Category Archives: Blog

Museum Anatomic Gifts in 2015

Canopic Jars Egyptian Canopic Jars for holding organs during mummification

Many families look for ways to make use of their own or their loved one’s body after death in some positive, socially beneficial way. Common options include whole body donation for medical school education and organ and tissue donation to help the living. We accept use of the body to teach the healers and heal the sick. But what of teaching the healthy public? Currently, society offers few options to donate one’s body for public science education.

The modern standout exception in this area is Body Worlds, the plastinated fascination that has drawn thousands.
Body-Worlds

Older examples might be the sliced whole humans found in some museums, including here in Chicago;
Slice of full body

and, similarly, jars of fetuses which show us a hopeless but informative blossoming of would-be life.
Feturs jars

Collections of organs have been typically under lock and key of medical schools; and only variably available to the public, depending on the collection.

Without a doubt, informed consent is a prerequisite to any sort of body, organ or tissue donation for any reason. But should families be allowed to consent to donate organs for public education?

Tell us what you think. We are considering the option. Take a look at a possible model for a consent.

Let’s have this discussion. And thank you for your thoughts.

Jar with question mark

Sleuth It: Case of Tendon Repair (Part 1)

Tendon writst

A family calls to request an autopsy. They complain that a recent surgery “killed their mother.” The patient had a history of heart disease, high blood pressure and diabetes and lived alone. The surgery was a tendon repair of the wrist and took place three days before the patient died. The surgery reportedly went fine and recovery was going well — just with some pain at the surgical site, but no swelling or infection. The family visited regularly. On the third day in the evening, the family was with their mother when she passed out.

What questions do you have for the family now?
At this point, what do you think could have made the mother pass out?

Submit your comments here and stay tuned for Part 2.

Legislative Update: Illinois House Bill 4054 – Coroner Training Board Act

Senate Floor Pano

House Bill HB4054Coroner Training Board ActStatus: July 15, 2015 Re-referred to rules committee.

Synopsis as introduced
Creates the Coroner Training Board Act. Creates the Coroner Training Board which will have the power to establish application, training, and certification standards for coroners, and to review and approve annual training curriculum for coroners. Provides that the new Board will select and certify coroner training schools, shall conduct or approve a training program in death investigation for the training of coroners, and be allowed to accept contributions and gifts from any organization having a legitimate interest in coroner training. Amends the Illinois Police Training Act and the Counties Code removing the Illinois Law Enforcement Training Standards Board from overseeing coroner training and replacing with the Coroner Training Board. Amends the Vital Records Act providing that 25% of the Death Certificate Surcharge Fund may be used by the Coroner Training Board (currently the Illinois Law Enforcement Training Standards Board) for the purpose of training coroners, deputy coroners, and forensic pathologists, and police officers for death (currently homicide) investigations and lodging and travel expenses relating to training.

House Committee Amendment No. 1
Provides that forensic pathologists (currently, pathologists) shall be appointed to the Coroner Training Board. Provides that the Board shall consult with the Illinois Coroners and Medical Examiners Association when adopting mandatory minimum standards for coroners. Expands the location of coroner training schools. Provides that the Board can develop a waiver process for lead investigator of coroner investigations for coroners with prior experience. Further provides that a Section of the Illinois Police Training Act does not impede the powers of a coroner to investigate deaths.

Comment:
Autopsy Center takes a general interest in the broad experiences of all families around the time of bereavement. We support legislative advances that improve and strengthen interactions with professionals during this difficult time — both through public education and improved professional standards. House Bill 4054 seeks to improve coroner qualifications and therefore represents an overall advance that will benefit families. The pluses of the bill include the value it places on coroner training and certification, forensics licensure, and independence from police oversight.

However, the bill leaves room for more balance in the handling of the statewide transition to certification – a complex undertaking. It specifically includes a waiver process whereby the Coroner Training Board may allow coroners to use experience to bypass new training guidelines. Depending on the leniency of the waiver process, the amendment may ensure that only new coroners (without experience and therefore the possibility of waiver) meet standards while making more limited impact on the quality of coroner work currently in place.

