Thursday, December 8, 2011
The forensic pathologist who scrutinizes Monterey County’s unexpected deaths stands in the middle of the coroner’s autopsy room, next to a 6’5”, 238-pound, 24-year-old man he’s about to open up, and talks about dancing.
“I hated the dance lessons,” Dr. John Hain says. “I was uncomfortable. But power lies with being with what’s uncomfortable, what we want to run from… and, eventually, I got pretty good.”
There will be plenty to be uncomfortable within a minute, at least for the uninitiated. There’s the scream of the bone saw that opens the skull. The scalpel’s slice through the cheddar-orange inch of subcutaneous fat. The lopping-shears snip of the rib cage to pull out and weigh the heart. The prodding and poking of the bile-bloated gall bladder, failed pancreas and poisoned liver.
These mortal machinations stopped bothering Hain long ago – he’s been in the field for 36 years – or maybe they never did. “I’m not aware,” he says, “of what grosses people out.”
But he’s aware of plenty that does bother him about life and death in Monterey County.
The one forensic pathologist the area has for a population of about 500,000 struggles to understand the reasons he sees so many suicides, homicides and overdoses laid starkly on the stainless steel beneath his knife.
“I can tell you how somebody died,” he says, “but I can’t tell you why they died. I keep coming back to that.”
In the quick hour he works with the dead body, bending limbs to measure rigor mortis and filleting the heart, liver and lungs – a dance of sorts itself – two other abnormal deaths are reported.
The following day, Thanksgiving, he sends an email.
“Yesterday’s array of cases turned out to be exactly a microcosm of what we keep seeing and what begs for our attention,” he writes. “The young substance abuser that accidentally kills himself through an unexpected complication of his addictive behavior, the depressed young man that successfully overdoses and completes a recurrent wish to commit suicide, and an anonymous teen, apparently shot because of something she did or did not do that enraged someone with a gun.”
For Hain it’s not enough to know that the man on the table died of acute pancreatitis and a fatty liver. He wants to know what pushed him into expansive binges, how people collaborate with self-destructive, murderous and fear-driven demons. And if that wasn’t ambitious enough, there are other things he’s analyzing with medical precision: how turnover and chain of command make an inherently grueling job harder than it needs to be. How the current patchwork coroner systems and weak data monitoring make tracking dangerous health risks impossible. How the job is going to get more difficult, unless something is done about it.
These are not comfortable topics. But he’s not running from them. Or dancing around them.
The majority of deaths recorded in Monterey County are relatively predictable – when an elderly individual dies at home or in the hospital of understandable causes, for example, a doctor can diagnose what caused it (heart attack, pneumonia, cancer) and sign the death certificate.
Those that aren’t so straightforward involve the coroner’s office. Of the 2,253 deaths recorded in the county last year, 1,012 did. They were, by law, abnormal: homicides and suicides, tractor accidents and scuba diving deaths, deaths in prisons and mental hospitals, deaths from contagious diseases and fatal poisonings, those who died alone and those with no known next of kin (see sidebar, p. 28). The coroner determines cause and manner of death, and informs all the relevant parties, from OSHA to child safety boards to family members.
When a cop or a fireman is called to a scene and diagnoses the appearance of such an atypical ending, the next call goes to the coroner. No matter the day or time, the sheriff’s deputy coroner on call, one of a department of four housed at the morgue next to the county jail in Salinas, reports to a scene that has been kept as intact as possible pending their arrival. (See sidebar, previous page.)
What they see when they arrive varies from the surreal to the sickening. Not long after Detective Kevin Gardepie started as a coroner’s detective in 2009, he had to sort through a charter bus crash that spilled French tourists all over Highway 101 in Soledad, killing five and keeping him up for 72 hours. Just the other day, he was called to the homicide of a 14-year-old girl that evoked his own daughter of the same age. At death scenes he collects as much information as he can, takes scores of photos, and shares everything he learns with Hain back at the morgue, usually attending the autopsy himself.
