Autopsies for beginners

There's a room just off the elevator with all the protective gear in it. I wear a vapor-lock mask (works great!, looks kind of like those world war two gas masks), face shield (looks like a welders' mask), hat (with skulls and, for some reason, roses on it), gown (like a surgical gown but, for some reason, with no back), kevlar cut-resistant gloves with rubber size 7 autopsy gloves (look like biogels to me, but they're bulk/non-sterile), and trauma boots. You can customize: some people triple glove, some people wear shorter shoe protectors, some people like butchers' aprons, some people like PAPR hoods or particle filters. Visiting detectives and investigators often wear disposable masks (which, in my experience, just don't cut that trashy smell.)

When we're explaining what an autopsy is to families, we tend to say it's performed in much the same way as any surgery is performed. If we're in a formal mood, we refer to ourselves and each other as autopsy surgeons which, if you think about it, is accurate. We're cutting people: we are surgeons-- just not the type you usually think of. There are some fairly glaring differences between autopsy surgery and any other surgery.

• we do not maintain a sterile field
• we do not maintain hemostasis (that's controlling bleeding)
• and we don't put everything back together better than how we found it

(In case you're wondering, we just tuck everything back inside and sew the body shut.)

But other than that, the analogy holds up pretty well.

There are a couple of different ways to do autopsies-- different autopsy surgeons and different institutions have different preferences. Basically, there are two main strategies:

1. Take the organs out of the body all at once (if you do it right, they come out in a neat, orderly pile that you can lay down on your table and inspect)
2. Take the organs out one by one

We do the second type.

Before you cut, you take a good long look at them from the outside, checking for any signs of disease or trauma, anything that could confirm (or call into question!) their identity, and, basically, anything at all that catches your eye (you never, ever know what could be important.) You can then take samples of femoral blood (just get a ten cc syringe and 18 gauge needle and aim for the soft spot in the crease), urine (same idea, but aim just above the pelvic brim), vitreous humor (from the eye, it's a good source of information about blood chemistry before death because it changes so slowly after death), and jugular blood (you're going to have to make an incision for this at the base of the neck and dissect down to the jugular vein, but it's easy to find.)

In order to get at someone's insides, you generally have to make two incisions: one that's shaped like a "Y" and extends from both shoulders to the sternum (people are telling me that the mid-sternum is a good place to aim for) and then extends all the way down the middle of the abdomen, and a second incision from ear to ear across the top of the head so you can get at the brain. Special circumstances call for special handling, which may require more incisions, but two will do fine for most cases. (The incisions are placed where they are to keep the hands and face nice in case they're scheduled for an open casket funeral.)

You then reflect the skin off to the sides using sharp dissection (a scalpel and a good strong non-dominant hand) and separate the abdominal musculature from the lower border of the rib cage. Take a look in the abdomen to see if there's blood or scarring or pus in there. If there's a lot of fluid it'll start to decompress as you're making your abdominal incision: try to collect it so you can get a good look at it and measure how much of it there was. To get at the heart and lungs, you'll need to remove the front of the rib cage: branch clippers work well-- aim far enough to either side that you can get a good look inside the chest. Then you'll open the pericardial sac (around the heart), check for fluid (or scarring, or pus-- you get the idea) in there. You can poke a hole in the pulmonary artery to check for clot (this is a good idea, clots there kill people suddenly and might explain why you're doing an autopsy.) Pull the heart forward, wipe the pericardial sac clean with a paper towel, and place a ladle in the sac. As you remove the heart, cutting the great vessels at the pericardial reflection, any heart blood will spill into the pericardial sac (and your ladle.) Put the heart on the scale and head back to the chest cavity. If you grasp the lungs at the hilum and pull a bit, you can take your scalpel and neatly remove them. The bronchi and vessels fit very comfortably between your fingers, so you can cup your hand around the lung to keep it clear of the blade as you go.

This part I'm pretty good at. But it's time to tell you a terrible secret. (Shh...)

Look: there are people who come from these residencies where they're all gung ho about autopsy being the mother of pathology and they get just tons of high-quality autopsy training and they hit the Coroner's Office and just tear the place up. Those people make me feel very, very inadequate. In my residency, the guy who used to be in charge of autopsy was a crazy old codger who alternated between harassing the department at large and teetering on the verge of getting fired and was almost too busy with these pursuits to properly ignore me during my rotations on autopsy. (We can get into how awful that is for everyone involved, least of all me, most of all the families who were hoping for a real answer to "why did Uncle Fred die?" some other time-- for now, let's just acknowlege it and move on.)

We all spend one month at the Coroner's as part of our residency and when it was my turn I was earnestly awful, a fact which was emphatically not held against me, as everyone knew why people from my program were all awful at autopsy. I loved my rotation, decided to go into forensics, and was welcomed into the fellowship with very large, very sincere-looking smiles, great parking, and pink crepe streamers, but that does not imply any autopsy skill on my part: I'm starting at a disadvantage and playing catch-up the best I can. My co-fellow and I are from the same program (which, by the way, has since fired the codger, hired a very good new professor to handle autopsy, and is in the process of sprucing itself up admirably but a bit too late for us) and spent this afternoon commiserating about how cruddy we are at autopsy. (Today's focus: the heart and what an annoying organ it is.)

So as soon as I figure out how to gracefully remove the liver, we'll pick up this thread.

Oh yeah, and before you start worrying about the dead, you should know that I am hovered over by full-fledged forensic pathologists and very, very experienced autopsy assistants (called, for reasons I do not know, dieners) who perform the parts of the procedure I can't yet reliably do. The plan is that , as I get better, they can start letting go (picture dad holding the back of your first be-training-wheeled bicycle.)