Inside the Autopsy Room: What the Dead Tell Us, Dr, Geoffrey Smith. Chief Medical Examiner GBI

In this episode, Dr. Geoffrey Smith, the Chief Medical Examiner for the state of Georgia, shares insights into the world of forensic pathology. He discusses the differences between medical examiners and coroners, the challenges faced in the field, and the emotional toll of dealing with death on a daily basis. Dr. Smith recounts personal anecdotes from his career, including experiences with murder trials and the impact of the fentanyl epidemic. He explains the process of death investigation, the importance of determining cause and manner of death, and the complexities involved in death certificates.

Takeaways

* Forensic pathology is a specialized field that requires extensive training.
* Medical examiners are often confused with coroners, but they have different qualifications.
* The emotional toll of working in forensic pathology is significant and requires coping mechanisms.
* Fentanyl has become a leading cause of drug-related deaths in recent years.
* The manner of death can be classified as natural, accident, suicide, homicide, or undetermined.
* Investigating sudden and unexpected deaths often involves complex medical and legal considerations.
* The process of death investigation includes collaboration with law enforcement and other agencies.
* Death certificates are important legal documents that require careful consideration of cause and manner of death.
* The recruitment and retention of qualified forensic pathologists is a growing concern in the U.S.
* Personal anecdotes from the field highlight the unpredictable nature of forensic pathology. 

Transcript

SPEAKER_01: 0:00

All right, folks, welcome to another episode of Interesting Humans. I'm Jeff Hopeck, your host. We are at the GBI, the Georgia Bureau of Investigation today in their autopsy suite. And today's interview, I have Dr. Jeffrey Smith, who's the chief medical examiner. And we are in for a treat today. I will say the last time I personally had this feeling was the The day in 2003 when I walked into the White House for my first day on the job doing U.S. Secret Service. I am nervous for this because this is incredible being here. We're not on video today, obviously, but thank you folks for having us. This is going to be an incredible conversation, and let's get right into it. Medical examiner, what is it? Why do people confuse it with coroner, Doc?

SPEAKER_00: 0:58

Well, hi. I'm happy to be here. And yes, my name's Jeffrey Smith. I'm a duly qualified medical practitioner who has chosen the fascinating yet little-known specialty of forensic pathology. And I'm currently privileged to be the chief medical examiner for the state of Georgia's medical examiner system, which is part of the Georgia Bureau of Investigation. We're actually a division, a branch within the Division of Forensic Sciences, the prime lab here. And the medical examiner's office was established here at the GBI in 1997. Prior to that, it's a little bit of the Wild West. They didn't have a formal state medical examiner's office. Obviously, those that know Georgia and... the metropolitan Atlanta area. There are a number of counties there that have sufficient population base to have their own medical examiner's office. And that's really just four of the 159 counties in the state of Georgia. So we medical examiners here, and I am happy to say we have 11 fully qualified, board-certified forensic pathologists working here at the headquarters at the Georgia Bureau of Investigation. We are consultants, really, for the coroners. And just so the distinction can be made, a medical examiner is a medical practitioner who's gone to medical school. Okay. And that individual, after obtaining their medical degree, do another four years of training in the specialty in pathology. And if you think of pathology as the doctors who make diagnoses in the lab, they look down the microscope, they're the ones who perform... tests. Maybe you go to the doctor and have a blood test. Go to a pathology lab so the clinical pathologist can interpret results. And that's a four year stretch of training. And then after that, those who dare go on and do a further year of training at an accredited training program in forensic pathology. And here in Georgia, currently have three accredited training programs. The first one was established at the Fulton County Medical Examiner's Office, where I did my training after I did my residency in pathology at Emory University. And obviously, my medical training was not in the United States. It was actually at the University of Auckland in New Zealand. And it's a six-year training course. basically three years of undergraduate and then three years of clinical. We don't have college in New Zealand. So it's based on the British system. So Fulton County Medical Examiner's Office has a training program. Here at the GBI, we have a training program for fledgling forensic pathologists. And I think that Cab County has just been approved for a training program. So all of the doctors here are highly qualified in the area of both pathology and forensic pathology. And we receive calls from coroners who are elected officials throughout the state of Georgia. Each county has a coroner. Okay. And those individuals, men and women, are elected, duly elected. And they are in charge of the death investigation from the local county aspect. And they're also responsible for signing the death certificates for individuals. So... Bodies of deceased individuals are transported from all over the state to one of our three facilities. There's the headquarters facility here in Decatur. There is a facility in Macon. And we have a facility in Pula, which is called the Savannah because it's 10 minutes outside of Savannah. And they have a lovely new facility down there. And we have a doctor working down there full-time at the moment. I think the... other doctors to join the ranks. Perhaps we can get into that sometime later in this discussion, just in terms of the issues that forensic pathology and forensic pathologists face, not only in Georgia, but throughout the United States. So that's by way of introduction.

SPEAKER_01: 5:39

Great. Very, very helpful. What's the craziest thing you ever saw?

SPEAKER_00: 5:45

Sometimes the craziest thing I ever see or experience is is my being called down to testify in a murder trial. And it can be just about anywhere throughout the state where I happen to have performed the autopsy on an individual who has died as a result of murder or homicide, as we call it. And very often... The attorneys will essentially call me and say, Doctor, we need you here at 9 o'clock in the morning. I say, great. I get up at 5 o'clock, hit the road, drive down to the courthouse, and I am told, Doc, we're glad to see you. We're just getting underway. Hopefully, we're going to get you before lunch. Oh,

SPEAKER_01: 6:41

no.

SPEAKER_00: 6:42

Sorry. And then it's a waiting game outside. And I have testified, and I'm not sure how many counties throughout the state of Georgia, but it's always a little bit of adventure because some of the counties have the old courthouses, some historic buildings. A lot of them are brand new courthouses. But there's always, it's a hive of activity. But usually behind closed doors, something's going on. We're sort of thinking, well, it's going to be my turn soon to testify in this case. And occasionally an investigator will come up. Can I get to you, doctor? Don't you worry. Well, the most recent episode was having done all that, apparently one of the witnesses for the defense didn't turn up. So the judge basically, after two and a half hours, sort of said, well, we won't be proceeding with this today, so everybody go home and have a very nice weekend. So it was a long haul, waiting around, and then false start. You're going to have to come back and do it again. But that's... It's not particularly crazy, but it's sort of craziness on one level that I have to deal with. I think you're probably interested in something. And I don't want to get into the details of particular cases necessarily. And I think, like I say, over the last 30 or so years that I've been doing this last count, I'm somewhere close to 11,000 autopsies and examinations myself. So it's hard to pick something that is crazy. But I would like to say that the majority of cases that we do not deal with... Sorry, we deal with are not particularly crazy. There are often crazy stories behind things, and sometimes they're crazy stories about somebody having a heart attack, which is not something you're going to see in the newspaper or anything like that. Right. The story that we're provided. So... But let me tell you, I think one thing comes to mind, which was a little bit of an eye-opener, and this was a good number of years ago, and I went out to, I think it was Burke County near Augusta, to testify in a homicide case, and it was an individual who got into a fight or some sort of altercation at a party and ended up deceased, and body came here to the GBI and I performed the autopsy, prepared an autopsy report and then a good number of months later I was called to testify in the case. And I got to the courtroom at Burke County and this was actually, I've done two stints here out of the GBI as a medical examiner and this was during my first stint early aughts, turn of the century. And anyway, I turned up and one of the people involved with the prosecution sort of said, well, you're going to be before our star witness. And I said, oh, okay. I mean, I'm seldom the star witness in these sorts of situations. It's essentially, I have to be there to describe what I saw at the time of autopsy and the decedent died as a result of this particular injury or that particular injury. So I wasn't expecting, certainly I didn't expect anybody to come out and sort of say, well, Doc, you're the star witness, but you're going to be after our superstar witness or anything like that. But I said, oh, who is the witness? And they said, well, you see that woman over there. And I said, yes, who is it? And she said, that's Ashley Smith. And she was the spouse of the deceased. And the name rang a bell, and I said, yes, Doc, you're familiar with the Brian Nichols case? You know, the Fulton County Courthouse homicides that occurred back in, I think, 2005. And I said, my goodness, yes. She was the woman who persuaded Brian Nichols after a night, you know, he was on the lam, night on the lam to turn himself into law enforcement. And so I think part of her story was that she had been through the grieving process because her husband had died violently and that sort of thing. And I just thought, no, my goodness, and the circle was closed because I actually performed two of the three autopsies on the victims of the courthouse so you know small world so i mean and again i don't know if that qualifies as crazy but you know just sort of the sorts of coincidences that you can have in this very small world of death investigation and you know part and parcel of it is the fact that we as forensic pathologists are a very you know small cadre of qualified medical specialists sure and um You know, that's part of the problem that forensic pathology is having in the United States at the moment, is that we are unable as a specialty to recruit and retain individuals to do the work that's necessary, where it's, you know, various numbers are quoted, but I think for the population base in the United States, they say we probably need somewhere in the vicinity of 1,500 qualified forensic pathologists And at the moment, I think we're running at around about 500 for the entire United States. Oh, my. So, you know, it's a problem. You know, there are various theories about it. I have my own theories as to why there was a problem sort of recruiting individuals. What do

SPEAKER_01: 12:43

you think?

