How Autopsies Work

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Introduction to How Autopsies Work

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.

Autopsy Image Gallery

Photo courtesy Sacramento County Coroner's Office
A body awaits examination in an autopsy bay. See more autopsy pictures.

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.

Meet Dr. Kiesel Dr. Kiesel is the Deputy Chief Medical Examiner of Fulton County. He has been a forensic pathologist since 1985. Here's a short resume:

attended Louisiana State University Medical Center in New Orleans

completed an internal medicine internship in the Tufts program at New England Medical Centers

completed two years of anatomic pathology residency training in Seattle at the University of Washington affiliated hospitals

completed a one-year forensic pathology fellowship as the assistant medical examiner of King County in Seattle

completed a one-year, sub-specialty training in forensics

was the first Washington State Forensic Pathology Fellow

was brought in as an acting coroner in Snohomish County

assisted in creating legislation to convert Snohomish County from a coroners system to medical examiners system

served in Snohomish County from 1987 to 1997

moved to Atlanta, Georgia, in September 1997 and began working in the Fulton County Medical Examiner system

When asked why he wanted to be a medical examiner, Dr. Kiesel replied:

I started off looking into environmental pathology. I have a Ph.D. in analytical chemistry. I became friends with the medical examiner in Seattle, and when an opportunity arose to do a fellowship, I took that opportunity and found it quite fascinating, and have stayed with the job.

Autopsy Basics

In order to understand how an autopsy works, it helps to first understand what they are and why they are done.

Photo courtesy Sacramento County Coroner's Office
Multiple autopsies are performed at once at the Sacramento County Coroner's Office.

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 Price of Knowing A privately hired autopsy can cost anywhere between $1,500 and $3,200.

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.

Reality TV?
On TV shows like CSI or The X-Files, medical examiners seem to be a major component in the investigation and can use DNA evidence for just about everything. Dr. Kiesel commented on some of the more common TV-driven misconceptions:

We can’t do DNA on every case and match up every little thing. Even though it happens on TV, it’s not within our capabilities. Very often it’s not within the lab’s capabilities. Sometimes there are financial constraints on what we can do.

Manners of Death

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*Statistics compiled in a 2001 study. Odds apply to persons living in the U.S. only.

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

Photo courtesy Sacramento County Coroner's Office
Pathologists at the Sacramento County Coroner's Office prepare to examine a victim from a homicide case.

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*Statistics compiled in a 2001 study. Odds apply to persons living in the U.S. only.

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?

Coroner History Dr. Kiesel spoke about the origins of the coroner:

"The history goes back to the old days where the position was originally called the "crowner." The crowner and a couple of knights would go out, and it was basically to make sure that when somebody died, the king got his cut of the booty."

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:

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*Statistics compiled in a 2001 study. Odds apply to persons living in the U.S. only.

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."

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*Statistics compiled in a 2001 study. Odds apply to persons living in the U.S. only.

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.

Photo courtesy Sacramento County Coroner's Office
Bodies are moved in specially outfitted, unmarked vans.

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.

Photo courtesy Sacramento County Coroner's Office
Bodies arrive in body bags or evidence sheets like the one shown here.

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.

Photo courtesy Sacramento County Coroner's Office
Special equipment is sometimes used to help move bodies.

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.

Autopsy Wear

Scrub suits
Gowns
Gloves (two pair)
Shoe covers
Clear plastic face shield

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.

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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.

Photo courtesy Sacramento County Coroner's Office
A body is X-rayed in the evidence sheet.

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.

Photo courtesy Sacramento County Coroner's Office
Technicians wear protective gear to prevent infection.

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.)

Photo courtesy Sacramento County Coroner's Office
One body is weighed while the other is fingerprinted before the external examination.

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:

toxicology

In the next sections, we'll talk about the internal examination.

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.

Photo courtesy Sacramento County Coroner's Office
The vibrating electric Stryker saw is used to cut into the skull without damaging the brain.

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*Statistics compiled in a 2001 study. Odds apply to persons living in the U.S. only.

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."

In the next section, we will learn about the examination of wounds and injuries.

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. Dr. Kiesel explains how wounds have patterns that help to determine their origins:

Bludgeoning, where you have someone who's been physically assaulted and beaten, you've got a lot of different injuries. Sometimes these injuries have patterns. Sometimes the injury patterns give you a clue as to what weapon may have been used. Sometimes there's more than one weapon. I had a case where a person was done in by one individual, but that individual used at least four different weapons. So we had four different types of patterned injuries on that person. Through years of education and experience, the medical examiner learns to recognize these patterns and the types of trauma with which they are associated.

