Kitobni o'qish: «If These Bodies Could Talk: True Tales of a Medical Examiner»
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All rights reserved. No part of this book may be reproduced in any form or by any electronic or mechanical means, including information storage and retrieval systems, without written permission from the publisher, except by a reviewer who may quote passages in a review.
Copyright © 2021 by Alexey Reshetun
© Electronic edition. Alpina, 2022
Alexey Reshetun
If These Bodies Could Talk: True Tales of a Medical Examiner / Alexey Reshetun; – M.: Alpina, 2021.
ISBN 978-5-9614-7711-5
* * *
To my colleagues – the forensic medical examiners at the Moscow Forensic-Medical Bureau.
FOREWORD TO THE NEW EDITION
It has been over a year since the first edition of my book was published. During that time, I have given many talks in several cities, given media interviews, and even been recognized in the street a few times (I am famous!). I have received over one hundred letters, both emails and handwritten, two of which invited me to join an organization to save the universe, the others simply expressing gratitude. I answered all of them, other than the two from another realm. It is nice when all kinds of people you do not even know like your work. That was a new feeling for me, something I was not used to. Before the first edition came out, I had no idea what kinds of things readers would share with me. I learned that many of them were really interested in finding out more about my specialty, that they were able to look beyond old prejudices, and some were even able to re-evaluate their lives. It would seem that my work was done. After all, the book came out, and people liked it. But, my dear readers, you have rightly pointed out to me that some things were missing from the book. I have tried to include them all here.
In this new edition, I will talk about the many types of tools we use at work. Each of them has a specific purpose. I will also talk about what we do in the lab, about exhumations, motorcycle injuries, dismemberment, and iatrogenesis, and, finally, about some of my favorite students.
Some chapters include case studies and quotes from real criminal cases.
I am always open to hearing from you. And I would be grateful if, after reading my book, you send me a few lines letting me know what you think. Email mossudmed@gmail.com or Instagram @mossudmed.
INTRODUCTION
Once upon a time, when I was a boy, I saw the three-volume Atlas of Human Anatomy1 by Raphael Sinelnikov at my parents' friends' house. I got carried away by the book and its realistic drawings and Latin inscriptions. I could not understand a thing, but the words sounded so mysterious and fascinating. I was too young to be thinking about a career in medicine, but I knew that I was deeply interested in the human body, and the way that every single detail has been designed so carefully.
Then I enrolled at the Omsk Medical Institute, which was renamed Omsk State Medical Academy just two years later (today, it is known as Omsk State Medical University). In Omsk (thanks, in part, to the excellent professors of the general anatomy department), I decided to specialize in this particular field of medicine. Even now, at Omsk State Medical University, there is an anatomical preparation2 of upper extremity blood vessels and nerves in a formalin bath, prepared by me under the watchful eye of the admirable Professor Vladimir Rublev. After Omsk, fate took me to the challenging city of Chelyabinsk, where I completed my studies over the next four years, and where I delved into the most interesting topics, such as topographic anatomy and pathological anatomy. I also began specializing in forensic medicine there. In 1997, the Department of Forensic Medicine was a sad sight, with boring classes and absolutely no scientific community. But we learned Vitaly Kryukov's textbook by heart, and by my fifth year, I knew what I wanted to do. I met Professor Pyotr Novikov, who only strengthened that decision. Then, I could not have imagined that I would one day be lucky enough to work in the same department as Professor Kryukov and so many other wonderful professionals whose books I read in medical school and as an intern. If someone had told me that one day I would rub shoulders with Evgeny Kildyushov, Evgeny Tuchik, Ivan Buromsky, Natalia Kachina, Yuri Solokhin, Natalia Selyutina, and Oleg Kriger, I would have never believed them.
But, as they say, man proposes, but God disposes. In 2006, I landed in Moscow, and I hope that is where I will stay. I work in the best forensic medical bureau in Russia – the Moscow Medical-Forensic Bureau. This bureau is Russia's most advanced forensic institution, with enormous labs, departments, and top professionals.
Over the last decade, so much has happened in my personal and professional life, but the one constant is that I have always studied. I have studied with people, some of whom are no longer with us, and I have studied books. I have a personal library of over one hundred forensic medical books, some of them dating back to the 1800s, and others are recent editions. Some of them have ink or pencil notes in the margins, left by their previous, nameless owners, and others have been restored. I have helped write a couple of them. To me, a book is always so much more than sheets of paper bound together.
And I had never thought that, one day, I would be asked to write a book of my own.
WHO IS THIS BOOK FOR?
It all began in 2011, when I discovered LiveJournal and created my own page, mossudmed.livejournal.com. At the time, I had been working as a medical examiner for about eleven years, and I had formed a set of views on human life, health, bad habits, and human vices.
I had decided that I would share my professional observations on LiveJournal, with occasional illustrations to help explain things. I did not do anything to promote my blog, but over five years, its readership grew, and it is now consistently among the top ten blogs in the Moscow region, and the top twenty blogs in Russia.
The blog's popularity grew to the point that Alpina Publishing House's Deputy Editor-In-Chief, Irina Gusinskaya, approached me with an offer to write a book. Thanks to her incredible enthusiasm and support, my book became a reality.
Medical examiners work between the earthly realm and that which has yet to be. We have a front-row seat to the way people sometimes forget to value their present life or think about the future. Medical examiners get up close and personal with the destruction wrought by nicotine, drugs, and alcohol. Most people have no idea of what those poisons are capable of doing, and as a society, we often turn a blind eye to certain bad habits.
