Category Archives: Education

Live Stream Autopsy in the Time of Fake News

There’s nothing more real than an image of an autopsy. You’d think. Not in the time of fake news.

We started live streaming autopsies in 2017 to hundreds of thousands of viewers (our first drew in over a million). Family consent beforehand and maintaining patient confidentiality during the case are, of course, requirements. We have an open Q & A during the case where I talk with viewers and answer questions. The videos are left up after the case and more Q & A rolls in, for later discussion. It’s been a phenomenon for us.

To sort it through, I pay attention to where our viewers lead us. Sure, we get our share of horror fans and, shall I say, worse? Our videos, I’m told, have found their way into a “serial killer” site. I’m not sure what that means. I’m hoping it’s for people CSI-curious about criminals…not a club for serial killers. And, through Google’s truth-outing, I’ve recently seen that we’re now up on a site called Cute Dead Guys — it is what it sounds like. I only know because of brief descriptors out there. I have not (and will not) be seeking the password access that tens of thousands have. To get personal, many of you who know me will have discovered the shocking truth that I don’t like horror movies or watch CSI. When I’m not doing autopsies, it’s Toy Story and Moana (“See the light where the sky meets the sea, It calls me, And no one knows how far it goes…”). Ahh, Disney. But I believe passionately in compassionate education about death, dying, health and the body. So I do what I do. It’s a balance.

On a more tame scale, our viewers have a fascination with death. Our social media serves an important normalizing function there. Our comment section on Facebook is filled with statements like “I watch all your videos. I love them. My boyfriend thinks I’m a weirdo.” And then a stranger replies: “I love them, too.” And so friends are made and it becomes ok to be interested and to learn. We work for that comfort on our site. It’s a place for people to feel comfortable with themselves and the topic. I explore and understand the body after death to help the family with closure. The autopsy is an intimate medical procedure. We design the Facebook page to highlight respect for the process and for our families. But we see the struggle with taboo in our culture that makes it so hard for people to be ok with wanting to know.

Next seems to be the largest group of our viewers: one that simply has a huge need for knowledge. Seeing the inside of the body is educational. Many comments reflect this: “I didn’t know fat was yellow.” “The skull is so thick.” “That’s where the pituitary is — no wonder they talk about some tumors being ‘inoperable’.” Many people aren’t exposed or educated about what’s on the inside. We show that. It fills a need.

And then, we have our share of professionals — nurses, paramedics, funeral directors and a variety of students. “Better than a textbook” is a theme. Stay tuned for “augmented reality.”

So that’s an encapsulation of who views us. It’s a simplification — we get moms who watch with their 3-year-old; one who watches to relax before going to sleep, and others. We think carefully about what happens to the material once we put it out there and consider how we should make it available. But we believe in education and keep our “graphic warning” front and center for our videos. The idea is not to shock, but to educate for those interested.

Now onto our place in the time of fake news. I wonder if one of our draws is simply that we are real — if that brings in a good number of our 23K Facebook followers. We are real but not a “reality show.” With the near-impossibility finding the truth on-line these days, I’m wondering if we become a place for that. In addition, we foster trust by talking without taboo. Our discussions cover death, dying, the body, nudity, health care, social media issues and the truth itself. Our Facebook page is modeled after the meaning of autopsy, “to see for one’s self.”

Let me add another phenomenon from our page. We have many people asking if the person in the video is dead. How can that be? We are removing a brain. This person in the video cannot be alive. The answer is complicated. In part, it’s the shock and surprise of seeing the procedure on-line. We’re not used to seeing autopsies. We’re used to surgeries — health care for the living — so it’s an adjustment. Another reason has to do with a deeper psychological readiness to understand “dead.” Like children developmentally, not all adults are there. It can take some processing. I get why people ask. And lastly, as one insightful Facebook fan commented — thinking of the person as alive is just easier. It can be psychologically stressful to be faced with full-on “dead.”

Only rarely do we have anyone call out our work fake. I have seen it only twice in closely reviewing thousands of comments. One person commented on Facebook that the fat looked fake — this was easily explained because there is no bleeding in an autopsy (since the heart stops circulating blood). So the fat sits there as a bright yellow plasticky-looking layer. The second comment, from YouTube was more direct: “Clearly fake. Pasta. Props on the special effects”[sic].

