Autopsy, a faded practice, revealed COVID-19 secrets

NEW YORK – The COVID-19 pandemic helped revive the autopsy.

When the virus reached hospitals in the United States, doctors could only guess what was causing their strange symptom constellation: which could explain why patients were losing their sense of smell and taste, developing skin rashes, struggling to breathe and reporting memory loss in addition to coughs and flu-like pain?

In hospital morgues, which have been losing prominence and funding for several decades, pathologists were busy dissecting the first victims of the disease – and finding some answers.

“We were getting emails from doctors, a little desperate, asking, ‘What are you seeing?'” Said Dr. Amy Rapkiewicz of NYU Langone. “Autopsy,” she pointed out, means seeing for yourself. “This is exactly what we had to do.”

The first autopsies of deceased patients confirmed that the coronavirus not only causes respiratory diseases, but can also attack other vital organs. They also prompted doctors to try anticoagulants on some patients with COVID-19 and to reconsider how long others should be on ventilators.

“You can’t treat what you don’t know,” said Dr. Alex Williamson, a pathologist at Northwell Health in New York. “Many lives were saved by looking closely at someone’s death.”

Autopsies have informed medicine for centuries – most recently helping to reveal the extent of the opioid epidemic, improve cancer treatment and demystify AIDS and anthrax. Hospitals have already been judged by how many autopsies they performed.

But they lost stature over the years as the medical world turned to lab tests and imaging. In 1950, the practice was performed on about half of the hospital’s deceased patients. Today, these rates have shrunk to somewhere between 5% and 11%.

“It really is a lost tool,” said Louisiana State University pathologist Dr. Richard Vander Heide.

Some hospitals found it even more difficult this year. Concerns over the safety of transmission forced many hospital administrators to stop or severely restrict autopsies in 2020. The pandemic also led to a general drop in the total number of patients in many hospitals, which reduced autopsy rates in some places. Large hospitals across the country reported fewer autopsies in 2020.

“Overall, our numbers have dropped significantly,” from 270 autopsies in recent years to about 200 so far this year, said Dr. Allecia Wilson, director of autopsies and forensic services at Michigan Medicine in Ann Arbor.

At the University of Washington in Seattle, pathologist Dr. Desiree Marshall was unable to perform COVID-19 autopsies in her usual suite because, as one of the oldest facilities in the hospital, she does not have adequate ventilation to safely conduct the procedure. Marshall ended up borrowing the county coroner’s offices for some cases at first, and has been working at the school’s animal research facilities since April.

Other hospitals followed the opposite path, performing many more autopsies even in difficult circumstances to try to better understand the pandemic and to follow the increase in deaths that resulted in at least 400,000 more deaths in the United States than normal.

At New Orleans University Medical Center, where Vander Heide works, pathologists have performed about 50% more autopsies than in recent years. Other hospitals in Alabama, California, Tennessee, New York and Virginia say they will also exceed their normal annual count for the procedure.

Their results have shaped our understanding of what COVID-19 does to the body and how we can fight it.

In the spring and early summer, for example, some critically ill patients with coronavirus used ventilators for weeks on end. Later, pathologists found that extended ventilation could cause extensive lung damage, prompting doctors to rethink how to use ventilators during the pandemic.

Doctors are now exploring whether anticoagulants can prevent microscopic clots that were discovered in patients early in the pandemic.

Autopsy studies have also indicated that the virus can travel through the bloodstream or hitch a ride on infected cells, spreading and affecting a person’s blood vessels, heart, brain, liver, kidneys and colon. This discovery helped to explain the wide range of symptoms of the virus.

More discoveries are sure to come: pathologists stocked the freezers with organs and tissues infected with coronavirus collected during autopsies, which will help researchers study the disease, as well as possible cures and treatments. Future autopsies will also help them understand the impact of the disease on long-haul trucks, those who experience symptoms for weeks or months after infection.

Despite these discoveries that saved lives during the pandemic, financial realities and a shrinking workforce mean that old medical practice is unlikely to fully recover when the outbreak subsides.

A diary of autopsies performed by Dr. Amy Rapkiewicz shows that most cases since early 2019 were COVID-19 positive at NYU Langone Hospital - Long Island in Mineola, NY, Wednesday, December 16, 2020.
A diary of autopsies performed by Dr. Amy Rapkiewicz shows that most cases since early 2019 were COVID-19 positive at NYU Langone Hospital – Long Island in Mineola, NY, Wednesday, December 16, 2020.

Hospitals are not required to provide autopsy services, and for those who do, the costs of the procedure are not covered directly by most private insurance or Medicare.

“When you consider that there is no refund for this, it is almost selfless practice,” said Rutgers University pathologist Dr. Billie Fyfe-Kirschner. “It is vitally important, but we do not need to finance it.”

Added to the mix: The number of specialists who can actually perform autopsies is critically low. Estimates suggest that the United States has only a few hundred forensic pathologists, but could use several thousand – and less than one in 100 medical school graduates enters the profession each year.

Some in the field hope that the 2020 pandemic will boost recruitment to the field – as will the “CSI boom” of the early 2000s, said Williamson of Northwell.

Wilson of Michigan Medicine is more skeptical, but she still can’t imagine her work becoming totally obsolete. Learning from the dead to treat the living – is a pillar of medicine, she said.

It helped doctors understand the mysteries of the 1918 flu pandemic, but it is now helping them to understand the mysteries of COVID-19 more than a century later.

“They were in the same situation,” said Vander Heide of the doctors who tried to save lives in 1918. “The only way to know what was going on was to open the body and see.”