In some of the relevant comparative licensed fields (medicine, law, law enforcement), use of experience is not a substitute licensure or certification.

On the other hand, waiver by experience is modeled in the area of re-certification. We therefore encourage lawmakers to incorporate the concept of re-certification into this bill, and further, recommend restricting experience waivers to re-certification. This will have the effect of broad, immediate attention to standards across the field; reflect the value of continuing education; respect the evolving field of forensics; incorporate respect for experience; and balance out HB4054’s implicit power structure.

Specific language amendments may be as follows:
Section 30a:
Add after page 2, line 13: “The Board will require mandatory re-certification every 4 years or every election cycle” (or similar language and with appropriate interval to reflect the pace of developments in the field.)

Section 30b:
Add at the end of page 2 line 14: “for re-certification” (or similar language)
Add within page 2, line 18 after “a waiver”: “for re-certification” (or similar language)

Summary opinion:
While HB4054 is a positive and comprehensive step forward, our summary opinion is that this bill is not ready for passage.

Poem – Mariner

Mariner photo

Journal of the American Medical Association Vol. 313 No. 11 (2015) p. 1171

Entering the body for an autopsy is a precise, medical procedure with scientific purpose. Nonetheless, the soul and spirit of this profound human experience float in the air of the autopsy suite. Journey into the body and into harrowing waters with Dr. Margolis’s poem “Mariner.” Published in the Journal of the American Medical Association this month.

Read the poem here.

Monthly Case: Early Graft Closure

Safe with notes
The case was of a middle aged man who died suddenly two weeks after a surgery. One of the photographs shows the cause of death. The other photograph from the same patient shows a similar process, but was not the cause of death.

Case discussion:
The photographs show grafts to the heart. These were grafts from a coronary artery bypass procedure. The grafts came from a vein in the leg (saphenous vein) and were attached to the heart to allow blood flow around blocked coronary arteries. The grafts have been cut open to see along the length of their insides.

The bottom graft shows the cause of the death. This graft is completely blocked by the clot seen at the right. The clot appears as a red tube inside the graft. It blocked blood flow from getting completely through the graft to where it needed to go – the heart muscle. It was as though the heart was functioning without this graft at all.

This was a sick heart with a recent serious heart attack that prompted the bypass surgery emergently. The graft was critical to the patient’s health and life.  Without the open graft and the blood flow to the heart, the patient died.

The top photographs shows a small amount of clot healing onto the inside of the graft.  It’s not enough clot to block the blood flow in the graft, but is the same process. This clot is brown and not red because it is starting to heal and scar, which changes the color.

To the left of the clot in the top photo is a hole surrounded by small sutures.  This is called a “side anastomosis.”  This graft was used twice.  Blood flow passed through the side anastomosis to a blood vessel there; and blood flow passed through the end of the graft (all the way at the right) to a blood vessel there.  Often, grafts can be used to bypass more than one blocked vessel.

Early graft closure from clot (thrombosis) is a known, but rare complication of coronary artery bypass grafts.  It’s unrelated to the technique of the surgery or any intraoperative factors, but just a part of the body’s reaction that can sometimes happen to the graft itself.

Meaning to the family:
In this case, while it was helpful to know that the graft closure was “no fault” of the surgeon, the patient had tell-tale signs of trouble during recovery after hospitalization (shortness of breath and fainting) that were not attended to. This was a complicated post-operative story to sort though. The autopsy was helpful to the family by clarifying the cause of death and its relationship to natural processes, the surgery and post-operative care.

Should you say “I’m sorry for your loss”?

Sorry for your loss

This question – whether or not it is appropriate to say “I’m sorry for your loss” to a grieving family member — is one I’ve heard explicitly raised by a variety of professionals. For example, a resident tasked with providing a family with autopsy results was simply unsure of how to begin the conversation; and if it was “ok” to empathize. Another worried whether extending condolences was too much of an invitation to deal with a family’s difficult feelings of grief. A funeral director caught off guard by a family’s sharp response (“No you’re not! You just want my money!”) questioned her willingness to do what had come naturally and switched over — forevermore — to “you have my condolences.”

