Working Stiff

by Judy Melinek, Md

  At the same time on that Saturday that I had been examining Johannes Roskam’s airway, thirty-six-year-old Yuliya Koroleva jaywalked into traffic in the middle of Amsterdam Avenue. She stepped out between two parked cars a few blocks north of the subway at 72nd Street and got creamed by a white minivan. The emergency room doctors diagnosed her crushed pelvis on X-ray, but it wasn’t until she was in the operating room that the surgeons discovered Yuliya was pregnant. She died on the table.

  Just as I was starting the Y-cut on Sunday morning, a woman with a gold Homicide Division badge hanging from her neck came into the autopsy suite. She looked at Yuliya’s naked corpse. “The driver of the van that hit her took off,” the detective said, then turned her eyes to me with an unsettling scrutiny. “Have we worked together before?”

  “It’s my first week. I’m a new fellow. Judy Melinek.”

  “Cheryl Wallace.” We nodded; nobody shakes hands in the autopsy suite. Cheryl had a solid build and wore a no-nonsense suit. I couldn’t read her features behind the surgical mask, but I could tell she wasn’t spooked by the macabre tableau—a dead woman, mangled below the waist, with another woman holding a scalpel to her breast.

  “Okay, Dr. Melinek—”

  “Judy.”

  “Judy. Okay. Here’s the deal.” She moved a little closer to the table, looked up and down Yuliya’s body. “We’re gonna need scalp hair for DNA testing, and tell me if you find any paint or metal fragments.” If the police found the vehicle that did this, a stray hair on the bumper or a matching paint chip on the body could cement a successful prosecution. Wallace’s eyes stopped at Yuliya’s belly. “You know she was pregnant?” I told her I did. “Do you know if it was viable?”

  “Not until I take a look at the fetus—and even then, maybe not conclusively. I can guess by looking at her that she’s still in the second trimester. The earliest a fetus can live outside the womb is twenty-four weeks, and she looks less pregnant than that. I’ll be able to say for sure when I get in there to measure the feet.”

  “How can you be sure? What if it’s a big baby?”

  “Fetus size is pretty predictable unless the mother has gestational diabetes, and the most accurate measure of gestation is the foot length. Boys and girls, big and small, they all have the same foot length at a given week in utero. I have a chart in my fetal pathology textbook that matches the size by dates.”

  The detective nodded. “That’s good.” I could see her filing the fact away. I took a liking to Detective Wallace. Brusque, maybe, but smart.

  Wallace left me alone to continue the autopsy. I was glad she did, because opening Yulia Koroleva’s uterus was the most heartbreaking thing I’d ever done. When I saw that perfect fetus, when I took it in my hands, my vision clouded over with tears and my professional reserve fell away. It was a boy, with ten fingers and ten toes. The pregnancy had been progressing successfully. Yuliya’s baby had fully formed organs, each in its correct location, without any abnormalities. The foot length of thirty millimeters told me he had been nineteen weeks old, exactly halfway through gestation. I returned him to his mother’s body, to be buried with her.

  The second case that Sunday was my first investigation of a suicide, a fifty-year-old man with a medical history of head and throat cancer who had slashed his own neck after getting the news from his oncologist that his cancer might have metastasized. The autopsy wasn’t difficult. For one thing, it was dry: An adult has about a gallon and a half of blood, and the MLI reported that this guy had left most of his on the floor of his bathroom. He had also left a suicide note to his wife, telling her she shouldn’t have to nurse him through another course of chemo. But suicide is a selfish act, and he wasn’t really thinking about her. She was the one who found the body. Anything the woman might have suffered if his cancer came back would have been better than finding her husband there on the floor of their bathroom, awash in his own blood, stone-cold dead.

