AUTOPSY PATHOLOGY ROTATION

1. Duration
2. Training goals and objectives
3. Introductory Remarks
4. Autopsy Pathology Rotation
5. Hours and Rotation on Autopsy Service
6. Senior Resident Responsibilities for the Optional On-call Rotation
7. Autopsy Responsibilities for Residents During Other Rotations
8. Procedures
9. Gross Autopsy Conference
10. Work-up and Sign-Out
11. Instructions for Dictation of Autopsy Reports
12. Use of the Supplemental Report
13. Deadlines
14. Autopsies on Patients Not Dying in the Clinical Center
15. Submitted Autopsies
16. Submitted" Autopsy Staff Person
17. Delinquent Autopsies (Autopsies Older Than 60 days)
18. Gross Examination - Outline of Basic Method,
    to be modified as needed for individual cases
19. Safety Considerations
20. Back to the Main Manual

A. Duration

• 4 months -Primary Prosector. Please refer also to information for Suburban, Holy Cross, and Children's National Medical Center for concurrent rotation information in the section on extramural rotations.
• 4 months -Supervisory Prosector.
• 1 month - Forensics. Please refer to information regarding Forensics rotation in the section in extramural rotations.
• Frozen Section Service is covered during both Surgical Pathology and Autopsy rotations.

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1. Patient Care
   1. Technical Skills
      The resident will master the technical skills relevant for the practice of autopsy and forensic pathology. In particular, the resident will be able to perform a systematic and complete gross human dissection (with assistance from the autopsy assistant) including body cavity, brain, spinal cord and relevant limb dissection within 3 hours. The resident will master the selection of tissues for microscopic examination, trimming and orienting tissues appropriately.

   2. Clinical Consultation
      The resident will learn to provide appropriate and effective autopsy and/or forensic consultation to clinicians and other health care providers. The resident will be able to review microscopic and gross autopsy findings, make appropriate diagnoses, and draw correct conclusions about disease and death processes. The resident will be able to communicate the range of findings with clinical and other professional staff. The resident will be able to complete the Preliminary and Final Autopsy Report within 2 and 60 working days respectively.

2. Medical Knowledge

   1. Fund of Medical Knowledge
      The resident will develop a fund of general medical knowledge and focused pathology knowledge relevant to the practice of autopsy and forensic pathology. This will include an understanding of mechanism, manner, mode and cause of death, the pathophysiology of disease as it affects multiple organ systems and interacts with other disease processes. The resident will learn to recognize the marks of the various injuries that are important in the practice of forensic pathology.

   2. Application of Medical Knowledge in the Practice of Pathology
      The resident will learn to effectively apply his/her general and focused medical knowledge in the formulation of a rational clinical-pathologic correlation, bringing together clinical history, laboratory data, imaging data and prior pathology findings with the findings at death to establish the cause of death and interpret the findings at autopsy.

3. Practice-Based Learning and Improvement

   1. Evidence-Based Practice
      The resident will learn to make effective use of conferences, lectures, and reading of the medical literature (texts, journals, and electronic medical databases) to support explanations and arguments made in the interpretation of autopsy findings.

4. Interpersonal and Communication Skills

   1. Communication Skills
      The resident will learn to communicate autopsy findings effectively with other health-care providers in both informal and formal situations. The resident will learn to prepare and present electronic presentation materials that consisely and accurately convey autopsy findings. The resident will learn to write clear, medically rational autopsy reports that include a clinical data summary, gross and microscopic descriptions, clinical-pathological correlations and an organized outline of diagnostic findings with an etiologically-specific cause of death. The resident should become familiar with and sensitive to the nuances appropriate to writing about a human death, including writing about unexpected, clinically-relevant findings. By the completion of the program, the resident should be able to produce essentially letter-perfect reports that require minimal or no modification by the attending pathologist.

   2. Teamwork
      The resident will learn to work as an effective member of the autopsy team. The resident will work with the autopsy assistant, other residents and attending pathologists to perform a safe and thorough autopsy, given the limitations of the permission

5. Professionalism

   1. Courtesy and Collegiality
      The resident must learn to treat other members of the health care team courteously and respectfully. The resident must learn to be collegial in all interactions with other members of the health care team. The resident will learn respect for the remains of those who have died as well as family members left behind.

   2. Professional Responsibility
      The resident must learn to take his/her professional responsibilities seriously and act accordingly. These responsibilities include on-call and regular coverage of the autopsy service, autopsy record-keeping, and collection of tissues for researchers. While on forensic rotations, residents should work professionally with the forensic pathologists and other individuals (e.g. autopsy assistants, medical photographers, police).

6. Systems-Based Practice

   1. The Health Care System and the Role of Pathology
      The resident must acquire knowledge of practice and health care delivery systems and an awareness of the role of pathology in the context of the greater health care system. In particular, the resident will learn the role(s) of the autopsy and forensic examination in the delivery of quality health care. The roles include the use of the autopsy as a quality assurance tool as well as its use in clinician education and in clinical research. In forensic settings, the resident will learn about the role of the forensic examination in medical-legal investigations of death.

