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From: Ed Uthman <[e-mail]>
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Subject: Autopsy-A Screenwriter's Guide (monthly posting, 27K, v. 1.004)
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Summary: This is a narrative account of a routine postmortem examination
 as performed by a pathologist on a patient who has died in hospital. It
 is aimed at screenwriters, novelists, and other interested individuals.
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Archive-name: pathology/autopsy-screenwriters-guide
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                     THE ROUTINE AUTOPSY
                        -------------
           The Procedure Related in Narrative Form
           A Guide for Screenwriters and Novelists
              Ed Uthman, MD <[e-mail]>
           Diplomate, American Board of Pathology

PURPOSE

The purpose of this paper is to make available to
screenwriters, novelists, and other interested individuals
an authentic detailed narrative account of a routine
postmortem examination (autopsy) as performed by a
pathologist on a patient who has died in hospital. I have
based this on my experiences as a practicing pathologist in
both academic and community practice settings in several
U.S. cities. I have deviated from the dispassionate,
unbiased language of my profession to present a more
subjective, sensorial view, which I think should be of
greater benefit to those using this information for the
purposes of entertainment.

BACKGROUND

Most patients who die in the hospital do not undergo
autopsy. In recent years, there has been a decreased
interest in the autopsy in the medical community. When an
autopsy is requested, it is either by the attending
physician or the patient's family. The hospital's
pathologist performs those cases of the former type for the
educational benefit of the medical staff. Cases requested by
the family are best left to an independent pathologist hired
by the family. Autopsies performed by the hospital
pathologist do not result in cost to the patient's estate;
rather, the cost is absorbed by the hospital and the
pathologist. "Private" autopsies hired by the family
generally cost between US$1200 and US$2500.

After the patient is pronounced dead by a physician, the
body is wrapped in a sheet or shroud and transported to the
morgue, where it is held in a refrigeration unit until the
autopsy. Autopsies are rarely performed at night, but they
are typically performed between 8 am and 4 pm every day,
including weekends and holidays. In medium-size and large
hospitals, the autopsy is done on the premises in a autopsy
suite, which is either within or adjacent to the morgue.
Small hospitals that do not have autopsy suites may arrange
for autopsies to be done at a larger hospital. Yet other
hospitals out in the country can only offer autopsies by
having them done at funeral homes. Doing an autopsy at a
funeral home is one of the most dreaded things a pathologist
has to face, as a funeral home typically is not as well
equipped as a hospital autopsy suite.

DRAMATIS PERSONAE

Immediately before the autopsy, the body is removed from the
cooler by a morgue attendant who will help with the autopsy.
This individual is called a DIENER (DEE-ner), which is
German for "servant." Most dieners do not realize the
derivation of this word and would probably object to being
called "diener" if they did. Dieners are not formally
trained, but many have some background of employment in the
funeral industry. For some reason, in the southern U.S.
anyway, about ninety per cent of dieners (my estimate) are
African-American. I would estimate that less than ten per
cent of dieners are female. Dieners tend to work at their
job for decades. I think this is because 1) management types
don't know what goes on in the morgue, and would not care to
mess around with its staffing come belt-tightening time, and
2) dieners are pretty much left alone by management and
enjoy a much greater degree of autonomy than most workers at
their pay grade and level of education. My own impression of
the "diener personality" is that they are somewhat secretive
and cliquish, and one gets the idea that they have a lot
more going on in their lives than they tend to let on. It is
not uncommon for them to receive a variety of strange
visitors in the morgue, some of whom have a less than savory
appearance. For fiction writers, I think there is a lot of
character development potential for dieners.

There has been a general belief that some dieners also take
payment under the table for notifying funeral homes of
deaths in the hospital (so that the funeral home can send an
agent out to approach the family), but I am not aware of any
cases where this allegation was proved. From my own
experiences, I know that in some cities the funeral home
business is extraordinarily competitive, and I am aware of
one case where agents of two funeral homes got into a
physical altercation in the morgue over the disposition of a
body that each claimed.

The other individual directly involved in the autopsy is the
PROSECTOR. This is the individual who is in charge of the
actual dissection. In small hospitals, the prosector is a
Board-certified pathologist, an MD or DO (osteopath) who has
undergone a four- or five-year residency in the specialty of
pathology, specifically anatomic pathology. In university-
based hospitals with teaching programs, the prosector is a
pathology resident (a physician who is training to be a
pathologist) or a medical student taking an elective
rotation in pathology. In larger non-university-based
hospitals covered by large pathology groups, the prosector
may be a pathologist's assistant. The "PA" is typically a
graduate of an associate or baccalaureate program which
provides training in several areas of pathology, especially
those that involve "hands-on" activities, such as autopsy
dissections, dissections of specimens removed at surgery,
specimen photography, and video applications. PA's enjoy
excellent pay and benefits (US$40,000 to start) in their
little-known area, and the demand for PA's continues to
exceed supply.

