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In serious need of some forensics chat...

Discussion in 'Pathology' started by Mindy, May 7, 2008.

  1. Mindy

    Mindy Senior Member
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    Hi guys!

    I am heading into withdrawal on this site. Do we have an forensic pathology chatter?

    Okay, here's a topic...

    Myocarditis and sudden death....how extensive a work-up do you need to rule it out? 10 lymphocyte-free myocardial slides? 5 slides? 2 slides? Is a single focus of myocardial lymphocytes with limited or no myocytolysis significant?

    Is insisting on 10 slides dogmatic? And if you find a single focus of possible myocarditis in those 10 slides, is it really a marker of a sudden death etiology? How does everyone feel?

    Okay, I tried... Do we have any forensic bound folks here these days?

    Mindy
    MA OCME
     
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  3. Katatonic

    5+ Year Member

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    Sorry but I couldn't help but post...I can't wait until I'm to the level where I can have a Forensics chat with you. :D I'll check back in a few years and give you an answer.
     
  4. getunconcsious

    getunconcsious Very tired PGY1
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    Hi Mindy! I'm just a lowly med student finishing MS3 this year but I am thinking of going the Forensic route. I got the opportunity to do a bit of shadowing at the morgue during one of my lighter rotations and I think I'm hooked! I have a whole forensic rotation scheduled for August of this year. I went back and looked at some of your forensic posts and they are very informative! Sorry I am not even close to the level at which I'd be able to discourse with you on myocarditis and sudden death, but just wanted to say hi and hope to break into the field soon! :) You've definitely provided some very good info on FP on this site and I for one really appreciate it.
     
  5. Mindy

    Mindy Senior Member
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    Hi:

    I am delighted to hear of the blooming interest in forensics! The field is in a strange place in that there is a huge pop culture interest in forensic pathology, but scant interest amongst physicians.

    I can't figure it out? Do people really dislike autopsies that much? Is it just an issue of comparitively low salary? The illusion of lack of academic influence within the field?

    Ugghh! I don't get it!

    My interest in forensics was really solidified as a medical student as well(okay, a PSF), when I rotated at the ME's office for a couple months. Then did occupational lung research for a few months (which carried into years). I found the medicine - law intersection to be really exciting.

    It is amazing how lively the morgue seems to me. It feels like the center of the universe. Maybe its just a good place for gossips and busybodies! I religiously watch the news to see what cases I am going to be doing the next day. Folks that work in the morgue tend to be dramatic as well--always some controversy. The saying that resonates through the halls of our office in one context or other is "keeping my finger on the pulse." It seems so accurate. For a place "people are dying to get into", it sure has a constant hum! In short, my days fly by... Or maybe, there just is never enough time in the day. I wish I had the liberty to talk about my cases here. You just can't believe the scope.

    YEAH! Thanks for indulging me. If you guys have any questions ask away (or PM me).

    Mindy
     
  6. mlw03

    mlw03 Senior Member
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    forensic pathology is an interesting field, just like many others in pathology, or medicine in general. some people will like it, others not so much. what is a "lively" morgue? i'm interested in forensic path because i enjoy the hands on nature of autopsies, the interaction with law enforcement and lawyers, and simply trying to use all the findings in a case to best determine cause and manner of death. no more, no less.

    mindy, i know that some FP discussion forums exist - perhaps you should look into those to find a more constant stream of discussion topics specifically for practicing forensic pathologists.
     
  7. Ale

    Ale
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    In my uncultured opinion, the lymphocytes don't mean much unless you have myocyte injury or necrosis. No necrosis, I consider them innocent bystanders. Why they are there, different topic.

    One single focus of myocyte necrosis will make it a myositis, focal.

    That does not mean that that killed the patient. The way I see it, to kill the patient it must have had enough impact to impair heart function. One dead myocyte wonÂ’t kill the patient.

    If the myocyte necrosis is occurring in areas of the conduction system, and the patient developed a bradycardia or an arrhythmia that would make sense.

