Алексей Решетун
If These Bodies Could Talk: True Tales of a Medical Examiner
3. WHEN THE CURE IS WORSE THAN THE DISEASE
"Errare humanum est" – "To err is human." Doctors are people, too, with vices, weaknesses, and virtues, just like anyone else.
According to the Merriam-Webster dictionary, iatrogenesis is the "inadvertent and preventable induction of disease or complications by the medical treatment or procedures of a physician or surgeon." That includes any condition leading to a worsening of a patient's health or his or her death that is directly or indirectly related to the actions or inaction of medical personnel.
The most important principle for any doctor is to "do no harm." A person who has been asked to help someone cannot make the problem worse or more painful. The principle of "do no harm" is broad, and includes deliberately damaging someone's health (which, fortunately, is quite rare), certain activities which, due to ignorance or negligence, worsen a patient's condition, or taking advantage of the patient for money, among many other things. A doctor's white coat is just like a soldier's uniform: it denotes the serious professional responsibilities of the person who wears it.
Article 71 of Russia's Federal Law number 323, "On basic health protections for citizens of the Russian Federation," states that any person who has completed medical school shall take a medical oath upon receiving his or her diploma. Some of the text of that oath includes the following:
"Having received the high rank of a physician, as I embark on my professional career, I solemnly swear:
– to honestly perform my medical duties;
– to devote my knowledge and skills to preventing and curing disease, preserving and strengthening human health;
– to always be ready to provide medical assistance;
– to treat patients attentively and with care;
– to act exclusively in the interests of the patient, regardless of gender, race, nationality, language, place of origin, property and official position, place of residence, attitude toward religion, beliefs, membership in public associations, and other circumstances;
– to show the highest respect for human life, and never resort to euthanasia…"
But just as I said above, doctors are people, too, with their vices and weaknesses, and often they view taking this oath as some kind of formality. But our entire social life revolves around formalities like this – from traffic rules to laws protecting citizens' health and the criminal code. Humanity continues to exist because of our ability to abide by both written and unwritten rules. Sometimes, when we violate these rules, we are held criminally liable. In other cases, punishment is doled out by the court of public opinion.
We live in an era in which lawyers and money decide everything, and the concept of "justice" almost seems conditional. There are situations where it is arduous, if not impossible, to hold doctors and medical associations liable. But is the doctor always to blame? Let us find out.
People often ask me if doctors have any sense of professional solidarity. Of course, just like any profession, doctors are often willing to support each other, and there is nothing wrong with that. But when professional solidarity morphs into covering up malpractice, that is something else, and completely unacceptable.
Just like any other profession, doctors are regulated at various levels. One of them is the Commission for the Study of Fatalities. This board has the grave task of investigating specific cases of fatalities occurring in hospitals. In Moscow, the Commission meets in a city government building, is chaired by the Deputy Mayor for Social Development, and is attended by the heads of nearly every local medical institution. It looks into serious discrepancies in diagnoses, though those discrepancies may be due to various factors, for example, the discovery of a different disease during the autopsy (hypodiagnosis), the absence of the diagnosed disease during the autopsy (hyperdiagnosis), errors in pathology reporting, cases of late (untimely) diagnoses, etc. Discrepancies are established by comparing the final clinical and pathological (or forensic) diagnoses.
There are three categories of so-called diagnostic discrepancies.
The first category is when it was objectively impossible to make a correct diagnosis, and the error did not affect the outcome of the disease or injury in any way. For example, a person is taken to the hospital in a very critical condition, in a coma, and dies within a few minutes. The final clinical diagnosis, which could be made based on a few tests results, appeared to be a "closed craniocerebral trauma." Later, however, the autopsy reveals that the man died of a stroke, and there was no trace of any head injury. These are two very different conditions, but given the difficulty of a correct diagnosis (the patient was in a coma) and his brief stay in the hospital (just a few minutes), an accurate diagnosis was objectively impossible.