   2. General Laboratory Administration
      The resident will develop an understanding of the general administrative aspects of autopsy pathology practice. The resident will develop a working knowledge of histology processing, laboratory information systems and the management of autopsy cases from initial accessioning to final sign-out. The resident will learn the regulatory and medical-legal issues that surround general hospital and forensic autoposies.

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C. Introductory Remarks
The autopsy service is covered principally by a junior (PGY1 or PGY2) resident. One resident is assigned to the service per month. The junior resident is responsible for the prosection, tissue blocking, slide review and first drafts of the preliminary and final autopsy reports. They are involved in the whole autopsy process from beginning to end and are accountable for turning in reports on time. If a senior resident is also assigned to the autopsy service, then they are also responsible for participating in all aspects of the autopsy process, but at an intermediate supervisory level. They must be present during the prosection and assist as needed. They review the preliminary and final report drafts before the attending on the case and they review the microscopic slides with the junior resident. With the supervision of the Chief of the Post-mortem Service, particularly capable senior residents may be given responsibility nearly equivalent to an attending. No more than one senior resident is assigned to any particular autopsy. An attending general pathologist and/or an attending neuropathologist is assigned to all cases and is responsible for reviewing the gross organs prior to issuing the Preliminary Anatomic Diagnosis (PAD) report and for reviewing the microscopic slides prior to issuing the Final Anatomic Diagnosis (FAD) report. Fellows in pathology (hematopathology, cytopathology) do not rotate on the autopsy service.

Consultation autopsies in which the prosection is done elsewhere may be divided into two broad categories. The first category, which accounts for most of the cases, involves autopsies performed on NIH patients at other hospitals. In these cases, formalin fixed tissues (usually a whole brain), and/or blocks and slides are received, usually before a final report is issued by the originating institution. The junior autopsy resident rotating in the month during which the materials are received is responsible for preparing a final autopsy report under the supervision of an attending pathologist. The resident participates in all aspects of case management and write-up. In the second category are cases sent for a second opinion. In these cases a final report from another institution has been completed and specific questions are addressed to the NIH pathologist. As with the other type of consultation cases, these cases are assigned to a junior resident who manages the case through sign-out and report preparation under the supervision of a staff pathologist. Preliminary Anatomic Diagnosis reports are not issued for consultation cases.

The types of autopsy cases seen at the NIH are derived from the currently active protocols. In the last three years these have included a range of neurological diseases, malignancies, and acquired and innate immunodeficiencies. Infectious complications and hematological abnormalities secondary to therapy are common in this autopsy population. Often unusual microbiological organisms are identified. The autopsy population is mainly adult, although about 10-15% per year are pediatric autopsies. The questions asked at autopsy may be very complex, as patients may be participating in research protocols using novel agents and therapies. Residents are responsible for researching the relevant literature to explain the pathophysiological changes and for presenting their findings in oral and written forms. All non-limited NIH autopsies are presented at the once-per-week autopsy conference, where clinical history, radiological findings and pathology are presented and correlated before a multi-disciplinary audience. Residents may also present autopsy findings on request to clinical conferences and M&M conferences held by individual departments or institutes.

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D. Autopsy Pathology Rotation

The trainee learns the techniques involved in autopsy prosection by assisting a member of the staff. He/she then performs prosections under supervision by the staff. After the resident is fully acquainted with performing autopsies, the following procedure is followed: The resident obtains the chart and autopsy permission form, the resident reviews the chart, noting pertinent details in the clinical history, and considers special procedures to be followed during the autopsy. The resident reviews the clinical history with the autopsy staff and the neuropathologist and consults the staff regarding any deviation from the normal protocol. Pertinent cultures are discussed, as well as preservation of tissues for special studies. The resident performs the autopsy dissection, further consulting with the staff if necessary. At the conclusion of the dissection, the resident reviews the gross findings with the staff, and prepares a list of preliminary anatomic diagnoses. The PAD is completed and sent to Medical Records by the end of the next working day. Rush blocks may be submitted for fast histological processing to answer urgent or significant questions raised by the gross findings. The brain is grossly sectioned after two weeks fixation in conjunction with the neuropathologist. The resident provides a detailed clinical history and discussion of pertinent clinical findings. After receiving all the microscopic sections, the resident reviews them first on their own and then in consultation with the senior staff using a double-headed microscope. The final autopsy protocol is prepared, including final anatomic diagnoses, gross and microscopic findings, and clinical pathologic correlation. All protocols are checked and corrected by members of the staff and are reviewed by the Chief of the Autopsy Service. Neuropathology findings are reviewed with the neuropathologist. Relevant gross and microscopic findings on all autopsies are reviewed and presented to the entire group of residents, pathology staff, and associated clinicians at a weekly Autopsy Conference. Radiographs and pertinent photomicrographs are also presented.

During the autopsy rotation, the residents also perform autopsies at Suburban Hospital, where they are under the supervision of the Suburban Hospital staff pathologists. However, they are encouraged to consult with the staff of the Laboratory of Pathology, NCI, on any matter. At Suburban Hospital, the residents are involved in all aspects of the case, from gross examination and dissection, to the completion of the final autopsy report. The experience at Suburban Hospital provides for a diversity of cases, include the evaluation of sudden death.

