Staff: Drs. Masha Bilic, S. Erin Presnell, Cynthia Schandl, Nick Batalis, and Ellen Riemer

Transcription

1 I. Core Rotation: Autopsy Pathology II. III. IV. Duration of Rotation: 4 months total Dates Offered: All months Maximum # residents per rotation: Two V. Prerequisites: None VI. VII. VIII. Rotation Director: Nick Batalis, M.D. Staff: Drs. Masha Bilic, S. Erin Presnell, Cynthia Schandl, Nick Batalis, and Ellen Riemer General Comments: The basic premise of the autopsy is to provide more definitive information regarding natural diseases, treatment, trauma, and/or cause of death to provide beneficial information to clinicians, families, coroners, law enforcement, and those interested in the biology of disease. Furthermore, exposure to forensic autopsies will introduce residents to medicolegal death investigation. Gaining knowledge from the autopsy is maximized when specific questions are asked, and proper steps are taken to address those questions (special dissections, ancillary tests, etc). Developing one's ability to assess which tissues should be sampled, to what extent, and for what tests or assays is an important objective. It is the responsibility of the entire autopsy pathology staff including the faculty, residents and autopsy assistants to follow this general principle. Oversight of dissections of tissues and organs and of the ultimate final reports should be viewed as an essential positive ingredient in internal and, ultimately, external quality control. The residents will assume graduated responsibility during their autopsy experience. Residents in their first autopsy block will primarily focus on medical autopsies and atraumatic forensic autopsies while developing their technical skills and understanding of death certification. Residents in their second autopsy block will be expected to help teach the less experienced residents while also performing their own autopsies, which should be of greater complexity and variety than during the first block. By the end of the second rotation the resident should be able to complete more than one autopsy per day and be able to prosect an autopsy without aid from an autopsy technician. All resident autopsies will be performed under the direct supervision of a staff pathologist.

2 IX. Overall Responsibilities: a. The resident on the autopsy pathology rotation is responsible for all medical autopsies performed during their rotation. If no medical autopsies are expected, the resident is required to participate in at least one forensic case per day. b. The resident is expected to save interesting cases for presentation at the monthly gross pathology conference. c. Regarding hospital autopsies, the resident must confirm proper consent and attempt to contact the ordering physician before beginning the autopsy. The resident should then conduct the autopsy examination with the assistance of an autopsy technician. This experience includes the study of the patient's chart as well as communications with staff pathologists, attending clinicians, hospital administration, morgue attendant, and whoever else is relevant to a particular case. All questions of uncertainty should be directed to the staff pathologist. d. Regarding forensic cases, the resident should elicit an appropriate case history prior to the start of the autopsy and to relay pertinent findings to the referring coroner at the completion of the case. e. The resident is responsible for following cases through to completion. This includes microscopic examination, laboratory results, ancillary studies, review of the literature, and clinicopathologic correlations. The resident is responsible for learning proper protocols and practice guidelines for performance of the autopsy. f. The resident is expected to complete a minimum of 50 autopsies (prosection, dictation, and microscopic interpretation). At least 25 of these cases should be adult non-medicolegal or natural forensic cases. g. Turnaround times: All cases should be completed as soon as possible and coordinated with the attending on service. Expected turnaround times (time from beginning the case until the final report is signed out by the attending) are currently 5 days for medical autopsies and 30 days for forensic autopsies. X. Daily Responsibilities: a. The first thing after any morning conference, the resident on service should report to the autopsy section to see what the caseload is for the day. The resident should begin to review the chart material and provide the staff pathologist with an overview of what the case will entail. Regarding medical cases, at least one clinician intimately involved with the patient's case should be contacted before the autopsy is begun in order to ensure specific clinical questions may be addressed. This communication/notification must be recorded in the report. The resident must confirm the autopsy consent and be aware of any limitations.

