Dead People

[yaah]

Since, as everyone I talk to points out to me, all pathologists do is cut up dead people, I thought we needed a new thread about this. I mean, the attractions to the field are:
1) Being able to work with dead people,
2) Dreading the thought of treating a living patient
3) Getting a big knife, sharpening it, and extracting organs, and
4) Not having to worry about sterile technique, compassion, the physical exam, and communicating with anyone.
Dead people are great because they don't ignore your advice, and they don't argue.

Thus, since one of my goals in life is to have a career where I can not only play with sharp knives without fear of retribution, I settled on pathology as my life's work. It happens to be a bonus that I can have a career where I can spend every hour of my job in a windowless, smelly, cold, metal room where my only companions are hardy roaches, crazy autopsy technicians, and of course dead people (or, as many like to call them, my patients).

And by the way, what about all that other stuff pathologists have to know about? Some people told me there was something to do with biopsies? Frozen sectionals or something like that? And I am pretty sure pathologists have to know something about hospital labs, but maybe that's a separate training program. Anyway, I am sure they will teach me what I need to know about biopsies in between my autopsy duties which should take up the majority of my 4 year residency. At least it will prepare me for my future career as a crime-scene investigator which, along with working with dead people is my ultimate goal.


I hope you all know I am being sarcastic. I spent a lot of today at my ACLS training session continuing to explain that the relevance of ACLS to pathology does not begin and end with a person waking up in the morgue fridge. No one should take this to mean I have no compassion or caring. Just an odd sense of humor. Seriously, though, we need a thread about dead people. What do you think. Clearly this should be our most popular thread.

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[BamaAlum]

Dead people are a lot like living people, except that they move a lot slower.....

 

[joedogma]

I for one would have liked to have seen the insides of Chris Farley or Belushi (the one that pretended to be a zit in animal house, not the other one who is still living and likes to make really bad movies) Those dudes treated their bodies like you would treat a a budget renta-car, you know, grind the gears on purpose, ride the breaks, turn the ignition key while your driving etc... Anyway, I doubt these guys had much left in the way of functional hepatocytes and their hearts were probably good for "teaching" purposes...

 

[caffeinegirl]

what a wonderful way of trying to sum up the entire field of pathology...NOT! It frustrates me as well, but I try to use the opportunity to "enlighten" my fellow classmates as well...though many times I am unsuccessful...I see it as their loss

One of the draws of path is that you aren't rushed when doing autopsies, so you don't have the annoying *beep beep* of the monitors, and you don't have to sweating under tons of extra gowns/gloves/caps/goggles and stressing about touching something that's not sterile..all the while standing really really still while retracting mounds of fat so that the attending can repair a vessel he inadvertedly cut. *end rant*

Anyway, to get back to the thread...dead people are much better. At least you don't have to struggle to put in a Foley

 

[Brian Pavlovitz]

When I tell fellow classmates that I want to be a pathologist, a great majority respond with either "you don't like working with patients?" or "Oh, I couldn't do autopsies all day." I guess if you've never been exposed to the field, you wouldn't realize the breadth of knowledge that a pathologist must have, as well as the communication skills that are essential. As far as patient contact is concerned, being involved in an active Fine Needle Aspiration clinic can give a pathologist a decent amount of patient contact.

Working on "dead people" has really helped me to understand disease processes, and put together much of the basic science years. I didn't care for gross anatomy (I was ready to be done about midterm if I recall), but autopsies have helped me to revisit the anatomy that I thought I had forgotten. Although to some it may seem grotesque, I think doing autopsies is quite noble, and provides a wonderful learning experience.

 

[yaah]

I for one would have liked to have seen the insides of Chris Farley or Belushi (the one that pretended to be a zit in animal house, not the other one who is still living and likes to make really bad movies) Those dudes treated their bodies like you would treat a a budget renta-car, you know, grind the gears on purpose, ride the breaks, turn the ignition key while your driving etc... Anyway, I doubt these guys had much left in the way of functional hepatocytes and their hearts were probably good for "teaching" purposes...

