‘The day I’ve been waiting for!’ I beckoned to him. ‘Come and have a look!’
Curious, he followed me into the fridge room. Once there, I moved behind the trolley in the middle of the huge foyer with my arms wide open, like a magician gesturing to an audience, to give him a clearer view of the body bag and its contents: it was a man wearing very ordinary clothes and yet … women’s underwear. And not just any women’s underwear: it was a whole pink lace ensemble, incredibly tight, that looked particularly uncomfortable over his nether regions as it mashed everything down. It was a surprise, not least because it didn’t go with his rough countenance and facial hair as well as his tracksuit trousers and T-shirt, the former pulled down to his knees and the latter pulled up to his chin.
I mention this, not because I think cross-dressing is inherently funny, but because at that point – a year so into my training – I really felt like I’d been initiated into the world of mortuary work, having happened upon this unexpected cadaver. Every mortician has his share of unusual cases and this was to be one of many for me. But there’s another reason I mention it. It’s to illustrate that a post-mortem examination isn’t just about removing organs and using fancy forensic techniques to determine what lies beneath; the examination begins with the outside of the body. In fact, usually as soon as the deceased is encountered in the mortuary. Sometimes external artefacts can be a clue to how and why a person died.
In most establishments, the fridges are opened and their contents checked against the mortuary registers first thing in the morning – a bit like doing a body stocktake after the overnight absence. Who knows what cases the police may have brought in from the streets in the middle of the night, or who may have been wheeled down from the wards? And the fridges, with their four or five shelves, can hold a lot of adults, their different scents merging to create a heady cocktail of death. In mortuaries with fewer staff you may need to book the new deceased in before or after you carry out the day’s post-mortems, but if there are enough staff you may split the duties with some carrying out autopsies and others body-checking. Either way, it’s an important part of the examination, and it takes two APTs if it’s to be done properly so that they can vouch for each other.
Like gifts, the deceased should always be wrapped. Sometimes it will be in simple white cotton sheets, particularly when the patient has come from a hospital bed, and at other times it will be in body bags made of white plastic, or white plastic sheeting. From those very first days at the Municipal Mortuary right up to the end of my mortuary career I never considered the daily opening of the bags a chore. After each one was unzipped there was a pause and an atmosphere of suspense … what might be inside? It always used to put me in mind of those Tonka toys called Keypers, from when I was a child. They were animals made from vibrant-coloured plastic and rubber, and their bodies opened up with a chunky key so you could store things inside, away from nosy younger siblings. One was a gorgeous pink swan and another was a peachy-coloured snail, but I had the majestic lilac horse and I adored it. It was the only one of my toys I never tried to do an autopsy on because she already opened up and I could see what was inside … a tiny little surprise friend called a Finder!
As well as their surprise inside they had a very distinctive smell which, unfortunately, some of our body bags did too, but in a totally different way.
Suffice to say, to me every day was like Christmas Day in the mortuary. This was especially true one December when we opened a body bag to reveal a plump old man with white hair and beard in a full red jogging suit. To this day I’m not sure if he was purposely trying to resemble Santa or if it was just a huge coincidence.
Once the deceased is accessible, everything is noted in one glance: clothing, jewellery, money or wallet, medical intervention, visible tattoos, injuries and more. The height and weight of the deceased are written down for the pathologist and for the undertakers, who will be able to get a head start on the coffin order if they know the size in advance. This is done by using a long measuring stick and removing the patient’s tray from the cold store on to the trolley which has scales attached, then pressing the button to manoeuvre them up and down with an electrical screech.*
Identity tags are then checked: there should be one on the wrist and one on the ankle, and they obviously need to match each other. Any jewellery the deceased is wearing is noted down if it hasn’t already been recorded by the staff who delivered the body, and is double-checked by the APTs. There is a rule that the words ‘gold’ and ‘silver’ aren’t used in mortuaries because we can’t really be certain what metal items are actually made of. If we write ‘gold ring’ on the personal effects form and the next of kin see that and don’t find a gold ring on their deceased – because it was just a yellow tin ring from Topshop, for example – they could sue us for a ‘missing gold ring’. Instead, we say ‘white metal’ and ‘yellow metal’. It’s very festive when you get to sing ‘Five yellow metal riiiiings!’ to your colleague in the middle of December when logging property. For the same reason we never say ‘diamond’ or ‘emerald’ either – we say ‘white stone’ or ‘green stone’ instead.
