Monday, August 19, 2013

Name that Organ! Adventures in Autopsy Science

During my employment as a Lab Assistant while attending school for my bachelor's degree in Medical Laboratory Science, I was lucky and intrigued enough to assist the Laboratory Pathologists with assigned autopsies. I was employed by State of New York Dept. of Mental Health, Clinical Laboratory division as a entry level Lab Aide. Among the various duties assigned to me this was the most interesting and uncommon for a student in between degrees. I studied Anatomy and Physiology in early college and believe me there is no better refresher course than assisting the autopsy with a Pathologist. Over the time of my employment at Dept. of Mental Health, I assisted with about a dozen autopsies. At first the experience is very unpleasant, daunting, and well just gross! The smell of a dead body is horrific. Up close and personal to the subject matter is very tough to handle. With regard to odor, some autopsies were worse than others. Depending on how long post-mortem the autopsy was performed. One thing that never got better was the smell recollection. Even though I worked part time, ran to school for classes late day and evening at college, the smell recollection would linger for several to many hours. Sitting in class I thought I was next to the autopsy table.

The Autopsy: Subjects as I will call them aka “the stiffs”, patients, customers? Would be brought out of the morgue to the table. I would need help from another lab assistant or Lab Tech moving the body from the morgue tray to the gurney and then to the autopsy table. Once on the table, a rubber block would be wedged under the neck of the body to support the head; that was important because you did not want a floppy head when the bone saw was applied to the skull. At this point readers if you are squeamish or affected by gruesome details of cutting up a body into chunks then you should click the red X now and vacate this post. You have been warned. An autopsy is performed to make determination of how a person died and/or the reason a person expired. The patients housed at Dept. of Mental Health were psychiatric patients. The patients who were autopsied died at the facilities. I do not know why autopsies were performed other than concerned family members of the deceased wanted to know.

Once placed on the autopsy table any bed linens covering the body were removed. Tools of the trade were arranged on a rolling table beside the autopsy table. The bone saw was plugged in and at the ready. Before moving the body from morgue to table, PPE was donned. PPE is known as personal protective equipment which included a disposable lab coat, shoe covers, and gloves. Once the autopsy process started, I placed a full face mask on my head. Depending on the Pathologists preference either he would start at the head or the body cavity upper chest. Most times I assisted, the Pathologists started at the chest and ended at the head. This accomplished two things to save time. Working the body cavity first allowed the Pathologists to complete work there so I could start with my tasks while he worked on the skull. Basically, the process was a search and biopsy adventure with any apparent pathology necessitating additional biopsy specimens, organ chunk collections, and or fluid collections. Gruesomely, a long incision was made at the top of the sternum continuing down the chest ending to about just below the navel area. A horizontal cut was made just under the breast tissue creating a giant T cut into the trunk of the body. Once the flesh was peeled away to expose rib cage, the bone saw was grabbed to cut through the bone of the cage. The idea was to remove the rib cage like it was a vest to expose all the organs underneath. Once the organs were visible that is when the lesson sometimes started. Pathologists would point and ask “So what is that organ? I would answer heart! He would then follow up with Yes – but which side of the heart is that? Then he would explain the architecture and function of the heart. Moving on to asking about the liver, and then the lungs I would get a visual up close anatomy lesson. Then some of the more obscure organs like spleen, upper intestine, and all those “female parts”. You know what they say down at the auto-parts store...Parts is parts! Once the geography lesson was over it was back to business at hand. Organs were removed one by one systematically layer by layer. On the autopsy table was a cutting board. That is where whole organs were placed measured, sliced, cut, and then chunks removed for analysis. The pathologist would slice up the heart into its four functional chambers carefully removing pieces that would eventually be processed onto glass microscope slides. It was a methodical process; each organ would be removed from attaching blood vessels and connective tissue, weighed on a scale in grams, measured in centimeters, then cut on the board. From there the organ went into a large plastic bag. Each organ would wind up in the bag after weight and size measurements and samples taken. Once the organs were removed from the body cavity, pieces of the spinal column were removed as well. Reproductive organs would be last to come out of the cavity. Breast tissue was removed from females, testes removed from males.  Each organ was inspected carefully to look for signs of disease.  Sometimes heart disease, liver disease, lung disease was apparent as well the effects of years of smoking.  Stomach contents would be inspected and sometimes the contents looked like what you might find in an old coat pocket; coins, paperclips, screws, pebbles, and whatever else that patient decided what non-nutritional item was on the menu.  After the organs were analyzed and sampled then the Pathologist moved onto the skull and thus the bone saw was revved up.  This grizzly device as seen above made a raucous racket and ear deafening screech while just turned on.  When cutting through bone the noise created was muffled slightly by the medium at which it was applied; skin tissue, bone, and brain matter within the skull.   Of all the procedures performed during an autopsy this was by far the most gruesome and shocking visually to observe.  Strategic cuts in the skin framing the forehead were made first so the skin could be peeled back to expose bare skull.  Then the bone saw would be applied to cut through the skull.  The bone saw blade would oscillate back and forth rapidly with jagged teeth that would cut through the skull with a ferociousness like no one has seen before.  Surprisingly, for so much racket and blade oscillation there was not alot of mess kicked up? Anyway - Might I digress... Once the skull was cut, the cap was removed to expose the brain.  Upon inspection of the brain it was apparent in some of the oldest of the older patients that someone had been there before removing brain matter.  Usually, there was a drilled hole in the skull that gave a clue that the patient was not all there literally.  The brain was then removed, measured, weighed, and samples were taken.  Sometimes the brain was kept and sometimes it was replaced back to its nest.  All the Pathologists either replaced or kept just depending on the case at hand and what was found in the autopsy process.
After the finding and exploration was complete then it was time to "tidy up".  With a big sewing needle and cord all of the cut skin was sewed back together.  I have done sewing by hand before to repair a shirt, torn seem, or replace a button but nothing like this.  All the pieces were sewn back together.  Oh, and that bag of organs...that was placed back in the body cavity.  Parts is parts you know!  Anyway, I wanted to give a first hand experience into postmortem analysis via the Medical Autopsy which is quite different than the Forensic Autopsy.