SPEAKER_00: 12:43

Well, let me go back into the mists of time and talk about my exposure to forensic pathology as a medical student in New Zealand. Okay. First of all, pathology, which is, again, the study of disease, was taken very seriously by my medical school. And the training in it started early third year. So this is undergraduate time. And we started having lectures. We started having small group sessions where we'd discuss cases. And I think that's where the light went off in my head as to what I'd like to do as a physician, because up Until that point of time, I wouldn't say I was a terrible medical student. I was just a somewhat reluctant and befuddled medical student, sort of thinking, where am I going to fit into this scheme of things here? This is a lot of hard work, and I'm not sure that I'm up to it. Pathologists were an interesting bunch anyway. They seemed to be much more relaxed than the clinicians that we dealt with. And I was fortunate enough to be part of a small group session where the pathology resident in charge of it brought in a basket full of organs that were preserved in formalin, in large acrylic containers. And he would hand them out to each one of our group. I think we had about five people in our group. And he would say, what is it? And what's going on here? And then... The light went off. I think my first specimen I had was somebody who died as a result of a heart attack. And I'm looking at this preserved specimen, and you start off by saying, I think it's a heart. Very good. What is wrong with this heart? And suddenly, all that stuff you'd be learning about physiology and anatomy fell into place because I'm dealing with a disordered heart. physiology and anatomy that somebody has died as a result of. And so the gears are starting to turn. I'm sort of thinking, okay, this is starting to get exciting. And that was part of the pathology was presented as not as something sort of, oh, the equivalent of medical bean counters sitting in a little office looking down a microscope. It was presented as something sort of dynamic and directly applicable to patient care. As part of my pathology training, we had to attend 50 autopsies before we graduate. Here in the United States, I'm almost ashamed to say that a good number of medical students can go through medical school without having seen an autopsy at all. That's because, first of all, the number of autopsies being done in hospitals have dropped dramatically over the last probably 25, 30 years. Okay. Pathology training has become, in the United States, has become very contracted. I don't know how many months of pathology exposure they get, but it's sort of shoehorned in with everything else that's being learned with the clinical aspect of things. So medical students are not being exposed to pathology. And I had a little bit of this myself. I remember when the professor of medicine, a very distinguished professor, came and spoke to my medical class of 130 students. And I can't remember, I think it was introduction to clinical studies. It was, we just finished our preclinical part and they brought out the big guns to sort of say, well, now you're on the road to becoming real physicians. And he gave a long, distinguished sort of speech about the sort of privilege and pleasures and rollercoaster ride of being a clinical physician. At the end of it, he said, if you're not interested in these sorts of things, you might as well go and be a pathologist. In this very disdainful sort of voice. And I was thinking, you know, right on. I might take you up on that. But, you know, there was still some sort of, you know, pathologists weren't real physicians, you know, where they, but anyway, so. Part of that pathology was being exposed to forensic pathology because the forensic pathologists work in the medical school pathology department. So if you went and watched an autopsy, chances are you were going to see something that one of the forensic pathologists was going to be doing, not just a hospital autopsy. You'd see somebody that was found in their home, they hadn't been seen for three days, their newspapers hadn't been collected. last seen walking their dog, and suddenly somebody from work sort of said, go and do a welfare check. And this person is found, collapsed, deceased, in their bathroom, on their bed, out in the back shed, something like that. And very often this narrative would be sort of a few sentences. I was immediately transfixed. I thought, man, this is great. I'm given three sentences and an entire... individual body to sort out what happened here. So I was hooked. You were hooked, yeah. Yeah, and it wasn't something that one goes to medical school thinking, I want to be a forensic psychologist. Now, you will get the occasional person whom I meet, a young person that sort of says, the only reason I went to medical school was to become a forensic psychologist, which is good. But a lot of people, I think, are very interested in forensic pathology because of greater exposure on TV. Quincy. Everybody sort of says, remember, Jack Klugman as Quincy, throwing back the blanket and all the police officers turning and sort of losing their cookies and fainting, that sort of thing. So he was, I think he was the first. Quincy sort of gave forensic pathology a good and a bad name. Because He was out there, not only did he do the autopsy, but he was there also doing a bunch of police work. Police work that's screwed up, where they might want to look here, and oh, by the way, I went and spoke to this witness. It's not really like that in real life. There's been more exposure on television, CSI, that sort of thing. But there's no way around, unfortunately, there's no way around the fact that if you want to be a forensic pathologist, you have an undergraduate degree, you have to get into medical school, you have to do a pathology residency, do forensic pathology training. Darn. And it's a haul. I was going to say, I'll come and work here. I just can't do the med school part. Exactly. But anyway, so it's a fascinating... Career, I've enjoyed it. Like I say, I started this on a part-time basis back in 1992 when my residency at Emory started. I was fortunate enough to have a couple of very good mentors. And it's been a roller coaster ride, but always enjoyable. I think they're the part of me, I think they're the part of every forensic pathologist that's the medical detective part to solving mystery. We know that there's no happy outcome. The patient is not going to come back to life. They're not going to resume their jobs. I think you probably, you know, sort of, before we started this recording, you wanted to touch on part of that as to how we reconcile what we do with the reality of medical and in the context of medical practice and where are the mechanisms for deriving satisfaction and also coping with the sorts of things that we see on a day-to-day basis.

SPEAKER_01: 21:19

Sure. And what does that look like? What's a ride home from work for you?

SPEAKER_00: 21:23

Well, I would have to say there have been sort of in the last 30 years, I think it's been three days at work where I came home and I thought, you know what, I just don't really want to do this anymore. And it's usually a, I think most, two of the three of them where there were multiple victims and it was particularly difficult egregious, atrocious sort of circumstance. And part of the coping mechanism, I think, begins early on. I think we sort of began to touch on this, that medical school, whether you like it or not, is two warring things. There's an encouraging sensitivity towards the human dilemma of illness. but there's also a desensitization to the horrors that you are going to witness. And I don't think that we as medical examiners are necessarily worse off than other busy physicians in hospitals. I think illness across the board has the potential for being damaging to the individuals that are exposed to it on a day-in, day-out basis. And yes, we see, as medical examiners, the end product of often vile humanity, human acts, and that sort of thing. But I often think, am I any worse off, for example, than physicians tending for children with cancer or individuals in the emergency room seeing individuals come in near death? Yeah. trauma surgeons, for example, or even gerontologists or geriatricians dealing with people at the end of their lives. I think it all weighs on the individuals, and I think part of the medical school training right from the get-go, from the exposures to the cadaver labs to, I think there were labs that we did, they start off with small animals and then i remember one particularly unpleasant lab for physiology which i wish i hadn't attended but was sort of made clear that you know you have to attend to pass this course which is essentially doing some sort of physiologic experiment on a group of dogs from anesthetized dogs but dogs from the pound so basically the justification is that well these dogs are due to be euthanized we might as well put them to use at the medical school. And I remember at the time sort of thinking, you know what, the juice isn't worth the squeeze for this as far as I'm concerned. And it goes on. I remember talking to one of the lecturers sort of saying I was not going to do a particular lab anymore because with all due respect, I don't like the, I think it was a lab with lab rats. So I think there's a process where you yourself as a physician are building up sort of resistance to being mortally wounded, if you will, psychologically. And I think you also realize, too, you get, you know, obviously there's peer support and that sorts of things, but it's up to you to how you cope with the sort of traumas that you're going to see from day to day. And as a forensic pathologist, I think, interestingly enough, part of the way that I cope with the fact that here is a deceased individual goes back to when I was working as a house doctor back in New Zealand at a hospice facility. And you're there as a house officer and you're attending to people at the end of life, end of life care. And I think you occasionally, I think on a number of occasions, you do have the, I wouldn't call it the privilege, but the experience of seeing somebody pass from life to death. You're there to pronounce the individual, the formality. Sure. I was astonished, even in an individual who is obviously at the end of their life, they may be suffering from cancer or some debilitating disease, that transition from life, breath, to death, not only can you see it, but you can feel it. and realize that whoever that person was is no longer there. And, sorry, you get a little bit emotional about it, but it is, you know, and I think a lot of people experience this, obviously, when they're, you know, with their loved ones, when they take a last breath. But it impressed me as a physician, time that whatever, whoever this person was in life, They're gone. And so the body is a shell. Now, as a medical examiner, one of the investigators was saying, well, Doc, here in front of you is a complex body of evidence, if you will. You have to work with this evidence to work out what happened to this person. So that helps. And I'm not a particularly religious person at all. I don't have necessarily this Christian belief that an individual has either gone to heaven or hell or anything like that at all. But I think there is that moment which most of the time as forensic pathologists obviously we don't experience because we're not there at the scene or we're seeing it somewhat taken away from the scene of the death. But I think, you know, sort of I don't take any consolation myself as a medical examiner in thinking the individual has gone on to a better or a worse plane or anything like that. Yeah, sure. So... But there are times when you see something particularly egregious, when you do feel like you need to knuckle down and call on your reserves, cope with things. And it's an ongoing process. It's not something where you do this for a number of years and then suddenly you decide, I am accomplished or I am complete. It's a day-to-day thing. And we... We as staff, both the autopsy staff that we have, our autopsy assistants and the doctors, we're constantly on the lookout for signs of stress. And here at the GBI, there's a lot of peer support. And there are buffers.

