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.