    Now, to answer your question of how many slides are necessary, I take into consideration that to make diagnosis in a live patient most of us only use a core Bx. In that case I think that your routine sections are more than enough.

    I would never call a focal myositis (i.e. 10 lymphocytes with necrosis) the cause of death in a patient, maybe contributory (if the patient was being treated for it and has a lot of histiocytes different story).

    Again I don't know much about heart, maybe someone else has something better.
     
  8. Mindy

    Mindy Senior Member
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    From mlw:

    "forensic pathology is an interesting field, just like many others in pathology, or medicine in general. some people will like it, others not so much. what is a "lively" morgue? i'm interested in forensic path because i enjoy the hands on nature of autopsies, the interaction with law enforcement and lawyers, and simply trying to use all the findings in a case to best determine cause and manner of death. no more, no less.

    mindy, i know that some FP discussion forums exist - perhaps you should look into those to find a more constant stream of discussion topics specifically for practicing forensic pathologists."


    I would have said the same thing a year ago regarding why I was interested in FP. Now, that I have officially been an ME for the better part of year, I realize how much more there is to it. It is a fast-paced waltz with many many different parties interested in what we do. It is not quite so cut and dry as simply determining the cause and manner. As an example, you will find once you are practicing that "a high profile case" is really an invitation for fairly intense public and political scrutiny. If you can't stand the heat... you'll soon see what I mean!

    You are right, there are some good FP forums full of full-fledged FPs! But, if my purposes are not painfully obvious, I post here for 2 reasons: 1) I have done so for the better part of a decade, 2) I really hope to keep particularly the bright young folks on this site interested in forensic pathology (and pathology in general), to think about their careers, and to have someone in the field to communicate with if they are interested. I have "grown up" on SDN, learned a lot from the choices and paths others have taken and shared. I really have a soft spot for this forum, its posters & lurkers.


    Hi Ale: Thanks for the great answer. You sure sound like you know a bit about the heart! For the most part I am in your camp on this one. I have heard some folks say that if you see myositis in one of one slide, then its probably all over the place. There is obvious flaws to this thinking. I have also heard that if you do any less than a 10 section search, then you have not properly excluded myocarditis. One of the things that FPs have to be cautious of is the cause and effect. If the deceased child has a focal myositis...and no other findings...then what? Many FPs are happy enough to call this a myocarditis. I am not sure where I am on this spectrum. I worry though, that the "expert" (hah, maybe one of you guys someday!) will say, "look at what the ME missed" (or "dismissed" as the case may be.)


    Best,
    Mindy
     
  9. tardieu

    tardieu New Member
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    It sounds like you had some cases of sudden death, did posts, ruled out all the common things, ruled out some of the more common less common things, and still came up with zeros. Been there. What do you do.? Dip back in the stock jar. Submit more sections. Scour them. Relook at your originals. Look close. You see some... weird things? Then you start to wonder if some of those tiny things you're seeing -- things you probably saw hundreds of times before and blew off, because the decedent had a GSW head or saddle embolus -- are significant... Maybe they mean something. This time.

    The operational issue is that in forensic pathology we have to fill the lines on the DC. Gotta come up with something. The bugaboo is most often the Manner. Take a case like the above: Someone drops dead. You rule things out. What's left? Some sort of toxic exposure that you can't detect without a potentially endless and certainly expensive and 9999 out of 10K times ultimately fruitless toxicologic fishing expedition, or some sort of molecular derangement that will require a similar expenditure and quite likely isn't even really known about yet. If you knew it was the latter, you could put COD something like "Undetermined natural causes" and manner Natural. But maybe it's the former - then manner could be Accident, Homicide, or Suicide. What then? You could do the W -- Undetermined, Undetermined. Or you grab onto that miniscule pocket of myocardial lymphocytes and hang on like grim death. Myocarditis - Natural.

