Алексей Решетун
If These Bodies Could Talk: True Tales of a Medical Examiner

Just like any other specialization, people choose forensic medicine because they are interested in it. Passion for your work means you are willing to overlook some of the negative aspects of your job and stay inspired enough to keep putting in long hours.

And, while it is true that sometimes our personal lives leave something to be desired, are medical examiners the only people who deal with this sort of problem?

3. PATHOLOGIST OR MEDICAL EXAMINER? WHAT IS SIMILAR, WHAT IS NOT

People, and sometimes even doctors, often use the terms "medical examiner" and "pathologist" interchangeably. If our colleagues have trouble telling us apart, how can we expect laypeople to manage this? At first glance, pathologists and medical examiners appear to be in the same line of work – but the differences between them are quite significant.

But first – the similarities. Both pathologists and medical examiners are doctors. They have both completed medical school before deciding to specialize in either pathology or forensic medicine. They both wear white coats, both work in a morgue, and they both examine dead bodies.

But that is where the similarities end. Pathologists work in a hospital and examine bodies at the request of the chief physician, who is their boss. Arthur Hailey did an excellent job capturing the relationship between pathologists and hospital staff in his book, The Final Diagnosis. Generally speaking, pathologists monitor treatments and diagnoses by examining the bodies of people who died in the hospital or of disease. For example, let us imagine someone who has a heart attack, known as an acute myocardial infarction. He is brought to the hospital in an ambulance, receives a diagnosis, and the doctors begin treating him. But sometimes, despite our most valiant efforts, people die. This is where the pathologist comes in to perform a postmortem exam to determine whether the doctors' diagnosis and course of treatment were correct. The pathologist will look at the histology of a dead body or examine biopsies from someone who is still alive. When performing an autopsy, he or she may choose not to examine the person's skull if there is no reason to do so.

Of course, pathologists do examine people who died at home, but only when they did so in front of witnesses (especially doctors), suffered from a long, chronic illness (confirmed by medical records), and the body did not present any sign of injury. In Russia, the number of people who die at home and are later examined by a pathologist varies among the regions – sometimes it is as high as eighty percent, and sometimes as low as ten percent.

The two most important words when describing the work of a pathologist are "disease" and "hospital." Pathologists do not examine people who died a violent death. If during a postmortem examination a pathologist sees signs of violent death, he or she must: (1) immediately stop the autopsy; and (2) contact law enforcement agencies to send the body to a medical examiner.

It is necessary to distinguish what exactly constitutes a "violent death." Most people assume that if someone is not found with an axe sticking out of their head, their death was not violent. In fact, things are not that simple. Any death that occurs due to factors in someone's external environment – cold temperatures, alcohol, carbon monoxide, or, yes, an axe wound – is considered violent. Intent does not matter here – if someone died from alcohol poisoning, whether he drank too much of his own free will, if someone poured vodka down his throat, or he drank it by accident is of little importance. In any case, the death will be considered violent.

In fact, only three types of death are considered non-violent: (1) death from disease (for example, our heart attack patient above, or someone who dies of pneumonia, a stroke, etc.); (2) death from old age (medical examiners will only see one of these cases every couple of years); and (3) death as the result of a stillbirth caused by congenital anomalies.

In short, pathologists do not examine violent deaths. That is the job of a medical examiner.

Medical examiners do not work in a hospital but in a specialized institution – in Russia's case, the Moscow Forensic-Medical Bureau. Though their offices may happen to be located in a hospital, they do not answer to the chief physician, and only examine bodies when directed to do so by law enforcement agencies. There, they handle all violent deaths (murder, suicide, accidental); sudden or unexpected deaths; deaths with no witnesses or with undetermined causes; unidentified bodies; almost all deaths involving children; and so-called "medical cases." The most important word that characterizes a medical examiner's work is "independence."

That independence is enshrined in the federal laws of the Russian Federation and numerous departmental regulations. Medical examiners do not answer to investigative authorities, the prosecution, or the defense, and they issue their conclusions based solely on their examination.