  When I was ten, my father took me to the Bronx Zoo one day during the school winter break. It was so cold the hot dog vendor was invisible behind a shroud of steam, and my dad cracked the guy up with a Turkish bath joke. He handed me his camera and had me snap a picture of him monkeying around outside the Monkey House. I was laughing so hard at his hooting, armpit-scratching schtick that the picture came out blurry. To this day I can still see it, and I can still taste that hot dog, and I feel a loss that never has lessened. That goofy middle-aged guy, with his Burt Reynolds mustache and square black glasses, in a heavy winter coat and wool hat, just being a fun dad. He hanged himself three years later. If I’d known then how deeply that moment would lodge in my memory, I would have taken two pictures, to make sure I got it right. He was probably thinking, as my first suicide case was probably thinking, “She’ll be better off without me.” But no. That perspective is self-absorbed and misguided. She never will be.

  It was hard to drag myself to that afternoon’s meeting with Dr. Hirsch and the other fellows after those two agonizing cases. The suicide had been easy enough to classify, but I had “pended” Yuliya’s death certificate while Detective Wallace was conducting her investigation. We never held on to bodies longer than we needed to—this was a matter of the utmost importance to Dr. Hirsch. Since we often could not determine the cause of death until all the tests and laboratory results had come back, roughly half of our death certificates would start out with a preliminary cause and manner of death, pending further investigation. Pending a death certificate allows the family to bury their loved one and get on with the administration of the estate. Once I had all the paperwork in order, I would issue an amended, final death certificate for Yuliya Koroleva.

  I asked Dr. Hirsch why I couldn’t declare this a homicide pure and simple. “It isn’t a homicide unless we can demonstrate harmful intent,” the boss replied.

  “Yeah, but the van driver fled the scene of a fatal collision. Isn’t that ‘death at the hand of another’?”

  “Not without evidence of intent.”

  “Even if he broke the law when he left her bleeding there and kept on driving?”

  “Yes.” From my silence Dr. Hirsch anticipated the next question. “Hit-and-runs may still be certified as accidents, but in all other ways they are treated as homicides. You did the right thing pending it. Don’t worry about the police investigation. They usually find these guys, and that’s when the work you did today will really pay off.”

  As usual, Hirsch was prescient. Two weeks later Cheryl Wallace showed up in my office with her partner, a six-foot-five man named Torres, with a lot of flesh and a gleam in his eye. “All right, Doc,” he said, right after introductions and handshakes, “settle a dispute.”

  They had located the driver of the white minivan. He didn’t try to deny he’d been at the scene of the crime, but his story didn’t match the eyewitness reports. They told the police that Yuliya had been moving from east to west when she’d stepped into traffic. The driver told them she’d been walking west to east. The witnesses said the minivan hit her, she went under it, and the driver zoomed off. He claimed the car in front of him hit her—and he didn’t see where she went after that. “So,” said Torres, “can you tell us who’s right?”

  I smiled. “Detective, I believe I can.” I pulled out the Koroleva file and showed them the body diagram I’d completed during the external examination, documenting Yuliya’s abrasions and contusions. “Look here. See that huge bruise on her left thigh?”

  In unison the two cops leaned closer to my desk. “What’s the height of that bruise off the ground, if she was standing?” Cheryl asked.

  I pointed to it on the diagram: twenty-six inches. “Looks bumper level to me,” I said.

  She looked at Torres, and they both grinned.

  “The dumb-ass,” said Torres.

  After the driver had fabricated his story under questioning, Wallace explained, the two detectives went along with it. They told the guy how thrilled they were that he had witnessed the crime from directly behind the of
fending vehicle. And what make and model had that vehicle been?

  “Blue Toyota Camry, he tells us,” Torres said, “the dumb-ass. Bumper height on a Camry is twenty-one inches.”

  “We looked it up,” Wallace added.

  “Doctor, would you like to guess what the bumper height of our suspect’s van is?”

  “Could it be the twenty-six inches I wrote down right here, as matching the bumper-shaped bruise on the decedent’s left thigh?”

  Cheryl Wallace was beaming now. “Left thigh. Amsterdam is a northbound one-way. If she’s going west across the street the way the witnesses put her, that means the point of impact would be . . .”

  “. . . on her left side,” Torres finished for her, and chuckled at the folly of liars.

  Wallace was peering at the body diagram and pointed to a wide, dark splotch on the figure’s back. “What’s this?”

