Working Stiff

by Judy Melinek, Md

  I was happy for the first time in nearly a year—but scared too. I had learned only what kind of doctor I did not want to be, and was convinced no hospital would take me as a new resident in any specialty now that I was damaged goods. The happiest I’d been in medical school was during the pathology rotation. The science was fascinating, the cases engaging, and the doctors seemed to have stable lives. The director of the pathology residency program at UCLA had tried to recruit me during my last year of medical school. “No, no,” I had told her back in the day, driven and cocksure. “I’m going to be a surgeon.”

  More than a year later, I called her to ask if she knew of any pathology jobs, anywhere, for a failed surgery resident.

  “Can you start here in July?” she asked.

  “What do you mean?”

  “Judy, I’ll keep a pathology residency position for you right here at UCLA if you’ll start in July.”

  Even more shocking was T.J.’s enthusiasm for the idea. “You’ll be leaving your family behind again,” I pointed out.

  “Doctor,” my fiancé replied, “I’ve followed you to hell and back. I’ll follow you to Los Angeles.”

  2

  They’ll Still Be Dead Tomorrow

  It’s no big deal if you don’t have a birth certificate. Other forms of identification will suffice to secure a job, open a bank account, even file for Social Security. However, if your survivors cannot produce a death certificate after your demise, they will descend into bureaucratic purgatory. They can’t bury your body, transport it across state lines, liquidate your investments, or inherit anything you have willed them. That death certificate comes from a forensic pathologist.

  Pathologists study the causes and effects of human disease and injury: all sorts of disease, all manner of injury, in every part of the human body. As a resident physician in pathology at UCLA, I spent four years studying what every single cell, tissue, and structure in the body looks like. On top of that, I learned what all the things that go wrong look like, and how to tell them apart.

  A forensic pathologist is a specialist in this branch of medicine who investigates sudden, unexpected, or violent deaths by visiting the scene, reviewing medical records, and performing an autopsy—all while collecting evidence that might be used in court. Like a clinical pathologist, she has to recognize what everything in the body looks like, but the forensic pathologist also has to understand how it all works. She has to know how all the things that go wrong with the body can kill you, and all the ways that trying to fix those things might also kill you. The forensic pathologist is the medical profession’s eyewitness to death—answering all the questions, settling all the arguments, revealing all the mysteries contained in the human vessel. “One day too late,” my clinician friends like to joke.

  Forensic pathologists work for either a medical examiner’s office or a coroner. The latter is an administrator or law enforcement official (often the sheriff) who investigates untimely deaths in his or her jurisdiction. The coroner hires doctors to perform autopsies, but these doctors usually don’t play an active role in the investigation beyond their work in the morgue. A medical examiner is a physician trained specifically in death investigation and autopsy pathology, who performs both the prosection (Latin for “cutting apart”) and all other aspects of the official inquiry. The ME is always a doctor and often trains other doctors as well, in a one-year fellowship program that follows four years of residency training in hospital pathology.

  I ended up training at the New York City Office of Chief Medical Examiner because I wanted to escape a mandatory monthlong forensics rotation at the Los Angeles County Coroner’s notoriously grim office. “They only give you decomps and car accidents,” I had heard fellow residents complain.

  “What do you expect? That’s what they’ve got over there,” the UCLA chief resident pointed out. I always enjoyed stopping by this doctor’s desk because he had a passion for forensics, and the academic journals he collected featured articles like “Heroin Fatality Due to Penile Injection,” and “Sudden Death After a Cold Drink.” Compared to those titles, “Apoptosis in Nontumorous and Neoplastic Human Pituitaries: Expression of the Bcl-2 Family of Proteins” didn’t stand a chance of holding my attention. Wouldn’t you rather read “Suicide by Pipe Bomb: A Case Report”? I would—and I did.

  “If you really want to learn forensic pathology, do a rotation at the New York OCME,” my chief resident advised. “All kinds of great ways to die there, and the teaching is brilliant. That’s where I did my FP rotation, and I loved it.”

  “Move to New York for a month?”

  “Why not?”

