Learning to Speak for the Dead
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Version 0 of 1. The dead man waited on a gurney. His corpulent frame, after days of decomposing, had turned the mottled green of a ripe watermelon. He had been found alone in bed in his Manhattan apartment, surrounded by an avalanche of discarded bottles and trash. Now Dr. Jacqueline Nunez was by his side. As a medical examiner training in New York City, she had the job of finding out what had happened to him. It would not be quick or easy, not like television crime shows in which deaths are neatly wrapped up in under an hour. The job requires examiners to break apart bodies: hard physical work. Stomach-turning, too. Dr. Nunez would be on her feet for hours, splattered by blood and other body fluids, at times breathing an unimaginable stench. She could spend weeks, or even months, piecing together clues that might never add up. Standing on top of a metal stool, Dr. Nunez cut into the torso. A thick greenish fluid oozed out. She grabbed an industrial-size ladle to scoop out more of it. Then she stuck both hands into the body to feel around for the liver. She came up empty, her gloves dripping. “Oh, what a mess,” she said. “I’m not sure what’s going on. This is the worst I’ve ever seen.” It got messier. Dr. Nunez cracked open the chest with clippers to remove the heart and the lungs. She cut out the intestines. Then, as a whirring electric saw was used to open the skull, Dr. Nunez reached in to lift out the brain. When she was finished, she cleaned up. Then she started on her next patient. DR. NUNEZ is part of a New York City fellowship program that has become one of the country’s most renowned training grounds for medical examiners. The Forensic Pathology Fellows Program has helped resurrect a long-troubled agency, the New York City Office of Chief Medical Examiner, which as recently as the 1980s was widely accused of incompetent management and bias toward the police. The estimated 500 forensic pathologists working nationwide are roughly half the number needed, according to the National Association of Medical Examiners. “Everyone who passes the medical examiner’s boards is sought after,” said Dr. David Fowler, the association’s president, who attributed the shortage to limited training opportunities and relatively low compensation compared with the pay that pathologists receive at hospitals or in private practice. Since 1990, the New York fellowship program has trained 100 medical examiners. The program has bolstered the agency’s status as a national model for medical examiner’s offices and has been the source of a new generation of forensic experts, producing the current or former chief medical examiners in more than 20 jurisdictions, including Washington, San Francisco, Honolulu and the States of Connecticut, New Hampshire and Vermont. Since the program is based in New York, the city is somewhat insulated from the shortage elsewhere in the country. Dr. Nunez, 34, is one of five doctors who have spent the past year preparing to become medical examiners. A cheerful woman who favors large gold hoop earrings, she is often mistaken for a schoolteacher. She grew up in Amityville, on Long Island, the older of two children of a landscape worker and a homemaker, and she went to medical school in the Dominican Republic. Instead of a black doctor’s bag, she carries a red-top Craftsman toolbox packed with knives, scalpels, forceps and scissors. She does not mind working on bodies, not even one that is decomposing, known as a “decomp,” which is often the least favorite case for medical examiners. “A lot of people — especially other physicians and other pathologists — used to tell me, ‘I would have loved to have done forensics, but I can’t deal with the decomp,’” she said. “I actually have no problem doing them, and one of the reasons is because I feel like I’m the last person that is going to be providing some kind of care, bridging their death and their life. I’m the last person.” NEW YORK CITY’S Office of Chief Medical Examiner is based in a squat, tired-looking building, at 520 First Avenue, with letters missing from its name. Inside, a Latin inscription behind the reception desk translates to: “This is the place where the dead help the living.” The medical examiners are the conduit for the two, providing answers, consoling grieving relatives and, if needed, informing police detectives. They fill a crucial but often overlooked role in a city where 5,000 autopsies a year are performed for deaths that are deemed sudden or suspicious or are a result of crimes, accidents or suicides. It was medical examiners who sifted through the remains of more than 2,700 victims after the Sept. 11, 2001, attacks. When there were no intact bodies, the pathologists had to improvise. They measured fingers to help identify people, using metal ring sizers that were donated in Tiffany’s little blue bags. That was also the year when Flight 587 crashed in Queens with 260 people aboard, and the year when envelopes laced with anthrax became a new terror threat. “When things get bad here, they get very bad,” said Dr. Barbara Sampson, who was appointed the city’s chief medical examiner