Problems with autopsy = problems in clinic?

[Abilene85]

I observed an autopsy this morning and it was…difficult. I'm an MS1, and my class just finished anatomy a few weeks ago. I adored anatomy. I loved cutting. I had no problems dealing with the death aspect of the lab. I think maybe that is because the cadavers donated their bodies for our education. I didn't try to treat my cadaver like a piece of flesh – I liked thinking about who he possibly was and I was thankful for his donation. Most people don't choose to have an autopsy, though - it is a decision made for them after death. I had problems separating the body during autopsy from the person she had been just a few days before, and unlike anatomy lab, it was a problem this time.

I was surprised by how violent the autopsy procedure is, especially compared to the delicacy used during most dissections in lab. In autopsy, the organs are literally chopped up by a giant knife and shoved back inside the body in a plastic bag. I know that autopsies are important and can tell us a lot of information that might help with future diagnosis, etc, but the techniques seemed almost disrespectful. It also bothered me a bit that there was no real relationship with the body. After spending so much time with my cadaver, I felt like I knew him – but this felt more like shoving bodies through assembly-line style. On top of these feelings, things were just so fresh, smells so rancid (the GI smell was made worse by the fact that it was not entirely foreign to me – it was mostly new and gross, but there was a slight familiarity from the scent of feces which just reminded me that this was a product of the human body). I'm glad I had a chance to see what autopsies are all about, and check pathology (at least forensic) off my list of potential future careers, but I found very little about the experience to be enjoyable. (And PS: The body next to the one we were working on was a suicide victim....hanging....my first experience ever with suicide...and he looked quite a lot like my uncle. That whole little bonus didn't make things any easier.)

So after this autopsy, I have 2 worries:
1) I won't be able to emotionally separate myself from the patient and their loved ones when that is needed to get the job done. I certainly don't want to forget that we work on people, but I don't want to have a breakdown Izzy Stevens style, especially in front of patients/families. I haven't yet come to my own conclusion about life after death, and I can get fairly emotional about the issue.
2) I will continue to be grossed out by smells and sights and live throughout the clinical years always worried if the next case or rotation will make me light headed and needing to excuse myself from the room.

Anybody have comments? I would especially love to hear from any older students who maybe felt like me but found they were worried about nothing once they spent a couple weeks in the hospital.

Thanks.

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[yaah]

Well, first off, most pathologists don't have anything to do with autopsies. It is a part of training (we have to do 50). But once into practice, most don't do them. Forensics is a separate fellowship which some people choose to do. There is a massive misconception which even extends to physicians about what pathologists do (i.e. it's all about death). Pathologists make diagnoses on every biopsy that comes through, and run the labs to make sure all other diagnostic tests are run appropriately. I would wager to say that 2/3 of patients out there think their surgeon or internist is making the diagnosis when they do a biopsy.

Pathologists are also keenly aware of the importance of the autopsy as well as the sensitivity involved. The thing is, when you do something frequently, it becomes second nature and you become dulled or accustomed to things that may have bothered you before. My first autopsy gave me a queasy feeling when I saw the knife go through also. Surgery is similar - making a giant cut in the abdomen for major surgery isn't a whole lot different, it may appear different because there are lots of drapes and gowns, but the smells can be there and the sensations can be also. But if you are fascinated by an autopsy it also doesn't mean you're a more sensitive person or are going to be a better doctor, same thing if you are repulsed by it.

You don't ever have to totally separate yourself from the patient, no matter what field you go into, but you do learn how to balance things. Some people can't handle physical gore (like lots of blood), some can't handle seeing things mangled (like in trauma), some can't handle autopsies, some can't handle a dying kid, some can't handle a mentally ill adult. Medicine has many fields. Part of medical school is experiencing all of these things, even those that you object to, and learning how to respond to them. By definition in medicine you will deal with death in some fashion. Death is cruel. Our job is to prevent it or at least delay it. Or in some cases to figure out why it happened.

But I also encourage you to not necessarily latch on to your first impression as the way things will eventually be. Maybe after seeing lots of clinical stuff and surgery you'll see another autopsy and find it fascinating. Maybe you won't. The point is, you have to allow yourself to experience different areas and see what they are like and whether your talents lie there.

 

[Blesbok]

That is only a bad thing if you want to go into forensics.

