On this mild winter day, it’s anything but mild inside the autopsy room at Spectrum Health Blodgett Hospital.
The forensic pathology team is autopsying two cases–a suspected drug overdose and a gunshot victim.
Working with a chest X-ray prominently displayed on a massive monitor mounted on the wall, Spectrum Health morgue assistant Elizabeth Brown recovers bullets from the gunshot victim as forensic pathologist Kent County’s chief medical examiner, Stephen Cohle, MD, obtains tissue samples.
Both Dr. Cohle and forensic pathologist David Start, MD, are employed by Michigan Pathology Specialists that contracts with Spectrum Health.
On this morning, with the help of Spectrum Health morgue assistant Katie Brinkerhoff, Dr. Start autopsied the suspected drug overdose case. He said his findings are consistent with a heroin overdose, but he’ll have to wait for toxicology reports to confirm.
Brown, who also works as an investigator, said it’s a difficult job, but an important one, finding answers amid tragedy and heartbreak.
“This is your job,” Brown said. “You’re doing this to get an answer for the family. I have to put myself at a distance and get the cops and the family the answers they need.”
They gather tissue samples of the brain, heart, lungs, liver and more on both victims. They will save these for three years. They smear blood samples on a human ID bloodstain card that will be saved forever.
After the procedures, staff places the bodies in bags, covers them with a sheet and moves them into the 37-degree morgue cooler where they await funeral home pickup.
When Dr. Start returns to his office on this afternoon, he finds a sticky note on his telephone detailing the time of his court appearance the next day.
He hopes his testimony helps bring closure for a family.
In the meantime, he’ll be examining slides prepared from body tissue samples under the microscope in his fifth-floor office, looking for more clues and evidence to document on more recent cases that have not yet hit the court system. And a case that’s almost half a century old.
Hundreds of slides reside in his office, including microscopic tissue sample slides he’s obtained from a suspected suicide in the early 1970s. Police recently turned up new evidence that suggests the case may have actually been a homicide.
They exhumed the body and Dr. Start is launching the posthumous tissue investigation to determine whether the gun shots were self-inflicted or fired by the hand of another.
Much like the evidence they examine, it’s a job shrouded in mystery. Health Beat caught up with Dr. Start and his staff to tour the autopsy room and morgue, and ask questions about their work.
Q: What’s the atmosphere like during an autopsy?
Dr. Start and his assistants say they like to play music while working. Stacks of CDS—everything from the Eagles and Michael Jackson to Billy Joel and Bob Marley—sit near the autopsy room entry door.
They say they like to keep things light-hearted, but treat the bodies with utmost respect.
“I think people would like to know when we do these examinations, we’re respectful,” Dr. Start said. “We’re not doing any sort of mutilation. That’s not the goal by any way, shape or form. Of course it’s an invasive procedure, but we treat the bodies with respect. In many ways, the autopsy room is like a modified surgical suite.”
Dr. Start said the autopsy room and cooler are under strict security.
The cooler, sometimes known as the morgue, is kept at a constant 35-37 degrees.
“If their loved ones are here, they’re safe, their personal items are secure and they’re treated with respect,” he said.
Q: How do you refer to the body?
“We consider the deceased person our patient,” Dr. Start said. “Most of the time we refer to it as a case. That helps us distance ourselves a little bit. We have the name written down, but we don’t refer to it as we’re doing the case. That’s helpful psychologically.”
Case numbers are written as SF (Spectrum Forensics) followed by the year and the case number—for example, SF-16-37.
Q: What happens if you know the deceased?
“I’ve known people but not known them well,” Dr. Start said. “Occasionally you may have to do someone where it’s work related. I just focus on the job at hand.”
Dr. Start said if he or another forensic pathologist knows a person well, they trade off.
“We don’t want them working on cases if it’s someone they know real well,” he said.
Q: What’s the biggest misconception people have about your profession?
“From what they see on TV, people think you’re going to be kind of strange,” Dr. Start said. “I feel like I’m pretty normal. I go to football games. I have a wife. I have a kid. I have a cat.”
The other misconception is that the autopsy room is dark and dingy as is often portrayed on television.
Except for the times when “Forensic Files” showed up to produce a show, which has happened about half a dozen times, the room is bright and cheerful.
The show’s producers, ironically, asked staff to dim the lights.
“When you see things on TV the forensic pathologists are kind of creepy and they’re working in the dark. We’re not just down in some basement eating sandwiches where it’s all dark. We’re regular folks.”
Q: Besides the lighting, what else does television tend to misrepresent?
“We get a lot of calls asking why it’s taking so long to get a report,” Dr. Start said. “It’s a complicated process—toxicology, DNA, microscopic studies—all of those things take time. On TV, they get the answers the same day.”
Q: Why do you do this job?
“It’s a way of helping people,” Dr. Start said. “It’s just a different way of helping people. A lot of medicine is diagnosing a disease. A lot of doctors get satisfaction from diagnosing correctly. Pathologists get a lot of satisfaction in determining what happened and helping people when they’re at a very difficult time in their life and looking for answers.”
Families want to know if their loved one suffered during an automobile crash or why he or she suddenly collapsed and died in the kitchen.
It can be helpful, too, to know if a loved one died of a condition that could be genetic.
