It's amazing that three weeks have already passed at Allegheny Hospital. I've had the opportunity to gross a wide variety of specimens and have gotten some much needed experience doing frozen sections. The residents have been very nice in letting me do their specimens and also in helping me out.
Another one of the good things that I like about the grossing system here that I like is that whenever you have a big specimen, you always need to get the 'blessing' of the attending. What that means is that whichever pathologist is going to be looking at the blocks that you make, you need to page them and have them come over before you begin your gross. They will ask for a clinical history and will advise you on what sections that they would like for you to take and how to process the specimen. It's great because you begin to think like the pathologists and after enough times you can predict what they are going to tell you. Of course, even if you already know what they are going to say, it's still important that you call them.
I had been studying for our end of the month exam so I was a little late in getting out this post, but I'm glad to say that I did quite well on it. Our reading material has gradually moved from about 50% pathology / 50% other (management, histology, autopsy, lab safety) to something more like 75% pathology / 25% other. It's time to open Robbins again and starting reading.
Also, this month I'll be working on a powerpoint presentation of pituitary pathology. I'm glad that I've mostly gotten the K-1 visa work out of the way, so now I have more time to devote to making a good presentation.
Because I was busy these past two weeks I'm thinking of writing another post while I can this weekend. So far this year, it seems that my posts have been largely about my personal experiences and less about practical topics of the "How to..." variety. It's about time I made another "How to..." post.
Saturday, April 28, 2012
Sunday, April 15, 2012
Week One at Allegheny General Hospital Surgical Pathology Laboratory
What a first week! The gross lab at Allegheny General has been a week of firsts for myself in many aspects. I've finally had the opportunity to gross my first gall bladders, digit amputations, colon and even a lower limb. These kinds of specimens are seen routinely at most surgical pathology laboratories so I can expect to perform many more throughout my future rotations and career.
The PAs and residents at Allegheny have been most helpful in answering my many questions. I believe that this brings up one of my weak points (or it could be a strong point in disguise) and that is that I pay a lot of attention to detail. Perhaps too much so. What happens is that I try and find every little thing that I can describe about a specimen and then I have trouble trying to find the words to describe in detail what I saw. Commonly I find myself describing so much that I make run on sentences or I stumble trying to find the words that I need. This slows me down. One of my goals while I'm at this site is to increase the speed at which I can gross specimens without sacrificing detail in my dictations.
My attention to detail has been a boon of other sorts however. For example, I noticed a well hidden ulcer in one of my specimens and was commended for catching it. With more experience, I am sure that I will become more proficient at what to include and what to exclude from my dictations.
The dictation system at Allegheny General Hospital actually uses a speaker phone to record your voice and sends your recording to a transcriptionist who translates your words into the computer. At first I had trouble adjusting to this because at Magee's Women's Hospital we used a software called 'Voiceover' to translate your words directly onto a computer screen in front of you. But, although only a week has passed, I actually prefer speaking into a microphone without having to deal with the computer screen.
The biggest drawback to just speaking into a microphone is that you can't see what you've said right in front of you. That is why it is very important to develop a routine for your gross and do it the same every time so that you don't forget or leave out something. I'm still getting used to the system, but I've found that I can speak more quickly into the microphone if I don't have to worry about how the software translates my words. The transcriptionists know to put a period at the end of each of my sentences and they also know when to add paragraphs or commas and make other grammatical corrections. The software on the other hand needs to have each of these spoon-fed to it. When using the software I find myself correcting formatting issues more than anything else.
"Why did it put a space there?!"
"Why did it put a hyphen there?!"
"Why does type out 'next item' instead of moving to the next item?!"
These types of infuriating technical issues are absent when you have a human at the other side. The transcriptionists at Allegheny General Hospital have my big thanks!
I am also pleased to announce that I have my first interview for a PA position at UC Davis on Tuesday! This interview is going to be conducted over SKYPE, so I am interested to see how smoothly things will turn out. It is still early in the year, but it is recommended for all PA students to get their names out there and apply for positions. The biggest obstacle to me being employed at UC Davis will be the long wait between now and my graduation eight months from now in December. If they are willing to wait until then, then I have no reason to turn down their offer. I won't know all of the details for certain until the interview, but it looks like an ideal place for myself to gain experience, integrate into their system and settle down.
In addition to a busy first week at Allegheny General Hospital, I've finally begun the arduous process of applying for a K-1 visa for Hanako to come to the United States. Hopefully, if I am able to send off the initial forms by the end of this month, then by the time that December rolls around she will be able to come to the US to get married and I'll already have a place of employment decided.
As many of you readers probably already know, Hanako is living in Miyagi Prefecture in Japan. It is the prefecture directly north of and adjacent to Fukushima. I still worry everyday about my friends, colleagues and students still in Fukushima due to the continued release of radiation from the Fukushima Daiichi nuclear power plant. Looking at these photos of the plant and the extent of the damage makes me want to get Hanako out of Japan as soon as possible. You can see a myriad of the most recent photos here: http://www.washingtonsblog.com/2012/04/a-visual-tour-of-the-fuel-pools-of-fukushima.html
They aren't pretty.
In the meantime, the only thing I can do is to try my best at work and learn as much as I can while doing these rotations. An opportunity like this will never exist again once I graduate, so it makes my hectic days all the more meaningful.
The PAs and residents at Allegheny have been most helpful in answering my many questions. I believe that this brings up one of my weak points (or it could be a strong point in disguise) and that is that I pay a lot of attention to detail. Perhaps too much so. What happens is that I try and find every little thing that I can describe about a specimen and then I have trouble trying to find the words to describe in detail what I saw. Commonly I find myself describing so much that I make run on sentences or I stumble trying to find the words that I need. This slows me down. One of my goals while I'm at this site is to increase the speed at which I can gross specimens without sacrificing detail in my dictations.
My attention to detail has been a boon of other sorts however. For example, I noticed a well hidden ulcer in one of my specimens and was commended for catching it. With more experience, I am sure that I will become more proficient at what to include and what to exclude from my dictations.
The dictation system at Allegheny General Hospital actually uses a speaker phone to record your voice and sends your recording to a transcriptionist who translates your words into the computer. At first I had trouble adjusting to this because at Magee's Women's Hospital we used a software called 'Voiceover' to translate your words directly onto a computer screen in front of you. But, although only a week has passed, I actually prefer speaking into a microphone without having to deal with the computer screen.
The biggest drawback to just speaking into a microphone is that you can't see what you've said right in front of you. That is why it is very important to develop a routine for your gross and do it the same every time so that you don't forget or leave out something. I'm still getting used to the system, but I've found that I can speak more quickly into the microphone if I don't have to worry about how the software translates my words. The transcriptionists know to put a period at the end of each of my sentences and they also know when to add paragraphs or commas and make other grammatical corrections. The software on the other hand needs to have each of these spoon-fed to it. When using the software I find myself correcting formatting issues more than anything else.
"Why did it put a space there?!"
"Why did it put a hyphen there?!"
"Why does type out 'next item' instead of moving to the next item?!"
These types of infuriating technical issues are absent when you have a human at the other side. The transcriptionists at Allegheny General Hospital have my big thanks!
I am also pleased to announce that I have my first interview for a PA position at UC Davis on Tuesday! This interview is going to be conducted over SKYPE, so I am interested to see how smoothly things will turn out. It is still early in the year, but it is recommended for all PA students to get their names out there and apply for positions. The biggest obstacle to me being employed at UC Davis will be the long wait between now and my graduation eight months from now in December. If they are willing to wait until then, then I have no reason to turn down their offer. I won't know all of the details for certain until the interview, but it looks like an ideal place for myself to gain experience, integrate into their system and settle down.
In addition to a busy first week at Allegheny General Hospital, I've finally begun the arduous process of applying for a K-1 visa for Hanako to come to the United States. Hopefully, if I am able to send off the initial forms by the end of this month, then by the time that December rolls around she will be able to come to the US to get married and I'll already have a place of employment decided.
As many of you readers probably already know, Hanako is living in Miyagi Prefecture in Japan. It is the prefecture directly north of and adjacent to Fukushima. I still worry everyday about my friends, colleagues and students still in Fukushima due to the continued release of radiation from the Fukushima Daiichi nuclear power plant. Looking at these photos of the plant and the extent of the damage makes me want to get Hanako out of Japan as soon as possible. You can see a myriad of the most recent photos here: http://www.washingtonsblog.com/2012/04/a-visual-tour-of-the-fuel-pools-of-fukushima.html
They aren't pretty.