in 2014. The agency’s staff of 600 includes 24 senior medical examiners, 20 of whom graduated from the fellowship program. The agency runs offices in every borough, three mortuaries and the country’s largest public DNA lab, along with other labs for toxicology, molecular genetics and histology, the microscopic examination of tissue. The agency’s $75 million annual budget is the equivalent of $8.82 per city resident for the laboratories, investigations and other activities, far more than the national average of $3.36 per resident, according to the National Association of Medical Examiners. Dr. Sampson, herself a 1998 fellow, says she looks for future medical examiners who can communicate and work well with others. The fellows, who have already graduated from medical school and completed a residency program in pathology, are selected after a four-week unpaid tryout. They receive a salary of $131,566 for the academic year, which runs from July 1 through June. At the end, the fellows sit for a nationally administered board exam; nearly everyone passes. Some will be offered permanent positions as senior medical examiners with annual salaries starting at $159,741, or invited to continue as fellows for a second year to specialize in the pathology of the brain and the heart. In contrast, general pathologists at hospitals and in private practice typically earn $200,000 or more. In total, there have been 58 women and 42 men in the program. About one-fifth are black, Hispanic or Asian. Many have foreign backgrounds. This year’s fellows include doctors who grew up in Croatia, Russia and Mexico. For some it is a calling. Dr. Stephen Melito, 32, went to medical school just so he could become a medical examiner. As a teenager in Farmingdale, on Long Island, he used to volunteer as an underage buyer of cigarettes in undercover police operations. For a high school class, he researched how to tell the time of death at a crime scene. Dr. Kanayo Tatsumi relocated to New York from Vermont less than a year after she was married. Her husband, a surgical resident, stayed behind to finish his training. Dr. Tatsumi, 33, was still in college when she interned at an Illinois coroner’s office. The first autopsy she observed was of a young woman killed in a car accident. She could not stop thinking about her. Had she been wearing a seatbelt? Had her airbag deployed? “It could have been me; it could have been any of my friends,” Dr. Tatsumi recalled. “I started realizing that we could do a lot to prevent injuries, even though we’re getting that data, if you will, from death.” THE MEDICAL EXAMINERS in training have desks side by side in Room 335 — known as the fellows’ room — where a bulletin board is crammed with photos of fellows in hazmat suits, at parties and holding babies. They alternate between “A” days for autopsies and “P” days for paperwork, while squeezing in lectures on topics like firearm injuries, blunt-force trauma and pediatric deaths. They go to crime scenes, rotate through the labs and learn to handle infectious diseases like Ebola and respond to terror threats. The A days begin with an 8 a.m. triage meeting. Dr. Nunez stood behind a lectern, presenting case histories to senior medical examiners, forensic anthropologists, police detectives and medical students. There were 11 cases that day, not unusual in number or scope: An older man died after falling at home; a younger man with a cocaine habit was found dead by his brother. Afterward, Dr. Nunez headed down to the mortuary. She checked the body bags in the hallway. “This is one of mine,” she called out to a technician. “This is another one. I’ve got one more.” Her next stop was the autopsy room, which has eight stations, each equipped with a metal table and a scale. By 9:30 a.m., Dr. Nunez was at one of the stations, engrossed in her first case. A thin black man lay on the table. She removed his pancreas. It had dark spots where blood had pooled, a possible sign that he had spent a lot of time out in the cold before he died. Just before 11 a.m., she was ready for her next case. Dr. Nunez does not take breaks or stop for lunch. “Once I get going, I just keep up the pace,” she said. “You build endurance, you pick up stamina and you get used to it. That’s what this year is for.” Her scrubs were stained with blood and fluids. “I’m not squeamish about it at all anymore,” she said. At 3 p.m., Dr. Nunez was still working on her third autopsy when the other medical examiners reconvened to review their findings. She did not have much to report yet. “It happens,” she said. “I’d rather we look at everything and not rush through anything.’’ Afterward, Dr. Nunez retreated to the fellows’ room to draft a report for each autopsy. She would order lab tests, interview relatives and consider other evidence before closing each case. Dr. Sampson reads every report. The fellowship program is the legacy of Dr. Charles S. Hirsch, the city’s chief medical examiner from 1989 to 2013, who was known to focus not only on technical skills but also on scientific integrity, common sense and compassion. “I still quote Dr. Hirsch two or three times a day,” said Dr. Susan Ely, a 1997 fellow who is now the program’s director. “His presence is still very much felt here.” Dr. Hirsch, a former chief medical examiner for Suffolk County, was appointed in 1989 by Mayor Edward I. Koch, to lead an agency battered by conflict and mistrust. The mayor had fired the previous chief medical examiner, Dr. Elliot M. Gross, citing poor leadership and management. In 1985, Dr. Gross was accused by defense lawyers and forensic specialists of producing misleading or inaccurate autopsy findings in cases of people who died in police custody. A mayoral commission cleared him of wrongdoing but faulted a longstanding agency practice in which deaths in police custody were routinely left as undetermined. Though the medical examiner’s office is now considered professionally run and independent, it has not entirely escaped controversy. The agency has been challenged for using a highly sensitive technique to analyze trace samples of DNA — known as low copy number DNA testing — that has been criticized as unreliable. In February, a former toxicology lab director sued the city, claiming that she was forced out in part for raising questions about its use of the technique. EACH FELLOW is expected to complete about 250 autopsies, a goal based on national standards for training medical examiners. The sheer diversity of cases in a big city ensures that they see just about every kind of injury imaginable. Dr. Judy Melinek, who chronicled her fellowship experience in a 2014 memoir, “Working Stiff,” recalled that she was told to go to New York by a former fellow who noted, “All kinds of great ways to die there, and the teaching is brilliant.” Dr. Rafael Garcia, 36, had barely started the fellowship program in July when he was assigned not only his first homicide but a double homicide. He spent seven hours working on just one of the victims, a man who had been stabbed 20 times. As it happened, he had attended a lecture on stab wounds the day before. Almost a year later, Dr. Garcia has completed 250 autopsies, of which about one-fifth have not been resolved. “It’s funny to see a TV show and how they do everything in the same day,” he said. “That’s not reality.” Dr. Garcia, a father of two who grew up in Mexico and trained to be an ophthalmologist, said he had no regrets about switching to forensic pathology. “Money is important,” he said, “but I’d rather feel happy with what I’m doing than just being frustrated by an entire life doing something that I don’t enjoy as much.” The fellows keep track of their autopsies in Excel spreadsheets that list the names of the dead, brief histories and findings. The most common deaths are accidental or natural; the least common are undetermined in cause or manner of death, or both. At one point in February, when Dr. Nunez surpassed 150 autopsies, her fiancé, an accountant, figured that she needed to complete about 25 autopsies per month in the time left. In May, she surpassed 215 autopsies. By Tuesday, she was at 242. Though she tries to stay positive, Dr. Nunez said the cases can take an emotional toll. She tries to decompress by going out to dinner with her fiancé and spending time with their extended families. Still, she loses sleep. “I feel like I want to give them more than I can, and I know I can’t,” she said of the victims’ families. “Something the senior medical examiners tell me all the time is, ‘You’ve done a full, competent exam.’ There are limitations. You have to learn to become comfortable with limitations.” The other fellows have ways of coping, too. Dr. Melito said he did not check the news at home in New Jersey, where he lives with his wife, Mary, a teacher, and their two young children. On hard days, he gets extra hugs. Dr. Tatsumi said she found herself crying a lot. In an autopsy, she will discover that someone did not die right away and probably felt pain or fear in the final moments. “That just destroys me,” she said. “I’m not very good at hiding things, and so I wear it on my sleeve; I wear it on my face.” The five medical examiners in training have been invited to stay on. All have accepted except for Dr. Melito, who is taking a job closer to home. In Dr. Sampson’s office, there are framed photos of every class of fellows on graduation day — the counterpart of the informal collage upstairs in the fellows’ room. Nearly all of these smiling group shots are arranged in neat columns running down one wall. “This side is all Dr. Hirsch,” Dr. Sampson said. She pointed across the room, where there are just two photos of the last two fellows’ classes. “And that’s my wall,” she said. “Hopefully, it will be long someday.” A photo of Dr. Nunez’s class will soon be added. Even in medical school, Dr. Nunez said, she was interested in the cause of a disease more than the treatment. A doctor would be poring over a patient’s lab work while “all I’m thinking is, I really wish I could take a piece of this woman’s lung to see what’s happening.” Dr. Nunez said that she still wanted those answers, but that now her desire was to serve the families left behind. “I think that’s definitely what drew me the most,” she said. “It’s being able to be useful, and bring closure to families, and give them answers that they otherwise weren’t going to have.” |