Dead Center

by Shiya Ribowsky

  Had the doctor known how to properly make out the death certificate, she might have gotten away with this fraud. But as with most of the physicians with whom I interacted, she had no idea how to actually write up a cause of death, fill out a death certificate, or even properly make the diagnosis of death. Now I am not talking about verifying that the decedent is in fact no longer among the living; even the greenest intern is able to recognize a flatline on an EKG machine. I am talking about the diagnosis, that is to say, the circumstances and cause that led to the person’s death. The ability to make this “final diagnosis” is something that is not taught in medical school, a lapse probably attributable to the same mentality of “fight death at all costs.” The result of this omission is that hundreds of doctors call OCME each year and say, as though they had not been through four years of medical school, “Okay, my patient is dead—what do I do now?”

  Officially the OCME takes reports on about twenty-four thousand out of the approximately seventy thousand people who die each year in the city. Unofficially, our office handles many more deaths than it reports in the informal conversations we call “consults.” The agency doesn’t keep accurate statistics on just how many consults are done, but during the time that I ran the communications and identification units, I estimated that our MLIs handled consults on an additional twenty thousand deaths a year. I estimate that almost half the cases called into OCME did not have to be reported because they were natural and expected.

  By the end of my first month as a trainee MLI, I knew more about hospital deaths and the reporting of them than did most of the doctors on the other end of the telephone calls. Which was why, when a doctor called to report a death, my first task was always to figure out whether the doctor was calling because the case was reportable or because he or she had no idea what to do. Experienced MLIs develop a sixth sense that enables us to divine why a doctor is calling, and a method of guiding practitioners through the call. I learned to ask questions in a sequence that quickly cut to the chase, such as, “Why did the patient come to the hospital?” It was necessary for me to take control of these conversations because if a clinician were left to ramble, they would tell me in painful detail about every aspect of the patient’s health leading up the death. Their inability to get to the point was not entirely their fault because after a patient has been around a hospital for month or so, the clinician who has been treating that patient tends to forget the initial reason for the patient’s admission. Moreover because of the regular rotation of the hospital’s house staff, the physician who is reporting the death to me may only have treated the decedent for a few days or even a few hours before the death.

  Many of these phone calls from confused physicians included the doctor saying such silly things as, “the patient died of cardiopulmonary arrest.” After hearing this, I would always say, “Okay, the patient’s heart and lungs stopped functioning, but what caused the cardiopulmonary arrest? Was he shot in the head with a bazooka?” Here my deliberately fantastical illustration would generally cause the physicians to laugh and immediately recognize that what I was searching for was an underlying cause for the CPA. The physician would then tell me about the specific underlying disease or trauma that caused the death so that together we could make a decision about whether the death was natural or whether it was an ME case.

  The sheer volume of such interactions led me to start teaching incoming house staff at the orientations held each year by local hospitals. Unfortunately I was an army of one in the service of this cause, since OCME itself seemed not very interested in this type of “missionary” educational work. Don’t get me wrong: no one at the agency prevented me from going out and giving these lectures, but at the same time, no other MLIs joined me in the task, nor were they encouraged to do so from above.

  Ultimately, a physician’s inability to make a final diagnosis doesn’t affect only how many phone calls MLIs must field. Teaching physicians how to make an accurate diagnosis of death and how to properly reflect that diagnosis on a death certificate provides crucial information on many matters that involve public health. This is not simply an issue for medical and death industry professionals—it affects the general public, and quite directly.

  Frequently, a newscaster or an interviewee on a television news program (or in print) will say that so many tens of thousands of people died last year in the United States from breast cancer or that lung cancer is now killing more women than breast cancer. Those statistics come from death certificates.

  The fact that so many death certificates are not filled out properly has repercussions beyond any individual certificate. It throws a shadow of doubt over such statements as “the number one cause of death in the United States is atherosclerotic heart disease (ASHD).” The reason that ASHD is the “leading cause” is not that we eat too much fast food, though of course we do. Rather, the reason is that doctors put ASHD down on death certificates more often than they put down any other cause of death—and not always because it is the actual cause. In dealing with thousands of doctors over the years, I came to understand that they very quickly learn that ASHD is a good diagnosis to put down on a death certificate because it won’t raise red flags with the local ME or coroner’s office. Red flags mean the doctors will be bothered with having to resubmit the death certificate with corrections for as many times as it takes them before they get it accepted as correct.

  Why bother trying to accurately describe the death as caused by pneumonia, if that diagnosis is guaranteed to generate at least two or three calls to you for more specific information? The person at the ME’s office or the coroner’s office will ask, “What type of pneumonia, bacterial or viral?” “Left lung or right?” “Was there underlying weakness in the lungs?” To avoid these questions, all across the United States senior medical residents are teaching junior residents a dirty little secret: put down ASHD on the “cause of death” line and those pesky people at the ME’s office won’t annoy you and the case will go away.

