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$800 and US$1500.

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.

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 five 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 potential for dieners, and I'm not aware that any
writers to date have taken advantage of this.

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 {*filter*} 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 {*filter*} and fluids from flowing onto the floor).
After the body is positioned, the diener places a "body
block" under the patient's back. This {*filter*} 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 {*filter*} bone (called the xiphoid process of the sternum).
In women, these incisions are diverted beneath the {*filter*}s,
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
{*filter*} 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 ...

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When I was stationed at Lackland AFB during late '50's I was a military
pathologist, but essentially doing the same profession. I had finished a
post and was going back to the office with the brain crock in my bicycle
basket. I turned a corner and there was a bunch or Airmen, new recruits,
marching down the road. They saw that I was a Captain and saluted!. I
saluted back and fell off my bike. The brain crock fell off the basket,
naturally, and out spilled the brain onto the sand. I actually do not
think these young guys new what the{*filter*}ens I had.

Another time at Lackland, I had done a post on a young man who had just
had a craniotomy for an astrocytoma and didn't make it. I noted a package
on the body's shroud, pinned to the chest. I thought "it's some valuable,
I'll tape it to the patient's chart...it's not mine." Several months
later, all hell broke loose. Apparently, a medical records clerk had noted
this on the chart and thought that it really belonged to the patient's
next of kin. So she mailed it to the wife. What it had in it was the
patient's hair, which the surgeon had thoughtfully considered as something
that the mortuary might need in the final prep of the body prior to the
services. Of course the wife thought this was macabre to the 10th power
and went ballistic1

Once in Berkeley, the City passed a law allowing people to be their own
funeral directors...you know, to save dough...and this went over big in
that city. One time we had a deceased person who was from the School for
the Deaf and Blind and some of his friends thought they would serve as the
funeral directors for this person. They filled out all the forms and
showed up at the hospital. We had to check with the City but finally had
to release the body to this group. As they were mostly deaf, it was a
strange evening. We helped them get the body onto a guerney and down to
the loading dock. Surprise! What they had was an open pick up truck! So,
what the hell,we just dumped the corpse into the truck and off they went.
We often joked as to what we'd do if they had come with a Harley!

The stories never end but this shall have to. Bill Palmer

--
William Palmer
Anatomic Pathology Institute
Oakland, CA 94618