I guess I don't understand the Russian roulette thing suicide or not in the first place. I would think from the evidence available to you all you should be able to say is that he died from a gunshot wound to the head. The hard findings stop there and then it's just speculation, which seems like very poor science.

A roommate's coworker hit and killed a pedestrian. The medical examiner ruled it a suicide which seems strange to me. From his examination shouldn't he just be able to tell that the guy died from being hit by a car (or even less, from massive traumatic injuries to X, Y, and Z)? How on earth could that medical examiner look at the dead body and know if it was a suicide, homicide, or accident?

Yes, my job is stressful, and I use food for comfort, so I'm continually yo-yoing from healthy and exercising to over weight and slothful. I'm in the latter category now and am not liking it at all. Two years ago at this time I the annual 50 mile bike ride hear, and I skied well this last winter. Now I could not go 15 miles on the bike. I could just kick myself.

It does not affect what I like to eat at all. I never liked liver anyway.

I agree completely. Manners of death were very important as our field developed in the 20th century. There were unrecognized homicides, many in children, and unsophisticated death investigation as far as forensic investigation.

The manner of death, as far a a doctor being able to determine it, are out-moded, but many of my colleagues say we should be the determining agent, because we are the ones trained to do it.

to summarize, The manner of death is not the cause of death. It takes in consideration the investigation of the circumstances of death and I use that information to make my decsion. If the investigation agency says the guy wrote a suicide note, or told someone he was going to step into traffic and did, I rule it suicide. I take their information at face value unless there is something inconsistent with my findings and their investigation. I don't investigate myself.

As an example of how variable the system is. A NYC ME recently presented a talk on why they rule "suicide by cop" as suicides. They die by gunfire at the hands of others, but it goes down as suicide. I actually understand the logic, but I think all it does is show how inadequate ruling of manner is in complex cases. With that said, it is straight forward in over 90% of the cases.

Here are some scenarios to think about;

A linebacker just before the play looks at the tight end and thinks to himself, I going to kill that guy, he blind sides him, his neck is broken and he dies a year later from pneumonia. The linebacker never tells anyone what he was thinking. Homicide, accident, or natural?

A boxer dies in the ring. Accident or homicide.

A guy drives off the road into a lake, doesn't try to get out of the car. On purpose, suicide? Did someone run him off the road, homicide? Was he having a heart attack,natural, I can figure that out. Or was he drunk and it was an accident, I can figure that out halfway, and have to depend on other people to give me the information that it was accidental.

Someone hits a person with a car. How finds out if she actually did it on purpose or not? Not me.

I told a prosecutor that we rule judicial executions as homicides, she looked at me and said, "no its not". I told her my four choices and asked her which fit better.

Manners of death are medical descriptions of the circumstances of death. Homicide does not denote a crime. But their is a lot of misunderstanding about it, by the lay public and judicial system. I've had prosecutors worry that they can't charge a person with vehicular homicide because I ruled the death an accident.

So I don't like the present system, their is way too much misunderstanding that the medical manner of death has some sort of legal weight, and its just not robust enough to classify all the weird ways people have found to get on my exam table.

Patient Zero for the zombie apocalypse always pops up in the morgue and infects the staff. If you kick its ass before it runs amok you could save the world.

Yes several. If I know them I will not do the case. Doctors, college friends, well known people etc.

The West Memphis Three?

I am not going to say anything about that except the following so don't ask, including pms,again.

The West Memphis Three murders happened when I was still doing a residency, that is I was in a hospital, learning how to be a hospital pathologist, and had no real experience in forensic pathology yet. So I have never had anything to do with the case.

To me, the West Memphis Three are 3 eight year old boys;
stripped naked, beaten severely, hog tied, and thrown into a water filled ditch. I've examined many horrible murders, this is about as bad as it gets.

As a forensic pathologist, those are the only three I would be concerned about. The rest I leave up to the system, have nothing to say about it or an opinion about who did what, which I consider the primary role of the forensic pathologist. So yeah, I know a lot about it, but I'm just not going to go there.

