Forensic Pathology: Autopsy
Guest: Dr. Nick Batalis - Pathology & Laboratory Medicine, MUSC
Host: Dr. Linda Austin – Psychiatrist, MUSC
Dr. Linda Austin: I’m Dr. Linda Austin. I’m interviewing Dr. Nick Batalis, who is a forensic pathologist here at the Medical University of South Carolina. In an earlier podcast, we discussed what forensic pathology is. Dr. Batalis, in this podcast, walk us through an autopsy. What are the steps involved in that procedure?
Dr. Nick Batalis: An autopsy, in general, is an examination we perform after someone has died to determine cause and manner of death; any sorts of natural disease or trauma. As pathologists, we’re, basically, concerned with two types of autopsy; general autopsy, and forensic autopsy. As we’ll discuss, there’s quite a bit of overlap between the two.
Starting with an autopsy, the first thing we’re going to do is take photographs of the body as we receive it. In both medical and forensic cases, we want to document how the body is received; any personal effects, any belongings of the decedent, as well as noting any injuries. After that, we disrobe the body and clean it. If there are any fluids or dirt, or anything, obscuring our view of the skin surfaces of the body, we’ll clean the body. We’ll then take another set of photos with the body cleaned.
Once this is finished, we then do a detailed examination of the body from head to toe, examining the outer surfaces of the body, looking for identifying features, such as hair color, eye color, their teeth, just their general appearance, which can help give a picture of what we’re looking at, and help the family know that we are, in fact, dealing with their loved one. After we do the identifying features, we’ll then describe any scars or tattoos; anything on that person that would help identify them as that particular decedent.
Also in this process, we’re going to be looking for any sorts of medical therapy. People have often been to the emergency room before passing away, or they’ve actually died in the hospital. We want to make sure that we notice all evidence of medical therapy which comes on the decedent. That could mimic some sort of trauma if we don’t take note of that.
The final thing we’ll do; this last part is more geared towards a forensic autopsy, is to describe any trauma we see. We save this part for last because we want to conduct the first part of the autopsy the same way every time. In the forensic autopsy, we’ll specifically focus on trauma, whether it’s a car accident, a gunshot wound, or a stab wound. The last part of the exam, we’ll describe in detail and, again, take many photographs of any injuries that we see.
Once we’re finished with the external examination, we then move on to what we call the internal examination. And similar to what some may have seen on TV, there is a Y-shaped incision that’s performed on the decedent’s chest. Then, we reflect back the skin and examine, and dissect, each of the internal organs from the chest and abdomen of the individual. Following this, we make an incision into the head, which goes behind the ears and over the crown of the head, and remove the brain and examine it, and dissect it, just as we did the organs of the chest and abdomen.
This brings up, again, another misconception about the autopsy. People think that their loved one is going to be disfigured by the autopsy process. But we take great care as we’re doing the autopsy, with a few simple sutures afterwards, that the decedent can be made to look almost identical to what they looked like before the procedure.
As we’ve taken the organs out and dissected them throughout the procedure, we’re examining them one by one, looking for any evidence of natural disease and/or trauma, depending on the case. Again, if it’s a hospital death, we’re examining more for natural disease. In forensic cases, we’re looking more for areas of trauma. In both cases, we’re going to mention both. So, if somebody’s died of a gunshot wound, but we find some sort of a lung tumor, we are going to sample that. We’re going to take sections of it so we can let the family know about it. The big difference, probably, between the two, at this point, would be preservation of evidence, especially in cases of suicide or homicide that involve guns or knives.
During the external, and internal exam, we’re going to be collecting evidence, whether it’s a bullet or a knife fragment. We may collect DNA fragments from the individual’s fingernails, anything that could help solve the particular crime that they believe was committed. That really separates the forensic autopsy from the medical autopsy.
Dr. Linda Austin: Now, you mentioned that you take the organs out, and take a biopsy of them, do you then replace the organs?
Dr. Nick Batalis: Yes. The organs, with few exceptions, are returned entirely, except for a small biopsy at the end of each autopsy. Occasionally, it is necessary, in order to make a firm diagnosis, to retain an organ, such as the brain. That’s one that’s often retained because we can section that much better later on. Or sometimes we may have a heart that we really need help with, and need to save for a period of days or weeks. In those cases, it’s up to the pathologist to communicate with the coroner and/or family about how to dispose of those tissues once the autopsy is completed.
