Sunday, October 16, 2011

FICTION: AUTOPSY by Mike Goldstein

What they don't tell you in medical school is, if you want to see who people really are, you should go into pathology. Not psychiatry.

In therapy, patients talk about themselves.

About their mothers. Their bosses who treat them unfairly and are out to get them.

Their postmen who open their mail and laugh at their tiny paychecks and overwhelming bills.

Their weird sexual fantasies about the girl in the next cubicle. The next office. The next classroom.

But they talk about these things behind closed doors. They open up because the record is sealed.

What happens on the couch, stays on the couch. Doctor-patient confidentiality applies. If the doctor says anything, they can sue and retire.

It's a win-win.

Nothing to lose.

The only person with something to lose is the psychiatrist. The therapist. The man bound by the law or the Hippocratic Oath or whatever to keep everything under wraps, no matter how devious and disgusting. No matter how much it makes him sick, he can't tell a soul. Only if there is a perceived danger to another person can the doctor say anything.

And how often does that happen? Not often at all, I can tell you that much from my psychiatry rotation in medical school.

But the psych patient, the person in therapy, he knows something is wrong. He knows there's a part of his brain not working quite right. A chemical being released too much too often.

Cognitive behavioral therapy. Lorazepam. Sertraline. The right combination of drugs and psychobabble can balance out the crazy just enough to keep them functioning in society without masturbating on the bus or raping the new secretary or killing the cat.

But when it doesn't work, what does the psychiatrist do with all that information?

The patient strangles himself to death while masturbating or dies of sepsis when the glass dildo shatters and rips apart his large intestine or is found dead with his dick in his hand and his daughter's panties shoved down his throat.

The doctor saw it coming, but he couldn't tell anyone. He knows all kinds of dirty secrets about his patients, and he can't tell a soul.

But I didn't go into psychiatry. I went into pathology.

What they don't tell you in medical school is, in pathology you have two types of patients: ones that are still alive, and ones that are not.

The alive patients, you won't really see much of them. A tumor. Gallbladder. Part of a liver or a thyroid. A little piece of a person that you'll slice up and stare at through a microscope to see exactly which type of cancer it's going to be.

Cut up some tissue, write a report and toss the human tissue into a red biohazard bag.

But the dead patients, you will see all of them. Investigate every square inch of their bodies to figure out what went wrong. Why they're dead.

In school, they teach you how to perform an autopsy. How to remove the organs and weigh them and mark down any abnormalities. Slice them up and put them under a microscope and into jars of formaldehyde and onto the shelves.

They teach you how to be a detective of disease. How to hunt through medical records and surgical histories and medication lists for clues. To see what picture they paint.

To find the cause of death.

Part doctor, part detective.

In school, everyone dies of cardiopulmonary arrest. Cancer. Aneurysm. Gunshot wound. It doesn't matter. None of those things actually cause the patient to die. It's the stopping of the heart and breathing that causes death.

You write in your report, the bullet entered the left ventricle causing cardiac tamponade and hypovolemia. You write that the doctors performed a thoracotomy to perform direct cardiac massage, but the injury was too severe and caused cardiopulmonary arrest leading to death.

And you close the case.

But the file isn't sealed.

Newspaper reporters. Television producers. They call and ask for interesting cases. Deaths that can boost ratings or circulation. The cases that will shock.

In school, you give them the tragic murders. Surprising high society deaths. You give them the details, because in medical terms they aren't very shocking. Rich or poor, everyone looks the same on the slab. There's no confidentiality, so the details get released to the public.

Everyone wants to know why so they can imagine themselves in that position and vow to live life to the fullest. To stop eating donuts for breakfast and beef jerky for lunch.

The Death-A-Day Diet.

In school, you give the reporters the details because everyone wants to know, and nothing is shocking or embarrassing.

But that's in school.

You graduate and go into private practice where you work in a lab five days a week. You make trips to the hospital to do a biopsy. A frozen section. A lipid panel.

And then you get the call. The morgue needs an autopsy done, and you're carrying the pager.

So you're back to playing detective. Only this time, the case is different.

The patient looks like a victim.

Ligature marks around the neck consistent with strangulation. Petechial hemorrhaging around the eyelids and the lip mucosa indicating the patient was still alive during strangulation.

Then you find chaffing on the penis. Evidence of recent ejaculation.

You dictate into your little recorder. Cause of death is cardiopulmonary arrest precipitated by strangulation during masturbation, also known as autoerotic asphyxiation.

