Dead Center

by Shiya Ribowsky

  That first encounter as an MLI-I with a dead body, which we classified as a natural death due to chronic alcohol abuse, was also, as I would later realize, the beginning of another, intensely personal journey for me: to the state of mind in which I could honestly avow that I do my job because I love it—not because I love decomposing bodies, but because I have a highly developed fascination with death. We all share that fascination, at least to some extent, I believe, as evidenced by the tremendous popularity of television shows like Law & Order and CSI, though perhaps we in the ME’s office do have more of it than civilians do. This fascination is what draws recruits to the death industry like moths to a flame. Death is the final unknown, and it is also unknowable. It is the ultimate mystery, and to me that makes it an irresistible challenge.

  And so I got used to putting my hands on dead bodies, moving past the “ickiness” of the job in stages, just like most of my colleagues. I came to believe that anyone who was able to plunge in without any difficulties was someone I didn’t want to share an office with, because that person inevitably turned out to be a sick puppy. Despite the way in which the people in the ME’s office are portrayed by the media, we are not the sort who eat bananas in the autopsy room while cutting up a body or otherwise act creepy. Society projects its discomfort with death and dying onto my colleagues and me and enjoys portraying us as ghoulish. It’s not true: most of my colleagues at OCME are warm, caring, and gentle and could make more money on the outside. They remain at OCME not because of a morbid fixation, but because they believe in its mission: uncovering the facts behind the death.

  While always teaching me to be respectful of the dead, my profession also gradually conditioned me to see each new dead body not as a recently living individual, but as an artifact—a tangible item like the pill bottle on the desk at the death scene or the blood spatter on the wall—that can be evaluated by me in the same manner and for the same purpose that I examined the pill bottle and the blood spatter: to discover what had happened to the dead person. It’s not lost on me that this body was once a person, but the person has left, and all I have to deal with is the corpus of what used to be a human being. It took three months for me to become comfortable around dead bodies, six months for the bodies to become artifacts, and a year for me to reach the point where I was able to attach no more emotional importance to the body than to the blood spatter on the wall.

  In other words, during our first year, we MLI-Is learn to cope. The most important element in that coping is the growing understanding of our sense of duty—the obligation to do certain things that would be distasteful to you and almost everyone else on the planet. Every day, we MLIs take our fears out of their hiding places, examine them, and come to terms with what they have to say. It takes a special kind of fortitude to willingly confront and interact with a rotting body, or one that is cut up into pieces. And it takes a person who understands the social necessity of this act to do it properly.

  There was much more to the job than I had imagined. My visions of rapidly becoming a younger version of Jack Klugman’s Quincy were soon dispelled, for I had much to learn. My training would not only entail acquiring a tremendous fund of forensic expertise but also learning the agency’s rules, regulations, protocols, and the subtle nuances of the political minefield that is New York City’s civil service.

  Around seventy thousand people die each year in New York City, and they die in every conceivable location—at work and church, in stores and parks, on subways and buses, in restaurants and theaters. Most people, though, die at home or in hospitals, or, to be more accurate, they are declared dead at a hospital. Their demise may have begun in a thrift shop on Bleecker Street, but continued during their travels to, say, the emergency room at St. Vincent’s Hospital, where they finished the task of expiring.

  More than a third of the city’s yearly toll of deaths will be reported to the ME’s office because they match certain criteria and therefore fall within our jurisdiction. To handle the volume, our office maintains a headquarters in Manhattan and satellite offices in each of the four outer boroughs. All of our training and educational programs take place at the main building, which, in addition to serving as Manhattan’s borough office, houses the agency’s citywide administrative functions and all of its laboratories. Very high-profile cases, such as the death of a politician or celebrity, or the victims of a mass fatality incident—even if the deaths occur in an outer borough—are often brought into headquarters. There is also a longstanding tradition that a police officer or firefighter killed in the line of duty anywhere in the city is brought to the main office in Manhattan for autopsy. It’s not that the borough offices are inferior in any way; it’s just that with the administration located in Manhattan it’s easier to handle media interactions and special situations there.

  The main office, that uncommonly ugly building at the corner of Thirtieth and First, sandwiched between two of the largest hospitals in the world, New York University Hospital and Bellevue Hospital Center, is always filled with activity. When I began, I was assigned for training to a PA and supervising MLI who had worked in that capacity with Dr. Hirsch before they came to New York City, when both were in the Suffolk County ME’s office. He took me on an orientation tour of headquarters, and his running commentary gave me some understanding of the overall functions of the OCME. The administrative offices, medical records unit, communications and identifications units, and MLI squad room were on the first floor; the autopsy rooms and walk-in body refrigerators were in the basement; the MEs’ offices were on the second and third floors, along with an employees’ lunch room (three decrepit vending machines, two moldy sofas, and a battered table), and the information-systems department. The fourth and fifth floors held the toxicology, histology, and serology laboratories, and the photography unit. The sixth floor was a shambles, in the process of being renovated to accommodate the serology lab, which was changing its name to the forensic biology lab and expanding to take the entire floor. Everyone was excited about the newfangled testing involving DNA that was going to push the new forensic biology lab to the forefront of forensic science and criminal justice.

