The dead businessman had a photograph of a teenaged girl in a tutu on his desk. There was a note, but it was in Japanese and no one at the scene could read it. An enterprising beat cop remembered there was a sushi joint on the block, so we took the note downstairs and asked them to translate it for us on the spot.
“‘I am sorry I couldn’t get the job done,’” the sushi chef read, a big knife still in hand and reading glasses perched on his nose. “He also says sorry to his wife and daughter. This”—he pointed to two words at the top—“is name. I write it down.” He transliterated the name in careful block letters on a detective’s notepad. We hadn’t told the sushi chef where the note had come from, but judging from the grim look that came over this previously jocular man—he had shouted a greeting to us in the traditional way when we’d come in the door—it must have been pretty obvious. The chef looked at each of us and gave a quick little bow. The cop who had brought the note knew to bow a little deeper in thanks. When we got back upstairs, we found out the addressee was the dead man’s boss. I looked again in sorrow at the photograph of his daughter. She was about sixteen, with graceful ballet poise and a bright, confident smile.
Why are so many of my suicides fathers with teenaged daughters? I caught two such cases within a week of each other in April 2002. On Tuesday it was Jeffrey Hopkins, a fifty-five-year-old lawyer with a history of depression and a lot of debt. Hopkins took sleeping pills, leaving behind a wife, a twelve-year-old boy, and a nineteen-year-old girl. Thursday’s case, Peter Clark, was a playboy millionaire who was going through a divorce and having business problems. His suicide was a method I haven’t seen often. It required the most meticulous planning. Clark bought a full tank of compressed helium and attached it to an airtight mask. Helium is inert and nontoxic, so it didn’t poison him; the mechanism of death was asphyxia by displacing oxygen. He had locked his apartment door with the inside chain and hung a note there, so that when his wife came home and opened it, the door stopped and the note popped up. It read, “I have taken my life. Please call the proper authorities.” Peter Clark had two daughters, one in grade school and the other just starting high school. I ached for those girls when I read the report.
I ached more the next day, when I called Clark’s wife. Their thirteen-year-old daughter had broken down the night before. She had seen a wedding dress in a store window, and it made her realize her father wouldn’t be there to walk her down the aisle. “My father wasn’t there for me at my wedding either. I was thirteen when he killed himself, just like your girl is,” I told the widow. “You have to tell her that suicide isn’t genetic. That was my biggest fear, once the shock wore off after my dad’s funeral. I thought I was doomed to kill myself too. I really did. You should make sure she knows that isn’t true. Suicide isn’t a disease. Tell your daughter that from me.” So much for my cultivated professional demeanor—we were both sobbing wrecks by then.
I ruled the deaths of twenty-one men as suicides during my time as a New York City medical examiner, but only five women. This lopsided ratio is not unusual. Nationwide the ratio of male to female suicide deaths is about three to one, and in some parts of the country it’s ten to one. Suicide attempts, however, skew in the other direction: Three times more American women attempt suicide than men do. Medical examiners end up with more men than women on the autopsy table because women as a group choose suicide methods that are less instant, such as an overdose of pills, and end up surviving the attempt. It takes anywhere from several minutes to a couple of hours before the lethal concentration of a drug in the stomach is absorbed sufficiently to stop breathing, and this offers a window for medical intervention. American men as a group choose suicide methods that are more likely to inflict irreversible lethal trauma—hanging, jumping from a height, and, especially, firearms. Nationwide, half of all suicides are by gun. In New York City, only one in nine is.
Gun suicide isn’t foolproof—or always all that quick. The worst, very nearly botched, gunshot suicide I saw in New York was a fifty-year-old man described by his neighbors as mentally disturbed, who was found decomposing in his locked apartment in February. He had a .22-caliber revolver in his right hand and a contact wound to his right temple. When I opened his head, I found the bullet had gone clear through the middle of both the man’s eyes. Its energy had blown the thin bones at the back of the eye sockets into the frontal lobes of his brain. He had autolobotomized, and probably lived in searing pain for several blind, awful minutes, maybe as long as half an hour, before brain swelling ended his ordeal.