Space can be at a premium in mortuary fridges – it’s popular real estate; people are dying to get in there after all – so the turnaround from arriving in the facility and having a post-mortem, then being released, shouldn’t be more than a couple of days. Often in the winter, when the death rate is higher, mortuary staff can descend into a bit of a panic if it looks as though the spaces are filling up, just in case there’s some sort of mass fatality, or a spate of unrelated deaths due to the cold, and they run out of room.
‘What are we supposed to do if the fridges get too full?’ I panicked to Andrew that first winter I worked at the mortuary and saw the number of decedents we received increasing.
He explained to me that mortuaries may charge a rate to the Coroner if decedents are there too long without Coronial intervention and release; that is, ensuring they are moved to a funeral home or similar. ‘It’s a day rate,’ he said. ‘We call it B&B.’
‘Well, really it’s just “B”,’ I countered with a wink, and Andrew smiled. It was nice to see him not so serious for once.
So already, by simply encountering the deceased, the external examination has begun, and in addition to the information already garnered, visual cues add further pieces to the puzzle. The size of the deceased’s body, whether excessively large or excessively slim, may have contributed to their death. Perhaps, in the case of anorexia or a wasting illness, the organs had simply failed? Obesity could indicate a heart attack, or else there may be visible injuries and external signs of what might have occurred. Another phenomenon noticeable on the exterior of the cadaver is evidence of one of forensic science’s most well-known tenets, Locard’s Exchange Principle, which stipulates that ‘every contact leaves a trace’. This guideline, attributed to French scientist Edmond Locard, dates from around 1910 and is the basic principle of all the ‘trace evidence’ referenced in crime fiction and on TV: hair and fibres, blood spatter and semen, footprints, tyre tracks and more. These can all be found at scenes, on the dead and on perpetrators, because every contact between one object and another causes materials from each surface to swap over. For our purposes, we can see from the body if the deceased had been involved in certain scenarios, particularly those to do with narcotics or violence. Leaves and twigs show someone was found dead outside, and conversely pen caps and newspaper print along with other household debris stuck to the decedent may indicate someone was discovered in an untidy home.
Immediately a picture begins to form.
The post-mortem colour of the deceased may also afford some sort of clue. People generally assume that all dead bodies are pale, but some are actually very pale: a dove grey compared to the usual ivory. It may take a while to notice these subtle differences but once you do you can diagnose a ruptured abdominal aortic aneurysm – or ‘Triple A’ – by how pale the deceased is, and how suddenly death occurred. Thi
s particular cause of death happens very quickly, when an aneurysm of the largest artery in the human body, the aorta, bursts. Blood gushes into the abdominal cavity, leaving the victim looking like the freshly bled victim of a vampire in a Hammer Horror film, giving us mortuary staff clues by sight.
Or perhaps the deceased is slightly pinker than would ordinarily be expected. This can indicate death by carbon monoxide (CO) poisoning, because the CO binds in an unusual way with the haemoglobin in the blood, giving the decedent a cherry-red tint. (Haemoglobin is the main oxygen-carrying compound in the blood, and its potential to do its job correctly is disrupted by the presence of CO.) Conversely, they may be blue, indicating cyanosis caused by inadequate oxygenation which points to completely different causes of death, such as asphyxiation. The vast rainbow of colours in which the patient may present keeps the APT guessing about the circumstances of death. Fluorescent yellow? Liver failure. Purple? Congestion. Green? Well, the less said about green the better, really.