At the third and fourth year level, residents have the option to rotate on the autopsy service and provide intermediate level staff supervision for junior residents. They assist and instruct residents in the autopsy dissection, and help prepare the case for presentation at the Autopsy Conference. They prepare the final anatomic diagnosis with the support of the Autopsy staff.

Mandatory rotations are provided in forensic pathology and pediatric pathology. Forensic pathology is offered at the D.C. Medical Examiner's Office, the Baltimore Medical Examiner's Office, and the Office of the Chief Medical Examiner, Northern VA. Division, Fairfax, VA. At Children's Hospital residents participate in perinatal and pediatric necropsies.

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E. Hours and Rotation on Autopsy Service

Routine autopsies are initiated between 8:30a.m. and 4:30 p.m. on routine workdays. The chart, autopsy permission, and body must all be ready and available to the resident before the 4:30 pm cut off time. If a routine case is not ready for prosection until after 4:30 pm Monday-Thursday, it may be delayed until the follwoing morning.

On Friday, the resident-on-call will take all cases when the chart etc. arrives after 4:30p.m. The resident-on-call will be responsible for all weekend or holiday cases (including holidays in the middle of the week) up to 2:00p.m. Sunday or on the day prior to the next working day. The resident-on-call will also perform any stat cases that need to be started before 8:30a.m. on Monday or the next working day.

Although most autopsies are done during regular hours, they will be done after regular working hours if there is a legitimate need for fresh tissues (e.g., for biochemical studies, for viral isolation) or if time restrictions are imposed by the patient's family (e.g., "an autopsy can be done if the body can be claimed at 8:00a.m. next day"). Stat autopsies will be performed by the autopsy resident from Monday to Thrusday and the on-call resdent will perform stat autopsies that are started between 4:30 pm on Friday to 8 am on Monday or the 1st working day. If you have any questions contact the staff member on call. The decision not to do a case has to be made by the senior staff member on call, the Chief of the Autopsy Service or the Chief or Deputy Chief of the Laboratory.

Residents will be assigned to the autopsy service for one-month rotations, which include NIH and Suburban Hospital. If more than one autopsy is scheduled on a given working day, the resident on service, the attending pathologist and the autopsy assistant will prioritize the autopsies.

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F. Senior Resident Responsibilities for the Third Year Rotation

Purpose

The senior resident has the opportunity to act in an intermediate level supervisory role over the junior residents on-call and on the weekday autopsy rotation. The senior resident gains some experience in making gross and microscopic diagnoses while still in the sheltered environment of residency. The senior has the opportunity to share much practical experience with incoming first year resident as well as to continue to learn new aspects of autopsy pathology. This arrangement is common in other branches of medicine, where the same patient might be interviewed by a medical student, intern, junior resident and chief resident prior to being seen by an attending.

Time commitment

Rotations are assigned by discussion among the interested seinor residents and are subject to guidelines of the ACGME. The Chief of the autopsy service and autopsy secretary should be notified the senior resident on call schedule.

Relationship of junior resident to senior resident

The Junior resident should contact the senior resident along with the staff when there is an autopsy or an on-call event (frozen, rush surgical, cytology). The junior resident should listen to and heed the advise of the senior resident. If there is disagreement in a course of action, then both residents should present the options (together) to the attending for a final decision. The Junior resident should be aware of the Senior resident responsibilities outlined below and should involve the Senior resident at each point in the case.

Relationship of attending to senior resident

Because of the varied experience levels of Senior residents, the attendings should not abdicate full responsibility of the case to the Senior resident. Short of this, Senior residents should be given as much responsibility as they can handle. However, until an attending is familiar with the experience and capabilities of a particular Senior resident, they should continue to supervise both residents closely. The Senior resident should be present at the review of organs and at sign-out with the attending so that they benefit from the attending's pathology knowledge.

Senior resident responsibilities

1. The senior resident rotation is an on-call responsibility and includes events on weekends and evenings. They should participate in all autopsies (neuro and non-neuro, submitted and in-house) as well as on-call surgical specimens (frozen sections and rush cases) and cytologies. Since the participation of a senior resident is not absolutely required, the Senior can be excused for emergencies. If the Senior resident is aware of a scheduling conflict, they should make an attempt to find another Senior resident to cover.
2. For autopsy cases performed at NIH, the senior resident should be heavily involved and should participate in all aspects of the autopsy work-up. This may include the following:
   1. Review history and clinical questions with Junior resident prior to start of case. Review any special approaches or techniques that may apply to the case (procurement of special tissues, EM studies, tissue set aside for hemepath).
   2. Be present during prosection at frequent intervals. The Senior resident may teach methods of prosection to new residents or alternative dissection approaches. Assist in the procurement of tissue for research, tissue bank, and special studies. Be present to go over organs with attending prior to signing of PAD.
   3. Review the PAD with the Junior resident-preferably working together on a hand-written copy before the Junior resident types or dictates the PAD. If there are questions, both residents should discuss the PAD with the attending.
   4. Review the microscopic slides with the Junior resident first, and proceed with preliminary work-up (special stains, IPox, EM etc.).
   5. Be present at autopsy gross conferences.
   6. Review draft FAD with Junior resident. In order to limit extensive rewrites, the Senior resident should limit comments to organizational rather than stylistic points and make sure the FAD includes the organization set forth in the Resident's manual.
   7. Be present at sign-out of slides with attending. All parties should make an effort to be present at this time. Note that this event should take place at least 3 weeks prior to FAD deadline to permit any additional studies to be performed.
   8. Sign both PAD and FAD.