I would like that, after reading my book, people are able to take a step back and see themselves from the outside, and take care to avoid having a hand in reducing the time they have with us in this world. I hope that the information in this book will help my readers preserve their health, and the health of their loved ones.
Though forensic medicine is not secretive, it remains a mystery for most laypeople, rife with all kinds of legends, preconceptions, delusions, and myths. As you read this book, you will understand what it really means to be a forensic examiner, and what our job entails. You will learn how forensic medicine differs from pathology, when and why an autopsy is necessary, what kinds of injuries can kill someone and what they look like, as well as many other aspects of my specialty.
It is not a scientific textbook, and it is intended primarily for people who have little to no background in medicine or, more specifically, forensic medicine. For that reason, I avoid any specialized jargon and dry facts and figures, and have attempted to describe pathological processes as simply as possible.
There is nothing fictional in this book. All of the stories described are actual cases from my own practice or were relayed to me by trusted colleagues.
PART ONE. LAYING THE GROUNDWORK
1. WHAT EXACTLY IS FORENSIC MEDICINE?
The answer to that question lies in the term "forensic medicine" itself. There are many definitions out there in all kinds of textbooks and manuals, but I personally prefer Professor Sapozhnikov's rather short and sweet explanation: forensic medicine is "medicine in law." Unlike in many other countries, in Russia forensic physicians are separate from the police and are not under their control, though they do work very closely together. Despite relatively bare-bones budgeting in forensic science departments (morgues are always funded on leftover scraps), this ensures that we remain independent – after all, that independence is the very foundation of forensic science in the first place.
Forensic science is not a new branch of medicine by any stretch. People everywhere have always wanted to know how their bodies work, how they get injured, and why people die. Written records dating back to antiquity and Mesopotamia mention doctors taking part in court proceedings. I would love nothing more than to have a time machine to go back and watch those trials and listen to what my ancient colleagues had to say.
A bit closer to our own era, we might look at early Germanic law from the fifth through the ninth centuries AD in northern Europe, or the Alemannic laws, which already included the concepts of "damage" and "severity of damage" to determine the amount of compensation to be paid to crime victims. That brings us to the medieval concept of "God's judgment" – trial by ordeal – which took precedence over any secular court, when whatever a doctor had to say was the least of anyone's concerns. Or we might learn how the first autopsy was allowed to take place in the French city of Montpellier during the fourteenth century.
Next came the Constitutio Criminalis Carolina under the Holy Roman Emperor Charles V, which especially recognized cases requiring medical expertise, or the work of Ambroise Paré and many other great thinkers, who laid the foundations for forensic medicine as a science.
In the late eighteenth and early nineteenth centuries, as the Inquisition was abolished, several European countries began holding open trials, which often required an expert physician to publicly substantiate and defend his conclusions. This greatly contributed to the forensic medicine's development as a science.
More specifically, what about Russia? Various elements of forensic medicine go back to the tenth century when courts considered a liability for "beatings," "desecration," and "fornication," among other crimes. By the eleventh and twelfth centuries AD, the legal code of Kievan Rus doled out punishments based on whether any bodily injuries sustained were "light" or "severe." At the same time, people began examining dead bodies, attempting to determine the cause of death. Several specialized institutions were created during the 1500s, including the Apothecary Chancery, which, among other things, was responsible for establishing health and sanitation conditions and examining the body of anyone who appeared to have suffered a sudden or violent death.
Here are two examples of how the Chancery worked.
Tsar Michael of Russia wished to marry a maiden named Maria Khlopova, but members of the court were against the marriage, and informed the Tsar that his intended suffered from "falling sickness" (epilepsy). When the Tsar learned that these rumors were likely untrue, he sent his fiancée to be examined by a commission including three doctors, a bishop, and several noblemen, who pronounced her in good health.
In 1677 the Apothecary Chancery ordered the examination of a clerk named Efim Bogdanovan to determine "what illness he had died from." Physicians found that "the illness Efim had was kidney stones, and one of those stones grew large, and as a result, death befell him."3
Going to the doctor was a scary business during the sixteenth and seventeenth centuries, as remedies were often more dangerous than the disease itself. It was not unusual for doctors or other well-meaning but uninformed people to accidentally kill or harm their patients. There was the documented case of a doctor named Mikhail Tuleischik getting drunk and accidentally selling a patient highly toxic mercury chloride instead of medicine. And in 1700, a nobleman named Saltykov was poisoned when a servant named Aleksei Kamen mistakenly bought him the wrong herbs. All of this led to a pair of laws in 1686 and 1700, which would later become part of the Complete Collection of Laws of the Russian Empire, "On punishments for those who do not know medical science and due to their ignorance of medicine, cause their patients to die." These were the first laws that considered any punishments for failed attempts to treat sick people.