In the meantime, the only thing I can do is to try my best at work and learn as much as I can while doing these rotations. An opportunity like this will never exist again once I graduate, so it makes my hectic days all the more meaningful.
Sunday, April 8, 2012
Last Week at West Virginia Deputy Chief Medical Examiner's Office
Well, the last week at the autopsy rotation has come and gone. Looking back, even though it has been one of our longer rotations, the days seem to have flown by quickly. I have already returned to Pittsburgh to begin my new rotation at the gross lab at Allegheny Hospital.
I'll be taking the bus in the mornings and afternoons to get to and from work for this rotation. On Saturday, I wanted to scope out my route, so I hopped on a bus and headed downtown. I have the option of paying for a transfer ticket, but the walk from downtown to Allegheny Hospital only takes about 30 minutes, so once I've arrived in downtown I'll just walk the rest of the way. I have a lot of patience, but I'd rather get the exercise than stand waiting for a bus.
So, my commute tomorrow morning involves walking for 20 minutes from my house to the bus stop, riding the bus for about 20-30 minutes depending on the traffic, then walking for another 30 minutes once I arrive in downtown. It's great because now I don't need to take time out of my day to get my jogging done.
I had promised to write a little about the organ cutting process, so I'd like to cover that.
The eviscerator removes organs, usually one by one but sometimes en-bloc, and places them on the next table for the organ cutter to begin. The role of the organ cutter is to examine each of the organs for any pathology, whether it be injury or disease. It should always be remembered that one is looking for a cause of death.
As each organ is taken out their weights are measured and recorded. Many disease processes can cause hypertrophy or atrophy of an organ and the organ weight can be very important in diagnosis.
Also, various representative sections of each organ and tissue are placed in a formalin container for reference when needed. For example, small pieces of each lobe of the lungs, the esophagus, the kidneys, the thyroid gland, etc...Virtually a piece from every organ or tissue that is cut into is sampled and stored.
For cases in which the tissues need to be looked at under the microscope, cassettes of each tissue of interest are made and a piece of the tissue is placed into the cassette. These cassettes go to histology for processing and the slides are later viewed by the pathologists.
When the organs are being removed one by one, the first organ that is usually out first is the heart. The general procedure for dissecting a heart starts off with cutting through the coronary arteries to look for atherosclerosis. Myocardial infarction is a huge killer and often times this ends up being the cause of death. In order to declare that a person died from a myocardial infarction you need to find a lumen with at least 75% stenosis (narrowing). The three vessels to examine are the right coronary artery, left anterior descending artery and the left circumflex artery.
Once the vessels have been examined the bottom portion of the heart (I'd say lower 35%) is sectioned through transversely. This will produce numerous rings of the right and left ventricles. You can look at the myocardial wall for any evidence of necrosis or scar tissue due to a myocardial infarction so long as sufficient time has passed. You shouldn't be able to see any gross evidence of a myocardial infarction in the wall if less 12 hours have passed since death.
The heart is then usually opened via the direction of blood flow. A cut is made into the right atrium from the superior and inferior vena cava. Then a cut is made down into the right ventricle (you can choose to cut anteriorly or laterally). From the right ventricle a cut is made up through the pulmonary arteries. A new cut is begun from the pulmonary veins into the left atrium and then down into the left ventricle. Finally a cut is made up the aorta.
The opened heart should expose numerous sites of interest including the fossa ovalis, SA node, tricuspid valve, pulmonary valve, mitral valve and aortic valve.
The lungs need to be checked for emboli and thrombi. This is done by using scissors to cut down the various vessels and bronchi at the hilum. Once these have been checked, then the lungs can be serially sectioned and representative sections can be saved in the formalin container. The most common pathology that I have seen with lungs is pulmonary congestion and edema. Smokers often have emphysematous changes which make the lungs floppy and the cut surfaces look almost like they are made of spider webs.
The order that the organs are examined doesn't matter, but usually what comes next are the adrenal glands. (The intestines are commonly saved for next to last). These are usually embedded in fat and look just like a yellow blob, but when you cut into them you will know that the adrenals are present because of the striped brown-yellow color to them. Usually there is nothing grossly abnormal with them and a small piece from each is saved in the formalin container.
The kidneys may come next. The capsule has already been removed from them, so there is no fat surrounding the kidneys when you receive them. The surfaces of the kidneys of people with diabetes will commonly have a granular appearance rather than a smooth once. The kidneys are bivalved in half and then cut again by bread loafing (same as serially sectioning).
For male pelvic organs, you will have part of the colon, the prostate and the bladder. The colon is opened with scissors from the rectum and the bladder is opened with scissors from the prostatic urethra.
For female pelvic organs, you will have part of the colon, part of the vagina, the uterus, the fallopian tubes and the ovaries. In addition to opening the colon as with the male, the ovaries and the uterus are bivalved.
The pelvic organs are usually unremarkable and without pathology. The ovaries may incidentally have cysts or the uterus may have fibroids, but they are not related to the cause of death. Nonetheless, they are mentioned in the autopsy report.
The spleen can be examined in much the same way as the kidneys. The spleen is very fragile and will tear as you are working with it. If the spleen is already torn when you see it, you should ask the eviscerator if they accidentally tore it when they were removing it.
The livers of alcoholics can commonly appear from mildly yellow (fatty change) to nodular and hard (cirrhosis). The liver is the largest organ in the body (excluding the skin) but it is relatively easy to section through. First, the gall bladder is opened to look for the presence of any gallstones. The liver can be serially sectioned. Toxicology tests are performed on liver tissue so there is a separate container where small pieces of liver are put into.
The diaphragm is almost always unremarkable unless there has been some sort of trauma.
The digestive tract from the tongue down to the duodenum is taken out in one large continuous block. It can look formidable, but if you start from the mouth and go down it is very doable.
First, the stomach contents are removed by making a small slash or cut in the stomach and letting the contents pour out. The contents are saved in a separate container. You never know what you will find.
Starting at the beginning, the tongue is serially sectioned to look for bruising and hemorrhage. People who die from seizures may sometimes bite their tongue inadvertently, but just because there is no evidence of hemorrhage doesn't mean they didn't die from a seizure.
The esophagus is opened up with scissors and cut down all the way to the stomach. The stomach is opened along the greater curvature to the pylorus and the pylorus is cut through to open up the duodenum. Each of the internal surfaces can be examined for ulcers, tears or other pathology.
The pancreas can be serially sectioned through. Sometimes it is difficult to locate it because it blends in with the surrounding fat, but it is slightly more firm and if you use your fingers you can find it.
The trachea is open by cutting down the larynx. Sometimes a person may aspirate gastric contents into their lungs and you may see that in their trachea as well. When a person dies in a fire, their trachea may have soot inside it. If a person died in a fire but their trachea is clean, then you know that they weren't breathing when the fire occurred and you may suspect foul play.
The thyroid glands can be serially sectioned through, but aside from the occasional nodule they are usually unremarkable.
The intestines are opened with scissors from the jejunum to the ileum and then the colon. This part is best done over a sink and it can get quite messy as you can imagine.
The aorta is opened with scissors and examined. Commonly older people will have calcifications that distort and narrow the aorta.
Lastly, the brain needs to be examined. In many cases of head injury a subdural hematoma will commonly be the cause of death. It is easily seen once the skull is opened. The Circle of Willis is examined for atherosclerosis and the cerebellum is detached from the cerebrum by a cut through the midbrain. The cerebellum is cut through the vermis and each lobe is serially sectioned. The brainstem is serially cut from the pons, to the medulla to the brainstem. The cerebrum is also serially sectioned from anterior to posterior. The 'loaves' are laid out on the table so that a frontal section of the brain from anterior to posterior can be seen. All of the important areas as well as the basal ganglia can be seen. Most commonly, the brain shows no abnormalities.
This rotation gave me the opportunity to participate in the autopsy process from start to finish. I have had good experiences eviscerating, cutting organs, writing a PAD and writing an autopsy report. It was all possible because of the guidance of my teachers there. At the beginning they were by my side every step of the way, but when I became proficient enough I would only call for their help when I had a question. I'm very pleased with my progress there and am thankful for all of the kind and hardworking people at the morgue. It's a must-have rotation and experience for us PA students.
I'll be taking the bus in the mornings and afternoons to get to and from work for this rotation. On Saturday, I wanted to scope out my route, so I hopped on a bus and headed downtown. I have the option of paying for a transfer ticket, but the walk from downtown to Allegheny Hospital only takes about 30 minutes, so once I've arrived in downtown I'll just walk the rest of the way. I have a lot of patience, but I'd rather get the exercise than stand waiting for a bus.