    Is it better to offer an answer, even one you may not be very sure about, but one for which there are at least some shreds of evidence? In a way that's what our clinical colleagues have to do. At some point they have to treat something. OR is it better to stay on the fence until you are pretty sure, avoiding jumping to conclusions and holding out for MORE evidence. In a way that's what our clinical colleagues do -- consult another "specialist".

    I'm in favor of using W more often. I think it's more intellectually honest, and maybe, just maybe, if we lay goose eggs more often, then there'd be more motivation among the powers that be and the public at large to pony up money for the practice of forensic pathology and research into these problems.

    But that's just me. It seems there's a big aversion to laying goose eggs. People want answers. And it's tough to admit to yourself and it's tougher to tell a grieving family who, for example, just lost a 5 month old that you have no idea what killed their baby.

    As far as the myocarditis thing: Any evidence base? Done a pubmed search? Sounds like a good research project.
     
  10. Mindy

    Mindy Senior Member
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    Great post Tardieu.

    I actually am a "W" fan myself. And the baby cases! Ugghhh, I dread healthy deceased babies. Though, so far, a fair number of mine do have an appreciable COD.

    The myocarditis literature is all over the place in my opinion.

    I have only signed one myocarditis case this year. I always feel if I am looking too hard, than the significance is questionable...but many many others do not agree (regardless of organ system).

    Mindy
     
  11. LADoc00

    LADoc00 There is no substitute for victory.
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    I have some forsenics chat ?s: can ME/FPs get overtime similar to police/fire and other city/county employees??

    Or are you a subcontractor where you are?
     
  12. Mindy

    Mindy Senior Member
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    Overtime for physicians at our office is compensated with time off (i.e. "comp time".) I have earned a lot of comp time, but I have not actually use much of it yet. This not the case in all offices. Government jobs usually have a magic number of hours you can work, and then by law you need to be compensated with time or money. Ours is 40/wk (though it may be 36 and I may have not figured that out yet!)

    I am a state employee, not a subcontractor. That is not uniformly true in our office, though, we do have some subcontractors. Difference is that they make a bit more, do not have government benefits, and are not unionized.

    Mindy
     
  13. LADoc00

    LADoc00 There is no substitute for victory.
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    so you are unionized then (being a state employee)? What union?
     
  14. mlw03

    mlw03 Senior Member
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    mindy:
    your efforts are admirable, and they certainly don't hurt the effort to get good pathology residents into forensics. i honestly don't know how much they help. my interest is 100% the result of a fantastic mentor who is a FP. most every pathology resident does a month of forensic path, and if they don't like it then, they're probably not going to want to do it full time. my mentor told me there are only about 450 active boarded FPs in the country, and that to adequately supply all jurisdictions we'd need about 1500. filling that gap will take 2 things: money and interested pathologists. and I expect the former would lead to the latter. if i like forensic as much as i expect to, then i'll go into it even if it means making only $150K/year. that's plenty for me, but i understand the reluctance to do it when you can make $250K doing private practice, and that doesn't involve scene call. how much does society care about quality medical legal death investigation? enough to pay good salaries to recruit strong FPs? enough to pay investigators a respectable salary? enough to give the FPs the resources they need to investigate cases adequately? in some parts of the country the answer is yes, but in plenty it's not. this just isn't an area that most Americans care about, until of course their loved one is involved. i don't have the solution, but i do enjoy the discussion, so thanks mindy. keep it up.
     
  15. SaveThisLabRat

    SaveThisLabRat $700 Billion Dollar Woman
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    Whoa! Posting since 2001. That's pretty awesome.

    <--- Future autopsy performer.
     
  16. Logos'

    Logos' Member
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    ...
     
    #15 Logos', May 9, 2008
    Last edited: Mar 6, 2010
  17. mlw03

    mlw03 Senior Member
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    300K in San Fran is about 150K in most parts of the country. San Fran home prices are THE HIGHEST in the country. how people like postal workers, teachers, and other civil servants make enough to make ends meet out there is beyond me. but it is nice to hear the area cares enough to pay its MEs a respectable salary.
     
