He was found dead in the doorway of a restaurant, under a tarp, huddled in the rain. He came to my office because his death was in public view. We didn't even know his name. A search of the police fingerprint database gave him an ID and revealed he was homeless, a veteran, and had no living next of kin. We found no medical records under his name. His body was a testament to hard living on the street. The dirt was so ingrained into his palms and soles that even when I laid into it with soap and an abrasive kitchen pot scrubber (looking for injuries or track marks) my efforts barely managed to uncover his natural flesh color. His face carried wrinkles beyond his 57 years. Dead people generally look like they are sleeping. This man looked worn.
The autopsy was one of the strangest I have ever performed. When I cut into the flesh, there was no passive blood flow. Instead of red fluid, his veins and arteries contained ... pink noodles. His circulatory system was filled with what looked like spaghetti -- the blood had congealed inside the vessels, in thin branching ropes. He had a moderately enlarged heart and a bit of black pigmentation of the lungs, and his toxicology report came back clean of alcohol or any drugs of abuse. The answers came to me under the microscope. His blood had been replaced by large white cell progenitors. It was ropy because it was mostly white blood cells, and not normal ones, either, but blasts. He had leukemia.
Leukemia is not a disease that usually presents with sudden death. The decedent must have known he was ill, getting weaker and slowing down as his circulating red cells disappeared and his blood thickened to sludge. Yet he never set foot in a hospital. I was the first doctor to make the diagnosis of acute myeloid leukemia. That's what went on his death certificate.
In medical school, I had been encouraged to go into primary care, to help fill our nation's need for general practice doctors in areas that have no doctors at all. Little did I know that by going into forensic pathology, a subspecialty of a subspecialty, I was going to end up practicing primary care medicine. My patients are frequently the under-treated and under-diagnosed, the uninsured and under-served -- which is why they end up on my autopsy table. We don't autopsy those who have had medical attention and who are under the care of a physician who is willing and able to sign a death certificate for a natural cause. We bring in and autopsy those who die suddenly, unexpectedly, and violently. This includes those who die at home or on the street and those we can't identify. They include the drug-addicted and the homeless, and those who are too poor to seek medical care. Sometimes I am the only doctor my patients have ever seen.
Like in other primary care specialties, there are too few of us forensic pathologists. My profession is enduring a nationwide staffing crisis, with inadequate numbers of doctors to fill job openings and not enough autopsy pathologists to keep up with the surge in sudden deaths caused by the opioid epidemic. To make things worse, to become a forensic pathologist, you have to spend an extra year of training beyond your peers, and in doing so have depressed your annual salary by close to $100,000 per year for the rest of your career by going into public service as a government employee rather than working in a hospital setting as a clinical pathologist. Our largest professional organization, the , has been lobbying Congress to institute loan forgiveness programs for those students entering our field, a benefit that has been in place for many years for other primary care specialties in rural areas. For us, the need is everywhere, including offices in urban centers trying to get out from under their backlog of bodies.
I work hard to excite students, to urge them to consider entering my field. My colleagues do, too: We are a passionate bunch. What our profession really needs, though, is a required rotation in forensic pathology in the third or fourth year of medical school. I know that if we forensic pathologists get the students into the morgue, we can show them how exciting and rewarding our branch of primary care medicine really is. There are mysteries out there -- things you will never see in a hospital, things you might not ever imagine. We need young doctors to join us in solving those mysteries.
, is a forensic pathologist and CEO of PathologyExpert Inc. Her New York Times bestselling memoir, co-authored with her husband, writer T.J. Mitchell, is . First Cut, the first novel in their medical-examiner detective series, will be published by HarperCollins in 2019.