And then the pathology assistant is telling you: The family needs to see you.

He's saying: It seems urgent.

So you cover up the body of their dead son, even though you all know what's under the sheet. The parents come in, and you're standing with them at the slab. The sheet's covering up the bruises on their son's neck. The chaffing. The dried seminal fluid caked onto his inner thighs.

They're telling you how good their son was. How he was a straight-A student. On the honor roll.

A good boy with a good reputation.

They stand there, nodding at you. Imploring you to understand that their son never does things like this. That he's not some kind of pervert.

And the mother looks like she's on the brink of a meltdown, so you nod.

You ignore the old bruises. The evidence of a regular pastime. You don't tell them you know he's been doing choking himself for a while because they've convinced himself that some friend talked him into doing it. Some horrible television show that needs to be taken off the air. A video game they shouldn't have let him buy.

But it's possible he was depressed. Suicidal even.

The father's saying: When we found him, he was hanging from a pole in his closet.

Fully clothed, the father says.

And he looks like he could crush your skull with one hand, so you nod.

He takes out an envelope and puts it in your hand. As you're counting the money, he says: So you're ruling it a suicide then?

You stuff the envelope in your lab coat and nod.

When the newspaper reporter asks, you tell her it's just a young boy who hung himself in his closet.

In school, you'd never believe something like this could happen. But before you know it, you're making money off of a mother's embarrassment. A father's shame.

A new suit.

Matching shoes.

Each custom autopsy report represents an addition to your wardrobe or a new toy. Some kid dies of dysentery after losing a cucumber up his ass, and you wear a new tie to work.

A student loan payment. A credit card paid off. Just falsify some records, and all your debts can go away without draining your paycheck. The word gets out there's a pathologist in town who will take care of any embarrassing deaths for a fee.

Family members and patients start bribing the paramedics to take them to your hospital. They ask for their pathologist by name. You start getting calls even when you're not carrying the pager.

When you find yourself making a down payment on a new BMW using the same envelope that blubbering mother handed you in the morgue, try not to laugh.

Try not to laugh, because soon enough you'll find yourself in a meat locker sitting at a folding table across from a man with a Russian accent. A man with deep lines in his face and dark circles around his eyes and who looks like he hasn't slept soundly in decades. And when you're sitting across from this man, you really don't want to laugh.

Men like him, they don't like being laughed at. It doesn't matter if you're laughing because that morning you fudged the autopsy report for a city councilman and now you're taking an envelope of money from a Russian mob boss.

The man with the Russian accent, he doesn't like people laughing at him. So try your hardest not to laugh, or he'll be paying someone else to falsify your autopsy report.

If they ever find your body.

Men like Kliment are good at making bodies disappear. But, even better than making a body successfully disappear would be to have the body found and ruled a suicide or an accidental death.

Something that would rule out foul play.

He's saying: They can still investigate and prosecute without a body.

And I'm nodding, but the envelop in my hand is heavy. The dusty metallic smell of old money wafts up to my nose, and I'm thinking of the student loans I'm so close to paying off. The remaining payments on the Beemer. The house.

He's saying: If the death is ruled something other than homicide, the investigation stops.

Don't laugh, because when you're holding a big envelope full of money and all you have to do is fudge a few reports on some people who were going to be dead anyway, the choices don't seem so black and white.

Before you know it, you've gone from covering up sexual fetishes to disguising murders.

You've still got your day job, because the jobs for Kliment are irregular and never more than three or four times a month. Just one day the phone rings, and that deep Russian voice gives you a heads up. They take the guy to a location near your hospital to make sure he goes there. They make sure to do it a night you're carrying the pager.

All this means they don't have to bribe anyone. Nothing to connect the dots.

You get the call and in thirty minutes, you're fishing a bullet out of some poor sap who refused to pay up. They call it protection money, but all it protects against is a bullet through the temple.

It may seem crazy to you, but crazy isn't paying a man you've never met before not to kill you. Crazy is making a knife wound to the neck look like an animal attack. It's forging a blood test and faking a bowel obstruction.

What's crazy is the knot my stomach forms each time the phone rings, waiting for that Russian accent to give me another name.

What's crazy is that even with the knots in my stomach, I keep doing it. Don't judge, because once you've accepted the first offer, there's no turning back. Life as you know it is over. Don't start thinking you're indispensable, because people have gotten away with murder for thousands of years.