  18. Mindy

    Mindy Senior Member
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    Yes! All of the morgue (non-management) employees are unionized. The fellow is not unionized either. (didn't we go through this before?!)

    I will be in the Nurses Union! (can't tell you much more about it yet, not sure what the real name of it is)

    Those S.F. salaries would be unheard of in nearly any other part of the country. Chiefs do not even make that. Check out the NAME website for realistic salary prices. (www.thename.org)

    Mindy
     
  19. tardieu

    tardieu New Member
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    Some chatter fodder.

    Basic scenario: 70 year old female found dead in a secured home. Lives alone. Medical history unknown. No indications of foul play or accident. Law enforcement not concerned.

    1. Autopsy? If not, how would you sign out and why?

    2. Basic scenario + HTN meds and sternotomy scar. Same questions.

    3. Basic scenario + HTN meds, sternotomy scar, and empty Rx of oxycodone by the bed. Med recs say oxycodone was for foot surgery two years ago. Same questions

    4. Number 3 + photos of husband laid out on the bed. He died of cancer a year ago. No note. Same questions.

    Would your answers change if (a) family wants an autopsy, or (b) family prefers no autopsy?
     
  20. Mindy

    Mindy Senior Member
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    I'll bite:

    1) Probably no autopsy if no obvious trauma. COD= ASCVD (atherosclerotic cardiovascular disease for the non-FPs); MOD= natural

    2) No autopsy; COD=ASHCVD (atherosclerotic and hypertensive cardiovascular disease); MOD=natural

    3) No autopsy; perform toxicology; COD=ASHCVD if tox negative, MOD=natural; COD=acute oxycodone intoxication if tox positive (and significantly high), MOD= accident

    4) Probably no autopsy; perform toxicology; (COD=ASHCVD if tox negative, MOD= natural; COD=acute oxycodone intoxication if tox positive (and significantly high), MOD=accident (or possibly undetermined since there is a suggestion of suicide. I do not think that unless I had a note, prior suicide attempts, or a significant & specific history of depression that I would make MOD=suicide in this case.)

    If the family requested an autopsy it would have to be because they believed the cause of death to be something other than a natural cause or oxycodone intoxication, i.e. something suspicious, before I honored the request. Though I often try to accomodate family requests whether they are for or against autopsies.

    Mindy
     
  21. LADoc00

    LADoc00 There is no substitute for victory.
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    Wow, nurse union is fairly "leet".

    that sounds intriguing actually.
     
  22. LADoc00

    LADoc00 There is no substitute for victory.
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    Are you thinking of IFS? Which is a private corp that owns their own tox lab?


    AMY HART Dept Head V Administrative Services $280,195

    http://www.sfgate.com/webdb/sfpay/?appSession=8376915755264&RecordID=&PageID=2&PrevPageID=1&cpipage=1&CPISortType=&CPIorderBy=

    That is the highest compensated ME in SF, still 70K shy of the top NURSING salary...bwahahahaha

    where did you pull the 500 buck an hour consultation fee from?
     
  23. mlw03

    mlw03 Senior Member
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    i too will bite.

    1 - agree w/mindy, but if family wanted one i'd certainly do it.

    2 - agree w/mindy. would have to get good story from family to do post.

    3&4 i'd like to discuss a bit more. mindy, the guys i've worked with are not fans of the partial autopsy, including toxicology only. they taught me that interpreting tox should be done in the context of complete history, gross, and microscopic findings. as i was taught, if you contribute the oxy, there's always the question of what else might be found had an autopsy been performed. thus they taught me you either do full autopsy with all appropriate ancillary tests, or you do external exam only and sign it out based on those findings. no partial with respect to labs or body cavities.

    i will agree to err against calling manner suicide without darn good evidence indicating it. defaulting to accident until good evidence indicating suicide is the policy i've been taught.

    as to family requests, i agree that deferring to families is best if possible, but in the end the FP's obligation is to society to determine why this person died, and if that goes against the family's wishes so be it. and i say that as a member of a religion whose most observant members are staunchly opposed to autopsies. and to those people i say that these are the laws of the country you live in and if this bothers you that much feel free to leave... i hear there are some wonderfully tolerant regimes in the middle east.