  T.J., to my surprise, said the same thing when I proposed the idea to him. I was pregnant with our first child, and he had decided for both financial and family reasons to become a full-time stay-at-home dad. This liberated us to move wherever we wanted, whenever we needed to, without struggling to reconcile our career goals. “Babies are portable,” he pointed out.

  So in September 1999, six months before Danny was born, we flew out to New York, and I took up a visiting rotation at the Office of Chief Medical Examiner. By the end of that monthlong assignment, I had decided that forensic pathology was the career for me—and that the New York OCME was the place to pursue it. I enjoyed the intellectual rigor and scientific challenge of death investigation. Everyone there, from new students to the most senior doctors, seemed happy, eager to learn, and professionally challenged. None of the medical examiners had cots in their offices. “There are no emergency autopsies,” another resident pointed out to me. “Your patients never complain. They don’t page you during dinner. And they’ll still be dead tomorrow.”

  I completed the application for the full one-year fellowship at the New York office as soon as we returned to L.A. Four months later, while I was on maternity leave, I got a call from Dr. Charles Hirsch, chief medical examiner for the City of New York, offering me a position as an assistant medical examiner starting in July 2001.

  * * *

  My first day on the job, I woke before dawn in our Bronx apartment. T.J. snored softly on one side of me and Danny, by then sixteen months old, echoed his dad from a bassinet on the other. I listened to the traffic heading for Manhattan just beyond the window and reverted to an old vice, biting my nails as I worried whether I had made another life-altering wrong turn—this time with a husband and child in tow.

  I left the apartment early, wanting to give myself plenty of time for the commute to Grand Central Station from Spuyten Duyvil, where the Henry Hudson Bridge arches out of the Bronx to plunge into the green mound of Inwood Hill. At Grand Central I descended with the crowd to the Lexington Avenue subway and emerged at 28th Street, growing more nervous as I walked east into the summer sun. A few blocks, I came to a corner, and there it was: 520 First Avenue.

  My new place of work was a soot-streaked blue cube trimmed in dingy aluminum and crowned with a naked boiler, its fiberglass insulation flapping in the wind. The front door hid in the shadows, behind a web of rickety scaffolding with great chinks showing half-painted, rusty bars between uneven boards. This squat eyesore was the Office of Chief Medical Examiner of the City of New York.

  The security guard looked up when I entered the lobby. High-relief stainless steel letters on the wall above her read, TACEANT COLLOQUIA. EFFUGIAT RISUS. HIC LOCUS EST UBI MORS GAUDET SUCCURRERE VITAE. I stared at the words. “Can I help you?” the guard asked, and when I told her my name, her face lit up. “The new pathology fellow? Welcome aboard, Doc!”

  Something in me had frozen. Two weeks before, I had been living the good life in Los Angeles. I had finished my formal medical training and was a full-fledged physician. I could’ve taken a nice mellow laboratory job anywhere in the country and sat behind a microscope all day looking at slides, making diagnoses on paper. Instead, I had uprooted our family to the unforgiving city where I grew up, a harsh place that held bad memories. And for what, exactly?

  The security guard’s expression softened
; it was clear she had greeted a lot of stunned people walking into that building. She glanced back at the polished silver motto and said, “‘Let conversation cease. Let laughter flee. This is the place where Death delights to help the living.’”

  The two of us stood alone in the cool, quiet lobby. “Oh,” I said at last.

  “Welcome to the OCME, Dr. Melinek.” The guard held out a sticker that read, VISITOR.

  * * *

  Dr. Mark Flomenbaum was the deputy chief medical examiner, Dr. Charles Hirsch’s right-hand man and my immediate supervisor—so I was surprised when he greeted me with a hug. Six foot two, with a long, gentle face, round glasses, and immense hands, Flome was famous around the office as a karate champion who broke boards for fun. He introduced me to the MLIs and the Identification staff on the first floor, then showed me upstairs to the office, right across from his own, that I would share with the two other fellows in forensic pathology for the year.

