Multiple possible causes of death: How medical examiners handle ambiguous autopsies.

What If a Body Comes Into the Morgue With Several Equally Plausible Causes of Death?


The state of the universe.
Aug. 13 2014 12:59 PM

The Case of Jerry

Medical examiner Judy Melinek on how she cracked her most ambiguous autopsy.

Toe Tag.
Figuring out what really happened requires scientific rigor in the autopsy suite and collaboration with the police and medicolegal investigators outside it.

Photo illustration by James Emmerman. Photo by Shutterstock.

Excerpted from Working Stiff: Two Years, 262 Bodies, and the Making of a Medical Examiner by Judy Melinek, MD and T.J. Mitchell. Out now from Scribner.

A bullet wound in the head is a cause of death, but the manner of death could be homicide (somebody shot you), suicide (you shot yourself intentionally), accident (you shot yourself while screwing around), or undetermined (there’s not enough evidence to figure out why the gun went off or who was holding it when it did). Accidents depend on circumstance, and sometimes the circumstances can’t tell me everything. Figuring out what really happened requires scientific rigor in the autopsy suite and close collaboration with the police and our medicolegal investigators outside it. What if the body exhibits signs of smoke inhalation, stab wounds, and multiple traumatic injuries to the internal organs—and toxicology shows a high level of cocaine? Which mechanism of death did the killing? In a case like that, witness reports can be as important as the story the body tells in the morgue.

Jerry, a 38-year-old drug addict recently released from rehab, was hanging out in an apartment in the Bronx with eight other people, smoking crack. In the course of the evening, he and a friend, Chuck, disappeared into a bedroom. After a little while their friends noticed smoke billowing from under the closed bedroom’s doorjamb, followed immediately by banging noises, voices yelling, and the sound of breaking glass. Outside the building, the neighbors reported smoke and flames pouring from a broken window, and Jerry dangling there from the ledge. He lost his grip, fell eight stories, and landed on the pavement.


When firefighters entered this helter-skelter scene, they had to break down the bedroom door, which had been lashed shut from the inside with a television cable. The room was engulfed in flames. They found Chuck in there, passed out behind a sofa, and he revived as soon as a firefighter grabbed him. Chuck then leaped up and ran like hell, screaming that Jerry was trying to kill him, before collapsing again, this time in the kitchen. While a fireman was dragging him out of the burning apartment, he pulled a knife. He ended the adventure highly agitated and cocaine-intoxicated, suffering minor smoke inhalation and a couple of burns, but otherwise uninjured. Jerry, on the other hand, was dead on the sidewalk—and figuring out exactly how he got that way became my task on a fine day in early March 2002.

The external examination showed me that Jerry had suffered significant second-degree burns to his hands and arms, though not nearly enough to kill him. More significantly, the right side of his back was covered with scrapes, contusions, and street debris on a single plane of injury. This meant the damage had come from only one impact, against a broad, flat surface. If Jerry had been beaten up, I would have found trauma on separate surfaces of the body—multiple planes of injury. Instead I could surmise that Jerry probably hadn’t had unwelcome help from Chuck when he went out the window.

But there was also the question of the knife. In addition to the cuts and bruises where he’d landed, Jerry’s forearms bore deep stab wounds. One penetrated more than 4 inches of flesh, passing nearly all the way through his arm without severing any major blood vessels, and coming awfully close to the ulnar nerve. That must have hurt. A lot. There was another stab injury, shallower, under his right armpit. Taken together they looked like they could be defensive wounds, as though he had covered his face with his arms while Chuck stabbed him. However, they also looked exactly like the sort of penetrating wounds that would be caused by a broken window.

You might imagine that the remains of a human body that had fallen 100 feet and landed on a city sidewalk would be a gruesome sight, but that’s often not the case. Not on the outside, at least. The gruesome is on the inside. Jerry wasn’t very bloody and didn’t look battered—but his heart was sheared in half, his liver torn up. Pieces of his right rib cage had scissored through both lungs, leaving them ratty and full of blood, and his airway was coated in soot from smoke inhalation.


After I’d removed Jerry’s mangled organs from his trunk, I was able to examine the blood vessels, bones, and muscles beneath. I started with the biggest artery and vein, the aorta and the inferior vena cava, disconnecting them from the inner surface of the spine. I inspected them carefully for ruptures but didn’t find any, so I deposited the whole dangling fork of tubules down at the foot of the autopsy table with the organs, and took a good look at Jerry’s spinal column from the inside. No fractures or bleeding. He hadn’t broken his back when he landed.

