April 22 2020
I found “ZERO deaths from Corona Virus” says Pathologist Prof. Dr. Klaus Pueschel, Director for Forensic Medicine of The University Clinic in Hamburg, Germany.
The understanding of the disease processes and accurate determination of the cause of death is the foundation of modern medicine, invaluable research, teaching, and public health planning tool. The knowledge is acquired by:
Documenting patient’s complaints, medical, family and social history;
Clinical examination;
Laboratory investigations;
Functional studies, for instance Treadmill Cardiac Stress Test and Pulmonary Function test;
Imaging.
The first two - documentation of patient’s history and clinical examination have been used as long as medicine exists - thousands of years. These were available to shamans, healers, and physicians. Hippocrates and Avicenna were the notables who summarized medical knowledge in their respective times.
Laboratory investigations and functional studies developed over the last 200 years, while imaging - diagnostic radiology is just over 120 years old. Dr. Cross, a practitioner in Rochester, MN, had purchased the X-ray machine in February 1896, less than 3 months after Wilhelm C. Roentgen had published his landmark description of his discovery.
The radiology gave us a “see through” ability and extrapolate images into understanding of pathologic processes to molecular and genetic levels.
Yet, how did we manage to acquire the vast knowledge in pre-imaging era? How did we made imaging so accurate?
The answer is simple: by performing dissections to understand normal, pathological anatomy, and surgical anatomy, as well as autopsies and detailed pathologic examinations to deepen our knowledge and use it to help the living. Autopsies allow for macroscopic and microscopic examination of tissues and remain the gold standard in diagnostics. Hence the saying “Pathologist is The Best Diagnostician”.
The legend goes that one night, William James Mayo a physician and surgeon in the United States and one of the seven founders of the Mayo Clinic , at the age of 16, accompanied his father to an abandoned hotel where one of the elder Mayo's patients worked as the caretaker. The patient had just died and Mayo was going to perform an autopsy.
Will stood by and watched the procedure and after about an hour, it was time to go to another patient's home. Mayo asked his son to stay behind and clean up. "Sew up the incisions and then tuck the sheet around the corpse. When you finish, go right home." Will nervously began to stitch up the incisions on the body and recounted the incident many years later saying, "I'm about as proud of the fact that I walked out of there, instead of ran, as of anything else I ever made myself do".
These were good old times! Fast forward to the modern age, at the time of what is publicized as “the worst pandemic since 1918”, I found only a handful of reports documenting autopsies and pathologic examinations of COVID-19 patients. The list is appallingly short:
On February 20th of 2020, Tiang and co-authors published results of pathologic examination of 2 cases of patients suffering from lung cancer positive for SARS-CoV-2;
On April 1st of 2020, Xu and co-authors published a case report of 1 patient positive for the virus who died from ARDS;
On April 6th of 2020, Fox and co-authors published the first autopsy series of 4 patients who died with the virus in New Orleans;
On April 9th of 2020, Su and co-authors published results of renal histopathological analysis of 26 patients, positive for SARS-CoV-2;
On April 10th of 2020, Barton and co-authors published autopsy results of 2 patients who died with the virus in Oklahoma;
On April 14th of 2020, Tiang and co-authors published results of post-mortem core biopsy of 4 SARS-CoV-2 positive patients;
On April 21st of 2020, the County of Santa Clara, CA medical examiner published results of autopsy of 3 patients positive for the virus, who died on February 6th, 17th and March 6th of 2020. All of these occurred before the death on March 9th, originally thought to be the first death in the County;
The total is 92 autopsies: 50 autopsies performed by Prof. Klaus Puesche and 42 patients elsewhere out of 176,984 deaths documented as of today!
The explanations for this obvious academic and research failure are limited mostly to:
The danger to examiner when performing autopsy in deceased with infectious disease;
The shortage of medical examiners/coroners;
The assumption that deaths from COVID-19 are natural and therefore do not warrant investigation.
The Press Release from the American National Association of Medical Examiners (NAME) dated April 11th of 2020 highlights the current status of death investigation and COVID-19.
“The public, in general, does not understand that there is not a uniform death investigation system in the United States. The US has a variety of systems: elected lay Coroners, physician Medical Examiners, Sheriff-Coroners, Justices of the Peace, state systems, county systems, among others. Each of these types of death investigation systems is governed by varying state laws.
So, a uniform response to COVID-19 by Medical Examiners will not occur. For these reasons and because the resources and number of COVID-19 cases will vary greatly by jurisdiction, NAME is not providing set protocols, or set guidance. Every jurisdiction’s response will need to differ, as a practical matter.
For most offices and systems, deaths from COVID-19 do not technically fall under the jurisdiction of Medical Examiners, as they are natural deaths. These deaths are similar to deaths from, say cancer that ordinarily are not reported to Medical Examiners who focus on unnatural and unexpected deaths.
Currently, for most jurisdictions, deaths from COVID-19 are occurring in hospitalized patients, who have been diagnosed with COVID-19. Medical Examiners in these circumstances will ordinarily not need to do an autopsy, but will likely be facilitating reporting of deaths to public health, and possibly signing death certificates.
In fact, Occupational Safety and Health Administration (OSHA) now recommends that COVID-19 deaths not be autopsied. Depending upon how the pandemic develops, Medical Examiners will become involved in deaths that happen in private residences (just like now), and will need to determine if deaths are COVID-19 related. That determination will be done by investigation and a variety of approaches, specific to local resources, facility features, and staffing.
Depending on the number of deaths, offices may just test for COVID-19 (by nasal swabs) without an autopsy. Autopsies will be performed when needed for legal purposes or when the cause of death cannot be determined by testing for COVID-19 alone. Of course, with escalation of the pandemic, Medical Examiners and Coroners will help the communities in this public health crisis, because of their expertise in handling the dead.
What do we learn from these examinations?
Medical Examiners determine the cause of death, whether a gunshot wound, or COVID-19. Specifically in early COVID-19 deaths, when autopsies were being performed, MEs were sharing information about autopsy findings, and about how the virus causes death. Also, MEs helped determine what viral-induce complications were common, such as superimposed bacterial pneumonia, and described any underlying disease processes that might make individuals more susceptible to death. The vast majority of offices are no longer performing autopsies on known COVID-19 deaths. Accurate certification and tracking of these deaths, however, is important for public health considerations.
How has COVID-19 affected the current shortage of Forensic Pathologists?
The United States has a significant shortage of Forensic Pathologists, made worst by the opioid crisis. About 500 Forensic Pathologists are currently working, with a need for about 1,200. Ten percent of Forensic Pathology jobs are unfilled. Therefore, Medical Examiners were already working hard, and performing too many autopsies before COVID-19. The National Association of Medical Examiners, has temporarily suspended caseload limits during the COVID-19 pandemic, and will not penalize offices for exceeding caseloads because of the pandemic for purposes of office accreditation. A real concern is that Medical Examiner staff, including investigators, forensic pathologists, and autopsy assistants also may become infected with COVID-19, furthering hampering community response.”
Aside from the above, the current state of affairs can only be explained by convenience of being able to blame everything on a “killer-virus”, which this lack of information gives to politicians and healthcare administrators. We are told to believe that everyone who is dying WITH SARS-CoV-2 is dying FROM it. This instills fear and panic into society and allows it to be manipulated at will.
The truth may be too inconvenient and dangerous for our “leaders” and “experts”. They forgot that "Truth - more precisely, an accurate understanding of reality - is the essential foundation for producing good outcomes" (Ray Dalio, Founder, Bridgewater Associates).