So, my commute tomorrow morning involves walking for 20 minutes from my house to the bus stop, riding the bus for about 20-30 minutes depending on the traffic, then walking for another 30 minutes once I arrive in downtown. It's great because now I don't need to take time out of my day to get my jogging done.
I had promised to write a little about the organ cutting process, so I'd like to cover that.
The eviscerator removes organs, usually one by one but sometimes en-bloc, and places them on the next table for the organ cutter to begin. The role of the organ cutter is to examine each of the organs for any pathology, whether it be injury or disease. It should always be remembered that one is looking for a cause of death.
As each organ is taken out their weights are measured and recorded. Many disease processes can cause hypertrophy or atrophy of an organ and the organ weight can be very important in diagnosis.
Also, various representative sections of each organ and tissue are placed in a formalin container for reference when needed. For example, small pieces of each lobe of the lungs, the esophagus, the kidneys, the thyroid gland, etc...Virtually a piece from every organ or tissue that is cut into is sampled and stored.
For cases in which the tissues need to be looked at under the microscope, cassettes of each tissue of interest are made and a piece of the tissue is placed into the cassette. These cassettes go to histology for processing and the slides are later viewed by the pathologists.
When the organs are being removed one by one, the first organ that is usually out first is the heart. The general procedure for dissecting a heart starts off with cutting through the coronary arteries to look for atherosclerosis. Myocardial infarction is a huge killer and often times this ends up being the cause of death. In order to declare that a person died from a myocardial infarction you need to find a lumen with at least 75% stenosis (narrowing). The three vessels to examine are the right coronary artery, left anterior descending artery and the left circumflex artery.
Once the vessels have been examined the bottom portion of the heart (I'd say lower 35%) is sectioned through transversely. This will produce numerous rings of the right and left ventricles. You can look at the myocardial wall for any evidence of necrosis or scar tissue due to a myocardial infarction so long as sufficient time has passed. You shouldn't be able to see any gross evidence of a myocardial infarction in the wall if less 12 hours have passed since death.
The heart is then usually opened via the direction of blood flow. A cut is made into the right atrium from the superior and inferior vena cava. Then a cut is made down into the right ventricle (you can choose to cut anteriorly or laterally). From the right ventricle a cut is made up through the pulmonary arteries. A new cut is begun from the pulmonary veins into the left atrium and then down into the left ventricle. Finally a cut is made up the aorta.
The opened heart should expose numerous sites of interest including the fossa ovalis, SA node, tricuspid valve, pulmonary valve, mitral valve and aortic valve.
The lungs need to be checked for emboli and thrombi. This is done by using scissors to cut down the various vessels and bronchi at the hilum. Once these have been checked, then the lungs can be serially sectioned and representative sections can be saved in the formalin container. The most common pathology that I have seen with lungs is pulmonary congestion and edema. Smokers often have emphysematous changes which make the lungs floppy and the cut surfaces look almost like they are made of spider webs.
The order that the organs are examined doesn't matter, but usually what comes next are the adrenal glands. (The intestines are commonly saved for next to last). These are usually embedded in fat and look just like a yellow blob, but when you cut into them you will know that the adrenals are present because of the striped brown-yellow color to them. Usually there is nothing grossly abnormal with them and a small piece from each is saved in the formalin container.
The kidneys may come next. The capsule has already been removed from them, so there is no fat surrounding the kidneys when you receive them. The surfaces of the kidneys of people with diabetes will commonly have a granular appearance rather than a smooth once. The kidneys are bivalved in half and then cut again by bread loafing (same as serially sectioning).
For male pelvic organs, you will have part of the colon, the prostate and the bladder. The colon is opened with scissors from the rectum and the bladder is opened with scissors from the prostatic urethra.
For female pelvic organs, you will have part of the colon, part of the vagina, the uterus, the fallopian tubes and the ovaries. In addition to opening the colon as with the male, the ovaries and the uterus are bivalved.
The pelvic organs are usually unremarkable and without pathology. The ovaries may incidentally have cysts or the uterus may have fibroids, but they are not related to the cause of death. Nonetheless, they are mentioned in the autopsy report.
The spleen can be examined in much the same way as the kidneys. The spleen is very fragile and will tear as you are working with it. If the spleen is already torn when you see it, you should ask the eviscerator if they accidentally tore it when they were removing it.
The livers of alcoholics can commonly appear from mildly yellow (fatty change) to nodular and hard (cirrhosis). The liver is the largest organ in the body (excluding the skin) but it is relatively easy to section through. First, the gall bladder is opened to look for the presence of any gallstones. The liver can be serially sectioned. Toxicology tests are performed on liver tissue so there is a separate container where small pieces of liver are put into.
The diaphragm is almost always unremarkable unless there has been some sort of trauma.
The digestive tract from the tongue down to the duodenum is taken out in one large continuous block. It can look formidable, but if you start from the mouth and go down it is very doable.
First, the stomach contents are removed by making a small slash or cut in the stomach and letting the contents pour out. The contents are saved in a separate container. You never know what you will find.
Starting at the beginning, the tongue is serially sectioned to look for bruising and hemorrhage. People who die from seizures may sometimes bite their tongue inadvertently, but just because there is no evidence of hemorrhage doesn't mean they didn't die from a seizure.
The esophagus is opened up with scissors and cut down all the way to the stomach. The stomach is opened along the greater curvature to the pylorus and the pylorus is cut through to open up the duodenum. Each of the internal surfaces can be examined for ulcers, tears or other pathology.
The pancreas can be serially sectioned through. Sometimes it is difficult to locate it because it blends in with the surrounding fat, but it is slightly more firm and if you use your fingers you can find it.
The trachea is open by cutting down the larynx. Sometimes a person may aspirate gastric contents into their lungs and you may see that in their trachea as well. When a person dies in a fire, their trachea may have soot inside it. If a person died in a fire but their trachea is clean, then you know that they weren't breathing when the fire occurred and you may suspect foul play.
The thyroid glands can be serially sectioned through, but aside from the occasional nodule they are usually unremarkable.
The intestines are opened with scissors from the jejunum to the ileum and then the colon. This part is best done over a sink and it can get quite messy as you can imagine.
The aorta is opened with scissors and examined. Commonly older people will have calcifications that distort and narrow the aorta.
Lastly, the brain needs to be examined. In many cases of head injury a subdural hematoma will commonly be the cause of death. It is easily seen once the skull is opened. The Circle of Willis is examined for atherosclerosis and the cerebellum is detached from the cerebrum by a cut through the midbrain. The cerebellum is cut through the vermis and each lobe is serially sectioned. The brainstem is serially cut from the pons, to the medulla to the brainstem. The cerebrum is also serially sectioned from anterior to posterior. The 'loaves' are laid out on the table so that a frontal section of the brain from anterior to posterior can be seen. All of the important areas as well as the basal ganglia can be seen. Most commonly, the brain shows no abnormalities.
This rotation gave me the opportunity to participate in the autopsy process from start to finish. I have had good experiences eviscerating, cutting organs, writing a PAD and writing an autopsy report. It was all possible because of the guidance of my teachers there. At the beginning they were by my side every step of the way, but when I became proficient enough I would only call for their help when I had a question. I'm very pleased with my progress there and am thankful for all of the kind and hardworking people at the morgue. It's a must-have rotation and experience for us PA students.
Sunday, April 1, 2012
Week Six at West Virginia Deputy Chief Medical Examiner's Office
I have been remiss in my writings for this blog and there are certainly a number of things that have occurred since my last post. I'm glad to say that I did well on our monthly test on Friday, so with studying out of the way for a short while now would be a good time to get my thoughts down on digital paper.
I had originally planned to continue writing a description about the autopsy process of cutting organs, but instead I will write about a good learning experience I had during this rotation. That is, learning how to write a preliminary autopsy diagnosis (PAD) and an autopsy report.
I won't write anything specific or any of the details pertaining to the case that I worked on, but I would like to write about the general procedures and thought processes that go on while examining a body and what findings to include on a PAD and an autopsy report.
Consent:
Before even looking at a body one must make sure that the proper consent has been given to do the autopsy. In a medical examiner's case in which the person dies a suspicious death there is no need to receive outside consent. Whether or not an autopsy is performed is up to the medical examiner. In an autopsy case in which the person dies at a hospital or a family member requests a private autopsy, the extent of the autopsy is determined by the person who holds the power of attorney (usually a family member). They can restrict the autopsy to examining just the chest, for example. Or, they may decide that you can examine all body cavities except for the skull. The signature of the power of attorney, the signature of the physician and the signature of a witness are all required.
