Forensic Pathologists React to Body of Proof

• Forensic Pathology Committee

Becca Battisfore:

Welcome to the latest edition of the College of American Pathologist’s CAPcast. I'm Becca Battisfore, Content Specialist with the CAP. On this episode, I'm joined by three members of the CAP's Forensic Pathology Committee, Dr. Aurelius, Dr. Eisenstat, and Dr. Grandhi. This will be the first in a series of episodes where pathologists will react to how forensic scientists are portrayed in TV and film. But before we get into the questions, let's learn more about our guests. Dr. Aurelius, would you like to introduce yourself?

Dr. Michelle Aurelius:

Sure. Hi, I'm Dr. Aurelius. I'm the Chief Medical Examiner here for the State of North Carolina. I've been a forensic pathologist probably for far too long, so I won't give it away too much. But certainly done thousands of cases, had an opportunity to work with many families, testify in courts, and look forward to having the chance to talk a little bit about how TV sometimes gets some things wrong.

Becca Battisfore:

Dr. Eisenstat?

Dr. Jonathan Eisenstat:

Hi, my name's Jon Eisenstat and I'm currently in my own private consulting practice, but I was the past Chief Medical Examiner at the Georgia Bureau of Investigation that covers a majority of the state of Georgia. It's a state run system that's within a law enforcement agency, but I've also worked within county medical examiner offices and in a couple of different types of jurisdictions. Coroner, coroner medical examiner and medical examiner. Grew up in California, wanted to be an actor. I was a theater major, and so I will have a little extra to say about the performances, but then I went into medicine, started out in surgery, I realized it was not the profession that fit me right. Moved to pathology and fell in love with forensics. Moved to Georgia in 2016 and was at the GBI for about... Excuse me, 2006 and was at the GBI for about 16 years.

Becca Battisfore:

Great. And Dr. Grandhi?

Dr. Natasha Grandhi:

Hi, I am Natasha Grandhi. I'm currently an associate medical examiner at the Georgia Bureau of Investigation, which Dr. Eisenstat just gave a pretty nice rundown of the office. We are in a joint medical examiner and coroner system, so we have a variety of interactions, with varying levels of training in the coroner setting as well as with other forensic pathologists in the region. And I am also currently the assistant program director for the forensic pathology fellowship training program, so I'm really excited to talk about some of the background training for the characters and experiences in the episode.

Becca Battisfore:

Great. For this first episode, we watched the pilot of a TV show called Body of Proof, and it ran for three seasons on ABC, starting in 2011. And it's described as a medical crime, comedy, drama, lot of things. And as with all medical and crime shows and TV in general. We know liberties were taken to add drama and intrigue, and so we'll keep that in mind. But I'm really looking forward to diving in and hearing from you all on what the show got right, got wrong, and any other insights you may have, especially on performances.

Let's jump right in. We'll go chronologically through the episode, touching on specific forensic related topics, but please interrupt me if there's something you want to discuss that I haven't mentioned. First I'd like to talk about the protagonist, medical examiner, forensic pathologist. Her name's Dr. Megan Hunt, and in the first few minutes we find that she was originally a neurosurgeon before becoming a forensic pathologist. I'd really love to know how likely is that? Is that even possible within what seems to be a couple of years, if that? They don't give a definite timeline, but seems like a very quick transition.

Dr. Natasha Grandhi:

What I gathered was that she was involved in some sort of a car accident and had some consequences as a result of that, and they mentioned the car accident was four years ago. Just to get into anatomic pathology, which is one of the disciplines that is required to practice forensic pathology, it's three years. The average resident does anatomic and clinical pathology combined, which is four years plus the one year of forensic pathology fellowship training. That's a minimum of five years. I don't think that she would have been successful with her recovery from the car accident and having some physical therapy, so I think they took some liberties on that. But she is a physician, she is trained in surgery, so that does give her a wealth of knowledge for how to apply that to certain head trauma cases. She does have some things that are working in her favor.

Dr. Jonathan Eisenstat:

Yeah, and I'll piggyback on what Dr. Grandhi said. First of all, going through a neurosurgery residency is not easy and takes a while, but I agree that having some type of clinical background, it can be a huge benefit. I had done surgery for a year and a half and had worked in a burn ward and a lot of forensic pathologists see a lot of burns of varying types. And so, I felt like I had a pretty good background on that before I went into forensics. But the timeframe in the show is a little difficult. Not trying to sway anybody who is 50 years old and wants to change their field and get into forensics when they're 55 or 60, but usually it's a little easier to go straight through anatomic pathology and then forensics.

