Lessons from an Autopsy (Warning: Graphic)

by LovingNurse 17,954 Views | 25 Comments

  1. 148
    What, other than an A&P review, can a nurse gain from attending an autopsy? I wondered. This was certainly not my first post-mortem experience, but it was my first autopsy. I pretty much knew what to expect as far as the autopsy process, so I felt prepared for the format I would see. I did not know what type of case I’d be seeing and just hoped it wouldn’t be something that “hit too close to home” in my personal life. I knew my interest was a clinical one, but I also refused to allow myself to forget that my “educational experience” was also some family’s horribly sad loss.

    The case was a 30 year old woman who was 2-weeks s/p excision of a suspicious lesion of her right great toe. While at home, she had a sudden onset of severe dyspnea and a witnessed collapse. Emergency crew was unable to resuscitate her. She had a reported history of calf tenderness x 3 days... so this was a suspected P.E.

    First was the external body exam, belongings inventory, and photographs. Her ECG leads were still in place, as were the defibrillator pads and a surgical shoe on the post-op foot. Toxicology samples were obtained from the vitreous humor of each eye (which I chose not to witness) and blood from a femoral artery. Apparently the vitreous humor provides a more accurate toxicology sample than does blood.

    The autopsy technician did much more than I had expected. He did all the prep work, opened the skull, chest, removed the brain & many of the organs for exam, etc. The forensic pathologist was on one side of the table and the technician on the other. They had very clear tasks and worked in tandem so quickly and methodically, that I literally couldn’t watch both at once.

    Intestines were tied off and removed, then each major organ was weighed, examined and sectioned. Tissues samples were taken. In the middle of all the (wet) tasks the technician was performing, he also jotted pertinent info down on a white slate with a grease type pencil.

    In the process of removing the brain, the scalp had been pulled forward & down, covering the woman’s face. This was actually helpful to me. Not seeing her face helped me focus on the clinical task at hand; determining what robbed this young woman of her life. When her face was exposed, my thoughts often veered toward the emotional aspects of the situation…Thinking about what her poor family must be going through, someone’s wife, mother, daughter. I pondered what a gift life is, and how she was probably frightened about the malignant skin lesion, but never thought surgery on her toe would lead to her death… How different a day makes in the life of many people. How just 17 hrs ago she was very much alive….How sudden her death was…No time for “I love you,” kisses, or goodbyes.

    I felt a sense of validation and thankfulness about how my own family has a firm habit of giving kisses and saying “I love you” when we part each morning; for we truly never know when we will have shared our last opportunity to do so.

    My thoughts drifted back to clinical thinking… How long did that calf hurt? Did she seek medical attention for it? The small incision was on the side of her toe…was it painful enough to immobilize her that much? Did she have an underlying clotting disorder? Was she on birth control pills or anything else that put her at increased risk for clots? Etc… etc…

    The autopsy was a speedy process. Each organ was fascinating. The form and function of our anatomy is something that will never cease to amaze me.

    Most of her lung tissue was dark black. The pathologist was not surprised when he opened the pulmonary vasculature and found a very large (and very long) “saddle embolus” straddling the two main pulmonary branches. Smaller emboli were found within each lung. Only a very small corner of lung tissue had retained the normal appearance of healthy lung.

    Lastly, they turned the body prone and dissected the calf, where they found remnants of a long DVT still in place. After all tissue samples were prepared, the calf was sutured. The biohazard bag (containing her organs) was placed inside the chest cavity and the chest was closed. Skull closed. (< All by the technician.) I went with the pathologist to his office to listen to him dictate his report.

    I left, not just with sadness for this woman and her family, but also with a huge amount of respect for what I’d just witnessed and gratitude for the lesson I learned through her tragic death. I’ve had patients with DVT and family with DVT, and have long been aware of the risks and need for prevention and/or intervention. Seeing her PE first-hand turned all the risks into images of sad reality. I have her face to put with the risk and diagnosis now. I know this will increase my vigilance when I care for my patients. I will not forget her. I will think of her when I encourage ambulation, apply SCD’s and TED hose, give Lovenox, and check for Homan’s sign. I will think of her when I educate my patients on risk factors and prevention, being extra sure they demonstrate understanding of the warning signs and need for prompt medical attention.
    I have grown from her tragedy.
    Last edit by LovingNurse on Apr 9, '08
    CaliLvr000, koreaabc92, webbiedebbie, and 145 others like this.
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    LovingNurse joined Sep '06 - from 'Right Here :)'. Posts: 211 Likes: 329; Learn more about LovingNurse by visiting their allnursesPage


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    25 Comments so far...