I did an autopsy on a 36 year old guy who had been a heavy drinker for 20 years, cocaine user, who knows what else. He aspirated, didn't come to the hospital until he was septic and in ARDS, died with a blood pH of something like 6.9. His lungs were like pieces of wood they were that consolidated. His liver was twice normal size and cirrhotic, his spleen weighed 1.5 kg. Heart was nearly 1kg. I think he was a good example of one of these guys. It was an extremely educational case for me. Very sad of course, but that case taught me a ton about ARDS, alcohol abuse, and other things. I also had a fascinating case of a diabetic woman who had undergone 2 CABGs and had unilateral renal artery stenosis, leaving her a 70g kidney and a 300 g kidney. The Goldblatt model in living color! Her heart was an exercise in dissection, having about 8 bypass grafts, a few old MIs, valve lesions, assymetic walls. She also had metastatic bladder cancer. I think the worst case I saw was a 45 year old guy, prison inmate with old TB who was admitted with pneumonia and found to have an esophageal-lung (you read that right) fistula. Turned out he had esophageal cancer, and at autopsy he was so cachectic he weighed about 80 lbs and nearly 30 of it was the cancer, which extended from his neck down to encase the liver, pancreas, stomach, and extended bilaterally into half of each lung field and posteriorly into the spine. The diener and I did not know where to start. The cancer was hard as a rock. That case made me realize what a terrible thing cancer can be.

Autopsies can teach you so much about medicine when you get to do things like dissect the biliary tree in an obstructed patient or explore the abdomen in a portal hypertensive.

And yes, Brian, at least we will know the amount of stuff we have to know to be competent at our jobs. It is both daunting and exciting at the same time.

Caffeine girl - the worst case of the "fat-retractin' blues" that I had was when I had to go in on a C-section on a woman who weighed 400 lbs. My job was to hold "the pannus" and keep it from rolling forward onto the C-section incision site. Turns out the site they wanted for the C-section was covered under a roll of fat that came down from the abdomen and really wanted to stay there. Dear heavens that was brutal. My arms still hurt. Thank goodness no vessels were cut. I also had to hang around on a 16 hour re-do CABG case where the woman when into arrest just before bypass started. They had a lot of work to do. It was interesting but having to hold the heart "just like that! don't move it or I will cut the coronary!" for exceedingly long amounts of time (in a re-do patient with porcelain arteries) is far from pleasant.

Hey - the "fat-retractin' blues." I should write a song about that. Got me a sore arm. Got me some greasy fingers. Got me some sore wrists from the ole' retractin' stick. Got me some head pains from the surgeon yellin' at me to keep myself still. Got me the fat-retractin' blues.

 

[joedogma]

Yaah, I was in a very similar situation during my OB-GYN rotation. C-section on a 350+ pounder (I still can't figure out the mechanics for conception). I too was blessed to hold the pannus to keep everything nice and midline for the operation. I was sweatin like a pig when I was greeted with a huge gush of amniotic fluid running down my leg. I was stuck standing in a pool of yuk because I was the only one available who could hold the pannus long enough to close. That night I went home, placed my red tinged sneakers into the trash and quickly crossed ob-gyn off my list of possible career choices (it wasn't high on the list to begin with thankfully).

This reminds me...I saw the same patient in the "high risk" clinic a few weeks before and the resident told her that she had to go to receiveing at the hospital warehouse where they weigh freight because the scale in the clinic was insufficient. Sounded reasonable to me but the resident didn't sugar coat it at all. I thought the resident was being a little rude, if not downright mean, in the way she gave the instructions to the patient. I was expecting the patient to get mad but was astounded when the patient responded "that sounds like fun!" What is this world coming to?

 

[cjw0918]

I guess I was luckier at my school- we used tape in an "X" under and over the patient's pannus to hold it up for C-sect. There was still a fair amount of retracting required, but it would have been a heck of a lot more difficult without the tape. I saw an infected C-sect skin incision under a pannus that had been brewing for about a month- that was nasty. Luck to all...

 

[yaah]

I guess I was luckier at my school- we used tape in an "X" under and over the patient's pannus to hold it up for C-sect. There was still a fair amount of retracting required, but it would have been a heck of a lot more difficult without the tape.

Gee whiz, I wish I thought of that. I always thought I had pretty good problem solving skills. I guess I wasn't thinking outside the box. Oh well. My arms have since recovered, and that woman also had a tubal at the same time, so she will not be having future c-sections. And I will not be forced to retract anything ever again in the OR, unless I am perhaps struck by lightning (which I worry about, because I am tall) and have a sudden desire to change careers and feed my enlarging ego by entering the field of surgery.

Hey, how did this thread ostensibly about the deceased turn into a thread about morbidly obese pregnant women? I guess we could compromise and create a new thread called, "The morbidly obese deceased" but the alliteration in there sounds too jingoistic. We could talk about autopsies on the morbidly obese, which are unpleasant. The record I measured for thickness of subcutaneous fat was I think 8-9 inches (abdominally). But that would be a guess.

