Post Mortems and maggots

Hi,



The most exciting thing that I did this week was visiting a mortuary and observing a number of post mortems. This was quite a graphic experience, and explanations are also graphic, so only read if you are happy with this! Post mortems are carried out on people who have either a suspicious cause of death where someone may be to blame (for example, after a surgery or in a possible murder case) or with an unknown cause of death, such as someone who is found dead at home, having not seen a doctor for some time. The post-mortems I saw varied from someone who has been dead for weeks and has started decomposing (maggots and all) to a patient who died on the operating table and still had all the tubes and devices stuck into his body. Later on in the week, I go on my GP placement again, and see a variety of family-planning-based procedures (my GP's speciality), and chat for an hour and a half with a really nice gent who has prostate cancer.


The mortuary visit happened on Monday, so there were a number of bodies needing a post mortem that had been 'stored up' over the weekend, as post mortems here are not carried out on Saturday or Sunday. The location was an innocent-enough looking building, but once I had gone inside, 'scrubbed up' into my blue scrubs and stepped into the room, it all became very strange. There were four tables with dead people lying on them, completely naked, and the walls and floor looked like a tiled public toilet (as I soon found, to make it easy to have all the blood and mess washed off). I was working with a pathologist, who explained what was going to happen but, to be honest, I wasn't really listening too much. I was overcome by the thick smell in the place, which pervaded wherever you were in the room. This was coming from all of the bodies to a degree, but mainly the partly decomposed body in one corner.

The patients are all identified by a tag, as in the movies, so you know that you are cutting up the right one!

The doctor who was carrying out the post mortems left to read up the case files for the patients we would be dissecting today. Only they are not called patients today, something I found very hard to get used to. They are simply just called 'dead' now, which makes sense seeing as they are no longer being treated. So while she was reading up the case notes for the dead, the mortuary technicians (who are people with nurse training) started to prepare the bodies. The one body which had died on the operating table was left, as it needed to be examined with all the medical devices in situ, but the other bodies were 'opened up' by the mortuary  technicians   for the doctor to examine.


This rather gruesome process involved the head being cut open across the back of the scalp from ear to ear, and the scalp being pealed forwards off of the skull, so ot flapped over the face. This meant that the skull underneath could be cut open with an angle grinder, and the brain removed and put into a bag. The skull was then put back on, leaving the head empty and scalp was re-attached and sewn back, so from the front (if using an open coffin) the person would still appear normal, though their brain had been removed. The chest is then opened up from the top to bottom with one long cut, and all of the organs removed, from the tongue down and put into the bag with the brain. The chest will be closed up at the end with all of the organs (including the brain) packed into it. While in a higgledy piggledy way, this means they look normal, again, so they can have an open coffin.


After these have been removed, the technicians job is done, and the pathologist can take over. The organs are cut apart one by one looking for any abnormalities or injuries which may have occurred to them, leading to the death of the person. The body is examined for any signs or injuries, and the organs are weighed. You can tell a lot of an organ is massively over or underweight, for example, a heart in heart failure could be very heavy compared to a normal heart. This was a great learning chance for me, as previously I have only worked on dissecting bodies in the dissection lab, which have been preserved with formaldehyde to last for a year, and hence have unusual textures and colours. These were (mostly) pretty fresh! I got the chance to help out by cutting some of the organs into slices and helping search for the expected problems with them that would have caused death. Cutting into the bowel and stomach was the worst part. These start decomposing first, because of the acidic conditions and all of the bacteria in them, and still have the remains of the patients last meal in them which need to be drained, along with a lot of gas. Needless to say, the smell, which still hadn't died away like most smells do, was still here in force.


There were a number of patients on who the post mortems were carried out on. There was a gentleman who had died in his sleep, and been found dead by his wife. Because of his history of  heart disease and a triple bypass 10 years ago, it was presumed he had had a heart attack while asleep, and that was the organ that the search was focussed on, though all of the other organs needed to be checked (what if he had had a massive stroke, or had a cancer that hadn't been diagnosed...) This man was difficult, because the previous chest surgery meant that he had lots of adhesions and metal clips in his chest to navigate through, though the heart arteries (even the new ones) were very clogged up, suggesting a cause of death.


It worth saying that, even at this point, this is still really strange for me. I am in a room cutting into organs on a table next to a body which has had all the organs removed and has a big gaping hole in its chest and abdomen. The tongue downwards has been removed to bring the windpipe out, and there is just a huge hole there. Other than this, with the scalp back on (this is for the best, the scalps-peeled-over-face look is really creepy) the person looks as though they are asleep. None of the strange colour or texture of the skin as with dissection, and while you are at this table, there are a number of other naked, opened bodies around the room. It almost feels like a horror film scene. And the smell, pervasive to start with, gets quickly worse after the bowels and bladders are cut into.


