READ: The Autopsy

Introduction

Introduction

An autopsy is a postmortem assessment or examination of a body to determine the cause of death. An autopsy is performed by a physician known as a medical examiner or pathologist who is trained in pathology. Autopsies are ordered when a person's death is unexplained, unexpected or suspicious. A medical examiner is trained to identify abnormalities in the body after death and can often determine important details about the cause or manner of death. Only about 10% of deaths are referred for autopsy and it is estimated that as many as 1/3 of all causes of death listed on death certificates are incorrect. Though they may not provide every detail needed in a death investigation, autopsies generally yield clues and leads in a case which make them an important component of Forensic investigations.

Georgia Virtual, Autopsy and the Role of the Medical Examiner, CC BY-NC-SA 3.0

Legal Considerations

Properties and Requirements of Autopsy

Autopsies are usually performed by a pathologist who is specifically trained in post-mortem examinations. They are usually performed to determine the cause of death, though this is not always possible. They are also performed for various reasons such as:

• To verify or exclude a disease diagnosis made prior to death. This can help families to decide if further testing or treatment is indicated for them in the case of genetic diseases.

• To help practitioners understand the progression of a particular disease or the effectiveness of a treatment.

• To document the presence of an undiagnosed disease.

• To collect evidence for criminal cases or to help government agencies such as the CDC track public health hazards and epidemics.

Family consent is required before an autopsy is performed in cases where autopsy is not required legally. Medicolegal deaths, or deaths that require an official examination by a coroner or medical examiner, legally require autopsy. Medicolegal autopsy requirements vary by state, but generally an autopsy is legally required in the following circumstances:

• Death by homicide, suicide or accidents

• Death amidst unusual circumstances when foul play is suspected

• Deaths in the workplace

• Death by a disease or agent that is a threat to public safety

• Death of a person in custody or incarceration

• Death of a person who is institutionalized (such as in a mental health facility)

• Hospital deaths where the person was unconscious when admitted or who died within 24 hours of admission

• Deaths of adults after medical procedures or anesthesia

• Deaths resulting from injuries sustained a significant time before death such as post-operative complications with blood clots

• All obstetric deaths

• Deaths in which the cause is not known with any degree of certainty

• All newborn and child deaths (This includes typical causes of child death and less common such as SIDS deaths, deaths from anesthesia or medical procedures and parental drug abuse)

• Deaths of people who received an organ transplant within 60 days prior to death

Families sometimes choose not to have an autopsy on their loved one due to ethical and religious objections. Families often state that they fear their loved one being disfigured by the autopsy, that their loved one has "suffered enough" or that it will delay or interfere with funeral arrangements. In the case of religious objections, most major religions allow at least limited autopsy when needed. Autopsy is accepted in most circumstances in the majority of the branches of Christianity, Buddhism, Church of Jesus Christ of Latter Day Saints, Jehovah's Witness, Shinto, Taoism and Confucianism. Autopsy is accepted in limited circumstances in Judaism, Islam, Hinduism and Sikhism.

In clinical or medical autopsies, or those not required by law, the family's permission must be acquired or no autopsy can be performed. In medicolegal, or required autopsies, the family's consent is not needed. These types of autopsies may also be called "Forensic Autopsies". In the case of significant protest to the autopsy by the family due to religious or ethical objections, decisions are made by a judge on a case by case basis.

Georgia Virtual, Autopsy and the Role of the Medical Examiner, CC BY-NC-SA 3.0

Autopsy Procedure

Autopsy Procedure

Bodies arrive at the medical examiner's office or hospital in a body bag or evidence sheet. Body bags are always new and are not reused so that only evidence pertaining to that body is in contact with the body bag. They are always closed and sealed during transport so that no evidence is contaminated or lost. Evidence sheets are sterile sheets used to drape over a body during transport. Just as with body bags, evidence sheets are never reused. After transport, the body is brought into the examination area by a diener. A diener is an assistant in the morgue who is responsible for moving and cleaning the body and exam room throughout the autopsy process. They also sometimes assist with the autopsy. If the body is not autopsied immediately, the diener will transport the body to be stored in the morgue in refrigerated storage. When the body is ready to be examined externally, the seals on the body bag are broken or the sheet is removed and the body is photographed before being moved onto the examination table. The medical examiner carefully observes the deceased person's clothing and notes the state and position of the clothing. Evidence is collected from the surface of the body such as hair samples, fingernail clippings, gunshot residue, fibers, glass fragments, paint chips, and other foreign objects.

Next, the body is examined with a UV light to search for other evidence such as body secretions. Before the body is cleaned, it is examined for obvious wounds. After the initial examination, the body is cleaned, weighed and measured. The body is then placed on a slanted aluminum examination table with raised edges, faucets and drains. The faucets and drains are used to wash away blood that collects during examination. The body lies face up with a "body block" placed under the back. The body block is a piece of plastic or rubber in the shape of a brick that raises the chest up for easier incision.

Before making any incisions, the body is thoroughly described in the autopsy notes with the following information: race; sex; hair color/length; eye color; estimation of age; identifying marks such as tattoos, birthmarks or scars; evidence of medical treatment; and x-rays made of the body.

Lastly, a blood and Vitreous Humor sample is taken to submit for toxicology testing. Vitreous Humor is the liquid part of the eye and is used in Toxicology testing. Drugs remain in the Vitreous Humor longer than in the bloodstream, so it is often tested to look for traces of drugs in the body.

Georgia Virtual, Autopsy and the Role of the Medical Examiner, CC BY-NC-SA 3.0

Steps of the Autopsy

Steps of an Autopsy

Once a body arrives at the medical examiner’s office there are several steps the medical examiner will go through. Remember that the main goal of the medical examiner is to determine the cause, manner, and time of death. The basic steps of an autopsy are outlined below.

