NEW YORK – The COVID-19 pandemic has revived autopsy.
When the virus first arrived in U.S. hospitals, doctors could only guess what triggered the strange constellation of symptoms: what could explain why patients lost their sense of smell and taste, developed rashes, had difficulty breathing, and reported memory loss in addition to flu-like cough and pain?
In hospital morgues, which have steadily lost prominence and funding over decades, pathologists have been busy dissecting – and finding answers – the first victims of the disease.
“We got emails from clinicians, quite desperate, asking, ‘What do you see?’” Said NYU Langone’s Dr. Amy Rapkiewicz. “Autopsy,” she noted, means seeing for yourself. “That’s exactly what we had to do.”
Early autopsies of deceased patients confirmed that the coronavirus not only causes respiratory disease, but can also attack other vital organs. They also prompted doctors to try blood thinners in some COVID-19 patients and rethink how long others should stay 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 have been saved by looking closely at someone’s death.”
Autopsies have informed medicine for centuries – most recently they have helped reveal the magnitude of the opioid epidemic, improve cancer care, and demystify AIDS and anthrax. Hospitals were once rated by the number of autopsies they performed.
But they have lost their status over the years, as the medical world turned to lab tests and imaging scans instead. In 1950 the practice was carried out on about half of the deceased hospital patients. Today those rates have shrunk to somewhere between 5% and 11%.
“It’s kind of a lost tool,” said pathologist Dr. Richard Vander Heide of Louisiana State University.
Some hospitals had it even more difficult this year. Safety concerns over handover forced many hospital administrators to halt or severely curb autopsies in 2020. The pandemic also led to a general drop in the total number of patients in many hospitals, reducing the number of autopsies in some places. Major hospitals across the country have reported performing fewer autopsies by 2020.
“Overall, our numbers have fallen quite a bit,” from 270 autopsies in the past few 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 will not perform COVID-19 autopsies in her usual suite because, as one of the hospital’s oldest facilities, it does not have the proper ventilation to perform the procedure safely. Marshall borrowed the county’s medical research offices early on a few cases and has been working from the school’s animal research facilities since April.
Other hospitals went the other way and performed many more autopsies, even under harsh conditions, to better understand the pandemic and keep up with a wave of deaths that have resulted in at least 400,000 more American deaths than usual.
At New Orleans University Medical Center, where Vander Heide works, pathologists 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 usual annual count for the procedure.
Their results have shaped our understanding of what COVID-19 does to the body and how we might combat it.
In the spring and early summer, for example, some seriously ill coronavirus patients were ventilated for weeks on end. Later, pathologists found that such extended ventilation could cause extensive lung damage, forcing doctors to rethink the use of ventilators during the pandemic.
Doctors are now investigating whether blood thinners can prevent microscopic blood clots discovered in patients early in the pandemic.
Autopsy studies also indicated that the virus can travel through the bloodstream or hitchhike on infected cells, spread to and affect a person’s blood vessels, heart, brain, liver, kidneys and colon. This finding helped explain the wide range of symptoms of the virus.
More findings are sure to come: Pathologists have filled freezers with coronavirus-infected organs and tissues collected during autopsies, allowing researchers to study the disease, as well as possible cures and treatments. Future autopsies will also help them understand the disease’s toll on long-haul vehicles, the ones that have symptoms weeks or months after infection.
Despite these life-saving discoveries made during the pandemic, financial realities and the dwindling workforce make it unlikely that old medical practice will fully recover if the outbreak recedes.
Hospitals are not required to provide autopsy services, and in those who do, the cost of the procedure is not directly covered by most private insurance policies or Medicare.
“When you consider that there is no compensation for it, it is almost an altruistic practice,” said pathologist Dr. Billie Fyfe-Kirschner from Rutgers University. “It’s vital, but we don’t have to fund it.”
Added to the mix: The number of experts who can actually perform autopsies is critically low. Estimates suggest that the US has only a few hundred forensic pathologists, but could use several thousand – and fewer than one in 100 graduating medical school students enter the profession each year.
Some in the field are hoping that the 2020 pandemic could boost recruitment in the field – much like the “CSI boom” of the early 2000s, Northwell’s Williamson said.
Wilson of Michigan Medicine is more skeptical, yet she can’t imagine her work becoming totally outdated. Learning from the dead to treat the living – it’s a pillar of medicine, she said.
It helped doctors understand the mysteries of the 1918 flu pandemic, but now it helps them understand the mysteries of COVID-19 now more than a century later.
“They were in the same situation,” Vander Heide said of the doctors who tried to save lives in 1918. “The only way to find out what was going on was to open up and see the body.”