Don't start thinking this is just some job you can retire from. Just up and walk away from.

Keep chanting the company line, because you're only safe as long as you're on the payroll. Just remember that sad fact when you get the call that puts you over the edge. The one that makes you question the morals you have left.

Because when I answer the phone, all I can think about is my body on the slab. When the Russian accent gives me the heads up on his latest unsatisfied customer, I'm thinking of just that. I force myself to keep my mouth shut and hang up. The words I want to say but can't are coiled in my throat, waiting for an opening to leap out and get me killed.

The words I want to say. A mashing together of morality, the law and sheer paranoia. My mouth opens, and the words fly out. And they smash against the bathroom mirror and fall dead into the sink. I wash them down the drain and wash my face.

Because I pay protection money in the form of a service. The money they feed me is just an incentive. The only way out is a bullet through the temple. The only way to live is to keep going.

So I do.

And when the hospital calls me twenty minutes later, I'm already on my way to the morgue.

But when I get to the morgue, there are two bodies. Two naked, graying bodies flanking the room.

I grab the assistant and pull him in close. I ask him, What's this?

"Sixteen year old girl and her father," he says. Then, he makes a gun with his fingers, pops a round at me, then one at himself. Murder-suicide.

This is one of my easiest jobs. Everything about it screams murder-suicide. Powder burns on the father's right hand and temple. A slight downward angle in the daughter's wound.

All I have to do is sign my name on the reports and go home. The police will pick them up and close the case. And a grieving mother and wife will bury her daughter and husband on the same day.

And she'll ask herself every day what happened.

And she'll badger the police. They'll tell her it was ruled a murder-suicide, but she won't believe it.

And after enough time, I'll be signing her autopsy report.

Other than the entry wound in her forehead, the girl's face is intact. If you cover up the hole, she could have died in her sleep. A congenital defect. Cancer. Something she couldn't do anything about.

What she could have done to deserve this is beyond me. Walked in on Kliment killing her father maybe. Or maybe she just happened to be there when the Russians showed up. Just in the wrong place at the wrong time.

The autopsy report sits on the slab next to her head.

My hand rests on her forehead.

The report is finished. It just needs my signature.

Don't laugh, but when you find yourself standing over the body of young woman you never met and wouldn't recognize on the street without the gunshot wound to the head, you'll make another in a series of bad decisions.

I sign the autopsy reports and fax them to the police department along with a one-page note.

Covering the bodies with a sheet, I switch the light off and exit the morgue. Walking through the hospital entrance, I cross through the parking lot and across the street to my car. The engine starts, and I pull away from the curb and pass the blue Ford with the two Russian gentlemen sent to watch me.

A black car sits at the curb in front of my house. I pull into the driveway, and it pulls in after me to block me in. The blue Ford stops down the block. Before I can take two steps out of my car, two detectives flash their badges and escort me to their back seat.

I hope you don't think less of me, but when the police sit me down in the interrogation room, I tell them everything. The bribes. The cover-ups. And when they threaten me with jail time, I tell them about Kliment. All the murders I can lead back to him.

Don't judge, but when they offer me immunity in exchange for my testify, I take it. Don't laugh, because when life in prison for covering up more than a dozen murders is the only alternative, you take the deal.

You move to a small town in Montana. Get a job waiting tables at a coffee place.

A new haircut, a beard. A new name and social security number.

You check for blue Fords whenever you get into your car. Take an extra lap around your block before pulling into your driveway. Screen your calls.

Once a week, you drive to the city to see a court-appointed psychiatrist. You tell him everything you told the police. The murders. The suicides. The sexual fetishes.

He asks you if you think about hurting yourself, and you don't tell him about the gun in your sock drawer. The one you got for protection. You don't tell him that you've never fired a gun before in your life, but if the time comes when you'll need to use it, you don't plan on firing more than one shot and you don't plan on missing.

You don't tell him that you take medication for the ulcer you've developed. The pills you take for your extreme hypertension. The Vicodin to help out the Sertraline he prescribed for your anxiety and panic attacks.

You don't tell him that you keep expecting to answer the phone and hear that gruff Russian accent on the line.

He asks you how you're doing, and you tell him you're fine.

What they don't tell you in medical school is, if you want to see what kind of person you are, don't go into psychiatry. Go into pathology and wait for the calls to come. For the first parent to hand you an envelope so her son can be remembered with dignity.

The doctor asks me how I'm doing, and I tell him I wish I had gone into psychiatry.

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