The draw to our page, value to our viewers for the education, the struggle some have with “understanding dead” and occasional call-outs of Fake! point to one thing: a person’s psychological readiness for the truth determines what they look for and can accept. I suspect this is true in the media in general. We should have compassion for people who need fake news. They must have some deep limitation as to what they can handle from the daily, painful reality that bombards and overwhelms us in the media. (This, of course, does not mean we should tolerate efforts to undermine the truth.) On the flip side, those fighting to access the truth — or place to say a five-minute autopsy video is of interest — show courage. Fake news is a broad cultural expression of psychological stress in the face of reality.

Autopsy Center is here to develop a place for those ready (or who can be ready) for the truth. One of the things we are doing at the Center is developing our high school program, Live from the Morgue. Schools from across the country can join us simultaneously during one of our video-educational sessions. We’re developing our school-to-school shared experiences specifically with an eye to breaking barriers at an early age.

Join us when you’re ready and if you’re interested. We’re here to share the truth. To our pasta-commenter from YouTube. No, not fake, not pasta, not special effects. Real. The human body. Props on how beautiful life has made us.

Check out our videos on Facebook or YouTube or download our Autopsy app.

New Procedure: Small Incision Autopsy

Small Incision Autopsy

We’re now offering an autopsy whose sole purpose is to provide families with information about inherited conditions: The Small Incision Autopsy.

Our over-riding goal is to provide families with closure after a loss. Generally, this means understanding why the patient died. But it can also mean explaining what may have caused troubling symptoms, assessing changes related to procedures and other treatments, and teaching about basic disease processes. If the death is unexpected and sudden, families can also wonder if there is an inherited condition to worry about. An autopsy can sometimes help by finding out.

The Small Incision Autopsy uses a small incision — much smaller than that of a routine autopsy — to access important areas of the body that can harbor just the information that could help the family.

Right now, we’re focusing on heart disease — a main cause of sudden death. Some important inherited causes of sudden cardiac death can include coronary blockages from high cholesterol; and the very under-reported valve condition, bicuspid aortic valve. Taking a focused look at the heart can uncover these and other heart conditions. The family can then get tested and treated. Knowing can save lives.

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Sleuth-It Diagnosis: Bicuspid aortic valve

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Safe bicuspid

What counts in the heart? The number of parts to each valve counts. In this case, the number of parts (leaflets) of the aortic valve was important.

You stopped counting after seeing two aortic valve leaflets. Normally there are three.

Two aortic valves rather than three is an inherited condition called “bicuspid aortic valve.” It affects 1-2% of the population.

Bicuspid aortic valve can be associated with aortic aneurysm and rupture, typically in late middle age among males with the condition.

The inheritance is not well-understood but does not have to affect every family member.

Once this diagnosis is suspected, family members can get tested. If any family member has the condition, they can be monitored for disease progression and treated (with blood pressure medicine, surgery if needed, and so on).

Knowing the diagnosis can save the lives of the affected family members.

The autopsy helped with the family’s closure; but also did much more than that by alerting the family to an inherited genetic condition.

Here’s more information about bicuspid aortic valve.

Sleuth It — What Counts in the Heart?

Aortic aneurysm imageYou perform an autopsy on an elderly man who died suddenly at home. The gentleman was stoic, somewhat distant from his family and never sought medical care. There are four adult children who call you to perform an autopsy. They would like to know what happened.

During the autopsy, you find that the sac around the heart is full of blood. Your first thought is to consider either a heart attack with rupture of the heart muscle; or an aortic aneurysm with rupture of the aorta.

The coronary arteries are whistle clean (no significant blockage by plaque) and the heart muscle is healthy. There was no heart attack. But the aorta coming out of the heart is twice as wide as normal and there’s a half-inch tear in it close to the heart. It’s the aorta that has ruptured.

You consider high blood pressure as a common cause of aortic aneurysm. But if there were many years of high blood pressure, the heart should be bigger than normal and the kidneys should have a rough surface. The heart is normal size and the kidneys are smooth. It doesn’t look like there was high blood pressure.