  While autopsies would find the exact cause of death, each year in this country, less than 10 percent of deaths are autopsied, according to the latest annual Vital Statistics summary published by the United States Department of Health and Human Services. That means that 90 percent of the time the cause of death listed on death certificates is either some clinician’s best guess, or worse, a diagnosis of convenience. This is a problem for the general public because vital statistics are only vital if they are accurate. The causes of death from each and every death certificate issued in the United States are compiled yearly. The data in the certificates are taken as gospel and are used by the Centers for Disease Control (CDC), the National Institutes of Health (NIH), the federal Department of Health and Human Services, and a host of other organizations as the basis for, among other things, tracking treatments and doling out research dollars. How can those institutions legitimately use this data as the basis of their calculations if for one reason or another the data is tainted?

  This is a national disgrace and a dangerous one, but, fortunately, it’s not hard to fix. I suggest that we begin at the medical school level, teaching students the importance of vital statistics and how to properly diagnose and report a death.

  Not only are these more accurate diagnoses of death better for public health and medical legal jurisprudence, but they’re also useful in advancing clinical medicine as well—which is something that we have witnessed in recent years with the epidemic of what is known as SIDS. To help clinicians diagnose and prevent this terrible killer of babies, MLIs in New York fill out a twenty-four-page questionnaire regarding each SIDS death scene—and we do it right in the place where the baby died, with the grieving parents. This is an awful process for the parents and for the MLIs, but we do it and help the parents through it, because of the great potential value of the information being collected. From such interview questionnaires and the information they contain, clinicians have been able to advise parents how to position their infants while they sleep to reduce t
he risk of SIDS—babies should sleep on their backs. Another such recommendation for parents emerging from the information gathered is that using a pacifier may lower their babies’ risk of SIDS by an even larger margin than having them sleep on their backs.

  One reason I had been bold enough to try to teach doctors about reporting deaths was that teaching in-house was a large part of my job as a supervising MLI. I trained recruits to OCME—MLIs, MEs, and other professionals. Often, as luck would have it, this training involved some unforgettable death scenes.

  While I was training a young female medical student, we were called to a wooded area (one of the few in Manhattan), in the Dyckman area. It was a greensward used for walking dogs and for other, less innocent purposes. A dog walker had come upon an abandoned van, sitting on its axles, with weeds and grass growing up into it. The man’s dog had smelled something inside, and had drawn him near to the van. Inside, he had glimpsed a body and had called 911.

  My trainee and I went into the van, and indeed found a body in an advanced state of decomposition. It was necessary to take it outside to examine it, so I said to her, “I’ll take the legs, you take the arms, and we’ll carry it out.”

  We both pulled, the body started to move—and the head came off, rolling across her foot, and around the floor of the van. The student screamed—a very loud and anguished scream—and ran outside. The cop on duty burst in, revolver drawn, ready to rescue us both from an unseen assailant.

  Outside, and trying not to laugh, I attempted to get the trainee to calm down.

  She couldn’t. She ran to the edge of the area, stamped her feet up and down like a little girl and shouted, “That’s the most disgusting thing that’s ever happened to me!”

  I laughed and laughed, and couldn’t stop laughing even in the car on the way back to the office. I did, however, manage to stop laughing long enough to order that the body be brought to OCME for an autopsy. I believed that the decedent had been a derelict who had lived inside the abandoned van and died there of natural causes, rather than having been the victim of foul play, but only an autopsy could confirm this hypothesis.

  The next day, I was out in the field when I received a call from one of our MEs, a man with a pronounced British accent. “That body you found at Dyckman yesterday,” he began, “Had it a head?” (It wasn’t that silly of a question. On other occasions, we’ve found bodies that had been decapitated to prevent identification.)

  “Yes, it had a head,” I responded. “Maybe it’s in the morgue fridge on the floor.” A search of the premises revealed no body-less head floating about. Since the head from the van had evidently not arrived at OCME with the body, I telephoned the county morgue supervisor whose employees transport bodies for OCME and asked him to inquire about the lapse with the driver of that particular run.

  The results of his inquiry came back as follows: “Duh, you told us to pick up the body, but you didn’t mention the head, so we left it there.”

  “Go back and finish the job. Pick up the head and bring it in. Please.”

  The medical student, after this unforgettable initiation, conquered her disgust, and went on to become a pathologist and to work for OCME. She is now one of the top MEs in the Bronx office.

