The Final Cut

Anatomy of an Autopsy

(Photo by Ben Ferrari)

One in 100 New Yorkers die each year, but the Office of the Chief Medical Examiner (OCME) of the City of New York is required by law to investigate only those deaths that are sudden, unexpected, unusual, suspicious, violent, or unattended by a physician. About 20,000 deaths are reported to the agency annually. When one of the OCME’s investigators (all certified physician assistants) responds to the scene, if there’s any doubt about whether the death is due to natural causes, the body is held at the morgue for further examination or an autopsy.

In about 5,500 cases each year, a “medical-legal” autopsy is warranted to determine the cause of death and, in the case of a homicide, to help reconstruct the fatal episode. The basic procedure takes from one to several hours, depending on the nature of the case. It consists of a systematic external and internal examination of the body and subsequent testing of its tissues and fluids. Only two major incisions are made: a deep Y-shaped cut from each shoulder to the pit of the stomach, and then straight down to the pubic bone, and another across the back of the head. When the body is sewn up and dressed for viewing, none of these marks are visible.

A forensic pathologist and mortuary assistant perform the autopsy at one of eight large stainless-steel, sinklike tables. To minimize the risks of contamination, they wear protective gear to shield themselves from such infectious diseases as tuberculosis and hepatitis. Each table has a downdraft ventilation system, and the entire room is under negative pressure, with 12 complete air exchanges per hour.

Meticulous care is taken to observe and record any potentially significant details. Because a body is perishable evidence, it is photographed and x-rayed before it is altered by the autopsy, and these images are sent to the Municipal Archives for permanent storage. Only the family of the deceased is entitled to a copy of the autopsy report and medical records.

Sorting out the cause of death from potential causes of death is a matter of judgment. “Most often,” says Charles Hirsch, MD, the city’s chief medical examiner, “it is done by a process of exclusion.” Dr. Hirsch, professor and chairman of the Department of Forensic Medicine and professor of pathology, has served the city in this capacity since 1989. His office, an autonomous agency within New York City’s Department of Health, is part of the criminal justice system. Its county morgues—one in each of the five boroughs—are open 24 hours a day, 365 days a year.

“There are two kinds of autopsies that are provocative and challenging,” explains Dr. Hirsch, who estimates that he has performed some 6,000 of them in his career. “Those in which we can’t find the cause of death, which happens in perhaps less than 1 percent of all cases, and those in which the question is not ‘How did this person die?’ but rather ‘How did this person live so long?’ In this field, you can’t help but have a pretty good concept of your own mortality. None of us really knows what’s ticking inside.”