He’d broken his pelvis, though—grievously. I could tell as much without even seeing the bones. When I wiggled Jerry’s hips, they felt—and sounded—like a bag of marbles. I cut away the iliacus and psoas, the two big muscles of the inner hip, and found beneath them a mess of fragmented bone on the right side, corresponding to the contusions on Jerry’s right hip. He’d landed there and smashed the stout pelvic girdle to bits.

Working Stiff.

I gathered a sample of the sciatic nerve for the stock jar and added a piece of undamaged muscle and a patch of skin, while the autopsy technician started with Jerry’s head. He made a U-shaped incision over the crown from ear to ear, then pulled the scalp away from the cranium, draping the front over Jerry’s face and the back over his neck. I examined the leathery underside of the scalp for blood or bruises and the outside of the skull for fractures, but didn’t see any.

With the skull exposed, the technician fired up the surgical bone saw, a power tool that looks like a jacked-up kitchen hand blender fitted with a crescent-shaped buzz-saw blade. It makes a god-awful racket and flings skull chips and bone dust into the air when operated, so the technician wears a full face shield, and I keep my distance till he’s done. Opening the skull requires concentration and skill. The autopsy technician has to cut a halo around the skull without hacking any “saw artifact” into the soft tissues underneath, and this cut has to be asymmetrical in some way so that the top of the empty skull doesn’t slide off after we’ve removed the brain and sewn the scalp back together. We need to perform a thorough postmortem examination but strive for the least macabre outcome possible in consideration of the family. If half the departed’s head on its satin pillow were to start sloughing away during the mortuary viewing ... people would get upset.


The tech did a textbook-perfect job with Jerry’s skullcap, and it came off with a tug and a brief slurping suck. The dura mater, a thick membrane that encases the brain, was still adhered to the inside of the skull like old-fashioned fabric wallpaper. I peeled it back, looking for signs of epidural hematoma—a pool of blood that presses on the brain, causing seizure, unconsciousness, and sudden death. I didn’t find any, nor did I see evidence of subdural hematoma on the inside of the dura mater. Jerry hadn’t died of a head injury.

The outer surface of the brain is white—your “gray matter” is deeper. Laced on top of it is a gauzy lining, the arachnoid and pia maters. In Jerry’s I could see some thin patches of red dotting the white background. I tried to wipe the blood away with my glove, but it was persistent, sticking in the cobwebs of tissue. Bingo—he had a subarachnoid hemorrhage. In the absence of a skull fracture, this type of intracranial bleed occurs when the brain shakes back and forth inside the skull, shearing the delicate blood vessels on its surface. This relatively minor injury to the head was proof that it was the last part of his body to hit the ground.

I couldn’t examine Jerry’s entire brain until I removed it, so I stuck two fingers under his open brow, hooked the frontal lobes, and slowly lifted it up while cutting away the nerves and vessels leading into the face. Next I severed the tentorium cerebelli, a shelf of dura mater that protects the “reptile brain” (the cerebellum and brain stem), and got a good clean look into the base of the skull. I reached deep down there with an extra-long scalpel to cut the spinal cord, while using the skullcap as a bowl to catch the brain when it fell away from Jerry’s head. There it was: the man’s cerebrum, cerebellum, and medulla oblongata in the palm of my hand.

I placed the brain in a plastic pail filled with formalin and wrote an order for a neuropathology consult. Your brain is the consistency of Jell-O when it comes out of your head. After two weeks in a formaldehyde solution, it will take on the consistency of mozzarella, and I will attend the brain cutting with our neuropathologist, Dr. Vernon Armbrustmacher. There is no medical euphemism for this anatomical assay: After examining its convoluted surface, Dr. A uses a long fillet knife and a plastic cutting board to cut the brain like a loaf of bread. Then we examine the structures inside it, one slice at a time. My husband gaped at me in horror the first time I came home from work, kicked off my shoes, and exclaimed without guile, “Man, what a tough brain cutting we had today!”