  Another doctor who worked his first field case with me is Mark Flomenbaum. Mark came to OCME in the early 1990s, already a board-certified pathologist who had completed his residency, and with it, a four week stint at an ME’s office, but he had never been out in the field. Early in his forensic training at OCME, he was assigned to me, and the call we caught first was to a residential hotel on the Upper West Side. It was one step above a flophouse, but it was a small step. A woman had been found dead in a very small room, wedged underneath a wooden cot. As we entered the scene, we were told this was a homicide, but the body had not been discovered for some time and was quite decomposed. The room was so tiny that in order to examine the victim, I had to stand the cot up on its end, against the wall. The space was not large enough to properly accommodate the curious Mark and me, so I asked him to move aside. I examined the body and narrated to him what I was doing and what I was finding. Having confirmed that this was a homicide, which meant that the body would need to be brought in and autopsied, I stood up and prepared to go. Mark moved away from the wall; but he had not been leaning against the wall itself; rather, he had been leaning against the underside of the upended bed, and as he came off it, you could hear his coat peel wetly away. His clothes dripped with, and reeked of, the decomposition fluids. He stunk so badly that we threatened to refuse to have him ride back to OCME in the car with us. We eventually relented, but during the ride back to the office, we tortured him for his odoriferous condition. Despite this rather rude introduction, Mark and I became friends; he finished his training, became an ME for New York, and worked for many years for OCME.

  Amy Mundorff, our anthropologist, had similarly been working for OCME for a while, inside the offices, before going out on her first field trip with me. It, too, was rather unusual. In response to a call, we arrived at a brownstone in Greenwich Village to find two uniformed officers, veterans, standing outside and giggling.

  “What’s so funny?” I asked.

  They told me. They had responded to a call about a very bad odor coming from a ground-floor apartment in the back. They had a rookie with them, a very green rookie, and when the apartment could not be entered from the front, they sent him around to the back to go in through a window. The rookie went to the back, broke the window, which was rather high, and stepped inside the apartment. But his first step was onto a glass coffee table, which shattered under his weight. Off balance, his second step landed his foot smack in the abdomen of the deceased man—a very squishy abdomen, since the man had been dead for some time and was a decomposed mess. The rookie’s foot went deep into that abdomen. He was so horrified and grossed out that he ran out the front door of the apartment, putrefaction fluids flinging off his foot. He ran past the veterans, down the street and out of sight, and had not been seen since. An hour later, the veterans were still giggling. “He’ll come back eventually,” they guessed. I wasn’t so certain.

  Amy and I entered the apartment and looked around. Because of the shattered glass, the bloody footprints, and so on, it looked for all the world as though it could have been the scene of a push-in robbery during which the robber had killed the apartment resident. Had we not known of the rookie’s adventures in breaking in—and out—I might have been tempted to guess that this had been a homicide instead of what it was, a natural death, with some pretty significant “postmortem artifact” (a fancy way of saying the cop really messed up the scene).

  Amy’s only comment on the scene was, “What you do is disgusting. Bones are much cleaner.”

  That was before she realized that the bones brought into OCME for identification often contained soft tissues along with them—sometimes, very soft.

  A while later, I smelled a rather awful odor emanating from Amy’s office at OCME and wandered in. A very large pot was boiling on a portable stove, and in it there was a head; she was boiling it to finish denuding it of flesh. I wrinkled my nose and made some comment about how wretched this was.

  “Care for some soup?” she needled.

  Because I did so well in training people, I became for a time the de facto MLI training officer of OCME. It was a good fit. I was the supervising MLI for Manhattan, and all our incoming MLIs would attend courses at headquarters and go out to death scenes in Manhattan, so they were in my bailiwick anyway. I enjoyed training people. Many incoming MLIs and MEs had been clinicians, and I construed their overarching task as learning to think in forensics terms. What’s the difference? A clinician thinks about distal events, about end results; a forensician thinks in terms of proximal events, the events that started the ball rolling—the first thing that happened. The clinician’s natural habitat is the emergency room, the hospital floor, or the like—a place where when a guy goes into cardiac arrest, that’s what they treat, watchi
ng the vital signs, giving drugs, and performing other interventions. If he gets well, terrific; if he dies, he’s no longer their problem. The clinician does not worry about what the person was doing at the time he began to die; the forensics expert does. For an average MLI or ME, completing the arc from thinking in clinical terms to thinking wholly in forensics terms takes about a year.

  In 1997, on the retirement of the previous director, I became director of identifications for OCME. Although this was a promotion of sorts, I received no raise in salary, continuing at the rate of a supervising MLI—the only difference was that now, I was a real manager. Previously, I had supervised the MLIs, but that was more of a collegial task; we MLIs treated each other as equals, even though some of us were more experienced than others. As director of identifications, I had to manage the communications unit and five identification units (one for each borough), all of which were staffed by clerks and other bureaucratic personnel. In hierarchical terms, I reported to the director of investigations, putting me on a track that would eventually lead me, I hoped, to achieve that position some day.

  I had been director of identifications for four years when the events of September 11, 2001, provided the OCME organization and me with the greatest challenge of my life, identifying the victims of the terrorist attacks.

  TEN

  BEFORE THE ATTACKS on the World Trade Center, the largest number of simultaneous fatalities the modern OCME had handled came from a mid-air collision over Queens in 1960, in which 134 people died, and from a fire at the Happy Land Social Club in 1990, in which 87 people died. In our disaster planning exercises before 9/11, we had envisioned events of that scale—and confronted a few, including the crash of US Air Flight 405, which slipped off an icy runway at LaGuardia Airport in March 1992, killing 28 passengers and crew members.