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“The beginning of an autopsy features sadness, reverence and a respect for each person’s dignity,” Wills said. “The family has very generously given us the opportunity to figure out what we couldn’t during life. It’s sad to know that the individual was once living and breathing, and know many people cared about this person. You have to realize this person has been through a great deal and they deserve the highest level of respect with the invasive procedure we are about to perform. Then the pathologist uses the techniques we were trained in to find answers.”
Declining numbers
Wills estimates that approximately 200 autopsies are performed at VUMC each year. But just a few decades ago, there were more than 500 autopsies per year. Wills, however, says there is no magic number.
“We should do enough to serve the purpose of the community and hopefully move knowledge forward,” she said. “An older pathologist would say ‘absolutely do more autopsies,’ but it’s different in these financial times. We need a purpose to perform a test.”
An autopsy is offered as a service to the families of Vanderbilt patients at no cost. Because a hospital must recover the cost of this test, the number of autopsies, both at smaller hospitals and hospitals like Vanderbilt, has declined. Another reason for the decline is the fact that there aren’t as many unanswered questions because of modern diagnostic technology.
Wills said that future patients benefit from the accrued knowledge of autopsies, and even the patient’s family members can be helped if medical problems are illuminated that could help them as well.
“We hope that reading and discussing the autopsy report with the clinician will help them understand the disease process of their loved one. Once the disease process is diagnosed and put into context for the family, they can seek genetic counseling.”
After a patient dies, the clinician discusses the autopsy option with their family. Decedent Affairs ensures that consent is properly completed, and contacts the first-year pathology resident about the new case. The resident then picks up the patient records, reconfirms proper consent and contacts the clinician about clinical treatment questions to investigate, depending on the patient’s health history and cause of death. The answers help physicians understand what went wrong and how to prevent it in the future.
The 64-year-old male had a history of right ventricle dysfunction and died during open heart surgery. The pathologists have been asked to investigate the cause of the dysfunction and why the patient had such difficulty with a defibrillator.
Before the procedure, the staff involved in this case is gathered around a desk in the corner littered with papers and files and boxes of supplies. Jessie Britton and Leavy McCoy, the technicians involved in every autopsy, are ensuring that all the necessary tools are ready and everyone has the proper gear.
During the autopsy, the first-year resident is assisted by a second-year charge while an attending physician looks on. But perhaps the most important teachers are Britton and McCoy.
“They have about a combined 70 years of experience,” Wills said. “They’ve seen everything, and they know everything.”
Britton has assisted with VUMC autopsies for more than 40 years, and McCoy for 28.
McCoy said that medical students have the book knowledge, but he and Britton teach the practical knowledge.
“I know anatomy as well as the professors,” he said. “I don’t know all the terminology, but I have practical knowledge as good as anyone. I can do it in my sleep.”
McCoy has a degree in mortuary science and has also worked at the Medical Examiner’s office. After 28 years, McCoy said facing death is just another facet of going to work.
“Either you can do this or you can’t,” he said. “You have to like it, and I think it’s interesting to get to solve a problem for a family and discover unknown diseases. Every case presents something new.”
The process
To begin the gross dissection, first-year resident Sam James, M.D., presents the patient history to Wills while the second-year charge, Jason Tedesco, M.D., looks on. This is James’ fourth autopsy, and Tedesco’s job is to oversee James’ work and help teach the procedure.
“Teaching is challenging,” Tedesco says. “You have to have patience. A lot of first year residents haven’t done too many autopsies before and need time and opportunity to learn.”
After a final verification of toe tag and hospital wrist tag, the first incision is made, a Y-shape, with branches from the shoulders meeting at the abdomen and continuing down around the navel in a single line.
Next, the breast plate is removed. McCoy picks up the striker saw, which has an oscillating blade that will cut bone and soft tissue but not the person operating it. He does the left side of the rib cage, then hands the saw to James and advises him on how to do the right side.
Every autopsy is treated as a contaminated environment, so the staff wears paper gowns covered with plastic aprons, shoe covers, hair nets, face masks and a plastic face shield. Those wielding the scalpels wear a pair of Kevlar gloves sandwiched between two pairs of rubber gloves.
To remove the breast plate, McCoy and James position themselves on each side of the body, grip it with both hands and make three quick coordinated tugs down toward the abdomen.
“An autopsy is very physical,” Wills said. “I’m a small person, and I have to stand on a stool to get the right angle.”
The next important step is to tie the carotid artery with a piece of string to prevent it from retracting during the autopsy, giving the funeral home easy access for injecting embalming fluid.
Wills said the needs of the family and funeral home are always top priority during autopsy. They will accommodate all cultural and religious requests, like the Jewish practice of burying the body before sundown, or the Native American practice of returning the organs to the body for burial.
“He will look perfectly normal after embalming,” Wills said. “We never touched the face, and we take out what we need while preserving the integrity of the body. We do autopsies in a very sensitive way. We do take great care, and we specialize each case in an attempt to answer the questions being asked.”
Once the organs are exposed, cultures can be taken. In a scene that could be out of the 19th century, a scalpel rests on an open flame from a small glass kerosene burner. McCoy presses the hot scalpel to the lung, and with a hiss and a puff of smoke, the area is sterile and James can get a germ-free lung tissue sample. He also uses a needle to collect urine from the bladder and blood from the aorta.
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