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CAUSE OF DEATH FORENSIC FILES OF A MEDICAL EXAMINER
By STEPHEN D. COHLE TOBIN T. BUHK
Prometheus Books Copyright © 2007 Stephen D. Cohle, MD, and Tobin T. Buhk
All right reserved.
Chapter One DECOMPRESSION
Late Spring 2004 Spectrum Health, Blodgett Campus East Grand Rapids, Michigan
I use the word decompression when referring to an outsider's first foray into the morgue, that moment when the living come in contact with the dead. The word seems appropriate for the experience. Divers decompress to remove noxious gases that can make them sick. In this chapter, Tobin will enter the morgue for the first time; he will decompress. He will begin a one-year tour of duty in the Kent County Morgue to learn about the world of the forensic pathologist from the inside. His exploration began with a telephone call last night.
* * *
Last night, fate had cooperated with our project, and somewhere in Kent County an accident or a homicide has provided a subject.
"We have a body," I inform Tobin, deciding to leave the details for the morning, to let the possibilities linger in his mind; I couldn't resist the temptation to raise the drama.
"Great," Tobin responds, his voice flat, devoid of inflection, a tone that belies the delight inherent in his word choice, "great," as if the news hasstunned him. "Ah, I don't mean to say I'm glad someone died," he adds to temper what appears his misplaced enthusiasm. He doesn't want to sound too enthusiastic, like some morbid death-junkie, but I know he's thrilled he will see an autopsy. It is an awkward emotion he will experience many times in the next eight months.
"Have you ever had hepatitis shots?" I ask.
"No." A long pause ensues, pregnant with the anxiety I can sense building. I can almost hear him breathing.
No immunization for hepatitis. Today, just about every parent has his/her child immunized against hepatitis B, but these immunizations did not become common medical practice until relatively recently.
"Is this a problem?" he asks.
"Doesn't matter. We use maximum precautions."
"The nervousness bordering on panic feels like a kidney stone rolling in my stomach, Doc."
"When my assistant opens the skull," I explain, trying to calm his fears, "you'll stand in the corner. Hepatitis may become briefly aerosolized with the dust when sawing through the skull."
"Are you sure this won't be a problem?" Tobin asks. The prospect of leaving the morgue with anything other than memories terrifies him.
"There's always a risk." My response doesn't make him feel much better. "But I'm not sure that one can even catch hepatitis this way. I never got hepatitis shots."
Perhaps now he feels better, much better, at least until I finish the story. "I have the antibodies for hepatitis B, so I must have contacted it at one point, but I don't know how. I must have cut myself with an infected knife."
Now his fears become intensified; the stone has begun to pitch in the acids washing against his stomach like waves crashing against a beach. Nonetheless, he's determined, but I imagine he won't sleep much tonight.
We agree to meet in the hospital lobby at eight the next morning.
* * *
It is a rainy morning in mid-May; a light drizzle falls from the sky, covering everything with a bright sheen. A heavy blanket of clouds that look like steel wool covers the sky. Symbolic weather, a device so effectively used by authors and Hollywood directors to indicate the psychology of characters or to foreshadow events. Edgar Allen Poe used storms to parallel the mental decay of Roderick Usher in a short story familiar to most school kids, "The Fall of the House of Usher." Shakespeare used stormy weather to great effect in Macbeth-the stormy weather always presages and in most cases directly precedes a death. A thunderstorm accompanies the murder of King Duncan, for instance.
For a week now, rain has bombarded Grand Rapids like the eighth plague, swelling the Grand River to a near-record-high 19.5 feet above its normal level. Today, the tapping of the rain eerily provides mood music for Tobin's first journey into the underworld.
Just beyond the parking ramp, the postmodern architecture of Spectrum Health, Blodgett Campus, looms. Formerly, it was Blodgett Memorial Medical Center until it merged with Butterworth Hospital in downtown Grand Rapids to form Spectrum Health. The structure is nestled in the middle of the area's most prestigious suburb, called East Grand Rapids, the home of former president Gerald R. Ford.
The old and new wings coexist, a common juxtaposition that never ceases to impress; the old, red brick a remnant of the days when the Model T was cutting-edge technology, the burnished, brown stainlesssteel skin of the modern wing, draped over a poured concrete skeleton, a visual symbol of the space-age technology that grew up with it. Today, the façade looks like a mausoleum. Why did the architects choose such a cold, clinical look? Certainly not to create a becalming effect in visitors and patients. This scenery seems fitting for the drama that will develop this morning; Tobin has come here to research the everyday workings of a real-life forensic pathology laboratory, but in entering the morgue, he will enter a play without an ending, a play for which the ending has not yet been written.