Dr. Michelle Aurelius:

Okay. I think I'm in trouble here because everybody else is way too nice. Dr. Eisenstat and Dr. Grandhi are way too nice, and for me, I interpreted like hair bristling on the back of my neck, every muscle going tense in the first five minutes because forensic pathology is not the trash can for every unsuccessful other provider. Let's just start with that. Let's see, I may have a quote here. “Most people would count their blessings,” As it related into her being able to practice at least something like forensic pathology. Sad for this fictional character, et cetera. But we are not a trash can. This is an amazing field with innovative technology, with science-based interpretation that applies to public health and to safety, with a new patient every day coming in with complex issues, head to toe. And it doesn't take just stepping away from your neurosurgery practice and just walking in the door, being ready to handle the intensity of an autopsy examination or the interpretation. We are not a trash can. Highly educated, highly trained and confidence in the decisions that we make.

Becca Battisfore:

That's a good point. It seemed like just maybe an additional certification or something was all she needed to switch careers.

Dr. Jonathan Eisenstat:

Well, you know what clinicians will say if they're knowledgeable about pathology, that the pathologist is the physician's physician. Because we have to know everything about everything, pretty much. From laboratory work to clinical medicine to surgical procedures to trauma, to pharmacology, radiology, especially with the way that forensics is going now with CT scans, et cetera, et cetera. Absolutely fascinating field, I absolutely agree. And if you love the basis of medicine, it's a great field to go into. I think it might be a good point just to say that there's a difference between a coroner and a medical examiner. Any physician can be a coroner. You don't have to be a physician to be a coroner, but not any physician can be a medical examiner or a forensic pathologist.

Becca Battisfore:

Thank you for making that distinction. I would've conflated the two. Let's go into one of the first scenes where we see her in action when she shows up at the crime scene. And I'll let you all take that away because I'm sure you have a lot of thoughts on it.

Dr. Natasha Grandhi:

Okay, if I could get her shoes or her outfit for court, I would be happy. But there is no way that that is a practical way to show up to a scene. And first off, not every medical examiner even goes to the scene. I know where I'm at right now, we previously had our investigators that go to the scene, but right now we work with coroner offices, and the coroner office investigator or the coroner will go to the scene. I wish I could stomp around in some amazing shoes and just direct people what to do and how to do it, but really, I rely on the information including the photographs and the investigative information that's given to me. And unfortunately, sometimes that's not all-inclusive.

Dr. Michelle Aurelius:

And how do you show up at a scene, first off, in a dress, heels you mentioned, hair completely down looking absolutely lovely. But we are involved in water, in the muck, in the mud, in the rain. We are here as essentially first responders to take care of the decedents or our patients, and you have no idea what the circumstances are going to be, so you have to be prepared for absolutely anything. That means carrying a scene bag, that means having on pants with enough pockets to contain whatever you need. It means being safe and having a protection for all of your skin. And it means not going to lunch or shopping after you've potentially splashed biohazardous material on yourself after going to a scene and only showing up with gloves. That is unacceptable.

And then on top of it, the scene doesn't belong to us. The scene belongs to law enforcement and that's where this great partnership comes in. Hopefully not adversarial. Everybody seems super fussy, at least in the first 30 minutes. Not adversarial, but a partnership, because usually the medical examiner, the coroner has jurisdiction over the decedent, the items that are on or within the decedent or that the decedent is wearing and the scene itself belongs to law enforcement. But yes. Let's get a notepad, let's get a flashlight, let's make sure we have all our reports. Make sure that we have our ID handy because again, we are guests. We need to make sure that we have potentially, for those of us who put decedents within body bags, we need body bags, we need identification tags for our patients. There are a multitude of things that we need to bring with us beyond a dress, heels and pair of gloves.

Becca Battisfore:

I was wondering, it seemed like Dr. Hunt was able to be precise about the time of death or so right on the scene. What's the reality of that?