I see other patients dissected, including the patient who died during surgery to the heart, who still has all of the tubes and medical devices in situ. The worst patient (no, 'dead', sorry) who I see is a patient who had psychiatric conditions, and just liked to live by himself in what was described as a 'filthy flat' by those who picked him up after he had been certified as dead. After not seeing him for a few weeks his neighbours called the police, who visited and then found him to be dead. He was decomposing, meaning there was little point in taking him to the hospital. The position of the body and state of the flat suggested a fall and a death, but this needed to be confirmed by the post mortem. The less said about this man the better really, as writing about him makes me feel a little queasy. The organs were black and mushy because of the decay, there were maggots all over the place which were eating the flesh, and the smell was awful. I couldn't deal with it and had to stand a few paces back for the second half when the stomach and bowels were opened up. Poor chap.


Despite all of this, I had a great experience in the mortuary, and learnt a lot about different stages of the body after death and lots about organs and how they look and feel when 'natural' (but not from the decomposed person, obviously!) I was told about other students who have thrown up in the post-mortem room, and run out, but this is no surprise after what I saw and smelt! I also heard about some of the more interesting people who have been seen there. The man who died of a perforated peptic ulcer (=hole in stomach) and had his body cavities full of sweetcorn from his last meal, seemingly in places it definitely shouldn't be. There was also the person whose stomach and bowel were full of metal objects, from car keys to cuff links, which they had eaten for some bizarre reason (though perhaps it was because of pica)

A mirena coil, the gynaecologists favourite contraceptive.

As well as this main experience in the mortuary, I did other things in the week (obviously), the main one being the time I spent with the GP on my placement. My GP has a gynae specialism, and so carries out some minor family planning procedures in the surgeries. Today I saw a mirena coil removed from a 30 year old woman so she could have children, and a contraceptive implant removed from a 14 year old girl's arm who was having irregular periods with it and didn't like it. Interestingly, she had come to the GP surgery with her grand mother, as she felt she could share this sort of information a lot more easily with her than with her mum, who she didn't feel happy discussing this with. This is not something that seems rare, from what I have seen, and I wonder if people feel it easier to discuss sex with their less immediate relatives, as they feel they will be treated as less of a child by them as they haven't grown up with them, I don't know... Perhaps this would be an interesting sociological study, as it seems to happen much more commonly than I would have thought.

Ward work and Hitler

Hi,

A relatively calm week, compared to the busy time I had last week with all those early mornings, which is a nice break. I still spend some time on the wards, after I enjoyed it so much last week, as other than a Parkinson's disease clinic I have no time tabled clinical sessions, just lectures. I am not sure about the timetable for this rotation; it seems to vary massively between weeks, sometimes meaning you have plenty of early mornings (last week), other times (like this week) with a few lectures dotted around and little else. I have a presentation to do next week, and other out-of-uni commitments, so it is quite nice for me to have some control over my week and when I can go in and when I don't.

In general, neurology is a very 'post-graduate' type of subject. A lot of the things we are learning or seeing we will not be expected to do (or even necessarily know) as junior doctors, and wouldn't be expected to be doing unless we were specialising in neurology after completing our degree, and working as a doctor. While a lot of neurology is very interesting, with the strange symptoms and signs people can have (the brain is pretty damn complicated), it is also very complex. It does often feel as though a lot of the things we are learning we will never have to apply at all. Will I ever have to interpret an EEG to diagnose absence seizures? I very much doubt it, unless I am a neurologist, and in which case, I will need to be taught again as I will have forgotten by then. I suppose you do learn a lot of things you may never need to know again in medical school - though it is a lot more pronounced in the first few years with all of the microbiology that you learn!


I had a great day on the wards on Tuesday, where I just spent the day with the neurosurgery ward team helping with their ward work. The patient I saw last week who had the cranioplasty (skull reconstruction) is doing very well, and I am told that he could well improve faster now this construction has given his brain more space. I spend a full day examining people before operations, helping out with notes and clerking and other day to day activities. The neurosurgery ward is run by more junior doctors most of the time, as the more experienced registrars and consultants spend their days in surgery instead. I really enjoy working on the wards, which is a fantastic sign, as after I graduate, this is where I will be working for a few years at the very least!


The single timetabled slot I had this week was a Parkinson's clinic, where I was with a specialist nurse seeing patients with Parkinson's disease. I had come across specialist nurses before (for example a heart failure specialist nurse) and had been very impressed with them. This time was no different at all, and he clearly knew exactly what he was talking about. By managing a case load of patients, it means they get better treatment than if the GP was managing their Parkinson's (much more experience), and possibly better treatment than a neurologist because of the specialist knowledge of the nurse, though this is debatable. It is certainly cheaper for the NHS, though, which I am sure factors into it. As well as talking to and examining some lovely people with Parkinson's, I got a good amount of teaching. A lot of it was the pretty standard stuff about the difference between Idiopathic Parkinson's and Vascular Parkinson's, which is fantastic for me to learn, but some of the things I learnt were not entirely medical, but none the less interesting.