  I showed her the marginal note I’d jotted during the autopsy. “Grease.”

  “Off the underside of the vehicle?” Torres asked.

  I rooted through the file and came up with a picture, from the external examination, of a long black smear on the dead woman’s upper back. “It’s on her skin, which means something took her blouse off,” I pointed out, and Wallace jotted it down.

  I asked if they had figured out who was the father of Yuliya’s unborn child. “We don’t investigate those kind of accidents,” Torres deadpanned. “Two guys are claiming to be the father. One’s ‘inside,’ but I don’t know if the math works out with his date of incarceration. The other guy is out.” I was glad I had frozen some fetal tissue for paternity testing. The two candidates could find out for sure, if they wanted to.

  I handed Wallace her copy of the body diagram and thanked the detectives for their solid work. “I didn’t want to see this one a hit-and-run. That baby really got to me.”

  “Nobody jump to congratulations just yet.” Detective Wallace held up the paper. “This helps, but I doubt the DA will think it’s enough to convince a jury.”

  “Grand jury, though,” her partner interceded.

  “Oh, hell yeah.”

  “Let’s see what the guys at Impound find on the vehicle.”

  I got a phone call from Cheryl Wallace a few days later.

  “I’ve got news for you, Judy. Our auto lab came up with human hair underneath that van. It matches the sample you gave us from Yuliya. Better yet, it came from a spot where the grease and oil were smeared away from the undercarriage. There was some cloth under there too. It’s going down to the DA, charged as a hit-and-run vehicular homicide.”

  I was relieved. Not technically a homicide in manner of death, but still an act of violence and a killing, and I had done my part to bring the charge.

  * * *

  Everyone thinks “murder” when you say you work as a medical examiner, but homicides are rare. “Natural” is the most common manner of death and represents about a third of the cases that come to a medical examiner’s office. Natural deaths are a consequence of disease rather than injury. Sometimes these are infectious diseases, but just as often they are not—during my first week on the job I signed out death certificates with heart disease, diabetes, birth defect, and liver damage from chronic alcohol abuse as underlying causes. We investigate natural deaths when they are sudden or unexpected, in order to identify the fatal disease, inform the family about heritable medical risks, and protect public health.

  During one of our afternoon teaching sessions, Dr. Hirsch introduced me, Stuart, and Doug to a subclassification scheme he uses in evaluating natural deaths. We don’t write these categories on the death certificate, but they are useful in the evaluation of autopsy findings—and in learning to think like a forensic pathologist.

  1. Incontrovertible evidence found on autopsy: ruptures or hemorrhage into a vital center.

  A sixty-nine-year-old woman was walking along the sidewalk on 116th Street in East Harlem when she suddenly dropped like a stone and never got up. When I opened her up, I found that a massive myocardial infarction had torn a nickel-size hole in her heart, flooding the pericardium and right pleural space with a liter and a half of blood. Cardiac rupture is the epitome of an “incontrovertible” natural cause of death. This category constitutes only a tiny percentage of my cases. They’re easy.

  2. Presence of potentially lethal disease (sufficiently advanced) in exclusion of other causes.

  Amanda Peabody was a television news producer who had just taken four months of maternity leave. On the evening of her first day back at work, a bystander found her slumped in her car, cold and stiff, the keys clutched in her right hand. Her purse was on her lap and there was no sign she’d been assaulted. Amanda’s husband told our medicolegal investigator she had a medical history of mitral valve prolapse, a usually benign heart murmur.

  At autopsy I saw the bad valve—bluish and thickened, with generous folds like a collapsed parachute, a type of heart damage called myxomatous degeneration. I found no pulmonary embolus, no aneurysm, no bleed in the brain—nothing else that could have caused sudden death. Toxicology came back negative. I had to conclude that Amanda’s heart had been damaged badly enough by the chronic backwash coming through the leaky valve that eventually it went into ventricular fibrillation and stalled for good. Her final pose was a testament to this fatal mechanism: stopped in time, frozen in the middle of a routine task.

