The Autopsy Part 2: The Internal Exam
There has been a lot of interest in how autopsies are performed. Frankly, it’s not something most people experience (in life that is). So I thought it would be informative to give you a little peak behind the curtain and find out how these procedures take place. Consider this a brief summary as each case may require special procedures depending on the crime or suspected cause of death. I have already explained the external examination. Now it is time to discuss the next phase, the internal examination. You might think that all autopsies include an internal examination but in my experience the final call is made by the coroner or medical examiner. Personally, I think every suspicious death autopsy should include an internal exam and most do but, occasionally the coroner may issue a death certificate based solely on the external examination. This may include cases of motor vehicle accidents, suicide, or natural deaths such as a patient dying after a long documented battle with a terminal disease.
The purpose of the internal examination is to fully explore all potential causes of death. Forensic pathologists are concerned with more than just criminal acts resulting in death. They also have an interest in public health and personal medical conditions that may affect the victim’s family members (like a hereditary disease). Likewise, a patient suffering from a terminal disease may die prematurely from improper care or negligence and sometimes the internal examination is the only way to uncover that evidence.
The internal examination begins with what we refer to as the “Y” incision. This is a dissection technique to gain access to the internal organs of the torso. Incisions are made from each shoulder to the sternum and then straight down to the groin. The skin is then reflected (cut) back and the ribs are cut along the sides and the “plate” is then removed to expose the organ area. Each organ is removed, weighed, photographed, and dissected by the pathologist. Small portions of each organ will be preserved for future study and tissue samples will also be collected for histological examination. They are looking for injuries, evidence of disease, as well as the general health of the organ. Pathologists will examine and collect the stomach contents which may reveal last meal evidence or prescription drugs (in cases of drug overdose). All along the way they will be documenting their findings in notes, charts, photographs, and occasionally video.
Then they open the cranium. The pathologist begins by cutting the scalp around the back of the head and then reflecting (peeling) the scalp up over the head to the top of the eyes and on the back side down to the bottom of the skull. This exposes a majority of the cranium. A bone saw is then used to cut through the bone and pull the skull cap off exposing the brain. The bone saw can generate some bone dust and an interesting musty smell so I generally make sure I’m on the other side of the room. The brain is covered in a thin white sheet or film called the dura that resembles an opaque saran wrap (bad analogy but appropriate for non-scientists) that has to be removed before you can access the brain. Once the dura is removed, the brain is removed and examined like the other organs. It may even be sectioned (cut into thin slices) to look for certain pathologies. The pathologist will also be looking for fractures or bruising to the cranium and scalp (as might be found in blunt force trauma). Following the examination of the brain the pathologist will examine the throat. Depending on the circumstances surrounding the death they may be looking for anything from an obstruction (choking) to soot (fire). Of course the mouth will be examined for injury as well. This could include missing teeth, bleeding, bruising, etc.
Black soot in victim’s airway
As I’ve mentioned, each autopsy may require examination and procedures not mentioned here. The order of the examinations (Trunk, head, throat, etc.) may also vary from pathologist to pathologist and the circumstances of the death. Most autopsies are completed in under two hours. Some can take a bit longer if there is extensive trauma to document (like 37 stab wounds). Although the physical procedure is relatively short it may take days or weeks to get all of the toxicology and histology results back (even if done in house) because of backlog. If the victim has evidence of prior injury (like healing fractures, bruising, or evidence of prior surgery) the pathologist will document it and assess if it played a role (contributed) to death. Every medical examiner has different rules as to who may attend the autopsy in person. Some are extremely restrictive (only the pathology staff and one member from the crime lab) others seem to allow anyone to attend. I’ve been in some with a dozen or more people crowding around and that can cause it’s own challenges. As far as evidence retention, the pathologist will take custody of all biological evidence. If there were something inside the body like a bullet, knife tip, or other trace evidence, the crime lab would typically take custody of it.
Today pathologists must physically dissect the body but there may come a day when much of this work is done in what some call a virtual autopsy. You’ll probably never get away from physical sampling but fifty years from now the autopsy procedure may look very different. Watch the below video for a hint at how these procedures may develop. I think if nothing else, the virtual autopsy may be a preferable method for presenting images in court.
