connects Seattle to it’s posh suburb, Bellevue. You can paddle under the overpass and there are some little marshy areas with tons of birds, shrubs, and tons of little banks with people relaxing on the grass, drifting on blow-up rafts, or swimming with their dogs.
Ash and I made a little lap around these areas and were on our way back under the freeway toward the university. We’re paddling along and look off to our left to one of the little areas where people were swimming and we see about 6 people, with gray hair—more of it on their chests than their heads—and they’re butt ass naked. It was about 2 p.m. This is about 200 yards from a very busy freeway and along a route well-trafficked by canoes, kayakers, and lots of boats—many with children in them.
Never seen that at Utah Lake. I didn’t actually see one, but I have to believe there was a decent sized water bong hiding up in the weeds somewhere, or some massive hand-rolled splithes, or maybe some peyote. I also have to believe some of these same folks were, many years ago, free lovin’ and dropping acid and following Jimi Hendrix and Janis Joplin across the country in sweaty VW buses packed with other people who looked like they would smell bad. I was tempted to snap a picture. I can’t imagine they would have minded. There they were, standing in the water, just ankle deep, in all their glory. Pretty awesome. Seattle is different.
Wednesday, July 21, 2010
Seattle
Got about a month under our belts in a new city. It’s been a whirlwind for Ash and me over the past few months. I graduated from medical school at the end of May and a week later, Ash and I got married. We went to Costa Rica for our honeymoon, came home and packed for a week, and then moved to Seattle. Just a couple of minor milestones for one month.
My parents helped us pack up the ole U-Haul and Ash's parents were an enormous help with the actual move. They drove our car up and helped us unload and get settled in. Pretty lucky to have supportive families.
I started residency at UW at the end of June and so far so good. I love Seattle. The Seattle summer temperatures are much more suited to my taste than Utah summers. It doesn’t get so bloody hot here. We live about 3 blocks away from Lake Union, for those of you who know the area. We’ve got a little view of the lake from our balcony and we’re loving living this close to water. We often walk down to the marina and sit on the bench and read while we watch all the boats and the seaplanes that come and go. We’ve become friendly with a couple of the neighborhood drunks that hang out on the benches at the dock. They complimented me on my sunglasses the last time we saw them. We’re hoping that if we go to the marina often enough some of the people with boats there will befriend us and take us sailing.
The city is beautiful, but there are a few things that we’ve noticed that will taking some getting used to. There isn’t a lot of space. You notice this the most when you’re driving. Roads here certainly weren’t built wide enough for a horse and buggy to make a U-turn like good ole SLC. In fact, most of the roads in our neighborhood are not wide enough for two cars traveling in opposite directions to pass each other. If you see another car coming down the road, one of you has to find a driveway, or an empty parking slot (a rare thing) to pull into so the other car can pass. I often find myself looking around for ONE WAY signs, convinced that I’m going the wrong way on a one-way street—nope. Quite a feat of civil engineering. Addresses are also neat here. As is the case in many cities, different streets can share the same name. There is a cockamamie quadrant system that is apparently “pretty easy, once you get used to it”. I don’t buy it yet. We’ll see.
Whoever is in charge of the street signs in the city should unquestionably be fired. The signs are small, usually posted to low, at angles not conducive to reading, and in locations that ensure that you will not be to see the sign in time to be able to change lanes to make your turn. I seem to cuss more than usual when I drive here.
People don’t really speed here. On the freeway you rarely see people going more than 65 mph (speed limit is 60). When I was at home, I felt that I wasn’t speeding until I was doing at least 10 over on the freeway. Perhaps the lack of speeding is due to the higher volume of cars. Traffic sucks here, but we’re fortunate to live very close to where I work so I can avoid most of the really congested roads. I’m close enough to ride my bike to all three hospitals I’ll be working at.
That brings me to another cool thing about Seattle. People ride their bikes a lot here. Bike lanes are far more abundant than most other cities I’ve been to and there are a lot of trails and paved bike paths (most of which I haven’t had time to explore yet…someday). And drivers are much more aware of cyclists and pedestrians than what I’m used to.
Apparently Seattle is considered the most literate city in the US with a higher percentage of college grads than any other major city in the US. It’s an interesting dichotomy because there’s a decent-sized homeless population as well which makes for a rather interesting juxtaposition. We've already identified a few of the guys that crash in our neighborhood in the park nearby or in front of some office buildings. It's pretty heartbreaking to see.
In our outings around town to stores, shops, parks, etc, I’ve noticed a far more liberal standard of what’s considered an acceptable level of B.O. than what I’m used to. Maybe it’s that people bike more here, but I’ve definitely encountered many a funk on some people who seemed hygienic from a distance, but have been quickly disabused of that notion when I’ve wandered into their waft zone. Deodorant folks.
I’ve been pretty busy working in the ER this month so we haven’t had a ton of time to go exploring but there is a lot of cool things to do close by. When I’m not at work, I pretty much feel like loafing and sleeping. We did rent a canoe last week and paddled around Lake Washington for a couple of hours, which was awesome. Ash is a good sport about my crappy schedule and general lethargy. She has been taking excellent care of me and is pretty much dominating at being a wife—not a surprise to those that know her.
We like our apartment cause it’s fairly roomy for these parts. We have a guest room and a guest bathroom if anyone is interested in visiting Seattle for any reason, we’d be happy to put you up. We live about 2 miles from downtown and about two miles from the UW campus and we have great access to public transit from our neighborhood. You can make a quick weekend trip out of it. Our first guests arrived yesterday. Ash's sister, Chrissi, and her adorable daughter, Ali, flew in last night. It's nice to have familiar faces around so when I say that we'd be happy to put you up, I sincerely mean it--call me if you'll be in the area or if you want a relatively cheap get away.
I hope to get more stuff up at some point—from the wedding and honeymoon, but who knows what my schedule will allow, so it may be awhile. In short, we're alive and well enjoying married life and a new city.
My parents helped us pack up the ole U-Haul and Ash's parents were an enormous help with the actual move. They drove our car up and helped us unload and get settled in. Pretty lucky to have supportive families.
I started residency at UW at the end of June and so far so good. I love Seattle. The Seattle summer temperatures are much more suited to my taste than Utah summers. It doesn’t get so bloody hot here. We live about 3 blocks away from Lake Union, for those of you who know the area. We’ve got a little view of the lake from our balcony and we’re loving living this close to water. We often walk down to the marina and sit on the bench and read while we watch all the boats and the seaplanes that come and go. We’ve become friendly with a couple of the neighborhood drunks that hang out on the benches at the dock. They complimented me on my sunglasses the last time we saw them. We’re hoping that if we go to the marina often enough some of the people with boats there will befriend us and take us sailing.
The city is beautiful, but there are a few things that we’ve noticed that will taking some getting used to. There isn’t a lot of space. You notice this the most when you’re driving. Roads here certainly weren’t built wide enough for a horse and buggy to make a U-turn like good ole SLC. In fact, most of the roads in our neighborhood are not wide enough for two cars traveling in opposite directions to pass each other. If you see another car coming down the road, one of you has to find a driveway, or an empty parking slot (a rare thing) to pull into so the other car can pass. I often find myself looking around for ONE WAY signs, convinced that I’m going the wrong way on a one-way street—nope. Quite a feat of civil engineering. Addresses are also neat here. As is the case in many cities, different streets can share the same name. There is a cockamamie quadrant system that is apparently “pretty easy, once you get used to it”. I don’t buy it yet. We’ll see.
Whoever is in charge of the street signs in the city should unquestionably be fired. The signs are small, usually posted to low, at angles not conducive to reading, and in locations that ensure that you will not be to see the sign in time to be able to change lanes to make your turn. I seem to cuss more than usual when I drive here.
People don’t really speed here. On the freeway you rarely see people going more than 65 mph (speed limit is 60). When I was at home, I felt that I wasn’t speeding until I was doing at least 10 over on the freeway. Perhaps the lack of speeding is due to the higher volume of cars. Traffic sucks here, but we’re fortunate to live very close to where I work so I can avoid most of the really congested roads. I’m close enough to ride my bike to all three hospitals I’ll be working at.
