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