James Hunt took a belt-and-suspenders approach. A Central Park jogger found him on the ground near the Bethesda Fountain, twitching, his head a gory mess. He had a .380 semiautomatic pistol in his left hand, and there was a nine-millimeter by his feet to the right. A gun case left on a nearby bench had a note on it that read, “Police: more ammo and knife collection in my bag,” and, sure enough, there was. This twenty-eight-year-old white supremacist left a twelve-page suicide note in his apartment, blaming his woes on Jews, blacks, etc., and leaving instructions for his mother about his financial affairs. His stated reason for killing himself: despondency over rejection by a “pure white woman.”
“He should’ve gone black—you never go back,” black beauty Zee from ID told the Jew doctor who was cutting up the sad, dead Nazi. The first time I autopsied a man covered in swastika tattoos, I will admit I enjoyed an atavistic jolt of vengeance. A lot of dead guys have swastika tattoos, though, and by the time I was pulling out this particular white supremacist’s organs, the thrill was gone. Hunt had put one gun in his mouth and the other to his head. The intraoral trajectory exited out the top of his skull. The other entrance wound was behind the left ear and left a classic muzzle stamp. That bullet fragmented into four pieces at the base of the brain, and its copper jacket ricocheted off the bone and ended up in the right temporal area.
James Hunt was the last of six suicides I investigated in February 2002. Six out of a total of twenty-five cases that month—roughly one in four—is a high percentage. Plus, it was plain bad luck that two of those, within ten days of each other, were subway suicides. Subway suicides seldom leave a note, and in order to rule out homicide or accident we have to rely on sometimes-conflicting reports from other riders about the actions of the decedent and those around him.
Early in February, a quiet, middle-aged father of three died under the uptown Number 4 train at Union Square station. The train driver and two witnesses on the platform said he was standing alone when he took a flying leap onto the tracks. He ended up underneath the third car. The man’s son, daughter, and wife were still stunned when I spoke to them the next day. The deceased had been a private man who rarely shared his feelings. They couldn’t tell me whether he had been depressed or even unhappy. He had just become a grandfather.
The autopsy was downright spooky: There was no blood in the man. He had broken ribs, a clean fracture of one femur, and his spleen was smashed to pulp, which normally results in a lot of hemorrhage. The mechanism of death was the dislocation of his skull off the cervical vertebrae—an internal decapitation. Connective tissues were still holding his head and neck together, but his neck bones, cervical spinal cord, and medulla oblongata were all pulverized. I struggled to collect a vial’s worth of blood in the body for the toxicology sample. I can always go into the heart and find blood, but his heart was empty.
“Where did the blood go?” Dr. Hirsch asked me at afternoon rounds after I presented the case.
“I don’t know! Maybe it’s at the scene, but I doubt it—he didn’t have any external wounds that looked large enough to dump his entire blood supply.”
“But the scene investigators might not have seen it, down there in a subway trench. Awful lot of dark sludge at the bottom of those, plus they have good drainage,” another doctor pointed out.
“There are cases where there’s no way for the blood to get out of the body, yet you still have the finding of an empty heart at autopsy. Where, then, does the blood go?” Dr.
Hirsch asked again, that professorial glint in his eye. No one ventured a guess, so he continued. “What we think is that the blood is going into an area where it is sequestered from the autopsy—specifically in the bony sinuses and trabeculae.”
I was stunned. “You mean his bone marrow soaked it back up?”
“The sudden, massive neurological trauma to his vital center caused the systemic collapse of vascular tone, a rare thing to see,” Dr. Hirsch continued, to the fascination of every doctor in the room. “The medulla was obliterated, right? Well, when that happened, every blood vessel in his body went limp at the same instant, leaving their contents to collect in the blood-generation spaces of the bone tissue.”
“The entire blood volume can disappear into the bones?”
“That’s the theory.”
“That’s remarkable,” I said, and meant it. Mine is a gruesome job, but for a scientist with a love for the mechanics of the human body, a great one. Everyone in the room agreed I had the coolest case of the day.