That brings me to another cool thing about Seattle. People ride their bikes a lot here. Bike lanes are far more abundant than most other cities I’ve been to and there are a lot of trails and paved bike paths (most of which I haven’t had time to explore yet…someday). And drivers are much more aware of cyclists and pedestrians than what I’m used to.
Apparently Seattle is considered the most literate city in the US with a higher percentage of college grads than any other major city in the US. It’s an interesting dichotomy because there’s a decent-sized homeless population as well which makes for a rather interesting juxtaposition. We've already identified a few of the guys that crash in our neighborhood in the park nearby or in front of some office buildings. It's pretty heartbreaking to see.
In our outings around town to stores, shops, parks, etc, I’ve noticed a far more liberal standard of what’s considered an acceptable level of B.O. than what I’m used to. Maybe it’s that people bike more here, but I’ve definitely encountered many a funk on some people who seemed hygienic from a distance, but have been quickly disabused of that notion when I’ve wandered into their waft zone. Deodorant folks.
I’ve been pretty busy working in the ER this month so we haven’t had a ton of time to go exploring but there is a lot of cool things to do close by. When I’m not at work, I pretty much feel like loafing and sleeping. We did rent a canoe last week and paddled around Lake Washington for a couple of hours, which was awesome. Ash is a good sport about my crappy schedule and general lethargy. She has been taking excellent care of me and is pretty much dominating at being a wife—not a surprise to those that know her.
We like our apartment cause it’s fairly roomy for these parts. We have a guest room and a guest bathroom if anyone is interested in visiting Seattle for any reason, we’d be happy to put you up. We live about 2 miles from downtown and about two miles from the UW campus and we have great access to public transit from our neighborhood. You can make a quick weekend trip out of it. Our first guests arrived yesterday. Ash's sister, Chrissi, and her adorable daughter, Ali, flew in last night. It's nice to have familiar faces around so when I say that we'd be happy to put you up, I sincerely mean it--call me if you'll be in the area or if you want a relatively cheap get away.
I hope to get more stuff up at some point—from the wedding and honeymoon, but who knows what my schedule will allow, so it may be awhile. In short, we're alive and well enjoying married life and a new city.
Monday, April 12, 2010
Debriefing the ME
Months have passed since I finished my rotation at the medical examiner, yet I continue to think about my experiences there pretty regularly. Although I’ve definitely had some emotionally intense experiences on most of my rotations, no single rotation can compare to the heaviness and sadness that I saw day in and day out at the ME. Since I’ve had some time to think about it a little more, I felt like writing something of a summary of my experiences—sort of a debriefing.
One thing I’ve realized is that you’ll never forget the first time you see someone who has taken a shotgun blast to the face. It’s impossible to capture the horrific carnage and the surrealism of it with words. It’s easily the most violent and disturbing thing I’ve ever seen. At the risk of sounding too cavalier or insensitive, I will tell you that “blowing your head off” is a pretty accurate description when it comes to shotguns (rifles in general, really). It’s particularly unsettling when it’s someone who has done it to him/herself. One woman in particular, still haunts me. I’m not sure if it’s because she was the first person that I ever saw who had done this (unfortunately, she wasn’t the last), or if it was other things about her case, but I’ve thought of her and her family nearly every day since it happened.
She was younger than me, married, and had children and seemed to have a lot going for her. Aside from the obvious fact that the majority of her head above her upper teeth was gone, there were other things about her autopsy that really got to me. One was the very faint and subtle stretch marks on her breasts from breast feeding her children. It’s small details like this that get you.
She also smelled nice—from a very feminine-smelling perfume or lotion. Another disturbing thing was the fact that if you looked at her from the neck down she had a perfectly healthy looking body and still had normal color. If you covered her head and looked only at her body, you probably would not have guessed that she was dead. One of the investigators was able to get a photo of her and I was stunned to see what a beautiful girl she was. In the condition we saw her in, it was simply impossible to know. Although a total stranger to me, it has been difficult to wrap my head around the catastrophic loss of a beautiful young mother in such a violent, permanent, self-inflicted way.
I saw 3 hangings that were all ruled suicides. The bodies did not look as bad as I was expecting based on what I had seen on TV and in movies. Sometimes in Hollywood, they make the face look super bloated and the tongue look swollen. I learned that the reason that the tongue sticks out is not due to swelling. The tongue often does protrude but it's because the rope (or whatever they use) puts mechanical pressure on the lower portion of the tongue and causes it to go up and out. (If you take your finger and push underneath your chin about an inch behind the bony tip of your chin, you can sort of feel why this would happen). Once the body is cut down, the tongue often returns to a fairly normal position. The ligature (rope, cord, etc) did leave a pretty deep rut (for lack of a better term) in the skin and soft tissue of the neck on all of the people I saw who had hanged.
I saw more overdoses than I can count. Some on illicit drugs, others on prescriptions. The autopsies for these are straightforward and pretty normal from a pathology standpoint. I saw some car accident victims that had too many fractures to count, and a man who had fallen about 25 feet and bounced off some scaffolding several times on his way down that was quite a wreck. Two men who had stabbed themselves to death. One man stabbed his neck and his heart with a kitchen knife. The other stabbed himself 17 times in the neck, chest, and abdomen with a bayonet. He actually survived in the ICU for a few days before we got him. As you might imagine, he was a mess.
Although most of the things you see in the ME are fairly depressing, occasionally things happen that you can’t help but laugh at. Like the man who was found dead on top of a blow up doll (you can imagine). I felt a little guilty laughing about it, but I think you can recognize that it’s sad someone is dead and still find some sliver of humor in the way it happened.
There was absolutely nothing funny about the dozen or so gun-shot suicides I saw during the month I was at the ME. I was struck by the irony of the scene photos of one of these cases. The guy was roughly my age and had shot himself in his parked car. I didn’t notice this initially because there were more attention-grabbing areas of the photo (as you might imagine) but I found it strange that he was wearing a seatbelt. Perhaps it was just the result of habit. But how strange to buckle up and then put a round through your head.
Another memorable case was a young guy playing Russian Roulette in front of his friends. He lost. One in six odds might not sound too bad, but when you’re talking about death, those are damn terrible odds. In Utah, someone who gets killed playing Russian Roulette is ruled a suicide, not an accident. This often really pisses off family members of the decedent.
Another man shot himself in the driver's seat of a stolen car he had parked in the lot of a shop in an industrial part of town. Among the reams of paper that he had in his car (tons of rants about politics, government, etc), he had written that he wanted to wait for the sunrise before he shot himself. We also found among his writings, a note that said he was considering going on a shooting spree before he killed himself. We found three other loaded mags in his bag so if he was a good shot, he could have taken out 17 others and still had a round to kill himself.
As you would probably guess, there were more males who killed themselves with guns than females, but it was closer than I would have predicted. I was definitely surprised by how many women we saw. The oldest person I saw that had taken their own life was 76. The youngest was nine—not a typo. A nine year old. That takes the cake for the most horrific thing I saw there. With a kid that young, we wanted to believe that it must have been an accident. But the placement of the gun and the fact that it was witnessed by a friend made it pretty clear that it was intentional. I imagine that the kid who witnessed this has a very slim chance of living a normal life. Not something anyone should have to see at any age, but at nine? Good lord.
I helped undress the body and was the one who checked the pants’ pocket. I welled up and had to leave the room for a minute or two when I pulled out an empty fruit snacks wrapper from the pocket—just a little kid. It’s those little details that I found the most haunting because it sort of puts things into context and makes it more real. This little child had been at school eating fruit snacks just a few hours before committing suicide. Although I’d like to, I doubt that I’ll ever be able to erase the image of that mangled little body and that wrapper.
Without question, the most sobering month of my life. So many things to think about, so many images I’ll never be able to get rid of, yet I’m glad I did it. And I’m very glad that I didn’t end up seeing anyone that I knew. Seems an odd thing to thank people for not dying, but I suppose that I should thank everyone I know for not dying that month, hard enough with strangers.
