Lesson 16: Have investigators do most of the external body examinations.

Just as a physician uses physician extenders such as physician assistants and nurse practitioners, the chief medical examiner can also use medical examiner investigators as physician extenders. Certainly, the investigator saves time and expense by routinely visiting death scenes instead of a pathologist, but I have discovered that the investigator may also save additional time and money by doing most of the external body examinations.

External body examinations are simply inspections of the outside of the body without the incisions of a medicolegal autopsy. The intent of the external body examination is to rule out any evidence of suspicion for foul play prior to releasing the body to the funeral home for embalming, cremation or burial. The investigator also obtains specimens for toxicology through needle puncture during the body examination.

Most offices require pathologists to do these body examinations. The pathologists in some offices routinely examine bodies prior to issuing cremation permits. Some offices charge money for these examinations. The office where I trained in Atlanta considered it unthinkable for anyone other than a forensic pathologist to examine a body.

I discovered upon taking the chief job in Kansas City that investigators here were accustomed to performing external body examinations. They learned to do these out of dire necessity during a time when they could not find a capable pathologist. I observed them as they did these procedures. They did them well, so I did not see any reason to prevent them from continuing. After 11 ½ years, I found no problems with their work.

Recently, my deputy medical examiner and I reviewed 150 consecutive body examinations performed by investigators. We followed each of their examinations with our own examinations of the bodies. We found no major discrepancies that might result in an error in the determination of cause and manner of death. Although different examiners might note small items in different ways, no significant findings were overlooked.

Allowing medical examiner investigators to perform most of the body examinations in cases where an autopsy would not be performed saves the office time and expense and adequately allows a proper examination of each dead body for subtle suspicious findings. There are several reasons for this.

First, the investigator in most cases has already viewed the body at the death scene. He or she is aware of the context where the body was found. He or she is privy to the information surrounding the death. Allowing the death investigator to perform a careful body examination at the morgue under bright lighting and after removing the clothing only further amplifies the information he or she already obtained. The pathologist, on the other hand, does not have the first-hand information that the investigator possesses, nor has the pathologist viewed the body at the scene. Although the pathologist has more medical training, he or she does not have the context that the investigator has. The knowledge base of the investigator also allows him or her to evaluate a body for the few findings that are suspicious in the medicolegal context, such as conjunctival petechiae, neck abrasions, stab wounds, gunshot wounds, or other external injuries involving the body surface or the body orifices.

Secondly, since the investigator does not have as high a salary as a pathologist, the time expended then becomes more cost effective for the local or state government.

Thirdly, allowing the investigator to examine bodies in non-suspicious cases allows the pathologists time to focus on the more important and significant cases, particularly those cases requiring autopsies.

In my office, medical examiner investigators performed most of the external body examinations but not all of them. I required pathologists to perform certain external examinations. All decomposed bodies, for example, had to be examined by pathologists. A trained forensic pathologist evaluated the changes from decomposition that are often either mistaken as injuries or the subtle violent injuries that are often masked by decomposition. Also, pathologists examined victims of gunshot wound suicide in cases where the self-inflicted nature of the injury was amply documented and the recovery of a projectile from the body was not required.

Although pathologists in my office dictated reports on all of their examinations, the medical examiner investigators performing body examinations simply filled out a worksheet that provided prompts for each of the items they were to look for. We retained those worksheets in each file.

Also, medical examiner investigators became adept in performing needle punctures to obtain specimens. They developed and maintained a skill that proved useful for them professionally.

I instructed each investigator to notify the pathologist on call of any finding that he or she could not explain or interpret. If they had any questions at all, I encouraged them to speak to the pathologist on call. At no time were these investigators belittled for anything they did not understand. All felt free and comfortable to disclose any item.

Allowing medical examiner investigators to perform external body examinations expands their usefulness as physician extenders.