Resident Guide

Introduction 

Welcome to the autopsy rotation! We are looking forward to working with you, and we hope your time will be educational as well as fun. We are here to share our knowledge with you, and we want your input as to how you think the rotation can be improved. Starting July 1, 2009, pathology residents will participate in medical and forensic autopsies as part of a single Autopsy rotation. The purpose of this, rather than to have separate Medical Autopsy and Forensic Autopsy rotation is to improve daily autopsy workflow, and maximize resident exposure to all different types of autopsy cases. The autopsy suite at MUSC is a busy place, and you will interact with numerous individuals on a daily basis. It is only with everyone’s best team effort that we keep this place running, especially during busy days when multiple cases are going on. If there is something you are unclear about that is not covered in this manual, and at any time during the rotation, please do not hesitate to approach any of the staff with questions and/or concerns you may have. We are here to help!

Purpose of the autopsy 

The purpose of each autopsy is to determine cause and manner of death. Cause of death is the most specific pathophysiologic process that is believed to have resulted in death. For instance “Severe multivessel coronary atherosclerosis” is a very common cause of death. In fact, it is the most common overall cause of natural death worldwide. “Single penetrating gunshot wound to the head with resultant cerebral parenchymal pulpification and hemorrhage” is a frequent scenario in forensic autopsy. Not uncommonly, causes of death listed in death certificates completed by clinicians are too vague. “Respiratory distress” and “Ventricular arrhythmia”, while they may accurately describe decedent’s status immediately preceding death, tell nothing about the pathophysiologic process(es) that led to them.

Keep this in mind when you think about cause of death in each of your cases. Thus, if you get a medical case in which “Hypoxia” is listed as the cause of death in the death certificate, begin thinking about various pathophysiologic states involving the lungs. In your review of the decedent’s record, pay particular attention to references of clinical diagnoses such as chronic obstructive pulmonary disease, acute pneumonia, rheumatologic disease with lung involvement, or any combination of these. Look for laboratory and radiology test results confirming clinical hypotheses. At autopsy, lung pathology will need to be discerned in detail to explain why decedent was hypoxic. So in the end, cause of death in such a case may be “Acute respiratory distress syndrome (ARDS) complicating acute infectious bronchopneumonia and bullous emphysema”. Note that each of these is a SPECIFIC pathophysiologic entity contributing to pre-mortem hypoxemia.

Manner of death may or may not be less difficult to determine. There are only five possible manners: Natural, Accident, Homicide, Suicide and Undetermined. Rarely, the pathologist cannot determine the cause and/or manner of death with certainty. This could be due to lack of adequate pre-mortem information, or conflicting information where one cannot pinpoint with certainty the most proximate single cause. It is acceptable in such cases to state that cause and/or manner of death are “Undetermined”. Usually, such cases are accompanied by a comment at the end of the autopsy report, which describes the limiting factors. The pathologist is allowed some degree of speculation on the possible sequence of events that led to death, but ultimately it is because this sequence remains speculative that the cause and/or manner of death are listed as “Undetermined”. 

Additional guidance regarding certification of death is available online at the National Association of Medical Examiners web page.

What are the benefits of knowing why and how someone died? Obviously, there is direct benefit in medical student and pathology resident education. There is a benefit to clinicians and our hospital, as correlation of pre-mortem and post-mortem diagnoses is an important way of institutional quality control and quality improvement process. Morbidity and mortality conferences depend on input from autopsy pathologists to gather meaningful data. There is a benefit to families of deceased patients, in terms of understanding the disease processes that affected their loved ones. This may help them in their grieving process. Occasionally, autopsy may be the medical procedure that answers questions regarding genetic disorders with implications for extended family. Medicolegal investigation of death in the form of forensic autopsy carries benefits to law enforcement and jurisprudence in crime investigation.

Expectations from rotating residents

During each of your months on the autopsy rotation you should participate in detail in each aspect of the autopsy procedure in your assigned cases. This means taking ownership of cases, and seeing that they are finished in an accurate and efficient manner from external examination to completion of the final report. If you take vacation during the rotation, coverage for the autopsy service should be arranged. Each morning, the mortuary staff should notify you by pager of any pending medical cases. If there are none, you should consult with the forensic attending, forensic fellow, or pathologist assistant concerning pending forensic cases. If there are two residents on service and only one medical autopsy scheduled, one resident should take the medical case and second resident should take a forensic case. During your first month, participating in one case daily, finishing the preliminary report (PAD = Preliminary Autopsy Diagnoses) and dictating that case will be plenty of work for one day. During subsequent months, this is the minimum. Senior residents can easily complete an autopsy case in 2-3 hours, finish the PAD, and participate in another case. Having said all this, you should touch base with autopsy attendings each morning to discuss division of workload. Half of the time, the same attending covers both medical and forensic autopsies, but the other half, attendings are different (attending autopsy schedule is posted in the autopsy office). Once there is an understanding of how many cases there are, which order they will be done in, and who is participating in which case residents can begin communication with autopsy technicians to bring bodies up from the morgue to the autopsy suite. Rarely, we use the downstairs autopsy room if there is a crunch with the number of cases, or the upstairs suite is occupied with numerous individuals, such as law enforcement, coroner deputies, and/or x-ray technicians.