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G. Autopsy Responsibilities for Residents during other rotations

The resident must insure that autopsy reports are signed-out and completed within the 30-day turn around time deadline, even if the deadline extends beyond the time of the autopsy rotation. In order to complete the report on a timely basis, the resident may need to dedicate time during the next extramural or intramural rotation.

Residents should attempt to avoid autopsy call during the weeks they are assigned to the in-house surgical service.

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H. Procedures

"In-House Autopsies." On weekdays the Admissions Office notifies the office that permission for an autopsy has been obtained and brings the chart and documents to the office.

On evenings or weekends the pathologist on call and the assistant on call are not required to actually be in the hospital until notified that the patient has expired and that permission by the next-of-kin has been granted. No autopsy procedures will take place until the resident pathologist handling the case initiates the autopsy (see Appendix B6 for autopsy checklist). Request for "stat" autopsies must be approved by the pathology resident in consultation with the senior staff pathologist handling the case and/or the Chief of the Autopsy Service. This decision will take into account the disadvantages as well as the advantages of performing an immediate autopsy.

The pathology resident must be given adequate time to review the patient's medical record prior to initiating the autopsy. This is especially important to identify high-risk cases, i.e., those with known hepatitis B, C, HIV or TB infection or those contaminated with radioactive substances. Read the paperwork carefully to make sure the restrictions are clearly stated and be sure to check lines 4 and 5 on the Report of Death (Appendix B9) for information about potential high risk cases. For "stat" autopsies the record must be hand-carried to the pathologist immediately upon completion of the death note. The pathologist's record review, which is essential to maximize the medical information obtained from the postmortem examination, is to be supplemented by a written problem list and an oral case history communicated by the primary care physician. Infectious or radiation safety precautions must be spelled out. No autopsy procedures will be initiated until the attending and/or senior resident have been notified and administrative approval has been obtained from the Clinical Center Admissions Office. (This latter process usually requires 30 minutes to several hours, depending on the proximity of the next-of-kin. In order to minimize administrative delays, whenever possible the Clinical Center Admission clerk should be informed that a stat autopsy is to be anticipated.)
When the purpose of an autopsy is to obtain human tissues for research purposes, a physician member of the research team must be available at the time of the postmortem examination to ensure that the dissected tissue samples are adequately processed and/or stored. The clinical researcher will provide all the necessary containers, media, dry ice, etc., required for tissue distribution.

The Autopsy Service has a commitment to support clinical research at NIH by providing human tissues to authorized scientists with reasonable requests and approved research protocols. The Clinical Service providing care to the patient will receive priority in tissue distribution. Other requests are handled through a formal tissue procurement policy. Contact Joseph Chinquee , Clinical Laboratory Manager, for information about tissue procurement policies and the tissue resource committee.

