As Overdose Deaths Pile Up, a Medical Examiner Quits the Morgue

https://www.nytimes.com/2017/10/07/us/drug-overdose-medical-examiner.html

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CONCORD, N.H. — In the state morgue here, in the industrial maze of a hospital basement, Dr. Thomas A. Andrew was slicing through the lung of a 36-year-old woman when white foam seeped out onto the autopsy table.

Foam in the lungs is a sign of acute intoxication caused by an opioid. So is a swollen brain, which she also had. But Dr. Andrew, the chief medical examiner of New Hampshire, would not be certain of the cause of death until he could rule out other causes, like a brain aneurysm or foul play, and until after the woman’s blood tests had come back.

With the nation snared in what the government says is the worst drug epidemic in its history, routine autopsies like this one, which take more than two hours, are overtaxing medical examiners everywhere.

“It’s almost as if the Visigoths are at the gates, and the gates are starting to crumble,” Dr. Andrew said. “I’m not an alarmist by nature, but this is not overhyped. It has completely overwhelmed us.”

As Dr. Andrew, an energetic man of 60 who, with his close-cropped gray beard, resembles the actor Richard Dreyfuss, has watched the drug toll mount, he is no longer content simply to catalog it. He wants to try, in his own small way, to stop it.

After laboring here as the chief forensic pathologist for two decades, exploring the mysteries of the dead, he retired last month to explore the mysteries of the soul. In a sharp career turn, he is entering a seminary program to pursue a divinity degree, and ultimately plans to minister to young people to stay away from drugs.

“After seeing thousands of sudden, unexpected or violent deaths,” Dr. Andrew said, “I have found it impossible not to ponder the spiritual dimension of these events for both the deceased and especially those left behind.”

With 64,000 overdose deaths last year nationwide — a staggering 22 percent jump over the previous year — it is little wonder that overdoses, the leading cause of death among Americans under 50, are reducing life expectancy. They are also straining the staffs and resources of morgues, and causing major backlogs.

This is especially true in New Hampshire, which has more deaths per capita from synthetic opioids like fentanyl than any other state. Last year the overdose death toll here reached nearly 500, almost 10 times the number in 2000.

Some medical examiners, especially in hard-hit Ohio, have had to store their corpses in cold-storage trailers in their parking lots. In Manatee County, Fla., Dr. Russell Vega, the chief medical examiner, said that when he reaches “overflow” conditions, he relies on a private body transport service to store the bodies elsewhere until his office can catch up.

In Milwaukee, Dr. Brian L. Peterson, the chief medical examiner, said that apart from the “tsunami” of bodies — his autopsy volume is up 12 percent from last year — the national drug crisis has led to staff burnout, drained budgets and threats to the accreditation of many offices because they have to perform more autopsies than industry standards allow.

At the same time, severe staff shortages unrelated to the drug crisis are crippling the profession, said Dr. Peterson, who is president of the National Association of Medical Examiners, which oversees accreditation. Few people go into forensic pathology in the first place, he said, largely because of low salaries, and as more forensic pathologists retire, fewer are replenishing the supply.

The result, Dr. Peterson said, is a national crisis that has already cost at least four offices their accreditation, which can undermine public confidence and lead to court challenges over a medical examiner’s findings.

For Dr. Andrew in New Hampshire, where a backlog of autopsies has put the state at risk of losing accreditation, that prospect is particularly distressing. He spent the first eight of his 20 years here professionalizing the office and earning its accreditation. Despite the caseload, the office has one of the most timely and transparent surveillance and reporting systems in the country.

A medical examiner’s office is considered deficient if an individual pathologist must perform more than 250 autopsies per year. Last year, Dr. Andrew and Dr. Jennie V. Duval, the deputy chief medical examiner, performed 250 each.

If this year’s number exceeds last year’s, New Hampshire could be in trouble. Pathologists cannot refuse to do autopsies just because they might risk losing accreditation. Nor would Dr. Andrew rush through them, he said, even if all signs pointed to a drug overdose.

Since the overdose toll began to climb about six years ago, Dr. Andrew has pleaded for more pathologists. The legislature finally authorized one in July, but until then, his office had only two, the same number as when he started, in 1997.

Upstairs from the morgue at Concord Hospital, in his cluttered office, Dr. Andrew pointed to a stack by his microscope of more than 80 folders containing glass slides of tissue samples taken during autopsies. Each folder represented an open case.

“Not all are drug cases,” he said. “But all are swept up in the backlog.”

He pulled out a logbook going back to 1997, when his handwritten entries began charting the earliest stages of what would become the drug epidemic.

“There’s a blunt impact, a drowning, one drug overdose,” he said, scanning an early page. A few years on, he found seven overdoses on a single page. A more recent page: 12 overdoses. Most were caused by fentanyl, which by now has so thoroughly replaced heroin as the biggest killer on the streets here that the state no longer talks of a heroin epidemic but a fentanyl one.

The logbook also revealed that drug users in their 20s and 30s are increasingly dying of heart-valve infections, known as endocarditis. The ages are young for such infections; in these cases, they result from dirty needles.

“We have seen more endocarditis in the last two years than we have in the previous 15 combined,” Dr. Andrew said.

The arrival in May in New Hampshire of carfentanil — the elephant tranquilizer that is 10,000 times as potent as morphine — has also ratcheted up pressure on his office.

So far this year, New Hampshire has had 41 suspected carfentanil deaths, 11 of them confirmed, far more than most states.

“It makes me feel like my hair is on fire, and I don’t even have hair,” Dr. Andrew said of the threat of increasingly potent drugs. “We’re already so far behind the eight-ball here, if we have an influx of carfentanil in this state, heaven help us.”

Back in the morgue, Dr. Andrew said he had learned to cope in this job, and its full immersion in death, by compartmentalizing what he sees and “locking it away.”

Every day, he said, a pathologist faces the fleeting nature of mortality. The people on his examining table could have lived a lot longer “but for a few millimeters of cholesterol in the wrong blood vessel, a second of inattention by the driver of a car or the lethal potency of a drug obtained on the street.”

And after a while, he said, one is bound to ask, “What’s all this about?”

His plan is to become an ordained deacon in the United Methodist Church, with two goals: to serve as a chaplain for the Boy Scouts of America, and to join the Appalachian Trail Chaplaincy of the United Methodist Church so he can minister to troubled hikers, at least on the 161 miles of the storied trail that cross New Hampshire and its White Mountains.

Dr. Andrew said he developed an appreciation for the essence of life by seeing its fragility. Most of the nearly 5,800 people he has examined on his stainless steel autopsy table, he said, “woke the day they died oblivious to the fact that it would be their last on earth.”

Examining cadavers, he said, as he removed the three pairs of gloves (two made of latex, one of Kevlar) that protect him during autopsies from blood-borne diseases, “is profound, profound work.” But, he said, it has only affirmed for him the view of the philosopher Thomas Hobbes, who called the human condition “nasty, brutish and short.”

For him, there is comfort in the concept of an afterlife.

“I’m very, very hopeful for what comes after this, because this —” he said, gesturing toward the woman he had just autopsied — “is pretty awful.”