One thing I’ve realized is that you’ll never forget the first time you see someone who has taken a shotgun blast to the face. It’s impossible to capture the horrific carnage and the surrealism of it with words. It’s easily the most violent and disturbing thing I’ve ever seen. At the risk of sounding too cavalier or insensitive, I will tell you that “blowing your head off” is a pretty accurate description when it comes to shotguns (rifles in general, really). It’s particularly unsettling when it’s someone who has done it to him/herself. One woman in particular, still haunts me. I’m not sure if it’s because she was the first person that I ever saw who had done this (unfortunately, she wasn’t the last), or if it was other things about her case, but I’ve thought of her and her family nearly every day since it happened.
She was younger than me, married, and had children and seemed to have a lot going for her. Aside from the obvious fact that the majority of her head above her upper teeth was gone, there were other things about her autopsy that really got to me. One was the very faint and subtle stretch marks on her breasts from breast feeding her children. It’s small details like this that get you.
She also smelled nice—from a very feminine-smelling perfume or lotion. Another disturbing thing was the fact that if you looked at her from the neck down she had a perfectly healthy looking body and still had normal color. If you covered her head and looked only at her body, you probably would not have guessed that she was dead. One of the investigators was able to get a photo of her and I was stunned to see what a beautiful girl she was. In the condition we saw her in, it was simply impossible to know. Although a total stranger to me, it has been difficult to wrap my head around the catastrophic loss of a beautiful young mother in such a violent, permanent, self-inflicted way.
I saw 3 hangings that were all ruled suicides. The bodies did not look as bad as I was expecting based on what I had seen on TV and in movies. Sometimes in Hollywood, they make the face look super bloated and the tongue look swollen. I learned that the reason that the tongue sticks out is not due to swelling. The tongue often does protrude but it's because the rope (or whatever they use) puts mechanical pressure on the lower portion of the tongue and causes it to go up and out. (If you take your finger and push underneath your chin about an inch behind the bony tip of your chin, you can sort of feel why this would happen). Once the body is cut down, the tongue often returns to a fairly normal position. The ligature (rope, cord, etc) did leave a pretty deep rut (for lack of a better term) in the skin and soft tissue of the neck on all of the people I saw who had hanged.
I saw more overdoses than I can count. Some on illicit drugs, others on prescriptions. The autopsies for these are straightforward and pretty normal from a pathology standpoint. I saw some car accident victims that had too many fractures to count, and a man who had fallen about 25 feet and bounced off some scaffolding several times on his way down that was quite a wreck. Two men who had stabbed themselves to death. One man stabbed his neck and his heart with a kitchen knife. The other stabbed himself 17 times in the neck, chest, and abdomen with a bayonet. He actually survived in the ICU for a few days before we got him. As you might imagine, he was a mess.
Although most of the things you see in the ME are fairly depressing, occasionally things happen that you can’t help but laugh at. Like the man who was found dead on top of a blow up doll (you can imagine). I felt a little guilty laughing about it, but I think you can recognize that it’s sad someone is dead and still find some sliver of humor in the way it happened.
There was absolutely nothing funny about the dozen or so gun-shot suicides I saw during the month I was at the ME. I was struck by the irony of the scene photos of one of these cases. The guy was roughly my age and had shot himself in his parked car. I didn’t notice this initially because there were more attention-grabbing areas of the photo (as you might imagine) but I found it strange that he was wearing a seatbelt. Perhaps it was just the result of habit. But how strange to buckle up and then put a round through your head.
Another memorable case was a young guy playing Russian Roulette in front of his friends. He lost. One in six odds might not sound too bad, but when you’re talking about death, those are damn terrible odds. In Utah, someone who gets killed playing Russian Roulette is ruled a suicide, not an accident. This often really pisses off family members of the decedent.
Another man shot himself in the driver's seat of a stolen car he had parked in the lot of a shop in an industrial part of town. Among the reams of paper that he had in his car (tons of rants about politics, government, etc), he had written that he wanted to wait for the sunrise before he shot himself. We also found among his writings, a note that said he was considering going on a shooting spree before he killed himself. We found three other loaded mags in his bag so if he was a good shot, he could have taken out 17 others and still had a round to kill himself.
As you would probably guess, there were more males who killed themselves with guns than females, but it was closer than I would have predicted. I was definitely surprised by how many women we saw. The oldest person I saw that had taken their own life was 76. The youngest was nine—not a typo. A nine year old. That takes the cake for the most horrific thing I saw there. With a kid that young, we wanted to believe that it must have been an accident. But the placement of the gun and the fact that it was witnessed by a friend made it pretty clear that it was intentional. I imagine that the kid who witnessed this has a very slim chance of living a normal life. Not something anyone should have to see at any age, but at nine? Good lord.
I helped undress the body and was the one who checked the pants’ pocket. I welled up and had to leave the room for a minute or two when I pulled out an empty fruit snacks wrapper from the pocket—just a little kid. It’s those little details that I found the most haunting because it sort of puts things into context and makes it more real. This little child had been at school eating fruit snacks just a few hours before committing suicide. Although I’d like to, I doubt that I’ll ever be able to erase the image of that mangled little body and that wrapper.
Without question, the most sobering month of my life. So many things to think about, so many images I’ll never be able to get rid of, yet I’m glad I did it. And I’m very glad that I didn’t end up seeing anyone that I knew. Seems an odd thing to thank people for not dying, but I suppose that I should thank everyone I know for not dying that month, hard enough with strangers.
Wednesday, March 24, 2010
Back to Sleep
Most mothers are probably familiar with the Back to Sleep campaign aimed at getting moms to put their babies to sleep on their backs. I realize that some mothers have been around long enough to see medicine flip-flop on the advice we, as a profession, offer in regards to the safest way to put your baby to bed. All I can say is that we, as a profession, are wrong sometimes and we do the best we can based on the data available. Currently, the recommendation is to put babies to sleep on their backs, IN THEIR OWN BED!
After a month in the medical examiner, I’m completely behind both of those recommendations. Performing an autopsy on a baby is horrific. Performing an autopsy on a baby that has nothing physically wrong with it and is dead because mom or dad smothered their child is about as heart-wrenching as it gets. I had some variation of that experience a few times during my month there.
There was one case that is fairly representative. It was 2 month old girl. Mom went to sleep with baby on her chest. At some point after a feeding, she had baby beside her with a barrier of pillows and a comforter, presumably to keep dad from smothering baby. When her husband woke up to go to work, he noticed that baby was not breathing, but was still quite warm. Their efforts to resuscitate were unsuccessful as were the efforts of the paramedics. I can’t imagine the horror of an event like this. Based on the body temperature, the baby probably had not been dead long when they discovered her. Apparently the barrier mom had constructed to protect the baby actually ended up impeding her breathing somehow.
She, no doubt, had many of the same thoughts that parents who often do this do: “I would wake up.” “I would feel it if I rolled over.” “I put the baby on my side of the bed so he won’t rollover on her” and on and on. Fact is, it happens and it is awful. The funeral home that brought that baby’s body to us did not show up for a long time after the baby died because mom would not let go of her. That poor mother held her decomposing baby for almost 36 hours before the mortician was finally able to get her to turn her over so he could bring the body to the ME for an autopsy.
I don’t have kids so I’m not going to pretend that I know what it’s like to be up with a colicky, vomiting baby that won’t stop crying. All I know is that those parents were good people who loved their child and never thought it would happen.
As I watched, in horror, as these tiny bodies were dissected, I was hoping that the ME would find a major heart problem or some other abnormality that would explain the child’s death. Something, anything that might help with the parents’ guilt. I saw a handful of autopsies on infants during my month at the ME, unfortunately, none of them ever revealed anything wrong with the baby.
Please put your baby to sleep on its back in its own bed.
After a month in the medical examiner, I’m completely behind both of those recommendations. Performing an autopsy on a baby is horrific. Performing an autopsy on a baby that has nothing physically wrong with it and is dead because mom or dad smothered their child is about as heart-wrenching as it gets. I had some variation of that experience a few times during my month there.