1. During the performance of the autopsy the staff member may be called at any stage to review organs or answer questions. In cases where the death is suspected to be due to protocol related complications or from iatrogenic causes, the Chief of the Autopsy service should be informed. The staff member should be called when clinicians are present to answer questions during the prosection. For cases performed during routine working hours, the unfixed autopsy organs should be reviewed by the junior and/or attending staff member at the time of the postmortem examination. NEVER HESITATE TO CALL THE STAFF ON DUTY FOR ADVICE AND INSTRUCTIONS.
2. Eye Enucleation: An unrestricted autopsy includes enucleation of the eyes for pathologic evaluation by the National Eye Institute. This procedure will be performed by the autopsy assistant unless otherwise stipulated by the resident in charge of the case. Whenever possible, this procedure will be performed at the beginning of the autopsy. The eyes will be routinely fixed in formalin and the National Eye Institute will be contacted by the assistants.
3. A general outline for prosection is given at the end of the autopsy section. This method should be modified as needed. During dissection, small blocks of tissue from all organ sites are fixed in formaldehyde. (Please refer to AFIP manual for instructions on blocking an autopsy). These blocks are placed in labeled plastic "save" jars and are trimmed after 24 hours' fixation. The save jars are stored on each resident's individual shelf until the autopsy is signed out. Representative large sections of all the organs are saved in a large metal canister. After the gross conference, any excess bulk tissue can be disposed. The remaining wet tissue is retained for 60 days after the autopsy is signed out. After these deadlines, the tissue is incinerated. If unusual circumstances make it necessary to save tissues for longer periods of time, write "SAVE" on the jar or canister.
4. The gross findings and clinical summary should be recorded within 24 hours according to the format in Appendix B7. These sections should be ready for review by the staff member at the time of the gross conference. Be brief and clear. Diagrams save words.
5. Cultures: DO NOT FORGET CULTURES AND SMEARS FOR ORGANISMS. Tissue cultures from lung and liver are routinely obtained; however, when there is a question of sepsis, cultures may also be taken from heart blood, spleen, and kidneys. For tissue cultures the surface of the organ is seared and a 1-2 cm3 piece of tissue is removed and transferred in a sterile fashion to a sterile 50 cc tube. Heart blood cultures require approval of both the pathology and microbiology attending. Abscess cavities should be cultured with sterile swabs. Heart blood (20 ml) is obtained by first retracting the skin and then searing the intercostal space overlying the heart prior to transthoracic cardiac puncture. The sample is aspirated into a 20-cc sterile syringe, equipped with a 11/2-in 16-gauge needle. Ten (10) ml are placed into a blood culture bottle, using sterile technique. Anaerobic conditions should be maintained. Microbiologic results from autopsies are available from the LIS. Viral cultures may be taken when the clinic history supports the study and routinely in pediatric AIDS cases. Culture equipment is stored in the autopsy suite or may be obtained from microbiology.
6. Special Studies: Whenever relevant, specimens should be fixed in 3% glutaraldehyde for subsequent electron microscopy (all soft tissue tumors, and other samples as required including formalin fixed lymphoid and hematopoietic tissue, or stored frozen for enzymatic analysis or frozen section immunohistochemistry.
7. Transport of Necropsy Specimens: Specimens for culture/chemical analysis are to be placed in appropriate containers, avoiding contamination of the outside of the vessels/requisition sheets. The specimens are then placed in a paper bag, along with the appropriately completed requisition forms, and brought to the microbiology lab by the diener.
8. Complete the pathologist's portion of the death certificate.
9. Clean up: Each prosector is responsible for safely discarding scalpel blades, rinsing and transporting dirty equipment to the sink area, and rinsing the specimen cutting board. Once surgical gloves have been soiled with blood/body fluids, do not contaminate the cabinets, tape recording instruments, etc. Aprons and autopsy clothing should be placed in appropriate areas for washing, sterilization, and cleaning.
10. Discard blood-soiled items (gloves, towels) or tissue fragments in the plastic-lined cardboard box destined for incineration on campus. Contaminated materials must not be mixed with the general refuse.
11. After the dissection is completed the prosector and senior staff member write a Preliminary Anatomic Diagnosis (PAD) and cause of death and dictate it for typing. This must be done promptly so that the signed PAD is returned to Medical Records no later than 1 working day after the autopsy is performed. FROZEN SECTIONS TOUCH PREPS/SMEARS IMPROVE THE QUALITY OF PADs AND ARE INVALUABLE IN BECOMING A GOOD GROSS PATHOLOGIST.
12. Observers of Autopsy Examinations: Permission to attend a postmortem examination may be granted at the discretion of the pathologist performing the examination, after clearance through the Chief of the Autopsy Service. In general, potential observers who have not been directly involved in the case of the patient are asked to attend organ recitals rather than the autopsy itself. During performance of the autopsy, admission to the autopsy area is closed to all personnel not directly involved in the procedure.
13. The Medical Legal Autopsy (see Appendix B8). When appropriate, medical examiner cases may be released for an in-house autopsy. In these cases it is important to consult the Chief of the Autopsy Service, the Deputy Chief of the Laboratory or the Laboratory Chief, as well as the attending physician on the autopsy service, prior to the initiation of the postmortem examination.
    
    Medicolegal questions that arise before or during an autopsy examination should be discussed with the Deputy Medical Examiner. If such a question arises unexpectedly during an autopsy, all prosection should stop and the Chief of the Autopsy Service, Deputy Chief of the Laboratory, or the Laboratory Chief should be contacted. The Maryland State Acting Chief Medical Examiner in Baltimore is David R. Fowler (301 333-3250). In addition, Dr. Fowler has appointed several local Deputy Medical Examiners in our area, one of whom is Dr. Frank Mayle (301-656-7775 or 1020).
    
    In cases where a drug screen is desired, bile and urine should be frozen as well as sections of brain, liver, and kidney (see AFIP manual). Vitreous may also be obtained.
    Samples for toxicological analysis are sent out on contract for analysis. Consult with Clinical Chemistry in the Clinical Pathology Department for details.
    Requests by lawyers, family members, etc., for copies of the completed autopsy protocol should be handled through the Medical-Legal section of the Medical Records Department.
14. Blocking the Case. Cases must be blocked within 24-48 hours upon completion of the autopsy. The tissues in the block bottle are trimmed so as to fit in cassettes and should not be more than 2-3 mm in thickness. See Appendix B4 for blocks that are routinely taken. "Rush" sections will be processed with the same priority as routine surgical specimens. A maximum of seven (7) rush sections will be permitted for each autopsy case. The jar containing the rush sections should be appropriately labeled and dated and placed in the designated area within the histology room. Be sure to sign the clipboard in histology with the autopsy number so the histotechnologists know which resident should receive the slides. (Residents are encouraged to process frozen sections to facilitate provisional diagnoses and touch preps/smears).
    After the entire case is blocked the resident should file the "SAVE" jar in numerical order on the long-term storage shelf. The contents of these jars and the contents of the metal canister are disposed of 60 days after the case is signed out. Any deviation from this time frame must be cleared by the Chief of the Autopsy Service and relayed to the dieners.

