Sunday, 29 January 2012

Post Mortems and maggots


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.

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