The College of American Pathologists position on autopsies during COVID-19

This post is written from my perspective of around ten thousand autopsies performed as an anatomic pathologist (Russia, Sant-Petersburg), pathologists’ assistant and morgue attendant (both in Chicago). Although the immediate trigger for this post were two articles about autopsies in CAPTODAY magazine’s May and June issues, other materials also added some details to my assessment of the autopsy performance situation during the COVID-19 epidemic in the USA.

The number of performed autopsies in USA shrinks every year by concentrating on rare unclear medical situations. Autopsies are done more as public service by relatives’ request or forensic examination, although the role of autopsies in establishment of current pathology knowledge is indisputable. For understandable reason, anatomic pathology operates without clinical work urgency and with some specific methods on its disposal.  In this regard, the importance of autopsies as educational diagnostic tool should increase during COVID-19 epidemic.

Autopsy performance regulations

In reality, postmortem examination, or autopsies, became a victim of the scare which came from China and Italy on the onset of the COVID-19 pandemic. Watching on TV health care workers in China dressed like astronauts before the takeoff and coffins piles in Bergamo, Italy, autopsy performance has been stopped due to Occupational Safety and Health Administration’s (OSHA) recommendation. For hospital’s administration, the OSHA recommendation is the order.

As a public service organization, OSHA issues recommendations based on information provided by professionals in the field. In the case of autopsies, in ideal, we can expect a reciprocal interaction between Center Disease Control and Prevention (CDC), College of American Pathologists (CAP), and OSHA. CDC provides necessary general health and nosology information, including regarding infectious diseases. CAP determines diagnostic and other medical approaches, while OSHA issues necessary correlation for safety performances (Diagram 1).


Diagram 1. Reciprocal interactions between CDC, CAP, and OSHA in autopsy regulations.

Under conditions of the epidemic, the role of CDC becomes dominated. CDC should provide reliable information to both OSHA and CAP, assuming the entire anatomic pathology group in the USA under the CAP moniker.            

However, the epidemic caught CDC flat-footed.  The confusing and ambiguous CDC’ and also Dr. Fauci’ (National Infection and Allergy Institute) statements are well-known. They are discussed in different posts of the Blog. The updated material CDC regarding autopsies is presented in the CDC’s Autopsy Guidance for COVID-19 post with some comments.

The College of American Pathologist’s position

What about CAP and hospitals’ pathologists? Already mentioned two articles in CAPTODAY (May and June issues) can shed some light to the pathologists’ attitude toward autopsy performance. It would be right to distinguish CAP and hospitals pathologists’ approaches. The CAP ‘s position was to hide behind CDC and OSHA limitations. All CAP’s documents only repeat the CDC’s provisions.  In CAPTODAY June issue, from the President’s Desk Getting through the pandemic column the CAP’s president Dr. Patrick Godbey haven’t mentioned postmortem examination at all.

The CDC’s guidelines include details of submission to histology (for example thickness of section) that means the pathology participation in the document. But on the crucial issue of autopsy performance, CAP preferred to follow CDC’s and OSHA’s recommendations for autopsy limitations.

The CAP’s Autopsy Commission Committee’s Amended COVID-19 Autopsy Guideline on May 5, 2020 is remarkable as a masterpiece of walking between streams of water. On one hand criticizing the CDC’s ambiguity, on the other hand following them instead of expressing the position and defending it.

 Dr. Williamson, a member CAP’s Autopsy Committee, was involved in listserv discussions which started in late March. His position as “We can’t and shouldn’t autopsy every COVID-19 death” is right but his next statement is disputable: “That’s an impossibility and it’s dangerous.” Why dangerous?  The CAP’s Autopsy Committee were proud that some pathology departments have met CDC’s engineering requirements without questioning why they were imposed. “OSHA guidance was ill- informed” he stated, but CAP’s Autopsy Committee should inform OSHA which is a bureaucratic organization. Doctors are equipped with education.  Pathologists are obliged to challenge the OSHA’s unsubstantiated limitations instead of hiding in listserv discussions and losing precious time. Epidemic is a fire, and pathologists must be a part of the firemen.

Until today, many hospitals, for example in Chicago, do not perform autopsies on coronavirus positive decedents. These cases are sent to the Medical Examiner office due to the absence of negative pressure morgue rooms.

Autopsy criminalization

It looks that CAP accepted regular pathologist’s secondary role in handling COVID-19 related cases after forensic services. CDC’s emphasized an autopsy as medicolegal event (see the CDC’s Autopsy Guidance for COVID-19 post). Why? What is criminal in COVID-19? It is a regular infectious disease like influenza or myocardial infarct unless it is suspected a foul play or relatives requested an autopsy. The National Board of Medical Examiners has taken the lead in postmortem examinations in COVID-19. But autopsy pathology is different from forensics. By training and resources hospital’s pathologists are (or should be) more equipped for natural disease pathology autopsies which are different from forensics by their predominately educational goal.

The previous clinicians’ habit to attend autopsies is now considered old-fashioned. However, the Greek word autopsia stems from the act of seeing with one’s own eyes. It appears that an opportunity would be very useful for clinicians to visualize the pathology process, which often is puzzling to them. In this regard, the CDC’s recommendation of the minimization of autopsy attendance is wrong. What is the CAP’s position on this issue?

Personal Protective Equipment (PPE)

Nobody would doubt that PPE must be used during every autopsy, especially on an infectious disease case.  OSHA’s requirements are reasonable (see COVID-19 Protective equipment post). However, some practices go too far in protective equipment. What they are afraid of? There is not a rational explanation.

The photo taken from CAPTODAY shows a pathologist and a morgue attendant. The latter’s PPE is like he is prepared for takeoff in space. However, the autopsy includes hours physically demanding work that should be comfortable. This re-breather space suit looking equipment is a prescription for errors and trauma. While spending many hours in the morgue doing autopsies, I can state this with some credibility, including my misfortunes.

Face protection by a pathologist and a morgue assistant

The photo also demonstrates misunderstanding of the principle of PPE in an infectious disease case autopsy. While wearing N95 mask, which according to OSHA/CDC guidelines should be used in the case of oscillating saw aerosol production, both on the photo expect the virus emanating from the body or evisceration organs. The virus does not know where their nose or mouth are. If it exists in the air, the virus landing will be proportionally distributed, including the open neck area. Actually, they are wearing a combination of two masks (N95 and surgical mask) that is unbearable for a prolonged work.

Conclusion

These are questions from a person who has experience in autopsy performances, including on decedents from infectious diseases. I haven’t seen, heard, or read about infection inoculation in the autopsy room. Pathologists are burdened by special knowledge that brings some responsibility. It is a shame to hide behind OSHA and CDC limitations for autopsy performances which are determined by unsubstantiated fear of unknown. Actually, it is the College of Anatomic Pathologists professional group’s disservice to the society, a kind of malpractice.

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