  3. In cases with marginal pathology, a compelling history, and the absence of other causes, history and circumstances dominate.

  Sometimes the decedent had suffered from a disease that is seldom lethal, but something in the story that surrounds the death scene leads us to diagnose that disease as fatal in this case. Patrick Balzer was a healthy, athletic forty-year-old lawyer, never a smoker and only a moderate drinker, with no medical history to speak of. At dinner one night he complained about bad heartburn. In the morning he woke up pale and short of breath. His wife called 911, but by the time the paramedics arrived, Patrick was dead.

  Unlike Amanda Peabody’s enlarged, clearly diseased heart, Balzer’s was firm, sleek, and healthy-looking, with little fat and no evidence of a heart attack. I dissected the cardiac blood vessels and found that only one of them, the left anterior descending artery, showed any sign of disease. That artery was half clogged by atherosclerotic plaque—a blockage caused by the buildup of fat molecules in the bloodstream. It’s not a whopper of an autopsy finding. I often found far worse heart disease in men who had died of something else entirely. Toxicology and histology came up negative.

  “There’s got to be something I’m missing,” I said at Hirsch rounds when I presented the case. “It can’t be just that one vessel.”

  “That one vessel,” my boss replied, looking over his glasses as the twinkle that precedes a Hirschism grew in his eyes, “along with the story the wife told, and the scene the medics found. Don’t deny reality for the sake of objectivity. The scene and circumstances support cardiac death, but the heart isn’t that bad, right? That’s bothering you because you are assigning too much weight to the physical findings of the autopsy. It’s our job as death investigators to take in the whole picture. You have to make a determination based on the strength of the evidence.”

  Hirsch was right, of course. We are scientists, and don’t like a thin data set. But when you bend over backwards to remain scientifically objective, you are denying the strength of some facts over others. I had been fixating on Balzer’s healthy-looking heart but ignoring the reported heartburn and shortness of breath. The man had a heart attack. Even if he shouldn’t have, still he did. That’s the reality, and that’s the cause of death.

  4. No pathologically demonstrable lesion.

  Some syndromes, notably schizophrenia and epilepsy, can predispose people to sudden death through neural, respiratory, or cardiac mechanisms that are not yet fully understood. In the middle of bitter January, the investigators brought in something they described as a “corpsicle.” It was the body of a schizophrenic woman who had
died in her bathtub more than a month before. Her bills went unpaid, the landlord shut off the heat to the apartment, and the body froze solid. I had to thaw it out before I could perform the autopsy, and then I found absolutely nothing wrong with the woman. Scene photos showed her head above the water line in the tub, which told me she hadn’t drowned. The only relevant item in her medical history was her mental illness—but it turns out this is enough. “Schizophrenia alone is considered a cause of death in the exclusion of other findings,” Hirsch explained during our fellows meeting that afternoon. “It is believed that schizophrenia predisposes its sufferers to autonomic instability and subsequent arrhythmias. Nobody’s figured out a way to test it, but that doesn’t mean we can ignore the fact that it occurs.” So the manner in that case was natural, with a one-word cause of death: schizophrenia.

  5. Cause of death undetermined despite best efforts.

  These are the dead ends, the most frustrating category of deaths by natural disease. A thirty-year-old Chinese immigrant died at home in his sleep. The autopsy was a demonstration case for a healthy man in the prime of life. He had no cardiac damage. His blood vessels were clean and supple. No indication of pulmonary disease. I did find a few small gallstones, which can cause pain that radiates in the back, or can be totally asymptomatic. This body told me nothing about why it had stopped living.

  A guy from Forensic Biology, upstairs in our building, agreed to act as my Chinese interpreter. From my office phone he spoke to the decedent’s cousin, who told him the dead man had been suffering from back pain for more than half a year and was taking traditional herbal medicines for it. He had seemed fine at dinner. His parents found him dead in his bedroom the next morning. “Ask them to gather up anything he might have been taking as medicine,” I instructed the Forensic Bio guy, “and bring them to our office.” He relayed the request, and the cousin promised he would do so.