Knife After Death

What happens during an autopsy and can you handle it?

What happens during an autopsy? Autopsies are a vital part of learning what happened in death. They can also help to provide closure for the family and friends of the deceased. However, they are not without their controversies. Some people find forensic autopsies to be disturbing or even traumatizing. This article will explore some of the activities that take place during an autopsy and why they might make some people feel uncomfortable.

What happens during an autopsy procedure episode transcript

Okay. I am back and we’re going to do the third episode of season two if you don’t mind. Again, I’m trying to keep up with one week, short episodes, quick-hitting topics, and I like to do current events if they’re relevant, but I don’t think there’s been anything this week that’s been necessary to talk about on this particular podcast.

what happens during an autopsy
What happens during an autopsy?

Episode Introduction

The week prior Bob Saget and Betty White died, but there really isn’t a ton to talk about with either one of those. I made a YouTube video about the Bob Saget case, just basically talking about what happens when we find somebody dead in a hotel room and the things that we look for. And then Betty White, I mean, she was almost a hundred years old, and so she lived longer than most of us. And there really wasn’t a whole lot to say in that case.

So no current events this week to talk about. So we’re going to talk about what are the moments during the autopsy that are faint inducing. In other words, what will cause people to faint or cause people to run out screaming or cause people to never want to ever talk to me again, at least from an autopsy perspective? I think I’ve made a lot of people never want to talk to me again, but that’s more of a personality trait.

A Future Medical Examiner Often Asks These Questions

Anyway, the reason why I did this is that I have a lot of people who ask me, what can I do to get into your field? And it’s tough because a lot of states won’t let people come and watch autopsies, so therefore you have a lot of people who can’t observe a case and know whether or not they could handle it. So I’m going to tell you if you can see an autopsy performed, you should. And certainly, if you’re in the health profession, I think it’s a little bit easier to get in and do that. And certainly, if you’re going into a field like mine, usually you can find somebody that will accommodate you.

But I also get asked, what should I look out for? Am I going to handle it? Am I going to fall to the floor and faint? And the answer is you really don’t know until you do it. So my first case, which I think I talked about it in one of the podcasts that I did last season, and I wrote about it in a magazine article and it was anxiety-producing, but it wasn’t a fear moment. It wasn’t something where I really felt I was going to snap or something. And so I managed to handle it. I think that you have a first in every kind of case., You’ll have like the first person that’s your age. You’ll have your first child. You’ll have your first murder. You’ll have your first horrific industrial accident. And so every new first brings up new opportunities.

And so it’s really difficult to predict how you’ll respond, but I’m going to do a real quick podcast here and talk about my observations of when people lost it in the room. Either they started to faint or they just felt sick and ran out or whatever. And so there’s really just a handful and they’re pretty specific.

The first step in seeing a deceased person

So, first is just opening the body bag. You have a body there. This used to be a person who was animated and walking around and talking and probably didn’t know they were going to die. That can sometimes be a little bit jarring to people. If they’re in healthcare usually they do just fine with it, but a lot of times we’ll have people who are not in healthcare who come for their first autopsy. And this would be a rookie police officer who hasn’t seen a case before, or sometimes we used to let people come from the community. Sometimes they would observe, they’ve never seen that before. Sometimes we have attorneys who will come in, they have to do it as part of being in their law office. It’s just a requirement for them or particularly prosecutor’s offices. And sometimes opening that bag can, you can just see the person turning gray. And usually, we have to stop and say, Hey, are you okay? Never had anybody faint on that one. But now we do a preemptive thing where if we have somebody new in the autopsy, in the morgue, we will tell them a little spiel. So in other words, don’t freak out. This is all about science. It’s about discovering why the person died and ultimately it’s about delivering justice.

If it’s a legal case or delivering closure, if it’s not a legal case and it’s just a natural type of death or it’s something where the family needs to know why the person died, we will provide closure. And so usually when we frame it like that, the person handles it pretty well. But I always given an add-on to that disclaimer and I say if you feel like you’re going to faint, get out, leave the room because the last person you want helping you after you’ve hit the floor is me, a pathologist covered in blood. I’m not going to be as good as somebody who’s an EMS and who’s used to people in dire straits. If somebody faints in my morgue, I’m probably going to just somebody else go deal with it because I can’t. And fortunately, we haven’t had that come up really too much, but I personally don’t want to have to deal with that.

