An Autopsy Long Ago with My Father

My father instilled in me a desire and a curiosity about diagnosis. It started with me watching him conduct autopsies as Medical Examiner of Bergen County, New Jersey. I accompanied him to the scene of countless murders and unsolved crimes, witnessing him examine each body for clues that could reveal the cause of a person’s demise.

Afterward in the coroner’s laboratory, he would discuss cases as he examined the deceased. All the while, he peppered me with question after question.

A Sudden Death

I recall vividly the case of a woman with severe obesity who expired suddenly. Prior to her death, she presented at several emergency rooms complaining of shortness of breath, sharp chest pain, rapid breathing, and bloody cough. She became more and more anxious as each emergency room doctor told her she was simply suffering from congestion and bronchitis. Each time she was sent home with a prescription of antibiotics, which failed to relieve her symptoms.

Within a couple of days her daughter found the woman lying dead on the kitchen floor. While performing the postmortem, my dad dug into the pulmonary vasculature and asked me what he was looking for. I was riveted as he pulled out a huge “saddle embolus,” which had been obstructing her pulmonary arteries. It had threatened her life all week – something overlooked by all the physicians who “treated” her. In the end, this massive embolism killed her.

A Life Shortened by Bias and Poor Care

What I learned later and marvel at after many years is the value of my dad’s extensive knowledge acquired in the course of performing thousands of autopsies. He often knew the cause of death even before he commenced an autopsy. The postmortem inspection served to confirm what he knew to be the cause of death. His questions served to teach me. If he had had the opportunity to treat the women with obesity while she was alive, she may have lived much longer and would not have needed an autopsy after her death. How incredibly sad.

From my current perspective as a physician, I recall that particular autopsy as the one that helped me understand the frustration that many people with obesity suffer on a daily basis – from discrimination and bias incurred from simply walking down the street to great disparities in healthcare. Many health professionals lack an understanding of obesity as a disease. As a result, they provide poor treatment.

Such substandard treatment could include the inability to perform a thorough examination or tests such as an X-ray or CT scan due to inadequate tools for patient size. It could be as simple as dismissing the patient’s chief complaint, shortness of breath, and attributing it solely to obesity. Substandard medical care cost this unfortunate woman her life. And sadly, this scenario is not uncommon in today’s medical practices and emergency rooms.

A Gap to Fill with Education

Education of our budding physicians is the key to filling this gap in treatment because the burden of obesity is great in the U.S. With effective education, I believe we will change how providers practice medicine in this country. Today, I might err on the side of over-diagnosing shortness of breath in my patients with obesity. That’s because I am remembering that teaching moment in the Medical Examiner’s office with my dad.

Today’s guest post comes from our friend Caroline Apovian. She is Professor of Medicine at the Boston University School of Medicine and current President of the Obesity Society.

Drs. John and Caroline Apovian at the Dedication of the John Apovian, MD, Cardiac Surgery and Structural Heart Center, photograph by Kevin Basralian MD

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August 13, 2018