The other subway suicide that February was an elderly man. His head had been split open, the brain eviscerated, and his spine broken in two places. Many people from both sides of the tracks and on board said he jumped in front of the train. His family told police he had attempted suicide several weeks before by slitting his wrists in the bath. Sure enough, on autopsy I found parallel scars on his wrists consistent with that previous attempt. There was no note in that case either.
“Why don’t these people leave a note?” I complained to T.J. that evening. We were walking home from the supermarket on Johnson Avenue. T.J. pushed Daniel in a beat-up beast of a stroller that doubled as our shopping cart. We had crammed groceries in the wire basket undercarriage and had surrounded Danny with bags of the less-destructible staples; he was banging away on the canned goods and dried pasta.
“Do you have any suspicion he was pushed or fell?”
“No. The witness reports are consistent. He wasn’t stumbling, he didn’t trip, no one was near him. The train driver said it looked deliberate. The poor guy. He’s the one I really feel for.”
“Don’t most suicides leave notes?”
“Only ten to twenty percent, depending on whose study you believe. The best homicides are when a single bullet goes in and out and gets recovered, and the best suicides leave a note. After that I’ll take a straightforward OD with a needle still in his arm, or white powder on a hotel tabletop any day.”
“Okay, Dan, up you go.” T.J. unleashed Danny from the stroller. It had rained the day before and the boy went straight for the puddles, having a ball. I couldn’t imagine a parent intentionally leaving his family behind the way I had seen so many do, but I knew from reading enough suicide notes that most of them manage to delude themselves into believing they are doing their loved ones a favor. They aren’t. You can take my word for it.
My father’s autopsy report is mundane. The decedent, “appearing to be the recorded age of 38,” is male, paunchy for his height but not obese. “The scalp hair is black with some graying,” it reads. “There is a bushy mustache present,” and “the teeth are natural and in good repair.” But I remember a crooked, smirky smile, and always enjoyed how bushy his mustache felt when he kissed me. He usually smelled of onions. The autopsy report doesn’t say that. It misspells our surname two different ways—“Melilek” and “Mililek”—but somehow manages to spell “Menachem” correctly throughout.
I read my father’s autopsy report soon after I made the decision to become a forensic pathologist. I felt it would be an omission to enter the field without reviewing the one autopsy report that had affected my own life. My dad hadn’t left a suicide note, and I was hoping to find in the result of the postmortem examination some hidden clue, something I could see with a medical examiner’s eye that might help me understand why he killed himself.
The description of the ligature furrow made by the gray extension cord around his neck is routine and unremarkable, running from under his left chin, around the right side of his throat and behind the nape of the neck before ending at his left earlobe. There were no scene photos, but it was easy to picture his head cocked hard to the right. I’ve seen it in other hangings. Dissection of the neck showed no hemorrhage in the strap muscles. The hyoid bone in the throat was intact. His lower extremities had the usual purple discoloration, and his face showed marked lividity and congestion. His glasses were still on when the police cut him down, but he was stiff and cool to the touch by then. “The body is opened by the usual Y-shaped incision,” the Westchester County assistant medical examiner wrote in 1983. “The muscles are deep brown-red and hypertrophic.” The decedent had significant heart disease for a young man—probably those White Castle hamburgers he loved so much. He also had a fatty liver, but the toxicology report found no cocaine, no heroin, no alcohol in his system.
He was sober. I couldn’t blame drugs. I could only and still blame Menachem.
I miss him very much. Even today, thirty years later.
9
Misadventures in Medicine
Learning death investigation as a medical examiner served to intensify my fascination with the human body. The trouble was, the more I learned in the autopsy suite, the more often I found myself diagnosing strangers outside it. The guy nodding off on a park bench, with switchyards of needle tracks up his arms and around his ankles, is going to overdose on narcotics someday soon. The matron pushing a shopping cart in the grocery store, with the yellow glow behind the whites of her eyes, is in liver failure. The hot dog vendor with oddly hairless shins, pockmarked and patchy with brown, leathery splotches, and swollen ankles? Heart failure, textbook.