The latter examples are more complex, so, for now, let’s talk about the first. We’ll come back to the others in a later post.

My view on the general issue is as follows:

In my line of work — as an autopsy pathologist who works closely with families — I always let the family know that I’m sorry for their loss. And I say this right away the first time we speak. I do this because I am sorry for their loss. It’s that simple. The human connection is the most important part of the interaction.

Holding back the words has more to do with the speaker’s own discomfort or unfamiliarity with death and grief than any rule about “how grief works” for the family.

Here’s a bit of context from my world.

Families who call me for an autopsy (the same ones speaking with you for whatever reason) have often spent weeks or months advocating or fighting within the health care system. And, of course, their loved one has died despite their and everyone’s efforts. When they call me, they may be expecting the fight to continue — I am (another) doctor. By saying “I’m sorry for your loss,” I also let them know right away that I’m on their side. It’s because I actually am.

Even separate from any difficult relationships they may have had within the health care system, the family will also have many feelings surrounding their loved one. They may be feeling angry because of perceived missteps in the treatment; guilty that they were unable to care for a headstrong or even self-destructive loved one; or feeling lost if the death was sudden. The quest for answers through an autopsy is always part of an effort to fill in emotional pieces of a story. Did that uncaring physician miss a diagnosis as I suspected? Should I have pushed harder for that x-ray? Did my husband suffer before I found him?

Given the often problematic relationships, the self-doubts, and the huge personal hole that can be left by a loss, families in grief welcome kindness. There is so much room among grieving families for simple, undemanding kindness. “I’m sorry for your loss” dropped into the well of grief splashes deep, soothing and welcome ripples. There’s so much power in the small gesture.

To the uncertain resident, I would say give yourself credit for wanting to reach out. Go ahead and say the words. You’ll find the family will really appreciate it.

The other two examples — the resident who worried about getting “too much family” by reaching out and the funeral director who got “too much family” in the form of a rejection — are really exceptions. The solution there has to do with believing it when you say “I’m sorry for your loss.” But stay tuned for for that discussion at a later point.

In the mean time, if you know a family or individual in grief, don’t hesitate. “I’m sorry for your loss” can be ice cream to the sore throat of grief. Even a small scoop can soothe.

Monthly Case – Uremic Pericarditis

Feb case safe view The case was of a middle aged man treated with intravenous antiobiotics for a skin and muscle abscess which developed after an operation. The patient died suddenly months after the abscess healed. The normal organ is seen on the right.

Discussion: The patient developed kidney failure as a result of toxicity from intravenous antibiotics. The patient required short term dialysis. He was recovering from his kidney failure when he died suddenly. The metabolic and possibly immunologic consequences of kidney failure had taken a toll on the heart, although the kidneys themselves were recovering. Uremic pericarditis is a known but poorly understood complication of kidney failure. “Uremic” means “related to kidney failure.” The heart is covered in fibrin (a blood protein) and inflammation and had begun to scar onto the surrounding sac (pericardium). “Pericarditis” means “inflammation of the pericardium.”

Public Act 98-0988: Nursing Home – Anonymous Complaints

 

Senate Floor Pano

Public Act 98-0988 Nursing Home – Anonymous Complaints
Name of Filing Sponsor: Dennis M. Reboletti (R) 45th District
Date Sponsored: 2/14/2014
Date Enacted into Law: 8/18/2014

Synopsis As Introduced
Amends the Nursing Home Care Act. Provides that a complaint regarding an alleged violation of the Nursing Home Care Act may be transmitted to the Department of Public Health by electronic means. Provides that when a person requests that the Department investigate an alleged violation of the Act, the Department shall require (instead of shall request) the complainant’s identifying information. Allows the complainant to request that his or her identifying information remain confidential or that the complaint be treated as anonymous, and requires the Department to maintain the complainant’s confidentiality or anonymity unless: (1) the complainant consents to the disclosure in writing, (2) the Department’s investigation results in a judicial proceeding, (3) disclosure of the complainant’s identity is essential to the investigation, or (4) disclosure of the complainant’s identity is essential for the purposes of investigating or prosecuting the complainant’s alleged knowing transmission of a false report to the Department. Effective immediately.
House Committee Amendment No. 1
Adds reference to:
210 ILCS 47/3-702