Other individuals may be present at the autopsy, usually for
educational opportunities. These may include the attending
or consulting physicians, residents, medical students,
nurses, respiratory therapists, and others involved in
direct patient care.

The prosector and diener wear fairly simple protective
equipment, including scrub suits, gowns, gloves (typically
two pair), shoe covers, and clear plastic face shields. Some
facilities have sealed-environment "space suits," but I
think one is more likely to infect himself as a result of
the clumsiness lent by these suits than if he were dressed
more lightly in the interest of nimbleness.

THE EXTERNAL EXAMINATION

The body is taken from the cooler by the diener and is
placed on the autopsy table. Experienced dieners, even those
of slight build, can transfer even obese bodies from the
carriage to the table without assistance. Since the comfort
of the patient is no longer a consideration, this transfer
is accomplished with what appears to the uninitiated a
rather brutal combination of pulls and shoves, not unlike
the way a thug might manhandle a mugging victim.

The body is then measured. Large facilities may have total-
body scales, so that a weight can be obtained. The autopsy
table is a waist-high aluminum fixture that is plumbed for
running water and has several faucets and spigots to
facilitate washing away all the blood that is released
during the procedure. Older hospitals may still have
porcelain or even marble tables. The autopsy table is
basically a slanted tray (for drainage) with raised edges
(to keep blood and fluids from flowing onto the floor).
After the body is positioned, the diener places a "body
block" under the patient's back. This rubber or plastic
brick-like appliance causes the chest to protrude outward
and the arms and neck to fall back, thus allowing the
maximum exposure of the trunk for the incisions. The
prosector checks to make sure that the body is that of the
patient named on the permit by checking the toe tag or
patient wristband ID. Abnormalities of the external body
surfaces are then noted and described, either by talking
into a voice recorder or making notes on a diagram and/or
checklist.

OPENING THE TRUNK

The diener takes a large scalpel and makes the incision in
the trunk. This is a Y-shaped incision. The arms of the Y
extend from the front of each shoulder to the bottom end of
the breast bone (called the xiphoid process of the sternum).
In women, these incisions are diverted beneath the breasts,
so the "Y" has curved, rather than straight, arms. The tail
of the Y extends from the xiphoid process to the pubic bone
and typically makes a slight deviation to avoid the
umbilicus (navel). The incision is very deep, extending to
the rib cage on the chest, and completely through the
abdominal wall below that.

With the Y incision made, the next task is to peel the skin,
muscle, and soft tissues off the chest wall. This is done
with a scalpel. When complete, the chest flap is pulled
upward over the patient's face, and the front of the rib
cage and the strap muscles of the front of the neck lie
exposed. Human muscle smells not unlike raw lamb meat in my
opinion. At this point of the autopsy, the smells are
otherwise very faint.

An electric saw or bone cutter (which looks a lot like
curved pruning shears) is used to open the rib cage. One cut
is made up each side of the front of the rib cage, so that
the chest plate, consisting of the sternum and the ribs
which connect to it, are no longer attached to the rest of
the skeleton. The chest plate is pulled back and peeled off
with a little help of the scalpel, which is used to dissect
the adherent soft tissues stuck to the back of the chest
plate. After the chest plate has been removed, the organs of
the chest (heart and lungs) are exposed (the heart is
actually covered by the pericardial sac).

Before disturbing the organs further, the prosector cuts
open the pericardial sac, then the pulmonary artery where it
exits the heart. He sticks his finger into the hole in the
pulmonary artery and feels around for any thromboembolus (a
blood clot which has dislodged from a vein elsewhere in the
body, traveled through the heart to the pulmonary artery,
lodged there, and caused sudden death. This is a common
cause of death in hospitalized patients).

The abdomen is further opened by dissecting the abdominal
muscle away from the bottom of the rib cage and diaphragm.
The flaps of abdominal wall fall off to either side, and the
abdominal organs are now exposed.

REMOVING THE ORGANS OF THE TRUNK

The most typical method of organ removal is called the
"Rokitansky method." This is not unlike field dressing a
deer. The dissection begins at the neck and proceeds
downward, so that eventually all the organs of the trunk are
removed from the body in one bloc. The first thing the
diener does is to identify the carotid and subclavian
arteries in the neck and upper chest. He ties a long string
to each and then cuts them off, so that the ties are left in
the body. This allows the mortician to more easily find the
arteries for injection of the embalming fluids.

