When someone dies under mysterious circumstances, what happens next? Most states in the United States have laws that require certain types of deaths be investigated:
- injury
- delayed complications of injuries
- poisoning
- infectious complications
- foul play
- people who die with no attending physician
If the death meets any of the above criteria, it must be reported to the local medical examiner or coroner for investigation and a legal determination of the cause of death. The main tool of this investigation is the autopsy.
The process of examining the dead to discover how they died is the subject of many TV shows and movies, but the facts aren't always so clear-cut. In an interview with Atlanta's Fulton County Deputy Chief Medical Examiner Eric Kiesel, HowStuffWorks cut through the mystery of this often misunderstood process and learned the details of the preparation, procedure, and tools needed to perform an autopsy.
Autopsy Basics
In order to understand how an autopsy works, it helps to first understand what they are and why they are done.
An autopsy is the medical examination of a dead body to determine the cause of death. Autopsies are performed when someone dies suddenly and unexpectedly while in apparently good health. Autopsies may also be performed at the request of the family of the deceased.
There are two types of autopsies:
- Forensic
- Clinical
The forensic autopsy or medical-legal autopsy is the kind you most often see on TV and in movies. According to Dr. Kiesel, "The forensic autopsy spends almost as much time on the external surfaces of the body as it does on the internal surfaces, 'cause that's where evidence is." Forensic autopsies try to find answers to the cause of death as part of an overall police investigation.
The clinical autopsy is usually performed in hospitals by pathologists or the attending physician to determine a cause of death for research and study purposes. Dr. Kiesel explains:
They're really interested in the disease processes that are going on, and they're interested ... in making that clinical-pathological correlation. A person came in with these symptoms, here's the treatment they got and here are my findings. They try to put the whole package together to help inform people of what happened or may have happened.
In the eyes of the law, all deaths fall into one of five categories of causes. In the next section, we'll look at the five manners of death.
Manners of Death
In death investigations, autopsies are most often performed by a forensic pathologist. A pathologist studies the effects of diseases, medical treatments and injury on the human body. A forensic pathologist specializes in using these studies to establish a legally admissible manner of death in a court of law.
There are five legally defined manners of death:
- Natural
- Accident
- Homicide
- Suicide
- Undetermined
After careful examination of all the evidence at hand, the forensic pathologist acting as a medical examiner or coroner (more on the distinction later) will assign a cause of death as one of these five manners.
For example, if the autopsy reveals a natural disease process such as leukemia or cancer, then the death would be considered natural.
The answers are not always that clear. The pathologist must consider all of the information. Severe head injuries that result in death with no evidence of assault could be hard to explain. But when that evidence is added to the police report that states the body was found next to an ice-covered, fallen ladder, the manner of death is an accident.
It would be easy to assume a gunshot wound is the result of a homicide. But an autopsy could reveal that the wound patterns, angle of bullet entry and gun powder residue indicate that the gun was fired while being held by the victim. The wounds are self-inflicted, so that would be ruled a suicide.
Dr. Kiesel had an interesting example of the unique possibilities when assigning a manner of death.
Let's say, somebody 30 years ago received a gunshot wound to the head and they developed a seizure disorder. It's 30 years later, and they die from the seizure disorder. Well, the seizure disorder was caused by the gunshot wound; the gunshot wound is an unnatural event. That case would actually be classified as a homicide ... there's no time limit to that trauma. There's a time limit if you wanted to take it to court and sue somebody, but there's not a time limit as far as our making the call.
In the next section, we'll look at the difference between a coroner and a medical examiner.
Medical Examiner or Coroner?
While many types of medical doctors are capable of performing autopsies, most states or local government laws mandate that an appointed forensic pathologist do the work. These appointees are called medical examiners and have an official position in the county medical examiner system.
Not all counties use the medical examiner system. Some counties use coroners and a coroner's system. There are two major differences between medical examiners and coroners and their corresponding systems.
Dr. Kiesel explains:
A medical examiner by definition is a physician ... In most cases, they are trained to be forensic pathologists... and are appointed to their positions. To be a coroner, you just have to be able to be elected to the job. You've got places where the local feed store operator is a coroner. I've got a friend out in Washington State who's a farmer, who's the coroner of his county.
Many coroners are qualified pathologists with years of experience. Some are physicians in unrelated fields. But depending on the county laws, a coroner may require no medical qualifications at all in order to perform his or her duty. This fact raises two questions:
First, why would a county opt for a coroner system over a medical examiners system if the differences in qualifications can be so great?