And now we have arrived at the era of Peter the Great. Peter reformed just about everything he could possibly reform, and medicine, including forensic medicine, was no exception. His Article on Military and Naval Regulations touched on many aspects related to determining the severity of the injury and the cause of death. For example, the Naval Regulations (1720) included the following paragraphs:
"108. Whenever someone is killed in such a manner that he does not die immediately, but only sometime later, it is necessary to determine whether he died of that beating, or of some other disease. In order to do that, following his death, physicians must cut up the body and examine it for a cause of death, and submit a certificate of such to the court in writing, confirmed by an oath…"
"114. Should there be a brawl in which a number of people begin to beat one man, and he dies of a wound or fatal blow or many blows, it must be determined whether those who took part did so intentionally, and who delivered the fatal blow? If this cannot be determined, the death shall be ruled accidental, and they shall be punished for the brawl."4
The Naval Regulation included examinations to determine whether someone was faking an illness: "Determine whether they are truly ill, and if there is any false pretense, and issue a certificate."5 By the sixteenth century, forensic medicine was already capable of answering many questions that are still under the scope of a medical examiner's work, even today. Take, for example, this excerpt from the certificate of a forensic autopsy performed in 1731:
The autopsy was carried out by doctors from the Medical Chancellery based on an Investigative Order to determine the cause of death of Major Apukhtin, who was found dead in a well at his home. The doctors were asked the following questions: (1) "Were they of the view that Apukhtin drowned himself in the well or was he poisoned?" (2) "Did the Major die a violent or natural death, or was it a case of suicide?" A complete examination of the body was conducted. The conclusion was as follows: "… All of the scratches on his body appeared to be from a tree, stone, or a fall… Based on this examination, it appears that the man drowned, which caused a lot of water to enter his stomach along with other damage, and he was neither murdered nor poisoned."6
Just like anything else in life, people have at times attempted to take advantage of forensic science, twisting it to try to suit their own political goals. During the late nineteenth century, the tsarist government opened the so-called Multan case, in which forensic doctors gave deliberately false conclusions.
"On May 5, 1892, in the village of Stary Multan in Vyatka Province, the headless corpse of the beggar Matyushin was found. Witnesses said he suffered from epilepsy. Following a forensic examination, which was not conducted until an entire month had gone by, the expert falsely concluded that Matyushin died from a cut to the neck. He attributed cuts on his lower legs to having been hung up to drain his blood out, supposedly 'as during a [ritual] sacrifice.' Based on this, members of the Udmurt ethnic group were accused of killing the man. This conclusion, however, was later refuted by progressive Russian scientists Feodosiy Patenko and Emiliy Bellin. Bellin conducted a series of experiments and was able to prove that based on the absence of any blood on clothes or other signs of having bled to death, the head had been removed after he was already dead, to simulate a ritual killing. Following three hearings to consider this scientific examination, the Udmurt peasants were acquitted."7
With time, forensic medicine has grown and developed. Thanks to new research, today, it includes a vast range of cutting-edge knowledge and technology, and is one of the most engaging fields of medicine. The Moscow Forensic-Medical Bureau boasts a highly developed scientific and practical infrastructure with leading experimentation and research. Medical students and those from other specialties work here, alongside numerous fascinating, creative people, including world-renowned scientists and young, innovative experts. Institutions carrying out their own "independent" examinations is a recent fad in Russia, which often gives people the false impression that these examinations are indeed independent, and that their conclusions are unbiased and objective. Alas, that is often not the case – and this is the reason why the independent status of state medical examiners is confirmed and enshrined in federal laws. State medical examiners' salaries do not depend on the contents of their conclusions, and the positions of either party relative to a court case have no bearing on their work.
2. JUST WHO IS A MEDICAL EXAMINER?
Before writing this section, I asked my blog readers to describe to me what, in their minds, is a medical examiner's appearance. As I expected, most of the responses were heavily influenced by stereotypes they had seen on television and in movies. Movies avoid ever showing medical examiners' offices, and instead prefer the drama of a forensic dissection laboratory – where autopsies are performed on dead bodies. In movies, a medical examiner is almost always an aging man, unshaven, balding, and eccentric, with a sweaty face and a wrinkled white coat. He seems to work exclusively in dimly lit basements, with a messy desk covered in old newspapers and half-eaten food, an ashtray overflowing with cigarette butts, and with mysterious stains on the walls, desk, and his lab coat. The character himself is inevitably strange and constantly making deadpan jokes about his work. Rarely does he leave the laboratory, and when he does, he always manages to be casually chomping on a sandwich or a bag of chips, which he will offer to the investigator, only to be surprised when his offer is rejected. Often, he is portrayed as being a bit tipsy and, in older shows, almost always as a smoker. When the investigator asks for his conclusions, the medical examiner will, without fail, wipe his hands on his coat, whip out his notes, and say, in a weather announcer's voice, "Well, it is just as I suspected…" before once again offering the investigator a chip.
But there is yet a second type of medical examiner character in movies, which is quite the opposite to the first one. He is also invariably a man, middle-aged, intelligent, always well-dressed, and he speaks in confident tones that assure you he knows absolutely everything about everything. He needs to establish the exact time of death – and he will, right down to the second. He needs to assess the damage – and he will do so methodically, as the picture of calm, without the slightest shred of doubt. For some reason, he does his job, as well as that of the criminal profiler, which has nothing to do with his position. Occasionally, this type of fictional medical examiner may be a woman – she will be efficient, with her hair in a messy bun, clicking around in high heels as she zeros in on the next task on her to-do list. Regardless of which type of medical examiner our screenwriters have chosen, they often mistakenly refer to the character as a "pathologist," who also happens to take photos of the body at the crime scene, gathers fingerprints, and bags up pieces of evidence. Even more surprisingly, along with the investigators, the character will report on the investigation results to the police chain of command! This is what my readers had to say. Enjoy some of their submissions below:
"I always imagine a medical examiner as a middle-aged man, about fifty-five, and balding with gray hair. He is not married, and he does not have any children. He lives in a small, tiny apartment that belonged to his parents once, which is in shabby condition because his wages are pretty low. He is not very talkative, very calm, and does not have any hobbies because he is always working. He only has one or two friends, who are also doctors, probably people he went to school with. He usually watches television at home. He does not drink much, but he is a heavy smoker. At his age, he is disillusioned with life, has no more dreams or plans. Once he retires, he will continue living the same way he always has."