Each medical examiner must be criminally liable (!) for his or her conclusions – Article 307 of the Russian Criminal Code ensures this, and I hope that will remain the case. It is not the case for pathologists, as they are not performing medical examinations for the court.

So, what does this law mean, exactly? In short, it means that medical examiners cannot be pressured by anyone to change their conclusions, which are used as evidence in court. No department chief has the right to force any conclusions on his or her subordinates. In my sixteen years as a medical examiner, no one has ever attempted to "advise" me what to write in my reports.

Of course, that does not mean that medical examiners are immune from unscrupulous behaviors toward their duties, but every profession has its bad apples. People are only human, after all…

There are often rivalries and competition between pathologists and medical examiners, ranging from friendly to downright contemptuous. Pathologists sometimes claim that medical examiners' work is just rough and approximate guesses, while theirs is a form of true art. And medical examiners in return shame pathologists for their reports, which are written based on the principle of "the shorter, the better."

In reality, pathologists and medical examiners complement each other very well, especially if they have to share a morgue or even a forensic laboratory (which is reasonably common). We often help each other out and give each other advice, attend joint conferences and meetings hosted by scientific associations, despite the differences between us.

Comparing pathologists and medical examiners is like comparing apples with oranges. Neither is more sound, and each simply has a different medical specialty with its specific tasks and goals.

4. TO CUT OR NOT TO CUT? THAT IS THE QUESTION

The vast majority of people have a contradictory reaction to the idea of being subjected to a postmortem forensic examination. They are horrified by the very idea of being moved around, "cut up," "gutted like a fish," or having their "organs taken apart." Most of the time, the relatives of a deceased person feel the same way. It is perfectly understandable – there is nothing glamorous about a forensic examination, and the medical examiner certainly takes no pleasure in it.

Despite all the advancements of the twenty-first century, we still have no other way to determine someone's cause of death. Sometimes, I am asked about virtual autopsies or why we cannot just use a CAT scan. In fact, that technology is sometimes used in Israel and Europe, but it has not entirely replaced the old-fashioned autopsy. While a CAT scan can show us things such as a broken bone, we will still have to cut the body in order to determine how it broke in the first place. And how else can we get samples of internal organs? Unfortunately, performing an autopsy is the only way to determine the exact cause of death, and to answer questions like when the person died, whether their injuries occurred while they were still alive and how they happened, and how likely it was that they were sustained in any given situation, etc. The relatives of the deceased need to understand that this is a necessary thing if they want to know how and why their loved one has died.

People's ideas of what happens at an autopsy are often founded on rumors, tall tales, and superficial knowledge of human anatomy (recently, some educated adults asked me, with straight faces, if a person's eyes fall out of their sockets when you remove the brain from their skull). It is natural, as the average person never needs to know this kind of information. But think of the movie Flashdance. We see the heroine working in a steel mill, holding her angle grinder in what has now become an iconic scene. We do not think about what went into that step in the process: how the blast furnace was designed or what sort of chemicals were added to the raw materials to make the steel. All we see is a steelworker on a hot factory floor, cutting metal. Scenes like this have come to symbolize steelworkers in our minds. Thus, when we think about surgery, we imagine a surgeon at an operating table under the harsh glow of the lamps overhead. We do not think about how the preparation for surgery began – many members of the medical staff also had a role to play in getting the patient ready; during the surgery, the surgeon is trying to anticipate any potential complications and how to avoid them. It is also how we tend to think about autopsies – we come up with a partial sketch based on stereotypes, and it is not a very pretty picture.

In fact, autopsies do not begin in a forensic laboratory but rather in the medical examiner's office, where he or she will complete the first step of reviewing any referring documents. Ideally, those documents will give the examiner a good idea of what may have happened to the person before he or she died – were they sick, did they take some sort of substance, were they beaten, was there anything suspicious about the place the body was found, etc.? That kind of information is vital for planning the next steps of the examination. Unfortunately, however, ideals are just that, and such detailed documentation is seldom encountered. Often, the information contained in the report is very scanty, if it even exists.