For one, I was told about 'Parkinson's trait' where people show traits in life which may make them more likely to get Parkinson's. The nurse was saying that many of the people who come in with Parkinson's have been very obsessive people, who have then developed Parkinson's disease. By obsessive, he means people who tend to focus on one aspect of life obsessively, such as model making or train spotting, and focus on this to the exclusion of other things. While (obviously) most 'obsessive' people do not develop Parkinson's later in life, it is very interesting to see that many of the people who do develop it have this 'personality type'. The nurse said that many of the patients who he sees have had mathsy / physicist / engineer type jobs, where its quite possible that being obsessive about small things can be beneficial. I don't know if it is some kind of genetic defect, predisposing people to Parkinson's later in life and making them obsessive early in life, or if it is the act of thinking about a few things obsessively (or gambling obsessively) which over stimulates neurones and can lead to Parkinson's, but it is a very interesting theory.

A video, watch until about 10 seconds in to see Hitler's Parkinsonian-like tremor in one hand behind his back, perhaps explaining why he usually had this hand behind his back or in a pocket.

The other thing I learnt, which I didn't know but probably should have, was that it is assumed that Hitler was developing Parkinson's towards the end of the war. The video above is 'real' footage of Hitler, and you can see up to about ten seconds in that he has a tremor, like that seen in Parkinson's, in his left hand which he keeps behind his back. Supposedly most of the footage showing these tremors was destroyed by the Germans, but some film (such as this Russian film) remains. Back then he would have been treated with anticholinergics. The nurse was telling me (and I don't know how much truth there is in this) that because of Hitler's Parkinson's disease, and the neurological problems it caused (thus ruining his leadership of the German army and nation) this was a reason that the Allies didn't attempt to assassinate him towards the end of the war, and possibly a reason why the Germans made an attempt on his life. Very interesting stuff, but probably more for historians than medical students! 

Half a head

Hi,


A very productive week this week, spending my time on a neurosurgery placement. I got to see a number of surgeries, which were the highlight of the week really, and spent the rest of the time on the wards and in clinics. A much busier week than many of my previous weeks, which was something I really enjoyed. It reminded me a lot of my third year, with all of the contact time with the patients and doctors, and helping out on the ward, the way I am sure I learn best. The surgeries I saw varied from operations to the spine, to operations on the brain and skull, and lasted for hours and hours each. I was a little disappointed that they were not more complicated, though. I was expecting 'Neurosurgery' to be very complex (everyone assumes it is) but really it just seemed very similar to the rest of the surgeries I have seen. Perhaps rocket science is equally as over-rated.

Before I get into my post, though, I would like to thank the people who run medical-artist.com who, in compiling a list of who they think the top medical student blogs are this year, were kind enough to put mine at the top. I am touched that they thought it was that worthwhile-a-read, and its always good to know what you are writing is appreciated. 


Getting back to my week, saying all I did about neurosurgery not being as complicated as I expected, it doesn't mean that I didn't enjoy the operations, or the time I spent in the theatre. I spent half a day in theatre on Monday and a whole day on Wednesday. When I say I spent a whole day, this means the surgical list running from 9AM to 7PM. While the surgeons may be seen as the 'jocks' of the medical world, they sure do seem to work hard! I was with another medical student for both of these sessions, and we were not allowed to 'scrub in' as we have done for other operations previously, letting us hold things for the surgeon and generally help out. This is probably due to the increased risk of infection, and the fact that most of the operations are done down a sort of microscope, meaning the surgeon could look at the minute anatomy more easily down the eye pieces, but there is no room for medial-student-help. The operations were shown up on a screen, making it easy to see what the surgeon could see, but also giving you the feeling that you could just be watching something similar on youtube at home...


Despite all of the time I spent in surgery, I only saw three and a half operations, as they tend to take a long time. On Monday, there was one operation all day for one complicated case, a patient with a meningioma (a type of brain tumour), which was in the posterior fossa of the brain where the cerebellum sits. A complicated operation where part of the skull needs to be removed, and the tumour searched for in the brain meant that this would take a whole day. Unfortunately I was only scheduled in for the afternoon, having lectures in the morning that I couldn't miss. This did mean that I missed the portion of skull being removed, which could have been interesting, but I did get to see the removal of the tumour and everything being put back on again. Seeing the surgeon search for the cranial nerves so they didn't get accidentally cut reminded me why my anatomy was so important, and I regret the fact that I have forgotten so much of the anatomy I had to learn in my first and second years! Interestingly, if the skull cannot be put back immediately (for example, because they think that there will be inflammation in the brain, which will cause it to swell and they don't want it to swell up inside the closed skull causing injury) the part of the skull cannot be kept and given back to the patient at a later date as it used to be. Because bone is a structural material, they used to be able to remove it, sterilise it and give it back at a later date. Laws relating to the use of human tissues mean that this is no longer possible, and instead the skull always needs to be kept with the patient. This means the portion of the skull is kept inside the abdomen along side your guts, where the patient carries it inside them until it needs to be put back (when the inflammation has gone down). The skull can shrink slightly because of the body's macrophages (immune cells) having a little munch on the edges, meaning if it is left in there for some time it can become too small for the original gap, but this is a very interesting concept! 