A cut is them made above the larynx, detaching the larynx
and esophagus from the pharynx. The larynx and trachea are
then pulled downward, and the scalpel is used to free up the
remainder of the chest organs from their attachment at the
spine. The diaphragm is cut away from the body wall, and the
abdominal organs are pulled out and down. Finally, all of
the organs are attached to the body only by the pelvic
ligaments, bladder, and rectum. A single slash with the
scalpel divides this connection, and all of the organs are
now free in one block. The diener hands this organ bloc to
the prosector. The prosector takes the organ bloc to a
dissecting table (which is often mounted over the patient's
legs) and dissects it. Meanwhile, the diener proceeds to
remove the brain.

REMOVING THE BRAIN

The diener takes the body block out from under the patient's
back and places it under the back of the head. This elevates
the head so that it is positioned as if it were on a very
thick, stiff pillow. The diener uses a scalpel to cut from
behind one ear, over the crown of the head, to behind the
other ear. Like with the trunk incisions, this one is deep,
all the way to the skull. The skin and soft tissues are now
divided into a front flap and a rear flap. The front flap is
pulled (this takes some strength) forward (like being
"scalped") over the patient's face, thus exposing the top
and front of the skull. The back flap is pulled backwards
over the nape of the neck. The whole top hemisphere of the
skull is now exposed.

The diener takes an electric saw (typically called a
"Stryker saw," even if it's not manufactured by Stryker) and
makes cuts around the equator of the cranium. This cut must
be deep enough to cut all the way through the skull, but not
so deep that the brain is cut (this takes some skill).
Typically, the cut is not totally straight but has a notch
so that the skull top (calvarium) will not slide off the
bottom half of the skull after everything is sewn back up.
After this cut, the calvarium is removed and set aside. As
the calvarium is lifted off, there is a very characteristic
sound that is sort of a combination of a sucking sound and
the sound of rubbing two halves of a coconut together. The
best recorded representation of this sound that I have heard
is in the brain transplant scene of the film _Robocop II_.

The outer layer of the meninges (the coverings of the
brain), called the dura, stays with the calvarium, so that
the top of the brain is now fully exposed. After the chore
of getting to it, it is a relatively easy matter to get the
brain out. There are no tough ligaments that hold the brain
in, so really all that needs to be done is to cut the spinal
cord and the dural reflections that go between the
cerebellum and cerebrum (called the tentorium). The brain is
then easily lifted out.

Since the brain is very soft and easily deformable, it is
not manipulated at the time of the autopsy. Instead it is
hung up by string in a large jar of formalin (a 10% solution
of formaldehyde gas in buffered water) for two weeks or
longer. The action of formaldehyde is to "fix" the tissue,
not only preserving it from decay, but also causing it to
become much firmer and easier to handle without deforming
it. The reason that it is suspended by string is to prevent
it from having a flattened side from lying in the bottom of
the jar (the brain is heavier than water and therefore
sinks).

EXAMINATION OF THE ORGANS OF THE TRUNK

At the dissection table, the prosector typically dissects
and isolates the esophagus from the rest of the chest
organs. This is usually done simply by pulling it away
without help of a blade (a technique called "blunt
dissection"). The chest organs are then cut away from the
abdominal organs and esophagus with scissors. The lungs are
cut away from the heart and trachea and weighed, then sliced
like loaves of bread into slices about one centimeter thick.
A long (12" - 18"), sharp knife, called a "bread knife" is
used for this.

The heart is weighed and opened along the pathway of normal
blood flow using the bread knife or scissors. Old-time
pathologists look down on prosectors who open the heart with
scissors, rather than the bread knife, because, while the
latter takes more skill and care, it is much faster and
gives more attractive cut edges than when scissors are used.
The coronary arteries are examined by making numerous
crosscuts with a scalpel.

The larynx and trachea are opened longitudinally from the
rear and the interior examined. The thyroid gland is
dissected away from the trachea with scissors, weighed, and
examined in thin slices. Sometimes the parathyroid glands
are easy to find, other times impossible.

The bloc containing the abdominal organs is turned over so
that the back side is up. The adrenal glands are located in
the fatty tissue over the kidneys (they are sometimes
difficult to find) and are removed, weighed, sliced, and
examined by the prosector.

The liver is removed with scissors from the rest of the
abdominal organs, weighed, sliced with a bread knife, and
examined. The spleen is similarly treated.