The answer is resources. In most rural areas, there may not be a whole lot of qualified forensic pathologists around nor the facilities needed for them to do their jobs properly. Additionally, rural areas with very little or no violent crime or unexplainable deaths don't need a full-time forensic pathologist.
The second question is: What is a feed store coroner going to do when faced with a dead body?
Dr Kiesel answers, "He's gonna go out and say, 'Well, he's dead.' That's the coroner's official duty."
The coroner is also responsible for:
- Identifying the body
- Notifying the next of kin
- Collecting and returning any personal belongings on the body to the family of the deceased
- Signing the death certificate
Some states, like Louisiana, require coroners to be forensic pathologists, but most county coroner systems do not. In the event that a non-medical coroner needs an autopsy performed, he or she can have it sent to a medical examiner. In some states, the government will provide the coroner with a medical examiner for the autopsy.
In the next sections, we will detail the process of examining a dead body inside and out.
Autopsy Procedure: External Examination
The body is received at a medical examiners office or hospital in a body bag or evidence sheet. If the autopsy is not performed immediately, the body will be refrigerated in the morgue until the examination.
A brand new body bag is used for each body. This is to ensure that only evidence from that body is contained within the bag. Body bags are closed and sealed to prevent any contamination or evidence loss during transportation.
Evidence sheets are an alternate way to transport the body. An evidence sheet is a sterile sheet that the body is covered in when it is moved. Just like the body bags, investigators use brand new sheets for every corpse.
The body is moved in the bag or sheet to the examination suite. The person responsible for handling the body is often called a diener. The diener is a morgue attendant who is responsible for moving and cleaning the body and, in some cases, assisting in the autopsy. The diener will also clean the exam suite after the autopsy is over. This job may vary from facility to facility.
Special equipment is often used to help move bodies. /When the body is received in a body bag, the seals of the bag are broken and the body is photographed inside the bag. In a forensic autopsy, it is important at this stage for the medical examiner to note the clothing of the deceased and the position of the clothing. This is because once the clothing is removed for the examination, any evidence pertaining to the position of the clothing cannot be documented.
Evidence is collected off of the external surfaces of the body. Hair samples, fingernails, gunshot residue (if present), fibers, paint chips or any other foreign objects found on the surface of the body are collected and noted.
If it is a homicide investigation, the hands of the deceased will be placed in bags at the scene. The medical examiner will open the bags and take residue and fingernail samples. Then the bags are removed, folded and submitted with the samples as part of the evidence.
/ A body is x-rayed in the evidence sheet.In some cases, a special UV radiation is used to enhance secretions on the skin or clothes. The radiation causes the secretions to fluoresce so that they may be collected for samples.
If protocol dictates, the body will be X-rayed while still in the body bag. This is an important step. Dr Kiesel explains why:
I had a body the other day where the person had been shot. The body came in, we shot an X-ray through the body bag, we took the body out of the body bag, we did the autopsy and we found all the bullets except for one -- couldn't find it. Well, it was still in the body bag. It was actually through and underneath the body. So [on the X-ray] it looked like it was still in the body even though it wasn't.
Once the evidence is all collected, the body is removed from the bag or sheet and undressed, and the wounds are examined. This is done before the body is cleaned up.
After the body is cleaned, the body is weighed and measured before being placed on the autopsy table for reexamination. The autopsy table is typically a slanted, aluminum table with raised edges that has several faucets and drains used to wash away collecting blood during the internal investigation. The types of table used vary from facility to facility. The body is placed face up on the table, and a body block is placed under the patient's back. A body block is a rubber or plastic "brick" that causes the corpse's chest to protrude forward while the arms and neck fall back. This position makes the chest easier to cut open.
At this point, a general description of the body is made. All identifying features are noted including:
- Race
- Sex
- Hair color and length
- Eye color
- Approximate age
- Any identifying features (scars, tattoos, birthmarks, etc.)
These features are noted on a handheld voice recorder or a standard exam form. In addition to all normal features, any external abnormalities are noted in these reports. Dr. Kiesel describes the wrapping up of the external examination:
We usually separate out into different categories our general description from our evidence of trauma, from our evidence of medical intervention. We'll get a blood sample ... we begin to collect some specimens for toxicology [the study of the effects of chemicals on the human body] ... [and] then we'll open the body.