Dr. Michelle Aurelius:

Essentially, I think the important thing to remember is that the most effective way to find out when some person died is have someone be there right with them. That's the only time that I would say, "Yes, I'm confident that this person died at this time because there's some type of physical evidence or reporting, stamp recording of when the individual died or a specific witness." But we need to make sure to convey that postmortem intervals when they are quoted and when they are defined are based on a range. There are so many variables that can impact them, including algor mortis or the temperature check that it's relatively ridiculous. It is not a precise science. Anyone tells you a specific time or they're 100 percent, it was two hours before they're not following science because it is not precise, and we need a range.

Becca Battisfore:

Thank you. Where would we like to start with the autopsy scenes?

Dr. Michelle Aurelius:

Where do we stop? That's the real question. It looks like, and I think, what was his name? Peter? Peter seems to be the autopsy technician also. And certainly there are some offices where the medicolegal death investigators are also the autopsy technicians. But in other offices like mine, that's a completely separate role. And so, our autopsy technicians are not just taking notes, they're also involved in assisting during the evisceration process, but do not assess the wounds, et cetera, but will help with photography and things like that. I don't know where to start with the autopsy. I should probably open it up to Dr. Eisenstat and Dr. Grandhi, because it's hard not to be fussy. I was like traumatized by many things. The first being that she came back, what? Three days later to do an external examination. So you start your exam with the outside of the body, you don't come back like four days later and she's still lying on the table. That's unacceptable, disrespectful, and decedents do need to be refrigerated so that we can decelerate the postmortem degradation after death. You've cut the brain, but you still haven't looked at the outside of the body, which is not the way to do it. It's to start from the outside, do head to toe, front and back in a very meticulous manner with the clothing on, then it's coming back and it's removing the clothing. It's looking at the front and the backside of the body. It's looking in the areas of the hair or under the arms or places that are normally hidden. It's taking a close look and cleaning the body after that, if there's anything that you need to collect evidence wise. And then it's performing the Y incision and examining the decedent. But it seemed to happen out of sequence and that was mind-boggling. But I'm going to pass it on to Dr. Eisenstat and Dr. Grandhi to keep going with it, because there are a lot of things. And then we got to talk about the brain.

Dr. Natasha Grandhi:

Oh, I was just going to say. I think she cut a fixed brain, a pseudo fixed brain, maybe, into the most perfect thin slices that were probably about five millimeters in thickness. It was beautiful and she had a wonderful slab to examine it at, but I agree with you. Everything was done out of order. She was taking photographs without a scale of injuries and she was taking the photographs herself in a very dark room. It was just very odd. And it was after she had already done the examination and I think determined what the murder weapon was, just based on a blunt injury. And she was making quite a few conclusions that were really more speculations even at the scene. She almost began her external examination, the first part of it, when she arrived at the scene and was talking about the sun exposure on the skin, meaning that it had to be two hours earlier for death because of the sun's pattern on the harbor or wherever they were.

It just didn't flow, like you were saying. And she was doing a lot of extra testing over the course of the autopsy that is not within the realm of what we do. We don't examine hair. We don't look at it under the microscope and send off things for examination and only then go back to the body. Some of the tests that we perform, such as toxicology, are sent to other laboratories or other areas of the institution and they can take a few weeks to come back. You really need to be able to collect everything you need at the time that you're doing the autopsy. Otherwise, we're not returning these loved ones back to their families for weeks on end, and that's just not fair. I really also had quite a few issues with the actual order of the autopsy and the things that were demonstrated. The testing that was done was also just extreme. I think at one point, for other cases she mentioned, testing copper levels and ANA levels, that would not be something typically done in the course of our forensic examinations. Dr. Eisenstat, I'm sure you have plenty to add on.

Dr. Jonathan Eisenstat:

Well, this has actually been very fun for me to listen to you guys because obviously I agree with everything you're saying, but if I were a medical student or a pathology resident who was listening to what you guys were saying, it would so pique my interest because those are all such cool things to learn about. You may not do the hair analysis. You may not run the GCMS to do the toxicology screen. You may not be the person at the crime scene who rolls the body and finds some absolutely esoteric thing lying under the body. But they're all things that we need to know, and they're all things that we learn during our training. And so, when a non-forensic pathologist gets involved in a forensic type case, the potential for errors is huge. And that can cause major issues, not just for the family and giving them the wrong answers, but it could be criminal issues, there could be civil issues.