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I. Gross Autopsy Conference

All autopsy cases in which a dissection of the body cavity was performed will be presented at the weekly Gross Autopsy conference. At this time microscopic sections (frozen, touch preps/smears or rush) should be available for the evaluation of puzzling gross findings. When present, the clinicians who cared for the patient are asked to present the case history. However, in their absence, the resident preparing the case will provide the clinical summary. An outline of the clinical course may be prepared and distributed to attendees at the conference.

Because it is a good idea for all of us to acquire a feeling for the "range of normal," most autopsies should display all the organs that were examined, not just those showing pathological findings. This includes the small endocrine organs.
Submitted autopsies will be presented at the option of the resident and/or staff person handling the case.

Cases will be presented at the Gross Autopsy Conference as soon as possible, generally within 2-3 weeks of the time the autopsy is performed. An announcement will be circulated to the clinical services 1 week in advance. Residents should attempt to contact interested clinicians to remind them of conference times.

The resident and staff person responsible for each case should prepare some meaningful comments, which they can share with other members of the audience. Handouts with references may be useful in this regard.

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After the prosector receives the slides from the Histology Laboratory he or she examines the entire case (the staff member responsible for the case can help) and decides if further cuts, new blocks from the lesion, or special stains are needed. Immediately after the material is gathered and examined, short microscopic notes are written to complement the gross in the autopsy forms.

Make an appointment with the staff on the case and sign it out. Have ready the clinical summary and gross description and be knowledgeable about pertinent laboratory and radiological findings. Always bring the slides of previous pertinent surgical and cytopathological materials to the sign-out session, along with a copy of the patient's surgical pathology and cytopathology diagnoses. If additional staff members' opinions about interesting/puzzling slides are sought, then their names should be cited in the report using the consultant feature in SoftPath.

After the case is signed out, prepare a draft for review with the staff before final typing.

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K. Instructions for Dictation of Autopsy Reports

1. Dictation Process
   1. Dictation of preliminary and final autopsy reports may be done using the telephone dictation system of the Medical Records Department
   2. The telephone number for the dictation of autopsy reports is 594-2828.
   3. The numerical code for dictation of a preliminary autopsy report is 18 and the code for a final report is 19.
   4. Reports will be entered into LIS.
2. Report Format
   1. All dictated autopsy reports must follow the order and format identified on the autopsy worksheets approved by the department.
   2. Failure to follow the required order and format may result in the suspension of dictation privileges for the offending individual(s) based on the judgment of the Chief of the Medical Record Department. In such cases the Chief, Medical Record Department, shall notify the Chief of the Pathology Department of the suspension and its terms in writing.
3. Turnaround
   1. All preliminary reports dictated by 4:00p.m. Monday through Friday will be transcribed by 11:00a.m. the following day. Preliminary reports dictated on Saturday and Sunday before 4:00p.m. will be ready Monday morning by 11:00a.m.
   2. All final autopsy reports shall be transcribed within 1 day of dictation.
4. Report Revisions-Residents are responsible for making editing changes to their own autopsy reports.

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Cases may be signed out before all slides have been reviewed providing that (1) the likelihood is very small that the pending slides will contribute substantially to the case; and (2)a note is included to the effect that "Special studies/etc., are pending. The results, if contributory, will be issued as a supplemental report."

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1. Death certificate-at time of postmortem examination.
2. Preliminary anatomic diagnosis (PAD) should be prepared within one working day from the time of the prosection. The report will be hand-carried by the autopsy secretary to the Medical Records Department.
3. Presentation at the Gross Autopsy conference-ideally within 1-4 weeks of expiration. An attempt will be made not to schedule cases while the resident is on in-house surgicals, but this should not be allowed to delay the presentation until the resident is off service.
4. Presentation of the Morbidity/Mortality conference to the surgeons (selected cases)-usually within 60 days of expiration. Residents will be notified a minimum of 1 week in advance of the scheduled presentation. Scheduling is bilateral, i.e., based on the convenience of the presenting resident and surgery staff.
5. Completion of the Gross Description should be accomplished as soon as possible after performing the autopsy (preferably within 1 week).
6. Final anatomic diagnosis (FAD) must be completed within 30 days of performing the autopsy.
7. Organs stored in metal canisters are incinerated 60 days after sign out. The contents of the "SAVE" jars are disposed of after sign-out is completed.

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1. The Laboratory of Pathology will perform autopsies on NIH patients not dying in the Clinical Center. An NIH physician involved in that patient's care shall be responsible for requesting that the autopsy be performed in the Laboratory of Pathology. That physician shall be responsible for obtaining the intervening clinical history subsequent to the patient's NIH admission up until the point of death.
2. The Laboratory of Pathology will perform autopsies on NIH patients who die outside the Clinical Center. An NIH physician involved in that patients' care shall be responsible for requesting that the autopsy be performed in the Laboratory of Pathology. That physician shall be responsible for obtaining the intervening clinical history subsequent to the patient's NIH admission up until the point of death.
3. It is the policy of the Laboratory of Pathology not to perform autopsies on non-NIH patients. Exceptions to this general policy may be made on an individual case basis (see Appendix B5).

