The compressor that broke earlier this month was repaired the next day, but use of this refrigerated trailer may be a sign of things to come. The St. Louis County medical examiner is considering using the trailer to store the overflow of corpses in drug deaths.

Fatal overdoses from heroin, fentanyl and other opioids are surging. If this pace continues, St. Louis County’s medical examiner, Dr. Mary Case, envisions hooking up the refrigerated trailer to her office’s power source and using it as a makeshift morgue on an ongoing basis.  “I think it’s a very real possibility,” she said. “Our storage facilities are strained to the limit.”

St. Louis County medical examiner Dr. Mary Case works on autopsy notes in her office on Friday, June 16, 2017. A miniature model skeleton stands in the corner of her office, which she uses to show visitors causes of trauma, including such things as bullet trajectories. Photo by Robert Cohen, rcohen@post-dispatch.com

The St. Louis County medical examiner’s office is in the single-story, brown brick George Gantner building on Helen Avenue, near Airport Road and Interstate 170. Inside the building, the main cooler is a stainless steel room where carts on wheels line the walls. The morgue has a capacity for 20 bodies, one per cart. A body is X-rayed and autopsied on that cart.

Largely because of a surge in drug overdoses, the morgue typically is crowded, especially on weekends. As new bodies arrive and before autopsies are performed or funeral homes retrieve them for burial, attendants make room by putting two bodies on a cart designed for one. A census sheet of the body count shows 24 days in May when more than 20 bodies were stored there. There were two days when 33 bodies were in the storage facility, and two days with 29.

The St. Louis County medical examiner’s office recorded 181 fatal overdoses last year, nearly double what it had in 2010. Officials expect to surpass that number in 2017. Homicides are also up, although not as sharply. The county had 78 homicides last year, compared with 48 in 2010.

“On some weekends, there are times when we have no capacity for the bodies that we have,” Case said. “If that were on a daily basis, when that happens, we will have to have refrigerated trucks.”

Usually, refrigerated trucks are meant for mass disasters. They were used in Joplin, Mo., when a tornado killed 161 people. New York City shut down an entire street to make room for rows of trucks to store remains of those killed at the World Trade Center. In a heat wave in 1995 that killed hundreds, Chicago brought in refrigerated semitrailers to hold the bodies.

‘The opioid tsunami’

Case, 74, who began her career here in the mid-1970s, is a board-certified forensic pathologist and chief medical examiner for St. Louis County, as well St. Charles, Franklin and Jefferson counties. She has seen it all, but she says the opioid crisis is surprising.

When Case arrives at work each morning, she enters the morgue and looks at a board listing the new deaths. “Some days, I gasp because there are seven, eight, nine cases,” she said. “It used to be if we had four or five cases, that was an ungodly day. Not anymore.

The list might say overdose, overdose, suicide, car accident, homicide. “It used to be, every few days there would be a drug overdose. Now almost every day, now maybe half of the deaths are drug overdoses,” she said.

The refrigerated trailer, if it’s parked nearby, would be a way to ease overcrowding without having to add on to the building. Worried that her staff handling bodies might be at risk if powder from the powerful drugs became airborne, Case this month requested that the county train them to use Narcan, an opioid antidote.

Heroin-related overdose deaths in the United States have more than quadrupled since 2010, according to the Centers for Disease Control and Prevention. Coroners and medical examiners across the country struggle to keep up. Using a refrigerated trailer meant for mass disasters to handle the surge in drug deaths isn’t such a stretch, Case said.

“We have a mass casualty of drug overdoses in this country, only it’s not all at once,” Case said.

The Centers for Disease Control and Prevention, in a report on the U.S. opioid epidemic, said 52,404 people died in the U.S. in 2015 from drug overdose, compared with 47,055 deaths in 2014. The drug overdose death rate increased significantly in the last few years: from 12.3 deaths per 100,000 population in 2010 to 16.3 in 2015, the report says.

Dr. Brian L. Peterson, chief medical examiner in Milwaukee County, Wis., is president of the National Association of Medical Examiners. “Virtually every medical examiner’s office and toxicology laboratory in the U.S. has felt the impact of the opioid tsunami,” Peterson said.

The sheer number of drug cases is threatening accreditation of offices across the country, Peterson said. The association has workload standards. An office is considered deficient if a pathologist must perform more than 250 autopsies a year. If the pathologist performs more than 325 autopsies a year, the office would get provisional accreditation at best, he said.

Nationwide, at least four offices already have dropped to provisional accreditation because of the bigger caseload, Peterson said.

“I expect that trend to continue,” he added.

‘Dire’ shortage of pathologists

There’s also an extreme shortage of forensic pathologists, Peterson said. There are about 400 working across the country, and 900 are needed.

Filling that void isn’t easy. Peterson said only 30 or 40 people finish their fellowships each year. Not all of them will go into full-time forensic pathology. With low staffing numbers, expected retirements and increased caseloads, “the situation in forensic pathology is truly dire,” Peterson said.

Addition of fentanyl, a synthetic opioid, has made illicit drug use more lethal. Death toll from opioids has quietly surpassed homicides.

Locally, if the burgeoning case load continues, Case said she might need to hire two additional pathologists. Her staff includes three full-time pathologists and one part-time pathologist. Because of a long-held policy in the office, they run toxicology tests and perform mostly external exams, but not a full autopsy, when evidence points to an obvious drug overdose. “We don’t have the manpower to do it,” Case said.