“It could be coronary artery disease or something else the family should be aware of,” Dr. Start said. “Determining what happened, that’s really what our job is.”
Q: What are a forensic pathologist’s other responsibilities?
“I go out to scenes,” he said. “If there’s a car crash where somebody is dead at the scene, either myself or one of the other investigators go. There are six investigators in Kent County and three in Ottawa County. Even If I don’t get called out, on any given week, one of us will be on call after-hours. The medical examiner investigator may need to consult with us to determine if an autopsy is necessary or not.”
Q: Does your job get depressing?
“We have a phrase down in the morgue that helps us to deal,” Dr. Start said. “‘There’s no sadness in the morgue.’ You can’t get your work done if you’re going to be emotional about it no matter what your job is. Whatever has happened to the person has happened to them. You can’t change that. Our job is to document.”
When medical students come in, they often comment how sad a case is.
“The fact is, all the cases are sad because everyone has some family somewhere,” he said. “With death, it’s kind of part of the process. Whatever suffering has occurred is done.”
Q: Which cases are the worst?
Child abuse cases are the most difficult, Dr. Start said, and decomposed bodies are difficult, too.
“Some bodies aren’t found for a week or two,” he added. “These can be difficult because, quite frankly, they smell bad and the tissue is more difficult to deal with. But you can still determine a cause of death and often get very good information. You recognize that it smells bad, but you focus on the job at hand.”
Q: Do you ever have nightmares?
“I’d never do this job if I had nightmares,” he said. “I don’t take the work home. You see a lot of awful things whether it’s an assault, motor vehicle crash or terminal disease. You do the best you can to be objective and scientific, but compassionate at the same time.”
Dr. Start said he focuses on documentation, not despair.
“If you get a terrible child abuse case, you’re so busy documenting the trauma you try not to think about the other parts of it,” he said. “You see some pretty awful things, at the scene, families crying and so forth. You realize it’s part of the process they have to go through. The best way I can help them is to be as thorough, objective and scientific as possible, so if it goes to court, I can testify. I really focus in on what I need to do knowing, ultimately, that’s what will help the family.”
Q: What criteria do you use to determine if you’ll do an autopsy?
“If an individual dies an apparent unnatural death and is dead at the scene, outside the hospital or at home, if it’s a motor vehicle crash, suspected suicide, homicide or overdose, we’ll go ahead and autopsy those individuals because there’s a lot of information that needs to be gathered,” he said.
If it’s a crash where injuries are well-documented and clearly lethal, an autopsy may not be necessary.
Suicides are another story.
“Even if it appears to be a straightforward suicide, sometimes we have a case that looks like a suicide that’s actually a homicide,” Dr. Start said.
Q: What about natural deaths?
“The naturals, we look at medical history,” Dr. Start said. “If someone has a history of coronary artery disease, stroke, diabetes, we may not need to autopsy those. Those are a little bit more of a judgment call.”
Even if the county or hospital don’t order an autopsy, the family can.
“We do take into account the family’s wishes,” he said. “With cancer, if families are interested in documenting the extent of the disease, they can order a private autopsy.”
Q: How do you do an autopsy?
When a case comes in, the first thing the team does is get a determination as to why the person is there. They get a history of the person from police or medical examiners that get the information from the scene.
“We find out when they were last known alive, if there’s evidence of drugs,” he said. “Drug use has skyrocketed in the last several years. We see a lot of those.”
The person’s belongings found at the scene of death always come with them. The team inventories and secures those items prior to releasing those belongings to the funeral home.
“We take care when removing the clothing because sometimes it has a lot of sentimental meaning to the family, like a motorcycle jacket,” Dr. Start said. “We’re very careful to not cut clothing if we don’t have to.”
Next comes the external exam, looking at the eye color, hair color, injuries and scars. Samples are taken from under the finger nails (in case the victim scratched a suspect during a crime).
“We then examine all the internal organs including the brain, chest, organs, abdomen and neck. We’re looking at everything to document disease or document injuries,” he explained. “Depending on the case, it generally takes about an hour and a half or so. Then we obtain samples for toxicology.”
Tissue samples of the lungs, liver, kidneys, heart and tumors are all looked at under a microscope.
“After the organs are dissected, they’re placed back with the body,” he said. “When we’re done, we clean the body, sew the incisions.”
Q: How many autopsies do you perform in a week?
“In a typical week, about 10,” Dr. Start said. “We did 548 last year, which is pretty much average. We like to think of our cases under the divisions of manner of death that are placed on a death certificate—natural, accident, suicide or homicide. Undetermined, rarely. Occasionally we have a case we can’t sort out because of the condition of the body, but it’s a rare thing.”
Q: What’s your relationship with Spectrum Health?
Dr. Start explained that he is employed by Michigan Pathology Specialists which contracts with Spectrum Health to house the morgue at Blodgett Hospital. He serves as the chief medical examiner in Ottawa County and the deputy chief medical examiner in Kent County.
He said it’s a unique situation for the medical examiner to work within a hospital, but an efficient one. He has immediate access to X-ray equipment and onsite toxicology, microbiology, chemistry and histology experts.
“We feel we provide Spectrum Health with a great service,” he said. “It’s a good relationship we have.”