If you want to go into any field that deals with live patients, especially a field where you have a long follow up with patients, it is a good thing that you care so much. You would do great in a lot of fields because of the fact that you care so much.

 

[yaah]

If you want to go into any field that deals with live patients, especially a field where you have a long follow up with patients, it is a good thing that you care so much. You would do great in a lot of fields because of the fact that you care so much.

That implies that people who can handle it don't care though, which is a ludicrous statement. And just because someone can't handle autopsy doesn't necessarily mean they care more - it just means that they can't handle autopsies. There are plenty of people in primary care fields, for example, who are bitter, miserable pills who care only for getting out of the office at the end of every day.

And like I said, don't take one experience as having a heightened level of significance for the rest of your career.

 

[AmoryBlaine]

Without the least bit of patronization intended: you're an M1! Don't worry if things bother you a little bit at first. I am an M4 going into emergency med and I still see traumas that make me want to hurl. Don't even get me started on bad decubitous ulcers...

It's not like I am in a position to supervise younger students to any great degree but I do keep my eyes open. I (and I think most residents/attendings would agree with me) would much rather see an M1 who was still a little impressed/uncomfortable with some of the stuff we do than the M1 who wants to make it clear to everyone that he's already seen it all and done most of it.

Regarding your point of gross cadaver vs. autopsy: keep in mind that the cadaver is the realm of 4-5 M1s who probably feel alot like you do. After doing a pathology residency I'm sure that an autopsy is mostly just a procedure. Also keep in mind that the pathologist almost certainly had no relationship with the patient in question at all, so asking them to get all sentimental at each procedure would be a little much.

You'll almost certainly be fine, just study hard!

 

[Ashers]

Well, first off, most pathologists don't have anything to do with autopsies. It is a part of training (we have to do 50). But once into practice, most don't do them. Forensics is a separate fellowship which some people choose to do. There is a massive misconception which even extends to physicians about what pathologists do (i.e. it's all about death). Pathologists make diagnoses on every biopsy that comes through, and run the labs to make sure all other diagnostic tests are run appropriately. I would wager to say that 2/3 of patients out there think their surgeon or internist is making the diagnosis when they do a biopsy.

Pathologists are also keenly aware of the importance of the autopsy as well as the sensitivity involved. The thing is, when you do something frequently, it becomes second nature and you become dulled or accustomed to things that may have bothered you before. My first autopsy gave me a queasy feeling when I saw the knife go through also. Surgery is similar - making a giant cut in the abdomen for major surgery isn't a whole lot different, it may appear different because there are lots of drapes and gowns, but the smells can be there and the sensations can be also. But if you are fascinated by an autopsy it also doesn't mean you're a more sensitive person or are going to be a better doctor, same thing if you are repulsed by it.

You don't ever have to totally separate yourself from the patient, no matter what field you go into, but you do learn how to balance things. Some people can't handle physical gore (like lots of blood), some can't handle seeing things mangled (like in trauma), some can't handle autopsies, some can't handle a dying kid, some can't handle a mentally ill adult. Medicine has many fields. Part of medical school is experiencing all of these things, even those that you object to, and learning how to respond to them. By definition in medicine you will deal with death in some fashion. Death is cruel. Our job is to prevent it or at least delay it. Or in some cases to figure out why it happened.

But I also encourage you to not necessarily latch on to your first impression as the way things will eventually be. Maybe after seeing lots of clinical stuff and surgery you'll see another autopsy and find it fascinating. Maybe you won't. The point is, you have to allow yourself to experience different areas and see what they are like and whether your talents lie there.

Well said. =)

All I have to add is that I saw an autopsy last year as an M2. It was the most disturbing thing I had seen in med school. While I don't remember it being too traumatic, I do remember being disgusted and feeling sick re: stuff with the face/head and bowel. The GI smell also bothered me. However, the face always bothered me in anatomy too, and I was never keen on the anatomy of the thorax and abdomen. I ended up leaving a little bit early.

It was a similar when I was on my surgery rotation. I learned how to make many faces and hide my disgust behind a mask. I did get used to bowel in surgery, but I never liked it or the smell when we had to cut it or cauterize it. There's a big difference between the smell of cauterized bowel and striated muscle.

 

[Blesbok]

That implies that people who can handle it don't care though, which is a ludicrous statement. And just because someone can't handle autopsy doesn't necessarily mean they care more - it just means that they can't handle autopsies. There are plenty of people in primary care fields, for example, who are bitter, miserable pills who care only for getting out of the office at the end of every day.

