Bullet Removal: That Was An Interesting Tactile Experience

When a homicide case comes in, particularly a gunshot, I cringe. Most likely not for the reason you’re thinking. My reaction has less to do with the loss of life and more to do with the fact that if the bullet didn’t exit the body, there’s a good chance this case will come back to me. Cold, I know, but the morgue hardens you.

An AP view of the skull with bullets and fragments. X-ray taken from a textbook.

A lateral view of the skull with bullets. X-ray taken from a textbook.

While it’s something I’m researching, I still don’t understand ballistics enough to go into the physics behind guns. What I can say is that whether the bullet exits a body has a lot to do with the bullet itself and where on the body the victim was shot.

I’m learning that bullet identification and recovery are important for several reasons. One, knowing the specific location of a bullet saves the pathologist a lot of time and minimizes needless searching during the autopsy.

Two, it’s important to carefully count the number of bullets present. They have to be correlated with the entrance and exit wounds, otherwise a discrepancy can lead to a search at the crime scene. It is possible that multiple bullets can enter through a single entrance wound, but typically only when automatic weapons are used.

Lastly, x-rays can reveal information about the angle and direction of fire. Small metallic fragments produced when a bullet strikes bone may lead directly to the bullet and clearly indicate the bullet’s path. This helps investigators recreate the positioning of the victim and their assailant.

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And since it’s never safe to assume that there’s an exit wound, x-rays are mandatory.

The first thing I do is visually examine the body. I check the head, chest, arms, abdomen, and legs for any bullet holes. My partner does the same. Two sets of eyes are better than one. If we find any, then I make mental notes of areas that need to be more closely examined for bullets on the x-ray.

Then we scan the whole body using x-rays. Even if it seems that the victim had only been shot in the head, the bullet could have traveled into the neck or chest. Bullets frequently end up in a site that’s far away from their entrance points, especially if they’ve hit a bone, so it’s important to be thorough.

If the full body scan shows that there are bullets, I will often walk over to the body and try to feel for the them. Sometimes the bullet is superficial, meaning it’s just below the surface of the skin. They’re easily felt and sometimes they can even be seen as small bumps. If that’s the case, I put a piece of tape over the bullet and mark it with a “x”. The pathologists appreciate it because it makes for a very easy retrieval.

If the bullet isn’t easily palpable and is located within the skull, neck, chest, abdomen, or pelvis, then additional image needs to be taken. Specifically, a lateral view. Instead of x-rays going from the front side of the body to the back like in the AP view, the lateral lets you see left to right. It gives me and the pathologists an idea of whether the bullet is more anterior (toward the front of the body) or posterior (toward the back).

After I submit my x-rays and return the body to the cooler, I’m done with that case and it can now be autopsied. But despite my best efforts, bullets can be difficult to find. It could have shifted during the autopsy. I’ve seen bullets that appear to be in one area only to wind up in a lung that has already been removed from the body. I’ve also seen bullets, particularly those in the skull, get lodged within the sinuses. In the event of the latter, chances of the body being returned to x-ray are high.

I don’t like when bodies come back. By this point, the autopsy is underway and the chest cavity is open. Most if not all of the organs removed. The skull cap will also have been sawed off, skin peeled down over the facial bones, and brain removed. It’s a much different version of the body than I had previously worked with.

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Recently I worked on a case where a man had been shot in the head. A large bullet fragment was lodged somewhere inside of the skull. The pathologist and tech tried to access it, but without x-ray, they were working blind. At this point, the body is returned to radiology and we use fluoroscopy to image the body.

Fluoroscopy is x-ray in real-time. When I take a regular x-ray, I’m given a static image in return. But with fluoroscopy, I can see a moving image. For example, if I were to stick my hand into the empty skull cavity, I could see my fingers wiggle in real-time.

When using fluoroscopy, forensic x-ray techs will often use a scalpel or tool with a long handle to help locate bullets. This keeps our hands out of the x-ray beam, minimizing our dose. I was using such a tool during this case, but our equipment wasn’t working very well. The image on the screen was very poor quality and I had a difficult time recognizing where I was within the skull.

