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.
Subscribe to:
Posts (Atom)