After the examiner has reviewed the documentation, he or she will move on to the next step – an external examination, followed by an internal one.

An external examination begins with a description of the clothes the person is wearing. If the deceased is unidentified, its description must be very detailed – any ribbons, inscriptions, prints, fasteners, pockets and their contents, any seams on the clothing are closely examined. This level of detail is necessary, as clothes can be significant for identifying a body. Sometimes, items found in someone's pockets or even the creases of their clothes will shed light on their lifestyle or health while they were alive – syringes, pills to treat various diseases, or sometimes even illegal drugs and narcotics. Any damage to the clothing or blood, vomit, semen, urine, or soil that might be on it is meticulously described and photographed. There have been cases when we were able to identify the perpetrator or the driver of a car that ran over a pedestrian simply by the foot or tire print left behind. Once the clothing has been examined, it is either returned to the deceased person's relatives or sent to the investigator for more study.

The next step is a thorough description of the body and any features it may have – tattoos, piercings, teeth, scars, pigmentations – and, of course, any injuries. If the body is unidentified, the medical examiner will create a verbal portrait of the person, measuring the width of their hands and the length of their feet. It might seem like overkill, but it is most certainly not. After an unidentified person is buried at the government's expense, the clothing, photographs, fingerprints, blood, and verbal portrait will remain behind for identification. That might happen in a month, or maybe in a year. Often, tattoos tell us a lot about a person's life or profession. I have had cases where a body was identified by the address tattooed on the person's chest. And I once examined a man who had a tattoo on his foot of a toe tag with the inscription "Hey, you at the morgue!" (Photo 1).

Here and elsewhere in the book are links for the photographs. Warning! The publisher does not recommend this material for anyone of a sensitive disposition.

Only once the external examination is complete will we move on to the step most commonly associated with a medical examiner's work – the autopsy. An internal examination must include three sections of the body – the cranial cavity, the chest cavity, and the abdominal cavity.

It is worth mentioning that any incisions made will be done with care not to be visible. For example, the incision on a person's head is done close to the nape of their neck, and the skin is then peeled forward and back, the dura mater of the brain is removed, and then the brain itself. The chest and abdominal cavities are cut with a single incision, and then, as a rule, the internal organs are removed all at once – from the tongue to the rectum. This is done because it preserves any anatomical links between the organs, and the doctor can see any injuries or pathological processes better. If necessary, the spine will be cut in order to examine the spinal cord, limbs, etc. Though medical examiners are not limited in the number of incisions they make or how deep or long they can be, or where, none of us will make an incision that will leave a visible mark on the body unless we truly have to. On the contrary, we strive to minimize any cuts we make. There are many ways to remove internal organs, and several of them involve just a tiny incision. In some cultures, young unmarried women are often buried in a wedding dress with a low neckline. In these cases, while performing the examination, the medical examiner will take pains to respect the family's wishes. After he or she has finished, all of the incisions will be sewn up, and sometimes padded with specific material so that no blood left in the girl's blood vessels will leak onto her clothes.

During an autopsy, examiners remove biological material from the body to carry out further studies. They nearly always take samples of blood, urine, and other biological fluids to detect any presence and concentration of alcohol; pieces of internal organs for microscopic examination; and sometimes entire organs (in cases of suspected poisoning, drowning, etc.) and bones and skin in cases of injury. In some cases, the police investigator will draw up a list of what needs to be taken, while in others, it is up to the medical examiner to decide. I think the fact that occasionally organs are removed for further lab study gives some people the idea that morgues are involved in the organ trade, which could not be further from the truth. But we will talk about that a little later on.

People who are not familiar with forensics often ask me: "What do you do with the organs when you are done with them?" Hundreds of times I have explained that all organs are considered to be part of the human body, and once we are done examining them, the majority are simply put back, with some exceptions when they are needed for additional study. After that, the orderly on duty will embalm the body or sew it up, clean it, and prepare it for burial. They will dress them, make them up, and place them in a casket. Mortuary workers are actual miracle workers, and thanks to them, relatives can bury their loved ones and have an open casket funeral, even if the deceased person suffered severe injuries.