Clinical History:
Knowing how a patient ended up in the morgue will give you the biggest clues on what to look for while performing an autopsy. You may find information on how the patient died, what predisposing diseases they suffered from, what illnesses they had, what medications they were taking, what operations they have had, how old they were and so forth. It's imperative to begin an autopsy armed with this knowledge rather than blindly performing an autopsy hoping to find something.
External Examination:
The arm-work of the autopsy begins with an external examination. Every piece of information that you can see is written down here. It's a complete physical examination, from head to toe and in every nook and cranny. Not a single proverbial leaf is left unturned. Things that you'll be writing down and measuring include:
gender
body weight
height
hair color, hair length, looking at the scalp for cuts or bruises
eye color, pupil diameter, appearance of the conjunctivae
patency of the nose and examining the ears
examining the anus and vagina or glans penis
condition of the teeth (natural, dentures, etc...)
scars, tattoos, bruises, cuts, piercings
IV lines, puncture sites, orogastric tubes, endotracheal tubes, catheters, etc...
clothes, jewelry, money, other possessions
degree of rigor mortis
degree of livor mortis
other things to keep in mind include edema of the skin, cyanosis, jaundice, burns, bed sores, bone fractures, etc...
Toxicology:
Next, body fluids can be drawn for toxicology. Typically, vitreous fluid from the eyes, blood from the subclavian arteries and urine from the bladder are drawn using needles. Various electrolytes, drugs and medications can be measured in a chemistry department on these fluids.
Examining the Organ Systems:
This is where the evisceration begins. I previously wrote a post of the evisceration process titled "Week Three at West Virginia Deputy Chief Medical Examiner's Office". While one person is eviscerating the body and removing the organs, another person can be examining the organs as they are brought out. I haven't yet described this process, but I will in a future post. One important thing to do is to measure the amount of fluid in the pericardial sac, the pleural cavities and the peritoneal cavity. You will also be weighing each organ. As each organ is cut any pathology that is found is noted. Some organs need to be examined under the microscope, so some pieces from each organ will also be taken and put into cassettes to be embedded. The submission of cassettes is somewhat similar to what happens in the gross laboratory, but more information can be found here at "A Trip to the Histology Laboratory".
Writing the Preliminary Anatomical Diagnosis (PAD):
This is a short and basic outline of the various pathologies found during the autopsy. The easiest way to begin is to break up each organ system into its various components and list the pathologies found in each. Here's a rough sketch of what it might look like:
I. Organ System #1
A. Pathology #1
1. Amount/Degree of Pathology #1
2. Amount/Degree of Pathology #1
B. Pathology #2
1. Amount/Degree of Pathology #2
II. Organ System #2
A. Pathology #1
1. Amount/Degree of Pathology #1
etc...
The PAD needs to be completed within 48 hours of the autopsy. This short time frame helps to keep the case fresh in your mind. If you wait too long, even if you took good notes, you might not remember everything about the case.
Writing the Autopsy Report:
The autopsy report is much more in-depth than the PAD. It usually runs for a couple of pages and is written in complete sentence form. It covers the patient's clinical history, their general information, their external appearance, any evidence of therapy, how the autopsy was performed and each of the organ systems. Although I would have liked to write out an example autopsy report for the elucidation of you readers, I have found a site (perhaps a bit morbid) that actually has autopsy reports of various people that have been made public. You'll notice that not every autopsy report is in the same format, nor are they all in the same length. You can find the autopsy reports here at: http://www.autopsyfiles.org/
For an example autopsy report that includes a clinical history, an external examination and an examination of the organ systems I would recommend Anna Nicole Smith, Edward Fatu or John F. Kennedy. (I haven't gone through all of them, only a few and I selected the ones that I thought would hit the major points.)
And that's all that there is to doing an autopsy! A complicated autopsy can take all day to perform while a simple one can be completed in a few hours. It should always be remembered that each autopsy performed has a person behind it and people who are eagerly awaiting the results, whether they are law enforcement or family members who have lost a loved one.
I had originally planned to continue writing a description about the autopsy process of cutting organs, but instead I will write about a good learning experience I had during this rotation. That is, learning how to write a preliminary autopsy diagnosis (PAD) and an autopsy report.
I won't write anything specific or any of the details pertaining to the case that I worked on, but I would like to write about the general procedures and thought processes that go on while examining a body and what findings to include on a PAD and an autopsy report.
Consent:
Before even looking at a body one must make sure that the proper consent has been given to do the autopsy. In a medical examiner's case in which the person dies a suspicious death there is no need to receive outside consent. Whether or not an autopsy is performed is up to the medical examiner. In an autopsy case in which the person dies at a hospital or a family member requests a private autopsy, the extent of the autopsy is determined by the person who holds the power of attorney (usually a family member). They can restrict the autopsy to examining just the chest, for example. Or, they may decide that you can examine all body cavities except for the skull. The signature of the power of attorney, the signature of the physician and the signature of a witness are all required.
Clinical History:
Knowing how a patient ended up in the morgue will give you the biggest clues on what to look for while performing an autopsy. You may find information on how the patient died, what predisposing diseases they suffered from, what illnesses they had, what medications they were taking, what operations they have had, how old they were and so forth. It's imperative to begin an autopsy armed with this knowledge rather than blindly performing an autopsy hoping to find something.
External Examination:
The arm-work of the autopsy begins with an external examination. Every piece of information that you can see is written down here. It's a complete physical examination, from head to toe and in every nook and cranny. Not a single proverbial leaf is left unturned. Things that you'll be writing down and measuring include:
gender
body weight
height
hair color, hair length, looking at the scalp for cuts or bruises
eye color, pupil diameter, appearance of the conjunctivae
patency of the nose and examining the ears
examining the anus and vagina or glans penis
condition of the teeth (natural, dentures, etc...)
scars, tattoos, bruises, cuts, piercings
IV lines, puncture sites, orogastric tubes, endotracheal tubes, catheters, etc...
clothes, jewelry, money, other possessions
degree of rigor mortis
degree of livor mortis
other things to keep in mind include edema of the skin, cyanosis, jaundice, burns, bed sores, bone fractures, etc...
Toxicology:
Next, body fluids can be drawn for toxicology. Typically, vitreous fluid from the eyes, blood from the subclavian arteries and urine from the bladder are drawn using needles. Various electrolytes, drugs and medications can be measured in a chemistry department on these fluids.
Examining the Organ Systems:
This is where the evisceration begins. I previously wrote a post of the evisceration process titled "Week Three at West Virginia Deputy Chief Medical Examiner's Office". While one person is eviscerating the body and removing the organs, another person can be examining the organs as they are brought out. I haven't yet described this process, but I will in a future post. One important thing to do is to measure the amount of fluid in the pericardial sac, the pleural cavities and the peritoneal cavity. You will also be weighing each organ. As each organ is cut any pathology that is found is noted. Some organs need to be examined under the microscope, so some pieces from each organ will also be taken and put into cassettes to be embedded. The submission of cassettes is somewhat similar to what happens in the gross laboratory, but more information can be found here at "A Trip to the Histology Laboratory".
Writing the Preliminary Anatomical Diagnosis (PAD):
This is a short and basic outline of the various pathologies found during the autopsy. The easiest way to begin is to break up each organ system into its various components and list the pathologies found in each. Here's a rough sketch of what it might look like:
I. Organ System #1
A. Pathology #1
1. Amount/Degree of Pathology #1
2. Amount/Degree of Pathology #1
B. Pathology #2
1. Amount/Degree of Pathology #2
II. Organ System #2
A. Pathology #1
1. Amount/Degree of Pathology #1
etc...
The PAD needs to be completed within 48 hours of the autopsy. This short time frame helps to keep the case fresh in your mind. If you wait too long, even if you took good notes, you might not remember everything about the case.
Writing the Autopsy Report:
The autopsy report is much more in-depth than the PAD. It usually runs for a couple of pages and is written in complete sentence form. It covers the patient's clinical history, their general information, their external appearance, any evidence of therapy, how the autopsy was performed and each of the organ systems. Although I would have liked to write out an example autopsy report for the elucidation of you readers, I have found a site (perhaps a bit morbid) that actually has autopsy reports of various people that have been made public. You'll notice that not every autopsy report is in the same format, nor are they all in the same length. You can find the autopsy reports here at: http://www.autopsyfiles.org/
For an example autopsy report that includes a clinical history, an external examination and an examination of the organ systems I would recommend Anna Nicole Smith, Edward Fatu or John F. Kennedy. (I haven't gone through all of them, only a few and I selected the ones that I thought would hit the major points.)