As he gazes up at the hospital's façade, a cloud passes over the sun, creating a brief eclipse. He remembers that someone died last night or he would not be here, and his smile melts away with the sun.
He takes a sip of tea, to relax. He's tired and needs the caffeine, but the butterflies in his stomach have had more than enough. He arrived far too early on Saturday morning to view his first autopsy. He slept little last night; somewhere during his REM sleep, he would later tell me, a nightmare emerged that in retrospect seemed like a bad horror film from the fifties-plenty terrifying at the time, though. I chuckled as months later he recounted the nightmare, although I understand the mental pathology that created it. Countless students from high school kids to medical interns have visited the morgue and watched autopsies, and every one brings with him some preconceived notion of this world, usually born of years watching television thrillers such as CSI.
An exotic dancer was stretched out on a stainless-steel table in a stainless-steel room, still in the miniskirt and fishnet stockings native to her trade, her torso covered with blood from the autopsy. The medical examiner, with one deft movement, managed to remove her breastplate (!) with a hideous sucking sound. Tobin watched the macabre tableau from a corner in the room, noting down each detail, when to the shock of everyone in the room, the deceased turned her head, opened her eyes, and began to speak. In a clear soprano, she uttered, "So, Doctor, what happened to me?" as if an interested observer more than a victim. (If this dream followed the cliché of the old horror film, she would have spoken in a pained, raspy horse-whisper.) The whites of her eyes were bright red.
Funny how the mind works, absorbing information, melding that information with images already stored somewhere in the human hard drive, and producing new combinations, which seem often to emerge during the deepest of sleep. Last night in his unconscious hours, Tobin's mind regurgitated a twisted version of a case I had described to him in an earlier conversation: the story of the man who exposed himself to the elements as a method of ending the guilt incurred over his adulterous affair with an exotic dancer. Last night, he saw the dancer, or the image of the dancer his mind had woven.
Those who lack experience think in stereotype. Tobin's first trip into the morgue would prove the veracity of this statement. Without live experience, one reverts to images engineered for television programs or movies. To this point, for instance, Tobin has never viewed a live autopsy; when he thinks of a morgue and the scene of an autopsy, his mind may conjure images of a stainless-steel room and blood-spattered walls (notice the word choice here), and a wall of drawers, each containing one body covered by a bedsheet. A medical examiner opens one of the drawers and pulls back the sheet to reveal ...
Like most people, Tobin has never seen a pathology lab. He has never even seen a dead body, even a dead relative in a coffin at a funeral.
An analogy will help explain what he will soon experience. Museums tend to objectify the past; people become mere artifacts. The effect is heightened by those fortunate enough to visit or enter historical sites. Divers who visit shipwrecks, for example, subconsciously objectify the wreck, forgetting that a tragedy of some sort sent the oxidizing pile of metal to the bottom with at least some loss of life probable, each victim's story a tragedy. It becomes too easy to romanticize about the artifact, the human element buried under the silt and dust covering the wreck, until the appearance of a shiny white porcelain toilet, glistening like a tooth under the beam of a dive light, provides a sharp reminder that humans once worked and perhaps played here, a sharp reminder that we are all human.
Watching fictional medical examiners on television is like diving on that wreck-the television screen becomes the lens through which the viewer sees a distorted version of reality. Entering the morgue, though, is like all of a sudden coming across that porcelain toilet on the wreck; the visitor can hear, feel, and smell the experience as the human tragedy becomes real. Although it becomes natural to objectify, as a forensic pathologist, you don't ever want to forget the human element, just as a doctor would not want to think of his patients as objects, but as living, breathing people.
The first foray into the morgue, like the first dive on a shipwreck, is the most powerful experience because the observer will not objectify as a practitioner might-although the first-time visitor often wants to steel his nerves by telling himself that the figure on the slab in the morgue is a clay figure. Yet reality will strike Tobin like a cold bucket of water; like many others who enter this world for the first time, he will see these victims not as objects but as people, as someone's father, sister, or child. He may want to forget this reality, but along his journey he will hear a phantom voice, like the collective voice of the deceased who ended their life's stories a floor below us, whisper in his ear that he won't.
At 8:15, I arrive at Spectrum. The hospital is a quiet place this morning, with few bodies moving through the central lobby. I spot Tobin on one of the couches in the lobby, dressed in black jeans, tennis shoes, and a button-down shirt; perhaps there is some message in his black jeans, or perhaps he just didn't know what to wear, although he doesn't have to worry about impressing the people he will soon meet. His attire presents a marked contrast to my pale blue hospital scrub pants topped with a gray T-shirt that bears the word "Atlanta" in bright red letters.
"I don't know about you," I say, "but I can't work without breakfast."