Once the examiner has finished, he or she will issue a death certificate, which allows the person's relatives to bury the body. In about a month, test results will come back, and the examiner will issue a final report – this is the part that interests the police.

So, back to our original question – to cut or not to cut?

In the case of a pathologist's examination, relatives have the right to refuse an autopsy. Legally, they are allowed to do so in these cases.

However, things are somewhat different when someone decides a forensic examination is necessary. In these cases, there is no right to refuse. As much as a medical examiner may feel empathy for the relatives of the deceased, it is not up to them whether they proceed or not. The investigator has already decided that a forensic examination must take place. Often, relatives will try to argue that the person's last will did not include an autopsy, or cite religious and ethnic reasons, or note that their loved one suffered from chronic diseases. But their efforts are in vain. The examiner is not the one who makes the decision, and he or she is obligated to examine the body. At most, we might hold off on the autopsy and send the relatives back to the investigator to ask that the body be handed back to them, but the likelihood of this happening is very slim. Over a year, the police might return one or two bodies to the family in these circumstances, and as a rule, they are almost always the bodies of children who had been very ill, who for some reason had been sent for a forensic examination.

Sometimes, cases appear obvious – an elderly person dies, and there is no suspicion of violent death. But once the examination has begun, it reveals that the person was, in fact, murdered. Remember the wisdom of Buddha – "There is no fire like passion, there is no shark like hatred, there is no snare like folly, there is no torrent like greed." Those words are more relevant than ever today.

A few years ago, in a town where I was working at the time, we received notice of an elderly woman who had died at home. It took us a couple of hours to get ready and reach the town. When we arrived at the woman's house, her body was not there, and her relatives were gone. The neighbor informed us that the funeral was already underway, and the body had already been taken to the cemetery. When we arrived, we discovered a grave and a casket with the body inside. We ended up causing an uproar, but finally we were able to take the body back to the morgue. There, we carried out an autopsy, which revealed that the woman had died of mechanical asphyxiation caused by a soft object covering her mouth and nose. Investigators concluded that the woman's son had smothered her with a pillow, and the initial doctor had not noticed her injuries (which would have been very difficult to detect) and issued a death certificate. Because of this, the body was almost buried.

During the turbulent 1990s, following the breakup of the Soviet Union, there were also cases involving bodies that evaded examination. Things were relatively straightforward back then – men with automatic rifles would show up at the morgue and kindly ask the orderly on duty to fork over the body. They did not mince words – give us the body, and you get to live. Fortunately, things have changed, and those situations are no longer a reality, but we do sometimes have to use the police to guard the morgue to keep overly persistent individuals at bay.

PART TWO. THE PROFESSIONAL

1. OUR TOOLS

People frequently use the word "scalpel" when talking about the work of medical examiners and pathologists. They are under the impression that in the morgue we work with scalpels, just like any surgeon. This is not quite the case. I think that it is worth talking about the tools we do use every day.

Medical instruments have existed since ancient times. In ancient Egypt and Greece, Arab and European doctors used a variety of gadgets to poke and prod at the human body. They were made to order from precious metals, usually silver, and were often highly valuable. Any practicing doctor or physician had his own set of tools, which were carefully stored in a specific case, with a separate compartment for each tool. It is interesting that, except for the materials used, very little has changed in the usual surgeon's arsenal. Certainly, over the last several centuries, surgery itself has made a great many leaps forward. We have new tools at our disposal, often made out of the latest materials and using state-of-the-art technology, such as surgical microscopes. But for those who work with the dead, whether in pathology or forensic medicine, there have been no such advancements comparable to the jump from the traditional lancet to the laser scalpel. We are still working with the same tools (with a few minimal changes) as our ancient colleagues.