And that's all that there is to doing an autopsy! A complicated autopsy can take all day to perform while a simple one can be completed in a few hours. It should always be remembered that each autopsy performed has a person behind it and people who are eagerly awaiting the results, whether they are law enforcement or family members who have lost a loved one.
Tuesday, March 20, 2012
A Close Call
Well, it was bound to happen eventually. Last week I had accidentally cut my finger on a scalpel blade while in the morgue. It would have been fine if the scalpel blade was clean, but it was right in the middle of my organ dissection.
As I was cutting the organs on a raised table I needed to grab my long 'slicer'. This is the long knife that is typically used to section through or bread-loaf organs. I reached for the handle, but it was out of my sight (big mistake) and adjacent to the table. As I grasped the handle, I could feel a slight scratching motion run across the tip of my index finger, but it honestly didn't feel like a cut. Of course, I was wearing two layers of gloves, but it wasn't a feeling that one would normally feel while wearing gloves, so I took a look at my finger and I could see that the glove had a cut through it at the tip of my finger. I knew then that I was in trouble.
I unconsciously exclaimed an expletive and took off my gloves. Sure enough, a drop of blood formed at the tip of my finger. I was incredibly surprised because the pain was almost nonexistent. The cut was so smooth and clean I could hardly notice that my finger had just been cut. Looking back at my table, I could see how I had gotten cut.
It turns out I had unbeknownst placed a scalpel next to the slicer handle (or the slicer handle next to the scalpel) so that when I reached to grab the slicer handle, my finger inadvertently rubbed across the scalpel blade. It was a perfect cut.
The biggest danger of being exposed to blood from another person (even if they are dead) is the risk of the transmission of disease. There are three big diseases that you should be conscious of in an exposure incident. They are, HIV, Hep B and Hep C.
Hepatitis B vaccinations exist and that is why we students, upon matriculation into this program, are vaccinated for this virus before we start the program. I'm definitely glad I was already immune, so I didn't have to worry whether I was exposed to it or not.
No vaccination exists for HIV, but fortunately, due to the nature of the virus, it is not easily spread even if you are exposed to it. Also, the number of persons in the US infected with HIV is relatively low.
My biggest fear was hepatitis C. It is more transmissible than HIV and a larger percentage of people have hepatitis C than HIV. Like HIV, there is no vaccination available for Hep C.
I immediately washed my hands with anti-microbial soap and tried to force out as much blood as possible from my finger. The morgue technicians were kind enough to draw some more blood out of the cadaver for me to take to the employee health office to test for antibodies in the cadaver blood. (The cadaver was already pretty 'dry' and it was really difficult getting any more blood out of it.)
I handed the blood off at the employee health office and eagerly awaited their response. I was in limbo. What if the body really did contain hepatitis or HIV? What if I really did contract some disease? It was a definite possibility that my whole life could change. I'm the type of person who for better or for worse, always imagines the worst outcome possible, and the worst outcome possible was definitely a grave one. I began to think about how I should conduct my life if I were to become infected. Could I still get married? What if I gave this disease to my fiancee? I'd never be able to forgive myself. What about having children and a family? What if my children were born with these diseases? Perhaps I should give up on the idea of raising a family.
Strange thoughts like these go through your head while you are waiting. The next day, they called me but unfortunately couldn't get a satisfactory lab result. Hemolyzed blood is more difficult to test with (well, after all, it's from a cadaver) and they needed to send out the blood to an outside lab.
It was all out of my hands at that point. I waited as patiently as one possibly could. Friday. Saturday. Sunday. Monday. Finally, today, the results came back.
Negative for both HIV and Hep C.
It's a load off of my shoulders to finally know. I do feel guilty that the hospital had to spend a good amount of money to get those tests done. I'd imagine that it was at least a couple of hundred dollars. Someday, when I have more discretionary money, I'll need to pay back the favor.
Life continues on as normal but with one important change. When you're working with your tools, always look at where your hands go.
As I was cutting the organs on a raised table I needed to grab my long 'slicer'. This is the long knife that is typically used to section through or bread-loaf organs. I reached for the handle, but it was out of my sight (big mistake) and adjacent to the table. As I grasped the handle, I could feel a slight scratching motion run across the tip of my index finger, but it honestly didn't feel like a cut. Of course, I was wearing two layers of gloves, but it wasn't a feeling that one would normally feel while wearing gloves, so I took a look at my finger and I could see that the glove had a cut through it at the tip of my finger. I knew then that I was in trouble.
I unconsciously exclaimed an expletive and took off my gloves. Sure enough, a drop of blood formed at the tip of my finger. I was incredibly surprised because the pain was almost nonexistent. The cut was so smooth and clean I could hardly notice that my finger had just been cut. Looking back at my table, I could see how I had gotten cut.
It turns out I had unbeknownst placed a scalpel next to the slicer handle (or the slicer handle next to the scalpel) so that when I reached to grab the slicer handle, my finger inadvertently rubbed across the scalpel blade. It was a perfect cut.
The biggest danger of being exposed to blood from another person (even if they are dead) is the risk of the transmission of disease. There are three big diseases that you should be conscious of in an exposure incident. They are, HIV, Hep B and Hep C.
Hepatitis B vaccinations exist and that is why we students, upon matriculation into this program, are vaccinated for this virus before we start the program. I'm definitely glad I was already immune, so I didn't have to worry whether I was exposed to it or not.
No vaccination exists for HIV, but fortunately, due to the nature of the virus, it is not easily spread even if you are exposed to it. Also, the number of persons in the US infected with HIV is relatively low.
My biggest fear was hepatitis C. It is more transmissible than HIV and a larger percentage of people have hepatitis C than HIV. Like HIV, there is no vaccination available for Hep C.
I immediately washed my hands with anti-microbial soap and tried to force out as much blood as possible from my finger. The morgue technicians were kind enough to draw some more blood out of the cadaver for me to take to the employee health office to test for antibodies in the cadaver blood. (The cadaver was already pretty 'dry' and it was really difficult getting any more blood out of it.)
I handed the blood off at the employee health office and eagerly awaited their response. I was in limbo. What if the body really did contain hepatitis or HIV? What if I really did contract some disease? It was a definite possibility that my whole life could change. I'm the type of person who for better or for worse, always imagines the worst outcome possible, and the worst outcome possible was definitely a grave one. I began to think about how I should conduct my life if I were to become infected. Could I still get married? What if I gave this disease to my fiancee? I'd never be able to forgive myself. What about having children and a family? What if my children were born with these diseases? Perhaps I should give up on the idea of raising a family.
Strange thoughts like these go through your head while you are waiting. The next day, they called me but unfortunately couldn't get a satisfactory lab result. Hemolyzed blood is more difficult to test with (well, after all, it's from a cadaver) and they needed to send out the blood to an outside lab.
It was all out of my hands at that point. I waited as patiently as one possibly could. Friday. Saturday. Sunday. Monday. Finally, today, the results came back.
Negative for both HIV and Hep C.
It's a load off of my shoulders to finally know. I do feel guilty that the hospital had to spend a good amount of money to get those tests done. I'd imagine that it was at least a couple of hundred dollars. Someday, when I have more discretionary money, I'll need to pay back the favor.
Life continues on as normal but with one important change. When you're working with your tools, always look at where your hands go.
Sunday, March 11, 2012
Week Three at West Virginia Deputy Chief Medical Examiner's Office
Things have been going as smoothly as things can be going so far. I still make mistakes, but I've been improving my speed and accuracy at performing the autopsies. As for myself, the time seems to fly when I'm working on a body. If I watch another person perform an autopsy, I can feel my legs weighing me down and I need to sit before gravity takes over. On the other hand, if I'm the one who's working, once I've gotten into my 'mode' my arms and body are moving so fast that I don't feel the need to sit.
This reminds me of the two basic functions that PA students at WVU perform during the autopsy rotation. The two duties are evisceration and organ dissection. Today, I'll do my best to explain evisceration, especially for those who haven't studied anatomy before. This subject may turn off some of you due to the nature of cutting into the human body, so if you feel uncomfortable it would be best to stop reading.