3 b. Gross conduction of the autopsy with procurement of specimens for analysis should be performed. c. The resident will review organs, tissues, and fluids procured for ancillary studies with the attending pathologist on service. d. Immediately after the case is finished the resident should prepare a preliminary anatomic diagnoses report (PAD) and notify the coroner (forensic cases) or requesting physician (medical cases) of the pertinent autopsy findings. e. A preliminary version of the full report should be dictated, or otherwise transcribed, by the end of the day before leaving work. f. If no further cases are pending the resident should use "free" time to review disease processes encountered during the autopsy and to consider the potential focus of a clinicopathological correlation. g. The resident should review microscopic sections as soon as the slides are processed in the histology laboratory and prepare a summary of the histological material. h. Arrangement for time with consulting pathologists who may need to be involved in the evaluation and completion of a case is the resident's responsibility upon discussion with the autopsy attending. i. If the brain is fixed at the time of autopsy, the resident should arrange with neuropathology to cut the brain within 1 ½ - 2 weeks after initial gross dissection. j. Resident Responsibilities for Nervous System Specimens on Autopsy Rotation i. Fix all brains and spinal cords with any clinical history of nervous system disease (particularly CNS; but consider peripheral nerve or muscle history also). ii. Muscle and nerve history requires muscle and nerve be saved (a portion of muscle must be frozen and portions of muscle and nerve saved in glutaraldehyde), and cross sections fixed in formalin. iii. Brains (and cords) fix for 7-14 days. iv. Brain cutting is once per week (presently Thursday at 2:30 PM). Your presence, with a clinical history and findings at general autopsy is required. v. Inform the neuropathologist in charge of brain cutting (Dr. Welsh) early in the week (preferably Monday because the Neurology and Neurosurgery teams want to know ahead of time if there is something of interest to them). vi. Let the autopsy technician know the day before to wash the brain and set up for brain cutting. vii. Acquire any scans that are relevant to brain cutting and bring to the session. k. Overall, the successful resident on the autopsy pathology rotation is one with a great deal of interest, initiative, efficiency and willingness to learn cooperatively.

4 XI. Readings and Pertinent Reference Material: a. General autopsy pathology 1. Introduction to Autopsy Technique, 2 nd ed. 2. Robbins Pathologic Basis of Disease, 7 th ed. 3. College of American Pathologist Autopsy Performance and Reporting, 2 nd ed. 4. Stocker and Dehner Pediatric Pathology, 2 nd ed. 5. Wigglesworth Perinatal Pathology b. Forensic pathology 1. Dolinak Forensic Pathology 2. Spitz and Fisher Medicolegal Investigation of Death 3. DiMaio Forensic Pathology, 2 nd ed. 4. Bernard Knight Forensic Pathology 5. College of American Pathologists Handbook of Forensic Pathology, 2 nd ed. c. Neuropathology References: 1. Anatomy: a)haines, Duane. Neuroanatomy, 5th Ed., LWW, Philadelphia, 2000 (Or other neuroanatomy atlas from your first year medical school course.) 2. Dementia: a) Hansen LA et al. Making the Diagnosis of Mixed and Non-Alzheimer's Dementias. Arch Pathol Lab Med 119: , b) Mirra SS et al. Making the Diagnosis of Alzheimer's Disease. Arch Pathol Lab Med 117: , General reference and histology: a) Love S, Greenfield's Neuropathology, 8th Ed, Oxford university press, XII. Goals: a. To be able to perform a complete autopsy or external examination and correctly assign the cause and manner of death as well as the underlying mechanism. b. To be able to correctly identify, interpret and document natural disease and injury due various types of trauma. c. Be able to correlate autopsy findings with clinical history and cause of death. d. To understand the effects of dangerous chemicals on the body with an emphasis on alcohol, illicit drugs and common drugs of abuse. e. To be able to correctly collect the appropriate fluids for toxicological analysis and other ancillary studies and interpret the analyses. f. To understand how the pathologist fits into the legal system during the investigation of death in a forensic case, and understand the impact and value of autopsy findings in hospital autopsy cases.