1. Basic information about the victim should be noted such as age, height, gender, hair color, and general condition.

2. The condition of the clothes should be noted. Clothes should be packaged appropriately as evidence.

3. The condition of the skin should be examined. Any bruises, scrapes, cuts, wounds, tattoos, scars, or other defining features should be documented.

4. An x-ray is sometimes performed if it is believed that bullets, or other foreign objects are in the body. X-rays are also helpful in cases where broken bones need to be seen.

5. Any evidence found during the examination should be appropriately packaged and documented. Fingerprints are often taken, along with blood and hair samples.

6. Once the external examination is complete, the examiner will open the body. A large Y shaped incision is made from  the shoulders to the belly button.

7. The medical examiner will look for broken ribs and then remove the ribs to examine the organs beneath.

8. Blood and tissue samples might be taken from certain organs during the process.

9. The heart and lungs will be examined and removed, then the stomach, intestines, and other abdominal organs will be removed. Each organ will be weighed and tissue samples will be taken from each organ for further examination.

10. Urine samples are taken to test for drugs or other substances.

11. The eyes and the head will then be examined for damage.

12. The top of the skull will be removed and the brain will be examined. Tissue samples will be taken.

13. Once the autopsy is complete and all organs have been examined and documented, the body will be prepared to be returned to the family for a funeral.

14. The medical examiner will complete any other testing on the tissues of the body, and then write a report about the cause, time, and manner of death.

15. A death certificate will be issued.

It is important that the medical examiner document all parts of the autopsies with notes and photographs. It is also important that tissue samples be saved for further investigation. Once the body is buried, there will be no way to recover any more evidence from the body. Any evidence that is found during the autopsy such as bullets, fingernail scrapings, etc., should all be packaged and submitted as evidence.

Many people wonder if an open casket funeral is possible after an autopsy has taken place. In most cases, you won’t be able to tell an autopsy has occurred once the body is prepared for burial and an open casket funeral is definitely possible. The only exception to this is if there were wounds to the head or face that required further examination.

Autopsy Tools

Autopsy Tools

Autopsy tools have changed very little in the past 100 years. Below are some of the most commonly used tools of autopsy:

Bone Saw - Used to cut through bone or the skull.

Bread Knife - Used to slice small, thin sections of organs for microscopic examination.

Enterotome - Scissors used to cut open the intestines.

Hagedorn Needle - A thick, heavy needle used to stitch up the tissue flaps after examination.

Hammer With Hook- Used to remove the skull cap.

Rib Cutter - Shears used specifically to cut through ribs.

Scalpel - Tool for making incisions; the one used in autopsy has a large blade for making long, deep cuts.

Scissors - Standard surgical scissors are used for cutting open organs and vessels.

Skull Chisel- Assists in skull cap removal.

Stryker saw - Electric saw used to cut through the skull.

Toothed Forceps - Similar to large tweezers, these are used to lift large organs.

While the tools for standard autopsies have changed very little in the past 100 years, new technology has allowed for a new type of autopsy methodology known as "Virtual Autopsy". Virtual Autopsy uses imaging techniques such as CT Scans or MRI Scans to process the body's external appearance and inner structures. It allows for non-invasive, detailed images from inside the body without the need to cut the body open. While it is currently used in some situations to supplement standard autopsies, the technology is not yet developed enough or accessible enough for the majority of death investigations. The equipment is quite costly and many limited county and state budgets can't afford it. As the technology continues to improve and becomes more affordable, other uses for this technology are also coming to light. Doctors may some day use this technology to help diagnose issues without the need for exploratory surgeries as they sometimes must do currently. 

Georgia Virtual, Autopsy and the Role of the Medical Examiner, CC BY-NC-SA 3.0

Reviewing Autopsy Reports

Reviewing Autopsy Reports

An autopsy report is written after the autopsy is completed. It is intended to describe the findings from the autopsy and declare the cause and manner of death. Cause of death is also known as "Mechanism of Death", and indicates the process that causes one or more vital organs or organ systems to fail when a fatal disease, injury, abnormality, or chemical insult occurs. It is the physiologic or structural change that makes independent life no longer possible after a lethal event has occurred. Examples include Hemorrhage, respiratory and cardiac arrest, and sepsis. Manner of death is a designation of whether the death was natural or unnatural.

The top 15 causes of death in the US are illustrated in the visual below.

Life expectancy in the US in 2011 was about 79 years. Life expectancy and cause of death varies throughout the world, however. For example, in Somalia, the life expectancy in 2011 was about 50 years. The top three causes of death were: 1) Diarrhea from diseases 2) Influenza and Pneumonia 3) War traumas. This is quite a difference from the top three causes of death in the United States! The country of origin and residence must be considered when conducting an autopsy if the deceased is from another country because they may have an illness or disease not commonly found in the area where they died.

Autopsy reports, in addition to cause and manner of death, also document other information. See the image to the right to discover what else is documented in a report.

When a pathologist or medical examiner writes the statement on the cause of death in an autopsy report, it is written as the "opinion" of the person. This is because the exact events surrounding the death are not always known. The examiner must give their best informed opinion after weighing all of the findings. Some autopsy reports are more in-depth and complex, whereas others are more focused and concise. The type of report varies by state and purpose as well as the possibility of being presented as evidence in a court case.

A death certificate is a legal document issued by a qualified medical practitioner certifying the death of a person and stating the cause of death, if known. Death certificates are required for various legal proceedings and settling of the deceased affairs. Families often seek a copy of the death certificate for various reasons such as to change social security benefit payments, collect insurance money or to modify banking accounts and household bills that were in the deceased person's name.

 Georgia Virtual, Autopsy and the Role of the Medical Examiner, CC BY-NC-SA 3.0