Stryker Bone saw-used to open people's skulls at autopsy
The book is taking a new turn as I redo my proposal. Initially, the book was to contain a series of fictional vignettes (that were based on reality) intended introduce readers to death professions. That proposal has been scrapped in favor of a reality-based manuscript.
The following is a vignette of a newly minted medical examiner's first day of work. It was formerly a sample chapter in a draft of my book. This chapter won't be in the book, but I didn't want to delete it forever. I'm leaving it here for those who might want to read. It is based on my experiences at the local medical examiner's office.
It was Dr. Erika Woodson’s first day as a full-fledged forensic pathologist. The past 13 years of hard work in college, medical school, residency, and fellowship had finally paid off. Growing up, she had always wanted to be a doctor, but had no knowledge of forensic pathology when she was accepted into medical school. That quickly changed after her sister, Trina, was murdered during her first year.
Trina’s life was snuffed out just two blocks from her home, when a stray bullet from a gang fight struck the vibrant sixteen-year-old in the back of the head. Trina was Erika’s best friend and suddenly, Erika’s world was turned upside down. Bringing her sister’s killer to justice became an obsession. She spent every second of her precious little free time learning everything she could about forensics, firearms, and physiology, which led her to the medical examiner’s office. Speaking with the forensic pathologist in depth about her sister’s autopsy was enormously comforting. She learned that Trina likely died quickly when the bullet traversed her skull. She didn’t suffer long. In this, Erika found closure.
Her sister’s killer was never caught, but Erika found purpose pursuing the study of forensic pathology. This was her way of making sense of the senseless. She wanted to be able to help others in the way she was helped.
While most of her medical school classmates moved all over the United States for residencies, Erika made great efforts to stay in the area, a difficult task. It was rare for a doctor-in-training to stay in the same city for medical school, residency and fellowship. This was her community though. It was where she belonged. Today, at long last, she was here to stay.
Having done her fellowship at the medical examiner’s office, she knew the ropes already. Walking into the autopsy room, it seemed like just another day of fellowship, only this time, she would no longer report to anyone.
“Morning doc!” shouted Bernard, one of the autopsy techs.
“Bernard, it’s good to see you. How’s your daughter?”
“Getting ready to start college. Got a full ride. I’ll miss her, but I’m so proud. Thanks for encouraging her to study hard. Someday she’s going to be a doc, just like you.”
A crowd had gathered in the hallway outside of the autopsy room awaiting morning rounds. Although there were 12 dead bodies lined up on autopsy tables in the next room, the mood of the group was lighthearted. Homicide detectives, investigators, and autopsy techs, bantered about the NFL draft, ragging on the one detective in the group who was a New England Patriots fan. Although Erika never cared much for “sportsball,” as she called it, she had learned to embrace certain aspects of the game for the sake of the camaraderie it invoked, even going as far as buying a jersey to wear on “Football Fridays.”
She joined in the conversation. “Hey, did you all hear the NFL was considering the cheetah as a new mascot for the Patriots?”
Everyone rolled their eyes. Erika was not yet adept at sports talk.
“Dr. Woodson, you’re off to a bad start today. You don’t want your first case to take place in the decomp room, do you?” threatened Dr. Raji Prem, the deputy chief medical examiner.
At 8:00 am, Dr. Prem announced, “Alright everyone, let’s get started.”
Bernard passed out the daily case list to everyone entering the room.
The group followed Dr. Prem into the autopsy room. Well-lit and airy, with high ceilings and angled windows, Erika thought of it as a “sleek and modern morgue,” likely a result of watching too much HGTV. Twelve corpses were laid out in unzipped body bags on stainless steel tables attached to sink stations. Some bodies appeared limp and floppy, with open eyes and gaping mouths, while others were in contorted positions, fixed in place by rigor mortis-the postmortem stiffening of the muscles. The dead were clothed in an assortment of pajamas, jeans, underwear, and hospital gowns. One person was burnt beyond recognition, a blackened silhouette with elbows bent and fists clenched.
“Why don’t you start us off, Dr. Woodson?” Dr. Prem asked.