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O. Submitted Autopsies

The referred cases are assigned to a prosector by the Autopsy Service secretary. Should a resident receive the submitted autopsy case directly from the staff person, they should notify the Autopsy Secretary so the case is properly accessioned. The material received may include gross organs, pathology protocol, slides and/or blocks, and/or wet tissue. Submitted autopsies will be assigned to a resident rotating on the Autopsy Service. Cases consist of former NIH patients, cases "sponsored" by Clinical Center physicians and approved by the Chief of the Autopsy Service, and outside consults to specific staff pathologists. Cases are eligible only if they are accompanied by an outside pathology report and access to supportive clinical data. Cases inappropriate for submission are those that are fragmentary or cases which are part of a series being collected with a specific research intent. The Chief of the Autopsy Service will review each submitted case to determine its appropriateness before it is assigned to the resident and staff. Because these cases may take several months to complete, second-year residents who are leaving NIH should make every effort to avoid autopsy rotations during their last two months of training.

The autopsy staff person on duty for the week is automatically assigned to assist the resident with the case, unless the case has been submitted to a specific staff pathologist. The autopsy secretary will notify the staff person involved at the same time the resident is informed of the pending case.

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P. "Submitted" Autopsy Staff Person

For submitted autopsies the senior staff physician on call the day the case was accessioned shall serve as the automatically assigned consultant. However, any person on the senior staff may be approached by the resident to sign out any given submitted autopsy. In any event the senior staff pathologist signing out the case must be approached within 2 weeks of accessioning of the case. Cases to which a senior staff person has not yet been assigned after a 2-week interval will be in "delinquent/submitted" status.

The prosector should write a brief microscopic in the NIH autopsy form and a summary. It is not necessary to repeat the gross observations of the referring pathologist. However a copy of the submitting institutions autopsy report should be appended to the NIH report.

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Q. Delinquent Autopsies (Autopsies Older Than 60 days)

The College of American Pathologists (CAP) requires that autopsy reports be in the patient's medical record within 30 days of performing the autopsy. In addition, the clinician's interest in the autopsy findings declines geometrically (in hours). Therefore, except under extraordinary conditions, the autopsies must be completed within the allotted time frame.

Failure to sign out a case within the 30-day limit represents a serious problem for the resident, the staff, the Laboratory of Pathology, and the Clinical Center. There may be serious consequences for residents with delinquent report. Please refer to the section on deliquest report in the Medical Staff Handbook.

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R. Gross Examination - Outline of Basic Method, to be modified as needed for individual cases

Preparation

1. Special fixatives - glutaraldehyde for EM (kidney cortex, tumors)
2. Unlabeled cassettes for small tissues - lymph nodes, parathyroids, special biopsies.
3. Camera for gross photography.
4. External examination - body identification, lines (type and insertion site), lesions, eyes, mouth, scars (length and location)

Dissection

1. General considerations
   1. Weigh: Thyroid, Heart, Lungs (R, L, both), Spleen, Liver, Adrenals (R, L, trim fat), Kidneys (R, L), Testes/ovaries (R, L, without associated structures), Brain
   2. Measure volume: Ascites, Pleural fluid (R,L), Pericardial fluid (with syringe).
   3. Measure size: Uterus, Uterine cavity, Ovaries, Prostate, Pancreas, Common bile duct (Circ), Ureters (R,L, circ), Heart (MV, AV, PV, TV-circ, LV, RV, septum - thickness 1 cm below MV), spinal cord (length)
      
2. Open body cavity (Assistants will do this)
   1. Note condition of serosal surfaces, assess organ location
   2. Take lung, liver cultures
   3. Measure abdominal fat pad, liver from lowest rib in mid clavicular line.
   4. Remove gut if feasible and then remove organ block (Assistants will do this)
   5. While assistants are removing main block, open gut along antemesenteric side, rinse briefly, inspect and sample colon, ileum, jejunum and Appendix A7. Measure appendix.
   6. Inspect chest plate. Using rib cutters, squeeze marrow from ribs onto paper, fix in formalin.
   7. Serially section breasts (females). Sample axillary nodes.
   8. With block removed, inspect body cavity, compress legs for blood return, sample deep inguinal nodes, psoas muscle, sciatic nerve and normal abdominal skin.
      
3. Begin with block posterior side up
   1. ID thoracic duct/azygous vein.
   2. Aorta
      1. Open descending aorta to L common iliac, ID ductus arteriosus dimple, coarctation, bronchial artery ostia, other ostia, probe openings of renal arteries, IMA, SMA, celiac a.
      2. Open aortic arch and ascending aorta.
      3. Separate the pulmonary artery from the aorta.
      4. Transect the ascending aorta and reflect down.
   3. Dissect esophagus free from trachea, severing at most proximal point and reflect down. Look for parathyroids in tracheo-esophageal groove.
   4. If adhesions present, dissect lungs from diaphragm.
   5. Dissect pericardium from diaphragm.
   6. ID the IVC and transect. The thoracic organs should now be separate from the abdominal pelvic organs.
      
