We’re in good hands: Virginia’s Medical Examiner sets nationwide standard

You won’t see Dr. Leah Bush doing rounds at the local hospital, but she is the kind of doctor families look to for answers. Bush is the Chief Medical Examiner of Virginia and one of many forensic pathologists who investigate thousands of deaths each year statewide. We had a chance to sit down and talk with her about her unconventional career path and the medical examiner field as a whole.

November 19, 2009; 12:00 PM • by Marge Weimer

You won’t see Dr. Leah Bush doing rounds at the local hospital, but she is the kind of doctor families look to for answers and law enforcement depends on. Bush is the Chief Medical Examiner of Virginia, based in Richmond, and one of many forensic pathologists who investigate thousands of deaths each year statewide. We had a chance to sit down and talk with her about her unconventional career path and the medical examiner field as a whole.

A road less traveled

Bush’s career in forensics began during her pathology residency at MCV Hospital in 1986. For pathology residents (who study and diagnose disease in tissues and organs) taking on part-time medical examiner work is not uncommon.

“I was looking for opportunities to moonlight – to make extra cash,” Bush said. “I needed a car; I had just graduated medical school [and] had loans to pay off, so I started casting around for ideas for part time work.”

Since then, Bush said she has performed over 5,000 autopsies.

Bush’s career in the Office of the Medical Examiner began later that year as Assistant Chief in the Tidewater District. Her move to Chief came in 2008. She said forensics provides a way to maintain a comfortable lifestyle and interesting career, especially for women interested in starting a family. Unlike emergency room doctors and obstetricians, for example, forensic pathologists have fairly reliable schedules.

“I didn’t start off as a kid thinking this is what I want to do,” Bush said. “I always knew I wanted to be a doctor – but I thought more along the lines of surgery or OB – and ended up falling in love with [forensic pathology] as a career.”

Bush’s childhood was almost as unique as her current profession. Her father worked for the Department of Defense as a principal in schools set up for soldiers with families abroad. At an early age, her family moved from the U.S. to Taiwan. When Bush was in first grade, they settled in Okinawa, Japan, where she eventually graduated from Kubasaki High School.

“Because I come from that background, I understand that not everyone thinks alike,” Bush said. “I embrace cultural differences and I know there are other ways to do things.”

That cultural sensitivity is evident in her current efforts to educate her colleagues. Recently, Bush held statewide training on how to treat the Muslim dead with respect according to their religious beliefs. Soon, the same training in regards to the Orthodox Jewish faith will be implemented.

“We want to follow their religious beliefs as best we can so we don’t upset them anymore than they already are by the death of their loved one,” Bush said.

Setting the standard

The Virginia medical examiner system is accredited by the National Association of Medical Examiners and employs 12 licensed pathologists.

“There are very few statewide medical examiner systems in the country – we’re one of the few.” Bush said. “All four offices [in Virginia] are accredited by the National Association of Medical Examiners, so people look to us as a model for our country.”

Each district in Virginia has a stand-alone office that covers the same population base.

Central District, located in Richmond
Northern District, located in Fairfax
Tidewater District, located in Norfolk
Western District, located in Roanoke

“At any given week, I’m at one of those offices,” Bush said. “I go to help out with doing autopsies; I go to just talk to the doctors and find out what their concerns are to make sure everything is running smoothly.”

The statewide system allows every citizen equal access to forensic expertise spanning from the morgue to the court room.

The National Association of Medical Examiners (NAME) was founded in 1966 to investigate deaths in the United States using properly trained professionals.

“We have 55 offices that are accredited in the country with four or five in progress,” said Denise McNally, executive director of NAME.

A typical day for a forensic pathologist is filled with case work (examinations/investigating deaths), court appearances when subpoenaed, and speaking to families. Bush said there is a misconception that doctors in the forensics field are somehow removed from dealing with grieving loved ones.

“If a family calls and wants to speak to the doctor who did their case, they get to speak to the doctor who did their case.” Bush said. “The doctors take all phone calls from families and as the Chief Medical Examiner; that’s my policy statewide.”

The most recent annual report from the Office of the Chief Medical Examiner, released in November 2008, states that the office investigated 5,968 deaths and of those deaths 2,943 required an autopsy.

Bush said that even though a death is being investigated by the medical examiner’s office, does not necessarily mean an autopsy will be conducted.

The Virginia Code states that any unnatural death must be investigated. That includes people who die suddenly and unexpectedly, unattended by a physician, violently, under suspicious circumstances or while in law enforcement custody.

“When we investigate we have two choices: we can do a full autopsy, which is external and internal examination; or we can just do an external examination,” Bush said.

What happens during an external exam

The morgue receives the body in a body bag, delivered by the police or funeral home (depending on the case). The forensic pathologist unzips the bag and takes a photograph of the body, called the ‘As Is’ photograph. This is to document how the body came from the scene. The doctor examines and notates the clothing, its condition, and if there is any damage (i.e. obvious wounds). At this point, the clothing is removed and the body itself is examined. The doctor draws diagrams detailing injury and notes personal identifying features like hair color, eye color, height, weight, scars, tattoos, piercings, etc. If an injury is found, the doctor will measure and photograph it. Finally, a search for trace evidence, such as hair and fiber, is conducted. If the cause of death can be determined from the external exam alone, the case can be completed.

What happens during an internal exam (or full autopsy)

If there are no obvious external injuries indicating a reasonable cause of death, the doctor will continue after the external exam into an internal exam, or full autopsy. The internal exam consists of opening the body and examining the organs as they are and possible internal injuries. The organs are removed, weighed and examined for injury and natural disease. Blood is taken as well as other body fluids and submitted to the laboratory to check for drugs and alcohol. After the lab tests are completed, the autopsy can be finalized.

Bush said the length of time it takes to complete a case, is dependent on several variables, the most time consuming being toxicology testing.

“If you’re doing a heart attack case, and all you really need is some quick drug testing and it’s negative, we can be finished probably with everything – the microscopic, the investigation, the lab and everything in less than a month.” Bush said. “But whenever there is toxicology, blood/drug levels, it stretches out another couple months.”

Extracurricular activities

In addition to her responsibilities to the State, Bush is currently a conducting pathology lecture series at MCV with the hope of encouraging medical students, residents, and faculty to consider pathology as a career.

She has also done work for the television crime-drama, CSI, offering up her forensics know-how to help create plausible story line details. Bush said her best friend from high school, who is now a heart surgeon in Los Angeles, met the show creators at a social event and put them in touch.

“I started out with the original Vegas group and that’s who I pretty much stuck with,” Bush said. “But every now and again I’ll get an (e-mail) from them saying, ‘can Miami or New York call you,’ and I’ll answer a question or two for one of the other ones.”

Even though her name doesn’t appear when the credits roll, Bush said the show’s creators let her know she is appreciated. Invitations to Christmas parties and other events, DVDs and autographed photos from the actors – just to name a few.

“The last thing they sent me was a barbecue set with a brand so I can stamp CSI on my steaks.” Bush said. “I haven’t used it yet.”