"He is average height or a little shorter. He is slightly overweight and unshaven. He is always bald, with hairy arms. He has a bad temper, can be caustic toward others, and occasionally even rude. Many think he comes off as a know-it-all. But his friends love and respect him. Of course, he drinks on the weekends and holidays, but he judges others for losing control. He used to drink too much himself but has managed to get his life together. He quit smoking, too. He has weird hobbies that have nothing to do with his job – like studying Esperanto. He is well read and educated."
"He is a large, grouchy man. He hates other people, even despises them a little bit. He looks down on them, even if they are physically taller. He divides the world into red, black, and white, and there are no nuances as far as he is concerned. He could slaughter a pig with a nail file if he had to. He is unpretentious in his food, clothes, music, and movies. People around him do not necessarily respect him, but they are a little afraid of him."
"He is thin, handsome, a ladies' man, a reliable, ordinary guy. He did not start as a doctor, just working as an attendant at the morgue, where his uncle was a medical examiner and took him under his wing. So, after graduating medical school, he returned and never left. He was single for a while, then settled down, got married, had a kid, bought a house, and he has many friends he has known since they were kids… His wife is a good match for him. She is totally the life of the party, so he will never be bored or let his guard down."
"I imagine him as a huge guy (at least six foot three inches, and 260 pounds), who works out at the gym, but he also has a real dark side. He spends a lot of time drinking alone, among the dead bodies, and thinks about the meaning of life and if any of them ever found it. He is lonely and has no family. If he has kids, their relationship is distant. His apartment is dusty, but he has a good stereo system. He listens to either classical music or death metal, no middle ground. He drives a black Cadillac coupe. And has a knife and scalpel collection hanging on the wall. He has a bunch of books about anatomy on the shelf, and a skeleton in the corner. Maybe it is holding a bottle of liquor and has a cigar in its mouth."
"The medical examiner on TV is always a man. He is even-tempered, calm, attentive, careful, not particularly talkative, and often an introvert. He likes to be alone, and only talks to those close to him. He has friends, but just a couple of people (they are friends from school or college). He never talks about work at home or around his friends. He likes reading, good movies, good food, or something creative. Sometimes, when he is in the mood, he might pick up some extreme hobbies – skydiving, for example, just to make himself feel alive. I do not know why, but I do not envision any significant others with him. Maybe there is a woman in his life, but she is not nearby. She comes and goes."
"He's a man between forty-five and sixty-five, with a beard, always standing in the background, a cynical joker, a bachelor, but he likes hitting on women all the time, especially at work. He drinks, but he is not an alcoholic. He might end up spending the night at work, taking his meals in his office."
"Hmm… he is tall, thin, wearing unfashionable glasses, and really needs a haircut. He has a dog, and he is very detail-oriented, and notices imperfections right away, so it was hard for him to find a wife, and he just ended up single… But he is happy like that and sees nothing wrong with it. He sees every detail around him, but he is slobbish, his personal life is quite a mess, and he's always losing his phone and gloves."
"He is tired of his job and his low salary; he smokes and drinks because he knows it is a dead-end job."
"He is cynical and sarcastic, with a lot of bad habits, so he looks older than he is. He has no fashion sense, and he lives alone or maybe even with his parents. He had a family once but got divorced because of his crazy work schedule at the morgue or maybe one of his bad habits. He is not athletic, but sometimes he tries to start living a healthy lifestyle. He spends way more time at work than at home. He's loved by his friends and colleagues alike."
"He is of average height, has a mustache. He is balding and a bit of a pervert."
"If he is a man, he is over thirty, and if she is a woman, she is at least forty-five, because otherwise the family and kids would not let her spend extra time at work. Either way, they are a cynic. They like to relax away from other people in nature, and are particular about drinking certain kinds of tea or coffee, or high-end alcohol and cigars. They are always obsessively washing their hands and cleaning off any surfaces and other things before using them."
"He is a man. He is forty-five to fifty-five years old. He is either a bachelor, widowed, or divorced. He does not have any kids, or maybe he does, but they have grown up and moved out of the house. He is very detail-oriented, to the point of being a bit pedantic. Maybe he is quite a perfectionist. He is always neatly dressed but nothing flashy. He has a couple of old friends he is close with, but who he only talks to every two or three months. He has a dog at home, a mutt named Fido. He likes reading. He has a television, but he has not turned it on in four years. He would rather take his dog for a walk in the woods than spend time at a noisy party, assuming the weather is right. He doesn't like people who are still alive because they make too much noise."
Do you see a pattern? It is almost terrifying – a bald man with hairy arms in a wrinkled suit, with sad eyes, who is possibly a pervert. To a certain extent a mad scientist. Movies and television have clearly made their mark.
Let us start with the fact that in recent years many women have begun working as medical examiners. I think this is part of a growing trend in career choices, as women become more emancipated, and men are becoming gentler and more sensitive, and more likely to prefer another, purer field of medicine other than forensic science. Women work side by side with their male colleagues, and often they work even harder. After all, they are just as capable.
Certainly, there are some remarkably tall male medical examiners, and some of them do have hairy arms, but probably not to the point of scaring children away. Medical examiners are also just as likely as anyone else to lose their hair.
Unfortunately, some medical examiners do smoke but not all of them, and the number of those who do is shrinking with every year. The fantastical image of an expert who happens to be a functional alcoholic is also a far cry from reality. Once upon a time, it might have been acceptable to drink in the workplace, but those days are long gone, and you will not find any drunk doctors or orderlies at the Moscow Forensic-Medical Bureau. Sixteen years ago, as an intern, from time to time, I did see a couple of the most intelligent, most competent and experienced experts step out of the forensic laboratory, make a beeline for the refrigerator, and take a few swigs of vodka. Unfortunately, most of these people have long since died, and those who have taken their place no longer behave like this.