5 XIII. Specific Learning Objectives: a. To be aware of the historical, philosophical, political and economical considerations pertaining to the autopsy. (P, SBP) b. To be able to conduct a complete autopsy examination regardless of age or sex (including removal of brain and spinal cord). (PC) c. To develop integrative thinking and writing such that preliminary and final autopsy reports reflect an understanding of the relationship between function and structure.(mk) d. Be able to correlate clinical history with autopsy findings. (PC, MK, SBP) e. To master the technique of light microscopy insofar as examination of tissue sections, intelligent selection of appropriate "special" stains and electron microscopy, distinction between autopsy tissues and surgical tissues, and recognition of abnormality in tissues of patients of age extremes. (PC, MK) f. To communicate verbally both formally (at conference) and informally the significant aspects of autopsy cases in order to educate peers and stimulate medical students. (CS) g. To develop scientific literary skills by preparing significant cases for publication in scientific and medical journals. (PBL) h. Learn rules and regulations regarding autopsies: CAP, JCAHO, Federal, State, LifePoint, County, and University/Hospital (P, SBP) i. Interact smoothly with all personnel. Discuss the case with physicians and coroners prior to performing the autopsy and let them know findings immediately after (CS, P). j. Interact appropriately with family or others involved with the case. (CS, P) k. Use appropriate text and journal references. Include appropriate references in the report. (PBL) l. Individualize the autopsy during dissection and in the preparation of tissues and reports. (PC, MK) m. Neuropathology Learning Objectives i. Learn what sections are needed to rule in or out disease based on the patient's history. (MK, PC) ii. Review neuroanatomy before gross brain cutting. (MK) iii. Review normal histology (adult and pediatric- they are different) before microscopic examination of the brain. (MK) iv. Review the slides before bringing them to the neuropathologist to sign them out. (MK) v. Become proficient at sectioning of gross brain. (PC, MK) vi. Be able to identify gross CNS structures and decipher where in the brain a lesion is located. (MK, PC)

6 n. Minimum 50 Required Cases (prosection, dictation, microscopic) (MK, PC) i. At least 25 adult non-medicolegal or natural forensic cases. ii. The following types of autopsies (listed below) are highly recommended prior to the completion of the autopsy rotations. 1. Adult a. Neoplasia b. Sepsis/Meningitis c. Congestive Heart Failure, NOS d. Male Genitourinary Disease e. Pneumonia f. COPD g. Adult Respiratory Distress Syndrome h. Cirrhosis i. Dementia, NOS j. CVA/Intracranial hemorrhage with dissection of the Circle of Willis k. Myocarditis/Endocarditis l. ASCVD/Aortic Aneurysm/Aortic Dissection m. Pulmonary Embolism n. Transplant o. Autoimmune Disease p. Hypertensive Heart Disease with Nephrosclerosis q. Chronic Pyelonephritis/Papillary Necrosis r. Underlying Diabetes Mellitus 2. Pediatric a. Prematurity b. Congenital Heart Disease c. Chromosomal Abnormality, specific d. Congenital Malformation/Deformation e. Skeletal Abnormalities iii. All of the above objectives are to be sought in cooperation with the help of staff pathologists, pathologist's assistants, coroners, and clinical physicians. o. The resident will gain expertise in death certification by performing autopsies and/or investigations assigned to him/her in order to diagnose the cause and manner of death. (PC, MK) p. The resident will document the autopsy findings photographically and with diagrams as necessary. (PC) q. During the course of the post mortem examination, appropriate bodily fluids/tissues will be properly collected and submitted for toxicologic analysis and other ancillary studies. The results will then be interpreted in the context of the history and autopsy findings. (PC, MK)

7 r. The resident may be responsible for being the initial contact person for coroners/ law enforcement agencies and funeral homes referring cases to the forensic section (i.e. during the fellow s absence or at the fellow s discretion). (P, CS, SBP) s. The resident will attend lectures given by attending physicians, and may be asked to present topics to the autopsy section at conference. (MK) t. The resident will assist the fellow and pathologist assistant in keeping the autopsy room organized and properly stocked. (PC) u. The resident will complete cases timely and accurately. (P) XIV. Methods of Evaluation: a. Resident/Fellow performance evaluation form filled out by the attending staff on e-value. i. Patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, systems-based practice. b. Completion of autopsy proficiency check list i. Patient care and medical knowledge c. Practical performance of checklist procedures. The autopsy skill s proficiency checklist must be completed in the presence of an attending before the resident can successfully pass the rotation. i. Patient care and medical knowledge d. Autopsy Case Log Analysis i. Patient care and medical knowledge