So I just tell people, look, there’s a door 20 feet away. You can go outside and get some oxygen. You can sit down, but just, if you’re feeling weird, get out. So if you ever do an autopsy with me, you’re going to get that spiel no matter who you are, if you’ve never seen it before.

So opening the bag, hasn’t been a problem. So then I always tell people that the next part is… Because we draw toxicology. We try to draw toxicology first before we do anything else, and so that’s blood and vitreous. Usually, we get urine when we get inside the body, we can actually take a syringe and put it in the bladder. But we try to get blood externally. We try to put a needle into the femoral artery or femoral vessels and draw out blood. And that’s usually not a problem for people, but vitreous is a problem.

Post mortem examination of vitreous fluid

So what’s vitreous fluid? So in your eye, there is a clear jelly-like substance called the vitreous humor. And we will put a needle into the eye to draw that out. And I know you’re thinking, if you haven’t seen this, you’re thinking, well, why would you do that? That just seems unnecessary. Well, the fact is with vitreous fluid, it’s actually an excellent fluid for toxicology. And it’s very good for some things. Number one is alcohol. If you’re looking at a blood alcohol concentration and you get the vitreous alcohol concentration, you can make a comparison because the vitreous lags behind in metabolism by a couple of hours, and you can and actually make a comparison and say, was this person still drinking and still raising their blood alcohol? Was this person at equilibrium or was this person already metabolizing and had stopped drinking? Sometimes that’s relevant.

Diagram of the eye and vitreous fluid.
Diagram of the eye and vitreous fluid. (Credit: Associated Retina Consultants)

The second is electrolytes. So you’ve got sodium and, I’m not going to go through every electrolyte. Potassium’s not good for the vitreous, but sodium is. So if you have hypernatremia, high sodium, or hyponatremia, low sodium, it’s excellent to look at the vitreous for the electrolytes.

So lastly would be glucose and glucose is of course the blood sugar. And if the glucose is very low, it’s not very helpful because, after death, your glucose gets sucked into your cells as they’re basically struggling to survive, all the glucose is going to get used up because ultimately your cells want to survive and it’ll use up all the glucose in the area. But if the glucose is high that can be very useful to tell you if somebody was having a diabetic complication, such as diabetic ketoacidosis. And that would be the other thing that you’re going to look for in vitreous is ketones.

Now, ketones, I’m not going to go through the biochemistry of ketones here, it’s a little beyond what we need to do, but we’re going to have ketones in there if we’re having diabetic ketoacidosis. So vitreous fluid is very important and I probably went on a little bit of a tangent there, but I wanted to give you a little background on why we do it.

We don’t do it just to see if people will pass out. We do it for a reason, for our decedent, our patient there. And a lot of people don’t do well with that needle in the eye. I’ve noticed a lot of police officers will tell me I’m I can’t even look at the body while you’re doing it. So sometimes we’ll give them a little warning or say, Hey, we’re going to do vitreous. And then they can stare into the wall or look out the door or something like that. So, there’s a natural aversion, I think, to seeing a needle go into the eye. But that would be one of the other times where we’ve had people have to leave. So that’s the vitreous draw.

Further Examination Through the Opening Incision

Now the next part is going to be the opening incision. And for me, that was the big one. When I was a young pathology resident and I was getting ready to do my first autopsy, that’s the one that really, I was worried about. If something was going to happen, physiologically to me, in other words. Because you know, you have to press on the skin and you have to find where you’re going to cut. And usually, you start at one shoulder and you come to the center of the chest and then you start at the other shoulder and you come down and form a V and then you draw it down the abdomen and you form a Y. That’s why it’s called the Y shaped incision. And my first autopsy, the woman had died very recently, within the last couple of hours. And so when I pressed on the flesh to map out where I was going to cut, it was very soft and very supple and very much a living person. And so the difference is with someone who’s been dead a while, many hours or a couple of days, and in the cooler, usually, the body is a little more firm. So rigor mortis is set in the muscles are firm and the soft tissue itself is a little bit harder because as you cool the fat down, it becomes a little waxier.

I always tell people, okay, an opening incision is the other one. And frankly, everyone seems to do pretty well with the opening incision more than I would’ve expected. But really what comes after the opening incision, I think is the one that bothers people, and that’s opening and taking the chest plate off. Okay.