 

[Mindy]

By Caffeine Girl:

One of the draws of path is that you aren't rushed when doing autopsies, so you don't have the annoying *beep beep* of the monitors, and you don't have to sweating under tons of extra gowns/gloves/caps/goggles and stressing about touching something that's not sterile..all the while standing really really still while retracting mounds of fat so that the attending can repair a vessel he inadvertedly cut. *end rant*

Ahh, but the funeral directors will call the diener incessantly trying to find out when you have a cause of death and the body can be released (i.e. "hurry up.")

You will be wrapped in 50 layers of plastic including everything you mentioned, but the morgue will not have any sort of sophisticated temperature control system most likely, unlike the operating suite. At MGH it is perpetually hot in the (basement) morgue, because it sits near the boiler room.

You CONSTANTLY stress about touching non-sterile items, just not for the same reasons. And you worry about cutting yourself with an old knife...I mean after all whatever it was killed the patient! I recently did a CJD case that scared the heck out of me.

You DO retract a pannus of fat. But while retracting you also free the rectum from the pelvis and attempt to hold back a strongly flowing river of feces from a toxic megacolon that the diener inadvertantly cut into!

Oh, but you very rarely have to hold still. That is a major plus for me.

Gosh, I love autopsies! (No I am actually not being sarcastic!)

Mindy

 

[yaah]

I like autopsies too. You really never know what you are going to find (or not find, as is often the case). It's really interesting how often the clinical history you get from the chart sometimes doesn't equate with the autopsy findings. Of course, things like sudden death from an MI can be hard to prove unless you can find the clot. But sometimes you find things like aortic tears, head bleeds, giant cancer, terrible lungs, PE and it all makes sense. Sometimes these things aren't even suspected clinically. But you can get a patient who died of respiratory distress, and their lungs may not necessarily look worse than a different patient. It's like detective work in a way.

One thing I learned though, that it seems like everyone who died of some bowel-related problem had recently eaten a meal including corn. I can't tell you how many times I found corn in the peritoneal cavity from a ruptured bowel (from a cancer, infection, whatever), or in an area of obstruction. I am still hesitant about eating corn...OK that was gross, sorry.

 

[caffeinegirl]

So how did this thread get onto pannus holding gripes? My bad I see..since I started the rant..oops
Thanks Mindy for giving me hope that it gets better (insert sarcasm here)...but at least hemostasis isn't a factor And..you get work with the entire body rather than specialize on a specific area

 

[Homunculus]

(or not find, as is often the case).

this was the frustrating aspect for me. medical autopsies to me were quite boring, as dying from acidemia or ARDS or other metabolic disorders doesn't have the "a-ha, here it is!!" to it that i wanted. forensic autopsies were more fun, and i really enjoyed digging out bullets and determining flight paths, structures injures, "lethal" wounds, etc etc.

as someone who seriously considered pathology as a career, i feel your pain. not everyone understands exactly what it is pathologists do on a daily basis that affects everyone else in the hospital. which to me is odd, considering that most patholoy courses are taught by pathologists and they go into details far more deep than autopsy slides. i think part of it is that pathologists are "out of sight, out of mind" so to speak. they usually have their own department, aren't on the floors much, and will wander into the lab and morgue occasionally (which aren't exactly the crossroads of hospital physicians or medical students). except for the phone call or tumor board, they aren't spoken to that much in person, and only the rad-onc people know them by first name.

i still think it's one of the best kept secrets in medicine, but i just wasn't ready to put my stethoscope away yet, lol.

 

[yaah]

Anybody ever find all 4 parathyroids on an autopsy case? I found 3 once, but one of those was descended too much and we thought it was a mediastinal lymph node.

Parathyroids are tough.

The biliary system can be a challenge too, but it somewhat makes sense so it is a fun challenge.

 

[Mindy]

3 huh? Pretty good! Never have I looked, nor have I ever run into a recognizable parathyroid on an autopsy. Just don't care about them much (unless of course there is some compelling reason to.) Have found a few incidental papillary thyroid cas.

Liver hilum tried to get me in trouble during a s/p liver transplant / hep c post, speaking of biliary systems.

Caffeine Girl: No worries... autopsies really do rock in my opinion. Somehow the tribulations are less concerning than those in the O.R. You know, its more like "Dang funeral home trying to get the body out again" (i.e. no big rush) vs. "Oh no, that high-pitched loud beep sure has been going on for a long time..." (i.e. ARRRGHHHHH!!!!)