There was one case that is fairly representative. It was 2 month old girl. Mom went to sleep with baby on her chest. At some point after a feeding, she had baby beside her with a barrier of pillows and a comforter, presumably to keep dad from smothering baby. When her husband woke up to go to work, he noticed that baby was not breathing, but was still quite warm. Their efforts to resuscitate were unsuccessful as were the efforts of the paramedics. I can’t imagine the horror of an event like this. Based on the body temperature, the baby probably had not been dead long when they discovered her. Apparently the barrier mom had constructed to protect the baby actually ended up impeding her breathing somehow.
She, no doubt, had many of the same thoughts that parents who often do this do: “I would wake up.” “I would feel it if I rolled over.” “I put the baby on my side of the bed so he won’t rollover on her” and on and on. Fact is, it happens and it is awful. The funeral home that brought that baby’s body to us did not show up for a long time after the baby died because mom would not let go of her. That poor mother held her decomposing baby for almost 36 hours before the mortician was finally able to get her to turn her over so he could bring the body to the ME for an autopsy.
I don’t have kids so I’m not going to pretend that I know what it’s like to be up with a colicky, vomiting baby that won’t stop crying. All I know is that those parents were good people who loved their child and never thought it would happen.
As I watched, in horror, as these tiny bodies were dissected, I was hoping that the ME would find a major heart problem or some other abnormality that would explain the child’s death. Something, anything that might help with the parents’ guilt. I saw a handful of autopsies on infants during my month at the ME, unfortunately, none of them ever revealed anything wrong with the baby.
Please put your baby to sleep on its back in its own bed.
Tuesday, March 16, 2010
One Eight Seven
In case you missed the significance of the title, 187 is the police code for homicide (actually I think it’s specifically the LAPD code for homicide made famous by the likes of Snoop and Dre--"Cause it's 1-8-7 on an undercover cop"). If you haven’t read the previous post (and it was a tad lengthy so it’d be understandable) you may want to do that or this one won’t make a ton of sense. I thought I’d write a little about homicides because they are a little different from other autopsies.
The first case that I was a part of was a guy that was actually killed by the police. Which highlights an important point about homicides in the medical terminology versus legal terminology—which is different. In medical terms, a homicide is when someone intentionally kills another person. In this case, the cop who shot the guy did so intentionally because the guy was trying to run him over in a car. That cop was well within his legal rights to use deadly force and will not be charged with homicide, but from a medical standpoint, the death is still categorized as a homicide. It’s a pretty important semantic distinction that can get confusing to people who don’t realize that the word “homicide” means two different things to a doctor and a lawyer.
I didn’t ever respond to the scene of a homicide so I’m not sure how different it would be from the other scenes I went to. One difference is that it’s a crime scene and is taped off with the yellow tape we all recognize from TV (I did actually go to the scene of a suicide that was cordoned off like that and we actually had to sign in to the scene before we were allowed to cross under the tape—sort of surreal moment). Another difference is the amount of photographs. If it’s a homicide there will inevitably be a lot more photos. The police are also taking their own photos and collecting evidence for their own lab. They usually have someone from their crime lab that is conducting an investigation simultaneously with the ME investigator.
The hands of the body are wrapped in brown paper bags that are taped up around the wrist. This is to preserve any evidence (blood spatter patterns, tissue from an assailant that might be under the victim’s fingernails, etc) so the doc can collect/document that evidence at autopsy (this is also often done with suicides).
The body arrives at the ME in a body bag with the zipper temporarily locked with a zip-tie. This is to ensure that the body isn’t tampered with in any way en route to the ME. The odds of this happening are extremely low, but creative defense attorneys will latch on to just about anything. But aside from the legal reasons to do it, it’s a good idea from a forensic standpoint anyway.
When the autopsy is to begin, the first photograph taken is of a watch placed by the sealed body bag to show that the body did in fact arrive in a sealed bag, and the watch is to show what time the autopsy began (yes this could easily be faked if someone wanted to by resetting the watch to a different time so I’m not entirely sure why they bother with it). Once the body is out of the bag and on the table, a bunch of ‘as-is’ photos are taken. The ME is often doing his external exam while these photos are being taken. This usually entails looking closely at the clothing and any visible injuries while the body is still clothed.
The next step is often the hands so the paper bags are removed at this point. He looks for defensive wounds, blood spatter, etc. The fingernails are clipped into evidence bags in homicides because there is a reasonable chance that the perpetrator’s DNA can be obtained from the victim’s nails if there was a struggle of any kind. Extensive sets of fingerprints are also taken from homicide victims (normal autopsies they usually just get thumb prints from both hands unless it’s a baby in which case they get footprints too). From there, the clothing is removed piece by piece and taken to a separate table for photographing (in a regular autopsy, clothing is not photographed individually, just cataloged and described in the report). These photos are frequently a part of the prosecution’s exhibits if the case goes to trial (which means the photos will be scrutinized and attacked by the defense attorney so you want to get good photos).
I had the opportunity to go to court with one of the doc’s who was an expert witness for the prosecution in a homicide case from about 5 years ago. On the stand, he described the murdered girl’s autopsy findings. He explained the injuries as the jury looked at the autopsy photos. The prosecutor also had him draw the injuries on a body diagram for the jury to see (cuts in red ink, bruises in blue). He explained the toxicology results and gave his opinion about how the attack might have occurred (the girl had been sexually assaulted and had several non-fatal cuts on her neck and then was strangled to death with her own belt).
The defense attorney’s cross-examination was not nearly as dramatic as I was expecting. The only point he really contended in his cross was the range for the time of death. His skepticism was definitely warranted. Time of death is one of the more difficult things to really pin down. It is no where near an exact science. Liver temperature is often used to estimate it, but there are tons of variables that you can’t account for. In this girl’s case, her body had been in a car for several hours in 44 degree weather so her body would have cooled significantly faster than a body at room temperature (the formulas for estimating time of death using liver temperature are usually based on room temperature). The best the ME can do is provide a range (usually of several hours) when the death likely occurred.
The courtroom stuff was all fairly interesting, but not nearly as dramatic as you see on TV. I was tempted to jump up during the cross-examination and shout something like, "Your Honor, I object, he's badgering the witness!" just to spice it up, but decided better of it. I was in the courtroom for about 30 minutes total, just long enough for the ME to testify. We heard that the guy was convicted about one week later (his DNA was at the scene, on the belt that was found around her neck—tough to get an acquittal if your DNA is strewn about the crime scene…unless you’re OJ).
One other point that I thought was interesting. They did not find the perpetrator's semen at the scene or at autopsy (they use the black light test similar to the way it's portrayed on TV). But that obviously doesn't rule out a sexual assault. There are reasons why there may not be any physical evidence of a sexual assault. For example, the assault could have taken place post-mortem and the perpetrator may have been wearing a condom. It's also possible that the scene looks like there was a sexual assault when there wasn't. For example, this girl was found with her pants and underwear around her thighs so it looked like an assault had taken place, and indeed, it may have. But it's also possible that the perpetrator started down that road but then got spooked and took off. Unfortunately, there isn't always a definitive answer.
Once all of the clothing has been removed and the body photographed, the autopsy proceeds much the same way that any other autopsy would. There might be a few extra tests if the ME knows that the case is likely to end up in the courtroom. For example, if there is a gun involved in the case, the ME will typically collect samples from the hands of the victim to analyze for gun shot residue. This test is pretty much worthless from a forensic standpoint. All it definitively tells you is that the victim was around when a gun was fired (if the victim is in the autopsy suite because he/she has a bullet in their head/chest it seems pretty obvious that they were there when a gun was fired). The test will not tell you who fired the gun. In other words, if the dead guy fired the gun himself or if someone else fired the gun at him, he will have gunshot residue on him. Why do the test then? Lawyers. If you didn’t do the test, a defense attorney would likely try to use that to discredit the ME and their techniques, so the ME’s order that test (which is paid for by your tax dollars) simply to appease attorneys. [Lest I come across as someone who hates attorneys, I should probably mention that I actually respect the vast majority of attorneys (even defense attorneys), but there are some defense attorneys who will, no doubt occupy the hottest seats in hell, probably alongside the doctors who similarly soil their profession with unethical conduct].