The pathologist and her tech were anxiously awaiting my verdict, standing safely behind a lead-lined barrier. My partner, a new tech who had only recently joined the team at the morgue, was operating the C-Arm for me while I searched. I was starting to feel the pressure, so I decided to rely on my instincts. In order to do that, I had to ditch the tool and use my hand. This isn’t something you should do, as it increases your radiation exposure. However, I needed to feel the structures and I needed to find the bullet fast.

I saw my hand moving on the screen in front of me, inching closer to the dark spot: the bullet. I was hyper focused until I wasn’t. Something has pulled me out of the blissfully ignorant bubble I had put myself in. Suddenly I was very aware that my fingers were pushing along the ridges of facial bones and squeezing into holes that were inside of a human skull.

What the f*ck am I doing?

I had seen the other more seasoned x-ray techs do this dozens of time, but this was my first time as lead tech. There was no one else to ask. My new partner had just started and, to her, I was the seasoned tech.

“Is it stuck inside of the bone?”

I heard the doctor ask me a question, but clearly I had my hand inside of a man’s skull and couldn’t form a coherent response.

Sorry, I’m a bit busy not thinking about where my hand is right now. Okay, just focus on the screen. Feel the bones, identify the landmarks, find the bullet. Easy peasy.

After more palpating and a lot of internal shrieking, I felt it. I found the bullet. It was wedged within the sphenoid sinus. I grabbed my tool, used it to replace my finger, and called the pathologist over for removal.

I felt victorious, upset, super gross, and exhausted all at once. Thankfully it was near the end of my shift so a hot shower wasn’t too far off.

It’s a weird thing, being an x-ray tech in a morgue. On one hand, x-ray techs have clearly defined responsibilities. We’re taught to work within our scope of practice—provide exceptional patient care, minimize exposure to patients and personnel, evaluate images and ensure they’re of diagnostic quality. That’s the succinct version anyway. However, I’m learning that the lines which define our scope are blurred here. One day you’re taking a routine chest x-ray and the next you’re wrist deep inside of a dissected skull.

A Composition on Decomposition

I have worked at the morgue for a little over a month and I can say with certainty that the worst part of my job is getting hands-on with head traumas and decomposed bodies.

I will get to head traumas another time. Right now I’d like to focus on decomposition because while disgusting, it’s a truly fascinating process from a physiological standpoint. Before I dive into the specifics, here’s a bit of background in case you’re just tuning in.

At the morgue, it is my job to x-ray every decomposed body that comes in, regardless of how the person died. As I stated in a previous post, I’m responsible for x-raying all gunshot wounds, motor vehicle accidents, and child deaths, without question. I’ll read reports from falls and suicides. Depending on the nature of the event, we may or may not need to x-ray them. Decomposed bodies always get x-rayed without question.

decompLet’s talk a bit about decomposition—yay! I should note that I will be showing some images that might be unsettling or upsetting. View at your own risk.

When you die, your heart stops beating and your body’s cells stop receiving oxygen. Typically brain cells are the first to die, while bone and skin cells can survive for several days. Blood begins to drain from vessels and pools in the lower-lying portion of the body. So if a person dies lying on their left side, that side will appear darker while the right side appears more pale. This is called livor mortis, or lividity.

livor mortis
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Side note: There are several “mortis” stages that a body goes through. The ones not covered in great detail here are pallor mortis, which is a pale or ashy appearance, and algor mortis, which is a change in body temperature. Algor literally translates to coldness.

Roughly three hours after death, rigor mortis sets in. Rigor mortis is simply a stiffening of muscles. In a living body, calcium ions flow into muscle cells and promote attachment between two muscle fibers, actin and myosin. Once attached, this causes the muscle to contract. A muscle remains in this state until ATP arrives to pump the calcium out of the cell. However, in a dead body, no oxygen means no ATP. Skeletal muscles will remain contracted until the muscles start to decompose.

Fun facts about rigor mortis:

  • It’s Latin for “stiffness of death”
  • Facial muscles stiffen before larger muscles
  • It can start anywhere from 10 minutes to several hours following death and can last up to three days (it’s greatly affected by temperature)

As the cells within a body begin to die, there is nothing maintaining their structural integrity, and so their membranes begin to break. As they do, they release enzymes that begin eating the cell from the inside out. This is usually referred to as autolysis, which means self-digestion. While this is happening, microorganisms and bacteria produce very unpleasant odors called putrefaction.