What should I do? Should I walk up to the woman with the melanoma on her neck and warn her that she needs to show it to her doctor right away? Do I urge the teenaged girl with parallel scars on her wrists to seek professional counseling before self-mutilation leads to suicide? Should I carry brochures for drug treatment centers to tuck into the pockets of junkies? My professional role is to find the truth in death and to tell others. Does that include counseling these predeceased New Yorkers? Is that part of my job description, a vocational responsibility for a doctor so intimate with the end of life?
Doing autopsies for a living did not make me afraid of the world—but I was being haunted by ghosts who weren’t dead yet.
* * *
The longest cause of death I ever wrote was “hemorrhagic complications of pancreatic debridement for treatment of necrotizing pancreatitis complicating AIDS due to intravenous drug abuse.” In plain English, a needle drug addict contracted HIV, so his doctors put him on powerful anti-AIDS drugs. One of these drugs damaged his pancreas, and he underwent surgery to remove the dead tissue. During the surgery, one of his big blood vessels was damaged, and he slowly bled to death. A therapeutic complication on a hopeless case.
“Therapeutic complication” isn’t a euphemism for hospital screwup. It is a special category in the manners of death in New York City, reserved for cases in which the patient died as the direct result of a nonemergent medical or surgical intervention, regardless of whether an error occurred. If you go into a hospital to have a scheduled procedure that is not meant to be immediately lifesaving and you come out dead, your demise might be classified a therapeutic complication. Back in L.A. where I did my residency, we called these “therapeutic misadventures,” a term Dr. Hirsch finds inflammatory and T.J. finds hilarious. It is the rarest manner of death except for “war injury,” which Hirsch still uses occasionally if someone dies of complications from an old battle wound. “It irks the nosologists at the bureau of vital statistics,” he told us during our training week, “but I just can’t call them homicides.”
Few other jurisdictions use war injury as a manner of death, and not all medical examiners classify medical misadventures as a separate category either; many just lump them in with the naturals or the accidents. Dr. Hirsch, however, felt it was an important part of our public-health mission to analyze medical e
rrors separate from other deaths that occur in hospitals. If a patient had an urgently needed, potentially lifesaving procedure and died anyway, then the death would be classified based on what disease or injury necessitated the procedure. For example, if he was in a fight and sustained a gunshot wound, and then bled out on the operating table, the manner of death is homicide. If he had kidney disease and his heart stopped during dialysis, the manner of death is natural. On the other hand, my signing out a death certificate as a therapeutic complication acknowledges that a medical procedure played a significant role in accelerating death, and clinicians tend to resent it when I classify their work as having produced a fatal outcome.
Patricia Cadet needed open-heart surgery or she wasn’t going to live for long. She was a black woman in her late sixties in heart failure, who went to the hospital for a scheduled quadruple bypass surgery—what doctors call a “four-vessel cabbage.” Her coronary arteries had become so narrowed by the buildup of cholesterol and other occlusive gunk that the heart tissue was starving for oxygen. In coronary artery bypass grafting (CABG, or “cabbage”), surgeons remove a section of healthy vein from somewhere it isn’t much needed (usually the leg) and sew it onto one of these blocked coronary arteries. The therapeutic goal is to go around the obstructed section. If the surgeon is fixing just one artery, that’s a single-vessel cabbage. Two is a double. Patricia Cadet was having four done, at once, under open-heart surgery.
During open-heart surgery, the medical team crack your breastbone, spread your ribs like they’ve opened an oyster, and stop your heart from beating while they work on it. Your body’s oxygen supply is managed by a heart-lung machine in the meantime. If your coronary arteries have become so badly mucked up that you need a CABG, however, it’s likely you have dangerous cholesterol deposits in other places, like the carotid arteries feeding the brain. So, after you go under general anesthesia but before the heart surgeon begins, it might be necessary for a vascular surgery team to first Roto-Rooter these vessels and maximize blood flow to the brain, in a procedure called carotid endarterectomy.
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