You wonder about the inherited condition, Marfan syndrome, which goes along with a stretched out aorta and aortic rupture. But patients with Marfan syndrome tend to be tall and this gentleman is short. Marfan syndrome is unlikely.

You continue a systematic assessment of the heart, continuing with the heart valves. First you assess the valves on the right side of the heart: Tricuspid valve. “One, two, three leaflets. All thin and pliable. No problem there,” you think. Now the pulmonic valve. “One, two, three leaflets. All thin and pliable. No problem there.” You move on to the left side of the heart, looking at the mitral valve. “One, two leaflets, no problems.” Then you look the aortic valve, “One, two….”

Suddenly you realize you better call the family in. The autopsy results may save their lives.

What did you see?

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Monthly Case: Coronary Artery Rupture

Jan safe case
What is shown?
The top image shows the heart sac opened in the chest. The sac is full of blood (cardiac tamponade). The bottom image shows the heart after the blood around it has been removed. The view is of the back of the heart. There is a T-shaped hemorrhage. The right coronary artery (RCA) wraps around from the front and is seen on the top right. The left circumflex coronary artery (LCX) also wraps around from the front and is seen the top left. The posterior descending coronary artery (PDA) branches off the RCA and travels down the middle of the back of the heart.

What was the story here?
The patient was a middle aged man who came in to the hospital short of breath for several days after getting through a cold. He had a coronary artery stent put in his right coronary artery. The procedure seemed to go well. Later in the afternoon, he became dizzy, collapsed and died. His wife spoke with the cardiologist who explained it was probably a “stroke.” The wife could not understand why, suddenly, there was a stroke right after the procedure. She also didn’t believe he had any blockages because the husband had been athletic. She requested an autopsy and retained a lawyer.

What caused the blood on the back of the heart?
The blood on the surface of the back of the heart tracks along the coronary arteries. (The coronary arteries travel over the surface of the heart). This suggests the blood came from the coronary artery itself. Because a stent was placed in the same area as the hemorrhage, this suggests that a coronary artery ruptured related to the placement of the stent. Other possibilities would be a CPR-related contusion (but that would not track along blood vessels); or a tear of the muscle heart muscle wall (but that did not happen either).

How did the person die?
After the vessel ruptured, the blood also leaked into the sac around the heart. When the heart sac fills with blood, there is no room for the heart to beat. The heart is squeezed by the blood in the sac. This can cause the patient to collapse and die. This is what happened here.

Could the rupture have happened on its own, unrelated to the procedure?
No. Spontaneous rupture of coronary arteries is documented but extremely rare. The rupture was right in the region where the stent was placed and indicated the procedure had a role in the rupture.

What else did the autopsy show?
The autopsy showed very little coronary blockage overall and a viral infection of the heart muscle (viral myocarditis).

How did the autopsy help?
The autopsy helped on a variety of levels. It determined the cause of death (coronary rupture with tamponade). It also provided information on the prior health of the heart (viral myocarditis). The patient’s shortness of breath was likely from his heart infection; and his heart infection was likely a complication from his recent viral illness (“cold”). The results also shed light on the role of the procedure in the patient’s death. Because the patient’s coronary arteries were “open,” the procedure was unnecessary. Moreover, it caused his death.

What was the impact of the autopsy results on the family’s emotions?
Difficult as the information was to consider that the death was intimately related to the care, the information from the autopsy helped the family move on from the painful restlessness of “not knowing.” At the same time the results deepened the wife’s concern regarding the cardiologist’s explanation and behavior. She began to suspect that her husband had been left to die at the time of the code (because the cardiologist did not seem to consider a diagnosis related to the heart). On top of this, she felt profoundly dismissed that there seemed to be no consideration that her husband’s death may have had any connection to a procedure hours before — a “common sense” consideration given the time frame. The autopsy results validated her concerns. Before the autopsy, the wife was left not knowing what had happened with the cardiologist telling her it was a stroke. After the autopsy, the wife knew what happened, which diminished her dependence on the cardiologist and seemed to have a liberating effect.

