How Autopsies Work

The forensic autopsy or medical-legal autopsy is the kind you most often see on TV and in movies. "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," former Fulton County Deputy Chief Medical Examiner Dr. Eric Kiesel says.

According to Kiesel, forensic autopsies try to find answers to the cause of death as part of an overall police investigation. On TV shows such "NCIS" or "Law & Order: Special Victims Unit," medical examiners seem to be a major component in the investigation and can use DNA evidence for just about everything. In reality, Kiesel explains, "the autopsy's going to tell you why they died, what killed them — but it won't necessarily tell you why they did it. So, all of the answers aren't going to be there."

The clinical autopsy, in comparison is usually performed in hospitals by a pathologist or the attending physician to determine a cause of death for research and study purposes. "They're really interested in the disease processes that are going on, and they're interested ... in making that clinical-pathological correlation," Kiesel says. "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.

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 four legally defined manners of death:

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 four 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.

Sometimes, assigning a manner of death can get really complicated. "Let's say, somebody 30 years ago received a gunshot wound to the head and they developed a seizure disorder," Kiesel explains. "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.

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 [source: Johns Hopkins].

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.

"A medical examiner by definition is a physician," Kiesel explains. "... 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. Rural counties might opt for having a coroner instead of a medical examiner because they don't have a lot of qualified forensic pathologists or the facilities for them to do their jobs properly. And a sparsely-populated jurisdiction that doesn't have much violent crime and sees few unexplainable deaths may simply decide that it doesn't need a full-time forensic pathologist.

The coroner is also responsible for identifying the body, notifying next of kin, collecting and returning the deceased's personal belongings to the family, and signing the death certificate.

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.

The body is received at a medical examiner's 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 [source: Saukko and Knight].

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 [source: Saukko and Knight].

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 [source: Waters].

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.

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 [source: Kiesel, Saukko and Knight].

If protocol dictates, the body will be X-rayed while still in the body bag. Kiesel explains why this is an important step. "I had a body where the person had been shot," he says. "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" [source: Kiesel, Saukko and Knight].

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 tables 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 [source: Saukko and Knight, Johns Hopkins].

At this point, a general description of the body is made. All identifying features are noted including:

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.

"We usually separate out into different categories our general description from our evidence of trauma, from our evidence of medical intervention, " Kiesel explains. "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] ... then we'll open the body."

In the next sections, we'll talk about the 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 extending all the way down to the pubic bone [source: Britannica]. 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 [source: Waters, Stoppler].

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 head of the body 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 body's 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.

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 funeral home is then contacted to pick up the deceased.

"An average autopsy case takes about four hours," Kiesel explains. "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 — four to six hours."

"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," Kiesel adds.

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

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.

"They weren't shot once, they were shot 13 times or 20 times ... you've got to sort out paths of all these bullets," Kiesel explains. "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' legal system won't accept that anymore."

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.

Tracing bullets can get really difficult when police are the shooters. "They really want to know, OK, what bullet went where, especially if you've got multiple shooters and especially if it's a case involving the police," Kiesel says. "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."

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," Kiesel says. "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.

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.

"We don't always use nice, delicate, surgical tools," Kiesel says. "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."

Autopsy tool shopping doesn't stop at the restaurant supply house. The medical examiner may also visit a hardware store for supplies. "Things like pruning shears tend to work better than surgical bone cutters for cutting through ribs. You know, a scalpel blade's only got an inch, inch and a half worth of cutting surface, whereas you can get a good, long knife that's got a 6-to-8-inch blade on it so you can cut more and faster," Kiesel says. "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, Kiesel says 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.

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 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 percent 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.

"There are changes that occur after death," Kiesel says. "Most of them are chemically related. Blood settles by gravity within the body, and there's a purple discoloration that occurs — that's called lividity. The body will become rigid. That's called rigidity or rigor ... People have looked at vitreous humor, which is the fluid in the eye; the corneas become cloudy ... You can look at the gastric contents [food left in the stomach or intestines]. You know, when did they last eat, and that can be helpful. Do they have a full bladder or not?"

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.

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.

"You've got to be the type of person who can emotionally disconnect it, " Kiesel says. "I mean, if you went into a case looking at it as, 'Geez, this is somebody's little girl or somebody's little boy,' you'd never be able to do the case. You can't personalize it in any way ... 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."

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