A medical examiner is a physician, hence, the title medical examiner. The medical examiner is authorized by state statute with the investigation and examination of persons dying suddenly, unexpectedly, or from physical or chemical injury. The responsibility of the medical examiner is to determine cause and manner of death, and to document and preserve evidence as it relates to the decedent.
A pathologist is a physician trained in the medical specialty of pathology. Pathology is the branch of medicine that deals with the diagnosis of disease and causes of death by means of laboratory examination of body fluids (clinical pathology) cell samples, (cytology) and tissues (pathologic anatomy).
The forensic pathologist is a subspecialist in pathology whose area of special competence is the examination of persons who die sudden, unexpected or violent death. The forensic pathologist is an expert in determining cause and manner of death. The forensic pathologist is specially trained: to perform autopsies to determine the presence or absence of disease; to interpret injuries and injury patterns; to interpret effects of poisoning; to evaluate historical and law-enforcement investigative information relating to manner of death; to collect medical evidence, such as trace evidence and secretions, and to document evidence of sexual assault. The forensic pathologist must have a working knowledge of other non-medical disciplines, including: toxicology, firearms (wound ballistics), trace evidence, forensic serology and DNA technology. The forensic pathologist acts as the case coordinator for the medical and forensic scientific assessment of a given death, making sure that the appropriate procedures and evidence collection techniques are applied to the body. At death scenes, forensic pathologists bring their expertise to bear upon the interpretation of scene findings, in the assessment of the consistency of witness statements with injuries, and in the interpretation of injury patterns or patterned injuries.
Death investigation always begins at the scene. The scene investigation may give clues as to drugs or toxins which may be related to the cause of death. Some poisonous agents are not detected on routine drug screens therefore the pathologist must have knowledge of medications and toxins in order to request the specific analytical tests needed to detect them. An example would include the "sniffing" or "huffing" of aerosol propellants, a risky activity which has been frequently reported in teenagers. Sniffing of propellant substances can cause sudden death by precipitating lethal cardiac arrhythmias. A special analysis (gas chromatography by head space analysis) is required to detect the chemicals in the blood. In other cases there may be sufficient natural disease to account for death but the individual may in fact have died of a drug overdose or other subtle cause. In the case of drowning and suffocation the autopsy findings are not specific and police investigation is critical to the understanding of the death.
In the examination of skeletal or severely decomposed remains, the forensic pathologist will frequently consult another doctor with special expertise in analysis of bones, a physical anthropologist. If sufficient skeletal parts remain, the pathologist or anthropologist may be able to determine the age, race and sex of the individual and sometimes estimate the length of time since death. Occasionally, specific markings on the bones may enable the pathologist to come to a conclusion as to the cause of death.
An autopsy is an examination of a dead body. In the course of an autopsy the body is examined multiple times; first as it is received, then again after it is unclothed, and yet again after being cleaned (any loose dirt, blood or other foreign substances are removed). At each step, identifying features, injuries or other unusual features are documented with multiple modalities (i.e. photographs, verbal and/or diagram). The body is then opened, and each organ is examined, in turn, for the presence of injuries or pre-existing natural disease.
In the course of an autopsy, samples of various organs, tissues and body fluids are retained for additional ancillary studies, if warranted. The ancillary studies include microscopic examination (Histology), drug testing (Toxicology), and microbiology (bacterial and viral culture). Additionally, depending on the type of case, other items of evidence may also be retained: foreign objects (bullets, knife blades or tips, ligatures, etc.), scalp hair (for comparison to hair on a suspect weapon or vehicle), fingernail scrapings (for analysis of blood and/or foreign DNA), sexual assault swabs, gunshot residue test swabs, and so on. The HCIFS is also very active in the collection of trace evidence from dead bodies (collected under visible and alternate light sources).
The types of deaths that we investigate are specified in the Texas Code of Criminal Procedure Section 49.25. These cases include: all deaths that are not natural, that is, all deaths resulting from physical or chemical injury. Such deaths fall into the categories of Accident, Homicide and Suicide. An interval of survival between an injury and consequent death does not preclude a death from being a medical examiner case. For example, if a person is involved in a car crash and consequently becomes quadriplegic, then dies from pneumonia ten years later as a result of the quadriplegia, the case is still a medical examiner case and will be classified as an Accident, resulting from the car crash. Sudden unexpected deaths are also medical examiner jurisdiction. This includes individuals of any age, without significant medical history to explain their demise, based on natural disease. A variety of cases fall into this category, including crib deaths, deaths of athletes, and middle-aged and older individuals dying in a variety of circumstances.