In short, evisceration of a body involves opening it and removing the organs. After the medical examiner has completed their assessment of the external features of the body and samples of vitreous fluid (from the eyes), subclavian blood and urine have been taken, the body is ready to be opened.
A wooden block is placed underneath the body just below the shoulders to prop up the chest. This helps blood from flowing over the shoulders and giving you a better angle to access the body cavities. The first incisions are made with a scalpel and start at both shoulders (near the acromion processes) and converge at the bottom of the chest where the ribs connect to the sternum (near the xiphoid process). From here, a single long incision continues down the abdomen towards the belly button. The cut continues around the belly button all the way towards the pubic bone, just above the genitals. These cuts look like a giant Y on the body.
Skin, fat and muscle needs to be pulled back (reflected) from the chest cavity. Initially the tissues will be quite adherent and you may not have a good grip to pull back the tissue. If it's difficult for me I like to use forceps to grasp the tissue so I don't have to cut with the scalpel blade so close to my fingers. After the first bit of tissue has been sliced free I can grip it with my whole hand, but if it's still slippery using a paper towel gives you a better grip. Tissue also needs to be reflected upwards towards the neck. But, because the skin here is thinner you need to be careful that you don't cut a hole though it. You also need to be careful that you don't accidentally put a cut into the trachea as you are freeing the tissue.
The same thing about reflection can be said about the abdominal cavity. But, because there are no bones over your belly, as soon as you cut through you are into the cavity. The stomach, liver and intestines are lying right underneath, so you need to be careful not to cut into them when you are cutting through the abdominal wall.
With most of the skin reflected, you need to find a way to get into the chest cavity. Your ribs are of course made of bone, but towards the front where they meet your sternum they are made of cartilage. This allows your chest to expand and contract when you breathe. A scalpel can't cut through bone very easily, but it can cut through cartilage with little effort. The cartilage is whiter than the bone, so all that needs to be done is use the scalpel and cut down the ribs where they are white. The cartilage begins to disappear towards where your clavicles meet your sternum (manubrium), so you may have to use an oscillating saw.
The oscillating saw is used to cut through bone. Think of a power drill, but instead of a drill it has a serrated blade for a head and it vibrates back and forth incredibly fast. Against soft tissues it doesn't cut very well, but it can go through bone like a hot spoon though ice. While cutting through bone (especially the skull) it gives off a lot of bone dust and the room fills with a burning smell despite all of the ventilation.
Once the cuts through the ribs have been made you can use a scalpel again to free it and remove the chest plate. Immediately visible will be both lungs and the heart encased in its sac. You can check to see if the thymus remains, but in many adults it has been replaced by fat. If it is there you can cut it out. The lungs need to be moved out of the way so you can see how much fluid (pleural fluid) is contained within the cavities. After that you are ready to open the sac that contains the heart (the pericardium). The sac also contains its own fluid so you need to move the heart out of the way and take a look at it. To remove the heart, you can grasp it in your hand, pull it as far as possible out of the chest, then using your scissors cut across all of the vessels at the base. Your first cut will probably be through the inferior vena cava and when you cut into it blood inside the heart will fall out into the pericardial sac and make your life a little harder by obscuring where you need to cut. Even if you can't see well, as long as you cut far enough away from the heart across the vessels you should be able to free it.
Next will be to remove the lungs. Each lung is attached at its hilum adjacent to the heart. Here is where the bronchi and vessels from and to the heart enter and emerge. As with the heart, you can usually pull each lung out of the chest cavity and cut across the vessels.
At the belly, you will see the huge liver and below that a curtain of fat overlying the intestines. This is the omentum and it can be cut off. The next step is to remove the intestines all in one piece. Removing the intestines can be a little tricky for a number of reasons. First, you need to be careful that you don't accidentally poke it because the contents will ooze or spill out and you'll have a big mess on your hands. Also, the intestines are a common place for adhesions to develop and they will definitely hamper your efforts to remove them. To start, you need to find where the small intestines 'disappear' into the body fat and clamp it. This location is known as the Ligament of Treitz. It's location is just below the stomach. Once you have placed two clamps onto it, you can cut between the clamps without fear that the contents will spill out. Now, you can begin the process of removing the intestines. The way to do it is to pull on your free end and use your scalpel or scissors to cut at the fat and mesentery wherever it becomes taught. If you do so, the intestines should get freed cut by cut and elongate. Where the small intestines enter into the large intestines becomes a bit more difficult because it is usually held down by more fat and mesentery here. You can find the appendix here and remove it as you continue freeing the large intestines. Eventually you'll follow the intestines all the way to the rectum. Here you need to use your hands to remove as much surrounding fat and connective tissue so that you are left with just the 'hose' of rectum attached to the anus. All that's left is to cut across it and you are finished with the intestines.
You can now take the time to remove the bladder, prostate/uterus and the remaining rectum as a single piece. The bladder is located closer to the front (anterior) wall and you can use your fingers to free it from much of the surrounding fat. As with the rectum, you'll use a knife and cut as far down as possible to free the bladder and everything else attached to it.
The next organ is probably the most difficult to handle, the liver. It's huge and slippery, but it fortunately doesn't have too many attachments. While trying your best to avoid accidentally cutting into the liver you can use scissors to free it from the diaphragm and cut across the vessels that enter and exit the liver. On the back side of the liver (posteriorly) is the gallbladder and you'll need to be careful to not accidentally cut into it. You can remove the liver with the gallbladder attached to it. Just handle it carefully so it doesn't fall onto the morgue floor.
Now you have better access to the spleen. Looking down at the body, it's located on the right (left side from the point of view of the body). The spleen is delicate and will rip easily, so you shouldn't be too rough in removing it. It should be attached by the artery and vein that pierce it as well as some ligaments that attach it to the stomach. When you're cutting, be careful not to accidentally cut into the stomach.
Before cutting out the kidneys you should go for the adrenal glands that sit on top of each. They are not always located on top though. Often they will be in between the kidney and the spine. The adrenal glands often blend in to the surrounding fat, but you know that you're in the right spot if you cut into them because of their stripped yellow/brown appearance. When there's a lot of fat then it can be more difficult to find them.
The kidneys are easy to remove once you know how. They are surrounded by a capsule (Gerota's fascia) and if you just cut across the capsule (it's ok to cut into the kidneys a little bit) then you can use your fingers to 'dig' around the kidney beneath the capsule. The kidneys are attached at the hilum (similar to the lungs) and all you need to do is cut across those vessels.
From here I like to cut off the diaphragm. It's best to just use a scalpel and cut it away from the lateral and posterior walls of the last ribs. You just need to be careful not to accidentally puncture the stomach.
The neck is a delicate area and there are special morgue technicians who will cut this area for us to avoid any headaches with the funeral homes. They cut around the trachea and esophagus up into the jaw. They use their scalpel to free the tongue and then remove the entire piece with tongue attached at the end. From here we free the esophagus from the aorta all the way down to the stomach and remove the whole thing intact. It's quite a sight to see the GI tract all the way from the tongue down to the duodenum removed completely intact and continuous.
Now, the aorta can be accessed and removed. A cut is made where the aorta divides at the pelvis into the common iliac arteries and with a pair of forceps and scalpel the aorta is pulled upwards and cut free.
The medical examiners like to also remove a piece of muscle and bone marrow. The easiest place to get the muscle is from the psoas major muscle, but you might know this muscle better as the tenderloin or where filet mignon comes from. The bone marrow actually is most easily taken from a lumbar vertebra. A hand saw is used to cut a wedge down out of the vertebra and that thin wedge contains a good sample of bone marrow.
The last place to look is the head. The brain needs to be looked at and removed. To do this, a cut is made from left to right (because I'm left-handed) across the skull starting from just behind the ears. This cut is done so that the person can still be viewed at a funeral without having to see any incisions. The scalp needs to be freed from the skull and a combination of careful scalpel cuts and pulling with your fingers will get the job done. The front half of the scalp will be pulled over the face and the back half will be pull back down behind and underneath the head.
With the skull exposed you can begin cutting into it with the oscillating saw. This part takes some patience because you need to cut perpendicular to the bone while holding a fairly heavy, vibrating power tool. You need to cut around the skull such that a 'cap' is able to be pulled of. This stage is the most noisy and perhaps one of the more smelly steps.
Eventually, the cap can be removed and the brain exposed. The brain will be attached at the brain stem and a variety of nerves will need to be cut through. Also, the covering of the cerebellum (the tentorium cerebelli) needs to be cut through to free the cerebellum. The brain can then be removed intact in one piece.
