It's Virtually Possible
The evening of 9/11, H. Theodore Harcke Jr., MD ’71, a U.S. Army Reserve colonel and radiologist and the state surgeon of the Delaware Army National Guard, received a call asking him to go to the Dover Air Force Base Port Mortuary. The radiology skills of the visiting scientist at the Armed Forces Institute of Pathology (AFIP) in Washington, D.C., were needed to help identify the victims of the attack on the Pentagon, determine causes of death and conduct forensic investigations.
“At the time there was almost no such thing as forensic radiology,” says Harcke, a retired pediatric radiologist from Wilmington, Del., “so my colleagues and I began to invent this idea of forensic radiology as a new specialty.” They also began laying the groundwork for using CT scanners to conduct “virtual autopsies” – the topic of a presentation he made during the Penn State School of Medicine Alumni Weekend this past Sept. 17.
Stationed twice at combat support hospitals in Afghanistan and once in Kosovo, and on Army active duty [Retiree Recall Program] Harcke is now the AFIP’s chief of forensic radiology and the principal forensic radiologist for the Virtual Autopsy Initiative at Dover. As a result of the initiative, the bodies of more than 5,000 servicemen and women – including all the combat fatalities in Iraq and Afghanistan as well as non-combat fatalities– have undergone autopsies. Since 2004, every one of those fatalities also has undergone a virtual autopsy with multidetected computed tomography (MDCT) scans to help guide medical examiners.
The scans help pathologists locate and recover metallic fragments and gather information about cause of death. The resulting database also has led to changes in the protective armor soldiers wear and in the vehicles in which they ride, as well as in advances in emergency battlefield medical care.
For example, to treat collapsed lungs medics often insert a needle and tube into the chest cavity to re-inflate the lung. But in reading the CT scans, in late 2005 Harcke noticed that in a half dozen cases that the tubes were too short to reach the chest cavities. Given the victims’ other significant injuries, Harcke couldn’t determine if that deficiency had led to their deaths. However, the victims clearly had not received effective emergency treatment for their life-threatening collapsed lungs.
Reviewing another 100 archived scans, Harcke determined that the standard 5 centimeter- long tubing was too short to penetrate the chest walls of 50 percent of the soldiers, who today are bigger and stronger than their predecessors. Lengthening the tubes to 8 cm, he calculated, would be sufficient for 99 percent of American GIs – a change the Army Surgeon General ordered for combat medics’ kits in August 2006.
“I was thrilled,” Harcke told the New York Times two years ago.
Harcke also led a radiology investigation that determined placement of needles for intraosseous infusion of resuscitative fluids for victims of shock is more successful if the needle is inserted in the proximal tibia (95 percent success rate) rather than in the sternum (80 percent success).
Virtual autopsies can also help determine the exact cause of death of supposed drowning victims and – in the case of burn victims – can alert the medical examiner to possible recovery of nuclear DNA from the spinal cord for identification purposes. It can also help determine whether fire or something that occurred prior to the fire was the cause of death. # # #
A resident of Haddonfield, N.J., Harcke graduated from the U.S. Military Academy at West Point in 1960 and served as a combat engineer for three years. He then earned a M. Ed. degree in mathematics at Pennsylvania State University before, at the non-traditional age of 29, he used the G.I. Bill to enter the School of Medicine’s first class.
“I liked the adventure of going to a new school,” recalls Harcke. “Due to construction delays we wore hard hats to some classes. But you knew everybody, your courses were taught by the department chairmen and every student had the opportunity for personal attention. The attitude was: ‘We’ve got to make this work’.”
Harcke’s interest in pediatric radiology ultimately led him to positions first at St. Christopher’s Hospital for Children in Philadelphia and then at the Alfred I. duPont Institute [now Nemours/ Alfred I DuPont Hospital for Children] in Wilmington where, between 1981 and 2002, his various positions included chairman of the Department of Medical Imaging. Although “retired” from duPont since 2002 he has continued as the part-time director of the hospital’s medical imaging research.
As a clinical professor of radiology and nuclear medicine at the Uniformed Services University of the Health Sciences in Bethesda, Md., and the co-author of last year’s Essentials of Forensic Imaging: A Text-Atlas (CRC Press), Harcke strongly believes virtual autopsies should play a much greater role in non-military medicine as well.
Yet despite universal requests only between nine and 12 percent of the 850 deaths that occur annually at the Penn State Hershey Medical Center are autopsied. That rate is actually higher than the national rate of less than 5 percent, and far less than the 50 percent rate that Harcke estimates existed a half-century ago.
“For centuries,” he says, “dissection is how medical students and physicians have learned about the human body, why people have died and why certain patterns of death exist – such as questions that arose years after Vietnam regarding the effects of Agent Orange or after the first Gulf conflict regarding the Gulf War Syndrome.”
Last year the Dover mortuary conducted autopsies that combined visual inspections with CT scans on U.S. citizens killed in the Haitian earthquake, a model which could be used in mass casualty situations. Nonetheless, Harcke concedes that the ultimate goal of completely non-invasive autopsies is not yet feasible in all cases. But as a next step he wants studies to determine when virtual autopsies can be elevated from just assisting in physical autopsies to serving as basic autopsies that can direct targeted, minimally invasive physical autopsies – procedures he believes many more families would allow.
Says Harcke: “In order to further medical knowledge, I’d like to see virtual autopsies used to improve autopsy rates in hospitals and return autopsy from cases required by law – such as possible homicides or un-witnessed deaths – to mainstream medicine as a post-mortem examination that becomes commonplace and accepted.”
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