Why would the cardiologist suggest the cause of death was a stroke?
The cardiologist’s comments are filtered through the wife and we can’t really know what he said. If the report is accurate, it is concerning. Was this “physician hubris” (“My procedure can’t have caused a problem. I know I did everything right!”)? Was he being dismissiveness of the wife’s intelligence? Was this fear of a medical error being discovered and an attempt to deflect the wife from the “truth”? Was he really suspicious of a stroke on clinical grounds? Which option, or some other, cannot be ascertained here. But, the possibility that truth dismissed caused the patient’s death (by inattention to a procedural complication during the code) is horrific.

Summary Comment:
The issues in this case are multiple. They include a missed initial diagnosis (myocarditis); an erroneous assessment of coronary blockages (open and not blocked); a procedural complication (coronary artery rupture related to stent placement); and, possibly, misdiagnosis of stroke during the patient’s code. Probably least in question here is the actual technique of placement of the stent — the reason being that the coronary artery wall into which the stent was placed was not firm with plaque, but a pliable normal vessel. It was possibly more easily damaged by a metal stent than one shored up by at least some firm cholesterol plaque. While seemingly remote, there is a possibility that standard of care was met at various points. It would take a review of the presenting data, angiograms, the operative note, the post-operative care, and so on. However, the autopsy served to secure the truth — of benefit to the clinicians and to the wife sorely in need of information.

Sleuth It – The Case Without Findings

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Click here to skip to discussion.

Test tube photo

A 44 year old man dies suddenly after a night of “partying.” The coroner has made her evaluation but declined to perform an autopsy. The two sons request an independent autopsy, which you perform. The body is thin, but well nourished. There is no evidence of trauma and the autopsy exam is entirely normal. You save some blood for toxicology, even though the family has not requested testing.

Afterwards, you meet with the sons. They explain that their father was drinking beer and doing “shots” of hard liquor, but wasn’t really “that drunk.” You talk though the pluses and minuses of testing the blood for alcohol: the sons already know their father was drinking, so the test wouldn’t add that; but the test might give a clearer sense of how much alcohol was “in the system.” The sons don’t want any toxicology testing, saying they know “how hard” their father partied.

Suddenly, they turn to one another, whisper, and then turn back. “Oh, yeah, our father also ….”

Which of these disclosures would help in this case?

Their father:

a. Had high blood pressure
b. Was depressed and took the antidepressant Zoloft
c. Did cocaine
d. Had a serious family history of high cholesterol
e. Just started taking Coumadin (blood thinner) for a problem with his heart rhythm.

Stay tuned next month for a discussion of the case.

January 9, 2016 Update:
Case Discussion.

It would help to know that the father used cocaine (choice c.). Cocaine can cause spasm (clamping down) of normal coronary arteries, block blood flow in the artery and cause a heart attack that way. It could certainly have caused the death.

It may also help to know if the father had an abnormal rhythm (choice e.). That might be explored more to see in what way the abnormal rhythm might have been a risk factor for sudden death.

Coumadin is a risk factor for bleeding into the head — but you performed the case and there was no bleeding. So the part of option e. that is helpful is the mention of an abnormal heart rhythm, not the use of Coumadin.

High blood pressure is a risk factor for a large heart and an abnormal rhythm — but you performed the case and the heart was normal.

Family history for high cholesterol is a risk factor for high cholesterol and blockages — but you performed the case and there were no blockages.

Zoloft is not commonly a drug that causes overdose.

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The Independent Autopsy or Private Autopsy – and Your Rights

Most people understand that autopsies can be performed by the hospital or by the coroner (or medical examiner). In the first instance, the usual story is that the patient has died in the hospital. Then the hospital (or health care provider) may ask the family to authorize an autopsy. The purpose of the autopsy is to find out more information about the patient’s medical condition or cause of death. In the second instance, there is a “suspicious circumstance” (e.g., homicide, suicide, etc.) prompting an investigation by the state. The coroner or medical examiner gets involved. He or she may take the body to the state’s facility to perform an autopsy. The purpose of the autopsy is to understand the circumstances of the death or “solve the crime.”