SPEAKER_02: 29:22

Buffers.

SPEAKER_01: 29:23

All right. So the next question I want to ask you, something's going to come into mind. And however you want to articulate it, however you feel comfortable, be the word yes, or details that you'd like, but is there something you've seen in your career, ace of body, whatever you refer to it as, is there something that you saw?

SPEAKER_00: 29:50

No. But I will tell you another anecdote. Please stop me if I'm too full of anecdotes. No way. And again, this is interesting because... It is an egregious case. It's a child case that I dealt with. And it wasn't at the GBI. It was at another medical examiner's office. And it was a young child who had died as the result of true child abuse at the hands of a grandmother. And the case occurred here in Georgia. And I did the autopsy, and I'm not going to go into the details of the findings at all, graphic description or anything like that, but the child died as the result of abuse. And I use that word sparingly because a lot of the time when children die at the hands of an adult, we call it child abuse, and it is, I guess, in the strictest sense of terms, but very often it's an individual occasion where an adult lashes out at the child with a fatal outcome. I tend to think of abuse as something that is ongoing over a period of time that results in the death of a child. This was a child abuse case. This child had been one of a number of children that this grandmother was in charge of, and this child had probably been singled out for whatever reason for abuse. And the reason why, I will circle around the answer to your question, because at the time, for me it was sort of a distressing case, but business as usual in terms of working out what happened to this child, doing my autopsy, issuing an autopsy report. And then came the prosecution case. And This occurred over a relatively long period of time because the grandmother, in the meantime, had left Georgia and was living in another state. And there was extradition issues. And there were some investigational issues that they needed to pull up. But basically, the DA's office got a hold of the case. And I think I met with four different people. assistant district attorneys who were going to prosecute this case over a period of time. I think it was over a period of about two, two and a half, three years. And I had gone over, you know, you meet with the attorneys, you discuss the photographs, you discuss the autopsy findings, they ask me to tell you which questions you're going to be asked at trial. I did this, I think, three or four times. And it was becoming, you know, just like, oh, we're talking about this case. Oh, I already met with an attorney. Yes, that attorney's left the office, or I've been charged with this case. So finally, trial actually came around. The defendant came back, and I was called to testify, and it was the usual. I've testified many hundreds of times now, child cases, adult cases. And it was the usual introduction. Explain to the jury what you do, Dr. Smith. How did you become involved in this particular case? Da, da, da, da. And then that was fine. And you talk to the jury. And you explain how you do what you do and qualifications that were part of the idea. And then they got into the case. And the ADA said, The district attorney said, and as part of your examination, doctor, do you take photographs? I said, yes, we do. And would the photographs help explain your findings to the jury? I said, yes. I'd seen these photographs, at least half a dozen. They put them up on the first photograph of the child up on the screen. And... I lost my voice. And I might lose my voice again because it was just suddenly the horror of it was there for everybody to see. And it was completely unexpected. I had to say to the judge, excuse me, Your Honor, do you mind if we just take a moment? And the judge was very good. He immediately sort of said, ladies and gentlemen of the jury, we're just going to take a few minutes, and I had a drink of water, took a few deep breaths, start again. But I didn't expect that sort of hammer blow to hit me right in the chest, having seen these photographs multiple times. So that's something that, in retrospect, sort of, Something from the universe told me that, whoa, there's a signal point. So it's hard to explain. Like I say, it wasn't the first time I testified in a child case. Something cumulative, I think, came back at that moment. Anyway, I think the testimony ended up being as effective as it could be. The individual was found guilty and justice was served. But it was quite a moment.

SPEAKER_01: 35:54

Wow. Yeah, I need that same moment right now. I can't fathom. It would be different during that, not as a father, but now as a father of four and six. All right. So do you follow, have you found in your career you'll follow all the way through the outcome? Like once you come home that day, do you have to follow anything else about that case?

SPEAKER_00: 36:25

Oh, well, very often I do. Things weigh on the mind simply because the autopsy did not provide the answers at the time. As I said earlier on, you know, an autopsy is a lab test. We basically do an examination. We identify injuries. We identify disease. We do testing, toxicology, lab testing, that sort of thing. But there may be holes in the story that we're missing as far as the investigation is concerned. Like I say, the investigators may at the time of the autopsy only know the name, age, race, and gender of the individuals. We say, Doc, this person, we know who they are, but we don't know where they've been or what they've been doing between when they were last known alive and when we found them by the side of the road or in the bush or in the shed in the back of their property. So in many cases, it's an ongoing collaboration with local investigators. I had a coroner. or local law enforcement, or if the GBI agents are involved. And here in Georgia, the GBI will come involved in a local investigation, such as a homicide, for example, at the request of local

UNKNOWN: 0:00

.

SPEAKER_00: 37:54

They don't automatically get involved in those investigations. And that happens a lot, because a lot of the smaller jurisdictions, they'll have mayhem occurring. And it'll be the first murder they've had there in two years, you know, a small rural county. And law enforcement basically sort of says, whoa, you know, we're going to need a bigger boat. And they will call in the GBI to assist with the investigation. As far as, you know, things playing on the mind, you know, again, very often the cases that you go home and you sort of, later in the evening you think about are not the ones that are going to appear in the news or on the front page of the newspaper. It's going to be one where you received a particular piece of investigational information. The case, the individual came as thinking, this is going to be what we think the cause of death is, Doc, based on what we see. You do the autopsy and you find it's not that at all. It's something completely unexpected. And, you know, a lot of the doctors, including myself, get a great deal of satisfaction of actually reminding ourselves that we are, in fact, physicians. We recognize the disease process that nobody diagnosed at all. And, you know, I've got a couple of doctors that, you know, are here that basically they'll be doing cartwheels in the hall if we find something that not only looks, you know, sort of really interesting at the time of the autopsy. Right. oh, I can't wait to see what this looks like underneath the microscope. And by the way, I'd love to get those medical records from their last hospital visit because obviously nobody recognized that they had this particular disease process. Wow. And again, part of this is also reminding ourselves as forensic pathologists that we are physicians. And I tell the trainees that the first day they come here, I sort of say, I want you to remember this. that you are trained physicians. Don't immediately think that you are autopsy doctors. You are trained physicians that not only use the autopsy, but also all the investigational tools at your disposal.

SPEAKER_01: 40:07

Okay, what's a time when was something different? Maybe the first thing that came to my mind was like it was a poisoning and they thought it was a gunshot or... When is a time when we think it's one thing, but then it becomes another?

SPEAKER_00: 40:23

Well, let me give you an example of that. And it's a very well-known case in Georgia. Since you used the word poisoning, we received a case. And again, this is going back in the mists of time. One of the doctors in our office received a case of a young man. And I say young man. He was in his 30s. So there's a young man, as far as I'm concerned, dying suddenly and unexpectedly. After feeling vaguely unwell, he went... The exact detail. Basically, I think he sought medical attention. The feeling was that he had some sort of viral illness or... It was treated symptomatically, and then he went by and was found deceased a short time thereafter. He came to the GBI medical examiner's office... and the doctor that did the autopsy sort of said

SPEAKER_02: 41:19

hmm

SPEAKER_00: 41:20

he appears to have some heart disease and that could be the cause of death but let's just look at the microscopic sections and wait for the toxicology to come back and that was one of those cases that came through one of a number and way below the radar until a month or so later when The doctor at the autopsy said, hey, you remember that case of the young guy that came in, sort of feeling vaguely unwell and a bit of heart disease, but died suddenly and unexpectedly?

SPEAKER_02: 41:53

Yeah.