The second category includes cases in which a correct diagnosis was possible, but both subjective and objective errors occurred, though they did not significantly affect the outcome of the disease or injury. Some of these discrepancies include cases involving objective diagnostic difficulties.
The third and most serious category, which is also the most troublesome for the doctor and the hospital, involves cases in which the hospital had everything it needed for a correct diagnosis, including specialists and equipment, but errors were made, leading to an insufficient or incorrect course of treatment, which played a decisive role in the fatal outcome of the disease. These are cases of iatrogenesis or the doctor doing more harm than good. Unfortunately, this is not unheard of.
Here is one example.
There was a case of a young man who had been found injured in the street. He was taken to the hospital and diagnosed with a "closed craniocerebral trauma," and though his condition was dangerous enough that he needed a feeding tube – that is, bypassing the gastrointestinal tract to provide the body with nutrition – he appeared to be on the road to recovery. A feeding tube, or parenteral nutrition, enters the body through the central veins, usually the subclavian. To do this, hospital staff had to insert a catheter through the vein and inject a specific nutritional solution into it. In the vast majority of cases, vein catheterization does not cause any problems whatsoever – but sometimes things can go awry. Sometime after the young man's feeding tube was inserted, his condition began to deteriorate. Despite continuous therapy, he died. During the postmortem examination, the examiner noticed that there was, in fact, no subclavian catheter, only notes in the man's medical chart and a puncture wound where the catheter would have been inserted. After removing the man's sternum, the examiner noticed that the pericardium was very tense, and upon closer examination he found a lesion on the heart wall measuring about 0.1 × 0.1 cm. There was a large amount of a milky-white fluid in the pericardial cavity, which had compressed the heart until it simply stopped beating. Analyses showed that the liquid was indeed from the man's feeding tube, and everything became clear. During the subclavian catheterization, the man's parietal pleura and pericardium were damaged, and rather than being pumped into the bloodstream, the nutritional fluid instead poured right into the man's heart cavity. It is unclear why the doctor performing the catheterization did not feel the catheter slip so far out of place. The IV catheter is soft, but damage can happen – cases of a catheter traumatizing the walls of the subclavian vein and causing bleeding, leading to death, are not unheard of.
These kinds of discrepancies make up the third category, and they lead to grave consequences for the hospital and the individual doctor, which can include fines, disciplinary action, and even criminal charges.
While working for an interdistrict department in the Urals, I would sometimes deal with situations involving a closed craniocerebral trauma, where the patient suffered a subdural hematoma – that is, a hemorrhage under the dura mater of the brain. This kind of hematoma is dangerous, as it squeezes the brain, which, from inside the hard skull, has nowhere to go, other than the foramen magnum, which causes cerebral edema and death. However, if a subdural hematoma is diagnosed early, it can be removed through a craniotomy, which will prevent cerebral edema. Often, a person will be taken to the hospital, and after examination, doctors will suspect he or she is suffering from a subdural hematoma. They will perform a craniotomy, say, on the right side. They do not find anything, so they simply stitch up the incision. But the patient dies, anyway. Later, during the autopsy, we will discover a subdural hematoma on the left. The doctors at the autopsy inevitably scratch their heads but are unable to explain it.
We have found gauze in corpses, forgotten by surgeons during an operation, and once while examining a person who had died very suddenly, we felt some kind of dense formation in the person's abdominal cavity. Since we have to examine any such formations, the medical expert made an incision, only to discover a pair of tweezers (Photo 25).
The man had an old surgical scar on his abdomen, but we were unable to determine what sort of surgery he had or when it took place.
Medical error and negligence and medical crimes are tough topics for me. You always want to believe that your colleagues are honest professionals, and immune to any indifference, extortion, or official forgery. A few years ago, a doctor friend of mine was planning on moving from the provinces to Moscow, and he asked me several times how much doctors make in the capital. I really did not have an answer because I do not work in clinical medicine. But it turned out he was not interested in how much his official salary might be – he finally asked me, point-blank, "How much can you take in bribes?" He was intending on extorting money from his patients. We fell out of touch long ago, but I know that he eventually left medicine. I am probably clinging to old rules, but I believe that if a person in Russia chooses to become a doctor, he or she should be motivated by a calling, rather than promises of riches.