As writers you may not want to get too deep into the weeds on autopsy procedure but, it is helpful to understand it. Autopsies are hard for some folks to deal with and some investigators and DAs would prefer not to be there. It’s easy to understand why. It is one thing to see a dead body. It is something else entirely to see one subjected to this procedure. Pathologists exhibit an enormous amount of care when performing these procedures. There is a decorum of professionalism and they don’t tolerate clowning around. It is a very serious event. Having said that it is also a place where emotions can rage inside each individual. Your characters may ride a wave from sorrow to anger and back again before the procedure is completed. Think about how each character might react to the details as they emerge during this procedure and use that to give the reader a little insight to their thought process.
Posted on October 15, 2012, in The Autopsy and tagged autopsy, coroner, Crime Scene, csi, detective, fiction, forensic pathology, forensics, medical examiner, murder, mystery, Pathology, police, thriller, tom adair, trace evidence. Bookmark the permalink. 5 Comments.
Thanks so much for this information! It’s been really useful in writing my second book. Can you describe smell of the morgue’s exam room? I’m sure it’s different depending on the type of body the ME is working on but is there one overwhelming scent? Also does the ME or the detectives put something under their nose to help them deal with the smells?
I love your posts for their facts but if you could remember to add some sensory information that would really enhance your posts. Thanks again!
You would think that for a guy that wrote a novel entitled The Scent of Fear I would include a little about smell! Doofus. I appreciate your question Kelly as the ability to integrate all of our senses at a crime scene (or autopsy) are critical to a proper investigation. So, how does an autopsy room smell. In a modern autopsy suite (like the one pictured) they smell a lot better than one would think. Most offices in the US do extensive cleaning after each autopsy. So in the background there is always the smell of cleaners like bleach or scented ammonia based cleaners. Then you have the bodies. Al bodies have the scent of decomposition. “Normal” bodies (those not inflicted with massive trauma and relatively fresh <48hours) will smell kind of like a chicken or Thanksgiving turkey with some of the internal parts still inside. It's kind of like that only stronger. A mouse that has been dead for several days is also a similar scent. Bodies in advanced decomposition are an entirely different matter. The stench can hit you like a baseball bat. Again, to me it is usually a mixture of ammonia, rotting meat, and laced in there is a trace of sweetness (which is counter-intuitive and gross). There are some products that are amazing at eliminating the odor of decomposition. One is called NI-712 orange by Neutron Industries. We stock it heavily. I've been at some real gaggers where after one spray of this aerosol the decomp scent is completely gone. So sometimes when you get to the autopsy the air smells like oranges and you never smell anything else. The really important thing to remember is that everyone has different tolerances. I am very tolerant of decomp smell, others are not (especially rookies or new detectives). In the autopsy suite you can tell who is used to the bad smells (those close to the body) and those who aren't and try to wedge themselves into the furthest corner of the room. Modern autopsy suites have video conferencing for this reason so the DA's, detectives, and other interested parties can watch the autopsy and speak with the pathologist in a conference room setting. They watch the autopsy via several cameras in the room and can have live chats with the pathologist. It's kind of like Skype but grosser (at least you don't have the smell). Does that help you?
I forgot to mention something. Most people wear two layers of latex gloves when at autopsy and when you have a really bad decomp the smell can infiltrate your hair, clothing, hands, etc. It’s really hard to eat lunch if your hands smell like decomp so one trick is to smear a light coating of toothpaste between the layers of gloves. So you put on a pair, rub in the toothpaste like lotion, then add another pair of gloves over that. The toothpaste will act like a barrier and absorb the smell too. Not much you can do about hair except shower, rinse, repeat!
This may be wierd to ask, or make me sound creepy, but I was watching an episode of The Closer and saw something I thought was wierd. Now I realize that it’s a tv show and I’m sure not everything shown is true to fact or even accurate! But in this particular episode they were doing an autopsy on a female rape victim who was beaten to death. The thing that was wierd to me was when the coroner started to do the rape kit he grabbed a scalpel like he was going to cut the girl open to do the rape kit! So my question is do they cut people open to do a rape kit during an autopsy? Or is it done the same way as it would be on a live person? -freaked out & curious
I didn’t see the episode but you’re right to be confused. I’ve been to hundreds of autopsies and I’ve always seen a rape kit collected in essentially the same manner as a living person. I suppose if there were severe trauma or decomposition there might be a need for dissection but that would be rare.