I am not going to continue to criticize what she did. What I will say is it was the most beautiful medical examiner's office I've ever seen in my life. I know that a lot of offices, including when I was at the GBI, were either building new buildings or updating their buildings because they used to be dated, but they're a lot nicer now because we deserve to work in nice places. But I will say I don't think I've been in an office where it's a corner window overlooking the skyline of Philadelphia. With the autopsy suite, a body lying on the autopsy suite, glass to the hallway where everybody's walking, and then glass to the outside. It would be lovely, maybe raise them so no one can see in. But I don't want people to think that ME offices are depressing places. They're actually not. They used to be, but they're not anymore.

One other thing that I do want to bring in is about PPE, personal protective equipment. I don't think anybody would really want to go into examining a body without protecting, especially mucus membranes and cavities and things. You want your mouth and your nose covered. You want your eyes covered, whether it be with a shield or glasses and an N95 mask. I don't have much hair left, but those who do, you want to wear a cap because you don't want to be the one whose DNA is pulled from the body when they do trace evidence. Which leads me to another thing, even though I said I wasn't going to critique too much. We don't cut the hair with scissors and then say, "Ooh, it looks like the hair was crushed and cut with scissors." If anybody out there goes into forensics, you learn about the appropriate way to take rape kits, to pull hair, for what reasons, how you go about preparing the specimens and then sending them to the other lab. Yeah, I think that we've covered the basics.

Dr. Michelle Aurelius:

Wait, wait, wait. We have not talked about, spoken about how that brain looked like a moldy piece of cheese. That is not a normal-looking brain. That character who died, so sorry about that, whatnot, has serious neurologic disabilities if that really was her brain. I did have a hard time with that. And I did find it interesting, it does seem that they're cutting the brain on a glass table. Freaky, would not recommend that you going to cut anything on a glass table. And then they also had, it looked like they had PCR, looks like maybe they had an MRI up on a screen in the background. Then they had some x-rays and then they had some people working in the laboratory. I'm not sure if that was the same space where the autopsy exam was performed, but it certainly was where you were cutting the brain.

And as Dr. Grandhi mentioned, you should need to, if you're going to fix a brain that well, it's a minimum of 10 days and it's in really soaked high intensity formalin. That's not something you want to be cutting around someone who's doing PCR testing or other types of testing. It doesn't always all happen in one particular area. But way to go, Dr. Eisenstat. PPE is important, important, important. Even for those who come in. I know at our office, law enforcement does not come into the particular room to watch the autopsy. We got stuff going around. We got COVID, we've got HIV, we've got hepatitis. This is a biohazard environment. And if you're not trained and fitted for the right equipment, you got to watch from the other side of the glass, you're not going to stand there. But yes, it certainly was clean, very clean. Typically, even surgery is not that level of clean.

Dr. Natasha Grandhi:

Going to your biohazard point. There's no smoking, eating, drinking any fluids in those areas. It's not hygienic, it's not safe. Your food is going to potentially be contaminated, so there are typically the signs posted that you cannot have food or beverages inside the morgue. And for chain of custody purposes, I know our office, we don't allow outside agencies to take photographs or to receive any evidence that we collect without completing a chain of custody. It's something that we take very seriously when we're doing an exam, because any evidence that we obtain may ultimately come into play if there's any civil or criminal litigation for the case. And so, we need to make sure that we have documentation that proves the chain of custody as well.

Dr. Michelle Aurelius:

Hey, wait a minute. Have we talked about the part where she's got paresthesia and numbness in her hands? Who can hold a scalpel blade and effectively do surgical type of incisions that take a high level of accuracy to make sure that we're doing the right thing, observing the right things, and we're handing her a sharp knife? Not only that, we're handling a sharp knife and she has an assistant there with her, this Peter person. She could cut not only herself but somebody else. Unacceptable. All right.

Dr. Natasha Grandhi:

I’ll quote her. I think she said, "You can't kill those who are dead." That may not be a direct quote.

Becca Battisfore:

But I think something like that. I felt that was just, as a layperson, disrespectful that choosing if you are going from neurosurgeon to forensic pathology and still needing the same skills. That was a little odd.