And like I said, don't take one experience as having a heightened level of significance for the rest of your career.

It isn't the "can't handle it" part I was referring to. It was the part where he was talking about how he thinks about the body as more than a body, but as a person. Honestly, there are plenty of people, myself included, that sometimes forget that the person they are treating has a family just like yours and mine. People that honestly care that much will often go the extra step to take care of a patient even if it means staying in the office late that day.

I am not saying that it will make him better than anyone, I am just saying look at it as a positive thing, not necessarily a negative one.

 

[Occams Razor]

I'm planning on becoming a forensic pathologist, so i have done a lot of shadowing with MEs. Some can be more callous with their patients than others, but so can any physician. Some GPs grab and manhandle their patients too.

One ME taught me that a deceased person is still your patient...he or she just happens to be dead, and depending on what your spirituality is, their soul/spirit is watching from the heavens/hell, or their soul/spirit in the room with you at that moment. Put things in a greater perspective for me.

 

[45408]

That implies that people who can handle it don't care though, which is a ludicrous statement. And just because someone can't handle autopsy doesn't necessarily mean they care more - it just means that they can't handle autopsies.

I don't think that was the intent - I certainly don't think a medical examiner is less of a caring person just because they do autopsies. There is great value to doing an autopsy, but I couldn't do them on a regular basis. I watched one, and I wasn't particularly disgusted or anything, but I couldn't help but think that this woman was alive two days before and probably had no idea she'd be on a slab in front of a bunch of eager beaver med students. Certainly, discovering that an "accidental" death was actually a murder and then bringing the killer to justice is absolutely necessary, but that doesn't mean I want any part of doing it.

 

[Tiger26]

I don't think that was the intent - I certainly don't think a medical examiner is less of a caring person just because they do autopsies. There is great value to doing an autopsy, but I couldn't do them on a regular basis. I watched one, and I wasn't particularly disgusted or anything, but I couldn't help but think that this woman was alive two days before and probably had no idea she'd be on a slab in front of a bunch of eager beaver med students. Certainly, discovering that an "accidental" death was actually a murder and then bringing the killer to justice is absolutely necessary, but that doesn't mean I want any part of doing it.

Agree w/Prowler and Asher. I was pretty disgusted when we had to observe. It was a good experience, but the creepy factor rises exponentially when you start thinking about them as a 'person' rather than a 'thing'. In anatomy, I guess, I almost thought of our cadaver as a 'thing' so it was easy to be detached, but the autopsy was so personal that I got kinda freaked out.

 

[la petite mort]

Is it customary for med students to have to observe an autopsy at some point in the program?

 

[Abilene85]

Thanks for all the replies.

la petite mort: My school does not require us to observe an autopsy. I chose to take the autopsy elective that was being offered for the first time this year. Based on our feedback, they might decide to include parts or all of the elective into our required coursework.

AmoryBlaine: "I am an M4 going into emergency med and I still see traumas that make me want to hurl." That was actually a very comforting thing to read. All I seem to hear is "you'll get desensitized in no time." Of course as an innocent lil' MS1 I can't believe those words. I am sure I will be able to handle things better in the future, after a lot more experience, but knowing how I feel and react to certain things, I'm not sure I will ever get completely desensitized. It's definitely nice to see that someone who is choosing a field with lots of blood and guts can still feel uneasy at times.


Everyone else:

I realized after posting that pathologists do a lot more than autopsies, which is why I edited to clarify afterwards with "forensics." I certainly don't want to perpetuate the stereotype.

With neuron on my mind, I couldn't help comparing the autopsy experience to temporal summation resulting in action potential. The autopsy was surprisingly fast. The first cut was okay, but the ribcage removal was a little unsettling. I didn't have time to calm down from that before tools were being shoved into the pericardial sac. Feelings were building, the GI scent hit me and added more, chunky blood even more, the non-graceful removal of organs…BAM. Action potential (needing to excuse myself to prevent passing out). I think I would have been okay if things had been much slower and I had had the time to get used to what I was seeing. Are surgeries as rough and quick as autopsies? I've seen video of liposuction, which seems pretty harsh, but I imagine most other surgeries are much more delicate procedures, since you have to watch out for surrounding structures.