SPEAKER_00: 41:53

Well, I just looked at the microscopic section of his kidneys, and they're full of crystals. And as soon as we hear the word crystals in the kidneys, it can mean any number of things. But what he meant at this point in time was that he had oxalate crystals in his kidneys. And it wasn't subtle. It was a sort of thing that if you do it, sort of look at the slide, and then under a certain light, it literally lights up like the Milky Way. And that's distinctly abnormal. So he's thinking, well, this is unexpected. And the most common reason we see that is ethylene glycol poisoning, antifreeze poisoning. And at about the same time, and again, it's amazing how the circle closes. At about the same time, we got a call from a law enforcement agency up north of the city and said, hey, let's do an autopsy on a guy named so-and-so. Yeah, as a matter of fact, we did. I said, well, his girlfriend had a husband who several years ago who was in his 30s who died suddenly and unexpectedly. Oh, okay. You guys didn't do the autopsy, but if you're interested in reviewing the autopsy findings in the light of what you have down here at the GBI, would you be interested in doing that? And the doctor sort of said, yeah, absolutely. And so he got the autopsy report and he got the microscopic slides from the case done by another medical examiner's office and he put the kidney slide from this previous death under the microscope, and boom, lit up like the Milky Way. And so suddenly, we have two young guys separated in time and space, dying apparently suddenly and unexpectedly with what looks like ethylene glycol poisoning. And their only common point is A woman who was married to the guy died several years earlier. And the current guy, who was her boyfriend, I believe, at the time, dying suddenly and unexpectedly. So anyway, to cut a long story short, both the young men at the time had heart disease. One previously was signed out as heart disease. So that diagnosis was missed. time, his body had to be exhumed to get organs so that he could test for ethylene glycol because, of course, he'd been interred for many years. But they were able to retrieve organs, do scientific testing to establish that he had ethylene glycol in his system. Toxicology on the current case of the PBI showed that he had ethylene glycol in his system. So you've got two young men dying suddenly and unexpectedly as a result of ingestion of antifreeze. So everything zeroed back in on this particular individual. And I think, like I say, this isn't secret. This case was adjudicated. It was a very high-profile case. The individual was convicted of murder. basically malice murder. Yeah,

SPEAKER_02: 45:30

for sure.

SPEAKER_00: 45:31

And so that's an example, a well-known example, of things weren't what they seemed initially, but the forensic pathologist did what he needed to do in the most recent case, and justice was served, I believe, in the case of the individual who died several years earlier. That's incredible. Yeah, so... You know, again, it's consummate sort of medical detection in conjunction with investigation and lab finding. Like, you know, we need to have the lab here to be able to sort of say, well, we think it's antifreeze. Can you test for it? Absolutely we can. Wow. So all that has to come together, you know, for the diagnosis. And ultimately, you know, sort of it goes to the courts. You need to be able to present all that evidence as a nice, tidy...

SPEAKER_01: 46:26

packet. Was there ever a time where you couldn't come up with a

SPEAKER_00: 46:30

cause of death? Oh, absolutely. First of all, probably the most common time when we can't come up with a cause of death is when the post-mortem interval, the time from when the person died to when the body is found, has resulted in advanced decomposition of the body. And that happens very quickly here in Georgia in the summer. I mean, we are bracing ourselves here at the office for the influx of individuals who are not found in a timely fashion. And with summer temperatures, humidity, and insects in Georgia, a deceased individual will decompose very quickly. So that decomposition can range from early stages to near skeletonization. What do you have

SPEAKER_01: 47:25

to

SPEAKER_00: 47:25

wear?

SPEAKER_01: 47:25

one comes in like that?

SPEAKER_00: 47:27

Oh, most people. No, you know, it's interesting. I mean, it's not something that people enjoy. Obviously, you can't enjoy it, but somehow, I don't know, your brain and your nasal passages somehow sort of just acclimate. I mean, there's no point putting a mask on. I mean, that stuff cuts through everything. Basically, The odor of decomposition is immediate. It penetrates your clothing, hair. It's a fact of life for we forensic pathologists. We adjust to it. Again, it's the business of sort of here's a problem that we need to solve, and we knuckle down and do it. So you acclimate, I can't even believe you used that word, acclimate to the smell of death. Yeah, I remember one time I went to a scene with an investigator where there was a decomposed body in a relatively small apartment complex. And we're at the scene, basically the medical examiner turns up and we're in charge of, we're not in charge of the investigation necessarily in terms of, if there's power play or anything like that. But we have to, first of all, establish that death has occurred. And then we take jurisdiction over the body once the investigators are satisfied that, you know, and this individual had been deceased for some time. But it was sort of the usual sort of hurry up and wait at the crime scene. Well, not the crime scene, the scene of death. And the scene was a small apartment, and a lot of time was spent in sides. in close proximity to the deceased individual. But I remember afterwards, the investigator and I had done a bit, this was when I was doing my training back at Fulton County, and the investigator, he was a fun guy, he basically, he would turn up every day at work, he actually had a blazer, tie, shirt, He was there in his finery. I was there in my quasi-medical student garb type of thing. And he looked at me, and he used to call me Geoff. He said, well, Geoff, it's time for lunch. And I said, absolutely. I'm hungry. And I remember we went straight from that scene to a little diner and sort of just walked right through it to our table. And I don't remember... remember anybody sort of looking up and sort of going, you know, sort of, hell, what was that terrible smell? But it occurred to us afterwards, it was sort of like, my God, we are not socially acceptable at the moment from the olfactory point of view. What were we thinking? And, you know, it was because we had, you know, when we left that scene, it was sort of like we had, again, our senses had essentially dialed things down to the point where We're not noticing this, but I'm sure there were people in that restaurant that wondered, what have they got going on in the kitchen out there? Who opened the back door? But I remember the investigator sort of saying, well, gee off, let's go and grab a bite to eat. I didn't sort of think, well, maybe we need to go back to the office and change, maybe have a shower.

SPEAKER_02: 51:14

What a story. Oh, my gosh.

SPEAKER_01: 51:17

Oh, that's awesome. All right, let's talk about fentanyl. So before the interview started, I was talking to Stella. Chris and Reggie and I were talking to Stella. And she mentioned that there was a day, I hope I'm saying this the right way, there was a day where almost every body that came in like 24 out of 30 is fentanyl. Am I saying that right? Is it that

SPEAKER_00: 51:40

popular? Well, it's... Stella might have exaggerated. She's prone to exaggeration. She was 23 out of 30. There are periods of time, like, for example, here at the headquarters, we are busy. We do have a backlog of cases, and it fluctuates depending on sort of how, you know, like I said, it's the one thing, one of probably a couple of things I can't control, but the one thing I definitely cannot control when I wake up in the morning and come to work is how many deceased individuals have come in for exams in my Cannot control. But if you look in certain periods of time, look at the list every day, and anywhere from probably 15 to 30% will be POS-OD, which means possible overdose. Sent in as a POS-OD. POS-OD, okay. Yeah, POS-OD. That's the abbreviation that we get. And the reason that is because essentially it's a person, they go to the scene, They find drug paraphernalia. The person has no other obvious cause of death. Very often they're a young person with no medical history, found deceased in a residence or wherever the body is found. And there's a high suspicion that drug overdose. And, you know, the superstar drug, you know, sort of when I say that disparaging fashion, the superstar drug for the past several years has been fentanyl. And fentanyl is a... probably know is an opioid drug. It's many times more potent than morphine. And my first experience with fentanyl was back when I was a medical student, when I would see little ampoules of what was called sublimase, which I thought was a great name, sublimase. And that's the stuff that anesthesiologists use. Anybody that has general anesthetic will get some. powerful painkiller. It's part of the anesthetic cocktail. Then people decided this is a great drug. Maybe we'd use it for chronic pain relief. And then the fentanyl uses a transdermal patch where they put the drug in a patch and the drug is absorbed through the skin over a period of time to provide low level of drug for chronic pain. And my first experience with a fentanyl death in the state of Georgia, I remember it very distinctly, was a young man who went out with his buddies. And their story was we went out, and my mate here, he had a beer. That's all he had. And he was legless. We had to basically leave with him dead. draped over our shoulders, get him in the car, drive him home, put him on his bed. That's where we left him, and he died. The young guy probably knows. I did the autopsy. He had a lot of the signs of having died suddenly and unexpectedly. His friends swore that the only thing he had was a beer, which, that was unusual because, hey, you know, usually bending our elbows most of the evening. Right. But he and the autopsy and the toxicology were absolutely unremarkable. I'm not even sure that he had, if he had any alcohol in his system, it was very low. His death wasn't due to an alcohol overdose. He didn't have any heart disease, any disease at all. He was a mystery. Some time later, coroner, local investigator. Again, I told the coroner, I said, hey, I don't know what's going on here. I'm basically sitting on my hands deciding what to do before we sign this case out. And the coroner said, well, let me go and just ask a few more questions. And he came back and said, Doc, this young man apparently was in the habit of taking family members' fentanyl patches, and he would put them on the inside of his mouth, and he'd get high. And I said, really? Okay, let's find out if we can test for fentanyl. We asked the lab, because it wasn't part of the normal toxicology testing at that point in time. It was relatively rare. Anyway, it came back positive for fentanyl, so he died as a result of a fentanyl overdose, and he was one of the first that I saw. And Again, that was at a stage where fentanyl was only available as the patch, chronic pain use, and as the little ampoules that anesthesiologists use. And so that was a snapshot in time. Then heroin made a big comeback back in the early aughts, and it seemed like there was a lot of heroin around. Suddenly, people, being the ingenious individuals that they are, decided that, hey, maybe we can manufacture a form of fentanyl that comes in powder form. And guess what? What happened? It's the beginning of the epidemic. And I think my experience, probably relatively few chronic fentanyl addicts, there are probably some because we do get the history of, you know, this person dies, known to use illicit drugs, drugs of choice, but it'll include fentanyl. So there probably are people that use it over a period of time, but they're really playing sort of a form of chemical Russian roulette because you never know the illicit stuff. You never know what you're getting. I think part of the problem, too, is that individuals that are accustomed to using one particular drug, whether it's cocaine or heroin or methamphetamine, are getting more than they bargained for. and they get fentanyl. We find it all the time. We do presumptive urine drug screening at the time of the autopsy just to give us an idea of are we dealing with a drug overdose here, confirm it with the toxicology, and yeah, it's been an epidemic. I mean, I don't have the numbers for you for the state of Georgia, but it's high. I think nationwide it seems that the fentanyl deaths are going down because of greater... recognition of the problem and also the availability of Narcan or Naloxone. Needless to say, we at GBI here as forensic pathologists, the effectiveness of Naloxone as far as we're concerned is zero. Yeah. Because we only see fatal outcomes. You only see one of that, right? And a more, I suppose, on the horizon approach, as part of what we're going to be having to be doing as forensic pathologists is now we are probably going to have to testify more in cases where individuals have died as a result of fentanyl toxicity and the local jurisdiction is charging the drug dealer, the supplier with some version of homicide. And I have to say I think it's a noble cause. I've been involved in a number of these cases already. I think the prosecution had a difficult time persuading the jury that a drug dealer, unless it can be shown that they absolutely knowingly gave this individual a large dose of fentanyl with malice and forethought, if an individual comes to a drug dealer and says, I have the money, you've got the drugs, I want the drugs, I'm taking them of my own volition. Again, playing that sort of Russian roulette. I think juries probably have a hard time sort of saying, well, he paid the money, he took the drug of his own volition, and now you want me to put this guy in prison. It's a tough call.

