Extremely limited autopsies

[yaah]

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OK, I am curious to see if anyone can top this. The case we have tomorrow is a limited autopsy - the limitations are "Pituitary Gland only."

Apparently they said that in order to get the pituitary out, the brain has to be removed. But the family still wants it limited to the pituitary. Hence we can remove the brain, but we have to put it back and can't examine it.

Anyone ever heard of crazy shizzle like this?

I had a case earlier limited to "lungs, liver, and thoracic lymph nodes." I thought that one was weird.

Reminds me of the diener at my med school - he told me that when he dies, his wife has instructions to request an autopsy with the following limitations: Limited to bowel only. Autopsy must be performed without gloves by the head of the pathology department.

I like that one.

 

[!dr_nick!]

Cant you remove the pituitary through the nose? Most surgeries on the pituitary gland take that route. i realize it would be a tad more difficult than splitting open the skull tho.

 

[b&ierstiefel]

Cant you remove the pituitary through the nose? Most surgeries on the pituitary gland take that route. i realize it would be a tad more difficult than splitting open the skull tho.

It's an autopsy though. I believe it is much easier and convenient to access the sella through the head. Now if this were a surgery for pituitary removal, then it's a different story.

 

[yaah]

Cant you remove the pituitary through the nose? Most surgeries on the pituitary gland take that route. i realize it would be a tad more difficult than splitting open the skull tho.

We are NOT going to do that! It's possible to remove it through the nose, but you need microscopic equipment and long tools, and you kind of have to pick at it to get it out. Probably much more messy than doing a standard autopsy brain removal - it would likely disfigure the face which is an autopsy no-no unless you are a medical examiner with a specific reason for doing it. And if you go through the nose you are never sure if you get it all. Much tougher also to get at the posterior pituitary.

 

[garfield]

I know someone who had "liver biopsy only", so they just called in the GI/liver fellow to do the standard needle core biopsies. What a ridiculously easy case; no long report. Sheesh.

 

[yaah]

In case anyone is interested, this old man's pituitary gland looked completely normal, at least macroscopically. Apparently there is a family history of adenomas or something but they don't think the family has an MEN syndrome. I hope the family gets what they were looking for!

There was also a brain only case for dementia, and it was a nursing home patient with no recent hospital records - they sent in a form with him providing "clinical history" and I think they made a nurse fill it out, because under the section "medications" it was incredibly detailed (as if I care what his does of Roxicet is), and under clinical history/cause of death it listed "Positive for C Diff colitis. Congestive heart failure." Nothing about the brain. Under past medical history it listed a bunch of conditions, one of them was dementia. Under the section "pertinent neurological history including length and type of symptoms" it was left blank. Bee-youtiful. The whole reason for doing these research brain-only autopsies is to correlate clinical with pathological and establish a research base.

 

[SpinachPizza]

My most limited case was "bone marrow biopsy only." I didn't even perform the biopsy, the hemepath resident did.

 

[SpinachPizza]

Under past medical history it listed a bunch of conditions, one of them was dementia. Under the section "pertinent neurological history including length and type of symptoms" it was left blank. Bee-youtiful. The whole reason for doing these research brain-only autopsies is to correlate clinical with pathological and establish a research base.

Hey, maybe it was CJD! 😛

 

[JulianDelphiki]

I know someone who had "liver biopsy only", so they just called in the GI/liver fellow to do the standard needle core biopsies. What a ridiculously easy case; no long report. Sheesh.

When I was a PSF I did an autopsy on someone and was limited to only taking needle core biopsies. I can't really remember why, I think the family said something about not wanting the patient cut and someone ?intern? suggested needle biopsy to see if his lymphoma had recurred. I just remember the attending didn't seem too worried about it. He said, "Try your best and you'll probably have the best luck getting something solid like the liver." He also said I was welcome to try for lung, kidney, and spleen.

I had never even seen one of the needle cores taken before, but I had our diener go get some of the apparatuses from the OR while I went to radiology and went over some CT scans that showed some lymphadenopathy in the paraaortic lymph nodes. One of the radiology residents counted up the vertebral bodies for me and measured how far off center I should aim.

Then for some reason everyone was gone for the day. I couldn't find the attending or the diener or anyone and the body was still on the gurney. So I made some anterior passes for the liver and spleen. Then I had a hell of a time getting the guy flipped over by myself to try for some posterior biopsies. For those I counted up the vertebrae, measured off center and tried to get some lymph node or something. Then I swabbed some betadine and went for lung (taking some for culture).

In the end I got some lung, liver, spleen, and kidney (whoops!). Not much on the diagnoses. Some hepatic steatosis. Nothing grew in my lung tissue cultures. Also worth mentioning--I had some lung and liver mixed in some of my samples, but I can't remember if I was going for lung or liver when I got those.

My attending didn't really seem to care (or think that the whole thing seemed odd.) We just signed out the case like any normal autopsy except I didn't have to do gross descriptions of anything and the micro descriptions were pretty abbreviated. I never got a call from the family or requesting docs about it.

It was pretty fun, but without ultrasound or CT who knows what the inexperienced needler will hit!

 

[Mindy]

I know someone who had "liver biopsy only", so they just called in the GI/liver fellow to do the standard needle core biopsies. What a ridiculously easy case; no long report. Sheesh.

Sounds suspiciously like a case I know, might we be colleagues perhaps?

Mindy

 

[yaah]

Actually, it probably is more common than we all think - in discussing this random pituitary only case among residents here (everyone scratches their head on that one), a couple of mentioned the "needle biopsy only" autopsies, sometimes limited to one or two organs.

 

[DrBloodmoney]

I had one where the guy had a pneumoconiosus/UIP thing going on who avoided medical care for years and the family wanted to know... so we did a 'lungs only.'

Skin-to-skin in 25 minutes + short report = happy resident

 

[GeoLeoX]

I had one where the guy had a pneumoconiosus/UIP thing going on who avoided medical care for years and the family wanted to know... so we did a 'lungs only.'

Skin-to-skin in 25 minutes + short report = happy resident

and one less than 50, you lucky bastard. i so should have jumped on that case.

 

[edamame]

Biopsy of lung through an incision that could be no more than 3 cm.
No access to needle-core equipment.

 

[yaah]

Biopsy of lung through an incision that could be no more than 3 cm.
No access to needle-core equipment.

Reminds me of the "only use prior surgical incisions" autopsies. Some strange requests out there...