Replaces everything after the enacting clause. Amends the Nursing Home Care Act and the ID/DD Community Care Act. Provides that a complaint regarding an alleged violation of the Nursing Home Care Act may be submitted by electronic means. Requires the Department of Public Health to make information available, through its website and upon request, regarding the oral and phone intake processes and the list of questions that will be asked of the complainant. Requires the Department to notify complainants that complaints with less information provided are far more difficult to respond to and investigate. Requires the Department to conduct an annual review and make a report concerning the complaint process. Requires the Department to provide its report to the Long-Term Care Advisory Board and the Illinois Long-Term Care Council. Provides that the Long-Term Care Advisory Board and the Illinois Long-Term Care Council shall review the report and suggest to the Department any changes deemed necessary, including how to investigate and substantiate anonymous complaints. Makes similar changes in the ID/DD Community Care Act. Effective immediately.

 

I.  Introduction.  In Illinois, the care of our elderly and disabled in nursing homes falls under the Nursing Home Care Act.  The state functions to support quality in nursing home care not only through the professional licensure process, but through implementation of standards and on-site reviews by the Illinois Department of Public Health (IDPH).  In the context of the legal and regulatory weave, citizen complaints provide an important voice in alerting the state to potential violations in standard of care.   The complaint process must at the same time protect the identity of the complainant (and by de facto, the possible family member who may still be under nursing home care); acquire necessary and sufficient information to proceed with an investigation; and guarding against fraudulent reporting.  Public Act 98-0988 seeks to address these tensions by incorporating an educational component to the reporting process and by establishing an annual review of the complaint process.

II.  Brief description of the law:  The law provides for the submission of electronic complaints to the IDPH, provides for transparency of the complaint intake process, requires the IDPH to let the complainant know that complaints with “less information” are “far more difficult to respond to and investigate,” and includes an annual review of the complaint process.

III.  Discussion and analysis:
        1.  Allowing for electronic submissions of complaints.  This section facilitates and decreases barriers to submitting complaints in our electronic age.  Currently, the IDPH uses a complaint form, accepts emails (dph.ccr@Illinois.gov), and phone calls (Central Complaint Registry, 800-252-4343).

       2.  Transparency in the intake process.  Here, the law ensures that the complainant can see on the website, or receive, upon request, a list of questions to be asked during the intake process.  This assists the department in ensuring the complainant understands what information the department finds necessary, and provides the complainant with a reassurance that he or she is being treated with a fair and standard process.

       3.  A requirement to let the complainant know that “complaints with less information are far more difficult to respond to and investigate.”   Of the four sections of the law, this one has the most complexity.  The language “less information” is general and therefore vague.  It does not specify which pieces of information would lead to a case that is more “far more difficult to respond to and investigate.”  Certainly, communicating more rather than fewer details about the potential nursing home violation itself would help the IDPH respond and investigate.   As far as disclosing the complainant’s own personal information (name, address, telephone number), the law specifies that the IDPH uses this information to allow for “appropriate follow-up.”  Such follow-up may indeed be of help in an investigation.  However, it is not clear in what manner and under what circumstances communicating less rather than more of the complainant’s personal information would lead to a case that is “far more difficult to respond to and investigate.”  The law, therefore, incorporates unspoken and undue pressure on the family (by the threat of inaction vis. their loved one) to give up their right to confidentiality in order to get a satisfactory response and investigation by the IDPH.

       4.  Annual review process.  The law specifies an annual review of the complaint process with attention to outcomes for anonymous and non-anonymous complaints.  This will allow for ongoing understanding and improvement of the complaint process.

IV.  Summary and opinion: The law takes an educational and information-based approach to improving the complaint process.  The law furthers the quality and effectiveness of the complaint process by adding electronic submissions, public education on the state’s intake questions, and an annual review process. However, the section on the consequences of “less information” is problematic.  If the law is reminds citizens of the state’s needs for complete information, it should also remind citizens of their right to protection.  Both should go together for this law to be in balance and therefore effective.