Got it.
I am out of the loop with zombies.

I'm very good at arguing, and at first looked at these court room battles as just that, a battle. But that was a mistake, because its not my fight. A good lawyer can make you say the sky is green. Its up to the other lawyer to come in and redirect reality back to blue skies again.

I know what I know, and just answer the questions according to that oath I take.

But I've seen all the tricks, I just don't take it personally anymore, mostly. When I have let my urges get the better of me and made the lawyer look foolish, I have realized its a huge mistake. Its their show, their rodeo, and you are just a bit player. Its not your role, which should be unbiased and clinical.

With that said, I have the capability of fully explaining the findings and defending them well. They can spin it the way they want. I've told the defense, in pre-trial meetings not to ask a certain question in the way they just did, because the answer will be such-and-such, but if they ask it in another way, the answer will be this-and this. And in court they asked it in a way that made their case stronger.

I re-read that answer and it looked weird, so sorry. I wasn't irritated by the question and it wasn't meant as any kind of rebuke to you to say don't ask again. It was a little dramatic and as I look at it now, somewhat stupid.

The answer is yes, through several ways I have been able to see many sides of the case that not many people have had the privilege to. My perspective is limited to what happened to the 3 eight year-olds. I understand all the controversy, and can't add anything to the discussion.


Also sorry for all the typos in the above posts, just use your imagination to correct them in your head, I can't edit anymore. I have got to get back to work.

No problem man, thanks for the reply.

Its just a case i've followed closely over the years & was interested to hear your take on it.

Carry on...

How is it possible that a person as well educated and successful as yourself is not able to use there/their and here/hear correctly? You're obviously smart and knowledgable and this is a good thread, but this baffles me.

DAFUQ

How did you decide to advance from hospital pathology to forensic pathology? How much extra training did you take?

I'd heard on NPR that budget cuts mean some counties won't do autopsies on patients over the age of 40, 50, or 60 except in obvious homicides. I guess my first question is whether that's true, and if so what are your thoughts on that?

I occasionally type the wrong form of there/their, who's/whose etc., but I 100% know their meaning and correct usage. Basically an oversight in quickly typing out thoughts. I assume that's the case here.

Do you watch shows like Forensic Files? Have you been featured on one of those shows?

Great thread.

When a case is an obvious suicide that doesn't involve the brain (ie not GSW), how much investigation goes into the brain? Curious what percent of suicides end up having some sort of brain lesion such as prior silent stroke, chronic changes secondary to TBI, tumors, parkinsonian changes, etc?

Don't be baffled, I'm naturally loquacious and have to type fast to keep up with my head. By the time I proof the posts, 30 minutes has gone by and it gives me a little box saying I can't edit. I apologized a couple posts ago. I'll try more better.

I've been on a Snapped. Hour of filming, and maybe 10 seconds of me. I looked and sounded stupid, and regretted it. I'm not going to say the episode, just embarrassing, but those people can really stroke your ego to do things like that.

I did my Fellowship while Dr. G was in Texas, so she's a good friend and one of my primary mentors, if that means anything.

I don't watch those shows though, I need a little separation from my own reality to get into movies or TV

I walked into Med-School wanting to be a forensic pathologist. I'm from a doctor family, dad and my two brother being MDs. But there were at least a hundred times I almost changed my mind, but that's the typical course you see in med-school, every different rotation you are on, that's what you want to do. But I kept coming back to it. You have to be a Pathologist first, back then the residency was 5 years, now it's 4. Then I had to decide not to do hospital pathology, which was tough, it's pretty lucrative. I'm comfortable, but my friends from residency are actually rich. I'm a bit ADD, though, and the routine of hospital pathology just didn't stimulate me enough, so I continued with my gut, and got a great Fellowship in Texas. One more year of specialized training in forensic pathology. Passed all my Boards, then had to make the real decision, I still could have gone into hospital pathology, but once you start being a medical examiner you rapidly lose the skills to go back and do hospital pathology. My advice to all the med students that rotate through my office is you have to find something you dig, or no matter how much money you make, you won't be happy. So I became an ME and haven't looked back.