In most cases, dingy basement laboratories are also a thing of the past. Employees at the Moscow Bureau enjoy brightly lit, sparkling offices on the third floor, a separate cafeteria, and strict sanitary and epidemiological regulations.
Medical examiners range from about twenty-four to seventy years of age. Just like any doctors, their chosen specialty is no accident. Occasionally, law students ask me, "Did it take long for you to get used to your job?" Medical examiners do not need to "get used" to their job any more than miners need to get used to working underground, cooks get used to working in a hot kitchen, or obstetricians get used to working on a maternity ward. By their third year, if not earlier, medical students already know if they are drawn to therapeutic or surgical specialties. To summarize, therapeutic specialties involve minimal blood, if any at all, while those who gravitate toward surgical fields can expect all kinds of blood and guts. Someone drawn to the therapeutic side of things will not specialize in surgery, and vice versa. No one is forced into any field. You definitely will not find young men and women beginning their internship in forensic medicine, only to suddenly be horrified upon learning – "Oh, heavens, we have to cut up bodies here!" – and running away screaming. Every student who chooses this or any other specialty is acutely aware of what they are getting themselves into.
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.
In the last few years, we have seen the advent of a specialized knife, developed by Professor Eugeniy Tuchik and Dr. Andrey Chertovsky, which is used to carefully extract the pituitary gland (Photo 10).
Another tool used to separate tissue is scissors. There are several kinds, but the most common ones are used for intestines. One of the blades is thicker than the other and has a thickened, rounded edge with a hook (Photo 11). It is inserted into the opening of the intestines, which are then clamped down and pulled back with the scissors. The hook ensures that the intestines will not slide off of the scissors. This blade should be used only for examining the intestines. Often, young medical examiners use it to open the trachea, where the hook inevitably gets stuck on the tracheal wall. The second blade can be used to examine the aorta, inferior vena cava, esophagus, trachea, and heart. A special set of curved scissors can be used to remove the eyes, and tiny scissors with thin, straight blades are for examining the coronary and other blood vessels.
Scissors are also used to cut hair and fingernails, which is almost always done in cases of violent death. The clippings are then turned over to the investigator.
Forceps are used to hold down organs and tissues. The classic surgical and anatomical forceps are used infrequently, but we do use something called "toothed forceps" (Photo 12). These are simple but very practical. Thanks to the wide surface area and many tiny teeth, they are good for clamping down tissue, without causing any damage. To examine hard-to-reach areas (such as the spinal column or spinal cord), we use a set of forceps that are the same shape, but half the size.
We cannot do our job without using metal rulers of various lengths and qualities. We use them to measure everything – from the length of someone's hair to the size of their injuries and internal organs.
We have another tool that we use for dissections, known as a scoop (Photo 13). It is a type of cup, with a volume of about seventy milliliters, and a long handle. We use the scoop to remove fluids from body cavities and measure their volume. Those fluids may be blood, ascitic fluid (which accumulates in the abdominal cavity) from cirrhosis of the liver, or pus from inflammation of the pleura and peritoneum, etc. The scoop is also used to remove urine from the bladder.
Sometimes, we use buttoned probes (the two top instruments in Photo 14) to examine blood vessels or to measure the length of a wound channel. These are also useful for carefully separating tissues and organs, for example, to remove the circle of Willis's artery (including the grooved probe at the bottom of Photo 14).
But what about our beloved scalpel? Medical examiners only use scalpels in rare circumstances, usually for the delicate separation of soft tissue, such as from the neck in strangulation cases.
I am often asked who sharpens our tools. That depends on where you are. Before, when Forensic-Medical Bureau requirements were far less strict, or at least no one was ever watching, medical examiners had their own instruments. They were responsible for cleaning and sharpening everything themselves and stored their equipment in a locker or an office. They kept their tools in boxes, cases, or caddies.
I have an oak briefcase (Photo 15), which was made in one of the penal colonies in the Urals and given to me by a friend who has unfortunately passed away. Today, medical examiners in Russia do not have their own instruments (at least in Moscow), and the orderlies sterilize and sharpen everything at the start of their shift before laying it out on a special rack for the examiners to use.
Sometimes tape measures are used when we examine the body of a deceased child, for example, to measure the size of their head, chest, and shoulders. We also use specialized instruments in these situations, which are not for examining adults.
These are the tools of the trade. As you can see, there are not very many of them, and the most important thing is not how many we have, but rather our skill at using them, and that they are made of high-quality steel. Sometimes, we still use (and treasure) old tools from our days in the Soviet Union.
2. PUT ON YOUR LAB COAT
One day, when I was only just starting my career in a small morgue, I stumbled upon a stack of old forensic examination certificates, some of which were nearly one hundred years old. They had been written out in black ink, in the beautiful, even handwriting of a laboratory assistant, on paper that had yellowed with time. Looking at them through modern eyes, they were very brief, concise and without any of the "flourishes" inherent in today's certificates. I adopted some of the phrasing used in these certificates as my own, and I continue to use some of it in my reports today. I recall how one examiner had concluded that alcohol was present in a person's body. He wrote something like: "There was a notable odor of alcohol emanating from the corpse, bearing witness to the fact that at the time of death the victim was in a state of alcoholic intoxication." It was from an era without any type of toxicology testing. Of course, nowadays, reaching a conclusion in such a way would be impossible, and forensic laboratories can determine the quality and quantity of any chemical substances in the body, reveal lasting damage caused over time, the presence of microparticles in wounds, plankton in internal organs, and much, much more. The quality of additional laboratory tests always depends on whether the biological material was correctly removed. In this chapter, I will describe how that material is removed to conduct various tests.
