CONCORD — Dr. Jennie Duval spends most of her workday in the basement of Concord Hospital amongst corpses.
As New Hampshire’s chief medical examiner, Duval is responsible for determining the cause of “sudden, unexpected or unnatural deaths.”
She performs autopsies in the hospital’s morgue, which is outfitted with a neatly written list of organ weights, a blue light to catch flies (“unidentified bodies,” which could have been decomposing for weeks, fall under her jurisdiction), and a stainless steel mortuary table.
Duval understands that her passion for forensic pathology is uncommon. A dimly lit morgue hidden in the hospital basement isn’t the backdrop most medical students picture for their nascent careers.
“You’re not working with living patients, it’s smelly, it’s unpleasant, it’s emotionally difficult,” she said.
But the unglamorous exterior of the profession has posed a problem for the state: There are too many bodies and not enough pathologists to autopsy them.
It isn’t for a lack of trying. The office has been trying to hire another full-time pathologist for nearly two years with no luck. The job listing on the National Association of Medical Examiners quotes the salary range as between $200,000 and $240,000.
“There are so many openings right now because every office is short,” she said. “Every office needs more help.”
Duval stumbled into her career by chance when she realized during a residency program that surgery wasn’t a specialty she felt comfortable in. If fact, it seemed that no medical career with living patients seemed to fit her strengths. What attracted most people to medicine — helping sick patients get better — made Duval anxious.
“I didn’t like treating patients — especially critically ill patients — that’s pretty stressful,” she said.
Duval dropped out of her highly competitive surgery program and took a pathology job in New Hampshire as a stopgap until she figured out what to do next. That’s where she met Dr. Roger Fossum, who had virtually created New Hampshire’s medical examiner position in the late 1980s. Before his sudden death in the ’90s (he was autopsied in Massachusetts to avoid conflicts of interest), Fossum encouraged Duval to pursue a career in pathology.
Duval had become enamored with the problem-solving and hands-on work required to do the job. She even liked explaining her findings to lawyers in court, which she said reminded her of teaching.
After many more years of training, she returned to New Hampshire as a deputy in 2001 and then moved up to the top job.
New Hampshire’s Medical Examiner Office had been chronically understaffed since Duval joined its ranks in the early 2000s. The office had been scraping by for years with two full-time pathologists. Then the opioid epidemic hit.
“We kept saying that we were managing until the opioid epidemic took off and then we’re like, ‘OK, we don’t just need a third pathologist, we can’t do this work without more help.’ ... It got out of control,” she said.
In the absence of doctors applying for open positions, the office turned to contracted pathologists to fill in the gaps, but they are more expensive and can often work only on cases that won’t end up in court.
In the mid-2000s, fentanyl, a highly potent synthetic opioid, started gaining popularity. That caused a surge in opioid overdoses. The number of annual fatal overdoses more than doubled between 2013 and 2015, sending a slew of cases to Duval’s desk for autopsy. With only a couple of pathologists, they simply couldn’t perform a full autopsy on every overdose case.
The Medical Examiner’s Office made a compromise with law enforcement: If they had a solid investigative lead, a full autopsy would be performed. Otherwise, the office would examine the outside of the body and send blood samples to toxicology without cutting the body open.
Duval cringes at the thought that one of the death certificates she produced could be wrong. According to a small study she organized, there could be a 5% error rate among the bodies she doesn’t autopsy. In other words, about 5% of the time, a death could be incorrectly labeled as an overdose.
“We’ve all had cases where the bodies are coming in for autopsy and it looks like an overdose,” she said. “Everything suggests it’s an overdose and then I do the exam and I find something totally different. I found the ruptured aneurysms. I found horrible pneumonias.”
Under this compromise with law enforcement, only about half of the overdose cases are given a full autopsy, she said. Even so, overdoses comprise about two-thirds of the office’s caseload. There are so many bodies to review, Duval has advocated — unsuccessfully — to reorganize the morgue’s freezer to double the amount of room.
Under national accreditation standards, if a pathologist performs more than 250 autopsies a year, an examiner’s office can be fined. Duval said she has no choice but to perform nearly 300 a year.
“You can’t not do an autopsy that needs to be done,” she said. “If you keel over right now, what am I going to put on your death certificate? The accreditation standards are to say that this is an office that is well-staffed, well-funded, doing good work, and I can’t say I’m well-staffed.”
As much as Duval loves her job, she recognizes that part of the reason her profession is unpopular is the emotional strain that accompanies each day of work.
Duval sees the graphic aftermath of tragedy on an almost daily basis. It makes routine activities, like sending her son off on a road trip or getting on a plane, nerve-wracking. Even more haunting are the deaths are that occur suddenly and without warning.
“You go to bed with your spouse and they don’t wake up. I mean, that is unimaginable,” she said. “If I can relate to them, if it’s their 20-something-year-old kid that just got killed, those are hard.”
Still, the experience puts her life in perspective.
“At the same time, you can look at that and say you just have to live because it’s gonna happen at any moment,” she said. “You have to live life to the fullest. Don’t put off plans.”