I apologized to Vera and offered to amend the autopsy report. When I pored over the identification photos later, though, I still couldn’t find the scar, even though the skin was still its natural color, mostly. It could be that the scar had been obscured in the furrow of his brow or under a five o’clock shadow. Maybe it stood out in Vera’s memory more vividly than it did on the body. Maybe it had some personal significance to her. Maybe she’d given it to him. Probably, though, Vera just didn’t trust me because I’d misread the name on her boyfriend’s chest.
“Never hurts to be careful,” counseled Dr. Monica Smiddy, another of the senior staff. Monica had a distinctive way of speaking, with a lilting and falling cadence in a muted Boston accent. She taught me to count everyone’s fingers and toes. If the dead man had lost the tip of a finger in a supermarket cart accident when he was eight years old, everyone in the family would expect that detail to be included in the autopsy report, even if it was totally irrelevant to the cause and manner of his death. Fail to note it, and the family won’t trust your conclusions. The same rule applied for the appendix—sometimes the presence or absence of a high-profile organ proves crucial in establishing the identity of the deceased. Dr. Smiddy instructed me to always take sample cuts of the testes in men and ovaries in women, “and always—always—count these organs. Some men have one, and some have prostheses, and believe me, the wife will notice what you write in the report. So be thorough and cover your bases. It pays to count to two.”
Day by day I practiced the rhythm of the medical examiner’s routine—autopsies all morning, then meetings and paperwork, interrupted and enlivened by occasional trips to crime scenes, or to the courthouse to testify. Though it would take weeks before the jitters settled and I became comfortable with my diagnostic skills, I was officially prepared to start working on my own. On July 6, 2001, after five days of watching other doctors perform autopsies, I did my first—and failed.
3
See for Yourself
Terrence Booker was a hospital case, a twenty-six-year-old with sickle-cell trait who had died on the inpatient floor of NYU Medical Center. Sickle-cell trait is the most common genetic aberration in the world, and almost everyone who carries it goes through life showing no symptoms. Some carriers of the trait, however, can develop sickle-cell anemia, a disease in which their normally disk-shaped red blood cells mutate into crescents and jam up their capillaries, impeding the flow of blood. Sickle-cell anemia is usually easy to diagnose because patients display a clinically characteristic set of symptoms, including fever, tachycardia (a racing pulse), and abdominal rigidity.
There is, though, one complication of sickle-cell anemia, vaso-occlusive pain crisis, which cannot be objectively evaluated. The blocked blood vessels cause ischemia: Tissues throughout the body starve of oxygen, resulting in acute, systemic pain. Ischemia can lead to fatal organ damage in a matter of minutes, so when a person with a history of sickle-cell anemia comes into a hospital with severe cramps all over, the medical staff take that complaint very seriously and start treatment right away. Treatment is straightforward enough—put an oxygen mask over the patient’s nose and mouth, hydrate him through an intravenous line, and administer an opioid analgesic painkiller, typically oxycodone or codeine. You know what else happens to be an opioid analgesic? Heroin.
Terrence Booker was a documented heroin addict who was probably malingering—faking a pain crisis to get drugs. Doctors have no way of knowing whether somebody’s lying about pain, really. You can’t fake a fever or tachycardia, but pain is purely subjective and there’s no test for it. When Booker showed up at the emergency room reporting that he “had sickle-cell” and was hurting all over, the ER staff had to treat him for a possible vaso-occlusive pain crisis. They admitted him as an inpatient and dosed him with the powerful clinical narcotic oxycodone.
In the middle of the night, Terrence slipped out of the hospital; he returned a couple of hours later, looking glassy-eyed and slurring his speech. A nurse found him unconscious, called a Code Blue, and the medical team rushed in with a crash cart. They put a breathing tube down his throat, started CPR, administered a drug to reverse the effects of opiates, and then sparked him up with a defibrillator. The Code Blue team succeeded in restarting Booker’s heart, but it was too late. He was brain-dead. His heart kept beating for another eight days. Then it stopped, and Terrence Booker’s corpse came to me.