Removing the chest plate of a dead person

What do I mean by chest plate? If you feel the center of your chest, there’s a very hard area, and the common name for it is the breast bone, but it’s the sternum, that’s the name of the bone. And from that, the sternum, the ribs come from the vertebral bodies around and attach to the sternum and that’s the ribcage. So you have to take off the chest plate, which is the anterior ribs in connection with the sternum. Well, how do we do that? There are two ways we do it.

One is with a saw and that’s usually not a problem for people. You turn on the bone saw you press it through the ribs. You go all the way up to the sternal clavicular joint, where the clavicle meets the sternum, right in the middle, and then you can dissect it right off. No problem. But sometimes we use loppers. And I just had talked about that before if you’ve been listening to my podcast, loppers are like branch cutters and they are literally from Lowe’s or your local hardware store. Lowes should actually sponsor me. So anybody listening to this, Lowe’s, if you want to just sponsor me or maybe home Depot, you can sponsor me because we’re using your cutting tools to open ribs sometimes. But anyway, to preserve the bone saw, sometimes we won’t use the saw itself, we will use the loppers, and they crunch.

Cutting Through the Rib Cage

So when you cut through each rib, there’s a very loud crunch and it is the crunch of bone. And so that has caused issues with people as well because it is an unsightly thing to see that. But that is a very common tool for the forensic pathologist. It’s common because it works really well, but it can be unusual to see that. And I know that many forensic pathologists will use those. And some people will just use the bone saw. Again, we don’t always use the saw because we don’t have a lot of backup saws and backup blades so we try to preserve the saw itself. But I’d say 30% of the time I use the saw and 70% of the time I use a lopper, so big cutting device.

And it’s mainly, not necessarily the sight of seeing that, but the sound, because not very many people are accustomed to hearing the crunching sound of human bones. So next would be after we take the chest plate off, if you’ve made it that far, you’re doing pretty well. There’s a very good chance you’re going to be able to make it through the autopsy.

The smell of autopsy through the abdominal organs

But once you open the abdomen, once you make the incision through the skin, through the subcutaneous tissue, and through the peritoneum, you open it up. Invariably, you get the smell of the intestines. So the smell of the autopsy comes from the intestines. And why is that? Well, bacterial growth in the intestines produces aromatic compounds that don’t smell very good. They’re sulfur-containing compounds. So if you have a really strong sense of smell, sometimes that can bother people. I know the smell. And it gets worse as decomposition proceeds.

So if you autopsy somebody a couple of hours after they died, there’s really not much of a smell at all, but the longer you go, the more bacterial growth you have and the more aromatic compounds you have. So that’s problematic for people who have really strong senses of smell. Now, lately, it’s not been as bad because, with the pandemic, most people are wearing a pretty good fitting mask during the autopsy because, obviously, we have COVID maybe in the air from aerosol production with sawing open the body and whatnot, splashing of fluids, but also the living people that are there. I’m more concerned about getting COVID from somebody that’s living and inside of my morgue than I am the body itself. So most people are wearing masks and as a result that dampens the smell a little bit.

Medical Examiner Tip For N95 Masks

By the way, a little mask hack for you, and if you haven’t figured out how to use it yet, then two years into a pandemic, then maybe I can’t help you, but people always complain about not being able to breathe in a mask. And frankly, I don’t like it either. I never liked wearing N95 masks because sometimes we’d have to wear them in med school if we had a TB patient, or sometimes we would have to wear them during residency if we had had some infectious disease patient or a dead patient who may have had an infection, whether it be MRSA or TB or something like that. And I hate, hate, hate wearing an N95 mask the whole time, because I feel like I can’t breathe. Well, I decided when the pandemic started, I couldn’t risk not wearing an N95 mask. So I breathe through my mouth.

And so I’m a mouth breather basically, right? But I breathe through my mouth and I find that the sensation of the smell isn’t as bad. So if I have a decomposed body, if I have a really smelly body, for some other reason, if I have a burned body, which can be very caustic smelling, I don’t smell it very much because I have my N95 sealed, I breathe through my mouth and I don’t have as strong as of a sensation. So if you ever want a little hack there just become a mouth breather for a little bit while you have your N95 on.

Stomach Contents During the Internal Examination

Also, the other bad one in terms of the bowel is the stomach contents. So people always ask me, is there anything that makes you gag as a pathologist? And truthfully, no, I have a really strong stomach, but stomach contents are disgusting. Absolutely disgusting because I mean, a lot of times you can see exactly what somebody was eating right before they died. And it’s obvious, but sometimes it’s chewed up well enough or it’s just a paste-type material. It’s not so bad. But the problem is is that once the food and drink hit the hydrochloric acid in the stomach, you start to get more aromatic compounds forming, sometimes it can be really a smelling. And then if you have any decomposition sets in, stomach contents are really way more horrific than the bowel contents. So sometimes the stomach contents will cause people to feel sick and want to leave.