In the next section, we'll look at the tools used to perform an autopsy.

Tools of the Trade

The tools used to perform autopsies have changed very little in the past 100 years. The only real major advance in tools is the addition of some electrical saws. But even those are still not used as often as the good old-fashioned hand tools.

Photo courtesy Sacramento County Coroner's Office

Bone saw - used to cut through bone or skull
Breadknife - used to shave slices off of organs for examination
Enterotome - special scissors used to open the intestines
Hagedorn needle - a heavy needle used to sew up the body after examination
Hammer with hook - used to pull skull cap off of skull
Rib cutter - special shears used to cut through the ribs
Scalpel - like a surgeon's scalpel but with largest blade possible for making long deep cuts or scraping away tissue
Scissors - used for opening hollow organs and cutting vessels
Skull chisel - used for helping to carefully pry the skull cap off
Stryker saw - the electric saw used to cut through the skull to remove the brain
Toothed forceps - used to pick up heavy organs

Photo courtesy Sacramento County Coroner's Office
The autopsy bay has everything the pathologist needs for the investigation within arm's reach.

Dr. Kiesel discussed some of the alternatives to the traditional tools:

We don't always use nice, delicate, surgical tools. If you put the word medical or autopsy on something, the price triples, so ... I can go to a restaurant supply house and get some good knives that cost me just a fraction of what it would cost to buy them elsewhere.

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*Statistics compiled in a 2001 study. Odds apply to persons living in the U.S. only.

Autopsy tool shopping doesn't stop at the restaurant supply house. The medical examiner may also visit a hardware store for supplies. Dr. Kiesel continues:

... we're not doing very delicate surgical procedures where we have to worry about if we nick the wrong thing somebody's going to bleed. So, our tools aren't quite that delicate, but we can still do some reasonably sophisticated things ... It's not like doing delicate microsurgery.

While this may seem gruesome, medical examiners are forced to work on a budget, and saving money on tools frees up funds for use on other investigative resources.

In the next section, we will learn how medical examiners unravel the mystery of time of death.

Time of Death

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Statistics compiled in a 2001 study. Odds apply to persons living in the U.S. only.

On TV and in the movies, you've probably seen countless investigators refer with seeming accuracy to a time of death. Have you ever wondered how that is possible? Well, it turns out that investigators use what is called the Time of Death Certainty Principle -- and it's not nearly as scientific or as certain as it sounds.

It goes something like this: If you know with certainty when the person was last known to be alive, and if you know with certainty when they were found dead, then you know with 100% certainty that they died within that interval.

That is the foundation of the principle. That may seem obvious, but that is only the starting point. Once they have that interval, investigators begin to look at both medical and non-medical factors to get an approximation of the time of death.

Dr. Kiesel goes into detail:

lividity

rigidity

rigor

vitreous humor

corneas

gastric contents

All of these recognized chemical changes associated with death happen at intervals of time that are widely known. But these are not airtight indicators. Variables like ambient temperature, chemicals in the blood stream and other factors can affect the rate at which these changes occur.

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*Statistics compiled in a 2001 study. Odds apply to persons living in the U.S. only.

Dr. Kiesel pointed out other things investigators look for when trying to establish a time of death:

non-medical

atomic clock

Haunting Work

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Having learned some of the grisly details of this job, it is easy to wonder how anyone could to do this for a living without suffering severe psychological side effects. Dr. Kiesel discussed the emotional and psychological side of this kind of work:

When you walk in, you never forget that this is somebody's loved one. You never forget that, but when you walk in to do the job, you kinda put that information aside. You look at them more as a puzzle, and your job is to sort out this puzzle.

I've got to find out what happened. Who, what, why, when, where. I mean, that's what my job is, to sort out and get those answers. And, do it in a respectful way.

A lot of people can't do this type of job. A lot of people don't want to do this type of job. There are a lot of jobs I wouldn't want to do either.

Jurisdiction Issues Federal agents took control of the investigation of the assassination of President John F. Kennedy, allowing a non-forensic pathologist to perform the examination of the president's body. This produced questionable results. At the time, there was some confusion over who had the right in a federal investigation to perform the autopsy of a public official.

To solve this problem, the law now mandates that examinations in federal investigations regarding the death of an official are to be performed by pathologists from the Armed Forces Institute of Pathology. In federal investigations dealing with the death of a civilian, agents will contract a qualified local pathologist to do the work.

For more information on autopsies, medical examiners and related topics, check out the links on the next page.

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How Autopsies Work