Some offices across the country have turned to hired guns to work as temporary fill-ins to perform autopsies. They are in high demand. Offices from Kansas to Hawaii are advertising for help. A busy medical examiner’s office in Reno, Nev., offered to pay up to $1,200 a day, plus travel and hotel costs. About 30 counties are advertising for this temporary fill-in physician help, Peterson said.

In Dayton, Ohio, Montgomery County is considering hiring a forensic pathologist from Florida who would fly in for five days and perform four or five autopsies a day on people who died of drug overdoses, said Ken Betz, director of the coroner’s office there.

Betz said his office is on pace to handle 700 to 800 drug overdose cases this year, compared to 371 in all of last year. The population of Montgomery County is about 500,000, or half that of St. Louis County.

“It’s terrible,” Betz said of the climbing drug deaths. “My staff is tired, overworked.” His county converted a garage to additional freezer space 1½ years ago, bought two refrigerated trailers at $46,000 each, and has rented space in funeral homes.

Dealing with a surge

The city of St. Louis has enough storage space. St. Clair County has no issues either, storing its bodies at hospitals. Madison County uses a refrigeration crypt in Wood River that normally has adequate space for 12 bodies but sometimes is crowded by victims of overdose. Stephen P. Nonn, coroner of Madison County, said he might consider adding another refrigerated unit inside the morgue.

In Berkeley, the 16-foot-long refrigerated trailer Case considers using was given to the county about five years ago as part of a Homeland Security grant through St. Louis Area Regional Response System. The trailer cost $35,000 but was stocked with thousands of dollars worth of equipment, such as cameras for identifying bodies, knives and other autopsy gear.

Case said she would use that trailer first, before renting 18-wheeler truck trailers like the ones New York City used after 9/11. Another option, Case said, might be to convert space in the office building for a cooler.

A portable morgue, intended for mass casualty incidents, is used outside the Berkeley office of the St. Louis County medical examiner's office on Friday, June 16, 2017. When a compressor broke in the main morgue's cooler this week, the portable unit was used temporarily. But with rising deaths due to opioid overdoses, the portable unit may be used more permanently.

Photo by Robert Cohen, rcohen@post-dispatch.com

The refrigerated trailer behind her office is identical to trailers from the same grant that are parked in St. Charles, St. Clair and Madison counties. “If God forbid there is a terrorist attack (in the region) … then all trailers would be delivered down there,” said Nick Gragnani, director of the St. Louis Area Regional Response System.

Told the county might use the trailer for the drug overdose surge, Gragnani said: “That’s fine. Do it.” He said he doesn’t want the gear bought for terrorism response to go unused.

Before getting the trailers, the Regional Response System’s mass fatality planning group in 2010 had discussed all sorts of scenarios where the bodies could pile up quickly, such as an earthquake along the New Madrid fault, severe weather events — and if a mass disaster were to strike a county’s morgue. However, nowhere on that group’s radar was the thought that drug overdoses might surge so much that the trailers would be needed, said Madison County’s deputy coroner Roger Smith, who was co-chair of that panel. “The number of overdose deaths has brought us a dynamic we’ve never seen,” Smith said.

Understanding the Epidemic

Daily census at the St. Louis County morgue

The morgue at the St. Louis County medical examiner's office in Berkeley has a capacity for 20 bodies, one per cart. Largely because of a high number of drug overdoses, the morgue typically is crowded, especially on weekends. As new bodies arrive and before autopsies are performed or funeral homes retrieve the dead for burial, attendants make room for the bodies by putting two on a cart designed for one. The body count can include cases from St. Louis County as well as Jefferson, St. Charles and Franklin counties, all venues for which Dr. Mary Case is the medical examiner.

Number of bodiesDaily body count
May 125
May 226
May 324
May 427
May 528
May 620
May 722
May 827
May 925
May 1017
May 1133
May 1227
May 1316
May 1429
May 1518
May 1622
May 1722
May 1829
May 1927
May 2033
May 2126
May 2223
May 2328
May 2422
May 2517
May 2617
May 2730
May 2825
May 2919
May 3020
May 3122
Source: St. Louis County medical examiner's office

Heroin-opiate deaths in St. Louis County

Heroin-opiate deaths in St. Louis County from 2007 to 2016. Fentanyl is a synthetic opioid up to 50 times more powerful than heroin. It is frequently mixed with or substituted for heroin. Heroin-opiate deaths include those with cause of death determined to be intoxication with heroin, fentanyl or heroin and/or fentanyl combined with alcohol and/or other drugs. Source: St. Louis County medical examiner's office.

YearHeroin-opiate deaths
200752
200887
200994
201094
2011126
201296
2013119
2014160
2015148
2016181
Source: St. Louis County medical examiner's office

St. Louis County homicides, 2007-2016

The St. Louis County medical examiner's office reports 533 homicides in the county from 2007 to 2016.

2007200820092010201120122013201420152016TOTAL
Jan163442313532
Feb481343542337
Mar318252478444
Apr244423723738
May315285527947
Jun30511541024549
Jul4965434781464
Aug222228339639
Sep468111149439
Oct544365337747
Nov383722169546
Dec544438176951
TOTAL39535348464647487578533
Source: St. Louis County medical examiner's office