  Dr. Stuart Graham was already settling in. Stuart had spent fifteen years in private practice running a clinical pathology lab in Florida until he decided to branch out. “I mostly sat at the microscope or reviewed charts in the blood bank. I don’t think I performed more than one autopsy a month for over a decade.”

  “We’ll fix that,” Flome said cheerfully.

  Stuart had a bone-dry sense of humor, a sliver of a drawl, and a fondness for bow ties. He and I were destined to share adjoining desks in the fellows’ room, our swivel chairs butting against each other. The office held a third desk behind a cubicle divider, for Dr. Doug Freeman, a lanky man with long legs and a slow stride, and wavy blond hair tied in a ponytail. He seemed like a genuinely nice guy of the midwestern mold. Flome explained that Stuart, Doug, and I would spend that first week of July going through administrative processing, which involved fingerprints, a physical examination, and a pile of red-tape paperwork. When that was done, we would each be issued a badge—an ornate shield set in a heavy leather wallet. He looked at his watch. “Okay. It’s time for morning Hirsch rounds. Let’s go down to the Pit.”

  Nobody seemed to know who had dubbed the autopsy suite the Pit. It isn’t a pit. It is, in fact, a remarkably neat and tidy place. Eight parallel stainless steel autopsy tables—ample, well-scrubbed, and shiny work surfaces with raised edges like a ship’s gunwales—line one wall of the long room. A high-powered dishwashing sprayer hangs behind each table, and metal slats support the body, allowing blood and fluids to drain into a shallow catch basin underneath. This leads directly to a biohazard sink—and if the case is a homicide, its drain remains plugged until absolutely all bullets, knife points, and other foreign objects have been accounted for. I was informed that hapless junior medical examiners have had to take apart the drains after they inadvertently flushed a piece of evidence.

  Suspended over the foot of the autopsy table is a scale with a metric dial face, for weighing organs. A big drum of formalin, the 10 percent formaldehyde solution that is the catch-all preservative for human tissue, rests in a corner. Against another wall, a soft whir comes from behind the glass doors of the curing cabinets. Inside these, on hangers, blood-soaked garments drip—homicide evidence drying out for laboratory tests, or for trial.

  Autopsy is morning work. Dr. Flomenbaum advised me and Stuart and Doug to be gowned up and standing at our assigned tables in the Pit by eight o’clock. That would ensure us enough time to finish an external examination of the day’s first case before the boss appeared.

  Dr. Charles Seymour Hirsch made morning rounds surrounded by MLIs and medical students at nine thirty sharp. A pipe-smoking, avuncular doctor right out of a Norman Rockwell painting, Hirsch always arrived wearing slacks, a tie, and suspenders, his keen eyes standing out over a surgical mask. Each morning we would deliver a summary of our cases to him while he scrutinized the X-rays and our findings from external examination. You had to have something to say about each case, but shouldn’t venture anything you weren’t prepared to back up on the spot. Morning Hirsch rounds could be the most nerve-racking part of the day.

  Dr. Hirsch set a tone of quiet dignity in the autopsy suite, and the rest of us emulated it. He showed a fondness for epigrams we called “Hirschisms”—and like any teacher he had his pet peeves. It didn’t take us long to learn them. He hated the phrase “consistent with” if the finding was, in fact, perfectly obvious, and gritted his teeth if we described anything as “massive” or “mild”—marked and slight are more specific. When presenting a case to Dr. Charles Hirsch, you had to refer to the decedent as a man, woman, boy, or girl—not as a male or a female. During our first week doing cases, Stuart presented the body of a man who had been “shot by a lady—”

  “Shot by a woman,” Hirsch interrupted to correct him. “Ladies don’t shoot people.”

  Morning rounds in the autopsy suite were brief; our opportunity for follow-up came every afternoon at three o’clock rounds, when all the medical examiners got together in a conference room to discuss (and sometimes debate) the day’s cases. Dr. Hirsch could take the most jumbled, messy case history and find a way to simplify it for the death certificate. “We are not trying to be all-inclusive when we write the DC,” he stressed, “just concise and accurate.”