My first postmortem investigation as a New York City assistant ME should have been simple. I started with an external examination of the body, removing the tangle of tubes Booker’s hospital caregivers had inserted into his veins and down his throat during their attempts to keep him alive. I documented all of them, along with the defects they left in the dead man’s skin, and then picked up a large-bore syringe to perform the first invasive step of the autopsy—inserting the needle into the side of each eyeball to aspirate a sample of the vitreous fluid. I watched through the eye’s open pupil as the tip of the needle came into sight. Dr. Flomenbaum had taught me that if I poked too far, the needle could hit the retina and cause what we call “postmortem artifact.” (I would later learn to abide, too, by Monica Smiddy’s “count to two” rule, when I pushed the needle into a cadaver’s eyeball and it popped out and clattered to the floor. Glass eyes are no longer made of glass; they’re made of plastic, and thankfully they don’t shatter.) Next I tried to take a sample of peripheral blood from the big vein behind Booker’s collarbone. I wasn’t able to get any, so I went instead to the femoral vein in his groin. I knew that once I opened the body up, all kinds of fluids were going to start moving with the pull of gravity, so it was important to get a needle sample of the closed circulatory system before making the first incision.
That first incision is the Y-cut. Using a scalpel, I sliced from the edge of each collarbone to the breastbone, pushing through the skin, fat, and muscle of the chest. Then I cut from this point all the way down the abdomen to the bone at the front of the pelvis. Once this was done I was able to open Terrence Booker’s chest like a book, filleting the connective tissue off the rib cage and peeling away the flesh of the belly to expose the peritoneum. The inside of the human torso is divided into five major cavities, which contain associated organ systems. The peritoneum is the largest of these and features the digestive tract. Behind it is the retroperitoneal space, home to the kidneys and a few other organs. Each lung is surrounded by a separate pleural cavity, and between these lies the pericardial sac—the heart’s own pocket. An autopsy generally tackles each of these enclosed spaces separately, since bodily fluids and blood may be contained in each without the others being affected.
I had been taught that in an ordinary autopsy like this one, without bullet holes or other obvious external complications, I should start with the peritoneum. I slit through the thin lining that surrounds the cavity to take a look. The presence of fluids of different colors (and odors) might point to liver or heart failure, infections, tumors, and various diseases—and I had seen during my training week that a laceration of the spleen or the aorta can leave half a gallon of blood in the peritoneum. Booker’s peritoneum didn’t have a lot going on. If a patient has a significant amount of liquid in the belly, I have to collect it for measurement using the stainless steel soup ladle I had bought at a housewares store on East 23rd Street. Many of the medical examiner’s tools are a good deal less shiny and exotic than the instruments our colleagues in hospitals use. T.J. was aghast the first time I dragged him on a tour of my workplace (on a slow afternoon, with no autopsies in progress), and he saw a long, age-worn butcher’s knife that looked exactly like a family heirloom his mother uses to carve roasts. Our staff keeps it saber-sharp for slicing organs. It works beautifully. One workstation has a set of kitchen knives in a wooden block. Hanging on a wall is a collection of hacksaws, and a pair of large spatulas.
“A hammer and chisel?” T.J. said in deepening horror. “What do you—no, don’t tell me.” Turning to my workstation, he pointed to a set of long-han
dled pruning shears, the kind used for cutting back tree branches. They were engraved with the name of a hardware store. “What are those for?”
“You don’t want to know,” I assured him.
But he insisted he did want to know, so I told him. “Snapping ribs.”
After examining Terrence Booker’s ribs to make sure there were no visible fractures, I clipped each one with those pruning shears and lifted off the whole breastplate, exposing the two pleural cavities and the pericardium. I knew that, as with the belly, it was important to note the color of any liquids in the cavities surrounding the lungs. Green fluid indicates infection, probably pneumonia. Clear fluid means heart failure. Blood—trauma. Booker’s lungs showed a little bit of the expected damage from spending a week under mechanical ventilation, but they were otherwise healthy—pink, spongy, and soft. A smoker’s lungs are bubbly, black, hardened lumps, exactly like those photographs used to scare middle school children away from cigarettes. The worst ones crunch when you handle them.