Erika picked up the investigation report on the autopsy station. “Case 8950, Erol Johnson, 49-year-old male with a history of alcohol abuse. Mr. Johnson was found prone on the sidewalk outside of Crabby’s tavern by a passer-by Tuesday at 22:00 hours. 911 was called. EMS pronounced him dead at 22:25. He was last seen alive by his friend Jim, a bartender at Crabby’s, who stated Mr. Johnson complained of having a headache and hoped a drink would help. Jim reported serving Mr. Johnson one beer before he left Crabby’s at approximately 21:45. He has superficial abrasions to his face and knees. There is no evidence of foul play. His wallet contains $50 in cash, credit cards, and his driver’s license.”
Dr. Prem pointed out some subtle bruising on the back of the man’s head. The investigator hadn’t noted this in the report. Could this have been from a fall? Some members of the group examined the bruise; others took notes on their case lists. Erika was intrigued and put a little star by the case on her list.
Another medical examiner walked to the next table and picked up the investigation report. “Case 8951, Joseph West, 16 year male old found hanging in the woods...”
Each of the six medical examiners on duty took turns reading the sad reports of drug abuse, suicide, and murder. It seemed that nearly every day at least one young man was shot to death in the city. Today’s victim was a 22-year-old covered in gang tattoos, which told stories of desire, belonging, and loss. The investigation report indicated he was involved in a drug deal gone wrong.
The group walked over to the decomp room, a special isolation space with airflow engineered to confine airborne infectious diseases and the noxious odors of decomposition. Several people refrained from entering the room.
Case 8962, UNK, UNK, was an unidentified male found decomposing near a known homeless camp. A lone maggot fell from his stomach onto the table, writhing in confusion at being separated from the massive maggot festival taking place on the body. Erika eyed it as it crawled towards her end of the table, and decided she wasn’t really in the mood today. She didn’t mind maggots too much, but maybe tomorrow. Hopefully Dr. Prem was only kidding about the bad football joke and wouldn’t make her deal with Mr. Maggots today. She pitied people like him. Her colleagues might be able to find a cause of death, but more often than not, his family members would never be located.
The group split up. The investigators returned to their posts upstairs, autopsy techs filtered back into the main autopsy room, and the homicide detective went to sit down in a viewing area. Erika gathered with the medical examiners. Dr. Prem addressed her, “Since it’s your first day Erika, you get to pick first. What cases would you like?”
What a relief!
“I’m interested in case 8950, Erol Johnson, the guy outside of Crabby’s, and I can take an overdose for the team. She scanned the list. “How about...8952, Mark Nguyen?”
“OK, be sure to look at Mr. Johnson’s brain. I suspect that’s where you’ll find the cause of death. Now, who wants the homicide?”
The group divided up the remaining cases evenly, two per doctor.
Erika donned her protective equipment and joined Bernard at the first autopsy table. Erol Johnson was wearing dirty blue jeans and a stained polo shirt. After listing his clothing on her body diagram paperwork, she signaled to Bernard that it was okay to undress the body, helping him to remove Erol’s clothing. Erol was a heavy guy. Aside from the bruising on his head, abrasions on his face and knees, and a healed surgical scar that looked to be from an old gallbladder surgery, she didn’t see any other injuries. Was it alcohol that caused his demise? The bartender reported serving him only one beer, which certainly wasn’t enough to kill him. Could he have been lying? Erol was also overweight. Perhaps he had a heart problem. The bruise to the back of his head was equally puzzling, since he was found face down.
Bernard drew blood from the femoral artery in the leg, then obtained urine from the bladder with a large needle. He inserted a smaller needle into Erol’s eyes, drawing out a small amount of clear vitreous fluid. The fluids would be sent to the toxicology lab upstairs for analysis. In this case, Erika would have the lab would test his blood, urine, and vitreous fluid samples for alcohol content. Bernard made a Y-shaped incision with a large scalpel, from Erol’s shoulders down to the bottom of his abdomen.
Erol had a large layer of abdominal fat that Erika measured. Two and a half inches thick. Not healthy at all. Forensic measurements occasionally threw her off. The rest of medicine used the metric system. She was trained to think in terms of millimeters and centimeters, but forensic pathologists in the US still used the imperial system because it was easier for lay people and juries to understand their reports.
