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.
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