V.  Recommendations:

I recommend the following:

-A review of the decision to include the “less information” section as a “notice” vs. as “[made] available through the web and upon request.”

-That the law be revised to inform the complainant not only that “complaints with less information provided are far more difficult to respond to and investigate” but also that “the Department shall not disclose the name of complainant unless the complainant consents in writing to the disclosure or unless the investigation results in a judicial proceeding, or unless the disclosure is essential to the investigation” or similar language (as provided in Sec. 3-702 (c) of the Nursing Home Care Act).

VI.  Final comment. Not yet addressed here is the issue of fraudulent complaints.  The law, as currently written, will have the effect of deterring fraudulent complaints.  It will do so, again, via the “less information” section, where there is an implicit threat.  The thinking is as follows:  “If you don’t give us (IDPH) your name, we might not follow-up.”  Since someone reporting fraudulently would not give his or her name, this will have the effect of weeding out frauds.  The problem, again, is that the law will also weed out or cause undue stress to families with legitimate complaints but too afraid to give up their right to confidentiality.

The challenge is to rethink who we are as a people expressing ourselves through our legislation.  Do we squeeze out the vulnerable in order to squeeze out the criminal?  Or is there another way?  Our country has always supported the rights of the few.  This law can be improved with that in mind.    

Resources

Central Complaint Registry:

Complaint Form

email:  dph.ccr@illinois.gov

Hotline: 800-252-4343

Monthly case: Undiagnosed Pancreatic Cancer

Rathke pancreas safe viewWhat is shown?   The top photo shows the pancreas split down the middle (horizontally).  To the left is the tumor.  Next to the tumor is a circle.  This is a tube cut across.  It is the common bile duct (the tube that drains bile from the liver).  The tube is abnormal.  It’s too big (dilated).  It is roughly twice as big as it should be normally. To the right is the spleen (the red organ taking up about a third of the image).  Below, the photo is illustrated.  The split down the middle of the pancreas is shown with a dashed red line.  The tumor is outlined in black.  Two red arrows highlight the common bile duct. The spleen is labelled.

What was the story here?  This case was from an autopsy of a man in his 50’s who had cancer of “undiagnosed primary.”  This means that he had cancer in his body but no one knew where the cancer started.  Specifically, he had cancer that had spread to his lymph nodes.  He had a biopsy of one of these lymph nodes.  Testing of the lymph node tissue showed that one possibility was that the tumor started in the pancreas.  But x-ray studies did not report a mass in the pancreas.  The x-rays showed the common bile duct was dilated, but no mass in the pancreas. The pancreas was never biopsied.

Why did the family request an autopsy?  The family wanted to finally find out where the tumor came from.  They were angry that no diagnosis had been made.

Why was the diagnosis not made here?  In this particular case, the tumor did not increase the size of the pancreas very much and, as mentioned, could not be seen on x-ray.  Some pancreatic tumors are not visible on x-ray.  These tumors are called “isodense.”  “Iso” means “same.”  So these tumors have the same density as normal tissue.  Approximately 10% of pancreatic tumors are isodense.  This means they cannot be distinguished in x-ray appearance from normal pancreatic tissue.

On the other hand, a tell tale sign of a pancreatic cancer is that it can pinch off the tip of the common bile duct and cause the rest of the duct to balloon out.  This happened here. But the finding was not considered in thinking about the possibility of a pancreatic tumor.

Lastly, the lymph node that was positive for cancer was in a unique place in the body.  It was above the left collar bone.  A lymph node here is called a “Virchow’s node.”   It is a tip off that the tumor could come from the pancreas.

So overall, there were three tell-tale signs to consider there might be a tumor in the pancreas:  the studies on the lymph node, the location of the lymph node, and the ballooned (dilated) common bile duct.  But because no mass was seen on x-ray, pancreatic cancer was not considered.  There was no consideration the tumor was hidden on x-ray because it was isodense; and, again, no biopsy.  This was a missed diagnosis.

How did the autopsy help?  The autopsy provided closure for the family because it answered an important question they wanted and needed to know: where did the tumor come from?  And it gave them a context for understanding the factors that went into the missed diagnosis.