Another significant difference in a homicide autopsy is the presence of law enforcement. One of the detectives on the case will usually be there. They often come for suicide autopsies as well. And they’re often there for what are known as bogus-ides. That is an autopsy that is thought to not really be a homicide (bogus) but is conducted as if it were a homicide because the police haven’t been able to rule out a homicide (this is almost always a suicide that has something unusual about it at the scene—e.g. the entry angle of the bullet is not typical or is in an unusual location, someone else was in the room when the person shot him/herself and homicide can’t be ruled out, etc).
Homicide autopsies although interesting, are also pretty unpleasant because you know that someone else did this to them. It’s a sobering reminder of the violent society we live in. I once heard a quote that I thought of during pretty much every homicide case that I was a part of: “Civilization is a cloak that humans wear awkwardly.” Unfortunately, that’s true far too often.
I certainly can’t divulge specifics of the homicide cases that I witnessed, but several of them were covered on the news. That’s another odd thing about working at the ME—you can often anticipate what’s going to happen at work the next day by watching the evening news. It was very interesting to follow what the news reported and compare that to the findings at autopsy. Sometimes accurate, sometimes not. That leads to another diatribe that I will save for another day (i.e. the news programs are all-too-often selling a product, not reporting objective news…). I will say that when it comes to the details offered by the media (newspaper, TV news, internet) take what you hear about homicides and suicides with a grain or two of salt. I think most people sense this intuitively, but I personally saw more than one example of media reporting things that I know were absolutely false or grossly exaggerated.
Busy week this week with the match coming up, but I hope to do at least one more post, probably about babies. It will be unpleasant, but, in my opinion, important.
The first case that I was a part of was a guy that was actually killed by the police. Which highlights an important point about homicides in the medical terminology versus legal terminology—which is different. In medical terms, a homicide is when someone intentionally kills another person. In this case, the cop who shot the guy did so intentionally because the guy was trying to run him over in a car. That cop was well within his legal rights to use deadly force and will not be charged with homicide, but from a medical standpoint, the death is still categorized as a homicide. It’s a pretty important semantic distinction that can get confusing to people who don’t realize that the word “homicide” means two different things to a doctor and a lawyer.
I didn’t ever respond to the scene of a homicide so I’m not sure how different it would be from the other scenes I went to. One difference is that it’s a crime scene and is taped off with the yellow tape we all recognize from TV (I did actually go to the scene of a suicide that was cordoned off like that and we actually had to sign in to the scene before we were allowed to cross under the tape—sort of surreal moment). Another difference is the amount of photographs. If it’s a homicide there will inevitably be a lot more photos. The police are also taking their own photos and collecting evidence for their own lab. They usually have someone from their crime lab that is conducting an investigation simultaneously with the ME investigator.
The hands of the body are wrapped in brown paper bags that are taped up around the wrist. This is to preserve any evidence (blood spatter patterns, tissue from an assailant that might be under the victim’s fingernails, etc) so the doc can collect/document that evidence at autopsy (this is also often done with suicides).
The body arrives at the ME in a body bag with the zipper temporarily locked with a zip-tie. This is to ensure that the body isn’t tampered with in any way en route to the ME. The odds of this happening are extremely low, but creative defense attorneys will latch on to just about anything. But aside from the legal reasons to do it, it’s a good idea from a forensic standpoint anyway.
When the autopsy is to begin, the first photograph taken is of a watch placed by the sealed body bag to show that the body did in fact arrive in a sealed bag, and the watch is to show what time the autopsy began (yes this could easily be faked if someone wanted to by resetting the watch to a different time so I’m not entirely sure why they bother with it). Once the body is out of the bag and on the table, a bunch of ‘as-is’ photos are taken. The ME is often doing his external exam while these photos are being taken. This usually entails looking closely at the clothing and any visible injuries while the body is still clothed.
The next step is often the hands so the paper bags are removed at this point. He looks for defensive wounds, blood spatter, etc. The fingernails are clipped into evidence bags in homicides because there is a reasonable chance that the perpetrator’s DNA can be obtained from the victim’s nails if there was a struggle of any kind. Extensive sets of fingerprints are also taken from homicide victims (normal autopsies they usually just get thumb prints from both hands unless it’s a baby in which case they get footprints too). From there, the clothing is removed piece by piece and taken to a separate table for photographing (in a regular autopsy, clothing is not photographed individually, just cataloged and described in the report). These photos are frequently a part of the prosecution’s exhibits if the case goes to trial (which means the photos will be scrutinized and attacked by the defense attorney so you want to get good photos).
I had the opportunity to go to court with one of the doc’s who was an expert witness for the prosecution in a homicide case from about 5 years ago. On the stand, he described the murdered girl’s autopsy findings. He explained the injuries as the jury looked at the autopsy photos. The prosecutor also had him draw the injuries on a body diagram for the jury to see (cuts in red ink, bruises in blue). He explained the toxicology results and gave his opinion about how the attack might have occurred (the girl had been sexually assaulted and had several non-fatal cuts on her neck and then was strangled to death with her own belt).
The defense attorney’s cross-examination was not nearly as dramatic as I was expecting. The only point he really contended in his cross was the range for the time of death. His skepticism was definitely warranted. Time of death is one of the more difficult things to really pin down. It is no where near an exact science. Liver temperature is often used to estimate it, but there are tons of variables that you can’t account for. In this girl’s case, her body had been in a car for several hours in 44 degree weather so her body would have cooled significantly faster than a body at room temperature (the formulas for estimating time of death using liver temperature are usually based on room temperature). The best the ME can do is provide a range (usually of several hours) when the death likely occurred.
The courtroom stuff was all fairly interesting, but not nearly as dramatic as you see on TV. I was tempted to jump up during the cross-examination and shout something like, "Your Honor, I object, he's badgering the witness!" just to spice it up, but decided better of it. I was in the courtroom for about 30 minutes total, just long enough for the ME to testify. We heard that the guy was convicted about one week later (his DNA was at the scene, on the belt that was found around her neck—tough to get an acquittal if your DNA is strewn about the crime scene…unless you’re OJ).
One other point that I thought was interesting. They did not find the perpetrator's semen at the scene or at autopsy (they use the black light test similar to the way it's portrayed on TV). But that obviously doesn't rule out a sexual assault. There are reasons why there may not be any physical evidence of a sexual assault. For example, the assault could have taken place post-mortem and the perpetrator may have been wearing a condom. It's also possible that the scene looks like there was a sexual assault when there wasn't. For example, this girl was found with her pants and underwear around her thighs so it looked like an assault had taken place, and indeed, it may have. But it's also possible that the perpetrator started down that road but then got spooked and took off. Unfortunately, there isn't always a definitive answer.
Once all of the clothing has been removed and the body photographed, the autopsy proceeds much the same way that any other autopsy would. There might be a few extra tests if the ME knows that the case is likely to end up in the courtroom. For example, if there is a gun involved in the case, the ME will typically collect samples from the hands of the victim to analyze for gun shot residue. This test is pretty much worthless from a forensic standpoint. All it definitively tells you is that the victim was around when a gun was fired (if the victim is in the autopsy suite because he/she has a bullet in their head/chest it seems pretty obvious that they were there when a gun was fired). The test will not tell you who fired the gun. In other words, if the dead guy fired the gun himself or if someone else fired the gun at him, he will have gunshot residue on him. Why do the test then? Lawyers. If you didn’t do the test, a defense attorney would likely try to use that to discredit the ME and their techniques, so the ME’s order that test (which is paid for by your tax dollars) simply to appease attorneys. [Lest I come across as someone who hates attorneys, I should probably mention that I actually respect the vast majority of attorneys (even defense attorneys), but there are some defense attorneys who will, no doubt occupy the hottest seats in hell, probably alongside the doctors who similarly soil their profession with unethical conduct].
Another significant difference in a homicide autopsy is the presence of law enforcement. One of the detectives on the case will usually be there. They often come for suicide autopsies as well. And they’re often there for what are known as bogus-ides. That is an autopsy that is thought to not really be a homicide (bogus) but is conducted as if it were a homicide because the police haven’t been able to rule out a homicide (this is almost always a suicide that has something unusual about it at the scene—e.g. the entry angle of the bullet is not typical or is in an unusual location, someone else was in the room when the person shot him/herself and homicide can’t be ruled out, etc).