The intestines are stripped from the mesentery using
scissors (the wimpy method) or bread knife (macho method).
The intestines are then opened over a sink under running
water, so that all the feces and undigested food flow out.
As one might imagine, this step is extremely malodorous. The
resultant material in the sink smells like a pleasant
combination of feces and vomitus. The internal (mucosal)
surface of the bowel is washed off with water and examined.
It is generally the diener's job to "run the gut," but
usually a crusty, senior diener can intimidate a young first-
year resident prosector into doing this ever-hated chore.
Basically, whichever individual has the least effective
steely glare of disdain is stuck with running the gut.

The stomach is then opened along its greater curvature. If
the prosector is lucky, the patient will have not eaten
solid food in a while. If not, the appearance of the
contents of the stomach will assure the prosector that he
will not be eating any stews or soups for a long time. In
either case, the smell of gastric acid is unforgettable.

The pancreas is removed from the duodenum, weighed, sliced
and examined. The duodenum is opened longitudinally, washed
out, and examined internally. The esophagus is similarly
treated.

The kidneys are removed, weighed, cut lengthwise in half,
and examined. The urinary bladder is opened and examined
internally. In the female patient, the ovaries are removed,
cut in half, and examined. The uterus is opened along either
side (bivalved) and examined. In the male, the testes are
typically not removed if they are not enlarged. If it is
necessary to remove them, they can be pulled up into the
abdomen by traction on the spermatic cord, cut off, cut in
half, and examined.

The aorta and its major abdominal/pelvic branches (the
renal, celiac, mesenteric, and iliac arteries) are opened
longitudinally and examined.

Most of the organs mentioned above are sampled for
microscopic examination. Sections of the organs are cut with
a bread knife or scalpel and placed in labeled plastic
cassettes. Each section is the size of a postage stamp or
smaller and optimally about three millimeters in thickness.
The cassettes are placed in a small jar of formalin for
fixation. They are then "processed" in a machine that
overnight removes all the water from the specimens and
replaces it with paraffin wax. Permanent microscopic
sections (five microns, or one two-hundredth of a millimeter
thick) can be cut from these paraffin sections, mounted on
glass slides, stained, coverslipped, and examined
microscopically. The permanent slides are usually kept
indefinitely, but must be kept for twenty years minimum.

Additional small slices of the major organs are kept in a
"save jar," typically a one-quart or one-pint jar filled
with formalin. Labs keep the save jar for a variable length
of time, but at least until the case is "signed out" (i.e.,
the final written report is prepared). Some labs keep the
save jar for years. All tissues that are disposed of are
done so by incineration.

A note on dissection technique: All of the above procedures
are done with only four simple instruments -- a scalpel, the
bread knife, scissors, and forceps (which most medical
people call "pick-ups." Only scriptwriters say "forceps").
The more handy the prosector, the more he relies on the
bread knife, sometimes making amazingly delicate cuts with
this long, unwieldy-looking blade. The best prosectors are
able to make every cut with one long slicing action. To saw
back and forth with the blade leaves irregularities on the
cut surface which are often distracting on specimen
photographs. So the idea is to use an extremely sharp, long
blade that can get through a 2000-gram liver in one graceful
slice. Some old-time purist pathologists actually maintain
their own bread knives themselves and let no one else use
them. Such an individual typically carries it around in his
briefcase in a leather sheath. This would make an excellent
fiction device, which, to my knowledge, has not been used.
Imagine a milquetoast pathologist defending himself from a
late-night attacker in the lab, with one desperate but
skillful slash of the bread knife almost cutting the
assailant in half!

Note on the appearance of the autopsy suite: Toward the end
of the autopsy procedure, the room is not a pretty sight.
Prosectors vary markedly in how neat they keep the
dissection area while doing the procedure. It is legendary
that old-time pathologists were so neat that they'd perform
the entire procedure in a tux (no apron) right before an
evening at the opera (pathologists are noted for their love
of classical music and fine art). Modern prosectors are not
this neat. Usually, the autopsy table around the patient is
covered with blood, and it is very difficult not to get some
blood on the floor. We try to keep blood on the floor to a
minimum, because this is a slippery substance that can lead
to falls. The hanging meat scales used to weigh the organs
are usually covered with or dripping with blood. The chalk
that is used to write organ weights on the chalkboard is
also smeared with blood, as may be the chalkboard itself.
This is an especially unappetizing juxtaposition.

CLOSING UP AND RELEASING THE BODY

After all the above procedures are performed, the body is
now an empty shell, with no larynx, chest organs, abdominal
organs, pelvic organs, or brain. The front of the rib cage
is also missing. The scalp is pulled down over the face, and
the whole top of the head is gone. Obviously, this is not
optimal for lying in state in public view. The diener
remedies this problem. First, the calvarium is placed back
on the skull (the brain is not replaced), the scalp pulled
back over the calvarium, and the wound sewn up with thick
twine using the type of stitch used to cover baseballs. The
wound is now a line that goes from behind the ears over the
back of the skull, so that when the head rests on a pillow
in the casket, the wound is not visible.