Autopsy: Internal Examination
The internal examination starts with a large, deep, Y-shaped incision that is made from shoulder to shoulder meeting at the breast bone and extends all the way down to the pubic bone. When a woman is being examined, the Y-incision is curved around the bottom of the breasts before meeting at the breast bone.
The next step is to peel back the skin, muscle and soft tissue using a scalpel. Once this is done, the chest flap is pulled up over the face, exposing the ribcage and neck muscles.
Two cuts are made on each side of the ribcage, and then the ribcage is pulled from the skeleton after dissecting the tissue behind it with a scalpel.
With the organs exposed, a series of cuts are made that detach the larynx, esophagus, various arteries and ligaments. Next, the medical examiner severs the organs' attachment to the spinal cord as well as the attachment to the bladder and rectum. Once this is done, the entire organ set can be pulled out in one piece and dissected for further investigation.
During this dissection, the various organs are examined and weighed and tissue samples are taken. These samples take the form of "slices" that can be easily viewed under a microscope. Major blood vessels are also bisected and examined.
The examiner opens the stomach and examines and weighs the contents. This can sometimes be helpful in figuring out the time of death (more on time of death later).
The examiner will then remove the body block from the back and put it behind the neck like a pillow, raising the patient's head so that it's easier to remove the brain.
The examiner makes a cut with a scalpel from behind one ear, across the forehead, to the other ear and around. The cut is divided, and the scalp is pulled away from the skull in two flaps. The front flap goes over the patients face and the rear flap over the back of the neck.
The skull is cut with an electric saw to create a "cap" that can be pried off, exposing the brain. When the cap is pulled off, the dura (the soft tissue membrane that covers the brain) remains attached to the bottom of the skull cap. The brain is now exposed. The brain's connection to the spinal cord and tentorium (a membrane that connects and covers the cerebellum and occipital lobes of the cerebrum) are severed, and the brain is easily lifted out of the skull for examination.
The vibrating electric Stryker saw is used to cut into the skull without damaging the brain. /Throughout this whole process, the medical examiner is looking for evidence of trauma or other indications of the cause of death. The process varies based on the nature of the case and is incredibly detailed -- the forensic pathologist has to adhere to an intricate, in-depth process to ensure the proper collection and documentation of evidence.
After the examination, the body has an open and empty chest cavity with butterflied chest flaps, the top of the skull is missing, and the skull flaps are pulled over the face and neck. To prepare the body for the funeral home:
- The organs are either put back into the body or incinerated.
- The chest flaps are closed and sewn back together.
- The skull cap is put back in place and held there by closing and sewing the scalp.
The funeral home is then contacted to pick up the deceased.
The whole process takes careful work. Dr Kiesel explains how long this can take:
An average autopsy case takes about four hours. That's including all the paperwork. There is about a half an hour before and after the autopsy for doing the external examination, the dictation, the paperwork. The autopsy can take anywhere from one hour to two hours if it's an uncomplicated case. If it's a complicated case like a homicide ... it can take many hours -- 4 to 6 hours.
Dr Kiesel continues, "The medical examiner will then take all of the information that they've received from the autopsy exam, all of the information they've received from the investigation, and they will determine a cause of death and a manner of death."
Examining Wounds
One of the greatest challenges of an autopsy is examining the wounds. The essence of the medical examiner's job is to use his or her skill and experience to determine the true nature and cause of a particular wound. Depending on the type of wound or weapon used, this can get difficult. Dr. Kiesel talks about those difficulties:
[When] they weren't shot once, they were shot 13 times or 20 times ... you've got to sort out paths of all these bullets. You've got to figure out where each bullet went. The old way of doing it was, 'Well, he's got 10 holes on the front, there are eight holes on the back, and there's two bullets inside, we're done.' [The] legal system won't accept that anymore.
Homicide cases have to be examined carefully and thoroughly. A part of a medical examiner's job includes testifying in court. Medical examiners are often called upon to explain their findings on the stand. Their findings can have a large impact on the lives of all those who are part of the case.
Dr. Kiesel explains how tracing bullets gets really difficult when the police are the shooters:
They really want to know, "Okay, what bullet went where," especially if you've got multiple shooters and especially if it's a case involving the police. You know, you've collected this bullet. Which officer's gun does that go to? So this person's went here, this person's bullet went here. You really have to chase it down a lot of steps sometimes.