A vast majority of people die of natural causes and in New York City, as elsewhere in the United States, most people die in hospitals. It makes more sense here, perhaps, because we sure do have a lot of hospitals—in fact, more hospital beds than there are in most small countries. And it’s not only New Yorkers who utilize them. The concomitant of having many available beds and good medical care is something that we at OCME recognized a long time ago: New York is a tourist destination not only for its theaters, restaurants, museums, and night life but also for its spectacular medical care, provided by some of the very best health care facilities in the world, including the sharpest of cutting-edge therapy. Yes, medical tourism swells the ranks of our sick and increases the number of deaths reported every year to our office. We at OCME don’t discriminate on the basis of where you’re from originally or even recently; all we care about is whether you’ve died in our jurisdiction. If so, we’ll look into your death as though you were a born-in-the-Bronx, died-in-Brooklyn, “Noo Yawkuh.”
According to the most recent annual summary of New York City’s Department of Vital Statistics, approximately 60 percent of deaths in New York City occur in a medical facility. In almost every such instance, the medical-facility deaths that require OCME’s attention are simply called in to us and handled over the phone by an MLI in collaboration with the reporting doctor. But in certain instances in which people die in hospitals, a scene visit is required—usually for a very good reason. Some of these I remember very clearly.
In one city hospital, a homeless man who was wandering around late one night found the deserted rehabilitation department and decided that a physical therapy tub looked like a great place to take a bath. I guess he wasn’t used to bathing because he managed to drown in the tub. Actually, the tub was pretty deep, about five feet, with steep, slick metal sides. At another hospital, one of the regular floor nurses blew her brains out with a large-caliber revolver, and did so in a public bathroom on the ground floor of the hospital, for reasons that never became clear to us.
Oddly enough, one particular hospital kept having deaths that were recorded on video. One patient with a psychiatric history committed suicide by throwing himself from a fourteenth-floor interior stairwell; though the initial jump was not recorded, each floor’s security camera recorded his descent, all the way to impact. We were able to put together an eerie still-frame montage of his final seconds.
Even stranger was the videotape of a death in that hospital’s sleep-disorder clinic. A female patient came in for evaluation in the hospital’s special lab, where attendants hooked her up to various electronic monitors while she lay in a comfortable-looking bed and tried to sleep. In an adjacent control room her heart rate, breathing, and oxygen levels were being monitored by attendants who also could watch her every toss and turn on multiple video cameras. But at one point during this diagnostic procedure, she had a seizure—her susceptibility to seizures was one reason why she was being studied—and in the midst of that seizure, she rolled over in bed so that she was on her stomach, facedown in her pillow. The lone attendant was on break, and thus did not know that the unconscious patient, in a postseizure state, was unable to lift her face off the pillow. She smothered to death.
Later, at OCME, as we watched the video of her death, which took an excruciating half hour, I kept fighting the urge to run into the lab and rescue her. Because of the immediacy of videotape, it was difficult to keep in mind that the images we were seeing had been recorded the day before. The camera’s perspective, looking through the glass into her room, gave you the feeling that you were right there in the lab and that all you had to do to save her was run into her room and turn her over. Had someone been watching her during that half hour, or at least been attending to the monitors, he or she would have done just that—gone in and turned her over, because they would have seen what we eventually saw, a day late and a life short. An attendant would have heard monitor alarms go off as her heart rate dropped, her breathing slowed, and her blood oxygen fell.
It was inexplicable to me that the monitoring technician had simply not been present while the patient slowly died, but supposedly he was on a legitimate break with no one there to cover for him during that period. We ruled that death to have been an accident. Shouldn’t there have been a finding of criminal negligence? That was not the business of the OCME; such findings can only be made by the DA’s office and are usually only made when the negligent person was in the process of doing something illegal. If the technician in attendance at the sleep study had been out of the room buying drugs, or engaged in some other activity that was illegal, then a case might have been made. But since he was on a scheduled break, he could not be held criminally responsible for the death. Which isn’t to say that the hospital should not have been held civilly liable for it. But civil liability is no more OCME’s purview than is criminal liability. I don’t know if the family sued the hospital, but I hope they did.
One of the ugliest deaths I encountered during a scene investigation at a hospital was that of a patient who died when the gurney on which he was strapped was sliced in two by a malfunctioning elevator. The OCME headquarters is located in an area of Manhattan known informally as Bedpan Alley because of the large number of hospitals in close proximity to one another. This death occurred at one of these close-by hospitals, and, in my rush to get to the scene, I simply ran out of my office in my shirtsleeves, leaving behind my OCME photo ID and my badge.