SPEAKER_01: 1:00:14

That's a tough call.

SPEAKER_00: 1:00:15

Yeah. I think they will get, I think they will get conviction probably. But, um, as medical examiners, we have no dog in the fight there. We're just basically there sort of saying this individual died as a result of fentanyl. They may have other drugs on board and it gets sort of into the weeds about, well, how much should the fentanyl contribute versus the cocaine or the methamphetamine or the antidepressant drug, that sort of thing. But, um, and we call them accident. Uh, you know, there were, We think that it's an inadvertent complication of drugging.

SPEAKER_01: 1:00:45

Yeah. Makes sense.

SPEAKER_02: 1:00:47

Yeah.

SPEAKER_01: 1:00:48

All right, Jeffrey, you've mentioned the phrase signs of dying unexpectedly and suddenly. Mentioned a few times, and this time I'd like to unpack that. What are signs that you see in the deceased?

SPEAKER_00: 1:01:02

Well, I think I used it in reference to a drug-related death. And... Obviously, the most reliable evidence of sudden and unexpected death would be an eyewitness account. Person A says, I was talking. Person B, when suddenly he clutched his chest, his eyes rolled back, he fell to the ground and was deceased. That is sudden. It might not necessarily be unexpected. That individual may have known heart disease. He may have had a coronary artery bypass and on multiple medications for heart. So his death would be sudden, but not necessarily unexpected. So when we talk as medical examiners about sudden unexpected death, those are key words we're listening for But the two are often sort of exclusive. Like, for example, we may be very interested in a sudden death and an unexpected death. But in the case that I just mentioned, a person with heart disease, yes, the death is sudden, but it's not unexpected. And so our interest as medical examiners, because of the medical history and the eyewitness account, we would probably not get involved in that situation. investigating that from the medico-lingual point of view. But as far as looking at autopsy findings of individuals who die suddenly and unexpectedly, there's a few anatomic findings that we see are sort of maybe nonspecific. The buildup of fluid in the lungs, for example. Sometimes, again, brain swelling. a very non-specific thing, but we see it in association with deaths that can be sort of sudden, but they're more often, they fall into the unexpected category, and something's happened where the brain has had, physiologically, has swollen, and it might clue us into something like perhaps a drug overdose or a death by asphyxia or some other mechanism that, like I say, it's fairly nonspecific. So most of the time we're talking about sudden and unexpected death. They're really sort of investigational findings from the locals who say, well, we're not sure that his death was sudden necessarily, but it's certainly unexpected because he's a young individual with no medical history. So And again, in relation to the drug death, death may be sudden, but then again, is it truly unexpected in the sense that if you sort of are dealing with potent narcotics, is sudden death necessarily unexpected?

SPEAKER_01: 1:04:02

Yeah. Interesting. All right. I want to understand the entire process from, I'll use the first one that comes to mind, famous case, Kobe Bryant's helicopter goes down, right? So you have signs of distress, people saying, oh, there's a helicopter spinning out of the sky. It lands on the ground. I want to understand the whole process from it. Hit on the ground and burst in flames, I'm guessing, all the way through getting to you and then who, how it gets determined, what goes on the actual death certificate. So every step of the way as you know it.