The heart is hidden behind the opaque pericardial sac, which I opened gingerly with my scalpel, looking for evidence of bleeding caused by trauma or a torn vessel. The week before, I had watched Flome autopsy a patient whose heart wall had ruptured in a massive cardiac arrest, blowing out like an overinflated inner tube and resulting in a tremendous mess inside the pericardial sac. There was no hemorrhage in Terrence Booker’s pericardium, and no sign of heart disease either.
Now that the major cavities were all open and cleared of fluids, it was time to remove the organs, one by one. While I did so, I took tissue samples. I keep a kitchen-variety plastic cutting board on the autopsy table, lined up with histology cassettes that I fill with the things I want to look at under the microscope—heart tissue, pieces of lung, liver, kidney, spleen, adrenal gland, and pancreas. I also took separate samples for the clear plastic stock jar that sits uncovered on the cutting board. This resembles a take-out soup container filled halfway with formalin, and serves as a sort of investigative insurance. Bits of tissue from each organ go into the preservative formaldehyde solution so that the case can be reexamined in the future, if the need arises. Each autopsy gets its own dedicated stock jar, which is sealed up and stored for about a year, or sometimes longer in unresolved cases.
I cut the left lung, right lung, and heart loose from their vascular moorings and slid them down to the cadaver’s feet, where there was plenty of room to examine and dissect them later. Some of the other MEs preferred to collect the organs on the side of the autopsy table, next to the body, but experience had taught me there is a danger of somebody’s lung ending up on the floor that way. Organs are slippery. Livers are the worst. Alcoholics, especially, have fatty livers. Those things are as slick as greased piglets and get bobbled all the time in the autopsy suite.
The entrails are one long piece. I reached down into the pelvis through the bottom of the Y-cut, and with a scalpel detached the bowel at the top of the rectum. I trimmed away the mesentery, a curtain of fatty tissue that anchors the intestine, and then fed it out by hand as a single rope, gathering the lower gut into a big metal mixing bowl. Once I severed the duodenum (the origin of the small intestine, just south of the stomach), the intestinal tract was out.
The liver is tethered by only three major vessels and a bunch of ligaments that attach it to the stomach and duodenum, so it’s easy to remove once the intestines are out of the way. When I lifted up Terrence Booker’s liver, I could see enlarged lymph nodes at the insertion point of the major blood vessels. This is a “soft sign” of drug use—an indicator but not proof. His spleen, right opposite the liver, looked perfectly normal; if it were bright red and mushy, he might have had a serious infection. I didn’t see any evidence of traumatic injury either—spleens are very delicate, full of tiny blood vessels and liable to rupture. Quite a number of people have two or three accessory spleens, like bright red mushrooms. Others have no spleen at all. Sometimes patients who had spleens removed due to trauma will have sprouted lots of little accessory spleens all over the abdominal cavity. The spleen is a weird organ.
I pulled out the duodenum, pancreas, stomach, and esophagus together and sent the whole long coil of upper gut onto the pile at the body’s feet, providing me easy access to the retroperitoneal space. I peeled each kidney and its attached fat tissue away from the underlying musculature of the back and took a moment to examine Booker’s adrenal glands, a pair of greasy little pyramids that perch atop the kidneys like yellow garden gnome caps. Unless the adrenals are bloody and red (a sign of overwhelming systemic infection), I can’t tell much by looking at them with my naked eye, so I cut a stock jar sample of each and then moved on. The last things to come out of the abdominal cavity are the bladder and rectum. Removing them requires me to reach really deep down into the pelvis, cut around the anus from the inside, and pull. There is a horrible sucking sound that takes some getting used to, and if the bladder is full it feels like a water balloon. I am careful not to burst it.