Homicide autopsies although interesting, are also pretty unpleasant because you know that someone else did this to them. It’s a sobering reminder of the violent society we live in. I once heard a quote that I thought of during pretty much every homicide case that I was a part of: “Civilization is a cloak that humans wear awkwardly.” Unfortunately, that’s true far too often.
I certainly can’t divulge specifics of the homicide cases that I witnessed, but several of them were covered on the news. That’s another odd thing about working at the ME—you can often anticipate what’s going to happen at work the next day by watching the evening news. It was very interesting to follow what the news reported and compare that to the findings at autopsy. Sometimes accurate, sometimes not. That leads to another diatribe that I will save for another day (i.e. the news programs are all-too-often selling a product, not reporting objective news…). I will say that when it comes to the details offered by the media (newspaper, TV news, internet) take what you hear about homicides and suicides with a grain or two of salt. I think most people sense this intuitively, but I personally saw more than one example of media reporting things that I know were absolutely false or grossly exaggerated.
Busy week this week with the match coming up, but I hope to do at least one more post, probably about babies. It will be unpleasant, but, in my opinion, important.
Friday, March 5, 2010
The OME
I did a rotation at the Office of the Medical Examiner (OME) fairly recently. The ME is the forensic pathologist (actually it’s 4 docs) that do the autopsies for the State of Utah. As you might imagine, it’s a pretty fascinating place to work. They do, on average, six autopsies per day. About 25% of their caseload is due to drug overdoses. That’s not a typo, one out of every four cases they handle is someone who either intentionally or accidentally (the majority) overdosed on something (usually narcotics—heroin, Lortab, OxyContin, Percocet, methadone—or stimulants, like cocaine). If that doesn’t sound like a lot to you, it is. It works out to be ~50 per month. That’s nearly two people a day. It’s way too many—big problem in this state.
Many of the cases the ME ends up taking are unattended deaths, meaning unwitnessed by anyone and not necessarily expected given the person’s age and state of health in the time just prior to their death. This includes the unsavory category of what’s known as a “decomp” which is short for a decomposed body—someone that has been dead for a while before they’re found. They arrive to the OME in various stages of decay from a little bit stinky to, as they say in the office “more maggots than person” (I saw some partially decomposed bodies, but no maggots). I did see some pretty good examples of mummification, which is when the tissue starts to dry out and shrivel and feels a little bit like driftwood (you usually see it in the extremities and face first, which are the only places I ever saw it).
Of course, they handle all of the suicides and homicides as well. They will also handle many deaths that occurred when someone was at work as these cases can end up in litigation and injuries have to be documented by a doc. They’ll investigate traffic accidents if the police ask them to. And, my least favorite cases, babies that die unexpectedly (meaning they didn’t have any known medical problems where death at a young age would be expected).
It’s not nearly as sexy as all the CSI-type TV shows would make you believe, but it’s pretty damn interesting. Here’s how it works. When someone is found dead and they’re obviously dead, it’s almost always law enforcement that hears about it first (if there is any doubt about whether someone is dead or not, EMS might get dispatched to the scene and the person will be pronounced dead at the scene by EMS or they may go to the hospital where they’re pronounced dead by a physician). The cops go check it out and they’re usually the ones who call the ME’s office. The ME has 4 full-time investigators based out of the OME (which is just south of the Moran Eye Center) and several more part-timers that live in various parts of the state. The investigators talk with law enforcement on the phone and if it sounds like an ME case, they’ll go out to the scene to check it out. The investigation is usually pretty straightforward. They look at the body, what’s around it, look for signs of foul play, anything that might be a clue about cause of death (weapons, drugs, etc), take pictures, and talk to law enforcement or anyone else who knows anything about the case.
If it’s not a homicide, the scene investigations are usually less than an hour. Once they’ve concluded their investigation, an independent company comes to transport the body from the scene to the OME where the autopsy is performed. The company in Utah is called Independent Professional Services—how’s that for a euphemism? I don’t imagine that they have any marked vehicles, but if you ever see that on the side of a truck/van, you may want to try to peek in the back window.
The first scene I went to was a small apartment of a 50-something year old man that hadn’t been seen by his neighbors for a couple of days and had been unreachable by phone according to friends. Friends finally called the landlord who was unable to get a response knocking on the door, but it was locked so she knew he was in there. The guy had put a sign on his door that said he wasn’t feeling well and did not want to be bothered, which was not unusual for him when he wasn’t feeling well. She unlocked the door and was immediately greeted by two very hungry cats. (If you're like me, your first question to the investigator at this point would be Do the animals ever start to eat the body? Dogs, sometimes. Cats, not usually. I did not see any bodies that had been disturbed by animals in anyway.) The man was sprawled out on his back in bed with no covers on him. The room was a bit stinky, but mostly due to the kitty litter (but a body that has been dead for about 2 days in a room that's about 80 degrees does have a bit of a funk). He also had a bit of vomit coming out of his mouth, which didn't help either.
As most people probably know, there is a ton of bacteria in your GI tract. When someone dies, the bacteria in your gut continue to essentially have a toga party—reproducing liberally. As they do so, they produce methane (and other gases). This causes bloating and as this gas continues to accumulate in the abdomen, it is not uncommon for this expanding gas to cause stomach contents to slowly migrate back towards the mouth. This guy was actually bubbling a little bit at the mouth as the gas bubbled up through the vomit (nice imagery, I know). So yes, dead people vomit. They can also fart and poop after death (which I saw multiple times—you think live people’s farts stink…lordy). [Anyone interested in learning more about what can happen to human cadavers after death should read the extraordinary book, Stiff, by Mary Roach. Fascinating read, very informative, also hilarious.]
Inside the apartment, there were no signs of foul play. The guy was very obese (plus his belly was pretty bloated) and eyeballing him, I guessed that he had died of a heart problem (I was wrong). One thing the investigators do at every scene is look for medications or illicit drugs. This guy had a few meds and a small weed pipe, but nothing that made us think he had OD’d. The investigator snapped a bunch of pictures, bagged up his meds, and then the body movers came and slung this guy on a gurney—he was pushing 400 pounds, so it was no small feat.
When we get bodies at the ME, they are in fact placed on the large stainless steel tables you see on TV. They get weighed and have their height measured. After some intake paper work, the body is moved to the autopsy suite (or the fridge if it’s not their turn yet--in Utah, it's a huge walk in fridge with many tables with bodies on them, not individual drawers like you see on TV sometimes). Next, a ton of ‘as is’ pictures—meaning the body is photographed in the position and clothing that it comes in. Then we undress the body (which can take some doing because of rigor mortis) and the doc conducts the external exam. He (or she, there is one female doc in the OME, but it’s easier to just say ‘he’) notes any tattoos, scars, wounds, or anything else that seems relevant. While he’s doing this, the rest of us are removing any jewelry. [Quick aside: it is really eerie to remove a watch that’s still ticking from a dead body—weird feeling I never got used to.]
Usually after the doc is done with his external exam, the deiner (an autopsy assistant—deiner is the German word for waiter or server) begins with the classic Y incision in the chest. The depth of subcutaneous fat is measured. Then the deiner dissects back the skin on the chest and stomach and then cuts off the front part of the rib cage with a pair of loppers (the kind you use to trim tree branches—seriously, they buy them at Home Depot). The sound is pretty unpleasant. It hurts to listen to, until you get used to it. From there, the internal organs are removed in a specific order, mostly because it’s more efficient to document if you always do it in the same order. Usually the heart first, then both lungs, liver, spleen, bowels, kidneys, and possibly others depending on the case (optional stuff like uterus, prostate, bladder, etc). The organs are weighed, and then the ME dissects them one by one looking for something amiss that might explain why the person is dead.
It’s uncanny how much the autopsy suite resembles a commercial kitchen. Stainless steel everywhere, sinks, large bowls, colanders, fine cutlery, ladles, strainers, cutting boards, garbage bags. It’s actually pretty unsettling at first.