Managing that responsibility would be a challenge for highly trained veteran forensic investigators with years of medical training, extensive field experience and an evolved emotional toolkit. The four Monterey County detectives were trained as sheriff’s deputies and average around three years’ experience each as coroner’s detectives. Their supervising Detective Sgt. Archie Warren has been with the division since August. Hain encourages their presence at autopsies, but as an independent contractor under the authority of the sheriff-coroner, he can’t mandate it, or send them back out to gather more information unless they want to. Insiders acknowledge that detectives need a good five years at least (seven’s more like it) to gather the experience to become experts, but Hain can’t prioritize retention and stability in ways that might keep detectives around longer, or revise the long-standing policy of rotating detectives through every three years. As with other sheriff-coroner counties – which differ from counties where a certified forensic pathologist (FP) directs a medical examiner’s office – Sheriff Scott Miller ultimately oversees the department, though he may or may not know the difference between a quarter-sized electrocution burn and an accidental application of lipstick.
Other obstacles make accumulating detective experience challenging. The hours can be brutal: Forty hours of overtime in an on-call weekend isn’t uncommon. Relationships suffer. “The logistics alone are very tricky,” says Detective Dan Robison. “I’ve gotten three calls – two homicides and a natural – at a time.” Other well-paying detective positions beckon.
“It’s not the most sought after position,” Robison says. “No one, cops especially, likes to be reminded of their own mortality.”
In a field that includes heart-wrenching child-abuse investigations, Sheriff Scott Miller still calls it “the most difficult job in the Sheriff’s Department.”
“For every deputy who wants to stay there forever,” he says, “there’s one who wants to get out the first chance he can.”
The shortage of talent isn’t exclusive to the deputies. Forensic pathologists are already rare – a study by the National Academy of Sciences found only 38 forensic pathology residency programs in the whole country, compared to, say, 100 for the rather specific field of anesthesiology – and the pool is not being replenished. And it’s only partly because a Monday morning like one Hain faced last month might materialize (eight cadavers from a weekend of homicides, car accidents and a care-home facility fire – plus a stillborn from the hospital). Facilities are often underfunded, and most are at least 20 years old. One-third suffer from poor airflow. Forensic pathologists must complete full medical school and a long pathology residence, often not matriculating until age 30, and look forward to carrying both student loan debt and the memories of dissecting stabbed and bullet-riddled humans with them. Other less graphic and more lucrative medical opportunities beckon throughout formative training years – morgues don’t get to snuggle up with drug companies, and coroner teams don’t get the university cash for research and growth as they go. While many doctors go into the practice to work with people, it’s usually of the breathing variety.
“It takes a unique personality to be happy as a pathologist,” Hain says. He concedes, at 62, that he’s at the twilight of his career. Santa Cruz’s own FP is in his 70s.
Hauntingly enough, the grim realities don’t stop there, and grow more grim through the prism of terrorist attack.
Down in a pretty little stretch of river in Marlboro County, S.C., where the water striders walk on water and sun dapples the shore, something ugly surfaced. A body was found floating by a log and reported to the local coroner, who found no identifying items on it at all.
But that’s not the ugly part.
Because the body lay just over the state line from North Carolina, the investigation of where it came from wasn’t handled by the neighboring county’s slick medical examiner’s office stocked with modern equipment and highly trained staff. Elected Marlboro coroner Tim Brown, a former building contractor, sent the body away to a private lab for autopsy. Upon its return, lacking the funds to bury the body or a cooler to chill it, he had it cremated.
It wasn’t until Brown saw on television that Michael Jordan’s dad was missing that he thought he might have burned up evidence of murder.
But that’s how erratic the standards are between coroner’s offices, and worse, how rudimentary their communication network is: One of the most famous fathers on the planet is found dead just miles from where he went missing and the county that has an all-hands-on-deck search going and no one is the wiser for weeks – and only then because the coroner happened to pick up the remote. Eighty percent of coroners and medical examiners rarely or never use the National Crime Information Center Unidentified and Missing Person files. If people in San Luis Obispo County or Alameda County are dying from an airborne disease or chemical attacks that demand autopsies to diagnose, there is no system to check in on it easily.
“In California there are 58 counties in the state,” Coroner’s Detective Randall Dyck says, “and their death investigation units are all different. There is no standardization.”