I always wait until I’ve removed the brain before I dissect the neck, because by then all the blood from the skull and face will have drained out, leaving a clear view of the long, flat strap muscles on the front of the throat. Bloody strap muscles are a strong indicator of manual strangulation. The outer surface of the skin may have no marks at all, but pull that skin up and I can count the killer’s fingers pressed into the bloodied muscle underneath. Since there were reports from witnesses that my dead guy might have been in a fight before he went out that window, I wanted to make sure I examined them. I found no trauma to the strap muscles. Chuck hadn’t tried to throttle Jerry.

Next I removed the “neck block,” grabbing hold of the trachea, thyroid, and esophagus and pulling the whole thing away from the base of the tongue. After a quick look into the upper palate and sinuses, I stuck my right hand through the back of Jerry’s jawbone and poked my left index finger through the inside of the skull. Then I nodded his head. If Jerry’s neck was broken, I might feel bones poking into my fingers, or I might hear a crunch. The neck shouldn’t crunch. I’ve diagnosed cases of atlanto-occipital dislocation, or internal decapitation, by jiggling the head around like this—the skull and topmost neck bone get wrenched apart, injuring the medulla oblongata and causing instant death, but leaving the head attached to the body. Jerry’s cervical vertebrae felt and sounded normal. He hadn’t broken his neck when he landed.

I took a break to document the blunt traumatic injuries I had already found, then turned my attention to the stabs on Jerry’s arms, dissecting carefully around each wound until I reached the end of the bloody track. Even though the blood had drained out of Jerry’s body by this stage of the autopsy, the traumatized tissue showed up bright red, from vital reaction—which meant these injuries had been inflicted while his heart was still beating. The wounds were knife-shaped, but that didn’t mean they had been caused by a knife. Jerry might have cut himself on the glass going through the window. I opened the wounds to explore for glass shards, probed gingerly with my triple-gloved fingers, washed them out, and looked again. Not a single sliver. This did not rule out the broken window and establish a knife as the cause of these cuts, however. Either one could have left the wound. I would have to rely on the scene investigation.

“How’d the autopsy go?” the detective asked me over the phone.


“It’s a bitch to dictate. Lots of injury. Mostly inside, but he’s got stabs on his arms. They might be defensive wounds, or they might have happened when he went out the window. I’m worried because there are no glass shards in there. The firefighter has that story about the knife, too.”

“So you need us to go back to the scene.” It wasn’t posed as a question, and it wasn’t bubbling with enthusiasm.

“If the guy went out the window fleeing the fire, this is an accident. But if he was running away from a knife-wielding assailant, it’s a homicide. I need either the knife, or a piece of glass at least 3 inches long covered in blood. I’ll pend the case in the meanwhile.”

“Okay, Doc.” He didn’t sound worried. Even if they found the knife and this turned into a homicide, it would be a slam-dunk case for them.


The detective and his partner were in my office the next day, bearing scene photographs of the broken window’s jagged and bloodied glass teeth. Everything in the bedroom was covered in soot, except for the bloody window shards. I could estimate based on the size of the window that those pieces of glass were long enough to cause Jerry’s injuries. The blood on them was smeared along their entire edge, which told me they had been inside his body. Jerry had suffered those deep and painful cuts when he jumped or climbed out the window, before falling to his death.

The lead detective told me that the knife never materialized, even after a complete search of both apartments. “The place was a mess. The firefighters bashed down every door in there. We reinterviewed the one who said he saw a knife, but he isn’t so sure anymore. There was a lot going on, smoke everywhere, and he was scared.”

“I guess he doesn’t often have somebody pull a knife on him while he’s dragging the guy out of a burning building.”

The detective’s partner spoke in reply. “It’s a crack house fire, Doc. You see all kinds of crazy shit.”

The toxicology report confirmed the presence of cocaine and showed a low carboxyhemoglobin level, ruling out smoke inhalation as a contributing cause of death. I finalized the manner on Jerry’s death certificate as an accident once I received the fire marshal’s report, four months later. The fire originated in the bed, and there was no indication it had been intentionally set. A crack pipe—witnesses reported it to be the decedent’s own—had sparked it.

Excerpted from Working Stiff: Two Years, 262 Bodies, and the Making of a Medical Examiner by Judy Melinek, MD and T.J. Mitchell. Copyright © 2014 by Dr. Judy Melinek and Thomas J. Mitchell. Reprinted by Permission of Scribner, a Division of Simon & Schuster, Inc.