Back to the big fella that died in his apartment. When someone has been dead for a couple of days before they’re found and their belly is full of gas, you have to exercise caution when you cut them open. It’s best to start with a small incision, preferably one that is not directly inline with your face. When a body is pretty bloated and you cut into the abdominal cavity, there is an audible whoosh as the gas escapes from the belly (sounds a little bit like uncapping an inflated air mattress). If they’re really bloated, small bits of fat and other bits of tissue can become projectiles as the gas escapes, which is why you don’t want to have your face directly over the incision. I heard (and smelled) plenty of this gas escaping from several bodies, but did not see any projectiles during my month there. One of the docs told me that he has seen bits of tissue get launched into the ceiling (it’s a 12 foot ceiling). Rather impressive, I imagine.
The smell in a situation like this is, as you would imagine, horrific. Us rookies frequently have to back away from the table, and on a couple of occasions leave the room, in order to keep from vomiting. Although I had some close calls, I managed to observe 100+ autopsies without puking or passing out.
Other things that happen during the autopsy (this is all pretty much going on simultaneously as several people are working on the body at once), blood is drawn by sticking a rather large needle either in the inferior vena cava or directly into the heart. Urine is drawn by putting a needle directly into the bladder, and vitreous humor (eye juice) is drawn by sticking a needle into the white part of the eye. Getting the vitreous is a med student job so I did it several times during the rotation. Sticking a needle into an eye—even the eye of a dead person—is a little uncomfortable the first few times you do it. It’s just one of those things that doesn’t feel or look right, like looking at a compound fracture. All the fluids are then sent for toxicology to determine the drugs, and the levels of those drugs, that were in the person’s system.
As the doc is dissecting organs at a separate table, the deiner is working on “popping the top” which means peeling back the scalp and cutting off the top of the skull. One of the more unsettling things for the outside visitors (cops, lawyers, etc). The people who haven’t seen autopsies before don’t really like this part very much—understandably so. It’s pretty hard to capture in words how weird this looks.
An incision is made starting just behind one ear and then moving around the back of the skull (at about where the neck muscles attach to your head) all the way to the other side just behind the other ear. Then the scalp is peeled off the skull in the direction of the body’s face. When it’s peeled back (or forward?) all the way, the scalp covers the entire face and the skull is almost completely exposed from the forehead all the way back to the back of the neck. The deiner then uses a bone saw (looks a lot like the saws used to remove casts, and like cast saws, it oscillates rather than rotates) and cuts through the skull in a ring pattern. The area they cut is pretty much the area that would be covered by a headband (it’s obviously not that wide, but that’s basically the pattern). They then use a little tool that looks a bit like a chisel and “pop the top” and the top of the skull comes off completely. They use a scalpel and cut the brainstem from the spinal cord, cut a few other small nerves, and pull the brain out. I’m not sure what this says about me or what to make of it exactly, but that was always my favorite part of the autopsy.
If you’ve never handled a fresh brain (I imagine that’s most of you) it is surprisingly soft, and actually feels a bit different from a brain that has been chemically fixed (in case any of you have felt fixed brains in anatomy or neuro labs). The consistency is similar to a few foods that I can think of, but lest I permanently ruin those foods for you, I will keep them to myself. I sill eat them, but I must admit, the experience is now different. The brain is then sliced into sections, again, looking for anything amiss. Small samples of all the organs are saved in a little jar of formalin (fixes the tissue) in case the doc wants/needs to come back to reexamine anything. The doc may also send samples of tissue for histology (you look at small samples of the organs under a microscope) depending on what they do or don’t see during the autopsy.
Unless there is something really unusual, the average autopsy takes about 45 minutes (obviously, there is some variability depending on the doc and the size of the body). If the case is a homicide it will take much longer as more photos have to be taken, all clothing is evidence so you have to be much more careful removing it, photographing it, and bagging it. Homicides usually require more tests too, which means more specimens, etc. In some cases, autopsies are actually less than 45 minutes. For example, when it’s a suicide and they used a gun and it’s pretty obvious what killed them, the full autopsy isn’t performed. You take pictures, recover a bullet if you can, but you don’t always have to open up the chest and belly if someone shot him/herself in the head (this is true of hangings as well).
I’ll try to write about homicides and suicides in a future post as this one is pretty long already. I’ll also hopefully find time to write about some of the amusing things that happened, and some of the absolutely heartbreaking things I saw.
As for our big fella, the doc didn't determine his cause of death during the autopsy. This is not uncommon. In cases like that, the death is signed out as 'pending' and the doc waits for all of the tests to come back (usually a couple of months). At that time, an official cause of death is named, which might be 'undetermined'. Incidentally, this fella's family put in his obituary that he had died of a heart problem. While it ultimately may prove to be the case, that certainly was not obvious on autopsy. One unexpected skill that I improved during this rotation was an ability to read between the lines of some obituaries.
This rotation was by far the most fascinating rotation I've done in all of medical school. It was the most thought-provoking, and the most disturbing. I'm personally not a drinker, but doing a month in the medical examiner's office could certainly make you consider it. Unforgettable.
Many of the cases the ME ends up taking are unattended deaths, meaning unwitnessed by anyone and not necessarily expected given the person’s age and state of health in the time just prior to their death. This includes the unsavory category of what’s known as a “decomp” which is short for a decomposed body—someone that has been dead for a while before they’re found. They arrive to the OME in various stages of decay from a little bit stinky to, as they say in the office “more maggots than person” (I saw some partially decomposed bodies, but no maggots). I did see some pretty good examples of mummification, which is when the tissue starts to dry out and shrivel and feels a little bit like driftwood (you usually see it in the extremities and face first, which are the only places I ever saw it).
Of course, they handle all of the suicides and homicides as well. They will also handle many deaths that occurred when someone was at work as these cases can end up in litigation and injuries have to be documented by a doc. They’ll investigate traffic accidents if the police ask them to. And, my least favorite cases, babies that die unexpectedly (meaning they didn’t have any known medical problems where death at a young age would be expected).
It’s not nearly as sexy as all the CSI-type TV shows would make you believe, but it’s pretty damn interesting. Here’s how it works. When someone is found dead and they’re obviously dead, it’s almost always law enforcement that hears about it first (if there is any doubt about whether someone is dead or not, EMS might get dispatched to the scene and the person will be pronounced dead at the scene by EMS or they may go to the hospital where they’re pronounced dead by a physician). The cops go check it out and they’re usually the ones who call the ME’s office. The ME has 4 full-time investigators based out of the OME (which is just south of the Moran Eye Center) and several more part-timers that live in various parts of the state. The investigators talk with law enforcement on the phone and if it sounds like an ME case, they’ll go out to the scene to check it out. The investigation is usually pretty straightforward. They look at the body, what’s around it, look for signs of foul play, anything that might be a clue about cause of death (weapons, drugs, etc), take pictures, and talk to law enforcement or anyone else who knows anything about the case.
If it’s not a homicide, the scene investigations are usually less than an hour. Once they’ve concluded their investigation, an independent company comes to transport the body from the scene to the OME where the autopsy is performed. The company in Utah is called Independent Professional Services—how’s that for a euphemism? I don’t imagine that they have any marked vehicles, but if you ever see that on the side of a truck/van, you may want to try to peek in the back window.
The first scene I went to was a small apartment of a 50-something year old man that hadn’t been seen by his neighbors for a couple of days and had been unreachable by phone according to friends. Friends finally called the landlord who was unable to get a response knocking on the door, but it was locked so she knew he was in there. The guy had put a sign on his door that said he wasn’t feeling well and did not want to be bothered, which was not unusual for him when he wasn’t feeling well. She unlocked the door and was immediately greeted by two very hungry cats. (If you're like me, your first question to the investigator at this point would be Do the animals ever start to eat the body? Dogs, sometimes. Cats, not usually. I did not see any bodies that had been disturbed by animals in anyway.) The man was sprawled out on his back in bed with no covers on him. The room was a bit stinky, but mostly due to the kitty litter (but a body that has been dead for about 2 days in a room that's about 80 degrees does have a bit of a funk). He also had a bit of vomit coming out of his mouth, which didn't help either.