I'll get to your next question in another post.

We try very hard to return everything back with the body, including the brain. The families have no choice in the decision to have the body examined, that's covered by law. In order to do an in depth neuropathology exam you have to keep the brain, fix the tissue and have a neuropathologist examine it grossly and microscopically. That gets real dicey with families. We do have to keep a small number of brains when it's vital to our conclusions or to a criminal case. But mostly we examine the brain at the time we do the case, looking for obvious changes, but that type of exam is not adequate to evaluate subtle neuropathology. We could see tumors and major old strokes.

I'd have to opine empirically only, but brain disease we could see being associated with suicide is very rare. I see a lot of suicides, and it's primarily a psychosocial problem.

Death investigation is wildly variable through out the country, and in many areas is shamefully inadequate. Many deaths occur which should be reviewed by a forensic pathologist, but are not.

To adequately investigate unattended, suspicious, or violent deaths, or deaths which significantly may impact public health (in short, the job description of the forensic pathologist), there should be about one case per 1000 of the population, per year, that needs to be evaluated by a qualified forensic pathologist.

The population of the US is 318 million, that should be about 318,000 exams a year. There are only about 500 of us, that's 636 exams per pathologist per year. When you do over 350 a year, major errors involving shortcuts, omissions, and lack of attention to detail start to occur. Over 300, the pathologist is over worked and stressed, which can lead to burn out over a few short years.

The offices are by and large government agencies, so money is always short, and everybody is looking for a cheaper way to do things.

So the numbers add up to major short cuts and the possibilities of significant errors, and down the road, when the "big story" hits the press, massive turmoil occurs. In the last ten years this has happened on a regular basis, just off the top of my head: Chicago, Mississippi, Oklahoma, North Carolina, Delaware, Connecticut, Boston, Louisiana, Florida, California, and on and on. With the same old pattern, a major controversy occurs with the specter of injustice and disrespect to families, scapegoats have to pack their bags. The politicos vow to clean it up, throw money at it, find "qualified" personnel etc. But there are only 500 hundred of us, the older guys or burn-outs still can make a career out of consulting on systems that are over-stressed as it is, so the pickings are good, and the Fellowship programs are barely keeping up. So where are they going to find these people?

Eventually the heat dies down, and the political money dries up, and the cycle starts all over again.

Now there are fantastic systems out there, usually driven by a forward thinking, politically adept Chief ME. San Antonio/Bexar County, where I did my Fellowship is a great example. But In a very large part of the population base, NPR is accurate. Its problem.

How cool is it when you get noob doctors or cops who've never seen a mutilated dead body before?

Most do surprisingly fine. I just don't want them to faint. Distracts me. The first time I ever went to the OR as a med-student, I started getting hot and feeling funny. I didn't fight it, went outside and sat down until my blood pressure came back up. The funny thing was it was an ear operation, couldn't even see the patient, no blood, just a big ol microscope type thingy all wrapped up in sterile dressing.

In the class behind me in school, one of the guys toppled over during a video tape on doing a spinal tap. He was a real gunner, our term for an extremely high med-school achiever, and thought himself very cool, upturned collar Polos, and Ray Bans (1980's cool). He did end up getting into Ophthalmology, which is very hard to get, so he did have the chops. But for the next 3 years, every time my roommate, who was in his class, saw him, he asked if he had done any taps lately. It would piss him off to no end. It got so that we would not have to say anything at all, we would pass him in the hall, and just smile at him, and he would turn purple and tell us to **** off.