     
  24. tardieu

    tardieu New Member
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    1 and 2: I would also not autopsy and would sign out as ASCVD, but not without growing reservations. I always feel a bit fraudulent doing this. I understand the reasoning &#8211; everything points towards a natural death, there's nothing additional giving cause to question that, so why expend the resources? (You guys didn't say WHY you'd sign out as ASCVD, so I'm assuming that's more or less your reasoning; I'd be interested in your thoughts if otherwise.) That argument is very reasonable and I agree with it. But why default to ASCVD? OK, I understand that ASCVD is the most common cause of natural death at that age. You could even go one better and say it's the most common cause of death for people at that age who have no indicators of any other disease. But there's a bit of circular reasoning in that proposition. If we assume these cases are ASCVD and sign them out as ASCVD, then of course ASCVD is going to be the most common cause of death for these cases. There have been enough cases where I was on the fence, debating about whether to external and sign out ASCVD or post, and posted, only to find something else, like COPD, PE, or something on tox, or nothing. (And I kick myself for doing the post.) Likewise, even when I've posted and ended up with ASCVD anyway, usually there's a thing or two for Part II. Ideal world of course we'd autopsy all these cases. Reality is we can't. So we have to resort to this kind of corner cutting, which, again, I think is reasonable. But, in cases where you're convinced there's nothing but natural causes, and there's no compelling reason to cut, why not use a phrase like "Undetermined natural causes" and manner Natural? This seems more intellectually honest, and it avoids muddying the statistical waters by defaulting to a diagnosis that hasn't been proven. Also, if we put this out there, it may, as I said in the previous post, make the FP resource situation more clear and provide some motivation for more allocation. Does anyone think we'd be losing anything important by eschewing the ASCVD default and opting for "Undetermined natural causes"?

    3 and 4: I would do a full post on these. Again, with some reservations. I was trained like mlw03. You're either convinced it's natural, and do external only, or you do a full post. No partials. (Although I saw this maxim violated often enough, eg. the head only suicide GSW) The argument here is as mlw03 characterized: You need the full context to interpret specific testing. That sounds nice. But I can't help but think it's a bit spurious. For example, in diagnosing clinical patients, it's never all or none. You're always doing a partial exam. The art is to do a "complete partial." Why not the same with autopsies? I've been counseled that the partial post is a set up for problems down the road, but I've never gotten a good explanation of what those problems might be. I would be curious to know, from those who do do partial autopsies, has this practice ever gotten you in hot water?

    As far as family wishes go, I agree that you have to do what you think is necessary to carry out your mission as a forensic pathologist. If it's that or going against family wishes, then family wishes have to give. There's ambiguity here too though. For example, a lot of families don't like the notion of retaining organs, such as the brain. But there are times when doing a complete neuropath exam, which, it is assumed, includes fixing the brain, etc, is forensically necessary. So, despite family wishes, the brain stays. However, is there any evidence supporting the proposition that examining a fixed brain, as opposed to a fresh one, is essential? It seems to have gone more or less without say that you have to fix the brain. But maybe not. I will say that if family wants a post, and it's a case I might otherwise external, I will post. I'm communist enough to believe in universal health care. And to my mind autopsies are part of health care.

    Thanks for your replies.
     
  25. Mindy

    Mindy Senior Member
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    Hi:

    What an interesting talk!