From here there is only one last thing that we PA students need to do. That is to remove the pituitary gland. The pituitary gland is located in the middle of the skull at it's base and it's surrounded on all sides by bone (except for where it attaches to the brain). The bony throne that it sits on is the sella turcica and the posterior bony wall can be broken. Using a scalpel to remove the rest of the covering membrane (the diaphragma sellae) will allow you to gently grasp the pituitary with forceps and remove it.
The above sums up the evisceration process and hopefully gave you all an idea of how organs are typically removed. Despite the 'brutal' nature of the evisceration process, you will be even more surprised to know that these bodies will be fixed up by the funeral homes so that you can't even tell an autopsy was performed in the first place. The autopsy evisceration may not evoke the most pleasant of thoughts, but it truly is an art.
This reminds me of the two basic functions that PA students at WVU perform during the autopsy rotation. The two duties are evisceration and organ dissection. Today, I'll do my best to explain evisceration, especially for those who haven't studied anatomy before. This subject may turn off some of you due to the nature of cutting into the human body, so if you feel uncomfortable it would be best to stop reading.
In short, evisceration of a body involves opening it and removing the organs. After the medical examiner has completed their assessment of the external features of the body and samples of vitreous fluid (from the eyes), subclavian blood and urine have been taken, the body is ready to be opened.
A wooden block is placed underneath the body just below the shoulders to prop up the chest. This helps blood from flowing over the shoulders and giving you a better angle to access the body cavities. The first incisions are made with a scalpel and start at both shoulders (near the acromion processes) and converge at the bottom of the chest where the ribs connect to the sternum (near the xiphoid process). From here, a single long incision continues down the abdomen towards the belly button. The cut continues around the belly button all the way towards the pubic bone, just above the genitals. These cuts look like a giant Y on the body.
Skin, fat and muscle needs to be pulled back (reflected) from the chest cavity. Initially the tissues will be quite adherent and you may not have a good grip to pull back the tissue. If it's difficult for me I like to use forceps to grasp the tissue so I don't have to cut with the scalpel blade so close to my fingers. After the first bit of tissue has been sliced free I can grip it with my whole hand, but if it's still slippery using a paper towel gives you a better grip. Tissue also needs to be reflected upwards towards the neck. But, because the skin here is thinner you need to be careful that you don't cut a hole though it. You also need to be careful that you don't accidentally put a cut into the trachea as you are freeing the tissue.
The same thing about reflection can be said about the abdominal cavity. But, because there are no bones over your belly, as soon as you cut through you are into the cavity. The stomach, liver and intestines are lying right underneath, so you need to be careful not to cut into them when you are cutting through the abdominal wall.
With most of the skin reflected, you need to find a way to get into the chest cavity. Your ribs are of course made of bone, but towards the front where they meet your sternum they are made of cartilage. This allows your chest to expand and contract when you breathe. A scalpel can't cut through bone very easily, but it can cut through cartilage with little effort. The cartilage is whiter than the bone, so all that needs to be done is use the scalpel and cut down the ribs where they are white. The cartilage begins to disappear towards where your clavicles meet your sternum (manubrium), so you may have to use an oscillating saw.
The oscillating saw is used to cut through bone. Think of a power drill, but instead of a drill it has a serrated blade for a head and it vibrates back and forth incredibly fast. Against soft tissues it doesn't cut very well, but it can go through bone like a hot spoon though ice. While cutting through bone (especially the skull) it gives off a lot of bone dust and the room fills with a burning smell despite all of the ventilation.
Once the cuts through the ribs have been made you can use a scalpel again to free it and remove the chest plate. Immediately visible will be both lungs and the heart encased in its sac. You can check to see if the thymus remains, but in many adults it has been replaced by fat. If it is there you can cut it out. The lungs need to be moved out of the way so you can see how much fluid (pleural fluid) is contained within the cavities. After that you are ready to open the sac that contains the heart (the pericardium). The sac also contains its own fluid so you need to move the heart out of the way and take a look at it. To remove the heart, you can grasp it in your hand, pull it as far as possible out of the chest, then using your scissors cut across all of the vessels at the base. Your first cut will probably be through the inferior vena cava and when you cut into it blood inside the heart will fall out into the pericardial sac and make your life a little harder by obscuring where you need to cut. Even if you can't see well, as long as you cut far enough away from the heart across the vessels you should be able to free it.
Next will be to remove the lungs. Each lung is attached at its hilum adjacent to the heart. Here is where the bronchi and vessels from and to the heart enter and emerge. As with the heart, you can usually pull each lung out of the chest cavity and cut across the vessels.
At the belly, you will see the huge liver and below that a curtain of fat overlying the intestines. This is the omentum and it can be cut off. The next step is to remove the intestines all in one piece. Removing the intestines can be a little tricky for a number of reasons. First, you need to be careful that you don't accidentally poke it because the contents will ooze or spill out and you'll have a big mess on your hands. Also, the intestines are a common place for adhesions to develop and they will definitely hamper your efforts to remove them. To start, you need to find where the small intestines 'disappear' into the body fat and clamp it. This location is known as the Ligament of Treitz. It's location is just below the stomach. Once you have placed two clamps onto it, you can cut between the clamps without fear that the contents will spill out. Now, you can begin the process of removing the intestines. The way to do it is to pull on your free end and use your scalpel or scissors to cut at the fat and mesentery wherever it becomes taught. If you do so, the intestines should get freed cut by cut and elongate. Where the small intestines enter into the large intestines becomes a bit more difficult because it is usually held down by more fat and mesentery here. You can find the appendix here and remove it as you continue freeing the large intestines. Eventually you'll follow the intestines all the way to the rectum. Here you need to use your hands to remove as much surrounding fat and connective tissue so that you are left with just the 'hose' of rectum attached to the anus. All that's left is to cut across it and you are finished with the intestines.
You can now take the time to remove the bladder, prostate/uterus and the remaining rectum as a single piece. The bladder is located closer to the front (anterior) wall and you can use your fingers to free it from much of the surrounding fat. As with the rectum, you'll use a knife and cut as far down as possible to free the bladder and everything else attached to it.
The next organ is probably the most difficult to handle, the liver. It's huge and slippery, but it fortunately doesn't have too many attachments. While trying your best to avoid accidentally cutting into the liver you can use scissors to free it from the diaphragm and cut across the vessels that enter and exit the liver. On the back side of the liver (posteriorly) is the gallbladder and you'll need to be careful to not accidentally cut into it. You can remove the liver with the gallbladder attached to it. Just handle it carefully so it doesn't fall onto the morgue floor.
Now you have better access to the spleen. Looking down at the body, it's located on the right (left side from the point of view of the body). The spleen is delicate and will rip easily, so you shouldn't be too rough in removing it. It should be attached by the artery and vein that pierce it as well as some ligaments that attach it to the stomach. When you're cutting, be careful not to accidentally cut into the stomach.
Before cutting out the kidneys you should go for the adrenal glands that sit on top of each. They are not always located on top though. Often they will be in between the kidney and the spine. The adrenal glands often blend in to the surrounding fat, but you know that you're in the right spot if you cut into them because of their stripped yellow/brown appearance. When there's a lot of fat then it can be more difficult to find them.
The kidneys are easy to remove once you know how. They are surrounded by a capsule (Gerota's fascia) and if you just cut across the capsule (it's ok to cut into the kidneys a little bit) then you can use your fingers to 'dig' around the kidney beneath the capsule. The kidneys are attached at the hilum (similar to the lungs) and all you need to do is cut across those vessels.
From here I like to cut off the diaphragm. It's best to just use a scalpel and cut it away from the lateral and posterior walls of the last ribs. You just need to be careful not to accidentally puncture the stomach.
The neck is a delicate area and there are special morgue technicians who will cut this area for us to avoid any headaches with the funeral homes. They cut around the trachea and esophagus up into the jaw. They use their scalpel to free the tongue and then remove the entire piece with tongue attached at the end. From here we free the esophagus from the aorta all the way down to the stomach and remove the whole thing intact. It's quite a sight to see the GI tract all the way from the tongue down to the duodenum removed completely intact and continuous.
Now, the aorta can be accessed and removed. A cut is made where the aorta divides at the pelvis into the common iliac arteries and with a pair of forceps and scalpel the aorta is pulled upwards and cut free.
The medical examiners like to also remove a piece of muscle and bone marrow. The easiest place to get the muscle is from the psoas major muscle, but you might know this muscle better as the tenderloin or where filet mignon comes from. The bone marrow actually is most easily taken from a lumbar vertebra. A hand saw is used to cut a wedge down out of the vertebra and that thin wedge contains a good sample of bone marrow.