In Russia, the Ministry of Health and Social Development Order number 346 from 2010 (among other documents) regulates the activities of state medical examiners. This order is available to the public, easy to find on search engines, and you can study it yourself. It states that blood and urine are to be taken from a body to determine the presence of ethyl alcohol – and if there is no urine, examiners are to remove a piece of the kidney. Alcohol toxicology tests are performed regardless of the person's age (there have been cases of alcohol present in the blood of newborn babies) or the state in which the body is found (of course, if the body is already in a skeletal state, there is nothing to test for alcohol), including cases of the late stages of decomposition (when this happens, examiners remove a fragment of muscle and part of the kidney).
We performed an autopsy on the body of a very elderly woman who had died at home. She had not gotten out of bed for years, and as a result had large bedsores on her buttocks and lower back. A large number of maggots had wormed their way into those sores. Imagine our surprise when toxicology results revealed a concentration of ethyl alcohol of 2.7 parts per million, indicative of high levels of intoxication. Investigators discovered that the woman's son was constantly having people over to the house to get shamelessly drunk, and they were more than happy to pour a drink for the old woman, too. Apparently, everyone was drunk enough that the maggots and bedsores did not bother the woman, or her son, who simply served his mother another shot rather than actually taking care of her. Though, perhaps in his mind, this was his way of taking care of her…
I only had one case of an intoxicated newborn baby in my career. It had an ethyl alcohol concentration of 2.2 parts per million in its blood, which would result in moderate intoxication for an adult – but this was just a newborn baby! An investigation revealed that the child's mother, a chronic and severe alcoholic, had given birth at home. From the moment of conception and throughout the entire pregnancy, she was heavily drunk. Of course, the fetus absorbed some of that alcohol, and it died shortly after birth. The woman was never tried in court because, according to Russian law, they have nothing to charge her with.
That is why biological material is removed to detect the presence of alcohol in all bodies – the presence and concentration of alcohol in a person's blood tells us if they were intoxicated at the time of death or not. Alcohol in the urine can tell us about specific circumstances – for example, how long the person had been consuming alcohol and how much – but only blood analysis can tell us how drunk they were.
Examiners at the Moscow Forensic-Medical Bureau take blood samples (in line with Order number 346n) from the femoral artery and place them into a disposable, sterile vial that has a stopper with a locking ring, without which the container cannot be reopened (Photo 16).
Once the examiner performing the autopsy has extracted the blood, he or she will place it into the vial, close the lid, and right at the table laboratory assistants will seal the container with a specific label indicating whom the blood was taken from, when it was taken, and what laboratory it is being sent to. The name of the examiner is also indicated here. The label seals the stopper and cannot be peeled off. The laboratory assistant then prints a referral to the laboratory, and places it and the vial of blood in a special thermal blood-transport bag, which is found in the forensic laboratory (Photo 17).
Once the examination is completed, the transport bag will be taken to the correct laboratory. If the morgue is in a different district of Moscow, the bag will be taken in a special vehicle belonging to the Moscow Forensic-Medical Bureau, which provides pickups and deliveries at each morgue every day. The laboratory performs the analyses and includes the toxicology results in a formal certificate or final report before sending them to the examiner who performed the initial autopsy. The introductory section of the report will include a description of the bottles in which the samples were delivered, the information from their seals, as well as any tags and inscriptions. This method ensures that the blood samples cannot be mixed up or altered, and chemical results cannot be falsified.
There are times when a body barely has any blood left in it. That is usually due to massive blood loss, whether external (due to injuries to the large blood vessels, for example) or internal (for example, due to bleeding caused by a stomach or duodenal ulcer). But how can you draw blood if the blood vessels are empty? Then, blood can usually be found in the dura mater of the brain, heart chambers, or vessels in the lungs, where it is almost always present. If there truly is no blood at all, then examiners will take a piece of muscle, usually the psoas. When this happens, toxicology results can only determine whether the person was intoxicated at the time of his or her death, but not how intoxicated they were.
Unfortunately, not every forensic bureau in Russia can purchase the special containers they need for these analyses. I once worked in a small town where we did not have access to disposable vials, and so we took antibiotics containers from the hospital, cleaned them, and used them for storing blood samples. That did not affect the results of any analyses, but they were difficult to handle. The vials had a metallic ring and closed with a rubber stopper, which we had to pierce with a syringe to place the blood inside. Occasionally, the containers would break, right in the examiner's hands. In most regions outside of Moscow, the police transported blood samples to laboratories – they would come several times per week, and we would store any biological fluids in a refrigerator until they could be transported. It was legal for the police to provide this transport service and was written into the order.
That is where the inevitable question arises – can you falsify blood toxicology results? History has shown us that you can, theoretically, try to misrepresent anything, and technically it is possible to add ethanol to a blood sample. But that would be very easy to prove, and if that transpired, it would be a flagrant violation of Article 307 of the Russian Criminal Code – issuing deliberately false conclusions. An examiner would be very foolish to try to distort the truth in this way. When alcohol is ingested, it is carried by the blood to all of your body's organs, and can be easily detected. If someone were to add ethanol to a blood sample and falsify the presence of alcohol in the person's body, exhumation would later reveal that no alcohol was present in any of the internal organs, which is impossible once anyone has consumed any alcohol. Some people believe that examiners could inject alcohol into particular internal organs, but this is also impossible, as it would result in uneven distribution and not in concentrations typically resulting from alcohol consumption, while in other organs and tissues (such as the muscles) there would be no alcohol present at all.