Of course, we should keep in mind that cases like this are the exception, rather than the rule. If we look at the vast numbers of patients that doctors see and provide skilled assistance to each day, the number of cases of iatrogenesis is negligible, and when it does occur, it tends to lead to scandals and outcry. Often I meet doctors who are dedicated to their profession, who work selflessly and responsibly, helping patients. While it is true that in Russia socialism was replaced with capitalism, and medicine has now been commercialized, most medical students are drawn to the field for noble reasons.
I knew of an ICU doctor who died on the job. He began his shift and was so busy that he literally did not have time to sit down or even take a drink of water the entire day. That evening, a patient in a critical condition was brought in and suffered several heart attacks during the night. Every time, the doctor brought him back to life. After the last cardiac arrest, at about 6 a. m., the doctor managed to restart the man's heart, and then, according to his colleagues, dropped dead onto the floor. Despite already being in the ICU, he could not be resuscitated. The next day, I examined his body. It turned out that several hours before he died, the doctor had developed a myocardial infarction, which caused a rupture to his heart wall, a pericardial tamponade, and sudden death. Certainly, the doctor must have been aware that something was not right with his own heart, but he was unwilling to leave his patients.
There are many stories of doctors practically pulling patients back from the afterlife, picking up arms and legs after serious injuries, and performing the minutest of operations, so delicate that the tiniest error would lead to disaster. Performing a forensic examination, reading the person's medical record and appreciating the monumental steps that have been taken to preserve his or her health can literally take your breath away. Those are the times when I realize that the work of a forensic medical examiner is child's play compared to what clinicians do, especially surgeons. In addition to the day-to-day stress of their jobs, doctors are increasingly finding themselves involved in litigation. The vast majority of these lawsuits, unfortunately, are motivated by nothing more than the desire for monetary compensation for moral damages. In other words – the patient did not like how he or she was treated and decided to sue the doctor and the hospital. I have been an expert witness for many such cases, and often the plaintiffs are suffering from some kind of mental illness. Of course, it is rare for the court to side with plaintiffs in such cases, but no one ever compensates the doctors being sued for their frayed nerves or lost time.
Despite all of the challenges, there are still many honest, skilled, and responsible people working as doctors in Russia who do their jobs to help people. I hope that their numbers will continue to grow.
4. LAND OF THE LIVING
"Where do you take the black eye pictures?" That was how my conversations usually started at the interdistrict morgue where I worked at the time. As I mentioned earlier, medical examiners are universal specialists, and our work also includes cases with live patients. In this chapter, we will discuss a medical examiner's work with outpatient services.
Outpatient examinations occur for many reasons – the police or investigators order them, detainees are suspected of having committed a crime, or frustrated citizens have come on their own initiative.
When someone is arrested as a suspect in a crime, he or she must be examined to reveal and assess any injuries (or the absence thereof). This is done to prevent the detainee from later claiming that he or she was beaten during the arrest. People in this situation are always escorted in Russia, to protect the medical examiner's safety. There have been cases of detainees attacking the doctors, or even trying to hold them hostage. Luckily, cases like this are exceedingly rare. Most of the time, detainees are glum, nursing a hangover, and only have a hazy memory of the night before and whatever landed them in this position. Almost all of them tell the same boring story.
I have only had to examine a few truly evil people. One of them had murdered six people, and I remember him very well. He was short and gray and suffered from mental illness. Previously he had been tried for drug trafficking. He raped and strangled all of his victims, except for the last one. The town did not initially realize that there was a "serial killer" in their midst, until one morning two schoolgirls' bodies were found on a children's playground. They were dressed in their school uniforms, still wearing white bows, which made the horrible situation seem even more tragic. Even worse – residents of the surrounding homes had heard the girls' screams the night before, simply assumed they were playing, and did not do anything (I will discuss this more in the chapter on strangulation). After this, the murderer managed to kill yet another woman, but this time, the neighbors noticed the commotion and called the police. He ran up a tree, where he was arrested and taken into custody. He immediately confessed to all six murders.