SPEAKER_00: 1:04:42

Sure. Well, you know, there's a number. A complex death investigation like that involves multiple agencies. Now, obviously, again, I don't want to go outside my lane here, but something like a helicopter going down, there's going to be the NTSB involved in that and maybe the FAA. I'm not sure. But the role of the medical examiner– And I'll basically walk myself through a scene like that because I have been to a small aircraft crash where there was a fire. The first thing is to give the investigators a wide berth to establish the parameters of the scene. The medical examiner or the medical examiner investigator will be in charge of counting for and the... cataloging transportation bodies to the medical examiner's facility for where the examination is going to be done. All right, so let's simplify things and say that there are two individuals. You use the example of Kobe Bryant. I'll use a similar example of a case that I was involved with directly of a small plane that crashed onto 285 several years ago, shortly after takeoff from... Yeah. Yeah, I remember. And basically that scene, there was some video, I think it was on a law enforcement camera, dash cam. See the plane going up, down, and sort of similar to that flight, Air India flight. See the plane going down, fireball. I was involved with that because there were... four people on that plane. And conflagration, four bodies, burnt, medical examiner, investigator went to the scene. And at that point in time, you have a very complex scene in the sense that you don't know sort of who was... There's chances that you don't know who the pilot was, where the passengers were sitting, because of the high impact they may have been thrown about in the plane, maybe separation of bodies. So the first thing... that the medical examiner investigator and the medical examiner at the scene has to do is, first of all, establish these are human remains, this is a human individual, and we don't know who that individual is, so they will be decedent A. Next, decedent B. Next, decedent C. Next, decedent D. So they are given a generic identification. It can be number one, number two, number three, alpha, beta, gamma. that sort of thing. But as long as that individual is received with a designated unidentified individual A, we will usually have an idea of who was on, for example, on the plane. In this case, it was a father, two sons, and one of the sons beyond. So you know that you have three male decedent and female decedent. Depending on how badly burned the bodies are, you may be able to distinguish readily, obviously, female versus male. You may be able to distinguish sort of an individual in their 20s from an individual in their 50s. Most of the time, in those sorts of incidents, the bodies are what we call burned beyond recognition. It means that I'm not going to be able to look at this individual and say, this appears to be so-and-so based on the photographic evidence. You've given me a picture of the driver's license or whatever. I'm sorry, I can't tell. We're going to have to essentially use more... Sure. Dental records. That would be like a dental record. So the autopsy itself... on individuals A, B, C, and D will initially be to determine the cause of death. Okay. And the possibilities in the situation like we're talking about is that did they die as the result of the crash? It means they sustained lethal injuries in the course of the crash. Or did they die in the fire? And that's obviously important to distinguish that. Again, there are certain hurdles, little roadblocks that we pathologists, forensic pathologists, have to overcome in identifying injuries because the fire itself will inflict injuries as a result of the intense heat on the body. So we have to be able to distinguish. Here's a plug for forensic pathology. This is why we do what we do and why we're trained like this because I don't want to be attributing fractures that were caused by the fire itself to fractures sustained on impact. you know, we will get individuals that have fractured skulls, long bones of the upper and lower extremities fractured, and they may be all due to exposure to intense heat, which means that the individual didn't sustain these fractures. They may, in fact, in the majority of cases, by the time the fire does its worst on the body, the decedent is dead. So, and This gets into things further down the road that lawyers are very interested in from a civil point of view, conscious pain and suffering. So for better and for worse, we will often be deposed on those. But just to break it down broadly, the individuals, most of the time, A light aircraft crash will have sustained lethal blunt force injuries. It means that they will have injuries as a result of the impact of the plane. Very occasionally, we'll find autopsy evidence that the person was alive at the time the fire started. And what we look for there is evidence that they were breathing at the time the fire started. And we will find products of combustion, smoke and soot, in the airway. That's presumptive evidence that the individual breathing at the time and they breathed in smoke. Okay. And very often, not always, but very often concomitant with those sorts of fires is the generation of carbon monoxide. So we will do testing for carbon monoxide in the blood as a result of the smoky fire, complete combustion. So that's the first thing. Once we have established that the cause of death in A is blunt force injuries, the cause of death in B is multiple blunt force injuries, the cause of death in C is multiple blunt force injuries, the cause of death in D is some injuries but also evidence of smoke inhalation, we will say, well, this individual was breathing at the time the fire started. Now, they may not have survived their injuries, but they were breathing at the time. Not everybody... necessarily dies instantaneously like you can sustain an injury that will allow you to be not necessarily conscious but breathing and again this is another murky area well yeah impact is this individual conscious having sustained these injuries are they conscious and that's where the attorneys will go after you saying conscious pain and suffering which means that you know they were the brain was still working yeah yeah So the establishment of the cause and manner of death, the manner of death is going to be an accident. The majority of time it's going to be, and that's where the other investigation from the NTSB side is. Was there a malfunction of the plane? The other thing that the FAA is interested in is they want to do their testing, mostly toxicologic testing, at their lab. So we procure specimens from, And they say, we would like specimens from the pilot because they're interested in what's going on with the pilot. The pilot, you know, was the pilot under the influence of drugs? Was the pilot, is there any disease that you sort of found at the autopsy? Oh, they said that this individual was on medication for, you know, sort of heart disease. Did you find any heart disease? They're going to look for any, you know, sort of medications, obviously intoxicating drugs, that sort of thing. So Part of the difficulty is sometimes they'll sort of say, Doc, we don't know who the pilot was, so you need to do this on... Sure. Or they were co-piloting, so we don't know who had the controls at the time, so can you... So there's that. Then comes down the business of identification of these individuals, and very often you can have some ideas at the end of the autopsy that this appears to be an older individual. So... I think this was probably, in this case, the parent. We have two young men here, and they're both burned beyond recognition. There's no identifying features on the body. The height and weight are of no use whatsoever because there's been burning of the body. So that's when we go to scientific identification if it's available. We'll look at dental records if available. We'll get DNA samples from presumptive relatives. We'll do x-rays of the body to see, oh, yes, so-and-so had a knee joint replacement 10 years ago in his right knee, and we'll be able to see that on the x-ray. And that very often is the most pressing thing thing that we have to do with medical examiners is identification. People need some sort of closure from that point. I mean, I think there is probably implicit understanding that somebody is involved in a catastrophic plane crash. Death is going to be due to something related to the crash. But it's when there's delays in terms of don't know who this individual is. So that becomes a very high priority as far as the medical examiner And we work in conjunction with our lab here, the DNA lab here. And again, it's contingent upon the investigators to approach the family, get the DNA sample, that sort of thing. And then at the end of that, once identification is established scientifically, we have a cause and manner of death, all ancillary testing is done, lab testing, any sort of microscopic examination, anything like that. We will sign the death certificate. Okay. Now, as far as the actual cause of the crash is concerned, that's of interest. Yeah. But it's not our prerogative to determine what that is. Right. It helps explain things. And we may be able to contribute. Like, for example, we may sort of say, look, there doesn't appear to be any problem with the plane at all. We got a distress signal from the pilot basically sort of saying, I'm going to have to turn back. You're not feeling well or something. Is there any reason why he might have said that? Well, all we can tell at the time of the autopsy was that he does have bad heart disease. We're not going to be able to sort of say, oh, my goodness, yes, he had a heart attack. That's something we can't do. But can use presumptive autopsy evidence and any other investigation to say, well, this is what may have happened. Okay. So the coroner's

SPEAKER_01: 1:17:10

role in that whole thing,

SPEAKER_00: 1:17:11

what? Well, the coroner, if you're talking about the coroner, like the incident that I was involved in was the medical examiner's office. I was working at the time, which was in another county. Okay. If it's one, for example, in one of the coroner counties that we take care of here at the GBI, the coroner will be there essentially to take jurisdiction over the body. So essentially he will basically be the one that says, yes, here is a deceased individual. I'm going to put this identification tag on the body, on the bag, and it's going to be... unidentified individual number one or unidentified individual number A. We think it's going to be so-and-so, so-and-so, heads up, but we're not sure.

SPEAKER_01: 1:17:59

Okay. And then they're done once the body's here, or do they do the death certificate, or who

SPEAKER_00: 1:18:03

does the death certificate? The coroner at that point in time will, the investigation, their part in the investigation will probably be over. They will probably approach the families or presumptive families of the decedents to DNA samples. But when we finally get to the death certificate, one of our investigators, or myself occasionally, but one of our investigators here, get on the phone and say the death certificate for the individual A, who is now identified as Mr. or Mrs. or so-and-so, so-and-so, is ready to be signed out. Here is the cause of death. Here is the manner of death. That coroner will sign that death certificate. Okay. So that's our role now. pretty much completed unless we get involved in civil deposition, that sort of thing. I remember a case where several individuals died as a result of a semi truck driving into the back of a minivan and exploded with a bunch of people on board, did the autopsies, found the cause of death, and a good number of months later, attorney for the families, came to me, discussed my findings, and essentially said, thank you very much, doctor. That's all we need to know. No deposition. They just wanted closure. Individuals died as a result. They didn't die as a result of collision. They died in the fire. Closure. Well, the attorneys basically at that point, I was told by this attorney that their mantra is, is if you survive the crash, you shouldn't die in the fire. So they're going to go after the cause of the fire in the minivan, which was a known problem at the time. I think I was told that the fix for this problem was a$2.50 plastic part, but it involved a recall of an enormous number of vehicles. And I guess the... Automobile manufacturers essentially sort of said, we're not going to do a recall. Take the hit when they occur.

SPEAKER_01: 1:20:22

Well, that's a big one. That's a big hit right there. Yeah. How many different types of causes of death possibilities are there? Hundreds. Oh, there are hundreds. Hundreds. So, okay.

SPEAKER_00: 1:20:36

Well, there's... They say there's one way to be born and there's many hundreds if not thousands of ways to die. I mean, when I get asked to explain cause of death to a jury, I say it's the thing that led to your demise. So it's a heart attack. It's a drug overdose. It's a road traffic accident. It's a fall from a ladder. It's a fall down a flight of stairs. It's a gunshot wound. It's a stab wound. It's a strangulation. It's a strike by lightning. There's all sorts of causes of death. The problematic part for medical examiners is something which we call the manner of death, and that's another part of the death certificate that we are responsible for figuring out. So you will hear the statement, cause and manner of death.

SPEAKER_01: 1:21:19

I'm

SPEAKER_00: 1:21:21

not going to go into the weeds with this, but essentially what I say to juries is, because the attorneys will ask, they'll sort of say, and doctor, what is the manner of death? And I say, well, the manner of death is much more prescribed. We have five manners of death there. one of five that we put on a death certificate in Georgia. And they are natural, which means that the death is due to natural disease, heart attack. They are accident, which is something that is unforeseen, unpredictable, like, for example, a fall down a flight of stairs. Anything that you sort of think of as an accident. A lot of people think road traffic accident. Sure. Suicide. It means that we are confident that the individual not only had the means, but the intent to take their own life. Homicide, and this is the one where people get very hung up, particularly in the courtroom. They say, doctor, you called this a homicide. Does that mean that this person was murdered? I say, no, it's not. Homicide, in the strictest sense of the term, as far as we medical examiners are concerned, a few little outsider exceptions, which I'm not going to go into, basically means that an individual died as the result of the action or action of another individual.

SPEAKER_01: 1:22:49

That's homicide.

SPEAKER_00: 1:22:50

Homicide. So if you and I go out hunting in my life, you and I go out hunting. One cold morning, we're out there sitting there, sitting in front of me, looking out, suddenly go, ah, you stand up and I stand up and you fire and I fire and I take off the top of your head with my shotgun blast. What's the cause of death there? The cause of death is the shotgun wound to the head. What's the manner of death? I don't know. Accident? No, it's a homicide because... I fired the gun that killed you. Now, it doesn't mean I murdered you. Now, I may have nefarious sort of intent that basically you screwed me over sort of about something. We're going to go out duck hunting. I'm going to make your murder look like an accident. So as medical examiners, we will call that a homicide. And we will leave it to investigators and the judicial system to decide what happens. So basically, I would probably be charged with some lower form of manslaughter, if at all. So to say, oh my goodness, I didn't even realize he'd come back and sat in front of me. And when he stood up, I just pulled the gun and pulled the trigger.

SPEAKER_01: 1:24:17

So homicide versus

SPEAKER_00: 1:24:18

murder. So we have to make it clear to the court that we're not calling things murder. That's up for them to decide. But homicide is essentially, I've done something which led directly or indirectly to the death of an individual.