This historically-formed process builds in a culture of control and oversight that can subtly exclude the family. Because the autopsy process is initiated by the institution (hospital or coroner/medical examiner), communicated to the family as an institutional “need to know,” and performed by the institution itself, the institution becomes — in the family’s mind — the gatekeeper for the autopsy. The family’s role is more passive. In the case of a coroner or medical examiner case, it’s to wait till the state’s work is done; in the case of a hospital case, it’s to consent to the procedure.

Attached to that passivity, the family may feel a lack of control over the disposition of their loved one.

With coroners and medical examiners, the family’s lack of control is real. The family does not have control over the process. State law typically grants coroners and medical examiners legal priority over the family when it comes to an autopsy. It’s part of living in society.

With hospitals, that lack of control can still be perceived. But it’s not real. It’s more about the hospital’s presence in the process. And about the family not knowing their rights and options.

When it comes to autopsies, the concept of choice is generally absent from our culture and, often, from the institutions that have first contact with families after a loss. It’s the coroner’s job to take the case based on legal guidelines. Choice of service does not come in to the picture. But, when interacting with a hospital, families don’t know and don’t hear that they have a choice. States such as Connecticut and Texas have laws that require families receive information about their right to choose their own service provider. Illinois and other states do not.

It’s really not different from other parts of health care. Most people know that, in general, they have the right to choose their health care provider — or even shop around; that they have the right to a second opinion; and even the right to switch providers or hospitals. The same is true of autopsy service.

This is where the private autopsy or independent autopsy comes in. These are autopsies performed by a service separate from the hospital and through a contract made directly with the family.

The term “independent autopsy” emphasizes that the autopsy is performed in a way that is completely separate from the care provider. For better or worse, many families can feel mistrustful of the hospital when the death occurs in the hospital. In this litigious age, it’s a “fox guarding the hen house” concern. The family may wish to have the autopsy performed by a service that is completely separate and unaffiliated with the care provider — an independent autopsy.

The term “private autopsy” emphasizes that the autopsy is performed through a service with its own (e.g, private) relationship with the family. The term “private” also highlights that autopsy results are given confidentially to the family and not to the hospital or care provider. An autopsy report from a private autopsy is not automatically submitted to the hospital to become part of the hospital medical record. The only time the report is released is at the family’s consent or as required by law. Medical confidentiality laws apply.

At Autopsy Center of Chicago, we provide private or independent autopsies. Know that we are a service to look to for an autopsy when your loved one dies either inside or outside the hospital. As long as the state has completed its evaluation, you can request an autopsy from any provider you like. Independently. Privately. Either way, it’s your right.

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Coming up in September: National Childhood Obesity Awareness Month

September is National Childhood Obesity Awareness Month.

At Autopsy Center, we are well aware of the consequences of obesity on health. Many of our patients who die from heart attacks have severe blockages in the coronary arteries as a result of high cholesterol. Often these patients are obese and have lifestyles that did not include exercise.

We also see many of the effects of obesity beyond high cholesterol. These including knee replacements from joint damage related to weight-bearing; strokes, torn aortas and aneurysms, heart failure and abnormal heart rhythms from high blood pressure; and foot ulcers or lost limbs from diabetes. Both high blood pressure and diabetes are often related to obesity. It’s a list of conditions that can kill.

Let childhood obesity be a red flag to you as a parent to begin to make a difference in your child’s life. Children with obesity are at risk for these serious health problems and early death.

While we can help families in the event of an untimely death, we prefer to see our families enjoy their children for a full life time.

Please take your child’s dietary and lifestyle choices seriously.

Take September to learn some new health choices for your child — and for life.

To learn more, please check out these Tips for Parents from the Centers for Disease Control.

Live from the Morgue is now live!

We are pleased to announce that fall, 2015 registration is open to high school groups.

Live from the Morgue is an offshoot of our successful class for adults, Science to Humanity: The Autopsy. Live from the Morgue is geared towards high schools students and available to high school groups form grades 9 through 12. Educators interested in learning more may visit our event page. We look forward to an exciting year of educational experiences in the Chicago area and beyond.