I know of a case where some police officers manipulated a young medical examiner. Their colleague died in a car accident while driving drunk. Like any Russian police officer, the deceased man had been insured. His colleagues approached the examiner and informed him that the dead officer's family would not receive any insurance money if he was found to have been driving drunk, and they asked him to help. Foolishly, the examiner agreed, and switched the blood of the dead police officer with that of an old man whose body was lying on the next table. Of course, the story did not end there. The insurance company was very surprised to receive the police officer's toxicology results, given that before getting behind the wheel, he had been seen by witnesses in a large group consuming alcohol at a restaurant, to the point he was barely even able to walk to his car. The investigation resulted in the police officer's body being exhumed, and, indeed, alcohol was found in his tissues and internal organs. The medical examiner confessed to everything, but the police officers then claimed that he had switched the blood samples on his own initiative.
"We just told him how sad it was that our colleague's family would not receive any insurance money, and he did the rest on his own!" they claimed. The examiner avoided any criminal charges, as he was inexperienced, and the incident happened in a small town, where everyone knew each other. But he was reprimanded and learned two vitally important lessons: (1) Never falsify any forensic results and (2) never trust anyone asking you for favors.
In addition to blood and urine, examiners will also take samples of internal organs (the liver, brain, lungs, and intestines) or sometimes entire organs (the kidneys) in cases of suspected poisoning. As I stated earlier in the book, removing some internal organs from bodies may have led to the myth that morgues are involved in the organ trade. However, it is impossible to use any organs found at the morgue for transplants – they cannot be used for this purpose due to the time passed since the moment of death.
Medical examiners can receive blood and urine toxicology results detecting the presence and concentration of alcohol in a person's blood in about an hour. The results are shown in parts per million, or ppm. Up to 1.5 ppm indicates mild intoxication, from 1.6 ppm to 2.5 ppm is considered moderate intoxication, and over 2.5 ppm means that the person was severely intoxicated. Determining the level of intoxication depends on many factors, and the examiner always interprets the degree of intoxication concerning living persons when interpreting toxicology results. The effect of "slight," "moderate," or "severe" intoxication on a specific person's body is highly individual. In some people, slight intoxication will barely be noticeable, while others will be unable to function at the same amount.
It takes much longer – up to four weeks – to detect the presence of narcotics, medications, and other substances, because in these cases biological fluids and internal organs have to be examined for a vast number of chemical substances.
Sometimes, blood is examined to measure the content of carboxyhemoglobin, a firm bond of blood hemoglobin and carbon monoxide. It is measured in percentages, and any amount over a certain threshold is a good indicator of carbon monoxide poisoning, or that the person died before a fire.
In nearly every forensic examination, pieces of internal organs are taken for histological assessment. Since the microscope was invented, people have been curious about microcosms, and have looked at them more deeply with each passing year, as technology has progressed and made this possible. Now we can see single-cell organisms, and, among other things, people have studied the reaction of tissues to injury. To the naked eye, injured tissue looks almost the same one minute, three hours, or a day after a traumatic incident. But at the microscopic level, many fascinating things start to happen once an injury has taken place. Immediately after an organ is injured, inflammation occurs – an entire army of cells races to the problem area to prevent the pathological process. That is why we can stop bleeding and heal wounds and scratches. Under a microscope, we can see how cells pass through the vascular wall, rushing to help; how some cells turn into others, and release certain substances, working to "patch" things up. In the end, the consequences of the damage will be erased. Inflammation is an extremely important process that allows humans to continue to exist.
Any processes taking place in the tissues and organs following an injury go through specific phases, which we can see under a microscope, and which are fixed in time – each phase takes place at a specific time following the injury, not before and not after. That is why histological studies allow us to accurately determine when an injury occurred. You probably know from movies and books that sometimes this is important in exposing a criminal who has been trying to lead the police to a dead end. One simple example: a body is found hanging in a noose. There are no injuries other than the strangulation lines on the neck. It would appear to be a hanging, the vast majority of which are suicides (we will discuss this further in the chapter entitled "Hanging: Fact and Fiction"). However, sometimes the examiner begins to investigate suspicious circumstances, and rather than sending the tissue samples to the archive, he or she takes them to the lab, where the results indicate that the strangulation lines in the person's skin occurred postmortem. At the same time, toxicology results indicate a lethal dose of some kind of medication. The examiner then informs the investigators, who can connect the dots and determine that a crime has taken place – for example, a business partner poisoned his colleague and then staged a suicide.
Another case: on the outskirts of a small town, a young man's body was found with several injuries to the head and body. After a hot pursuit, three people were arrested and confessed that they had beaten the man. One of them claimed he had punched the man several times in the face and left but that the man was still alive. The other two beat him after that, but they also claimed they did not do it for very long or very hard. At first glance, all of the injuries appeared to be more or less the same, but the medical examiner figured they would take several pieces of damaged tissue from various injuries, and marked them all. It turned out that the first man was indeed not lying – he had beaten the victim several hours before the time of death, but it was the injuries inflicted by the other two suspects that were the immediate cause of death. Thus, the first suspect was acquitted of the murder.
Unlike pathologists, forensic examiners do not look at microscope slides themselves (that is, sections of tissue that have been stained and set on glass slides to be examined under a microscope). That is the job of highly qualified expert histologists.