  For the first two months of our training, Dr. Hirsch also led a separate teaching session with the fellows, offering detailed feedback about our diagnoses and early autopsy reports. He taught the three of us that the medical examiner’s most solemn duty was to make two distinct determinations for the death certificate: the cause of death, and the manner of death. “The cause of death is the etiologically specific disease or injury which starts the lethal sequence of events without sufficient intervening cause,” Hirsch recited. “Write that down and commit it to memory. Think of it as the answer to the ‘what’ question—what is the one thing that began the chain of events ending in death. The manner of death is a medicolegal classification of the circumstances—the answer to the ‘how’ question. We group all deaths into six categories: homicide, suicide, accident, natural disease, therapeutic complication, and undetermined.” We would come to learn that the manner of death affects a whole range of institutions—from insurance companies to the district attorney, from the police department’s Homicide Division to the landlord of the deceased. As one of the Identification staff put it during my first week on the job, “Maybe nobody cares about you when you’re alive, but lots of people take an interest once you’re dead.”

  Before I was assigned my first postmortem investigation as an assistant medical examiner, I spent a week in the morgue observing while the senior MEs cut their cases. Dr. Susan Ely guided me through the first day. She was a slight, attractive woman with a daughter the same age as my son, so we bonded and commiserated while changing into scrubs and netting our hair in the locker room. I replaced my glasses with plastic prescription racquetball goggles, which Susan thought were hilarious. I told her I had the same opinion of her disco-vintage platform shoes. “They bring me up to autopsy table height,” she half joked.

  In the Pit, I alternated between her table and Flome’s, observing how two different doctors approached the task of performing the last and most thorough physical exam you will ever have. An autopsy is not the same as the cadaver dissection I had done in medical school gross-anatomy class. “Autopsy” means “see for yourself,” and it has more to do with figuring out what went wrong in the body than with exploring the anatomy.

  An autopsy can take anywhere from forty-five minutes to over four hours, beginning with a thorough external examination and proceeding from the outside in. I learned to document every piece of clothing and every item of jewelry on the body—not excluding pieces of precious metal studded into unlikely flaps of the human anatomy. If you knew how much hardware some of your fellow citizens are toting around in their knickers, you might see the world as a stranger and funnier place.

  Since the body and everything on it is my responsibility, I often have to reach into a dead man’s pocket and pull out what
ever might be there—and people who meet with violent deaths are often engaged in some aspect of the underground cash economy. I once collected $12,400 in hundred-dollar bills off a body. I know the exact amount because I counted it very, very carefully—twice. Whenever I found any cash, I would make a point of showing it to the technician, and if no tech was working with me at that moment, I would hold the money up in the air and announce to everyone in the autopsy suite, “I have a wad of cash here!” People working for medical examiners have lost their jobs for stealing money off the dead, so it is standard practice for us to announce, loudly and in public, the discovery of hard currency.

  Once the body has been reduced to its natural state, I examine it closely for signs of injury, and document all findings. To a trained eye, bruises, scrapes, cuts, and penetrating wounds can tell a story. If the body is in rigor mortis, I will pry its fingers open to see if there is anything grasped in the palm of the hand. I’ve found the hair of murderers in the clutch of their victims this way. Suicides by poisoning sometimes still have the pill bottle in their death grip, and drug abusers who overdosed may have the needle dangling from an arm.

  “In addition to trauma, we document tattoos, scars, unusual physical features, circumcision, amputation, and birthmarks,” Dr. Flomenbaum taught me over the autopsy table. The families of the deceased take the written description in the autopsy report very seriously, and if there is any inaccuracy—if I missed a single old scar—the validity of the entire death investigation may be cast into doubt. Dr. Barbara Sampson, who also trained me in my first New York autopsies, cautioned that seemingly trivial physical characteristics might be important to the family. Tattoos, for instance. I learned this lesson the hard way after receiving a piqued phone call from the girlfriend, named Vera, of a dead shooting victim. In my report I had written that he had “Nera” tattooed on his upper chest. I’d also failed to note a scar on his face. Vera thought I had autopsied the wrong guy.