Additionally, the leaked enzymes produce many gases, including hydrogen sulfide, carbon dioxide, and methane. The pressure from these gases cause the body to bloat, which is the second phase of decomposition. The pressure can become so intense that some bodies can actually double in size. Bloat usually occurs around five days after death, according to an article I read.

Bloat
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Fun fact: Tongues and scrotums aren’t immune to bloating. Bloat is most common in the face, abdomen, and in males, the scrotum. One of the only good things about working with decomposed bodies is that we don’t have to open the body bag. However, this can make positioning a body for an x-ray more challenging since landmarks aren’t easily identifiable. One of the ways we “get our bearings” is to feel for facial landmarks. Usually we go for the nose and eyes, but depending on the stage of decay, sometimes the tongue is a dead (heh, pun) giveaway. The tongue expands so much that it protrudes from the mouth acting almost like a handle.

The tech I trained with opened every decomp bag so I could see the process in its various stages. Disgusted, I still looked because my sense of curiosity is a glutton for punishment. Before opening the bag, she would say, “Here, feel this.” Completely at a loss for what body part my hand might be touching, I’d ask her what it was. “That’s his scrotum.” I skeptically pulled my hand away because it felt more like a knee or elbow than soft tissue. But I was proven wrong when she opened the bag. The scrotum had such a buildup of pressure due to the gases within the body that it had no choice but to expand to double its original size.

Although a great way to startle a first-week forensic tech, this can actually be dangerous. The buildup of pressure combined with the loss of integrity of the decomposing skin could cause the body to rupture. So think twice before you go poking around decomposed bodies, okay?

Black
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By this point, the combination of feeding maggots, purged fluids, and cellular breakdown means the body has entered active decay. During this time, liquefaction of tissues becomes more visually apparent and extremely strong odors exist. If you think a fresh dead body smells bad, you’re gravely mistaken. I don’t know how to begin to describe the smell of a decomposing body.

One article attempted to do so, stating:

  • Cadaverine and putrescine smell like rotting flesh
  • Skatole has a strong feces odor
  • Indole has a musty, mothball-like smell
  • Hydrogen sulfide smells like rotten eggs
  • Methanethiol smells like rotting cabbage
  • Dimethyl disulfide and trisfulfide have a foul, garlic-like odor

Another article went the less scientific route, asking 20 people to describe the smell of death. I think this one is the most accurate:

“Rotten eggs, feces, and a used toilet left out for a month x 1,000.”

Working with bodies in active decay is very difficult. The vicious attack on one’s nose is frustrating enough, but the bodies are slippery too. The pressure from the gases forces fluids within the body to escape through open orifices, like the mouth, nose, anus, etc. And since we’re working through the body bag. The material of the bag paired with the slippery goop makes for a very frustrated x-ray tech.

Toward the end of active decay, when all of the body’s soft tissue has decomposed, hair, bones, and cartilage remain. Although decomposition begins almost immediately following death, it can take up to one year for a body to completely decompose to a skeleton. From there, it can take another eight to 12 years to decompose a skeleton. It depends on a variety of factors. Is the body buried in a dirt grave? Was it buried in a coffin? Was it embalmed? If not buried, what’s the temperature and environment like?

After active decay, the body enters something called butyric fermentation. While I’m not certain this is an official stage of decomposition, it’s something that occurs once the body has dried out and butyric acid accumulates. Butyric acid is present in human vomit, so you can imagine how awesome this stage smells. During this “stage,” the skin turns leathery and marks the transition from active decay to dry decay. In dry decay, roughly 50 days to one year after death, the body is almost completely dry and may actually mummify depending on environmental conditions.

At the morgue, I have worked with bodies in every stage of decay. None were pleasant, but I suppose the beginning stage is the easiest. When it comes to working with dead people, I prefer those that are still exhibiting rigor mortis. In a later post, you’ll see how I contradict that statement, but for now I stand by it. Without rigor mortis, bodies move too easily and seem too life-like. It interferes with the mental barrier I’ve constructed so I can do my job without puking and/or crying.