At the hospital, there was near-chaos, including a quite frantic Latino family of the victim, the bloody elevator scene itself, and an apoplectic hospital administrator. I tried to enter the scene, but without an ID, I was stopped by hospital personnel; however, the cops who had responded to the emergency call knew me and let me through. I examined the bloody elevator and the victim. An orderly had been in the midst of pushing the patient strapped to the gurney into the elevator. Somehow, with the elevator’s doors open and the gurney half in and half out, the elevator began to descend, crushing the gurney and just about tearing the patient in half. After I examined the scene, I then wanted to speak with the decedent’s family. They were still talking to the beleaguered hospital administrator, and when I walked over and introduced myself, I guess this was more than he could handle. He actually began to gibber (I had never seen anyone do that before) and demanded to see my ID. I groaned to myself and ruefully admitted I didn’t have it on me. This was a day when the administrator must have felt that nothing was in his control, but here was one thing he could: an insistent outsider with no ID. He immediately attempted to evict me and forbid me from talking to the family.
I explained to him, calmly, one more time, that I was from the ME’s office and I’d simply left my ID at my desk. Regardless, he had security throw me out of the hospital.
I marched back in, escorted this time by the police who knew me, and who vouched for my identity and for the fact that the ME’s office has the duty of examining the death scene and the victim and of speaking with the family. However, the blustery administrator—worried, no doubt, about a potential lawsuit against the hospital for negligence—still refused to let me talk to the family. It wasn’t rational, but he wasn’t in a thinking frame of mind. The police kindly offered to intercede for me.
I told them it wasn’t necessary; push did not have to come to shove since I had already examined the scene of the death to my satisfaction. So I told the administrator that I would talk to the family outside the hospital if he wouldn’t let me speak with them inside and, over his shoulder, issued an invitation to the family to join me on the sidewalk. They did, and we spoke for a few moments. I explained what the next steps would be and that I would see them again tomorrow at OCME headquarters.
Needless to say, I never thereafter left the OCME to go to a scene without my ID in my pocket.
The elevator death was an accident, but other deaths in hospitals are not so accidental. Through my work at OCME, I became, unwillingly, an expert on the various ways in which a pati
ent could get himself or herself killed while in a hospital and on just which hospitals were killing what sorts of patients, and how often. This became sought-after information.
Just as at Thanksgiving, because of my expertise, I was always asked to carve the turkey, I was also asked in less festive settings to be a physician/hospital rating service. A friend, before undergoing surgery, would call and say, “I’m going in to Such-and-Such Hospital and Dr. So-and-So is gonna take out my whatsit.” Then the friend might couch a question such as, “Is the surgeon any good?” or “Is the hospital a good one?” but what he or she was actually asking me was, “Has this doctor slaughtered any patients recently?” and “Does this hospital regularly report disastrous outcomes to OCME?” I always gave answers that incorporated the best of my knowledge, but even when my recommendations were sterling, I knew that my friends had, and still have, good reason to worry when they enter a hospital—any hospital.
Hospitals are very dangerous places. Between overtired residents, overworked nurses, understaffed wards, complicated machinery, drugs that can have sledgehammer side effects, and good old-fashioned human error, the modern hospital has more ways to kill you than did the Spanish Inquisition. Some of those proved frightening, even to this seasoned investigator.
In one instance, a young athlete went into a hospital for a routine elective surgery and never came out. Exercise had bulked up his arm muscles to the point that they were causing pressure on the nerves running through his elbow, giving him a continuous sensation of the sort that happens to all of us when we hit our “funny bone.” He was admitted to the hospital for a standard operation that would relieve this pressure. It was performed, but in the recovery room, the otherwise perfectly healthy patient developed postoperative hypertension, a not-all-that-uncommon side effect of anesthesia. Then—and unfortunately for the patient—an intern became rambunctious. The patient’s blood pressure was climbing fast, and the intern called down to the pharmacy for Esmolol (a rarely used but very potent beta-blocker) to relieve this high blood pressure. The rookie intern, greener than the scrubs he was wearing but possessing a cowboy attitude not yet tempered by the life he was about to take, then made a dosing mistake of massive proportions. The young intern mistakenly administered, instead of a small dosage, the entire bottle of the beta-blocker, via a “pushing” intravenous method. Having never before used this extremely powerful drug, the intern was unaware that the large bottle the pharmacy had sent up contained enough of the medication for a twenty-four-hour drip. (The pharmacy sent that because it did not carry the smaller, single-dose ampoule.) Before all the dosage had been pushed into the athelete’s system, he went into irreversible asystole (flatline) and died.
Word quickly went around the hospital that the intern had “boxed” a patient—that is, killed him. The case was reported to OCME, where it was ruled an accident. Had the intern been a licensed physician at the time, his license to practice medicine might have been taken from him. Since he was not yet licensed and because he was acting under the supervision of more experienced physicians, the authorities could take no action against the intern. The only punishment he received was a suspension from the hospital for a minor amount of time.
When things go wrong in hospitals, they can go horribly wrong. In another case at the same hospital, a death occurred in the ICU when a resident physician neglected to deflate a balloon at the end of a catheter before removing the catheter from the patient’s subclavian artery. This particular catheter, called a Swan-Ganz, is put into critically ill patients to closely monitor their cardiovascular functions. The balloon at the tip of the catheter holds it in place inside the artery right near the heart, and this balloon must be deflated before the catheter is removed from the artery. In this instance, it wasn’t, and when the catheter was pulled the inflated balloon burst the artery. The patient bled to death in a few seconds. This same hospital had a third similar death when a guide wire inserted in an artery for a similar procedure was not properly taken out.