We remove a small piece of every organ measuring about 1 × 1 × 0.5 cm using a knife or sharp scissors. Right at the table, the samples are then placed in formaldehyde for fixation (formaldehyde is very harsh, and medical examiners take steps to minimize contact with it). The fixation is left for a day or two, during which the samples are soaked in formaldehyde to prevent them from rotting. If there are no pathological changes in the organ, we will take one sample, but if there are changes, we will normally take several (sometimes we take quite a lot). As I stated earlier, sometimes the pieces are marked, indicating which tissue or organ they are from. Usually, we can tell what they are simply by their outer appearance, but not always. For example, when we take two samples of muscle tissue with hemorrhaging (and we suspect that the injuries occurred at different times), after fixation in formaldehyde, without labeling, we are unable to determine which muscle they were taken from – the neck or the chest.
After fixation, the tissue is dissected. The organ and tissue samples are removed from the formaldehyde, cleaned with water, and placed on a special table. At the same time, examiners prepare the special cassettes into which they will put the samples (Photo 18).
Small pieces are cut from each fragment of tissue or organ (Photo 19, Photo 20, Photo 21, Photo 22), and four pieces are placed in the cassettes, while the others are wrapped in gauze, signed, and stored in formaldehyde (the so-called "wet archive"). In Photo 23, we can see what is stored in the archive, and, below, what is stored in the cassettes for study.
In these cassettes, we can see the dura mater of the brain (the thin strip on the upper right cassette), and in the lower left cassette we can see four pieces of brain, and even punctate hemorrhages (Photo 24).
Then the cassettes are placed into an automated tissue processor, and a microtome automatically cuts very thin pieces, which are placed on a slide and dyed with distinct colors, each of which has its specific purpose.
Only after this will the histologist study the specimen under a microscope. Since ancient times, there has been an urban legend among medical examiners: once, as a joke, a morgue worker sent a thinly sliced piece of sausage to a histological lab, under the guise of heart tissue, and the histologist diagnosed myocardial infarction – a heart attack. I am sure this is just an urban legend because even in myocardial necrosis, some fragments of cells called cardiomyocytes will always be visible.
I have experienced one situation like this. A body was found at the bottom of a sewer. The police had to use a rope to draw the body out, which, for some reason, was not tied around the man's body to pull him out, but around his neck. The next day, as I examined the body, I found something that looked like strangulation marks and sent a sample for histological analysis. I did not know that the body had been dragged out by the neck.
Imagine my surprise when the test results revealed that the strangulation had occurred while the man was still alive! And imagine the shock of the police when they found out. After all, this meant that the man had died from asphyxiation while they were removing him from the sewer! A big scandal was brewing, and the police department began to panic. They were saved by the fact that further tests revealed without a doubt that the cause of death was something else entirely, and a young examiner had simply misinterpreted the microscopic samples. Sometimes, we all make mistakes…
Various tissues and organs can be removed from a body for forensic examination and laboratory work with biological material and its traces – blood or other substances spattered on clothing, skin wounds, damaged bones, skeletal remains, organs to detect plankton, etc. Like other forensic labs, the crime lab plays a significant role in establishing the truth. Forensic physicians can say a lot about how a person was injured, but we will know even more after examining the injuries closely under a stereomicroscope, for example, a stab wound caused by a knife. With skin wounds, morgue workers are usually only able to give a general description of the weapon used – it had a blade this long, the butt was this wide, and it had this or that shape. But in fact, each knife has its individual properties that are only visible under a microscope. Microscopic emargination tells us whether the blade had notches or curves; skin tears on the end of the butt mean that the thrust was on the butt of the knife. Under the microscope, we can see the puncture wound, and defects in the blade that will show up in the wound might indicate uneven sharpening by hand. Thanks to this type of examination, we can identify the knife that dealt the fatal blow. Frequently, police will provide medical examiners with several knives and ask us to determine which one was used to wound the victim.
When it comes to bone damage, we can determine which axe was used to deal the blow; unburned gunpowder particles on the sides of, or deep within, a wound tell us that a shot was fired at close range; and sometimes we can establish a crime scene based on fragments and particles on the clothing a victim wore at the time of their murder. Finding plankton or pseudoplankton in the organs is a reliable indicator of death by drowning, and sometimes we can even determine the body of water where it happened. By the way, diatom plankton under a microscope is a beautiful sight, and finding them can turn into a real quest.
A flap of skin about half an inch wide is excised from the wound edge to investigate an external wound. If that happens to be on the face, and the investigator wants to remove it, that is what we will do. The skin is very elastic, and any visible defects that remain will later be stitched up, or, if that is not possible, replaced with fragments of tissue and covered in makeup. The skin flap will then be placed on cardboard, marked, and sent to a forensic laboratory.
Bone damage is studied by removing a piece of the bone, or sometimes the entire bone itself. If investigators need to determine the age of an unidentified body, they may need the entire skull to be removed. Once again, this is not the decision of the medical examiner. The investigator determines what should be removed from the body, and the examiner simply follows those instructions. Pieces of the lungs, kidneys, and long, tubular bones will be removed to look for diatom plankton. Entire bones or fragments are also removed in cases of mechanical injury, and based on the nature of the fractures and features at their edges, the medical examiner can determine the direction of the traumatic force, and, therefore, the positions of the victim and attacker when the injuries occurred.
The examinations performed in our laboratories, whether spectral, biochemical, biological, molecular genetic or otherwise, allow us to answer any questions as objectively as possible. Many wonderful professionals work in these labs, in constant contact with medical examiners.
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.
Bepul matn qismi tugad.
