"Did you hear about what happened in Baltimore?" my colleague asked as we walked back to the hospital from lunch.
We are on the other side of the world, in New Zealand, but as two American forensic pathologists we still pay attention to incidents like these. When you work in a field like forensics it's hard not to feel immediately connected to the traumatic incidents that affect your peers in our small but global community. My colleague had trained in Baltimore and I had interviewed for a job there once; we both know folks currently on staff at the medical examiner's office.
From the perspective of that office, of the Francis Scott Key Bridge probably wasn't the emergency scene it was for other responders and agencies in Baltimore. The Baltimore medical examiner's office is used to handling multiple fatalities on any given day, and in the immediate aftermath of the bridge's collapse there were only two bodies recovered from the water.
Eight men, , were known to have been working on the Francis Scott Key Bridge when the container ship MV Dali slammed into it and took it down. Two of those men were rescued and known to have survived, and two bodies were recovered, which left four unaccounted for in the immediate investigative period. One of the survivors reported that all eight of the crew had been on a break, sitting in their parked trucks when the bridge went out from under them.
Sonar scans performed by rescuers in the murky waters of the Patapsco River led authorities to believe that the crushed construction vehicles were encased in concrete rubble and other debris from the collapsed bridge. The four missing men from that work crew were immediately -- and still are -- presumed dead.
In the collapse of a massive piece of the human-lived environment, like a bridge or a building, the questions that come up first and foremost have to do with the victims' causes of death and, in that death, the possibility and degree of their conscious pain and suffering. The cause of death in the Francis Scott Key Bridge disaster could be either blunt force trauma or drowning. One way of distinguishing between those is to do an autopsy examination and look for signs of bleeding into crushed tissues, which indicates that the person's heart was still beating when the internal structures were traumatized, or to look for fluid in the lungs and airways, which would indicate that they had inhaled water.
In cases where a forensic pathologist sees and documents life-threatening blunt traumatic injuries, they will sometimes just list the blunt force trauma as the cause of death and omit the drowning entirely. That's because drowning can be considered a "diagnosis of exclusion."
Water can passively enter the airways and sinuses after death, and has been found, for instance, in the bodies of homicide victims who were known to have been killed and then disposed of in water. In some rare types of witnessed drownings, termed "dry drownings," the lungs are found at autopsy paradoxically full of air. The decedent probably had an upper airway spasm that prevented the water from entering the lungs, yet still asphyxiated as a result of this spasm -- which was a result of being in the water, and thus, it's deemed a drowning.
Given the variety of ways drownings can cause death, and the many conditions that can accompany them, it is not unusual for medical examiners to rely on the scene and circumstances rather than on any specific anatomic finding when we rule that drowning played a role in a death.
Sometimes these two traumatic mechanisms -- blunt trauma and drowning -- can work in concert to cause death. During the 2014 Oso landslide in Washington's Snohomish County, a cliff gave way following several weeks of well-above-average rainfall, causing a debris flow that crushed its victims in liquefied mud. being brutally battered by debris while struggling to keep their heads above the flow. When the crushed bodies of dozens of decedents were found months later, it was reasonable to conclude that their experience had been the same as the survivors', even though the victims' remains were so severely traumatized and decomposed that it was hard to distinguish antemortem from postmortem injuries.
We do not seek to clarify these gruesome forces and awful circumstances out of bureaucratic compulsion or macabre curiosity. Understanding and delineating the mechanism of death plays a role in conscious pain and suffering testimony in court. The reporting by forensic experts of a decedent's conscious pain and suffering has implications for family members, who deserve to know what happened to their loved one. It can also play a role in litigation against those responsible for the death when the time comes to litigate blame for that loved one's suffering.
In this case, I would not be surprised if the bodies of those workers entombed in rubble in their vehicles at the bottom of the Patapsco River are not recovered at all. Even if they are recovered, it will be very difficult to identify the men. The container ship that impacted the bridge reportedly carried , including corrosives, flammables, and lithium ion batteries. This may complicate the recovery efforts and could raise health and safety concerns for staff handling of any remains.
Regardless of whether the remaining decedents are recovered or identified, there will be international repercussions to this disaster and these deaths. Among the deceased or missing construction workers are Guatemalan and Mexican nationals. The Singaporean-flagged and the Danish shipping company that chartered it, Maersk, are now being investigated by the National Transportation Safety Board, and the results of that investigation may impact the Baltimore medical examiner's determination of manner of death. It will most likely be declared an accident, but it could still be homicide if, when all the investigations are done, the medical examiner determines that criminal acts had played a role.
Like the June 2021 collapse of Miami's , the legal repercussions of Baltimore's multiple-casualty bridge collapse will take many years to resolve. Only time will tell if the regulatory response to this tragedy improves the safety of our waterways and bridges, or leaves us vulnerable to more such catastrophes, as the irresistible forces passing through our ports meet the immovable infrastructure we rely upon to move around.
Judy Melinek, MD, is an American forensic pathologist currently working as a contract forensic pathologist in Wellington, New Zealand. She is the co-author with her husband, writer T.J. Mitchell, of the memoir . You can follow her on Twitter and Facebook .