    I also do not do partial autopsies, and my training does not promote them at all. BUT! We do not consider toxicology to be a partial autopsy. In fact, I pull tox (meaning vitreous, femoral and/or subclavian, and urine) on every case I do "only" an external examination on. I minimally hold these specimens at the toxicology lab, and many times have them run. I consider this an integral part of my examination and do not consider tox by itself a "partial autopsy". A "view with tox" is a very standard procedure here.

    Here are some questions:
    1) Do you peform autopsies on all motor vehicle accidents (single car, no charges, obvious COD?) If not, are you or anyone else not concerned with the blood tox (ETOH, etc.?)
    2) Do you perform autopsies on all suicidal ODs with a note?


    I agree with tardieu's ASCVD commentary. It is more of a convention here (like many places) than a matter of fact, I am afraid. I have used the phrase signed the COD as "Undetermined" and the MOD "Natural" on rare occasions. I have had some of these bounce back to me from vital statistics as well, as not being acceptable.

    In short, we are a pretty busy morgue. Today's roster had 36 cases on it. Cases 3 and 4 are "low yield", as far as heavy suspicions are concerned. If I had a OC of 500 ng/ml femoral blood in a 70 year old who had a 2 year old rx, I would be fairly convinced it was an OD, regardless of whether or not my autopsy showed a cardiomegaly and a healed lateral wall MI.

    Keep up the commentary! Others?!

    Mindy
     
  26. mlw03

    mlw03 Senior Member
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    to mindy's new questions:

    (and remember i'm an incoming pgy-1 who's done a few forensic rotations as a med student, so that's the level of knowledge i'm arguing with)
    these answers are based on the FP i've trained with thus far:

    1 - yes, do a post. all non-naturals are full posts, period.
    2 - again, yes. same reason as above.

    now here's the caveat. the guy i've trained with doesn't work in a huge, super-busy jurisdiction. a typical day for them is 2-4 posts, with plenty of 0 days and rarely more than 5. so you could argue he has the luxury of time that mindy, working in boston, does not. as we're seeing in this discussion, the practice of FP is a balance of medicine, law, and jurisdictional expectations. and i think every FP does the best they can for their circumstances.

    as to the ASCVD default issue, i really like tardieu's point, especially the part about it being intellectually more honest; in those cases we don't know the cause is ASCVD, rather we just know it's the most likely and put it on the DC. assuming certainty about the manner being natural, i really like that idea. and if there's any uncertainty the manner is natural, they're getting a post anyway. i'll probably bring this up when i start on FP rotations (or just going in on weekend to facilitate my own learning). would the vital stats people allow this? i'll be curious to hear what the practicing medical examiner's have to say about this.
     
  27. tardieu

    tardieu New Member
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    I don't know why vital recs should have a problem with "undetermined natural causes" It's analogous to phrases like "homicidal violence of an undetermined nature" with MOD homicide, which for those who may not know, is used by many offices in cases where everything points towards homicide but the specific COD cannot be determined, such as a badly decomposing dismembered body in a suitcase. I have misgivings about that phrase too, but the point is that vital recs lets it pass.

    As a separate issue, I also have misgivings about vital recs clerks questioning the professional opinions of MDs. It's fine to screen out the obviously wrong ones, such as those DCs where it's obvious the certifier simply listed the dec's conditions, and you end up with COD GBM due to HTN due to COPD due to GERD due to ED. I've seen it, and seen it pass through, abbreviations and all. If it makes sense, the certifier's opinion should stand.
     
  28. Mindy

    Mindy Senior Member
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    Trust me, I had a problem with it to. But, the vital stats people (at least in Massachusetts) can be a bit dogmatic. And they do have every right to "bounce" DCs. As one colleague told me "Its all about the boxes" with them! But, to be fair they are trying to produce accurate health stats.

    Turns out, I didn't really give you the full story, anyway. In correcting my DC, vital stats "recommended' that I change:

    COD = Undetermined
    MOD = Natural


    to:

    COD = Undetermined (etiology unknown)
    MOD = Natural


    Then, my DC was accepted.