  By the time we descended again to the first floor and the communications unit, my head was spinning, but my tutor insisted that I pay attention in the communications area, because “this is where it all begins; this is where the cases come in.” In a relatively small room, clerks manned the phones 24 hours a day, 365 days a year, recording all the cases reported to OCME citywide. Most of the cases are reported by either physicians calling from hospitals or police officers calling from a death scene. Every once in a while a case gets reported by a funeral director or some other authority that has a body and requires our help.

  The clerks seemed to be a surprisingly happy bunch, considering that every time their phone rang it was a call about someone being dead. At the time, the procedure required the clerks to write up the “Telephone Notice of Death” on multi-sheet carbon-paper forms—it would be years before computers entered the building. They recorded basic demographic information about the dead person and preliminary information about the case, such as the address where the body was found, who found the body, and who reported the death. A case number was issued and the case was assigned to an MLI.

  The investigators served as the gatekeepers for the agency, performing a sort of triage, and just because a case had been written up by the communications unit did not mean there would have to be an autopsy, or even a lengthy investigation. I quickly learned that the MLIs separated the incoming cases into two main categories: hospital deaths and scene deaths. We dealt with each category in a different manner. Hospital deaths were almost always investigated entirely by telephone. The investigator would conduct one or more phone interviews with the reporting physician, who would present the case to the investigator. After the presentation, the investigator would then decide whether the body would require an autopsy or could be released. However, scene deaths (occurring outside of a hospital), which
were usually reported by a cop calling from the incident location, often required an on-the-scene investigation, and the MLI assigned to these cases would spend most of the day out in the field.

  In a small room adjacent to the communications unit was an office whose beat-up metal furniture looked as if it had been there since the 1950s. It was in this tiny room, the MLI office, that I learned how to do triage, to differentiate a case that needed to come in (an ME case) from a case we could investigate briefly and release (a No-Case), and from those we could decline to investigate at all (a Nonreportable). Wherever the body was, I learned the steps to take and the questions to ask of the reporting caller, using the caller’s information to quickly discern the need for further investigation.

  Society likes to group together similar things, to affix nice convenient labels so we can identify units as belonging to the same set. It’s no different in death. Here society has developed a mechanism of grouping the many different causes of death into just a few categories subsumed under the title “manner of death.” Such a grouping is needed because while there are many causes of death (countless, in fact) in New York we have decided that there are only six manners of death—six boxes into which all the various causes must be lumped.

  There’s a great deal of difference between cause and manner. In forensic terminology, the cause of death is the actual disease or trauma that took the person’s life, while the manner of death refers to the circumstances by which the cause arose. In New York City, these circumstances are lumped into six manners of death categories: homicide, suicide, accident, therapeutic complication, natural, and undetermined. For example, if John is shot in the head, the cause of death is the gunshot wound to the head—any six-year-old child who has watched enough television is going to be able to make the correct diagnosis for that cause. The manner of death, however, is not so easily ascertainable. If someone shot John deliberately, the manner could be homicide. If John shot himself, the cause would remain the same, but the manner would now be suicide. If John had been cleaning his gun and inadvertently discharged the weapon into his head, the cause of death would still be the same, but the manner would be decreed an accident. If we couldn’t figure out how John’s gunshot was sustained, the cause of course remains the same, while the manner of death would be classified as undetermined. John’s gunshot could not have arisen by therapeutic complication or natural manner, but it could have been by any one of the other four manners.

  The key to doing triage with our incoming cases was learning to plug them into one of these six categories. Whether it was a scene investigation or an over-the-phone interview with a physician about a hospital death, the MLIs would first attempt to ascertain the cause and manner of death. Once we gathered as much information as possible, a disposition would be made. In the case of our friend John, because of the violence and the possibility of foul play, it would be ruled an ME case, meaning that his body would have to be brought in.

  These tasks come right out of the city regulations. Section 557 of the charter of the city of New York states: “There shall be a medical examiner’s office and it shall investigate all deaths of persons in the city of New York occurring from criminal violence, by causality by suicide, suddenly when in apparent health or in any unusual or suspicious manner.” Additional rules governing what we do and delineating our areas of responsibilities are in the city’s administrative code, Section 17-202, and in its health code, all of which empower us to conduct independent examinations of deaths that occur in New York City and fall within our jurisdiction. Independent means, for example, that we don’t work for or answer to the police; we just do our job and come up with an independent finding that includes a precise identification of the decedent and our opinion on the cause and manner of the death.