“It’s analogous to the terrorist information accumulating pre-9/11,” Hain says. “It’s being collected, but it’s not shared.”
Dr. Randy Hanzlick, a professor of forensic pathology at Emory University in Fulton County, Georgia, where he’s also head medical examiner, has been following the progress, or lack thereof.
“There are listservs and computer groups that can disseminate and obtain information from medical examiners and coroner’s offices around the country, but this is informal and not used by various state and federal programs,” he says. “Unfortunately, many programs still rely upon information derived from death certificates, which can take months to years to [compile] national data.”
The U.S. Centers for Disease Control and Prevention, for example, just came out with a sobering survey of skyrocketing opiate intoxication deaths nationwide based on such certificates. The information allows public officials to scale awareness campaigns and laws accordingly. The only problem: The study covers 1999-2008. In the three years since, an untold number have made their way into addiction and death. Tracking health risks with information that stale is like fighting a cross-Atlantic war based on recon delivered by rowboat. Without current data that can be compared across counties and regions, lawmakers, parents and policymakers have a dramatically compromised ability to make decisions and warn the public.
As Hain says, “They can’t prevent needless death.”
A 352-page report by the National Research Council found a dearth of strong standards for analyzing evidence and studies establishing the reliability of forensic methods. “Moreover,” it reads, “many forensic science labs are underfunded, understaffed and have no effective oversight.”
The report has generated no change, according to Hain.
“It’s disturbing there’s been no movement,” he says. “I don’t think there are resources or the political will. The dead don’t vote, as they say.”
The wider takeaway: Instead of one deceased 24-year-old on the table, Hain could conceivably face a room full of bodies, of all ages, casualties of a disease or a poison detected only after post-mortem examination. That would provide a particularly dramatic reminder that the coroner is a two-chambered heart: on one hand a vital criminal accountability agent, deciding how unexpected deaths happen in concert with law enforcement. On the other, it’s a public health service. Since only one place in Monterey County’s 3,322 square miles is equipped to dissect what’s killing us, it screams for connectivity.
“Some type of poison or drug or disease could be disseminated or experimented with,” Hain says, “and we wouldn’t pick it up or detect it until too late.”
~ ~ ~
The skin would slip from the body. The body would bloat, turn green and give off a stink. The stink would transcend the intensity of long-rotting chicken in a lidded garbage can. “Amped up stronger than you can imagine,” Hain says.
Largely because of smells like that, the morticians whose space he was sharing would ask him to cut open the cadaver outside, or in a garage, where dim lighting complicated already messy matters.
“The bodies did not get examined very well,” Hain says.
Such was life when Hain began working with the Monterey County Coroner’s Office in 1988 as part of a contracted group of hospital-based, non-forensic pathologists. Where the morgue sits today, there was only a fat swath of gravel.
He would have to travel across the county, visiting eight morgues all told, lugging his vacuum for bone dust and his saws and jars and knives with him. The death investigators would meet him at each outpost, logging obscene amounts of travel. (By contrast, with one central morgue, they still traveled 37,102 miles in 2010.)
Today he enjoys spotless facilities with a roomy morgue refrigerator, tissue sample suites and an autopsy space he customized himself. But change didn’t come from a shift in national policy or budgetary priorities, it came by way of bootstraps: About two decades ago, as Hain debated resignation in large part because the morgue he had been promised had been repeatedly de-prioritized, it occurred to him that post mortem tissue recovery might present a lifeline. Ultimately UC San Francisco’s program helped fund the morgue by leasing space in exchange for the opportunity to harvest skin, bones, joints, aortic valves, corneas and other tissues that can be reused in reconstructive surgeries.
And Hain crystallized a lesson: “It’s hard to change government,” he says. “You can’t get it done in that direction.”
Fortunately other avenues exist on a much more local level.
Tri-county regionalization ranks highly for Hain. Monterey County’s facility is as sleek and functional as any comparable county’s in the state. Though it has processed San Benito County’s deceased since the early ’90s, it has the capacity to conduct twice as many autopsies as it does currently. He sees a cache of direct and indirect positives that can come from it, beyond immediate economies of scale that will save both counties cash. With forensic pathologists at a shortage, more work means a better draw for talent.