The empty trunk looks like the hull of a ship under
construction, the prominent ribs resembling the
corresponding structural members of the ship. In many
institutions, the sliced organs are just poured back into
the open body cavity. In other places, the organs are not
replaced but just incinerated at the facility. In either
case, the chest plate is placed back in the chest, and the
body wall is sewn back up with baseball stitches, so that
the final wound again resembles a "Y."

The diener rinses the body off with a hose and sponge,
covers it with a sheet, and calls the funeral home for pick-
up. As one might imagine, if the organs had not been put
back in the body, the whole trunk appears collapsed,
especially the chest (since the chest plate was not firmly
reattached to the ribs). The mortician must then remedy this
by placing filler in the body cavity to re-expand the body
to roughly normal contours.

Ultimately, what is buried/cremated is either 1) the body
without a brain and without any chest, abdominal, or pelvic
organs, or 2) the body without a brain but with a hodgepodge
of other organ parts in the body cavity.

FINISHING UP

After the funeral home has been called, the diener cleans up
the autopsy suite with a mop and bucket, and the prosector
finishes up the notes and/or dictation concerning the
findings of the "gross exam" (the part of the examination
done with the naked eye and not the microscope; this use of
the term "gross" is not a value judgement but a direct
German translation of "big" as opposed to "microscopic").
For some odd reason, many prosectors report increased
appetite after an autopsy, so the first thing they want to
do afterwards is grab a bite to eat. The whole procedure in
experienced hands, assuming a fairly straightforward case
and no interruptions, has taken about two hours. Complicated
cases requiring detailed explorations and special
dissections (e.g., exploring the bile ducts, removing the
eyes or spinal cord) may take up to four hours.

AFTER THE AUTOPSY

Days to weeks later, the processed microscopic slides are
examined by the attending pathologist, who renders the final
diagnoses and dictates the report. Only the pathologist can
formally issue the report, even if he or she was not the
prosector (i.e., the prosector was a resident, PA, or med
student). The report is of variable length but almost always
runs at least three pages. It may be illustrated with
diagrams that the prosector draws from scratch or fills in
on standard forms with anatomical drawings. The Joint
Commission for the Accreditation of Healthcare Organizations
(JCAHO), which certifies hospitals, requires the final
report to be issued within sixty days of the actual autopsy.
The College of American Pathologists, which certifies
medical laboratories, requires that this be done in thirty
days. Nevertheless, pathologists are notorious for tardiness
in getting the final report out, sometimes resulting in
delays of years. Perhaps the non-compensated nature of
autopsy practice has something to do with this. Pathologists
are otherwise very sensitive to turnaround times.

THE BRAIN-CUTTING

Remember the brain? We left it suspended in a big jar of
formalin for a few weeks. After the brain is "fixed," it has
the consistency and firmness of a ripe avocado. Before
fixation, the consistency is not unlike that of three-day-
old refrigerated, uncovered Jello. Infant brains can be much
softer than that before fixation, even as soft as a flan
dessert warmed to room temperature, or worse, custard pie
filling. Such a brain may be difficult or impossible to hold
together and can fall apart as one attempts to remove it
from the cranium.

Assuming good fixation of an adult brain, it is removed from
the formalin and rinsed in a running tap water bath for
several hours to try to cut down on the discomforting, eye-
irritating, possibly carcinogenic formalin vapors. The
cerebrum is severed from the rest of the brain (brainstem
and cerebellum) by the prosector with a scalpel. The
cerebellum is severed from the brainstem, and each is sliced
and laid out on a tray for examination. The cerebrum is
sliced perpendicularly to its long axis and laid out to be
examined. Sections for microscopic processing are taken, as
from the other organs, and a few slices are held in "save
jars." The remainder of the brain slices is incinerated.

_____________________________________________________________

An HTML version of this FAQ, with a few hypertext links, is
available through the author's home page at:

           <http://www.neosoft.com/~uthman/>

Please send any constructive comments concerning this FAQ to
Ed Uthman, MD <[e-mail]>.

Copyright (c) 1994-96, Edward O. Uthman. This material
may be reformatted and/or freely distributed via online
services or other media, as long as it is not substantively
altered. Authors, educators, and others are welcome to use
any ideas presented herein, but I would ask for
acknowledgment in any published work derived therefrom.

END