SPEAKER_01: 1:24:34

So one can't be the other, but one... So a murder...

SPEAKER_00: 1:24:40

All murders are homicides, but not all homicides are murders.

SPEAKER_01: 1:24:45

Okay.

SPEAKER_00: 1:24:46

And the other category, just before we leave this subject, is undetermined, which means that I've done an autopsy, I've done the lab work. I've got all the investigation. And I still can't decide. I don't know whether this is an accident or a suicide. I don't know whether homicide or an accident. You know, can't decide. Yeah. We're basically sort of saying, look, I can only take this so far. It's, you know, one or two of these things. And these are the cases that, you know, sort of you asked me, there's some time when you can't determine the cause of death. Sometimes we can't determine the cause of death and the manner of death. Like, for example, the skeletonized remains out in the middle of nowhere and we don't know what happened. Oh, right. Cause of death, we don't have enough material to work with. And we don't know the circumstance. Most often we can get to a cause of death, but sometimes we have problems with the manner of death because there's just not that little. And again, this is the, you know, I stress to my trainees and my staff that basically the biggest part of what we do, investigational. And what we do is basically listen. We listen to people telling us about what's going on in

SPEAKER_01: 1:25:57

this cave. For example, you would have one of these interviews when you say you're listening to people. You patch them in here and sit and do it here? Or families coming in? No,

SPEAKER_00: 1:26:06

families generally don't come in. Families, generally we will talk to families, but the coroner is our intermediary there. Okay. Like a coroner might call up and say, look, doc, the family are interested to know why you said this, this, or this. Say, well, here's why I said that. Are you comfortable conveying that information or would you like me to speak to them? And he'll often sort of say, ah, I think I can handle this. I know the family well. Okay. Something like that. Or sort of say, doc, you know, sort of this is way above my pay grade. I'd really like you to be able to explain to them what, you know, sort of you put on the death certificate. And I'm happy to do that. I mean, that's part and parcel. Again, people sort of think, well, you're a forensic pathologist, so all you deal with is dead people. What's the doctoring there? A lot of times the doctoring is basically talking to grieving family members and loved ones, explaining. Sure. And that's how a lot of the time we provide closure. They want to know things like, I know you put this on the death certificate and your autopsy report. Do you think they suffered when this happened? And often we have to say, look, I really don't know. But a lot of the time we can say, no, absolutely not. I mean, basically, your husband essentially had a heart attack and literally lights out in a split second. Quick. Yes. And sometimes that is the most important piece of PR that I can do for sort of the office and for that family.

SPEAKER_01: 1:27:49

Yeah. What's the breakdown of the five different manners? What's the most common and what's the

SPEAKER_00: 1:27:55

outlier? It might surprise you to hear this, but in most medical examiners, the most common manner is natural. And that's because a lot of people die suddenly and unexpectedly. And unexpectedly. No medical history, no available medical history. They're young. And, you know, conceptually people shouldn't, you know, die. It shouldn't happen. Well, this gets to sort of another interesting part of forensic pathology. You know, some pathology in the hospital, we're trained for that initially, sort of look down the microscope, do the lab tests, that sort of thing. So that's the stuff that happens in the hospital situation. But forensic pathology is usually what's happening outside of the hospital situation. And there are enormous numbers of individuals who, quite justifiably, are suspicious of the medical profession. So you're going to have to drag them kicking and streaming to get to a doctor. They don't have access to medical care. They have symptoms. Like some people say, yeah, you're complaining of a stomachache. Days. I said, go to the doctor. He said, ah, I'm just going to go down to the pharmacy and get some Tums or some over-the-counter thing. They died. And I said, well, it wasn't a stomachache. He was actually having a heart attack. Or it's a pity he didn't go to the hospital because he's got an appendix. Essentially, he thought it was going to get better, and it ruptured. So the most common one is natural for most medical examiner's office. Probably here at the GBI, we do fewer natural cases than other medical examiner's offices because the coroner will say, doc, he's got a good medical history. I'm comfortable with a natural death. I don't think you need to do an autopsy in this situation. The coroner is the one that we're guided by. If the coroner has a natural death and they're comfortable with it, I'm going to press them and basically say, well, I think this person needs to come in for an autopsy. Unless there's something sort of a little bit sort of unusual about it, or you might sort of say, well, I understand that he has this medical history, but what you're telling me is something a little bit different, and it might be a good idea to sort that out. I would say, obviously, drug-related deaths and the road traffic accidents and on-the-job sort of incidents, probably accidents are up there fairly high. We deal with a lot of homicides, and it's mandatory that they come in for autopsy yeah okay we're not we're not going to get a coroner calling up these days i'm going to talk about the bad old days these days a coroner is not going to be calling up and sort of saying well doctor we've got a guy here that was involved in an altercation with his neighbor who shot him twice with a shotgun we've got the gun we know it's a shotgun injury we're not sending hang on a minute no that body's coming yeah autopsy right

SPEAKER_01: 1:31:02

yeah Let's look at some of the plane crash ones. So use the example that you gave before. What would be the cause and the manner, just so I have it right?

SPEAKER_00: 1:31:11

Okay, the cause of death in the plane crashes would be, the majority of times, would be multiple blunt force injuries, manner of death, accident. This was something inadvertent, unexpected, an act of God.

SPEAKER_01: 1:31:28

Yeah. Okay, then let's look at the poisoning ones, that awesome case. The

SPEAKER_00: 1:31:31

poisoning one is basically poisoning is always homicide. And it's always murder one because somebody, and it's relatively rare. I mean, I think this is the only poisoning case that I can summon from my memory banks. We occasionally get allegations of poisoning. And it's a family member and sort of a... The most common thing is either a mother or a father who has remarried a younger spouse. They die. The family sort of say, that stepmother of ours poisoned him. There's allegations of poisoning, which are almost always unfounded. First of all... question we ask is, well, what sort of poison are we talking about? There are millions of poisons. They say, I don't know. We just think they were poison. So we will take that seriously, bring the body in, do an examination, and we will test. We're not going to spend millions of dollars looking for every single poison under the sun. We will do a relatively comprehensive toxicologic testing and document our other findings and Actually, those go away pretty quickly. The cases that don't go away that are often the most heart-rending are the suicides, because I think there is a natural sense of disbelief that a loved one would take their own life. Even when there is evidence they're seen, for example, like they left a note or being sort of in the past sort of taught self-destructive some of the most wrenching discussions you can have with a family and I usually do those face to face is essentially presenting the evidence that this individual had the means and had the intent to end their own life and I don't think I've ever left one of those discussions where somebody's looked me in the eye and sort of said, you know what, doc? Thank you so much. You've got it right. It's usually, thank you very much, doctor. We appreciate your time. And I might get another phone call, might have to have another meeting. But usually after a period of time, I think most people make it

SPEAKER_01: 1:34:27

easy. The death certificate, almost like a contract word, family has to write off on it and sign it or it doesn't go into action?

SPEAKER_00: 1:34:38

It's an interesting question because I think a lot of the times people are objecting to the suicide, there's the personal reason, there's just the sense of disbelief about it. But the number of times individuals say, well, I just don't want to see suicide, on the death certificate, or I'm worried that my community is going to see suicide on the death certificate. First thing is, in our instance here at the GBI, it's happened. Pull up the coroner. I'm not singling out any coroner. I'm just saying in the past, coroner with a cause of death. whatever it is, manner of death, suicide, and the coroner will put something else on the desk, which he or she are perfectly entitled to do. They are? Yes. Now, it doesn't happen very often, but the sorts of situations where it might happen is one where maybe it's not quite so obvious. Well, as far as I'm concerned, for example, Before I tell a coroner that I think it's a suicide, I have to be pretty close to 100%. If I'm not sure whether this is an accident or a suicide, I will defer to undetermined or accident, depending on the degree of that sort of thing. I will not put suicide if there's sort of doubts about it, just simply because it's such an important opinion. Sure it is. But if we call in one which... scientifically investigationally we think is a suicide coroner for whatever reason you know feels that they're going to spare the family the stigma or you know the whatever suicide they may put something else

SPEAKER_01: 1:36:40

there any foul play that this foul play happened in that ever

SPEAKER_00: 1:36:44

no basically the death certificate is an opinion there's nothing binding legally The death certificate. Essentially, it's a medical opinion. And everybody has an opinion.