    Seriously, would I lie to you???!!

    MLW: I also was exposed to an office like the one you describe. I loved it! But, that sort of situation is a bit of a luxury, I think. In the end, its taxpayer dollars, and I think it needs to be allocated as efficiently as possible. I would feel a bit like I was trying to justify my job if I autopsied every 90 year old grandmother who broke her hip after a witnessed fall at home and died after a few days in the hospital.

    Mindy
     
  29. KCShaw

    7+ Year Member

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    Myocarditis (+ sudden death): I'm curious where you heard the 10-slide suggestion, and whether you mean 10 slides/levels or 10 sections/cassettes. I've heard of places that do a heap of levels when looking for -vasculitis- in biopsies from the living, but even then the exact procedure seems to be institutional rather than a widely performed gold standard (some doing 5 levels, some up to 15, some stepping through the tissue until it's gone, etc.). It sounds like something a place might use for a biopsy, but I'm not sure that it translates well to the autopsy setting.

    Per an old text by Virmani & co, they were using at least 2 inflammatory foci per -section-, with at least 5 inflammatory cells and myocyte necrosis per focus (1) (alas, don't have the more recent book at hand at the moment, and haven't talked to that group specifically about this for their modern day opinion). Without having looked at the data this is based on, I can only say it sounds like a reasonable answer to the "is it significant" problem. I can also say that individual myocyte necrosis is not obscenely rare, and the cardiac pathologist I've sat with has elected to not do anything with 1 dead cell in 5 postmortem sections, save perhaps put it in a comment or description.

    An old article out of Mayo (2) almost thinks about addressing this using postmortem sampling, but it may not completely answer the question. I've only got access to the abstract, which describes the known problems of false-negative biopsies -- but doesn't describe how they made the final diagnosis of myocarditis. Possibly there are useful details in the full article.

    As for myself, in the absence of a suggestive history (and probably even in its presence) I would look at my 5 standard cardiac sections and forego levels. If anything, I'd add sections before levels. My mind might change on this when my name becomes the only one on the report, though. Heh.

    Anyway. Haven't researched much more than to see most studies appear to be based on the living and small biopsies or are very old and difficult to obtain full text for -- but it's an interesting topic. Families, lawyers, and some clinicians will still adore hounding pathologists with "but it's supposed to be patchy/focal, how can you say it's not there if you haven't levelled through the WHOLE BODY?!?" -- but, that's just the burden we carry, hopefully without too much personal second-guessing.

    --
    1) Virmani, Renu, James B. Atkinson, and John J. Fenoglio. Cardiovascular Pathology. W.B. Saunders Company, 1991.
    2) Hauck, A J, D L Kearney, and W D Edwards. "Evaluation of postmortem endomyocardial biopsy specimens from 38 patients with lymphocytic myocarditis: implications for role of sampling error." Mayo Clinic proceedings. Mayo Clinic 64, no. 10 (October 1989): 1235-45. doi:2593714.
     
  30. KCShaw

    7+ Year Member

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    (We really do need our own forum, y'know..)

    Basic scenario: 70 year old female found dead in a secured home. Lives alone. Medical history unknown. No indications of foul play or accident. Law enforcement not concerned.

    1. Autopsy? If not, how would you sign out and why?

    2. Basic scenario + HTN meds and sternotomy scar. Same questions.

    3. Basic scenario + HTN meds, sternotomy scar, and empty Rx of oxycodone by the bed. Med recs say oxycodone was for foot surgery two years ago. Same questions

    4. Number 3 + photos of husband laid out on the bed. He died of cancer a year ago. No note. Same questions.

    Would your answers change if (a) family wants an autopsy, or (b) family prefers no autopsy?


    Rather than going through 1 by 1, I'll comment broadly on the existing replies, because I think they're good ones. Personally I buy into the problem of ASCVD feeding ASCVD -- it's an overused presumptive COD, but a lot of offices are stuck with it because of lack of funding and paucity of trained FP's. Taking the cynical view, there's also only faint community interest in deaths that can't immediately be blamed on someone else, which feeds back into the funding problems.