What I remember most about this man was that just from looking at him I would never have thought that he was capable of murdering six people. That image is forever burned into my memory, and to this day, I sometimes find myself involuntarily comparing people to this terrifying man, who was later found incompetent and sent away for compulsory treatment.
Sometimes, the police cannot bring a detainee for an examination, and the medical examiner has to go to them. In Russia, this means traveling to a penal colony. I have been to Russian penal colonies many times. The first thing you notice, when visiting, is how clean these places are. Even if the asphalt is old, there is not even a pebble in sight or a speck anywhere. The prisoners march around in single file, singing songs. Flowers are growing, and everything is either painted or whitewashed. The second thing that sticks out to me is how polite everyone is – of course, prisoners have their ways of speaking to each other, and everyone knows the prison staff are not playing around. But the way they talk to outsiders is quite specific. All of the prisoners who are allowed to move freely around the penal colony (they do exist) greet everyone. They are not sullen or mumbling, but they pronounce "Hello!" as they stand up straight and look you in the eyes.
About twelve years ago, there was an incident that I cannot ever forget. I had been called to a penal colony for a rather pressing situation – to examine a prisoner who had been subjected to "enhanced techniques." The day before, someone had been transferred from another prison. As usual, they were sent for a complete examination and inspection, which included their natural body orifices. Despite how dramatic it sounds, there have been documented cases of prisoners hiding drugs or even knives in their rectum. It appeared that one of the prisoners, who happened to be from the country of Georgia, refused the order to "bend over and spread 'em." An altercation broke out, and the man was taken to a cell, where the guards had beaten him with rubber batons. I went to the cell to examine him, where I found the characteristic bruises and welts on his buttocks and thighs.
At the direction or order of law enforcement agencies, sometimes people come for an examination after having gone to the police and written a statement against their abuser. They are then sometimes sent to a medical examiner to document their injuries. Sometimes, the injuries have happened quite some time before the examination takes place, and the victim may have even been hospitalized for a while, and other times they are still very fresh. This group also includes both male and female victims of sexual violence. These patients also often face misunderstandings related to the less-than-accurate information documented by medical examiners. For example, rather than using accepted terms for injuries ("bruising," "abrasions," etc.), some doctors decide to get creative and use terms like "soreness" and "cyanosis" that have nothing to do with the injuries at hand. Sometimes, doctors do not document the exact location and number of the injuries, but that kind of information is extremely pertinent in court. By the time these patients have come to a forensic medical examiner, as a rule, all of their injuries have probably healed, and the examiner will have to note that in his or her report. All that is left are medical documents in which, again, the injuries are not accurately described. That leads to a very unpleasant situation, in which someone has been beaten, suffered injuries, only to heal and come to a forensic examiner in good faith, but their injuries have already faded. We have to empathize with someone who has suffered both physically and emotionally but has no record of those injuries. But we also have to think about this from the doctor's perspective – their job is to exclude any serious trauma, prevent complications, and save lives – in their minds, they often have no time for bruises. But when it comes to harm to one's health, nothing is trivial.
In some regions of Russia, forensic medical examiners examine victims right at the hospital – the examiner will come and describe any injuries on the person's body. This approach makes it easier to document everything that may later prove relevant to the examiner and avoid unpleasant situations for the victim.
