Privileged: the undertaker and me in the middle of the night

It was the night after Thanksgivings about 1 am when I received the call from the acting medical examiner. The county employed only one ME at that time.  He was a senior physician who had cut back his clinical practice and he was off for the holiday weekend. The physician covering the job that night was a distinguished gastroenterologist, the first in the county to remove a gall stone lodged in the pancreatic duct with an instrument he passed down the esophagus, through the stomach and into the pancreatic ducts.  He had traveled to Japan about five years earlier to learn the technique before gastroenterologists at major academic medical centers began teaching this to their trainees. I had learned of his unique expertise  soon after my arrived in New Jersey over three years earlier. That night I learned that his technical skills were driven by his concept of conscientious and responsible professional behavior.

My wife and I were sleeping in the first house we own in Piscataway. The hospital operator had given the acting ME my number. I awoke on the phone as the acting ME spoke in his distinctive German accent. The police had informed him that one my patient died in his son’s presence earlier that night.  The ME had an obligation to further investigate this death by ordering a post mortem examination if the death was not certified to be of natural causes.  

The acting ME wanted to tell me that someone had to go to the deceased’s apartment before the undertaker could remove the body---someone who knew the patient, his medical background and mood; someone who would understand the reasons for the patient’s death. That someone he said “is you because you were the patient’s doctor.” The acting ME continued: “You do not want the emergency medical technicians and ambulance people to get up in the middle of the night to remove the body to the hospital simply for our convenience. These individuals are volunteers who donate their time to transport the living and what would they think of doctors who ask them to transport the dead in the middle of the night on a holiday weekend?”

In my fourth year as an attending physician, I was not about to argue with the acting ME. I simply asked for the patient’s address, dressed immediately and set out for the neighborhood in Plainfield to inquire, pronounce and certify my patient’s death.

As I drove I began gathering my thoughts about Mr. Kelly.*  I thought of his life as a former alcoholic who was treated for TB. He was retired and living with his thirty plus year old son in a mutually dependent relationship. Mrs. Kelly was never in the picture suggesting that the patient’s former alcoholic lifestyle must have destroyed his marital  relationship.   His son always accompanied his dad to my clinic. Mr. Kelly had been hospitalized when I initially saw him for profound weakness, weight loss and debilitation. With his past history of TB which can affect the adrenal gland, you did not have to be a medical mastermind to consider adrenal insufficiency as the cause of his illness.  When I made that diagnosis and gave him cortisone, he enjoyed a remarkable health renaissance. As I drove to his apartment, I thought “Why did he die suddenly?”

When I reached the address on a commercial street with apartments above retail stores, a black station wagon, the undertaker’s vehicle, was parked just ahead of me in front of the building. The name plate in the back side window indicated this was a well established funeral firm. The building door was open and I climbed the dark staircase in this firetrap of an edifice to the third floor. The undertaker was outside the open apartment door in the hallway at the top of the staircase. He was about twenty years old. His last name was the same as that of his firm.  He was the youngest member of the family business!  Mr. Kelly lay on a sofa in the small dark unkempt living room, quite dead and already cold. His son was sobbing sitting nearby. 

The son said that when his dad returned home in the late evening from a Thanksgiving trip to upper New York state, he was very weak and vomiting. Mr. Kelly had left the apartment Thanksgiving morning and forgotten to take his cortisone drug with him. He had been drinking again to celebrate Thanksgiving the evening before. He had been sick all day but decided to drive home.

This history suggested that it was a miracle that Mr. Kelly was able to get home alive but a tragedy that he did not drive himself to an emergency room first, where he could have been saved by an injection of intravenous cortisone.   His weakness was so profound that his son had to drag his father up the stairs. His abdominal pain and vomiting were typical of acute adrenal insufficiency. He fell onto his parlor sofa and probably died of low blood pressure characteristic of adrenal insufficiency.

The son was attentive to his father and I could not conceive of him being devious enough to make up this story.  He was not the type of person who could poison his daddy;  nor was he an able enough actor to be playing a role as a bereaved son.   I went down to a street phone to call the acting ME as there was no phone in their apartment.  I apologized for awakening him at 2:30 am to tell him that I did not think a post mortem exam would be more informative than what I recognized already.  I thought it appropriate to release the body to the undertaker if the ME agreed. I would certify that the cause of death was natural secondary to adrenal insufficiency.  The ME was pleased and immediately ended our conversation.  

When I returned to the apartment, the young undertaker was sitting next to the son trying to console him. He asked if a priest would be helpful. The son did not disagree.  So the undertaker went to the same street phone which I used and called a thereby parish. When he returned, he told me that a priest would not be visiting. Because we were two flights above the street, the undertaker, the son and I toiled to bring the body down the stairs to the station wagon. Once Mr. Kelly was secured in the back of the wagon, I asked young Kelly if he would be all right. When he said he was okay, I shook hands with him and told the undertaker where to pick up the death certificate. I thanked him for his help. We all parted at the curb. I arrived home at dawn, thinking that the world was still asleep as the undertaker and I did our job that night.

Twenty-five years later the physician who was acting ME that night came to me as a patient with one of the most profound diabetic neuropathies I had ever encountered. He was addicted to narcotics to relieve pain. He asked me to help him detoxify from narcotics while treating his neuropathic pain. I told him I was not qualified to use methadone. He said I underestimated my reputation and that the medical board would understand that I was prescribing methadone appropriately and ethically. I undertook that challenge and his care and recovery was one of the most privileged experiences of my career. 

*not his real name