“If counties don’t have enough work,” Hain says, “they have trouble finding qualified FPs.”
A bigger operation opens the possibilities for an additional pathologist, which means more flexibility to attend trainings and tap sanity-saving vacations. A wider service area will steady the unpredictable spikes in cases, and provide more teaching opportunities to groom the next generation of pathologists. Developing a functional regional model, meanwhile, could allow for rare regional standardization of death investigation and replication elsewhere.
Despite the fact that Hain has enjoyed working with sheriff’s deputies, he also wants the opportunity to hire investigators outside of law enforcement’s sphere so he isn’t constantly training new deputies on matters of life and death. At one point within the last three years the entire detective staff was in its first year in the office.
“Mistakes were made,” Hain says. Not enough information was collected at the scene – a medicine vial overlooked, drinking containers left uncollected. “They don’t know what they’re missing. Fortunately, none we know of were serious enough to have highly embarrassed the office.”
Hain reached out to Sheriff Miller upon his 2010 swearing in.
“Sheriff-Coroners have great difficulty comprehending the highly specialized nature of death investigation,” Hain wrote, “especially the need to hire, retain, and motivate death investigators… Interest, intelligence, and training are not enough to make for a highly competent death investigator. This is only attained through real life work experience.”
Miller is open to such a change, but not making any moves now. “We’re considering all of Dr. Hain’s ideas,” he says. “We’re not ready to move ahead, but we’re open to suggestions.”
Meanwhile, as Hain hammers away at how the coroner might better manage death, that pesky question of why there is so much death to deal with in the first place persists.
One day a different type of person from the thousands Hain had autopsied to date was laying on the table. It was someone he knew, dead from an overdose.
“I knew him very well,” he says. “I knew grief.”
To complete any autopsy, Hain practices a distancing discipline. “Far enough away,” he says, “so I’m not emotionally involved. It’s how I serve people best.”
This time it would help him stay upright. But while colleagues like Detective Sgt. Warren wonder, “Is this a good thing or a bad thing – when you get a little numb, going to homicide after homicide?” Hain doesn’t entertain that question. He doesn’t want to lose touch.
Nearly two decades of work with Pacific Grove-based Breakthrough Men’s Group help allow him to do that.
“I am all too familiar with how people die,” he says. “I have become equally interested in what enlivens men in a culture such as ours.”
They tackle the old patterns: expectations of self-sufficiency, high performance, zero vulnerability, and, fittingly, emotional distance – from family, others, oneself. “We go after what destroys men,” Hain says.
He sees parallels with his work: Identifying threats both macro and micro, societal and personal. “Raising awareness is the key to discovery,” he says. “If we don’t raise awareness, we miss the world around us, what’s available. It all fits together in quite a marvelous way.”
The thing society isn’t aware of, though, is just how much people are wounding themselves, sometimes as a part of those patterns the Breakthrough group mends. “Most deaths I see are from self-destructive behavior, drug, alcohol overdose-related or accidents from recklessness or under the influence of addictive substances,” Hain says. “Or homicides that are related to gang activity, rage, people trying to belong.”
The primary obstacle to that awareness, Hain adds, is fear: Fear of being judged, shamed and embarrassed. He sees it most dramatically as news of suicides and overdoses are shielded in media and skirted at funerals, though both types of death outpaced motor vehicle fatalities during Monterey County’s 2010.
“We’re trying to give the dead a voice,” he says. “They have something important to tell us.”
Later he elaborates: “It’s important to discuss and expose. I’m disgusted with a system that’s hiding suicides and drugs and substances. Burying it is harmful. It encourages it to exist. Like child abuse – kept wrapped up, it keeps happening.”
And this gets at the fundamental thrust of autopsy work, and Hain’s grander mission. This channels the power of not cowering before the uncomfortable.
“We must understand this is part of the human condition,” Hain says, “and it’s not all pretty.”
Running from the unpleasant won’t make it go away. Before we can face it, we have to be willing to look.
“That’s the dance,” Hain says, “for all of us.”