Part of my training as a forensic pathologist at the New York City Office of Chief Medical Examiner included forensic neuropathology, which meant I was given the opportunity to attend a course on brain diseases at the U.S. Armed Forces Institute of Pathology. I was privileged to join doctors from all over the country in Bethesda, boning up on our understanding of all the things that can go wrong with the brain and spinal cord. There were lectures on tumors, neurodegenerative conditions like Alzheimer's disease, and head trauma. Most everyone there was an experienced resident physician in their final years of training. Over 90% of those in the room were neurosurgeons; neuropathology is an important part of the neurosurgery board examinations. Only a handful of attendees were pathologists.
When the instructor in the forensic neuropathology course projected onto the lecture hall's screen a series of autopsy photos in vivid color, a collective, horrified gasp rose in the packed auditorium. I was puzzled. What was wrong with these guys? They were experienced physicians. Sure, pictures of shotgun wounds to the face and comminuted skull fractures from suicidal jumpers can be unpleasant, but how could it be they were so revolted that some of them were averting their gaze? This is medicine -- they've seen it before, right?
And then it occurred to me: No, they hadn't. Neurosurgeons never see patients with injuries as devastating as these, injuries that are, in our parlance, not compatible with life. These are the patients who never make it to the hospital. They get declared dead at the scene, and then they come to us forensic pathologists in the morgue. So does every death that happens unattended at home, including simple falls from standing.
This is why I was not surprised that a recent New York Times on the death of actor and comedian Bob Saget reported that "some neurosurgeons said that it would be unusual for a typical fall to cause Mr. Saget's set of fractures -- to the back, the right side and the front of his skull. Those doctors said that the injuries appeared more reminiscent of ones suffered by people who fall from a considerable height or get thrown from their seat in a car crash." The Times quotes commentary from Houston neurosurgeon Gavin Britz, MD, saying, "'This is significant trauma. This is something I find with someone with a baseball bat to the head, or who has fallen from 20 or 30 feet.'"
No, it's not. Blunt trauma from swung baseball bats and falls from 20 or 30 feet cause much more serious injuries than Saget's. The injuries in Saget's autopsy are common in patients found dead at a scene after they have had a simple fall from standing height. By asking neurosurgeons to review an autopsy report prepared by a forensic pathologist, the New York Times chose to rely on interviews with doctors who are opining way outside their realm of expertise. In doing so, the paper has fed those reckons to a pack of social media conspiracy theorists who have, predictably, amplified doubts about a celebrity's manner of death as clickbait for profit.
Forensic pathologist and author Darin Wolfe, MD, has made a 30-minute episode of his podcast about the anatomy and physiology of Saget's head injury, and his on the subject have deservedly garnered thousands of followers. He explains that Saget suffered a linear non-displaced skull fracture with a corresponding impact on the back of the head, and associated subdural hemorrhage and contrecoup injuries to the front of the brain and cranium. That sounds like a lot to take in, but those findings are typical in a case of a death after an unsupported fall onto the back of the head.
I've done autopsies exactly like this one. When someone slips in the bathroom, for instance, or faints and passes out, they can fall backward onto a hard surface. When that happens, the scalp impact -- coup in French -- shakes the brain inside the skull, and the brain bounces off the front of the cranium, sometimes fracturing the delicate bony plates above the eyes. This can bruise the brain opposite the point of impact, and it's called a contrecoup injury. It also tears delicate blood vessels on the surface of the brain that are tethered to the dura mater, the protective inner lining of the skull, resulting in bleeding on the surface of the brain (subarachnoid hemorrhage) and between the brain and skull (subdural hemorrhage). A person suffering this injury may regain consciousness temporarily, enough to get up and move elsewhere and maybe even lie down in bed, but the blood will continue to accumulate in the closed vessel of the cranium, squeezing the soft tissues of the brain until the fall victim eventually dies from the trauma of brain injury while "sleeping it off." As Wolfe says, "If you are outside the field of forensic pathology, you don't typically see this type of injury complex" -- and in his blunt assessment, the half-baked medical opinions published in the Times article about Saget's death, which point without evidence to the possibility of foul play, are "irresponsible and stupid."
I agree. I have reviewed the Saget autopsy report. It makes clear that Saget suffered planar injury -- a single impact to the back right side of the head with a single fracture that propagated forward and to the right -- and that he had no defensive injuries to his arms or other parts of his body to suggest a struggle. He also had an enlarged heart with cardiovascular disease, which could have triggered a faint; as we term it, a syncopal episode. Drugs and alcohol did not appear to play a part in his death.
Wolfe makes another crucial point, one that every forensic pathologist knows through daily experience: An autopsy is not interpreted in a vacuum. The determination that Saget's death was not suspicious was most likely supported by a police and medical examiner scene investigation that was not released to the public -- or to the neurosurgeons speculating in ignorance in the pages of the New York Times. In a death investigation that begins with a body found in a hotel room, the medical examiner will first request evidence establishing whether or not the room was locked. Hotel security will consult closed-circuit security camera footage and check the electronic key card system to see if and when the door was opened. Police will interview hotel staff and guests in adjacent rooms to find out if they heard anything suspicious. Forensic investigators will review the decedent's calls and cellphone messages, email and computer files, social media activity, and any written materials found at the scene. They will find and interview anyone who may have come into contact with the decedent. The police crime scene unit will search and photograph the hotel room thoroughly, logging into evidence all personal items found there. All these investigative materials, all this data, can allow the forensic pathologist to confidently declare that the death was due to an accidental fall rather than a case of foul play. The manner of death can be definitively ruled on the death certificate as accident -- not as homicide or undetermined. Calling up an expert outside the field of death investigation to take a gander at the decedent's documented brain injuries in a vacuum and then second-guessing the manner of death determination that the examining forensic pathologist has made is bad science and lazy journalism. Both the reading public and the Saget family deserved a better story than this one.
is an American forensic pathologist and CEO of PathologyExpert Inc. She is currently working as a contract pathologist in Wellington, New Zealand. She is the co-author with her husband, writer T.J. Mitchell, of the New York Times bestselling memoir , and two novels, and , in the . You can follow her on and .