These cases bring up the larger question of the efficacy of all therapy. One of my tenets is that eventually all therapy fails, which I can prove since no one gets out of this life alive. Moreover, most hospital deaths are not the result of egregious error but of the normal progress of pathology. However, modern therapy can mask the natural progression of disease. So quite often, when we are evaluating what has happened in a hospital bed or in the ER, the questions arise: Did the underlying disease assert itself, or did the patient actually die from complications of the therapy? Or at some point did applying proper treatment slip over into accidentally killing the patient? Cases involving these matters are absolutely among the most difficult presented to OCME. Often the decision is a judgment call based on the nuances of a particular set of circumstances.
The tenet that all therapy fails has as a corollary the notion that death can be a positive outcome of a hospital stay. By this I mean that death is a natural occurrence, and in every human instance, it is an eventual one, so that sometimes a death in the hospital is inevitable and thus a proper outcome. This is not the view that is taught to medical students and residents, who have drilled into them the idea that death is the enemy, that they must fight decay and disease all the time and at all costs. Obeying this “always fight off death” edict sometimes causes physicians to make a mockery of the basic commandment of the Hippocratic oath, “First, do no harm,” by keeping a patient alive when the more natural course of events—the more natural outcome of the progress of his or her disease or condition—is a natural death. Sometimes patients are kept alive by such extreme artificial measures that when they die, it becomes almost impossible to sort out the original underlying natural disease, which disappears under a welter of therapeutic complications.
This understanding of excessive and sometimes wrong-headed treatment plays a large role when I speak to people about the care they receive in a hospital or doctor’s office. Many people seem to believe that when they’re admitted to a hospital they must surrender their rights and freedom of choice when it comes to their therapy. It is vital for patients to realize that everyone—whether in a hospital or a doctor’s office—has the right to (and should) double-check every dosage of medicine they receive. In addition, the patient has the right to find out who is about to do that invasive procedure on them and question that person’s ability to handle such a procedure. Has that person done it before? If it is a relatively junior person, is he or she under close supervision while doing it? If the patient does not deem the answers given to be satisfactory, he or she should refuse consent to the procedure until the patient has obtained answers that allow him or her to believe that the procedure will be done properly. I am also an advocate of writing up a health care proxy—a patient designating someone to legally make medical decisions for him or her if the patient is incapacitated—and having it handy, to prevent ending up as a guinea pig in some doctor’s experiment.
When things do go wrong at hospitals, families routinely request that the ME’s office do autopsies on deaths that they believe are suspicious, and they ask us such questions as, “How do you know the hospitals isn’t lying about the cause and manner of death?” and, “Could they be covering up a mistake?”
When I’m asked such questions, my answer is this: nothing prevents hospitals from writing up a death as though it were a nonerror—except that the hospitals know that by and large they wouldn’t be able to get away with it. To hide such an error would require a massive conspiracy involving all of the forty to fifty people who had been in touch with the patient in the hospital, risking the probability that among them there would be one or two who would not go along or who would blab the truth to family, the police, or the decedent’s insurance company investigators. Also, any autopsy by our office would likely uncover any falsity. Therefore, hospitals mostly do not lie about these deaths, although now and then I have run across individuals who fudge a little.
After all, some things in the dying process are susceptible
to multiple interpretations. Did the patient expire from the complications of the disease—that is, a natural death—or because some therapy failed? Sometimes it’s six of one, half a dozen of another. For the most part, I saw very little effort by hospitals to deliberately avoid reporting deaths properly. Those hospital personnel who have the responsibility of overseeing the reporting of deaths don’t have MD licenses; they are clerks and administrators, which means they would not lose their licenses should the death be ruled the fault of the doctor. As a result, they have no reason to be complicit in a hospital cover-up and are quite straightforward with us. Moreover, hospitals and physicians are insured to cover complications of therapy.
If a case is not reported to us when it should be, the usual reason is ignorance of the statutes. However, once in a while some doctor naively tries to cover something up by writing a creative death certificate—and not always to conceal a deliberate fraud. I once had a case in which a young doctor at a county hospital issued a death certificate that read “Cardiopulmonary Arrest” (CPA) as the cause of death. I decided to call the doctor. At first she did not want to discuss the case with me, but after one of the senior hospital administrators explained to her that she was required by law to answer my questions, she acquiesced. From my questions, I learned that the decedent had committed suicide. He was from a devout Catholic family, and the doctor, still an intern, was simply trying to heed the family’s plea to certify the death as “natural” so that no stigma would be associated with the death, and the Catholic cemetery (which might not allow a suicide to be buried in consecrated ground) would bury him as the family wished.
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