Another important aspect of the preliminary examination of our fridge’s residents is checking for pacemakers or implantable cardioverter defibrillators (ICDs), which are used to regulate people’s heartbeat in life. These particular implanted devices must be removed if the patient is to be cremated because they can explode in the heat of the furnace. In fact, they tend to be removed anyway as they can be recycled, either whole or in part. (Whole, functioning pacemakers can be given to charities such as Pace4Life to be used in the developing world.) If the deceased has a post-mortem, then it’s removed as part of that process, but if the person doesn’t need a PM there is a way to remove it which is minimally invasive.
The first time I ever removed a pacemaker I was utterly convinced I’d kill myself. You see, pacemakers and ICDs are two different things and before any sort of incision can be made to remove them you must distinguish between the two.
Jason trained me for this. The procedure is classed as invasive, but it’s probably the quickest and easiest to learn and therefore ideal for the trainee APT. One morning he handed me some gloves and a plastic apron and asked whether I was ready to ‘tick something off that training and examination log’. The gloves and apron made me think I was in for yet more cleaning. Trainee APTs get pretty handy with a sponge, and at clearing sink drains of hairballs and yellow sludge, in their first few weeks of mortuary work. Although that sounds disgusting, it’s actually incredibly important to ensure the drains don’t get blocked with any remains, and using forceps to remove the debris can be satisfying and therapeutic. I used to go completely into a ‘Zen’ zone, pulling out globules and hair and leaving the plughole gleaming. That said, when Jason then went to retrieve some string, scissors and a scalpel, I happily guessed what was coming next. We had permission from the family to remove the pacemaker from the deceased and I had watched him carry out the procedure a couple of times. Now it was my turn.
I used my hands to feel for the device on the left side of the chest and could definitely discern its outline. They can be felt by palpating the skin, although that can be slightly more difficult if the patient is on the plump side as pacemakers are slim objects with rounded edges and the excess adipose tissue can obscure their gentle curves. Their purpose is to help control abnormal heart rhythms, or arrhythmias, with small electric pulses that encourage the heart to beat at a steady rate – not too fast or too slow but just right, which would please Goldilocks – so they need to be fairly innocuous and small.
As I hovered the scalpel blade over the flat front of the pacemaker I quickly looked up at Jason, alarmed. ‘Are you sure it’s not an ICD?’
An ICD is a larger device which can warn you of its presence with its size, but I hadn’t quite seen or felt enough of them to know the difference at that point. They’re implanted into people who are at risk of a sudden cardiac arrest, and in the case of one occurring they administer massive electric shocks which kick-start the heart. These devices can’t be removed like a normal pacemaker: if an unsuspecting APT cut through the wires with metal scissors it would give her a huge electric shock, possibly even kill her. Instead, the ICD pacing clinic has to be contacted so that a cardiac physiologist can attend and turn it off. They arrive with a small machine which they use to deactivate it and take readings, ensuring that the device is indeed no longer ‘live’. It can then be removed in the same way as a pacemaker, although via a slightly larger incision, with no risk.
‘I’m sure it’s only a pacemaker, hun – but if it is an ICD at least you’re wearing rubber shoes!’ Jason said with a wink.
On this occasion, however, I didn’t really have any nerves, despite it being my first ever incision into a human, because I only needed to make a slit around two inches long into the flesh. I knew I could handle that at least. Also, the person beneath my blade was not alive. As much as the deceased are still very much people to those who work in mortuaries, for me there is subconsciously a clear distinction between alive and dead. Later on, during my first full incision, I found that the phantom pain I’d felt with the anorexic dentist’s bedsores was the one and only time it occurred and I’d quickly become immune to it. My brain seemed to grow to understand that the patient couldn’t feel the scalpel and that I had a job to focus on and get done.
