CONCORD, N.H. — On some days, Dr. Jennie Duval calls as many as six families after fatal overdoses — some of the families stunned and heartbroken, some of them resigned to a death they saw coming.
This, Duval said, is the most difficult part of her job as the only full-time medical examiner in New Hampshire, which leads the nation in per-capita deaths caused by fentanyl and other synthetic opioids.
“It’s not like I can rush the call,” said Duval, the state’s chief medical examiner, as she described a heart-wrenching notification. “It takes a lot of time. But sometimes I feel like a broken record.”
The crush of fatal overdoses has forced the office to abandon its practice of conducting an autopsy on each suspected overdose victim. Still, Duval has no alternative but to work a grueling schedule of 10- to 12-hour days that drains her physically and emotionally.
“If this epidemic is cresting, I’m not feeling it,” Duval said in a conference room at Concord Hospital, the strain of another long day visible on her face. “There are many more autopsies that I’m not doing.”
Duval’s only assistance comes from two contractors who each work five days a month. Among them, they conducted 548 autopsies last year — about one-third for overdoses in a state where 476 people are confirmed or suspected to have died from drugs in 2017. Duval conducted nearly 300 autopsies, far above the profession’s suggested limit of 250.
The state Legislature has approved funding for two physicians to join the office. But in the ultra-competitive field of forensic pathology — a limited pool of doctors to fill many openings in the country, coupled with the challenge of recruiting in a rural state with long winters — Duval is crossing her fingers that help arrives soon.
“It takes a certain kind of person to do this job,” she said. “It’s not pleasant. You’re dealing with death every day.”
The state’s former chief medical examiner, Dr. Thomas Andrew, said the opioid epidemic was part of the reason he retired last year to pursue a calling for the ministry.
The office’s overall caseload has more than doubled since 1997, the year Andrew became chief medical examiner, and reached 1,820 in 2017. Twenty years ago, opioids were linked to less than 10 percent of deaths referred to the office, Andrew estimated.
“It was simply a slowly unfolding catastrophe that, even in seeing it coming, we didn’t have the surge capacity to account for it,” Andrew said. “The casework was getting done, don’t get me wrong, but the numbers became so overwhelming.”
The medical examiner’s office investigates fewer than 20 percent of the approximately 12,000 people who die in New Hampshire each year. They include victims of suicide, accidents, and sudden, unexpected deaths of people under 60.
The number of cases that include an autopsy makes up about one-third of all referrals, although they are mandatory for some cases, such as homicides.
Choosing which overdose victims to autopsy “is a gamble,” Duval said.
Some cases seem obvious — a syringe in the arm, opioids near the body, and a documented history of drug abuse, she said. But even cases that appear straightforward can involve factors that are discovered only through an autopsy, Duval said. Perhaps a pulmonary embolism will be found. Perhaps other damage might have caused or contributed to the death.
And as the opioid crisis continues, autopsies can yield valuable information about the effects of synthetic drugs such as fentanyl.
“It’s the right thing to do,” Duval said. “You want to have every piece of the puzzle.”
New Hampshire is not alone in its staffing struggles.
Dr. Kim Collins, a South Carolina physician who is president of the National Association of Medical Examiners, said the profession is finding it hard to fill vacancies as fewer students choose the field and more forensic pathologists are retiring.
Each year, only about 30 to 40 young doctors in the United States become certified in forensic pathology, Collins said. Medical schools are devoting less attention to the subject — “some medical students will never even see an autopsy,’’ Collins said — and the field pays far less than many other specialities.
Massachusetts, for example, is working to add three or four more doctors to a staff that already has hired two others since the beginning of the fiscal year, said Daniel Bennett, the state secretary of public safety, who oversees the medical examiner’s office.
The state’s nine full-time medical examiners average more than 300 autopsies a year, Bennett said. Massachusetts also has three part-time forensic pathologists, nine contracted examiners, and three young physicians who work for the office on a fellowship program.
Still, Massachusetts must improve to be fully accredited by the national association that Collins leads. Bennett said the opioid epidemic, mirroring its impact elsewhere, has created a backlog in completed autopsy reports that the office hopes to shrink to industry guidelines this year.
The national association requires that 90 percent of autopsy reports be completed in 90 days. In Massachusetts, 58.3 percent of autopsy reports met that standard between October 2015 and September 2017.
To help address the lag, Governor Charlie Baker wants to boost funding for the office by $1.7 million in fiscal 2019, to a total of $11.9 million.
In Maine, two full-time forensic pathologists handle nearly all the autopsies. Two others work on a per-diem basis and handle about 10 percent of the cases.
“We did have trouble with turnover in this office, and it was difficult. Once you get an employee trained, they leave, usually for more money,” said Mark Belserene, administrator of the state’s medical examiner’s office.
“We were successful in reclassifying positions to better reflect the actual tasks and also to bring the salaries up to a more competitive level,” Belserene said.
Despite the physical and mental stress, Duval plans to stay put as New Hampshire’s chief medical examiner.
“I’m not going anywhere,” she said with a small smile.
Although the caseload continues to climb, the addition of two doctors should make the work more manageable. Still, Duval said she does not expect the yearly number of autopsies to fall below 250 for any examiner.
The opioid crisis should ensure that.
Brian MacQuarrie can be reached at firstname.lastname@example.org.