SPEAKER_01: 1:36:57

Okay, so an outcome in court is different than what's stated on the death

SPEAKER_00: 1:37:01

certificate. Oh, sure. Like, for example, well, you know, the most common one would be, well, you know, this is a homicide. You know, subject A shot subject B. Subject A went to trial. cause of death, gunshot, manner of death, homicide, but the jury sort of say, well, yeah, he died of a gunshot, but I don't think he did it. Or it was justified. Or, you know, just, you know, and that's why we don't have a vested interest in what happens in court. We have to be there as neutral. I don't know who did this. You know, one of my doctors basically always has a chuckle when after he's testified, sometimes the attorneys will ring him up and sort of say, doc, you know, break out the champagne. We got a conviction. And he says, well, I'm glad you got your conviction, but I sure as hell hope you got the right guy because I have no idea. Wow. No idea. Good luck. Well done. Yeah. So I don't get on the phone unless there's occasionally I will follow up with attorneys to find out the outcome of the case in terms of like if it was a particularly contentious case or– case for example where my opinion was being challenged you know by an opposing expert yeah so say with all due respect doctor i think you did a great job on this autopsy but you got it wrong that doesn't happen very often i mean usually that's there are there are certain most of the time we are there just basically the cause of death is not in dispute somebody dies of a gunshot got it the defense attorney is basically sort of sitting there looking at these photographs one explaining them to the jury and saying, oh, can we just get this done with, you know. So a lot of defense attorneys don't want the medical examiner there. They're sort of saying, right, he died of a gunshot wound. We agree. And the reason that is is not because, you know, out of disrespect. It's just they really don't want the medical examiner up there describing all these injuries that their client allegedly inflicted upon this deceased individual and showing them photographs. So they will often sort of say, we're happy to stipulate. The prosecution will say, no, we're going to get the doctor here to tell the jury what happened.

SPEAKER_01: 1:39:16

Do they ever come straight, like lawyers in court, do they ever come right out and, doc, get out of frustration? Do you think he did it or not?

SPEAKER_00: 1:39:25

When are they going too far? The most common thing that defense attorneys will get up and ask, I think more out of a sense of showing their client that they're doing something, be having... had my direct examination, the defense attorney will get up, basically say, doctor, you weren't there when this incident occurred. And no, I was not. But doctor, you have no idea who shot. No, I do not. Thank you very much. No further question. Oh, that's it. That's it. They

SPEAKER_01: 1:39:59

don't question like, doc, we found this time when you were wrong. Are they ever doing

SPEAKER_00: 1:40:04

anything like that? No. You can be, I guess, sort of try and avoid having situations where you can be impeached either from previous testimony where basically in one case you said this, this is a near identical case, and you're saying something else. It's not usually a problem. I mean, I think for the majority of cases that... we deal with as medical examiners, the cause of death when we go to court is not in question. The ones where it is and become most contentious are the child cases where the allegation is on the side of prosecution based on the medical examiner's findings was that this is an injury caused the death of this child and it was inflicted by another person. So that's a homicide. The defense will say, no, We understand the injuries. We know where you're trying to go with this. But we think the decedent fell off the bed and sustained. Therefore, it's an accident. So that's where you get the back and forth between expert that everybody finds exciting. While the medical examiner said that this child sustained lethal blunt force injuries inflicted by the caretaker, the defense expert is saying, no, The story that the caretaker is telling that the decedent fell off the couch while they were climbing up trying to open the window is it. So those are the ones. And I don't think I've... As a medical expert myself, I have not been confronted by a defense attorney saying to me, Dr. Smith, you really screwed up that case back in 19-something-something-something, didn't you?

UNKNOWN: 1:42:05

No.

SPEAKER_00: 1:42:05

you're more likely to get that when, as a medical examiner, if you're one of these hired guns that go around sort of getting large sums of money to testify for one side or the other. Oh, geez. Create, you know, sort of raising sand. Yeah. They may sort of say, well, how many times, doctor, have you appeared for the defense in these sorts of cases, you know, where you're alleging that all these cases that are accidental, Isn't it strange, Doctor, that the only time we ever see you in court is as a hired expert in these sorts of cases where you're saying that, no, this is an accident? Unfortunately, there are individuals out there who go around doing that, but you're on the blacklist, if you will. They say you've gone over to the dark side when that happens. Oh my goodness.

SPEAKER_01: 1:43:02

All right. Last, last discussion point. So a couple episodes ago, I interviewed a guy who was, it's a hunting accident. Um, doesn't, it was his first time hunting. He didn't want to go hunting. I think it's interesting because you said you're not, I'm not a hunter as well. Never, never have hunted. So he goes out and he's close to a deer. He kneels down and then from a hundred yards away, his cousin takes a shot. but the cousin didn't know that the kid was there. So he gets through the center of his throat a.30 rifle round. He was 18 now. I'm interviewing him a couple weeks ago, and he's age 55. So he's clearly survived it. He said the surgeon told him it was the equivalence of getting struck by lightning five times. So I want to hear just your opinion on this. How does a.30 round go through the center of the throat then instead of going straight out the back, which it should, it goes south five inches through his windpipe, blows out his lung, but then comes to rest. I can't...

SPEAKER_00: 1:44:09

Well, I can explain things in terms of the... I don't know that I would use the analogy, the lightning analogy. Okay. Basically, a.30-30, it's a rifle round, and when it... exits the muzzle of the gun, it's going at several thousand feet per second. Now, your average handgun round is going at several hundred feet per second. Right. But because the round has so much more gunpowder propelling the projectile, it's going way faster. And if you cast your mind back to your high school physics, energy is not related to the mass of the bullet, it's related to the velocity squared. So... every time you double the velocity, a geometric increase in the energy of that projectile. So by its very nature, the 30-30 is, first of all, it hits the target, transferring an enormous amount of energy. As to how this individual survived with the gunshot wound, as you describe it, I'm not sure. The other thing I do know about bullets is that at that rate of speed, a bullet will travel in a straight line until it runs out of energy. So in order to account for that trajectory in the neck and ending up down, what, in the bottom of the lung or...

SPEAKER_01: 1:45:39

Yeah, pierce the lung, the hole in the

SPEAKER_00: 1:45:42

lung. Yes, he probably would have to have been... The bullet's not... straight at him if he's standing upright, hit the neck, and then do a 90 degree... Right. It doesn't do that. Bullets don't do that. Basically, that bullet is in there and out the back. And down. The fact that he survived is a miracle. Again... We're going to travel in straight lines, so... Makes sense. That's the only thing I can think of. And like I say, from what you're telling me, it sounds like it was a miracle. I don't know what the surgeon found or that sort of thing.

SPEAKER_01: 1:46:40

Anyway, lucky. All right, just tell me, and then we'll end here. Tell me a good day driving home and then the exact opposite driving home. What's a bad day driving home? What's a good day driving home?

SPEAKER_00: 1:46:51

A good day driving home is when my staff are behaving themselves. I don't have any personnel issues. A bad day driving home is when I've got personnel. Somebody's misbehaving. No, a good day going home would be, I think this is something that's sort of generative within oneself is, you know, I'm still performing autopsies myself, even though I've sort of had this, you know, exalted title as Chief Medical Examiner. I enjoy doing cases. I think I'm still effective and useful being in the autopsy suite doing cases. I think a good day is just knowing that you have applied your expertise in a focused fashion to the work that you've done and that you have been able to provide some answers to interested individuals that whilst not necessarily providing consolation at this point in time, then we'll be providing sort of, I suppose, the beginning of working towards some sort of closure. Like I say, there are no sort of, I can never get on the phone with a coroner and basically sort of say, you know, the autopsy was a success and the patient is ready to resume life again. It doesn't exist. It doesn't happen. So I think because a lot of what we do, and again, not in the high-profile, sensational cases, a lot of what we do is complex medical concepts If I can get on the phone with a family member and explain to them my findings, language that they can understand, telephone call, they can say to me, thank you very much, doctor, that really helps, in whatever way that it helps, then that's the best I can do for that particular individual. Obviously, there's other people. They're basically going to sort of say, well, thank you very much, doc, you've Confirmed our suspicions of an accident. We confirmed our suspicions of homicide. Those cases, that's satisfying, helping law enforcement enter it. And then at this stage in my career, I derive a lot of satisfaction from seeing the younger doctors starting to really get it, their stride in the profession. That takes some time. I mean, you know, it's a pressure year as a forensic pathology trainee to do, you know, the 200 cases. You have to get all your reports finished. You have to read a bunch of material. You have to turn up, you know, put up tyrannical supervisors. And then, you know, at the end of that, you're expected to go out and get a job. And it's, you know, sort of, it's like, I liken it to sort of, you know, driver's license driver's license has shown that you have a certain proficiency in operating your vehicle yeah now you start to learn how to drive

SPEAKER_02: 1:50:17

i love that

SPEAKER_01: 1:50:18

that's i mean i could stay here all day this was so incredible so thank you to all of you who put it on the interns as well thank you to you guys i

SPEAKER_00: 1:50:27

hope i haven't over talked

SPEAKER_01: 1:50:31

i actually felt bad even talking at all i just want to sit here and just listen to you and i can listen to you all day so I really mean it. Thank you for taking the time. I know this is going to help many. I know it's helped us. It's just so cool to hear what you guys do. I want to shake your hand. Thank you very much. Thanks so much. Awesome.