We have different types of tools – those for holding tissues together, for separating them, and for clamping them down. Let us take a look at them all.

The most basic tool for sewing tissues together is a needle. In forensic medicine, we do not use surgical, atraumatic needles. After all, our patient's wounds are not going to heal, and we do not need to worry about scarring. Mortuary workers use smaller needles when they are preserving and restoring a body. Occasionally, when a person has died a violent death, their face and hands, which are often visible in an open casket funeral, have serious injuries. This is where mortuary workers perform their magic, using small needles, glue, and special solutions to lighten the skin, and makeup to give the person a more lifelike color. They are able to "remove" the most horrific injuries so that the person's family can hold an open casket funeral. To stitch up a standard sectional incision, we use a specially shaped flat needle with sharp edges (Photo 2).

An experienced orderly (orderlies are responsible for stitching up cadavers) can do his or her work very quickly, usually within a couple of minutes. Suturing is a simple process – the needle is inserted on the inside of the incision and moved from left to right, with the edges of the skin coming together, pulled slightly inward to create an airtight seam – this is very important.

The needles have grooves to make them easier to hold and less likely to slip, but they are still not unusually comfortable to hold, and after sewing up a few bodies, anyone's hand will start to cramp up. I know this firsthand, as I have on occasion found myself working without any orderlies, and had to sew up, clean, and dress bodies myself before they could be sent to the family members.

Of course, in my line of work, we do not need to worry about using sterile material for sutures. We do not use catgut (a thread that dissolves in time), but rather a thick, synthetic thread.

During the 1990s, following the breakup of the USSR, morgues in Russia, like everything else, were sorely lacking in available supplies. We ended up having to buy thread with our own money at the market in the city I was working in at the time. Once, my boss and I were shopping for thread, and he was meticulously testing the merchandise, checking it for thickness, and trying to break it. The unsuspecting saleswoman, who was probably trying to be helpful, asked us, "What are you guys going to sew?" My boss answered her honestly: "Dead bodies." The saleswoman did not appreciate his sincerity.

The tools we use to separate tissues have a lot more variety.

In addition to suturing incisions, orderlies also have to open up skulls, and, when necessary, spinal cords, which they do using a type of saw. Previously, they usually did this with a handsaw (Photo 3).

It was not an easy job, but with skill and practice, they could do the work quickly. While I was still an intern, I observed Aleksandr Krieger, an orderly at the Chelyabinsk Regional Forensic-Medical Bureau, opening skulls with a handsaw in one to two minutes. Those saws are still used in our work, and forensic medicine interns begin honing their skills in opening skulls for autopsies, as doctors have to be able to perform an orderly's duties in addition to their own. Sometimes, they use old, electronic autopsy saws – with an electric motor mounted on a high rack and fitted with wheels, and the cutter itself on a flexible shaft. It is operated with a pedal, is not particularly easy to use, and is prone to breaking.

Today most morgues use standard electric autopsy saws, which also have a small saw blade attached to them (Photo 4).

They can cut through a skull in about thirty seconds. One of the drawbacks of these electric saws is that bone shards and blood can spatter a long distance. That is why we use a transparent plastic screen (Photo 5), which covers our heads, so anything that happens to fly out stays on the screen.

Abroad, it is common to see special oscillating saws, which work using a rotational motor on the nozzle, to create high-frequency vibrations with comparatively small amplitude. These are lighter, easier to use, and even cordless, but they are still too expensive for Russian morgues.

We use a hammer and chisel to open the sawed-off bone fragments at the base of the skull or sinus cavities. These tools are made entirely out of metal, which makes it easy to disinfect them. The hammer has a special hook, which can be used to pull back at the arc of the skull in order to access the brain (Photo 6).

The chisel can then separate any uncut fragments of the skull and open the sinus cavities and spinal column (Photo 7). The chisel needs to be durable, so it does not bend or fold, which can happen with poor-quality modern tools.

Of course, the principal tool we use for separating tissue is a knife. In forensic medicine, we usually use three types of knives – costal, small amputation, and large amputation knives (Photo 8).

