By Rose Hoban
On the television show CSI, the female medical examiners often wear high heels and smart suits; the men wear dark glasses and designer windbreakers. They bring the evidence back from a crime scene, put it into a lab machine, and toxicology reports get spit out in minutes. They have up-to-date computer systems and databases that spit out information and link to other databases.
But during a break in testimony at the General Assembly Monday, North Carolina’s chief medical examiner, Deborah Radisch, joked that her shoes are usually flats, not heels.
And in hours of testimony before a subcommittee of the Joint Legislative Health and Human Services Oversight committee, Radisch and others from the state Department of Health and Human Services detailed the many ways the North Carolina system falls far short of fiction, with too-small autopsy rooms, outdated software and facilities, personnel shortages and cuts in funding that have hampered the state’s ability to resolve investigations around deaths.
Even lawmakers said they may have been lured by the TV series into thinking the medical examination process was more sophisticated than in reality.
“I’m afraid I was probably captured by CSI,” said Sen. Tommy Tucker (R-Waxhaw). “All the colors and the data and the fine information systems and all the techniques and the microbiologists involved and pathology that’s involved, and then to find out it’s kind of backward from the way we’re doing things.”
Radisch emphasized to lawmakers that many of the local and county medical examiners –the people who actually certify deaths and who are responsible for reporting to Radish’s office – are essentially volunteers. Local medical examiners can be physicians, physician assistants, nurse practitioners, registered nurses or paramedics who are called in the event of a death. They receive only $100 per case.
It was that system of medical examiners that drew intense scrutiny by the Charlotte Observer earlier this year in a series that detailed the lapses in the state’s system for investigating deaths.
In that series, the paper detailed how this system leads to inconsistency across the state, where in Mitchell County as many as three-quarters of deaths have autopsies done, while in Johnston County only one in five deaths merits an autopsy.
And lawmakers pointed out that this year’s series was not the first time the state’s journalism organizations have looked at the medical examiner system and found it lacking: The last investigation was in 2001; it found many similar problems.
“I’m disappointed. Those questions were in the 2001 investigation, studied by the NCGA. To me, this is one of the most important functions of government,” Tucker said.
Twenty-three recommendations for improving the state’s medical examiner system were made in the wake of the 2001 newspaper investigation. But according to Radish, of the recommendations made to the DHHS secretary in 2001 only two were fully implemented, another three were partially implemented and the rest were not followed, mostly because the legislature did not fund them.
Not enough people for too many bodies
Not every death requires an investigation: only those that occur in state-operated facilities, those where the death is unexpected or for people who are victims of violence or who die under suspicious circumstances. But sometimes the need for an examination is not clear, and making that determination requires training and experience.
But Lou Turner, section chief for the Office of Chief Medical Examiner and the state’s public-health lab, pointed out an unmet need for training the local medical examiners.
“We need to mandate medical examiner orientation and training,” Turner said, noting there is no official orientation, program coordination or training courses for local medical examiners.
She pointed out that of the state’s local medical examiners, about 56 new examiners have recently been trained and appointed but another 63 have quit in the past year, leaving a deficit.
“We have no assurance that medical examiners are keeping pace with knowledge of, or improvement in, medico legal death investigations,” she said. “We want to improve the knowledge and resources that are used by our medical examiners, provide them with the skills and knowledge they need … and target specific training needs throughout the state.”
Turner said the state would need to spend at least $150,000 to get medical examiners trained, on top of raising the per-case fee to $250, at an additional cost to the state of another $1.49 million.
Those local medical examiners are overseen by pathologists – specially trained physicians who do the autopsies. There are pathologists at the Office of the State Medical Examiner and at regional centers in Charlotte, Winston-Salem, Raleigh and Greenville. But the state medical examiner’s office has had a number of vacancies that have only been filled recently.
Radisch recounted that in 2010 forensic pathologists in her office were handling, on average, 500 cases. The national standard is to have forensic pathologists handle about 250 per year, she told the committee.
DHHS Sec. Aldona Wos chimed in that Radisch had done 400 autopsies herself that year, in addition to running the Office of Chief Medical Examiner.
Wos said that’s why when she took office last year, she pushed the legislature to raise pathologists’ salaries to about $185,000 per year to lure more to the state. Wos said getting pathologists to relocate is no easy task, as there are only about 500 pathologists in the U.S. But she said two new pathologists are about to start.
Long due bills
But getting autopsies done is a losing proposition for most of the institutions that do them, said Peter Kragel, who runs the pathology department at East Carolina University’s medical school. His office does most of the autopsies for 22 counties in the northeastern part of the state, about 850 cases last year.
At the same time, his office has been losing money since 2011; Kragel told lawmakers his program was in the red to the tune of about $400,000 in fiscal year 2013-14.
“We can limp along for some period of time,” Kragel said, but he said that soon the facility at ECU would become unworkable under the number of cases combined with the loss of funds.
State officials reported to lawmakers that, on average, an autopsy costs between $2,815 and $3,579, depending on the institution doing the work. But those autopsy centers only receive $1,250 from the state and another $400 from a special fund at the state medical examiner’s office.
“These fees have not kept pace with inflation and increases in basic operating expenses such as supplies, equipment and salaries for board-certified forensic pathologists,” Turner said. “Our partners at ECU and Wake Forest reported they can not continue to perform autopsies at the current fee structure.”
Turner offered comparisons between what North Carolina pays for medical examination and autopsy services in Virginia, Maryland and West Virginia. North Carolina had the lowest per-capita spending on the services of any of those states (see chart).
She also presented a laundry list of objectives that would bring North Carolina up to national standards and allow for the state medical examiner’s office to become accredited and update crumbling centers in Winston-Salem, Greenville and Charlotte at a total price tag of tens of millions.
And while lawmakers hesitated about the total price tag, they seemed to warm to the idea of spending some money to improve the system.
“We have prioritized what we’re asking for in order to stabilize the system,” Wos told the committee. “We have short-term recommendations that are realistic. We only come to you with what is absolutely necessary for the short term.”
In addition, Wos said she had longer-term proposals for spending, but that she could wait.
“So you’re saying that in the midst of us asking for you to come for all these reports, that you actually have confidence in us” to appropriate funds? asked Sen. Don Davis (D-Snow Hill).
“Absolutely,” Wos responded. “This is a fundamental obligation for all of us.”
In that, she found agreement among all of the legislators.
“The dignity of death should be a requirement that the government provides for a correct death certificate,” said Tucker.
“It is astonishing that we don’t have more resources and people being able to be qualified and trained to do it right,” he said.