The third, most common, group of people we see in Russia are those who come for a forensic examination of their own volition to "take black eye pictures," as I described at the beginning of this chapter. There are many reasons why someone might do this. Some people might wonder why someone would need to go to an examiner and spend the time and money necessary for an examination just to go write a statement and punish their abuser. However, our people have come up with a very important use for expert opinions. These reports are usually used by women who have been victims of domestic violence at the hands of their husbands or partners. Unfortunately, the cycle of abuse is notably common, and in some cases, deeply entrenched. (Incidentally, we should also remember that men can be victims of domestic violence, too, and wives have been known to beat their husbands.) One way that abuse victims attempt to restrain their violent spouses is by opening the door to filing a statement with the police. That is where a forensic report from a medical examiner comes in. Upon seeing documentation of the injuries they have caused, sometimes abusers will temporarily calm down, and promise to turn over a new leaf. Alas, the cycle of abuse is complex, and the victim wants to believe him, but miracles simply do not happen in real life, and sooner or later she will have to return to take more pictures of more black eyes.
We have occasionally had situations at the morgue where people were waiting their turn to be seen for a forensic examination only to be involved in another altercation. For example, once, a husband and wife both showed up at the same time, after having fought the night before. Both spouses had planned on photographing evidence of their injuries in hopes of calming the other down, and neither expected to see the other there. The conflict bubbled over once again, but this time with the involvement of bystanders who took one or the other's side, and the situation devolved into an all-out brawl. People began using anything available to them as weapons – including tiles on the porch and even a metal urn (which later had to be thrown out, because it was almost flattened). People fell from the porch and received fresh injuries. All the while, they were also hurling insults at each other that would have made a sailor blush. Just about thirty feet away, bodies were being handed over to relatives, sometimes to the mournful sounds of an orchestra, as funeral attendees became the unwilling witnesses to the showdown. This situation ended in the same way so many others like it had before – the police department was nearby, and squad cars arrived to haul away everyone involved in the altercation. A few days later, everyone returned to photograph their injuries, this time with an order from the police.
Another time, a man came from the neighboring district, claiming that he had been beaten by his wife. According to him, she was responsible for all of his injuries. I should mention that examiners will note down everything a person says, even if it appears to be complete nonsense. After recording the person's version of the events, the examiner will offer to document and describe all of the injuries. This man was insisting that he had been the victim of a vicious attack at the hands of his sadistic wife, who simply wanted him dead. He was unaware of any reason for her beating him and had no inkling as to why she would do this, as he was almost an ideal husband, with few shortcomings, though, of course, he drank, but only when he had a really good reason. His injuries were standard – scratches, bruises, nothing out of the ordinary.
Sometime later, after that catch of a man had left, a woman came to document her injuries. She was hoping to scare her monstrous leech of a husband, whom she claimed had ruined her youth, middle-aged years, and future old age. He was a pathetic man, a drunk, and a parasite, a worthless husband. He had beaten her for almost no reason – she had simply told him a few times, very nicely, to find another job other than gathering metal from other people's back yards. She told us she had been very calm throughout the conversation, like the gentle, teetotal woman she was. However, the smell coming from her betrayed any notions of her sobriety. The man and woman had different last names, but, sure enough, they had the same address, and were indeed married. Upon learning that her husband had come by just an hour earlier, the woman ran to the police station to file a report. I have no idea how their story ever ended.
Another time, I witnessed a particularly absurd situation.
A young woman came for a forensic examination. She was from the village and said she had been beaten up by her boyfriend. She was very determined and had threatened him with court cases and a heavy sentence, had ended the relationship, and periodically seemed like she was about to faint. After noting down all the details of the horrifying encounter she described, I asked her to show me her injuries so I could describe them, but she suddenly became too shy, which seemed inconsistent with her previous statements and behavior. I explained to her that I could not describe the injuries without seeing them, the report would not be useful, and her attacker would not be held liable for his crimes. That convinced her, and she showed me her back, legs, and abdomen, where she had claimed her boyfriend had kicked and punched her. In all my years as a medical examiner, I had never seen anything like this – she was covered in blue marker ink. Of course – we talk about being "black and blue." And as the police later explained to me, the woman was furious at her boyfriend for breaking up with her and decided to get revenge by having him sent to jail. To do so, she and a friend drew bruises all over her body, in hopes of seeing this scheme through. They did not succeed.