4. Abdominal/Pelvic block
   1. Open IVC, inspect hepatic, renal vein orifices
   2. Cut IMA, SMA, celiac and renal arteries at junction with aorta, dissect aorta and iliacs free and remove.
   3. Sample periaortic nodes.
   4. Adrenals and kidneys
      1. Start at R post. lateral corner of block, dissect diaphragm from liver.
      2. Locate R adrenal (between diaphragm and R kidney, trim fat, weigh, serially section (photograph)
      3. Free R kidney and ureter, slit open R ureter between bladder and renal pelvis, cut ureter closer to kidney than ureter, transect renal vessels, weigh, bivalve from side opposite hilum, strip capsule, open pelves, (photograph), serial section in a radial pattern perpendicular to initial cut
      4. Locate L adrenal above L kidney, remove as for R adrenal.
      5. Remove L kidney as for R kidney, transecting ureter close to bladder (left long).
   5. Sample Pelvic LN.
   6. Open rectum, post. midline, separate rectum from vagina/prostate.
   7. ID urethra, open anteriorly into bladder, open bladder and inspect (Y-shaped cut).
   8. Female genital tract: Incise lat. walls of vagina and uterus, open uterus like clam shell, serially section uterus perpendicular to long axis, measure and cut ovaries, serially section fallopian tubes.
   9. Male genital tract: serially section prostate perpendicular to urethra, remove spermatic cord and epididimus from testes, weigh and bivalve testes.
   10. Liver/Pancreas/GI Block.
       1. Remove spleen, weigh, serially section perpendicular to long axis, 1 cm intervals, photograph
       2. Dissect diaphragm and crural muscles free
       3. Posterior aspect:
          1. open celiac, L gastric, splenic and SMA.
          2. ID portal vein and open portal and splenic veins.
          3. Sample mesenteric nodes
       4. Anterior aspect:
          1. Open esophagus, stomach (greater curvature) and duodenum, inspect and clean.
          2. ID ampulla of Vater, probe common bile duct, pancreatic duct
          3. Open common bile duct, cystic duct and gall bladder (vol., color, stones), remove gall bladder
          4. Open pancreatic duct
          5. Remove GB from liver bed and open hepatic artery, sample portal/peripancreatic nodes.
          6. Separate liver by cutting portal structures, weigh and cut coronal sections (1 cm), photograph
          7. Dissect fat off pancreas, measure, serially section perpendicular to duct, keep esophagus/stomach/duodenum and pancreas together
5. Thoracic block.
   1. Heart
      1. Open pericardium, inspect surfaces
      2. ID pulmonary veins, transect close to lungs
      3. Open pulmonary artery, inspect for emboli
      4. ID SVC, transect close to heart, open SVC
      5. Dissect behind aorto-pulmonary trunk, transect great vessels about 1-2 cm above valves.
      6. Turn apex of heart anteriorly and upward, detach the pericardium.
      7. Open R atrium by cutting from IVC into R atrial appendage, connect to SVC if sinus node not needed, remove clots, inspect tricuspid, fossa ovalis, put finger thru valve.
      8. Open L atrium by cutting between all 4 pulmonary veins, open L atrial appendage, remove clot, inspect, finger thru mitral valve.
      9. Weigh the heart.
      10. Put formalin soaked paper in each side and fix overnight.
      11. Serially section coronaries (L main, RCA, Circ, LAD, diagonals) at 1 mm intervals, with heart anterior side up, serially section myocardium from apex to 1 cm below MV at 1 cm intervals and inspect for MI and ventricular dilatation (photograph), cut vessels and valves along lines of flow (lateral wall for A-V valves and anterior along septum through AV and PV), measure valves and walls.
   2. Lungs
      1. Starting below thyroid, dissect mediastinal fat, vessels and nodes off trachea and mainst veins.
      2. Transect mainstem bronchi at carina. Weigh each lung. Inflate lungs with formalin and fix overnight.
      3. Open R and L mainstem bronchi along superior and inferior edges.
      4. Cut from medial to lateral, use two probes in bronchi. Alternatively, lay lung on hilar side and cut section parallel to hilum. Complete serial sections of lung parallel to initial cut at 1 cm intervals.
      5. Open secondary bronchi, arteries in central sections. Palpate and inspect.
   3. Trachea and Thyroid.
      1. Remove strap muscles from trachea.
      2. Look for parathyroids.
      3. Dissect thyroid, weigh and serially section.
      4. Open trachea along posterior (membranous) side.
6. CNS
   1. Spinal cord.
      1. Assistants will remove section of verterbral bodies and spinal cord.
      2. Fix spinal cord.
      3. Inspect and fix vertebral marrow.
   2. Brain

Assistants will generally remove brain, pituitary, sinuses and temporal bone (if necessary). Weigh brain and fix. Neuropathologist will supervise brain cutting. The brain will be presented at the weekly brain cutting session for review, cutting and blocking in of pertinent tissues. Slides will be reviewed either at individual appointments or during the weekly scheduled brain cutting conference time.

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S. Safety Considerations

Please refer to Clinical Services Safety Manual, Autopsy Manual, and Appendix C1 for safety considerations.

Further information about the department can be found at the LP Web site: http://home.ccr.cancer.gov/lop/clinical/default.asp This site contains the departmental roster and detailed specimen collection guide. The Web site is a useful supplement to this manual.

For more information about Integrated Services section.