As I said before, my part in the neurosurgery involves standing by the edge and watching what happens. On Monday this involved standing up from 12 'il 6.30 straight, which seemed like a long time, but on Wednesday I was standing from 9 'til 7, though I did get small breaks as they switched the patients around. Working for this long means you have to be tough to be a surgeon, but at least they and the anaesthetist get to sit down as they work. I feel sorry for people like the scrub nurse who have to stand for the whole day! On Wednesday the three operations I saw were the changing around of a spinal cord stimulator, the removal of a pituitary tumour via a transsphenoidal route (via the nose) and the replacement of most of someone's skull which had been removed in a traumatic accident. A long day, which I shared with my fellow medical student and an osteopath who was a friend of the surgeon and had come to watch and learn.


The spinal chord stimulator replacement surgery was pretty simple and only took a few hours. Because there was already one in place, this was more about replacement of the unit which had run out of batteries for a new one. This machine is inside the body, and has a small battery with wires in the spine. The patient is given a remote with which they can control how much voltage is put into their spine. Rather than being the terrifyingly painful experience I would imagine it to be, supposedly it is a great pain killer for chronic pain, working by blocking the pain signals going up the spinal chord. 


After this surgery was the surgery for a woman who had been diagnosed with a pituitary tumour. The pituitary gland is a small gland in the brain which controls most of the bodies hormones. Tumours here are usually benign, but they can cause the secretion of many hormones, or interfere with vision as the nerves from the eyes run next to the pituitary gland, and if it gets enlarged it can interfere with these. This surgery is done via the nose, using a similar method to that the Egyptians used to remove the brains from the skull before mummifying their ancestors. This is because the pituitary gland is right behind the nose, and going in this way means you do not need to go through brain, though it does mean that the entire operation is done while looking down one of the nostril! Impressive that this can be done, but it did involve watching a screen for ages as the surgeon fiddled around in the nose. A little more interesting than my experiences of TURPs previously, but only just.

Transsphenoidal surgery route - pretty clever huh! An approach favoured by Harvey Cushing, whose name has become associated with a number of medical syndromes and diseases

The best surgery of the day, and the reason I stayed 'til the end with only a cheese and pickle sandwich keeping me going was the man who had had a serious head injury in April and was having his skull reconstructed. Back in April, he had been hit in the head by a large part of a car while at work, which was travelling at about 70 miles an hour. This had crushed half of his skull, and on admission to hospital he was not expected to survive. Fortunately, with some dramatic surgery, he had recovered and had been living in a rehabilitation home until now. His skull had not been put back on at the time, hough, because of all the inflammation, and because of the large loss of one of his cerebral hemispheres (half of his brain) his head was a very strange shape, missing about a quarter of the top part of his head. It had skin over it, which was growing hair, but he looked distincly different, and wanted to go back to looking more normal, which was the purpose of the operation. A metal plate had been constructed to fit the shape of the skull, and this was going to be screwed in.


I saw him the day before when I was on the ward, to clerk him before the surgery, and was surprised with how well he seemed. Obviously, for someone who was missing half of their brain, he was not perfectly healthy, but other than slow slurred speech, and slight confusion when I asked him to carry out slightly more complex tasks. On physical examination, his body was neurologically normal other than brisk (increased) reflexes across the body. Amazing the sort of injuries the brain can deal with and bounce back - a very plastic organ! Either way, I build up a good rapport with him on this day, and I felt that he really appreciated my presence in the operating theatre before his anaesthetic (he was understandably nervous). As someone who had been a helicopter pilot on the army about a decade ago, this injury had clearly changed his life hugely, but he seemed so determined to do as well as he could. It really puts my problems in perspective! Either way, the surgery went well, the highlight being when the surgeon noticed the surgery lights shining on the plate he was about to insert cast lots of glittery reflections around the walls. He ordered the main lights to be turned off and created a disco... This may seem a little insensitive, but a nice break after hours of painstaking dissection around the edges of the remaining skull. The fact that I really enjoyed talking to the patient about his story (and the theatre-disco) and didn't really care so much about the surgery reiterates to me that I don't think surgery is the sort of speciality for me. It is clever and technical, but so is being a car mechanic.