Autopsy procedure 

Before each case is begun, all the information pertinent to the case needs to be reviewed. In forensic cases this includes the “I” (information) sheet which contains information provided by the coroner. The “I” sheets are usually available from the forensic fellow, pathologist assistant, or the forensic attending. Initially, if there are any additional questions about the case, the fellow or the attending will call the coroner. As you get more comfortable during the rotation, forensic attendings may want you to participate in direct communication with coroners. Before medical cases, decedent’s electronic and written medical record (latter is provided by the morgue staff) is reviewed in detail. This is so that autopsy procedure can be directed in a meaningful way, and all the proper procedures can be performed. For instance, if there was pre-mortem clinical suspicion of septic shock and this was never documented by pre-mortem microbial cultures, postmortem culture may be advised. If there was a question of diffuse lung pathology, we sometimes decide to inflate one lung with formalin for 48 hours prior to dissection to facilitate airway expansion and prevent as much as possible limitations of microscopic evaluation posed by artificial collapse of lung architecture. This procedure will be demonstrated for you by the attending the first time around. Before you begin, you should have a decent idea of what you are looking for based on record review. For quality assurance, the ordering clinician should be notified before the case starts. Ask the clinician if there is anything specific that they think we need to be looking for during autopsy. Clinician notification is a required component and needs to be documented in the appropriate spot on the Preliminary Report (PAD).

Of note, you must verify the validity of the autopsy permit (to be signed by the next of kin) and any limitations imposed upon the autopsy (i.e. chest only autopsy, external exam only). 

When the body is on the table, we begin with external exam. Each case is accessioned in Cerner by an autopsy technician or pathologist assistant. The accession number is used for all the labels during the autopsy. Digital photographs are taken first of the whole entire clothed body, followed by photos of decedent undressed, and a frontal “mug-shot” of the decedent’s clean face with a chuck under the head and autopsy label at the neck. Each photo requires a label and an associated measuring device (i.e. ruler). It is recommended to photograph any unusual or interesting external or internal findings/pertinent pathology. External exam should be a well organized, head to toe procedure done the same way in each case. You should use autopsy template paragraph on external examination, or a 1-page external exam diagram (available in the autopsy suite) to get familiar with this procedure. First, document the decedent’s height, weight, temperature, rigor and livor. Then proceed through the short list in the upper left hand corner of the external exam autopsy form (hair length and color, eye color… etc). document clothing, identification bands and/or tags, medical equipment, remove the clothing and equipment and then document identifying marks (e.g. tattoos) and scars. Clothes, jewelry and other personal belongings should be listed individually on the carbon copy personnel effects form available in the autopsy suite and then bagged. Clothes go in the large red biohazard bag (tie for closure), and small items in the re-sealable small biohazard bag. Staple the clothing form listing all items and small biohazard bag (if any) to the large biohazard bag. do not separate the carbon copy of the form (this is done by a staff member that releases the belongings to the authorized person). Each bag is labeled with an autopsy sticker and left near the body. You may find the following approach useful when doing external exam: doing a head-to-toe exam several times, each time focusing on a different thing (i.e. medical equipment one time, marks and scars the second time, and so on…). This way you are less likely to miss things. 

Prior to beginning internal exam, make sure autopsy stickers label cassette and tissue formalin-filled containers and that cassettes have been made; “Formalin” warning stickers should also be in place. This is usually done by either autopsy assistant or technician, but it does not hurt to check. Notify the autopsy technician assigned to the case of the general plan and what we are looking for with each case. Tell them ahead of time if postmortem cultures will be done, and what will be cultured. X-rays are usually done in pediatric forensic cases (skeletal survey) and in gunshot wound cases (AP and lateral of the affected areas). These have to be ordered using appropriate radiology form available in the autopsy room. Radiology techs are notified by phone to come to the autopsy room and perform the x-rays. Type of examination needs to be specified on the radiology form. Medical babies may get a whole body x-ray called a “baby-gram.” Virtually all fetal autopsies should have placental tissue and fetal Achilles tendon tissue sent for cytogenetics using appropriate media (available in autopsy) if samples were not sent by clinicians at the time of delivery and no prior amniocentesis is on record. Recent practice has been that the autopsy resident grosses in the placenta associated with their fetal autopsy case in the surgical pathology grossing station. Let the surgical pathology resident in the gross room know to put appropriate placentas to the side for you, and to not place them in formalin until tissue is collected for cytogenetics.