A costal knife is used to intersect the ribs and make incisions in the skin. It is short, sturdy, with a wide blade and thick back, which the user can lean into to increase the weight on the blade. It is made out of metal, just like the other knives. Old knives from the USSR were of very high quality, with sharp blades that could be sharpened well and used for a long time before they got dull.

Those knives would last for years, and we used to grind them right down to the edge. During the late 1990s, the quality of sectioning knives, along with so many other goods, took a nosedive, even though at first glance they looked just like the old ones. Only part of the blade was hardened, with a very narrow cutting edge. It was better to discard the knives rather than try to grind them – they did not sharpen well at all, and they dulled very quickly.

I remember a case involving a young medical examiner. He was working with one of those dull costal knives, and anyone who has done it before knows that working with dull instruments is pure torture. He finally got a new knife, started cutting a chest cavity, and quickly learned a tough lesson about not following the procedure for a sectional examination. All incisions are made from the head moving downward, but for some reason, he began cutting from the ribs toward the head. He was used to his old, dull knife, and was not expecting the new knife to cut so easily. It slipped right out of his hands, and he accidentally sliced the cadaver's face clean off from chin to forehead. Of course, we were able to pick up the face and sew it back on, but I doubt my young colleague ever made the same mistake again.

Costal knives are somewhat heavier than other tools and are sometimes used like axes to dissect ossified costal cartilage.

The only difference between large and small amputation knives is their size. They are the medical examiner's main tools, and they are used for evisceration (removing internal organs) and the dissection of internal organs and tissues. They are called "amputation knives" because surgeons once used them to perform amputations. They have a longer, thinner blade than costal knives and are relatively light. It is easy to accidentally cut or scrape yourself with these knives. Experienced medical examiners make a point of blunting the tip of their knives to prevent any accidents. Sometimes, examiners wrap the handle of their knives in a strip of cotton material to prevent their fingers from slipping, especially when working with cadavers that have already started to rot. Despite all these efforts, though, we all experience injuries during our first few years on the job, and I myself have plenty of scars on my left hand from either not paying enough attention or rushing my work. Some orderlies have been known to use common cutlery knives made in Germany or Japan. This is discouraged and seems to be rarer today than it once was. Again, amid the period of shortages following the breakup of the Soviet Union, I was working in a small city in the Ural Mountains, which boasted coal mines and no less than four penal colonies. I managed to take advantage of my position and acquire a large amputation knife and a costal knife from the penal colonies. They were a perfect size, made from high-quality steel, sharpened wonderfully, and had incredible handles. I was able to work with these tools for six months until I moved to Moscow. I have been told that after I left my knives seem to have "gone walking."

I have another story involving a large amputation knife.

A medical examiner from one of the regions came to work with us. He had been working for about a decade, with a real wealth of experience and the ego to go with it. We began checking his qualifications and asked him to show us his stuff. That was when we learned that he had only ever worked with a large amputation knife, whether it was the appropriate tool or not. When we told him about the other knives we had, he was surprised – he even asked why we needed so many when that one was already so big. He became testy and argumentative, claiming he was capable of performing the entire examination with a single knife. Then, we asked him to separate the soft tissue of a head using the Medvedev method. It is a method for examining the bones of the face by first separating the soft tissue of the face, moving down to the lower jaw, along with the eyes. Following the examination, the flap of skin is rolled back, without a trace of having ever been cut open. We asked my would-be colleague to perform this technique and left him unsupervised for no more than a minute. When we turned back to him, the innocent cadaver's ears were lying on the table. Our examiner had never learned the Medvedev technique, and decided to begin by removing the ears. Obviously, we did not hire him.

There is one knife that is used exclusively by those who work in the morgue, and never by surgeons – the brain knife (Photo 9). It looks like a large amputation knife but is thinner, double-edged, and does not have a point. This kind of knife is used to remove pieces of organs and tissues for histological examination, and rarely to examine the brain itself.