  We investigate, sometimes we autopsy, and in all cases, we write up a report that presents the OCME’s best guess as to the cause and manner of death. Yes, essentially we guess, because when the ME’s office issues a death certificate all we are doing is rendering our opinion based on the facts available to us at the time. Should important facts come up later, we reserve the right to alter our opinion and want to be on record in a way that allows for that possibility.

  For the same reason, our records, meticulously kept by a staff of twenty, are held by law in perpetuity. Technically speaking, no case in our office is ever officially closed. During my early months at the ME’s office, I enjoyed browsing through some of the really old record books, dating back to the early twentieth century. The causes of death listed therein seemed almost quaint. I read about people dying of the vapors and apoplexy, asphyxiating from exposure to illuminating gas or being trampled by horses. The records show that there certainly was a great deal of consumption going around back then.

  It takes a staff of twenty to run the medical records unit because that unit also includes a very busy correspondence section. While our reports are not generally available to the public and not fully subject to Freedom of Information Act requests, they are available to certain individuals and institutions. The district attorney’s office automatically gets a copy of every homicide file, and also may request a record if it is bringing or considering bringing a criminal case. A record is also available to the family of the decedent upon request as well as to the referring hospital, if the death occurred in that hospital. Should a criminal case be brought, a record would also be available to the defendant’s attorneys, though, in that instance, only by subpoena. We also get hundreds of letters from prisoners demanding to see our records on their victims for their court appeals; we often must comply with those requests.

  We need twenty people in the medical records unit for the same reason that we need forty MEs: New York City is filled with people, a certain percentage of whom die every day. By comparison, the Massachusetts ME’s office has only five examiners to cover the whole state. Our office is unique not only in size but also in the way we divide the labor. Although OCME has about an equal number of MEs and MLIs, the former almost never go to a death scene, other than for training purposes. We MLIs handle all the investigations and all the death scenes. Unlike most forensic jurisdictions, our office is also a center of medical education, doubling as the Department of Forensic Medicine of New York University’s medical school; Dr. Hirsch serves as chairman of that department. Through that NYU affiliation, our office graduates four board-eligible forensic pathologists a year.

  Under Dr. Hirsch’s administration, the OCME has become, in my opinion, the best medical examiner’s office in the country. One of the reasons for this success is that it employs PAs as MLIs, who serve as its eyes, ears, and first examiners of bodies and death scenes.

  On the whole, our office is a dynamic place, with scores of visiting physicians, aspiring MEs, medical and PA students, and paramedics rotating through for training each year. The turnover among MLIs is small but noticeable, today amounting to 5 percent every two years. But in the early 1990s, when I began, the loss rate was higher because the MLI corps had not been in existence very long and some PAs were picked for it who either decided after a while that they didn’t really like the work, or who in the eyes of the supervisors weren’t up to snuff.

  The arc of training for an MLI-I can be best understood as a progressive role reversal. At the outset, the supervisor does most of the investigating and the trainee observes; by the end of a year of training, those positions are reversed, and the trainee does the bulk of the investigating while the training officer observes. In between those two points, the shift of responsibility is gradual and less readily categorized. As in all such shifts of responsibility, the trainee learns by doing, which means that he or she learns, in part, by making mistakes.

  I certainly made my share.

  As a trainee, I once entered a death scene in which a young woman lay on a bed, in the fetal position, with her hands together, positioned as a cushion for her head—the classic sleeping position, as you might pantomime it for a friend. There was dried blood across her
wrists and pooled beneath her hands. The uniformed cop on duty and the detectives were speaking of her death as a suicide, and I quickly decided that they were correct: the decedent must have slit her wrists.

  My supervisor leaned in toward the body, put on a thin pair of latex gloves, and through the glove, with his fingernail, scraped away the blood from one of the wrists. It came off readily, and underneath it there was no wound. “Shiya, it’s pulmonary edema,” he said to me of the dried bloody fluid, and traced it back from whence it had come: her nose. The blood was a flux that had emerged during her last moments and had then coursed down the face and over her hands and wrists. In a person as young as this decedent was, that finding almost always means just one thing: drugs. We searched the rest of the apartment, and soon enough found the drug paraphernalia that we were certain had to have been there. Later we made the determination that her death was due to an accidental overdose of heroin.

  I learned several lessons from this mistake. First, I must not yield to the drumbeat of what others in the room were telling me about the death; rather, I must conduct my own investigation and do so with an open mind. Second, when there was blood evidence, I must go beneath the surface appearance to determine its source. The third lesson was less obvious: I needed to formulate a style of investigation in which I did not go near the body until after having thoroughly searched the periphery—had I followed that philosophy in this case, I would have seen the drug paraphernalia first, and would therefore not have made an easily refuted guess about the cause of death.