The Beth Israel Deaconess Medical Center- Department of Pathology

THE AUTOPSY MANUAL

Revised and Adopted:

June 2003 / WCQ

October 2003 / JLH

June 2004 / JLH

June 2006 / JLH

Updated by:

Jonathan L. Hecht MD PhD; Jeffery Joseph MD, PhD; (Original version by Peter Ciano MD; William C. Quist MD PhD; Melissa Upton MD)

Phone/pager Numbers (75)4-XXXX, (63)2-XXXX, (66)7-XXXX, (outside page) 632-7243:

East Morgue 667-5783

West Morgue 632-9018

Jonathan Hecht, M.D., Ph.D. (Director) Beeper # 39030

Jeffery Joseph, M.D., Ph.D.(Neuropath.) Beeper # 35290

Autopsy secretary (Chris Sturdivant) 667-5759

Autopsy supervisor (Gail Howe) Beeper # 31426

Deiner (Emerson Springer) Beeper # 92588

Autopsy Check list: Autopsy # : A____-_________

Pt. Name:____________________MRN:_

The following things must be done prior to beginning an autopsy: Check off every box after it has been performed and sign below:

· Log in the case into the autopsy log under the next sequential number.

· Speak with an involved clinician and discuss the case. Write down the major questions for autopsy on the permit. Ask if any additional doctors need a copy of the report, and list them on your PAD.

· Go over the permission with attending (Is this an ME case? Do the organs have to be returned to the body? Who needs a copy of the report?)

· Go over the restrictions and major questions with attending

· Consult relevant staff (IS for medical renal, JJ for Neuro issues).

· Make extra copies of the following and take them with you to the autopsy suite

1. Permission form

2. Certificate of death

· Compare all of the deceased IDs with the permission form and certificate of death making sure they match before beginning the autopsy

· Return the signed original report of death and permit to Admitting, after you complete the autopsy.

I have performed the above:

_________________________________________________________

Name (Resident) date

Return this completed form along with copies of the permission form to Chris Sturdivant.

Return the chart to medical records when you have finished your review.

Basics:

1) Follow the above checklist (most items precede the dissection).

2) If you have any questions or complications before during or after the autopsy page your assigned attending, chief resident or director of autopsy. You should never feel like you’re working on your own.

3) Document findings in detail (the form on the next page may be helpful).

Photograph all abnormalities before they are sectioned/destroyed. Perinatal photographs are required on all cases (abnormal or not).

4) Start promptly; do not spend more than 30 minutes with the chart and getting hold of clinicians. The Deiner does not determine the start of the autopsy. If he is not available at the appointed time, report him to his supervisor (Gail Howe) and begin on your own.

5) Do not take chances with your safety, and call for back-up early if you get confused (there is no such thing as a 5 hr post).

6) Be prompt with your PAD/FAD. These documents must not be vague, but also must address clinical questions directly- describe what is seen and try to make conclusion in the final summary

Autopsy Service Coverage

1) Every day 8:00am - 3:00pm unless you make special arrangements.

Weekends 8:00am - 3:00pm. The weekend staff member on-call is responsible for any autopsy done on a weekend. They are responsible for supervising the dissection and signing out the PAD/FAD unless they make other arrangements. That attending is requested to attend or to send a representative to autopsy conference on the following Thursday

2) We accept outside cases if the patient has a BIDMC number and a contact clinician either here or at a nursing facility. Do not accept any other outside cases (i.e. death at home) without involving the autopsy director.

3) The deiner is usually available, but should not be the source of delay – if you need to eviscerate, do so (ask your chief or senior for help). If possible, arrange the autopsy start time with his supervisor (Gail Howe).

4) Talk to clinicians, not families (get your attending involved if this comes up)

Examination of the Autopsy Permission Form-

Do not accept a form from Admitting that lacks signature of family/next-of-kin, or the signature of the pronouncing physician. All cases of a medical-legal nature should be cleared by the Medical Examiner, who may accept or waive the case.

If you call the medical examiner, document the interaction on the report of death in the appropriate section of the Report of Death.

Be clear on restrictions. These may be specific and written in the “SPECIFIC RESTRICTIONS OR REQUESTS” section of the Permit or generic (check-boxes on form) in the “Disposition of organs” section of the Permit.

Division of Labor

1) The resident performs an external exam as the deiner is transferring the body to the table.

2) The deiner usually eviscerates, but the resident must supervise and verify his work (i.e. forgetting to take the prostate is the resident’s fault). The resident MUST be in the room during the entire autopsy.

3) The deiner cleans the autopsy room each week, but not after each case. You will be cleaning up your dissection area.

4) For West Campus cases, the deiner is expected to transport the organs to the East morgue within 24 hrs.

Associated conferences (Thursday 11AM Gross and monthly Gross-micro).