The importance of examining people in whom the cause of death appears obvious is several fold. In the case of shootings or other fatal assaults the forensic pathologist, during the course of the examination, may recover bullets or other important trace evidence. In the case of motor vehicle occupants, it is important to determine who was driving and to assess driver factors, vehicle factors or environmental factors that might have caused or contributed to the crash.
The medical examiner law in Texas (Texas Code of Criminal Procedures section 49.25) is very clear with respect to which deaths fall under the jurisdiction of the medical examiner i.e. in which cases the medical examiner has the duty and responsibility of determining cause and manner of death. However, the law does not specify what elements must be included in that death investigation. In many cases, a medical examiner will be satisfied that an autopsy is not necessary, after discussion with police at the scene, with family, and/or with the decedent's personal physician and that adequate medical information exists to explain the cause, mechanism and circumstances of the person's demise and that injury or foul play have been ruled out. In such cases, a medical examiner may elect to perform an "external examination" rather than a complete autopsy.
An external examination will include photography of the body as it is received; photography of the body unclothed and cleaned, documentation (photography, diagram and verbal description) of any identifying features, etc., collection of samples for potential toxicology analysis and potential DNA analysis. Most traumatic deaths are autopsied; however, in some instances where the decedent has been hospitalized for a substantial time prior to death and where injuries, cause and mechanism of death, and circumstances are clear (and there is no suspicion of homicide), the person may not be autopsied. The latter category primarily consists of victims of motor vehicle crashes who have been hospitalized for weeks or months. Certain types of cases, especially homicide and suicide, are typically autopsied regardless of the duration of post-injury survival. Importantly, the medical examiner retains final discretion in all cases within medical examiner jurisdiction, and each case is decided on a "case-by-case" basis.
If the medical examiner determines that an autopsy is necessary, a complete autopsy (including examination of all internal organs and brain), will be undertaken. Limited autopsies (e.g., "chest only," "head only," "chest and abdomen only") are common in hospital pathology, but are inadequate in medical examiner practice.
Of course, the specifics of a particular anatomical and/or toxicological examination will vary depending on the nature of the case. In other words, the specifics of an examination are tailored to the question(s) being answered.
The route to becoming a forensic pathologist is long. In the 13 post-graduate years outlined below, one must remain open-minded to other fields, and carefully consider all options, all along the way. As for advice... the best advice is simply "keep your grades up."
These popular TV series certainly glamorize all aspects of forensics. (Come to think of it, the TV series even glamorize the crimes the forensic personnel are setting out to solve). Our job is really much more mundane, smelly and adversarial than what's portrayed on TV. Further, technical inaccuracies abound in the TV shows, particularly with regard to the time frame in which tests are ran. The TV shows all also take liberties with character development, where single characters assume the roles of multiple police detectives, crime scene analysts, and pathologists. More disturbing is the mindset portrayed on Crossing Jordan, in which the pathologist sets out to "prove" somebody's innocence or guilt…our role is neutral (the latter philosophy is more accurately presented on the original CSI).
Having said that though, the interest generated from those shows have been terrific for the forensic community. We have seen a deluge of bright young folks interested in our field who probably would otherwise have no idea of what we do. The fact that you're reading this is an example of that. The TV shows are also worth watching from another standpoint as well: entertainment. After all, the story lines are generally pretty good, even if some of the details are bogus.
There is no typical day. Obviously we spend much of our time performing autopsies. But that's just the beginning. We frequently attend death scenes, testify in court, lecture to medical students and residents, give hands-on training to physicians-in-training, meet one-on-one with families, meet with lawyers on civil and criminal matters, give depositions, and the list goes on.
The variety extends to cases as well. Many of the cases that find their way to the newspapers are homicides…gunshots, stabbings, beatings, etc. But then there are natural deaths: sudden unexpected deaths in babies for example, where mourning parents are desperately awaiting answers (is there an underlying genetic or metabolic abnormality?) or simply closure; natural deaths in adults (is there an infectious or hereditary disease that the rest of the family should be worried about?); motor vehicle crash victims (is there an underlying reason for the crash: heart disease, brain abnormality, drug or alcohol impairment?), and again the list goes on.
- After high school the future forensic pathologist attends undergraduate college for 4 years and receives a bachelors degree.
- After undergraduate college the aspiring forensic pathologist spends 4 years in medical school, earning an M.D. or D.O. degree.
- After medical school there are several routes by which one may become a forensic pathologist.
- One may spend 4 years training in anatomic & clinical pathology followed by 1 year of fellowship in forensic pathology.
- A second option is to train for 3 years in anatomic pathology and train for 1 year in forensic pathology. The fellowship training in forensic pathology involves practical (on-the-job) experience supervised by trained forensic pathologists. The forensic pathology fellow actually performs autopsies and participates in death investigation. To become certified, one then must pass an examination given by the American Board of Pathology certifying special competence in forensic pathology.