When I began my career, I was often surprised that most people who have come for an independent forensic examination attempt to make their injuries seem more severe. They describe the circumstances of their injuries, using all manner of insults, and when asked if they lost consciousness during the attack, they invariably answer, "Yes, of course, I did!" even if only for a few minutes. People believe that the more colorfully they can describe their attack, if not resorting to outright lies, they will increase the official damage to their health. Once they receive the official report describing their bruises and abrasions as not a threat to their health, they are indignant, as they do not understand that the attacker's sentence will not depend on how well they described their injuries.
I have also had situations where someone comes to me for a forensic examination, only to be brought back later as a corpse. These are the times that remind me just how short and unpredictable life is, and you begin to appreciate it even more.
A young man came in for an appointment. He was simply dressed and ashamed about the reason for his needing a forensic examination. After talking to him, I learned that he was planning on divorcing his wife. She was, apparently, a very decisive woman who enjoyed being in control and periodically enforced that control with her fists or any other objects conveniently to hand. The man was truly miserable, and the straw that broke the camel's back had happened the night before.
The situation was quite simple – he and his wife had not wanted to share the television. Or rather, his wife had wanted to watch a show, and he… well, who cares what he wanted to watch? The argument ended with the wife watching her TV show, and her husband being severely beaten. I noted several bruises and abrasions on his head and torso. When I asked what she used to beat him (a standard question), the man lowered his eyes and answered, "A frying pan, Doctor." That was what had pushed him over the edge. He decided to file for divorce, and to avoid any further trouble from his wife, he wanted to be able to intimidate her with the fact that he had already documented his injuries and would simply go to the police if he wanted to.
The man had a glimmer of hope that the domestic violence would eventually stop, though it was clear to me that this was in vain because he was simply one of those people who endure everything. But you cannot make choices for people, and he chose to take his report and go home.
The next morning, I went to work, and, as always, began looking through the list of new arrivals, to see who had been brought in that day – how many murders, sudden deaths, etc. I recognized the man's name on the list. He had been my patient the day before. I went to inspect, and sure enough it was him, lying on a table with a wound in his chest. When I examined his body, I learned what had happened to the poor man. After his forensic examination, he went home, and on the way had gathered some courage and shown his wife the document with his claims. As usual, his wife did not accept that kind of audacity, and an argument ensued, followed by a physical altercation, which ended when the wife grabbed a kitchen knife and stabbed him directly in the heart. The man died instantly.
There was another very memorable case of having to perform an autopsy on someone I had previously met.
This was a man who came to be examined. He was a little over fifty years old, a German businessman whom I found impressively articulate, and, despite his age, in excellent physical condition. He was strong, athletic, and clearly lived a very healthy lifestyle. Sometime earlier, there had been an attempt on his life over a business dispute. He had been shot and a bullet pierced his chest, but he had survived, and was now being examined at the request of the investigator. In cases like this, we always study original medical documentation for the period of the person's injuries and treatment, and also examine them for signs of any prior injuries.
I conducted the exam, described the man's scars, and then cataloged everything and issued the report. As cases like this go, there was nothing unusual or out of place. The next morning, I was called to go examine a body. We arrived at the center of town and went to an ordinary courtyard surrounded by nine-story Soviet-style apartment blocks. A dead man was lying near the entrance to one of the buildings. According to eyewitnesses, he left his apartment building and was walking to his car, when automatic fire was heard through the basement window, after which two men ran from the basement to a car parked nearby and sped off. An AK-47 was lying right there. It had all the signs of a professional hit. We turned the body over, and I immediately recognized him as the businessman who had been in my office just a day before, in connection with a failed assassination attempt. He was shot right in front of his wife and child, who were waving goodbye to him through the window. That was about the first (but certainly not the last) time I saw the horrific damage an AK-47 can inflict – bullets had gone through the man's body, destroying his thigh bones, and knocking huge pieces of concrete out of the wall from the building across from his.
All of these incidents took place at the interdistrict department in the Urals. As a rule, in big forensic bureaus, people specialize – some examiners work with the dead, others work at the morgue, and others work on patients who are alive.