NAME:___________________________________________________ AUTOPSY#______________

Length/Height: Weight:

Hair (color/length):

Skin:

Eyes (pupils/color):

Ears:

Teeth:

Nose:

Genitals:

Extermities:

Personal Objects:

Brain wt (g)/findings:

NECK & THORAX ABDOMEN GI TRACT

Pleural: L(ml): R (ml): Peritoneal (ml): Esophagus:

Type of fluid: Type of fluid:

Adhesions: Adhesions:

Thyroid (g): Adrenals: L(g): R(g): Stomach:

Breasts: (contents):

Gallbladder:

(Contents(ml/stones)):

Liver (g):

(Parenchyma):

Trachea Small intestine:

Lungs: L(g): R(g):

Parenchyma: Spleen (g):

Bronchi: Pancreas:

Arteries: Kidneys: L(g): R(g):

Nodes: Cortex: Colon/rectum:

Medulla:

Ureters/bladder:

Prostate (size):

Pericardium (ml): Diverticula:

Adhesions/open:

Testes: L (g): R(g):

Heart (g):

Dominance (L/R):

Walls (cm): LV: RV: Uterus & Cervix: Appendix:

Valves: TV: MV: Tubes:

Ovaries: L:

PV: AV: R:

Atherosclerosis:

Systemic: BABIES (cm)

Coronary(%): CR: CH:

RT:

Lt. Main: Foot:

LAD:

Circ: Head circum:

Lymph nodes: Cord:

Muscle/skeletal:

TABLE OF CONTENTS PAGE

1. Introduction 6

2. Autopsy Service Coverage 7

3. Preparation for the Autopsy- Review of Permit and Restrictions 7

4. Safe Performance of Autopsies and Handling of Tissues and Formalin 10

5. Infection Control Guidelines 11

6. Autopsy Room: General Overview and Division of Labor 13

7. Autopsies on Patients Who Die Outside the Beth Israel Deaconess Medical Center 14

8. Medical Examiner’s Cases 15

9. Ancillary Studies 17

10. Organ Donation 21

11. The Complete Adult Autopsy- detailed procedure 21

11a. Cardiac Exam 23

12. Stock Bottle & sections. 29

13. Autopsy Neuropathology 29

14. Recording the Cause of Death 32

15. Reviewing the Case with Staff pathologist, Sectioning, and Photography 33

16. Preparation of Autopsy Documents 34

17. Communication of Autopsy Findings 34

18. Infectious Autopsy 36

19. Severe Acute Respiratory Syndrome (SARS) Patients 39

20. Fetal/Neonatal Autopsy 41

20. Autopsy Conferences 53

21. Observers 53

22. Requests for Tissues for Research Purposes 53

23. Quality assurance 53

24. Templates (adult and fetal) 46

25. Appendices

Introduction

This manual outlines the procedures and regulations pertaining to the various aspects of the Autopsy Service. While the manual is not meant to be exhaustive, it addresses most of the specific issues that relate to the autopsy. We have delineated in detail the entire autopsy process from the reception of the postmortem permission to completion of the final autopsy report. Questions not specifically answered by this manual may be addressed to the Chief Resident(s), the Staff pathologist responsible for that case, or the Directors of the Autopsy Service, as indicated by the particular problem. This manual will be amended or updated as needed. Your suggestions/comments are welcomed.

The Autopsy Service performs ~150 postmortem examinations per year (representing ~20% of the deaths at the Hospital). The autopsy at this institution ranges from unrestricted cases in which all the internal organs, including the brain and spinal cord, are examined and removed, to autopsies limited by specific restrictions delineated in the autopsy permission. The majority of our cases are complete adult examinations. A percentage are fetal/neonatal or restricted cases.

In addition to their value in epidemiologic studies, detecting or elucidating previously unknown disease processes or complications of therapy, providing a basis for reassurance or genetic counseling of the patient's family, and provision of materials for research purposes, the autopsy represents a critical mechanism for assessing the accuracy of clinical diagnosis and quality of care (reviewed in Cameron et al., Br Med J 281:955, 1980; Goldman et al., N Engl J Med 308:1000, 1983; Landefeld et al., N Engl J Med 318:1249, 1988). Indeed, a large number of well-performed studies indicate that 1) roughly 25% (at a minimum) of autopsies reveal important diagnoses not detected before the patient's death and which, if detected clinically, probably would have resulted in a change in treatment which might have cured the patient or prolonged his/her survival, and 2) physicians are unable to predict which autopsies are most likely to reveal clinically unsuspected, important new findings. As a result, it is the position of both this Department and the Hospital Administration that every attempt should be made to secure autopsies on every patient dying at the Beth Israel Deaconess Medical Center. Quite clearly, the value of the autopsy is greatest when it is performed properly and the results of the examination are communicated to the patient's physician effectively and promptly.