I debated whether or not I would show you this. I was given permission to use x-rays for education purposes at school, so I felt conflicted about posting anything here. I don’t think I’ll make a habit of this, but I really wanted you to see the differences between an x-ray of someone who had just died compared to that of someone who’s actively decaying.

Compare

Normal on the left and decay on the right.

Can you see the difference? Isn’t it interesting?! Because we work through the bags, I’m never quite sure what stage of decomposition the body is in. But the x-rays always show it. Now, an x-ray won’t tell you down to the day of decomposition the body is in, but it can give you a fairly good idea of whether it’s in the beginning stage or active stage. I think it’s fascinating. Hopefully, as I learn more about pathology and identifying different types on x-rays, I’ll be able to notice even the most subtle of decomposition markers. #XrayGoals

Down Among the Dead Men

My interest in the medical field began in high school. Junior year to be exact. My anatomy class took a field trip to a chiropractic college to see a cadaver dissection. While we couldn’t get hands-on, I immediately took an interest in the topic of body donation and working in the medical field. (Side note: I have been meaning to write a post about my decision to donate my body. Hold me accountable.) It wasn’t until nearly six years after that class that I really began taking steps to make a career in health care a reality.

Long story short, in 2015 I enrolled in a 20-month radiography program—which is the reason why this blog has been quiet for so long. I graduated this past May and immediately began working. I purposely sought out part-time and temporary positions for a few reasons. One, because as a new grad, I had realistic expectations about my hireability (Is that a word?). Two, because I was interested in many modalities/settings and didn’t want to spend all of my time in just one. And finally, I hadn’t found the job yet.

But in July, I found it. The local morgue was looking for a part-time x-ray tech. I’m not talking hospital morgue. I mean the morgue that serves the second largest county (in terms of population) in the U.S. It was the least-desirable shift, but I had to apply. For years I had researched careers in forensic and pathology fields. I strongly considered going to medical school to become a medical examiner. I even toyed with the idea of mortuary school. I worked for an autopsy company and read dozens of books by pathologists, pathology assistants, crematorium and funeral directors, and so on. I had to get this job.

The tricky part was figuring out how to show my enthusiasm without coming across as creepy. I mean, I’d be working with dead bodies. No one should be that excited. But I really wanted this. I wanted it because I had to know if I was cut out to work in this field. I went in to interview, and at the end of it they asked if I wanted a tour. A tour of the morgue? Um, yes please. Unfortunately the autopsies had ended for the day, but I still got to see the rooms and the giant refrigerator where all the bodies are stored. I stood there asking question after question, trying to contain my excitement and solidify the fact that I’m most definitely a normal person with a very healthy curiosity.

Morgue
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It turns out my questions didn’t scare them away because a few weeks later I was offered the job. It took weeks of background checks, medical screenings, and paperwork before I received my start date. In that time, my emotions ranged from excited to terrified to overjoyed to nervous to perplexed. I was happy that I had the job, but I was nervous that I wouldn’t be able to stomach it. Sure, I’ve worked with cadavers before and that never bothered me, but this is different. These people, some of whom have suffered horrific and tragic fates, are not embalmed. Not only that, but I’d work with bodies before they’re cleaned, before bullets have been removed, bodies that are in pieces or decomposing. What do bullet holes look like? What does a decomposing body smell like? Will I throw up? How will I emotionally handle murder and child abuse cases?

Panic set in. My anxiety took over and I began imagining every terrible scenario I could think of. Maybe I’d get locked in the body cooler. Or perhaps a body bag would start moving. I’d bump into the pathologist and mess up their autopsy. I’d vomit on the x-ray control board. Would I start questioning my own existence? If I see tragedy first-hand, would it weigh heavily on my soul? I thought I was ready, but the fear of the unknown had taken hold and there was no rationalizing it. I needed to get through my first day. I needed to smell the smells and see the sights. I wanted to see the worst of the worst so I’d know if this was something I could handle.

Ask and you shall receive. I’ll cover what my first week at the morgue looked like in my next post. Right now, I really need a shower because my hair smells like dead people.

**Unless specified (and granted permission) none of the pictures included in these posts are from my workplace. They’re found via Creative Commons.**