The last place to look is the head. The brain needs to be looked at and removed. To do this, a cut is made from left to right (because I'm left-handed) across the skull starting from just behind the ears. This cut is done so that the person can still be viewed at a funeral without having to see any incisions. The scalp needs to be freed from the skull and a combination of careful scalpel cuts and pulling with your fingers will get the job done. The front half of the scalp will be pulled over the face and the back half will be pull back down behind and underneath the head.
With the skull exposed you can begin cutting into it with the oscillating saw. This part takes some patience because you need to cut perpendicular to the bone while holding a fairly heavy, vibrating power tool. You need to cut around the skull such that a 'cap' is able to be pulled of. This stage is the most noisy and perhaps one of the more smelly steps.
Eventually, the cap can be removed and the brain exposed. The brain will be attached at the brain stem and a variety of nerves will need to be cut through. Also, the covering of the cerebellum (the tentorium cerebelli) needs to be cut through to free the cerebellum. The brain can then be removed intact in one piece.
From here there is only one last thing that we PA students need to do. That is to remove the pituitary gland. The pituitary gland is located in the middle of the skull at it's base and it's surrounded on all sides by bone (except for where it attaches to the brain). The bony throne that it sits on is the sella turcica and the posterior bony wall can be broken. Using a scalpel to remove the rest of the covering membrane (the diaphragma sellae) will allow you to gently grasp the pituitary with forceps and remove it.
The above sums up the evisceration process and hopefully gave you all an idea of how organs are typically removed. Despite the 'brutal' nature of the evisceration process, you will be even more surprised to know that these bodies will be fixed up by the funeral homes so that you can't even tell an autopsy was performed in the first place. The autopsy evisceration may not evoke the most pleasant of thoughts, but it truly is an art.
Sunday, March 4, 2012
Week Two at West Virginia Deputy Chief Medical Examiner's Office
I can't believe that it has already been two weeks since I've returned to Morgantown and started this rotation. Time seems to be flying fast. I've resettled in with my former landlord and life here is snug as a bug. At least, as snug as a bug can be in winter.
This new rotation is exposing me to another side of pathology that is not often talked about in textbooks but is still an important function needed for society. That is the role of the pathologists' assistant in the morgue.
As you are probably already familiar, the morgue is the place where death investigations occur. There are two types of autopsies that are performed here. A body may be brought in as a 'medical examiner's autopsy' or as a 'hospital autopsy'.
If you've ever watched any crime show on TV, then you're probably already familiar with the 'medical examiner's autopsy'. Usually somebody discovers a body, the police get involved and want to know all about the cause of death. Despite all of the violent crimes that can be found on TV, the bodies that come into the morgue aren't all homicide victims with explicit gunshot or stab wounds. In fact, many show no external trauma at all. More often than not, only a thorough examination from head to toe and into the body can offer the clues as to how a person had the misfortune of coming to the morgue.
The hospital autopsy cases are where a person dies while at the hospital, usually of a long illness and the family members request an autopsy to document the extent of the disease. In these cases, the family members can limit how much and what the medical examiner does. The family members may request that the autopsy be limited to just opening the skull, for example.
Despite using our knowledge of the human body, the working environment of the morgue is quite different from the surgical pathology laboratory. In the lab, you are spending most of your time at a bench and dissecting a single specimen at a time. A great deal of focus, careful handiwork and attention to minute details are required. On the other hand, in the morgue you are on your feet and using your whole upper body. The bodies need to be moved from table to table, bones need to be cut through with saws, organs need to be picked up, weighed and so forth. There's a lot of upper body movement and you're using your torso and elbows to get at just the right angle to do the job.
Perhaps this is one reason why I've found the morgue to be more challenging than the laboratory. All throughout my life I have been a very meticulous, methodical and thorough worker. I always need to look at all of my options available and think long and carefully before coming to a decision. Every action has a calculated purpose. The morgue requires the opposite of all of these. In the morgue, time is more important than grace. The body in front of you is already dead, so there's no fear of hurting the body by handling it too strongly. A person needs to work quickly to eviscerate the body and remove its organs so that the next case can be looked at. I personally prefer to work slowly, carefully and methodically so working in the morgue is not just in opposition to my normal mode of work but also to my personality. I have been told more than once by the medical examiners that "You need to go faster. Just cut through it. Why are you making baby cuts? Just grab it and get at it.", but I am always concerned that if I go too fast I'll make a cut that I shouldn't have. I've never liked making mistakes and it is my fear of making a mistake that keeps me from working faster. I can only hope that in the coming weeks that I become more proficient and work more quickly without hesitation.
Another aspect of the morgue is the human side of each case. In the laboratory, you never have a face to put to your specimen. You are only given a name and medical record number. In the morgue, you are exposed to the entire person, all the way from the expression on their face to the last meal that they had. There is a very real human aspect to each case and you can't help but put yourself in their shoes. Upon looking at each body laying on that cold metal table, a wave of pity comes over myself. Whether they are young and athletic or old and frail, each one is reduced down to it's very naked basic self. It's a reminder that deep down inside, we are literally all made the same. Hearts, livers, lungs, kidneys, intestines, stomachs, brains etc... This is all that our bodies are when we pass on. One cannot help but feel a renewed gratitude for being alive after having worked in the morgue.
This new rotation is exposing me to another side of pathology that is not often talked about in textbooks but is still an important function needed for society. That is the role of the pathologists' assistant in the morgue.
As you are probably already familiar, the morgue is the place where death investigations occur. There are two types of autopsies that are performed here. A body may be brought in as a 'medical examiner's autopsy' or as a 'hospital autopsy'.
If you've ever watched any crime show on TV, then you're probably already familiar with the 'medical examiner's autopsy'. Usually somebody discovers a body, the police get involved and want to know all about the cause of death. Despite all of the violent crimes that can be found on TV, the bodies that come into the morgue aren't all homicide victims with explicit gunshot or stab wounds. In fact, many show no external trauma at all. More often than not, only a thorough examination from head to toe and into the body can offer the clues as to how a person had the misfortune of coming to the morgue.
The hospital autopsy cases are where a person dies while at the hospital, usually of a long illness and the family members request an autopsy to document the extent of the disease. In these cases, the family members can limit how much and what the medical examiner does. The family members may request that the autopsy be limited to just opening the skull, for example.
Despite using our knowledge of the human body, the working environment of the morgue is quite different from the surgical pathology laboratory. In the lab, you are spending most of your time at a bench and dissecting a single specimen at a time. A great deal of focus, careful handiwork and attention to minute details are required. On the other hand, in the morgue you are on your feet and using your whole upper body. The bodies need to be moved from table to table, bones need to be cut through with saws, organs need to be picked up, weighed and so forth. There's a lot of upper body movement and you're using your torso and elbows to get at just the right angle to do the job.
Perhaps this is one reason why I've found the morgue to be more challenging than the laboratory. All throughout my life I have been a very meticulous, methodical and thorough worker. I always need to look at all of my options available and think long and carefully before coming to a decision. Every action has a calculated purpose. The morgue requires the opposite of all of these. In the morgue, time is more important than grace. The body in front of you is already dead, so there's no fear of hurting the body by handling it too strongly. A person needs to work quickly to eviscerate the body and remove its organs so that the next case can be looked at. I personally prefer to work slowly, carefully and methodically so working in the morgue is not just in opposition to my normal mode of work but also to my personality. I have been told more than once by the medical examiners that "You need to go faster. Just cut through it. Why are you making baby cuts? Just grab it and get at it.", but I am always concerned that if I go too fast I'll make a cut that I shouldn't have. I've never liked making mistakes and it is my fear of making a mistake that keeps me from working faster. I can only hope that in the coming weeks that I become more proficient and work more quickly without hesitation.
Another aspect of the morgue is the human side of each case. In the laboratory, you never have a face to put to your specimen. You are only given a name and medical record number. In the morgue, you are exposed to the entire person, all the way from the expression on their face to the last meal that they had. There is a very real human aspect to each case and you can't help but put yourself in their shoes. Upon looking at each body laying on that cold metal table, a wave of pity comes over myself. Whether they are young and athletic or old and frail, each one is reduced down to it's very naked basic self. It's a reminder that deep down inside, we are literally all made the same. Hearts, livers, lungs, kidneys, intestines, stomachs, brains etc... This is all that our bodies are when we pass on. One cannot help but feel a renewed gratitude for being alive after having worked in the morgue.
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