It was time to multitask. Erika told Bernard, “We’ve got Mr. Nguyen too—I’m going to do his external. I’ll be back,” and headed over to the other side of the autopsy room. Mark Nguyen, aka case 8952, was a 39-year-old salesman found dead on the floor of his club level executive suite at the Marriott. To his friends, Mark seemed like a successful, happy guy. He knew how to make people laugh and was always optimistic. He had recently been promoted at work and seemed to be doing well in the new position. Police learned that Mark had a wife and a five-year-old daughter. His wife was beside herself when she received the call. Aside from some minor back pain, she said her husband had been perfectly healthy. She knew that he had been taking something for his pain, but didn’t know what or how much.
The investigation report indicated that Mark had been drinking at the hotel bar earlier that evening after a day of work. His hotel room and belongs were secure. Unless someone had been invited into the room and left, foul play was unlikely. Photographs of the hotel room showed a spoon with powdery residue next to several pill bottles on the desk, suggesting that Mark had taken to crushing the pills and snorting them. This was something commonly seen in people with addiction issues.
Mark was wearing only boxes with a rubber ducky pattern, which Erika easily removed, smiling a little at the cute pattern. He was fit and healthy looking for a dead guy; his external exam was unremarkable. Erika suspected the internal exam would be equally unremarkable. If Mark had a secret addiction, toxicology tests would tell her the truth.
Erika returned to her other case. Bernard had removed Erol’s chest plate with a pair of long-handled garden shears and drawn blood from his heart, which could be used for comparison with the blood in his leg. He reached into Erol’s abdominal cavity and lifted up his liver, nicking the gallbladder to squeeze bile into a cup. Methodically, he sliced off a small piece of liver and placed it in another cup. Liver and bile were additional items toxicology could test. They would be busy today. Bernard set the liver and bile cups next to the blood, urine, and vitreous fluid on the cutting station perpendicular to the autopsy table. Erika labeled the cups, placed them in a metal basket, and took it over to a cart in the middle of the autopsy room. When she returned to the cutting station, Bernard had set about removing, or eviscerating Erol’s organs. The organs were taken out still attached to each other, in what was called a bloc.
Working up a sweat during the procedure, Bernard muttered, “They just keep getting bigger and bigger.”
He detached Erol’s bladder, and with a grunt, pulled out the organ bloc and set it down on the cutting board.
“Thank you, Bernard.”
Erika dissected out and weighed each organ, slicing each organ like a loaf of bread. She noted that the liver had a slightly bumpy texture. This was likely cirrhosis caused by chronic alcohol abuse. Erol’s heart was also slightly enlarged. His coronary arteries showed moderate plaque build-up, which she also saw in his aorta. These findings were common in men of Erol’s age—certainly not enough to have killed him. She took sections of each organ and placed them in a container of formalin, should she need to microscopically examine them in the future. The office called this the “stock jar.” The jar would be saved for 10 years in a huge storage room, stacked to the ceiling with thousands of other stock jars.
Erol’s face was currently covered by his scalp. It was a bit of a gruesome sight, but when his brain was removed, his skullcap would be returned and his scalp could be flipped back into place, like nothing ever happened. Erika focused on the bruising Dr. Prem had pointed out during rounds. As Bernard peeled back more of Erol’s scalp, she saw a collection of blood around a small crack in his skull. Bernard flipped on a bone saw to open the scalp, carefully sawing around the injury. Removing the skullcap was a noisy affair, beginning with the loud whine of the bone saw, then a sharp crack, and finally the crunchy peeling of membranes away from the skull. Erika found the sounds oddly satisfying. Bernard moved aside to let her examine the brain. Sure enough, there was a large collection of clotted blood trapped in between the membranes protecting it, known as a subdural hematoma. This was Erol’s cause of death.
Erika carefully removed the brain, weighed it, and instructed Bernard to place it in a bucket of formalin. The brain would soak in the bucket for two weeks, awaiting examination by an expert neuropathologist.
Although Erika had found the cause of death, the manner of his death was still unknown. This was not from a fall. It was in the wrong location. Erol’s injury was no accident. This was some sort of blunt force trauma that would require further investigation by police. Erika still needed to wait for the toxicology report to come back, but this was starting to look suspicious. Either Erol was in an unusual accident or had been murdered.
Bernard and Erika walked back to Mark Nguyen. It was time to repeat the dissection procedure again. Stick, stick, stick, slice, slice, slice, saw, saw, saw, floop.
