Forensic pathology has been a recognized medical subspecialty only since 1959, and I fear that for my profession, time is already running out.
Doctors need to know why people die so they can improve their diagnostic skills. Families need to know for closure and for insight into hereditary risks. Societies need to know so that public risks can be identified and criminal wrongdoing prosecuted.
Historically, pathologists have been major players in cause-of-death determinations, both as hospital specialists and as medical examiners. The autopsy has been our most powerful tool.
But hospital autopsies are rarely done anymore. Doctors increasingly rely on CTs, MRIs and other radiological imaging scans.
Those techniques had limited capability when I went to medical school, but they’ve progressed to an amazing degree. They’re starting to encroach on my field of forensic pathology.
As is often the case, the military is on the cutting edge of medical progress. The New York Times reported that since 2004, the body of every service person killed in Iraq or Afghanistan has been scanned as well as autopsied. A huge database has been created, and doctors have learned a lot from comparing the results of the two procedures.
A lot of forensic pathologists are concerned that scans aren’t accurate enough to meet the needs of law enforcement and the courts. We’ve all seen skull fractures and relatively small but very important accumulations of blood around the brain that premortem scans missed. We’ve all seen cases where larger collections of “blood” reported on scans weren’t blood or weren’t there at all.
But techniques will continue to improve, and I’m confident that postmortem radiology will play an increasingly important role in forensic medicine. Already, the California Legislature has decided that coroners may use electronic image systems to fulfill the requirements of an autopsy required by law.
I concede that postmortem scans – they’re called virtopsies – have some advantages:
Those who have aesthetic objections to “cutting people up” and those whose religions require that bodies remain intact are far more comfortable with non-invasive scans.The risk to autopsy personnel of contracting a communicable disease from a corpse is considerably greater than the risk to a scan operator.The shortage of forensic pathologists is approaching a crisis, says the Los Angeles Daily News in a report on the inability of the medical examiner’s office of Los Angeles County to keep up with its workload. Training programs are barely keeping up with the retirement rate and doing absolutely nothing to address population growth.The use of scanning technology doesn’t have to be all-or-nothing. Fewer full autopsies and fewer forensic pathologists would be needed if pre-autopsy scans
located bullets and other projectiles, making them easier to find;ruled out certain diseases or injuries to parts of the body, allowing the autopsy pathologist to do a limited examination;screened victims of a mass catastrophe to determine which corpses needed a full autopsy. But scanners are expensive. Even a refurbished machine costing a couple of hundred thousand dollars is beyond the reach of a small coroner or medical examiner jurisdiction. And anyway, who would run it? Pathologists don’t know how to read scans, and radiologists don’t know how to interpret postmortem changes. New training programs would be needed.
A recent article in Diagnostic Imaging quotes a radiology professor from Maryland, who says the field of forensic radiology is “in its infancy. It’s still a subspecialty with a diaper on.”
But in another generation, that “infant” will be immeasurably more mature.
Dr. Carol J. Huser, a forensic pathologist, served as La Plata County coroner from 2003-12. She now lives in Florida and Maryland. Email her at email@example.com.