As most people probably know, there is a ton of bacteria in your GI tract. When someone dies, the bacteria in your gut continue to essentially have a toga party—reproducing liberally. As they do so, they produce methane (and other gases). This causes bloating and as this gas continues to accumulate in the abdomen, it is not uncommon for this expanding gas to cause stomach contents to slowly migrate back towards the mouth. This guy was actually bubbling a little bit at the mouth as the gas bubbled up through the vomit (nice imagery, I know). So yes, dead people vomit. They can also fart and poop after death (which I saw multiple times—you think live people’s farts stink…lordy). [Anyone interested in learning more about what can happen to human cadavers after death should read the extraordinary book, Stiff, by Mary Roach. Fascinating read, very informative, also hilarious.]
Inside the apartment, there were no signs of foul play. The guy was very obese (plus his belly was pretty bloated) and eyeballing him, I guessed that he had died of a heart problem (I was wrong). One thing the investigators do at every scene is look for medications or illicit drugs. This guy had a few meds and a small weed pipe, but nothing that made us think he had OD’d. The investigator snapped a bunch of pictures, bagged up his meds, and then the body movers came and slung this guy on a gurney—he was pushing 400 pounds, so it was no small feat.
When we get bodies at the ME, they are in fact placed on the large stainless steel tables you see on TV. They get weighed and have their height measured. After some intake paper work, the body is moved to the autopsy suite (or the fridge if it’s not their turn yet--in Utah, it's a huge walk in fridge with many tables with bodies on them, not individual drawers like you see on TV sometimes). Next, a ton of ‘as is’ pictures—meaning the body is photographed in the position and clothing that it comes in. Then we undress the body (which can take some doing because of rigor mortis) and the doc conducts the external exam. He (or she, there is one female doc in the OME, but it’s easier to just say ‘he’) notes any tattoos, scars, wounds, or anything else that seems relevant. While he’s doing this, the rest of us are removing any jewelry. [Quick aside: it is really eerie to remove a watch that’s still ticking from a dead body—weird feeling I never got used to.]
Usually after the doc is done with his external exam, the deiner (an autopsy assistant—deiner is the German word for waiter or server) begins with the classic Y incision in the chest. The depth of subcutaneous fat is measured. Then the deiner dissects back the skin on the chest and stomach and then cuts off the front part of the rib cage with a pair of loppers (the kind you use to trim tree branches—seriously, they buy them at Home Depot). The sound is pretty unpleasant. It hurts to listen to, until you get used to it. From there, the internal organs are removed in a specific order, mostly because it’s more efficient to document if you always do it in the same order. Usually the heart first, then both lungs, liver, spleen, bowels, kidneys, and possibly others depending on the case (optional stuff like uterus, prostate, bladder, etc). The organs are weighed, and then the ME dissects them one by one looking for something amiss that might explain why the person is dead.
It’s uncanny how much the autopsy suite resembles a commercial kitchen. Stainless steel everywhere, sinks, large bowls, colanders, fine cutlery, ladles, strainers, cutting boards, garbage bags. It’s actually pretty unsettling at first.
Back to the big fella that died in his apartment. When someone has been dead for a couple of days before they’re found and their belly is full of gas, you have to exercise caution when you cut them open. It’s best to start with a small incision, preferably one that is not directly inline with your face. When a body is pretty bloated and you cut into the abdominal cavity, there is an audible whoosh as the gas escapes from the belly (sounds a little bit like uncapping an inflated air mattress). If they’re really bloated, small bits of fat and other bits of tissue can become projectiles as the gas escapes, which is why you don’t want to have your face directly over the incision. I heard (and smelled) plenty of this gas escaping from several bodies, but did not see any projectiles during my month there. One of the docs told me that he has seen bits of tissue get launched into the ceiling (it’s a 12 foot ceiling). Rather impressive, I imagine.
The smell in a situation like this is, as you would imagine, horrific. Us rookies frequently have to back away from the table, and on a couple of occasions leave the room, in order to keep from vomiting. Although I had some close calls, I managed to observe 100+ autopsies without puking or passing out.
Other things that happen during the autopsy (this is all pretty much going on simultaneously as several people are working on the body at once), blood is drawn by sticking a rather large needle either in the inferior vena cava or directly into the heart. Urine is drawn by putting a needle directly into the bladder, and vitreous humor (eye juice) is drawn by sticking a needle into the white part of the eye. Getting the vitreous is a med student job so I did it several times during the rotation. Sticking a needle into an eye—even the eye of a dead person—is a little uncomfortable the first few times you do it. It’s just one of those things that doesn’t feel or look right, like looking at a compound fracture. All the fluids are then sent for toxicology to determine the drugs, and the levels of those drugs, that were in the person’s system.
As the doc is dissecting organs at a separate table, the deiner is working on “popping the top” which means peeling back the scalp and cutting off the top of the skull. One of the more unsettling things for the outside visitors (cops, lawyers, etc). The people who haven’t seen autopsies before don’t really like this part very much—understandably so. It’s pretty hard to capture in words how weird this looks.
An incision is made starting just behind one ear and then moving around the back of the skull (at about where the neck muscles attach to your head) all the way to the other side just behind the other ear. Then the scalp is peeled off the skull in the direction of the body’s face. When it’s peeled back (or forward?) all the way, the scalp covers the entire face and the skull is almost completely exposed from the forehead all the way back to the back of the neck. The deiner then uses a bone saw (looks a lot like the saws used to remove casts, and like cast saws, it oscillates rather than rotates) and cuts through the skull in a ring pattern. The area they cut is pretty much the area that would be covered by a headband (it’s obviously not that wide, but that’s basically the pattern). They then use a little tool that looks a bit like a chisel and “pop the top” and the top of the skull comes off completely. They use a scalpel and cut the brainstem from the spinal cord, cut a few other small nerves, and pull the brain out. I’m not sure what this says about me or what to make of it exactly, but that was always my favorite part of the autopsy.
If you’ve never handled a fresh brain (I imagine that’s most of you) it is surprisingly soft, and actually feels a bit different from a brain that has been chemically fixed (in case any of you have felt fixed brains in anatomy or neuro labs). The consistency is similar to a few foods that I can think of, but lest I permanently ruin those foods for you, I will keep them to myself. I sill eat them, but I must admit, the experience is now different. The brain is then sliced into sections, again, looking for anything amiss. Small samples of all the organs are saved in a little jar of formalin (fixes the tissue) in case the doc wants/needs to come back to reexamine anything. The doc may also send samples of tissue for histology (you look at small samples of the organs under a microscope) depending on what they do or don’t see during the autopsy.
Unless there is something really unusual, the average autopsy takes about 45 minutes (obviously, there is some variability depending on the doc and the size of the body). If the case is a homicide it will take much longer as more photos have to be taken, all clothing is evidence so you have to be much more careful removing it, photographing it, and bagging it. Homicides usually require more tests too, which means more specimens, etc. In some cases, autopsies are actually less than 45 minutes. For example, when it’s a suicide and they used a gun and it’s pretty obvious what killed them, the full autopsy isn’t performed. You take pictures, recover a bullet if you can, but you don’t always have to open up the chest and belly if someone shot him/herself in the head (this is true of hangings as well).
I’ll try to write about homicides and suicides in a future post as this one is pretty long already. I’ll also hopefully find time to write about some of the amusing things that happened, and some of the absolutely heartbreaking things I saw.
As for our big fella, the doc didn't determine his cause of death during the autopsy. This is not uncommon. In cases like that, the death is signed out as 'pending' and the doc waits for all of the tests to come back (usually a couple of months). At that time, an official cause of death is named, which might be 'undetermined'. Incidentally, this fella's family put in his obituary that he had died of a heart problem. While it ultimately may prove to be the case, that certainly was not obvious on autopsy. One unexpected skill that I improved during this rotation was an ability to read between the lines of some obituaries.
This rotation was by far the most fascinating rotation I've done in all of medical school. It was the most thought-provoking, and the most disturbing. I'm personally not a drinker, but doing a month in the medical examiner's office could certainly make you consider it. Unforgettable.
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