There was one coroner that I worked with and she was a seasoned coroner. She had seen all of these terrible things and sometimes she would come into my autopsies and watch. But when it was time to cut the stomach, I had to warn her, I would say, “Hey, we’re getting ready to cut the stomach”, because that’s the one thing that she could not stand, was seeing the stomach on contents. And I agree to this day after thousands of autopsies that I’ve done, it’s still the worst part of the autopsy for me.

And I had one case once, and I’ll talk more about this case sometime in the future, but basically, it was a person that died in a hotel room with the thermostat set to 88 degrees for some reason. And so they decomposed and they had died essentially of acute alcoholic intoxication. So the stomach was filled with this alcohol decomposing food and the heat made it all that much worse. And when I opened those stomach contents, I basically had to hold my breath for the entire time. And then I had some medical students with me and they have completely plastered against the wall as far away as possible. And so again, stomach contents can be horrific depending on the situation.

Watch your terms with a family member present

So the next thing is, sometimes things are said during the autopsy that can disturb people. Things that I say that sound normal to me and fine to me heard from an observer can trigger a reaction. And I can think of one case, oh, actually a couple of different cases where we note that the body is warm while we’re autopsying So if you autopsy somebody within say 12 hours of death, 12 even 16 hours sometimes, the interior of the body will still be warm. Now that’s not to say that it’s going to be the actual body temperature, 98.6 degrees Fahrenheit, but basically, the external surface of the body will be cool. You’ll open the body up and then as we start to dissect, you feel that it’s warm. And I had one case where a woman had come to the autopsy and she basically was with somebody who had come to visit. And I put my hands into the abdomen and I commented that it was warm. This guy is still warm, I think I said, and I didn’t even realize that that would bother her. This was the first autopsy she had ever been to and I glanced over and she looked like she was turning green and she basically…

That’s the one person I’ve had that basically ran out. I mean, sprinted, bust the door, open, run down the hall. And I literally never saw that person again. And if you know me, you’ve heard me tell that story a couple of times. And it may have even appeared in one of my previous podcasts, but I’m fatigued and can’t remember everything that I say. But commenting on the body, the warmth of the body seems to bother people a little bit. I’ve had just a couple of people faint in my entire career. And one of them was partial fainting that dealt with describing how the body felt. I don’t know why that bothered the person, but they actually went to the ground, but they didn’t lose consciousness. And then they dragged her out of there, and she did a really good job because she went and had something to drink or something of that nature and she came back in and finished the autopsy. And I was like, wow, real trooper there. I would’ve been gone. I would’ve been, just out of embarrassment alone, I would’ve left, but she did a really good job.

Sounds of Clinical Autopsies

And so the sights and smells can be bad, but then you have the sounds. So the sounds of the autopsy, I think can be triggering for some people. And I guess I really should have recorded this and played it here in the podcast, but it’s when you open the head, there are a couple of different sounds that seem to really trigger people. Now the last time I did a podcast I described opening the head and folding the scalp forward over the face, but I didn’t describe what that sounded like. There is a very thin layer of tissue under the subcutaneous fat of the scalp that is attached to the skull. And when you fold it forward, it makes a ripping sound. Well, it’s a neat sound actually. I like it to be honest, but some people cannot stand that ripping sound, but because it’s little, almost like spiderweb consistency of tissue in between the scalp and the skull and there are few things more satisfying than taking a razor-sharp scalpel and dissecting that tissue away from the scalp. It’s one of my favorites. I know I’m a bit of a weirdo, but that’s fine. You guys knew that already.

Oh, by the way, I’m a little bit hoarse right now, but don’t worry, I’m not sick. I made the mistake of eating a Jolly Rancher before I got on to record this, and so basically my assistant gave me a bag of Jolly Ranchers a couple of weeks ago. I hadn’t had them for 20 years and I’ve now developed a crippling addiction to Jolly Ranchers. And so I put the Jolly Rancher in there and it melted down and now the inside of my mouth and throat is coated with this syrupy thick candy. So that’s why I sound a little bit hoars today. I apologize for that. Anyway, we have the folding of the scalp. Sometimes the sight of that can be a little disturbing as well because the skull, it looks like any skull you would see in an anatomical model.