Dr. Linda Austin: How often does it happen that the cause of death is a real surprise to you, that you go in thinking it will probably be one cause of death and it turns out to be something else?
Dr. Nick Batalis: Quite often. That’s one of the things that makes this job challenging.
Dr. Linda Austin: As well as meaningful, I would think.
Dr. Nick Batalis: And meaningful.
Dr. Linda Austin: Because that’s the point of it, to make sure that you’re right. If you were always right, there would be no point in doing the autopsy.
Dr. Nick Batalis: Right. It’s amazing, just your own preconceptions about what the cause of death may be, as far as what may come up. And in cases of medical autopsies, 15 percent of those, despite a workup in the hospital, we actually find a cause of death that’s different, or a major discrepancy in a disease process. So, I’d say 20 to 25 percent of the time, the cause of death really surprises you.
Dr. Linda Austin: What are some of the common myths about autopsies that you hear that might be good to set straight?
Dr. Nick Batalis: The first one, which we already touched on, is that the family member; the decedent, will be disfigured by the autopsy and they won’t be able to have an open casket at the funeral. As I said, this is totally untrue.
From the forensic side, shows such as CSI and Crossing Jordan, while they’ve been good for popularizing our field and encouraging many people to go into forensics, they’ve kind of put up a wall for us too. People see shows on TV, and see the autopsy, and how they know within minutes exactly what caused the person’s death. In some cases, you can; such as a gunshot wound. Other cases may take weeks, or even months, to finally get a firm diagnosis for cause of death. And that can be frustrating for families who are waiting weeks and weeks for us to make our diagnosis. They think, that’s not like on TV. We try to assure them that we’re doing the best we can, that we’re working hard to come to a firm diagnosis.
Dr. Linda Austin: And why would it take weeks or months? In what situations does it take that long?
Dr. Nick Batalis: Each autopsy is a little bit different. For instance, we’ll have a case where we have to take extensive microscopic sections, or if we find a tumor that we’re unsure of, we may need to send those blocks off to get special stains to help figure out exactly what kind of tumor it is. Another thing we run into is toxicology. Often, in the news, we see a famous person; such as Heath Ledger, or any of these other celebrities that have died recently, whose toxicology reports often come back in a week or two, and the general public comes to expect this. When, in fact, toxicology testing often takes weeks to months to complete. There are very few labs in the nation that do forensic toxicology testing, so there’s a pretty big backlog. A lot of times the toxicology report, then, can be the limiting factor.
Dr. Linda Austin: Any other myths that you hear frequently that might be helpful to dispel?
Dr. Nick Batalis: It seems like there are so many, but I’d say those are two of the biggest ones. I think there’s just a general lack of understanding of what a forensic pathologist is in the community, with terms such as coroner and medical examiner, and forensic pathologist. I always like to stress to medical students, or high school students, or the general public, that a forensic pathologist is a physician first. We complete our four years of medical school first, so we’ve dealt with live patients before. We took the same oath that every other cardiologist or general practitioner did and we’ve chosen to subspecialize in this area of medicine. I think that’s another myth, or misconception. Often, I think, folks don’t quite realize that a forensic pathologist is a physician.
Dr. Linda Austin: And, explain the terms coroner and medical examiner.
Dr. Nick Batalis: The two terms, coroner and medical examiner, are, basically, the death investigation systems in the United States. In the United States, each of the two comprise about half of the population. A coroner is an elected official, elected by the general public. And, depending on the state, they may be required to be physicians, or there may be other educational requirements, whether it be a college degree; or, in some areas, a high school degree. As an elected official, they’re in charge of the system. In South Carolina, that’s how we are. We work for the coroner. A suspicious death is reported to the coroner and they ask us to perform the autopsy. They coordinate the information with the families; the autopsy report, the scene investigation, to coordinate the death.
In a medical examiner system, which is usually found in the larger cities, the chief medical examiner is generally a forensic pathologist. They’re kind of at the top of the pyramid and everything else kind of flows down from there. As I said, generally, this occurs in larger cities.
If both systems are run correctly, the end result is good communication between the doctors and the families, with an understanding of why the person has died; brought about by a solid collection of evidence in forensic cases. Kind of like apples and oranges, I guess. As long as they’re done correctly and professionally, both systems accomplish the goal.
Dr. Linda Austin: Dr. Batalis, thank you so much for talking with us today.
Dr. Nick Batalis: Thank you.
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