    Personally I think if you're going to sign a case out as X, you need to see X rather than assume it's there. Assumptions work great for clinicians, but less so for FP's, IMO. This means I have no qualms about targeted autopsies to confirm & properly document suspicions (heart only, liver only, etc.). I certainly respect the approach that every autopsy needs to be "complete," and put it all together at the end -- but I'll add the point that no one performs every technique on every autopsy. Sure, everyone has a pretty similar (though not identical) approach to what they call a "standard, full autopsy," but I can't say it catches everything every time. We should cast a wide net, but part of training needs to be learning how to draw the noose in around just the important things very quickly.

    For manner, I'm starting to like the use of undetermined in cases of suicide vs accident in the absence of a good history & note or similar strong evidence of intent/premeditation. Intent is very difficult to determine; were they doping up because they felt bad and just wanted a buzz, or were they doping up because they felt so bad they intended to die?
     
  31. yaah

    yaah Boring
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    There is not enough activity to justify a separate forum. As it is now, each new thread in the path forum stays on the main page for several days.
     
  32. Mr. Freeze

    Mr. Freeze Not right. (in the head)
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    My wife and I were watching Dr. G the other night (you guys prolly can't stand that show), but it occurred to me that FP might be something I wouldn't have otherwise thought I was interested in. Probably early in the game to know.

    One thing in particular I don't think would sit well with me though is that people don't often die in nice neat manners of natural causes. I think the general disregard for life in certain cases would bother me. So maybe someone could address how they deal with those issues. Before school I was a fireman for 10 yrs. so I've seen a few things too, but somehow they seemed different because you were "working" and had something to take your mind off **** that people just shouldn't see. So maybe the ME's role in ensuring justice is enough, for example, to distance yourself a little from the process. I just don't know if being distant is healthy.

    And it may be elsewhere, but maybe someone could address what they dislike about FP. Not salary issues though. I won't have a career I hate no matter how much it pays. The inverse is also true.
     
  33. KCShaw

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    "Bad things": First, some people cut through this very quickly and easily to get to the "this is the job" part. Some people don't. This is just something you need to recognize up front. Having said that, I think the phenomenon you described as a fireman still applies -- personally, I was able to objectify a case and deal with it as a case/job after the first two or three. There generally aren't emergent things to do as with a fire blazing around, but there are still things to do -- data to gather, techniques/procedures to perform, things to describe, and interpretations to consider. It's not ALWAYS easy, but you either find that comfortable middle ground emotionally or you get out of the field. Best way to find out is spend some quality time at an ME's office.

    Another thing to keep in mind is that not every office will have a grisly homicide every day -- most won't, and in some places there will only be a handful a year. Even at the busy big city offices, the majority of autopsies end up not being homicide (lot of drug, MVA, etc.). Some people get more bothered by the senseless accidents, etc., than by the things one human did to another.

    Things to dislike: I think a lot of people initially don't recognize the politics involved in forensic pathology. There is a lot of playing nice (or carefully choosing battles) with coroners (when present), lawyers, families, local or state politicians, hospitals, clinicians, and communities, among others. There is a lot of misunderstanding with regard to what forensic pathologists do (and don't do), and increasing demands for information and transparency, which in turn has an effect on what we do and how we do it. TV has had both a good and a bad influence here. But again -- some people end up finding this interesting, or an enjoyable challenge, while others crash and burn. Facilities tend to be behind the times, histologic slides may take weeks to prepare and come back to you (as opposed to overnight at most pathology labs), toxicology and other lab tests may take months to come back (this is highly variable depending on what's ordered and where you are). For what it's worth, though salary is still on the lower side among pathologists, advertised starting salaries have crept up significantly the last few years.

    Yet, with all that said, I reckon it's the best job on the planet.
     

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