The Folding of the Scalp During Further Investigation

So it’s weird to see a person who used to be alive laying there, and then all of a sudden you just see the top of their skull. Sometimes that’s bothersome for people and I’ll have to admit the first couple of autopsies I did was an unusual sight for me as well. But then we go ahead and get the bone saw out. There are no shortcuts there. You can’t use loppers to open a skull. You have to go through and saw the top of the skull open and removed that calvarium, And so there are two sounds associated with that. The first is the insertion of the skull key. So what you make a cut in the bone all the way around and then to actually remove that calvarium, there’s a tool called a skull key. There are actually other names for that tool, I’m not going to get into that right now, but basically, it’s T-shaped. You put it into the groove that you just cut and you turn it quickly. You turn it like you’re turning a knob on something and it cracks the skull open. It doesn’t produce an injury, don’t get me wrong, we’re not being harmful to the body, but it cracks the remaining attachments of the skull away from the area that’s been cut.

And so that loud pop can sometimes be bothersome to people. And then at that point, you basically gently insert your fingers in between the skull that’s still attached and the skull that you’ve sawed and you pull back. And when you pull back, it pulls the periosteum and the dura mater away from the calvarium itself. And when it pulls it away, it’s yet again, another almost sucking and ripping sound at the same time. It’s got a hollow sound to it. And that sound can be really unusual and disturb people.

But again, a handful of people have been troubled by this. And I will say this in the future, I will record these in some high definition way and I will play them for you, or I’ll have them in videos because you really have to see this stuff and hear this stuff. But like I said, not very many people have gone down during my cases. And I did this podcast for people who are interested in possibly attending an autopsy. Those are the moments that I’ve noticed that people seem to get upset with. But by and large, the vast majority of people come in and they do the case and they absolutely have no problem with it at all.

Attending an entire body autopsy

And I think that if you go, there’s a very good chance you’re going to do just fine with it. You just have to have the mindset that this is science. This is anatomy, and ultimately this is closure for the family. And when you put it in that mindset, I think you tend to do a lot better with it. You’re not thinking about it as a person, a living person that’s laying there. And one of the things I’m thinking about doing is making a sticker that says I survived my first autopsy or baby’s first autopsy or something like that. And then handing that out to anybody who doesn’t have a reaction. And that can be a little chip for them, maybe a badge. You know how people used to get those letter jackets and they used to put badges on them or they used to put their graduating year? Well, they can put a little badge or their little iron on that says, I survived my first autopsy.

Summary of “Common Faint-Inducing Moments for Autopsy Newbies”

So I don’t know, maybe I’ll put that in my merch store as well. Although I don’t actually have a merch store, a lot of people have asked for that and I’m working on it, my agent’s working on it. So just be calm. I have a day job. So I’m going to get to this stuff soon.

Speaking of that, in my earlier podcast, I talk about the Knife After Death website, and my good friend, who I’ve known for many, many years, who I’ve known for like 35 something years, is helping me restart that website up and we’re going to be putting a lot more content on there because I found that my social media is limiting. So I’m on TikTok and all this stuff and a lot of these places will ban anything that’s even slightly grotesque. So it’s difficult to teach pathology if you’re not going to allow images to be shown.

So TikTok is pretty much worthless for me other than answering questions, YouTube limits my videos if I show anything that’s a little bit untoward. So we’re thinking about putting that stuff up at Knife After Death, and you can see there’s a little signup place there. And I know that there are people listening to this saying, oh man, I signed up for that a year ago, and I didn’t get anything from you. You’re a terrible person. And you should just stop making content. But you have to bear with me, I did have the busiest year of my career in 2021, so I wasn’t able to devote time to it. And now I actually have someone to help me. And so keep a lookout for that. And you can go to the website. It’s still being built right now. We’re working on putting the content on there and I’ll keep you guys updated, but I hope this podcast was helpful. And if you do have to go see an autopsy, then maybe this will help usher that in without too much nervousness for you. With that being said, I’ll talk to you next time.

Summary of the episode

So, in short, there are a few things that can make someone new to autopsy faint or feel uncomfortable. Some of these things include seeing the body, hearing the cutting of the skin, and seeing the organs. However, the vast majority of people don’t have a problem with it and most find it interesting and informative. The website Knife After Death is being rebuilt and will have more content including images that have been banned from other social media sites.