Dr. Michelle Aurelius:

But I do agree with Dr. Eisenstat. There's no question that having some type of clinical background or surgical background is a great foundation. They are surgical based type procedures. They're very intensive. They require fine-tuning and great motor skills and the ability to be able to feel your hands.

Becca Battisfore:

And then let's talk about, and we don't see this, but medical examiners at trial. I assume in future episodes there are scenes where Dr. Hunt might be at a trial, but she does say, "Guess I'll see you at the trial." Could we maybe spend a few minutes just talking about what it's like to be at a trial or to be a expert witness or fact witness?

Dr. Michelle Aurelius:

And I'll kick that one off, just dovetailing quite a bit though on what Dr. Eisenstat discussed. There are such important findings and connections that forensic pathologists need to make that help sometimes for law enforcement to determine whether the information coming from a particular suspect may be valid or not. We are always a part of those types of conversations and answering questions based on the scientific interpretation that we have of the work that we do. But for Dr. Hunt, it's pretty alarming that she would not only be able to testify firsthand as an expert for the autopsy examinations and her findings, but once she's interviewing suspects and making wild, outlandish accusations, et cetera, she has just stuck herself in the middle to not be an impartial person.

From a forensic pathologist and medical examiner perspective, we are working for the decedent. We are there to tell their stories about how and why they died the best that we can. For us, the issue isn't pointing the finger at a particular suspect. That's not for us to do. You don't want us to do that. You want us to be as unbiased as possible so that we can scientifically tell the story of this decedent. When you get us emotionally involved, and we don’t, and put us in a room with a suspect and there are handcuffs and firearms and badges galore, that's not the right place for us. We need to have the highest level of standards for ourselves and our assessments and our scientific basis, and not get caught up in the investigation, because our role is not to identify suspects. Our role is to help answer and speak for the decedents themselves.

Dr. Natasha Grandhi:

I think one of the other things that is unique about us acting as an expert witness is to also educate the jury, so that they can use what we found in the context of everything else they're presented at trial and make an informed decision on whatever verdict it is that they issue. Because we don't have all of the information when we go to trial. I know there have been a few times I've been on the stand, and they ask me a defendant's name, "Do you know this person?" And I have to even look at the subpoena to know who they're talking about. I've never heard anything there before. But what's very important is the range of fire in a gunshot wound as to who may have been the perpetrator. How close were they? Does potentially self-defense come into play?

I don't ever know the circumstances surrounding that altercation, but that information like the presence or stippling may actually place somebody in the story close to the individual where self-defense becomes a possibility. And if the jury doesn't know that, they don't understand what the presence or absence of those features mean, then they can't make an informed decision with the rest of the information that they are presented with. We get to take these really complex scientific principles and convey them to a level that the average person could understand it, and that's a challenge in itself.

Dr. Jonathan Eisenstat:

And I'll just close that out, since I do pretty much all consulting work now to explain the difference between the expert and the fact witness. The fact witness is really someone who's stating facts. If you were the one who did the autopsy and you are giving, "There was one gunshot wound, it entered here, it left there," and that's it. And you're not giving a big interpretation, that is a fact witness. An expert witness is allowed to give their opinions. And so, that's pretty much what I do now. There's always going to be people on both sides. I mean, that's basically how the legal system works. What I was always told from my training was that you can agree to disagree, but don't be disagreeable.

And so, I've had plenty of cases where I've looked at the case, I stay within my area of expertise and I'm just talking about the injuries or the cause of death or the cause of injuries or whatever, And I have a different interpretation than the person who did the autopsy or the examination or whatever. And I don't think I have ever come out and said, "No, that person is absolutely wrong. And they're horrible." I've disagreed with them. And that's okay if both sides can explain it to the jury in an appropriate way and the jury can take that and see how they put it with all the rest of the facts of the case, then that's great because they're the trier of fact, not you. Fact witness, this is what I saw. This is it. Expert witness takes that and then extrapolates it out a little bit further and gives opinions.

Becca Battisfore:

That's so interesting and it reminds me of episodes of Law and Order where you see that expert witness versus a fact witness. Thanks for the explanation. And I want to wrap up about this episode, kind of tying back to what we started talking about is just this general perception of medical examiners and pathologists as loners or they're on the outside of things or hiding in the basement. And I already know that is just not true, but we saw that in this episode at the end. Her boss is saying, "You should get some friends." How do we feel about that?

