Holding a Death in Your Hands: What Autopsy Reports Tell Us About How Someone Lived

"The red/blue/green/yellow pants were cut prior to examination, revealing blue/red/white underwear. Black/white/green shoes were removed."

"On the left dorsal hand is a monochromatic tattoo stating ‘kitten' with an abstract design."

These are the kinds of phrases that greet me every time I pick up an autopsy report. I have the job of reviewing our clinic's mortality reports. Since it's a clinic for the homeless, a lot of our patients' deaths are medical examiner's cases. When I started reading autopsy reports regularly, one thing I didn't expect was their respectful, lyrical descriptions of extreme violence and suffering.

"When first viewed, the decedent is clad only in a white towel, which is wrapped around the genital region. The towel remains with the body."

On this single body there was a "well-healed scar on the posterior midline neck." And on the left chest. And on the anterior right shoulder. And on the right volar forearm near the antecubital fossa. And on the lateral right wrist. And on the right dorsal forearm. And on the left dorsal forearm near the elbow. And on the upper right buttock. And on the right anterior upper thigh. And on the dorsolateral right lower leg. And on the posterior left thigh. And on the anterior left thigh. And on the anterior left thigh near the left knee. And on the left back. In addition, the fifth and seventh ribs had healed fractures.

Those were all old scars, some of them quite large, marks of a life spent embattled by -- and perhaps, battling--the world around him. There waere also four fresh injury sites, including a pencil-thick catheter screwed into the bone of his left shin, the result of a violent attempt, as he lay dying, to get IV fluids into him.

Many professions outside of medicine have their version of a post-event analysis of what went wrong, and how to prevent it. The autopsy report is as close as a human being gets to having his own black box recorder reviewed after a fatal crash.

Barring any unforeseen acts of extreme violence, most of us will never have one of these reports written about us. In some ways, that's a shame. An autopsy is the only true way we learn, in the very end, if what we thought we were treating is actually what was going on. Asking for permission to do an autopsy used to be automatic, part of the process of breaking bad news to a family.

I can remember how AIDS, and then prion-based diseases, changed all that. The risks of bodily fluid exposure to the people doing autopsies became a valid concern. Autopsies became something that you asked the family to authorize only if there was a "good reason."

Which means that except for highly unusual hospital-based deaths, autopsies are now done on only two types of people: people who have suffered violent, unexplained deaths, and people who are homeless, because they can often die, as the saying goes, "unattended."

"The soles of the feet are dirty."

At our clinic, the physician who cared for the patient fills out a standard form, called a Mortality Report, stating the known circumstances surrounding the patient's death, and also stating whether, in his or her opinion, the death was medically expected and whether it could have been prevented. My job is to read these forms, go over the medical chart and the autopsy report (if there is one) and decide if I agree that the death could, or could not, have been prevented through standard medical practice.

"The scalp hair is straight, brown, with a moderate number of gray strands."

As with the autopsy reports, a tremendous amount of respect and deeply felt emotion are buried within these Mortality Reports. Those of us who work in our clinic are aware that for many of our patients, we are the only "family" they have, the only people contacted when they die.

Having that role, and reading these autopsy reports, can be deeply disturbing. You can imagine. Perhaps you sat, and held that person's hand -- the hand with the kitten tattoo. You tried to help this person create a better, healthier life. Maybe you even thought she made it, that having a place to lay her head was the beginning of a new life.

"The hands, fingers, fingernails, feet, toes, and toenails are normally formed, intact, and unremarkable.

"Microscopic diagnoses: Cirrhosis of the liver. Chunky polarizable material, lungs.

"Cause of death: Acute polysubstance intoxication (methadone, morphine and diazepam) with cirrhosis."

Autopsy reports are public records. You can go and ask for one or more at your county medical examiner's office. You'll need a name, or a date of death, since these reports are not made readily available en masse. But you could easily ask for the John Does of your town. Then make a copy. And, like me, hold a death in your hands.

Author's Note: Identifiable patients mentioned in this post were not served by R. Jan Gurley in her capacity as a physician at the San Francisco Department of Public Health, nor were they encountered through her position there. The views and opinions expressed by R. Jan Gurley are her own and do not necessarily reflect the official policies of the City and County of San Francisco; nor does mention of the San Francisco Department of Public Health imply its endorsement.

Photo credit: Albrecht Dürer sketch via Wikimedia Commons.