I made the short incision with the scalpel easily, right across the flat front of the pacemaker. Then, with a gloved thumb and forefinger on either side, squeezed the device up through it. The skin, yawning open to reveal yellow adipose tissue and the shiny surface of the pacemaker, put me in mind of a conker bursting out of its soft bed in a horse chestnut shell. The wires were still attached and I easily dealt with these by cutting them with the scissors. I then cleaned the device with disinfectant (our ever trusty Bioguard) and placed it into a labelled plastic bag to be collected at a later date by the Cardiac ‘cath’ lab. Finally I stitched up the small incision – I’d had some practice with this on Jason’s previous pacemaker incisions – and it was barely noticeable. After I gently pressed a sticking plaster on top of the stitches and smoothed it down, the deceased was ready to be re-bagged.
‘Well done, hun!’ Jason said, as he ticked a box on my training log and signed his name next to it. I was one step closer to being a qualified APT.
Explosions in crematoria due to pacemakers were quite common before removals routinely took place, with the first reported incident happening in the UK in 1976. In fact, a 2002 paper in the Journal of the Royal Society of Medicine found that about half of all crematoria in the UK had experienced pacemaker explosions which caused structural damage and injury. The most recent was a case from the late 1990s in Grenoble, France, in which the pacemaker of a pensioner exploded with the force of two grams of TNT and caused around £40,000 worth of damage. The widow (who hadn’t informed the crematorium of the pacemaker) and the doctor (who never checked for one) were both found liable for negligence and ordered to pay damages.
In addition to pacemakers and ICDs, there are other implants that need to be noted on examination and possibly removed if the deceased is to be cremated, so we had to really take notice of the body and the paperwork. During cursory external examinations one of the most obvious additions is breast implants, particularly in older ladies, as they stand to serious attention, defying gravity when everything else has nestled down into the tray. In fact, they are even more noticeable on the dead than on the living because they cool and stiffen so much in the fridge that they resemble two police helmets. However, they’re not a huge problem in a furnace as they tend to just create a sticky residue that eventually burns up.
The same can’t be said of a relatively new type of metal implant called Fixion Nails which are used to treat fractures of large bones, such as the humerus in the arm, and the tibia and femur in the leg. These expandable devices slide into the medullary cavity of the bone and are pumped up via a hydraulic mechanism filled with saline. In 2006, a published paper described the implications of this new device in the deceased when a seventy-nine-year-old man was cremated w
ith one in his arm:
At the crematorium, one of the staff was overseeing the firing of the oven through a transparent observation port when the coffin exploded. This was felt and heard by other staff elsewhere in the building. Extensive damage was caused to the oven, and considerable distress to the staff. It transpired that the cause of the explosion was the humeral nail.
Since the hydraulic Fixion Nail is filled with saline, the heat from the crematorium machine causes the salt water to expand into a gas which explodes in its tight metal casing.
This kind of story illustrates the importance of a good cursory external examination, keeping an eye open for every possibility. After these checks have been completed, the deceased can go back into the fridge while we await news as to whether or not they will require the full post-mortem examination.
* * *
Does anyone like examinations? Whether it’s a dental exam, a breast exam or an academic exam, the word usually has a negative connotation. But we can’t get away from examinations: we have them for everything – even, it seems, when we’re dead.
In order to progress from my role as mortuary assistant or trainee APT I had to take an exam myself, in Anatomical Pathology Technology. This is usually taken after two years, a period during which the practical training log is also completed. I, however, took mine after one year due to previous experience in embalming as well as my work on my degree. There was then the option to progress from APT to Senior APT with another two years of work and examinations. Although this is as long as a degree, it’s a technical qualification and not a medical one.* The difference between APTs and pathologists is that pathologists are qualified doctors who first complete a medical degree, then go on to specialise in pathology, which is the study of death and disease. They have a lot more exams and treat live people for many years first, something I absolutely didn’t want to do: my fascination was with processes that occurred after death and how that could tell a story.
The Chick and the Dead Page 6