Dr. Michelle Aurelius:

I think we're all with you all the way. Again, forensic pathology is not the trash can for all individuals who are not successful in their chosen other part of medicine. It is an amazing, invigorating, involved, very complex job that involves bringing so many elements together and working to solve the pieces of the puzzle to help speak for that decedent on scientifically based methodology. It is pretty amazing and very phenomenal. And what's interesting is they say, "Oh, well, only introverts should be forensic pathologists." That is not true. I mean, now I speak to everyone. I speak to grieving families in the worst moments of their lives. I speak to attorneys, I speak to courts and juries. I talk with members of the public or the members of the media to talk about trends and overdose deaths.

Medical examiners are critical in not only telling the individual patients or decedent story, but also in making sure that we're conveying the information about how and why people die, to follow general trends so we can ultimately save lives. Sometimes that relates to public safety. You are going to testify so that if an individual is deemed not to be safe in the community because they're suspect has turned to someone who's been charged as guilty, and they're set away from the public. But it's also things like seatbelt laws, like helmet laws like tracking infant mortalities and unsafe sleep environments, substance use disorders and suicide deaths. The medical examiner, coroner and death investigation system contains answers that our patients want to tell the community to ultimately save lives in all of those areas.

Dr. Jonathan Eisenstat:

Beautifully said, and if you ever get an opportunity to visit the office of Chief Medical Examiner in New York City, where I did my training, over the entry... Well, as you enter into the building, there's a Latin saying, I don't even ask me how to say it in Latin, but in English it is, "This is the place where the dead helped the living." And that's exactly right. Medical examiners have their hands in everything. The opioid epidemic, the COVID epidemic, everything Dr. Aurelius just said. It took me a long time to get here, but I love where I ended up. I love the profession.

Becca Battisfore:

Wow, that was a very powerful quote. Thank you for sharing that. And then finally, for anyone who is interested in forensic pathology and watches shows like these, I think we've made a few points on this already, but what else would you like them to know?

Dr. Michelle Aurelius:

It's a fantastic, intellectually engaging field. It's hands on. You're not behind a computer all day. You have an opportunity to have a high level of skill, whether you're an autopsy technician, a medicolegal death investigator, a medical examiner, a forensic pathologist, or all of those things combined together. It's incredible that every single day is different, that you have challenges every day that intellectually challenge you, and you have such a great opportunity to ultimately, I know it sounds crazy, save lives by telling the stories about how and why people die.

Reach out, gather information. The College of American Pathologist is a tremendous resource. There's specific information about forensic pathology. Check it out. There are also other organizations that can answer your questions and connect with your local medical examiner or coroner's office and see what kind of opportunities might be available. Because just the tip of the iceberg may have been this fantastic show that you watched. And like Dr. Eisenstat said, that doesn't mean we wouldn't have enjoyed these shows, or these are not great foundations or ways to get you interested in forensic pathology, pathology or medicolegal death investigation. But if you have that interest with the shows, come on and join us. Explore, make connections, and learn more about it.

Dr. Jonathan Eisenstat:

It is an awesome profession. You get to investigate, you get to put the pieces of the puzzle together. You learn about drugs, you learn about infectious diseases. You sometimes get to go to the scene. Like Dr. Aurelius said, every day is different. It's a fascinating field. I think you can tell we're a very diverse group of people that are within the profession. We're a very social group of people. Come on out to a NAME, National Association of Medical Examiners meeting and you'll see how tight-knit of a group we are, yet how after the meeting there are social hours and people do things. It's an awesome profession, great group of people and great organizations that support it.

Dr. Natasha Grandhi:

And because we do really see so many unique and diverse things, we have endless opportunities for publications and research projects, so you can get involved at any level. If you want to do case reports, if you want to shadow, if you want to come up with your own data analysis, just reach out and talk to us. We do like to encourage people into the field and we'll find whatever strange thing or consumer safety product, maybe, that you want to investigate, and we'll find a way for you to look into it and write it up or see cases.

Becca Battisfore:

It sounds like there are no two days that are alike, which is incredible. I want to thank you all for joining me. This was such a fascinating discussion, and I want to thank you all for listening to this CAPcast. Stay tuned for future episodes of Forensic Pathologists React. And for more information about the College of American Pathologists, visit CAP.org.

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