From the quizzical expression on his face, I can predict his dilemma. Breakfast? Should he or shouldn't he? He doesn't want to leave his breakfast on the morgue floor.
"I don't mind telling you, Doc, it's been like a kidney stone rolling around in my stomach all week. I'm nervous as hell."
A grin and a few words will increase the drama a bit. "You should be."
"Should I eat?" His Adam's apple rises, like his blood pressure I suspect, and falls, and he swallows.
"Well, you should eat something."
He decides to take the doctor's advice and makes himself a cup of black tea and selects a croissant from the hospital's self-serve cafeteria-a reserved, safe breakfast; I select something with a little more substance: oatmeal and sausage.
After a little casual conversation, curiosity has bested him. "What subject will you examine this morning?" Tobin asks. Already, somewhat subconsciously, as if his mind contains some defense mechanism that objectifies human death, he has become accustomed to referring to victims as "subjects." It is an attractive defense mechanism.
"Subjects. We have two."
Tobin's first experience in the morgue will be a double feature.
The first subject, a sixty-six-year-old male from a northern Michigan county, was found dead in his car, the victim of an apparent heart attack. The second subject, a forty-seven-year-old female from Grand Rapids, is an apparent suicide victim, and thus an autopsy becomes necessary to ensure that her suicide was, in fact, a suicide and not a homicide.
In a few minutes, Tobin will visit these two.
"Are you sure I'll be alright without the hepatitis shots?" Tobin asks between sips of the tea that he cradles between his palms (he hasn't touched his croissant). The question has remained on his mind since we last spoke, like an itch that he can't scratch.
He flinches. "It's like I can feel an invisible bug crawling up my leg."
Although that invisible bug he feels crawling up his leg most likely won't bite him if he follows the necessary precautions, it isn't invisible. It's real....
Remember the scene in The Wizard of Oz in which Dorothy and her three companions must pass through a field of pink flowers to reach Oz? The flowers are a trap laid by the Wicked Witch of the West to waylay the trio and prevent them from reaching the Emerald City; with a magic spell, she has turned the flowers into opiates that will put them to sleep.
Now imagine the field filled, not with pink flowers, but with raspberry bushes, tangles of branches, each covered with thorns, reaching out and grabbing at clothes like hungry fingers. A number of dangerous viruses inhabit these raspberry bushes, and one tiny scratch from a thorn could lead to a terminal infection. In fact, merely walking through the field could result in an infection. Imagine this scene, and you imagine the tremendous risks medical examiners assume each day on the job. Pathology is one of the most dangerous branches of the medical profession.
If pathologists signed liability waivers, the documents would be the length of a telephone book and contain a virtual alphabet of germs and viruses that arise during the business we do in the morgue, from the common and treatable to the rare, exotic, and incurable. The names of the insidious critters that crawl in with victims are as scary as the bugs themselves: anthrax; blastomycosis; coccidioidomycosis; diphtheria; a variety of hemorrhagic fevers; hepatitis A, B, and C; human immunodeficiency virus (HIV); legionella; meningococcus; plague; streptococcus; rabies; rickettsiosis; tuberculosis; tularemia; and a host of others. Many factors cause the increased risk, especially the type of clientele that frequents the world's morgues: pathologists will see more intravenous drug users than others in the medical profession, and blood-borne pathogens such as hepatitis and HIV often plague this population. Microorganisms that inhabit the blood cause the greatest risk to pathologists, since medical examiners work closely with blood and items, such as clothes, that contain blood. For this reason, pathologists often face a greater risk than the physicians who attended the infected patients before death. Any contact with infected blood could lead to an infection. Some of the viruses possess an amazing resilience: hepatitis B can live for as long as a week, even in dried blood. Even the dried crimson streaks on the barrel of the dry-erase marker we use to log organ weights could contain hepatitis virus.
The easiest path to acquiring an infection in the morgue is sustaining a cut from one of the "thorns" that from every corner of the morgue tug at the clothes and skin of pathology department personnel. The morgue's "thorns" primarily consist of the cutting implements we use: scalpels, long knives, and the oscillating blades of the Stryker saws used to cut skulls. An errant cut or slice that penetrates the latex gloves and skin underneath could be a fatal error. And one need not apply much force to create a deep cut with the ultrasharp blades. Combine an exhausted pathologist with a sharp blade, and this scenario could easily occur.
Other "thorns" exist as well in the bodies of the victims; shards of bone from compound fractures, cracked ribs, glass or objects embedded in wounds, such as knife blades-all could cause an accidental cut and lead to an infection.
Excerpted from CAUSE OF DEATH by STEPHEN D. COHLE TOBIN T. BUHK Copyright © 2007 by Stephen D. Cohle, MD, and Tobin T. Buhk. Excerpted by permission.
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