Since my patient was male, I finished the prosection by collecting his testes. This is not done in the manner you might expect. Instead of cutting open Booker’s scrotum, I reached down and inverted it, gaining access to his sex organs while leaving them outwardly intact. I examined the testicles one at a time, took a small section of each to save in the stock jar, and then poked them back down where they belong. Families can be very particular about the testicles, and I had been taught to replace them unless there was a tumor or signs of injury.
That first autopsy took me more than two and a half hours, twice as much time as I would need after a couple of weeks’ practice. The prosection went smoothly, I collected all the necessary samples, I didn’t bobble any organs—but I learned nothing about Terrence Booker’s cause of death. The lab tests were no help either. Histology could neither establish nor rule out an acute sickle-cell crisis. I strongly suspected Booker had died of an opiate overdose, but couldn’t prove it because there was no tox report. During all the excitement that night in the hospital, with the Code Blue alarms and the intubation and defibrillation, nobody had kept a blood sample. No blood sample, no toxicology—and no way of knowing what chemicals were in his bloodstream at the moment the patient went brain-dead.
After performing a meticulous autopsy with no findings, I couldn’t say for sure what had killed this man. I wrote the cause of death as “anoxic encephalopathy due to loss of consciousness of undetermined etiology.” This translates as “lack of oxygen to the brain from fuck-if-I-know.” Worse, because I couldn’t establish whether Terrence Booker’s loss of consciousness was due to natural disease or toxic insult, the manner of death had to be “undetermined.” Inconclusive. Supremely frustrating. Not the way I wanted to close my first case.
* * *
During the next week at my new job I would come to appreciate the wisdom of the medical school maxim, “When you hear hoofbeats, think of horses—not zebras.” In other words, most things are exactly what they seem, and the simplest answer is usually the right one. I autopsied a seventy-eight-year-old man with advanced heart disease and peripheral vascular disease one day, and a fifty-five-year-old woman with even worse heart disease the next. Both had died in hospitals a few days after undergoing surgery. Both were family requests; the families thought the operations had contributed to the deaths. When I opened up each body, though, I found the same thing: heart disease so far advanced that I couldn’t blame the surgery, even a little, for the demise of either patient. In the coming two years I would write those five letters, ASCVD, on a lot of death certificate worksheets. Arteriosclerotic cardiovascular disease, the biggest cause of excess mortality in the United States, kills a whole lot of New Yorkers.
Traumatic death investigation is unique to forensic pathology and something I hadn’t seen during my residency training; hospital pathologists perform autopsies only on patients who have died of natural causes. My first trauma cases came over the weekend. On Saturday I got a sixty-two-year-old man, Johannes Roskam
, who was rescued from a fire in his home only to die three hours later in the NYU hospital emergency room. During the morning meeting, Susan Ely handed me a burn diagram dividing the body into regions, each representing a percentage of skin surface area—one arm worth 9 percent; one leg, 18 percent, for instance. As a part of Roskam’s external examination, I shaded the injured areas on the diagram and calculated that thermal burns covered approximately 20 percent of his body.
After I removed Roskam’s bandages and the thick white ointment beneath them, I found that most of the injured skin was red and sloughing, with blisters around the edges and raw dermis showing underneath, characteristic of a second-degree burn. Some areas showed third-degree burns, with all the layers of skin reduced to carbonaceous debris, exposing yellow subcutaneous fat and muscle tissue the color of burgundy wine. This body did not exhibit fourth-degree burns—black and white, charred all the way down to the bone.
The thermal burns were severe, but they hadn’t killed Johannes Roskam. He had perished, like most fire victims, of carbon monoxide poisoning. Carbon monoxide is a gas released during combustion, which binds to the hemoglobin in red blood cells, forming carboxyhemoglobin and crowding out oxygen molecules until you asphyxiate. Once I opened up Roskam’s body, I found a thick coating of black soot in his airway—nasal passages, throat, and windpipe—indicating that he’d been breathing during the conflagration. When the toxicology report landed on my desk several months later, it said his carboxyhemoglobin reading was 65 percent, well into the lethal range. The fire marshal’s report came two weeks after that, showing that the decedent had been smoking a cigarette in bed. The fire was accidental, which made my ruling of manner of death “accident” too.
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