Just as Erika predicted, Mark’s internal organs were in pristine condition. He also had two accessory spleens, a fun little abnormality she saw in about 10% of her cases. Accessory spleens, or splenules, were small extra balls of spleen tissue located next to the spleen. They didn’t do much of anything besides sit there and look cute, although they could potentially be affected if the person developed cancer. In this case, it was just an interesting observation that, for some reason, always made Erika smile. She decided to dissect Mark’s brain herself, removing the cerebellum, then slicing through the brain and the cerebellum. It looked normal and wouldn’t need to be examined by an expert. No obvious cause of death. Toxicology time. Erika left Bernard to suture the bodies closed and place them in refrigeration until a funeral home came to pick them up.
She spent the afternoon writing her autopsy reports. She worked from a template, filling in the blanks and extra details, pondering Erol Johnson’s brain injury. His death was clearly due to blunt force trauma, but from what… or who? A huge piece of the puzzle was missing. Erol’s manner of death would have to wait for outside answers.
Due to the opioid crisis, the toxicology department had a huge backlog of cases. It would be four months before Erika’s first two cases as a medical examiner could be closed. Erol’s toxicology report came back first, with only trace amounts of alcohol in his system. Definitely not a contributing cause of death. However, she learned from police that Erol had been in a bar fight the night before. An angry bar patron struck him in the back of the head with a liquor bottle, knocking Erol to the floor. He temporarily lost consciousness, while his assailant took the opportunity to flee. After Erol came to, he didn’t seek medical care and decided to just go home. He showed up to work at his construction job the next day, unsurprisingly, with a terrible headache. His injury was slowly bleeding, putting pressure on his brain.
When Erol stopped by Crabby’s after work, his brain was putting pressure on his brainstem. At this point he might have seemed a little tipsy to his bartender friend, but this was nothing new. When the drink did nothing to relieve his symptoms, Erol may have finally decided it was time to get help. But it was too late. The pressure from the hematoma had irreparably damaged his brainstem, which controlled his breathing and blood flow. Erol Johnson’s death was caused by a subdural hematoma due to blunt force trauma. Manner: homicide. Unfortunately, police were unable to track down his assailant, despite numerous accounts of the fight. This was the reality that Erika knew all too well. But she did her best to ensure the autopsy report was as detailed and accurate as possible, should she be called to court to testify if the man was ever caught. Erol Johnson lived alone and never married. Few of his family members were living. A cousin in Alabama was notified of his death, who seemed more annoyed than anything at having to handle Erol’s funeral arrangements. The whole situation was sad. Erika made a mental note to call her cousin on the way home from work to show her that she cared.
Mark Nguyen’s toxicology report showed high levels of Vicodin, a prescription painkiller and Valium, an antianxiety drug were in his system. Alcohol was also present at a high concentration. It was not a single drug that had killed him, instead it was the deadly combination of a benzodiazapine (Valium), an opioid (Vicodin), and alcohol. Mark hadn’t intended to live or die addicted to pills. Both drugs were initially legally prescribed to him. It was likely that he took them as directed for some time before developing a habit. Then, he needed more and more and couldn’t stop himself. Mark also wasn’t known to drink often. His trip to the bar in combination with the drugs he took later when he went to his room what did him in.
Erika saw far too many overdose cases like Mark’s during her training and knew there would be many more to come. It was her belief that drugs were good. So good, in fact, that once a person took them, they wanted more and more of the goodness, until it took over their life and they didn’t want to do anything else. It was better never to know how good drugs could be. Unfortunately, people like Mark never intended to know. He was prescribed the pills for a legitimate reason, by a physician, never realizing the dangers. Addictions were difficult to kick.
The silver lining to the high volume of overdose cases was that public awareness about prescription drug abuse was heightened. Changes were happening. Labels warning of addiction were added to drugs. Physicians came under greater scrutiny about painkiller prescriptions, which had positive and negative aspects. Less people like Mark were prescribed painkillers, but unfortunately those with severe pain experienced greater difficulties obtaining drugs they legitimately needed. Erika maintained hope that preventive education could help reduce the number of people who died from overdoses in the future.On her way home, she coincidentally listened to a podcast interview with a man who had recovered from addiction then started a charity providing clean water to people in developing countries. Although she saw the consequences of addiction at work, stories like this were a reminder that people could also get better.