I do still worry that my personal issues surrounding death will become a problem. I'm well aware of the fact that we will deal with a lot of death and dying during our education, and I'm sure everyone questions their beliefs at some point. I have spent a considerable amount of time trying to sort out my feelings on the matter, but still seem no closer to a decision than I was years ago. I guess instead of worrying I should just view med school as a great way to continue my soul-searching.

 

[la petite mort]

In the autopsy videos I've seen, I am always astonished at how quickly they work. For example, the top of the head is as neatly sliced and pried off as if it were a hard-boiled egg, revealing the brain intact. In less than 10 seconds, it seemed like. Skilfull work than can come off as impassive, I guess.

Remember that there's a place for nearly everyone in the medical field, as long as you have the dedication.

 

[Tiger26]

They do as much in about 1.5 hours as we did in a semester of anatomy, or so it seemed

 

[yaah]

With neuron on my mind, I couldn’t help comparing the autopsy experience to temporal summation resulting in action potential. The autopsy was surprisingly fast. The first cut was okay, but the ribcage removal was a little unsettling.

I always thought the ribcage removal was the worst part. The snapping sound is a little freaky. It's even weirder when you actually have the garden shears or whatever you're using in your hands and you snap it yourself.

 

[vtucci]

We were required to attend an autopsy during our M2 pathology course.

To the OP, do not worry about being squemish about the autopsy. We had a few people pass out. Everyone has different strengths and interests.

I agree that I would worry far more about the med student who claims to always be comfortable with the situation. At some point in our training (or as a general rule depending on your point of view), we should feel uncomfortable or we are not pushing ourselves far enough. We also need to be prepared for certain realities (i.e., we will likely be responsible for harming or even killing a patient because we missed something, did something incorrectly etc. during the course of our career).

As much as we may want it to be a science, medicine is still largely an art. My favorite quote from a doc was "when I was a 4th year medical student, I thought I knew 75% of what I needed to know to practice medicine on a daily basis. When I was a resident, I realized I knew about 50% of what I needed to know to serve my patients on a daily basis. Now, that I am an attending and have been practicing for 25 years, I know that it is a good day when I can say that I know 25% of what I need to know on a daily basis for my patients." Sobering? Absolutely but I would trust this physician in a second over those who have not taken this lesson to heart.

Like Amory, I am planning to enter emergency medicine and there will be things that will bother me to the end of time, albeit with varying intensities (e.g., the smell of burnt flesh, evidence of child abuse/rape etc., uncontrollable vomiting, particularly if projectile, or uncontrollable diarrhea). I think if given the choice most of us would prefer to avoid certain stimuli. That being said, I deal with these things when I must.

 

[Jwax]

I (and I think most residents/attendings would agree with me) would much rather see an M1 who was still a little impressed/uncomfortable with some of the stuff we do than the M1 who wants to make it clear to everyone that he's already seen it all and done most of it.

I understand why you don't want someone coming in there with a know-it-all attitude, but if they have seen most of the cases and understand what's going on... how could you respect them if they looked around all wide-eyed and astonished? I was very keen on EM for a long time, and I spent ~1.5 years shadowing an EM doc as a pre-med. So when I got to do a ped EM rotation, I wasn't particularly suprised by much that was done. Still got excited by things such as PVTs and a blue baby, but most else was nothing new and I acted as such. Am I going to get looked down upon for that?

One ME taught me that a deceased person is still your patient...he or she just happens to be dead, and depending on what your spirituality is, their soul/spirit is watching from the heavens/hell, or their soul/spirit in the room with you at that moment. Put things in a greater perspective for me.

I like that.

I always thought the ribcage removal was the worst part. The snapping sound is a little freaky. It's even weirder when you actually have the garden shears or whatever you're using in your hands and you snap it yourself.

I remember back in my first biology lab when we were doing our fetal pig dissection. The only things that bothered me was skinning the pig and breaking the rib cage. I was pretty sure I wasn't going to be able to handle any kind of gory medicine at that point. Now I am psyched b/c I get to shadow a trauma surgeon this weekend.

 

[Abilene85]

I'm looking back on my OP a week later, and I realize I used some harsh language. I just want to clarify that the people I worked with were extremely professional and respectful. I was just not prepared for the experience.


This week, we had to interview a "standardized widow" and ask permission for an autopsy on her husband's body. Have you guys ever had to request permission for an autopsy from the families of your patients? What was your experience like?