I was in my Fellowship and a new OSI guy, military investigator, was there to see his first case. We had quite a few deaths on the military bases in town, and they were the police agencies. I gave him my standard spiel, If you feel yourself getting hot, sweaty, or light in the head, don't fight it, go have a seat as soon as possible, its just a simple vaso-vagal response. You will pink up and be back with it in a few minutes. Well he was a big guy, tough looking, and probably in actuality, pretty tough on the inside too, so I guess he thought he could fight it. We started, and he almost made it. The last I saw of him he turned around and started slowly toward the door, and slowly sinking into finally what was, I guess you would call it, a duck walk.

I have had jurors do the same thing too. I was at a pretty bad trial, mother in-law finally pissed off son-in-law beyond the point of rational behavior. Baseball bat, home run swing, back of head. Well the inexperienced prosecutor thought a 2 by 3 foot poster of the injury, instead of the 5x7 inch photos I like to use, would make a better impression. I guess it did, halfway through explaining the injury there was a big thump, and a juror had fallen forward and hit the front of the jury box. I leaned back, and said to myself, oh ****, now its going to be a mistrial, and I'm gonna have to come back here, a long drive, and do this all again. I sat there for a few seconds ruminating on that before it suddenly occurred to me, Oh ****, I'm a doctor. And went and helped. They pinked up after a few minutes with only just a little residual embarrassment, the defense said no problem as long as the doctor thinks she is ok, and we went on with the trial.

i skimmed the last page to see if this was asked, apologies if it indeed was

you said:
I'd be very interested to hear more about this. Specifically, your four choices, and ideally her thoughts on the matter and a description of the debate, if any, that ensued between the two of you after you presented your choices.

actually, i'm sort of a grammar nazi. a closet one, as i realize nothing positive ever comes from it, so i keep my irritation to myself. But lately, I find myself making these mistakes more and more. sometimes even pressing enter on skype before noticing. b/c i'm a grammar nazi, i instantly correct myself, but i could see how more balanced people than myself might just not care, or not care enough to notice in the first place.

/derail over

The five current choices we have on our state death certificates to categorize manner of death, used to describe the circumstances in which people die, not the cause of death (that goes on the top line, and is written out), are simple check boxes, Natural, Homicide, Suicide, Accident, Undetermined. Some states have a check box that says Not Classified as well. The autopsy report we put out lists the cause of death as I., the manner of death as II.

That conversation was a pretty simple example of how the ME classification of manner of death is misunderstood, even by prosecutors.

If I classify a death as a homicide, it doesn't denote a crime. You get shot in a war, you shoot the guy coming into your house at 3 in the morning, you shoot the guy robbing your store, as a cop you shoot the guy pointing a gun at you, you execute Ted Bundy. These are all deaths at the hands of another, and are homicides.

It has nothing to do with whether the judicial authorities think its capital, 1st degree, or 2nd degree murder, manslaughter, reckless endangerment etc. People don't understand that. I've seen hit and run perpetrators be charged with manslaughter. Prosecutors think the manner of death is better as homicide. But if investigation shows the "hit" was inadvertent, it should not matter if the "run" is a crime. But conventions vary from office to office, we used to make hit and runs homicides by convention. But after a 20 minute meeting between the doctors a few years ago, we changed to accident (as long as investigation supports that).


Even prosecutors sometimes don't understand that. Homicide has a different definition to them, a legal one, it denotes a crime, murder. But if you strap a guy down and juice him up, you are killing him, a homicide. So I was just trying to broaden her horizons, and I made her understand. But it will be a continual and unending process. Again, 90% of the time it is straight forward and no issue, but in the other cases it fosters a lot of misunderstanding.

As an example, the recent death of the street cigarette vendor in New York while being restrained by police. The convention at this office is to rule those types of cases as undetermined manner (not cause of death, that would be no problem to specifically describe), with a comment in the autopsy report that any civil or criminal ramifications of the death are left to the appropriate judicial agencies. The New York ME has a different policy, they classified it a homicide.

If you look up forensics in the dictionary it has two definitions. The application of science to legal issues, or the art of debate.

Ruling on manners of death is definitely in the latter category, and you should be there at the cocktail hours at our meetings, seeing all my colleagues go at it. I just don't think it is part of the real practice of medicine.