  4. 2
    Thanks for reminding us how important the everyday, "small" stuff is. It's so easy to overlooks these things during a busy shift...
    SakredStrega and LovingNurse like this.
  5. 1
    Great Article! Thanks for sharing your experience with us all.
    LovingNurse likes this.
  6. 1
    I felt like I was there with you and the knowledge you gained and shared will help me teach my patients, too. You are a great writer!
    LovingNurse likes this.
  7. 2
    Quote from LovingNurse
    .. it was my first autopsy...
    The case was a 30 year old woman who was 2-weeks s/p excision of melanoma of her right great toe.
    While at home, she had a sudden onset of severe dyspnea and a witnessed collapse. Emergency crew was unable to resuscitate her. She had a reported history of calf tenderness x 3 days... so this was a suspected P.E. ...
    You described this situation very well!

    I was impressed by the number of clots and size of them! Would there usually be that many (I'm thinking out loud)? Would this happen if PT/PTT etc were monitored and treated? Or did they not know about the calf tenderness til after the fact? What a tragedy...

    6 months after I graduated I had a pt in the ICU (I was floating). A man in his 40's or 50's, he died suddenly and we were unable to revive him (I forget the original DX - maybe an MI). It all happened so fast! I felt like I "should have" known earlier or been able to head this off before he died - so I went to the autopsy, even tho the other nurses said there was nothing I could have done differently. The guy had indeed thrown an embolus and that was the cause of death.

    Two years ago I was experiencing some chest pain that was "different" from what I'd had as a result of anxiety, so I was sent to the ER and after a CT was told I had a pulmonary embolus. I FREAKED! And the wait for a room seemed forever ... finally, the chief resident came by and said that the other resident had been mistaken, that it was "only" early airway disease. Made me want to say, well, ONE of you guys is mistaken - I hope it IS the other guy ... scary...

    Thank you
    RN BSN 2009 and LovingNurse like this.
  8. 1
    Beautifully written, compassionately described...........what a gift you have, LovingNurse. I hope someday that if I should need care, a nurse like you will be there for me.
    LovingNurse likes this.
  9. 4
    Thank you for the kind words, folks :heartbeat... I wasn't sure if I should really even submit this or not. If it helps anyone out there, nurse or patient, then I guess that's something good that can come from something very sad. :redpinkhe

    I was impressed by the number of clots and size of them! Would there usually be that many (I'm thinking out loud)? Would this happen if PT/PTT etc were monitored and treated? Or did they not know about the calf tenderness til after the fact? What a tragedy...
    Zoeboboey... Glad you were okay! You have some of the same questions I did/do - but the history was quite limited. I can add that there was not an obvious difference in her calf size like I would've expected to see. The ankles looked the same, the DVT calf was only 1 cm larger than the other. When they dissected the calf, there was black clot way up the length of the vein... so the embolus was l-o-n-g.The pathologist did not finish dissecting it up into the thigh to see the entire length; he just needed to confirm the origin.

    I had the impression there were little pieces that broke off first, then a huge piece that got stuck in the bifurcation of the pulmonary artery. Sorry to be so graphic, but the huge clot looked like a long, giant leech that straddled (the "saddle") the split....half blocking blood flow to the right lung, the other half blocking blood flow to the left lung. - No matter how much air was moved into her lungs, there was no blood supply getting through to the lung tissue, - so they couldn't exchange gases at all.
    No wonder these poor folks get the feeling of impending doom. How awful.
    koreaabc92, Annie09, Drysolong, and 1 other like this.
  10. 1
    LovingNurse - no no, your description was PERFECT for helping me to picture it!! That poor woman ...
    LovingNurse likes this.
  11. 1
    Excellent post! I applaud you for your thoughtfulness noting that it was not just an autopsy but also the loss of a human life.
    Your post was insightful and very well stated!

    Brenda
    LovingNurse likes this.
  12. 1
    Thank you for a very sensitive article. I won't forget it.

    I'll be graduating in May, and you may be interested to know that I have been taught never to check for Homan's sign, because the action involved can break loose a clot if there is, indeed, one forming. Rather, we are instructed to palpate the calves gently for tenderness and heat. I haven't read the recent literature on this, so I can't cite any findings to support the (new) practice, but it definitely is what my school is teaching.

    Thanks again for this interesting piece!
    LovingNurse likes this.


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