Once the body is opened, be on alert for any unexpected findings. Just because you think you may know what you will find inside, only if you are exceedingly detail-oriented will you succeed in making sense of the entire case. In the beginning, let the autopsy technicians do their job of opening up and removing the organs (you will eventually be asked to perform all parts of the autopsy, including prosection). However, if you observe an unexpected fluid collection (e.g. tan colored pericardial fluid), it is probably a good idea to send this for culture in a sterile container. Usually attendings are present during the entire autopsy procedure; if not, please call your attending with ANY questions. If there is a rotating medical student, having them scribe during the autopsy while you actively engage in teaching them about what you are observing is a good way to optimize their experience.

Ancillary studies are usually performed at this time, including cultures and, for forensic cases, toxicological specimen procurement (blood in gray top tubes and purple top tubes). A blood spot on filter paper is required for all medical and forensic cases. All the organs are removed and weighed and their external surfaces are examined before they are dissected as you dissect organs in surgical pathology. Make a note of any abnormal findings as you go along, and have the scribe write these down. Most attending use a single sheet gross autopsy protocol form and write down all the findings in a condensed format. For those of you who like to write in more detail, there is a several page autopsy gross protocol handout available. Some may choose to write everything on the one-page form, and transcribe in more detail gross autopsy findings in the longer form upon case completion. Make sure you bread-loaf each organ in ~1cm slices so that you do not miss any focal pathology. Lungs usually require palpation after bread-loafing. Focal acute bronchopneumonia may have subtle consolidation which can only be palpated. Sample all pertinent organs/tissues for histological examination.

In complete medical autopsies, the brain is usually fixed in formalin for about 10-14 days before it is dissected in a separate session with our neuropathologist, Dr. Welsh. Please notify Dr. Welsh about a week ahead of your brain-cutting session that there is a medical autopsy brain to be cut. She likes a short premortem history and synopsis of autopsy findings e-mailed to her. PLEASE NOTIFY AUTOPSY ASSISTANT OR AUTOPSY TECHNICIAN A DAY AHEAD OF THE BRAIN CUTTING SESSION TO PULL THE BRAIN FROM YOUR CASE AND START RINSING IT!!! This is essential because brains that are not rinsed are unpleasant to cut due to pungent formalin fumes. Forensic autopsy brains are usually cut fresh.

After the autopsy

Once you leave the autopsy room, your focus should be on completing the Preliminary Autopsy Diagnosis (PAD) Report. This is best done immediately after case completion, while details are fresh in your head (though technically CAP guideline for Preliminary Autopsy Diagnoses is 48 hours after case completion). You should complete report directly in Cerner. Once you enter case number under “Online Review” button, select Preliminary Report. Once in the body of the report type AUINFO and then press F9 to get to the medical autopsy template; enter FAINFO then F9 to get the forensic template. Fill the required information in the box, and then information as appropriate for your case. Notify the attending that the Preliminary is complete so that it can be verified. Gross autopsy findings should be dictated or typed using appropriate autopsy template as soon as possible after the case, and no later than 48 hours. This way the case is fresh in your memory and details are easy to recall. All original paperwork should go to the administrative assistant to prepare an autopsy folder. If you need to remove a folder, it must be checked out from the administrative assistant. 

Mr. Grimball usually brings autopsy cassettes over to the surgical path grossing room daily. It is the resident or fellow’s responsibility to appropriately transfer cassettes to the metal tray and record them on the cassette submission form. Mr. Grimball can then log the cases in the Autopsy book. The slides are generally available in about a week, and are placed in your mailbox if you are the dictating resident/fellow. Please preview the slides and form your diagnostic impressions BEFORE you bring the slides to the autopsy attending. First and second year residents should go over slides with autopsy attending. Upper level residents in their third rotation month, if agreed upon with the attending, can complete microscopic examination independently. Microscopic findings are then entered in Cerner, and report is finalized. 

A postmortem clinical correlation comment or paragraph depending upon the complexity of the case should be included on all medical and pertinent forensic autopsy reports. Routine cases need to be completed within 30 days and complex cases should be finalized within 60 days; delays should be documented by an explanatory comment placed in the autopsy file. 

Means of Resident Evaluation

The residents will be evaluated on the basis of their availability for autopsy cases, depth of participation in each case, general medical knowledge and professionalism. (see E*value) 

Autopsy Attending Schedule

Ms. Maxine Robinson has the schedule posted in the autopsy office and can inform you which attending covers which service. 

Sample Autopsy Reports

Available on Request 

Autopsy staff 

Attending Physicians:

Nicholas Batalis, M.D. (Forensic and Medical Autopsy)
Russell Harley, M.D. (Forensic and Medical Autopsy)
Erin Presnell, M.D. (Forensic and Medical Autopsy)
Ellen Riemer, M.D., JD (Forensic and Medical Autopsy)
Cynthia Schandl, M.D., Ph.D. (Forensic and Medical Autopsy)

Pathology Assistant:

Eowyn Corcrain, MSc

Autopsy Technicians:

Kimberly Boretsky  
Raymond Edwards  
Brent Grimball  

Administrative Assistants:

Maxine Robinson (Forensic Autopsy) 
Phyllis Ross (Medical Autopsy)  

Mortuary Staff: 

Julius Fielding  
Bob Gregowitz  
Gail Chesnut