Chief Medical Examiner to VT's Death Investigators: Ask Questions, Assume Nothing | Culture | Seven Days | Vermont's Independent Voice

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Chief Medical Examiner to VT's Death Investigators: Ask Questions, Assume Nothing 

Local Matters

Published April 28, 2010 at 7:46 a.m.

When 19-year-old Nicholas Garza left his friend’s dorm shortly after 11 p.m. on February 5, 2008, it was the last time the Middlebury College freshman was seen alive. For various reasons, including the fact that most students had already left campus for their midwinter break, Middlebury police didn’t start investigating the young man’s disappearance for another six days. Garza’s body was found four months later under some logs in Otter Creek.

Throughout the ordeal, Garza’s family and friends were critical of local law enforcement. But, according to Michael Cannon, a longtime death investigator and 30-year veteran of the Colchester Police Department, Garza’s was a textbook case of how water deaths should be investigated: The police interviewed many witnesses who’d seen him shortly before he went missing. They asked all the right questions and took lots of photographs. When Garza’s body was found, the medical examiner and police were able to say conclusively that his death was accidental because of that initial investigative work.

Last Saturday, Cannon was among the presenters who spoke to a group of about 100 police, firefighters, nurses and EMTs gathered in a dark, windowless auditorium at the University of Vermont for a daylong training for death investigators. The subject, according to Vermont’s chief medical examiner Dr. Steve Shapiro, was “people’s worst nightmares.” That is, understanding how people die and accurately pinpointing the cause.

Each year, some 5000 Vermonters shuffle off this mortal coil at a rate of nearly 100 each week. Shapiro looks at all of them. That doesn’t mean he investigates each one; his office only autopsies about 450 bodies annually. But Shapiro reviews every death certificate filed with the Department of Health to make sure everything looks kosher.

For example, if the cause of death is listed as “cardiac arrest,” does that mean the individual died of a heart attack, lung cancer, diabetes or a gunshot wound? If Shapiro doesn’t know, he picks up the phone and calls the doctor who signed the death certificate to find out.

“The guy who’s found clutching his chest and had been complaining to his wife about chest pains is more than likely a heart attack,” he says. “The 35-year-old whose wife was sleeping with the plumber? We’ll look into it a little more.”

Similarly, if the gun found at the scene of an apparent suicide is a .38 but the slug is a .22, “Someone has some explaining to do,” Shapiro adds.

One of the reasons for last weekend’s training, he explains, is that most death investigations in Vermont are no longer done by physicians. Back in the 1950s, country doctors often drove to the scene of a 3 a.m. car wreck or a suicide to document the exact cause of death. By the mid-1990s, however, local police were having trouble finding physicians who were willing to go into the field to do death investigations, given what they were paid for their trouble.

So, in 1999 Vermont switched to a system of using nonphysicians — nurse practitioners, paramedics, EMTs, physician’s assistants and the like — as assistant medical examiners. Currently, all 63 assistant MEs in Vermont have gone through a state certification process, and about a third of those are nationally certified through the American Board of Medicolegal Death Investigators.

While Shapiro admits that the current system isn’t perfect, he believes that Vermont has one of the best death-investigation systems in the country. And he intends to keep it that way, in part by ensuring that all his death investigators get as much training as possible.

There are critical reasons to do so. Last year, a report by the National Research Council found “serious deficiencies” in the nation’s forensic science system and called for major reforms, new research and rigorous training for death investigators. Much of the impetus for that report, Shapiro explains, was the work done by the Innocence Project, which represents prison inmates who’ve been wrongly convicted of serious crimes due to bad science.

The Vermont legislature is currently considering a bill that would allow people other than licensed physicians to sign death certificates, something most states don’t allow.

Much of last weekend’s training conference at UVM was devoted to drownings and “body recoveries from water” — a downside of living in a place with so many lakes, rivers and streams. Water fatalities, such as boating accidents and apparent suicides, aren’t always investigated with the same diligence as deaths that occur on land, Shapiro points out.

It’s complicated by the fact that submersion in water can accelerate decomposition, and blows sustained while floating can be indistinguishable from ones that contributed to the cause of death. Familiarity with the symptoms of death by water — such as the clarity of the eyes — can help police determine whether a victim drowned or was dumped.

About half of all water deaths involving infants and children are later determined to be homicides. Which is why Shapiro tells his investigators to treat them all as such until proven otherwise.

“Who likes investigating these things? No one,” Shapiro told the group. “But ask the hard questions. These could be your nieces, your nephew, your cousins or your kids.”

Ultimately, Shapiro says that most of his work is less about solving crimes than it is about preventing deaths from avoidable causes such as smoking, hypertension, obesity and accidents in the elderly.

“The ‘CSI’ stuff doesn’t help what I do,” he says. “The reality is, if I have a body with a knife sticking out of its back, it’s not rocket science … It’s really all about using information to protect the living.”

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About The Author

Ken Picard

Ken Picard

Ken Picard has been a Seven Days staff writer since 2002. He has won numerous awards for his work, including the Vermont Press Association's 2005 Mavis Doyle award, a general excellence prize for reporters.


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