If These Bodies Could Talk: True Tales of a Medical Examiner

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.