Autopsy Service Coverage

Postmortem examinations are performed seven days per week between the hours of 8:00am and 3:00pm. Limited autopsies (brain only) may be started later since. The cases are performed by pathology residents, assisted by a Deiner (Emerson Springer), under the supervision of a staff pathologist. A pathology resident and staff pathologist are on-call at all times to deal with questions and problems that relate to autopsy pathology. On rare occasions, families or physicians will request an autopsy to be done after usual working hours. In virtually all instances, a postmortem examination can wait until the next morning, but exceptional cases are those in which the funeral home may need the body the evening of the patient's death or in which prompt dissection is needed for specialized studies (e.g., viral cultures, electron microscopy). Dr. Hecht or Dr. Connolly must approve delays/after-hour posts. The resident should contact the autopsy supervisor (Gail Howe) to determine if an autopsy assistant is available; however, the resident may be required to perform the autopsy without the autopsy assistant.

Preparation for the Autopsy

A. Protocol for Autopsies –

1. EAST and WEST CAMPUS (Resident assignments are to one/either or both)

a) Admitting should contact the resident regarding autopsies through the AP administrator or directly (weekends), but it would be prudent for the resident to call or walk to the admitting department to see if there are any autopsies pending (754-2212)

b) At the Admitting Department:

Pick up the Report of Death Form and expiration worksheet

Pick up the charts, if available, or check with the floor or with medical records

c) Make sure that the Report of Death Form is properly filled out and that the right hierarchy of consent was used in giving the permission for the autopsy.

Spouse -> ALL children or designated representative child -> BOTH parents or designated representative parent -> other relative or caretaker with a statement of their relationship to the deceased

d) RESTRICTIONS (specified on the permit):

Two sections of the permit pertain to restrictions on pathology.

1) “SPECIFIC RESTRICTIONS OR REQUESTS”: These are specific prohibitions regarding dissection (i.e. No head, chest only, etc).

2) “DISPOSITION OF ORGANS FOLLOWING AUTOPSY” (section is reproduced below):

These are directions on how the organs are to be treated once they are removed.

a) In section one, if the family chooses the second box (“I do not authorize…”), the organs must be returned with the body in a bag within the abdominal cavity.

1. The case will not be presented at Gross conference.

2. The brain should be cut in the fresh state with guidance as needed by a neuropathologist.

3. The organs are reviewed in the fresh state by the attending before they are returned to the body. Histologic sections should be taken liberally (more than the usual 7 cassettes) at the discretions of the attending.

4. You may keep small chunks of organs if their fixation will add value (i.e. a bowel lesion may be kept/fixed with an associated short segment, heart values with vegetations may be detached for fixation and later sectioning), but this privilege should not be abused to accommodate an attending who wishes to view the organs on the next day. The vast majority of each organ must be returned.

b) In section one, if the family chooses the first box (“I authorize…”) then a statement of which organs have been kept for fixation must be included in the PAD/FAD. That line is part of the proscribed template (included at the end of this manual).

c) In section 3, if the family chooses the second box (“I do not authorize…”) then organs cannot be permanently donated to the medical school for teaching. The resident must notify neuropathology that the brain cannot be donated to Harvard Medical School.

§ This permission covers the removal of internal organs and tissues as may be deemed necessary by the examining physician for analyzing disease processes and determining the cause of death except as specified above by the person authorizing the autopsy. It is understood that due care will be taken to avoid disfiguring the body.

§ The person authorizing the autopsy has the right to control the final disposition of the organs. Beth Israel Deaconess Medical Center will return all organs with the body of the decedent at the time the body is released, except for those organs for which prolonged fixation or complete detailed examination is required in order to complete the autopsy, unless the authorizing person designates an alternative disposition below.

§ The organs retained for detailed examination will be specified in the final autopsy report. The results of the autopsy will be available from the deceased’s physician in approximately 8 weeks.

1) Disposition of organs (choose one):

I authorize Beth Israel Deaconess Medical Center to retain any organs for further examination to determine the cause of death or understand the effects of therapy.

I do not authorize Beth Israel Deaconess Medical Center to retain any organs. All organs will be returned with the body for burial and a limited report of the findings will be issued to the deceased’s physician. Skip items 2 & 3 below.

2) Disposal of tissue and organs. Tissues and organs taken at autopsy must be disposed of in a lawful way. The person authorizing the autopsy may arrange for disposal or the Medical Center will dispose of the organs. (choose one):

The Beth Israel Deaconess Medical Center- Department of Pathology

Pt. Name:____________________________________MRN:_________________

Autopsy Service Coverage

TABLE OF CONTENTS PAGE

Introduction

Autopsy Service Coverage

Preparation for the Autopsy

Pt. Name:____________________MRN:_