There were some antics played out though...I have great respect for Pathologists.  These are the folks who discover what has caused death of our loved ones.  Pathologists also determine how death came about in criminal cases.  Pathologists run the clinical laboratory, hold the license issued for lab operation from local State Governing bodies, and also hold the CAP (College of American Pathologists) certification that all clinical laboratories strive to maintain every year.  But, some Pathologists are wacky, some are funny, and some just carry around morbid humor.  Once such wacky experience I had with a Pathologist while assisting the autopsy was a shocking incident.  This Pathologist was busily trying to cut some bone from the spine on a patient when he slipped with the scalpel blade and jabbed his finger.  A gloved hand is not going to keep a sharp blade from penetrating so when he pulled his hand out of the body he was working on and pulled off the glove, blood was spurting and dripping all over the floor.  He rinsed his hand in the "clean" sink, wrapped his finger with gauze tightly, gloved up again and continued on.  Some expletives were uttered in a foreign language I am sure of it, but he carried on till the end.  With another Pathologist on another case, the good doctor came into the morgue smoking a cigarette.  With the body on the table, tools all laid out, he puffed on his cigarette, said "lets get started", placed the cig on the edge of the autopsy table, and began his work.  He picked up that cigarette a couple of times for a puff while engrossed in autopsy work. That was wacky!  By far the saddest cases I observed were the patients that had holes drilled in their skulls with very apparent sizable brain matter missing usually from the front of the brain.  The procedure carried out on these patients was called a Frontal Lobe Lobotomy.  It was thought years ago that removing certain regions of the brain of a person exhibiting crazy behavior might just curb that behavior and make the patient more docile.  Maybe some of our prominent government figures could benefit from such a procedure to help them cope with the daily grind of "political mishaps"?  Anyway - might I digress?

The adventures I experienced as a young laboratory scientist in the morgue were a valuable cache of knowledge and life experience.  Don't knock it.  The autopsy process has been brought to the headlines of today's newspapers and TV news.  It is gruesome but a necessary part of medicine we all benefit from.  It is a great learning experience to observe an autopsy.

Saw Photo Courtesy of Dr. Ed Uthman

Take care friends.  Be well and be happy.

Scott R Mayorga  A.A.S., BS MT(ASCP)H CLS

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