Meth mouth

Ever notice that county patients have really, really lousy teeth? When I was on the wards, I never really put two and two together but the dentists all seem pretty clear that a lot of it is meth mouth. Here's how they break it down:
Meth makes your mouth dry
Dry mouth makes your plaque germs happy
Ta daa! Meth mouth.

Apparently, it's very, very fast, too: folks who start in their teens and twenties end up ready for dentures by age 40...

Autopsies for beginners, setting up

Dry things stick to wet things and, let's face it, the insides of people are full of wet things. So before you start, get a couple of longs sheets of paper toweling from the dispenser, place them on your work surface, and wet them down. This will keep your organs from slipping around while you're trying to dissect them. If one of them is being particularly slippery, you can get another small length of paper towel and use it to help you grip the slimy little thing...

Story time with the boss

Stop me if you've heard this one before. (I've anonymized it the best I can but this sort of thing is hard to anonimyze.)

So apparently, a whole bunch of years ago (in a galaxy far, far away), there was this plane crash.

There's a little plane, like a Cessna or something, traveling from one little airport to another little airport and the pilot apparently has a heart attack.

Unfortunately, the little plane is heading toward a big airport and smacks into the tail of a passenger jet that was heading toward the big airport. This is just enough to knock the big plane out of the air (too.)

Unfortunately, the big plane crashes into a residential area...

into a park...

where they were having an office picnic...

with a whole bunch of people at it.

And, oh yeah, the plane was carrying a whole bunch of fresh fish.

So, from the forensic standpoint, there's two crashed planes, a park full of people that got smushed, a fire (at this point there is clearly going to be a fire) and the whole thing is thoroughly admixed with fish.

So sometimes a heart attack kills a whole bunch of people and covers them with dead fish.

Random case

So we are supposed to dictate "circumstances" into our report.

So this guy is some sort of gang guy and he's over at his baby's momma's house with one of his other girlfriends when yet another girlfriend drops by, notices the situation, pulls out a gun and attempts to shoot one of the other women-- (Why not both? Really couldn't say...) So gang guy somehow gets in the way-- (you'd think he was more experienced with guns and, well, women by this point)-- and ends up dead.


So you're thinking about this, holding the dictation thingy in your hand, trying to come up with a tactful way to put all this... (Can't really dictate "one too many women in that house" now can you?)

Random case

Attention tattoo artists:
Please study anatomy. I don't mean icky inside people anatomy; surface anatomy will do. The point is, the people you draw should look like people. Otherwise it's annoying.

Honestly, my guy today had a tattoo of a mostly naked woman on his shoulder and all I could think was "breasts don't look like that... breasts don't look like that..."

(I'm not talking size, or gravity-defying behavior. I'm talking basic shape-- which is not, by the way, OVAL-- and the fact that the nipples don't both face straight forward like they're big cartoon eyes or something.)

Really, next time you look at some you should pay attention...

New supervisor today

So five of us ganged up on my decedent today. (I'll put him in the random case file so that the whole "today" thing won't identify him.) Seemed a bit unfair.

Several things to note about today:
1) While most people can hear me in my mask provided they scoot closer and listen particularly to the part of the mask where my filter is rather than the part of the mask where my mouth is, the medical student, for some reason, can't hear me no matter what I do. Hearing "huh?" after every single solitary sentance tends to make one a bit taciturn. Plus she wears very weird shoes. I don't mean weird-- I mean weird-- as in they answer the question "can shoes be disturbing?" weird.
2) One tech was training another tech to be a tech today. This probably works out well most of the time. This time, my professor was one of those people who likes to do everything himself, which means that tech #1, tech #2, and, for that matter, me and the medical student, all stood around and watched him do the case. It was one of those times where they hand you something and you start doing it and they take it out of your hands and do it themselves and pretty soon you're just standing there wondering what's for lunch.
3) The case kinda took twelve times forever. It's not like he was being particularly slow or anything, but he was kind of, well, puttering. It was sort of like a quiet Sunday afternoon in his garage with a dead person and a whole lot of tools.

Reading list so far

Geberth, Practical Homicide Investigation
Safferstein, Criminology
Bloodspatter evidence
Interrogation techniques
Two of the "how to be an expert witness" books
parts of "Forensic entymology"
and most of "Death of Innocents"

Random case

Sudden death in a locked-down schizophrenic. Did a lit search and found an association between antipsychotic medication and sudden death with a possible mechanism: QT prolongation resulting in torsades de pointes...

Autopsies for beginners, step 2

If, while you were eviscerating, you noticed that the intestinal contents were of no interest whatsoever to you (consisting of food rather than, say, blood...) you can just stick your hose in the small intestine, turn on the faucet, and flush out the gut. Be careful of little holes in the gut that you made during dissection. Also, I tend to hang the caudad colon off the end of the table and into the sink for reasons that shouod be obvious. Once you're done, take the "sweet spot" of your big scissors and slide it along the intestine, delivering the opened part into your organ bucket. That way, you get a good look at the mucosa and your tech won't swear at you to messing up the table.

While we're on the subject, go ahead and rinse the table when you're done: dried blood is a lot harder to deal with than wet blood.

D'ja ever have that dream

So a bunch of us have had the dream where you're doing the autopsy and your patient wakes up. Kathy's starred the chief of pathology, who sat up in the middle of his own post and just would not stop talking. (The chief is a bit of a blabbermouth.) Mine was more alarming. I was on the autopsy floor in one of the bays, surrounded by other people in the other bays doing other cases, when my initial incision oozes a little too much. I slowly realize that it's not really oozing: it's bleeding. I drop the tools and back away and Dr. Rodriguez comes over to ask what happened. I can't really say, so I just point to the wound. He purses his lips, lets out a little puff of air, and says "Another one..." He then helps me push the table out to the transportation area and past it to the parking lot. As we go, he calls over his shoulder for transport to call an ambulance. The dream ends with me in the parking lot, ripping off my blood-stained gown and gloves, pulling my mask down around my neck, and holding pressure on the wound while keeping up a "there there" patter in my best professional soothing voice.

So I'm in the office (for real) the other day and people get to talking and there's this story that they swear is true where one of the gurneys falls off the back of the transport van and the guy moans. Which buys him a trip to the hospital, where he lives another two days before he makes hiw second and final trip in the van. The thing is, he'd already had his temperature taken. In this office, we use liver temperature. Which means a (small) incision in the abdomen and a (large) meat thermometer inserted into the liver (which you do by feel.)

Love and the cutting room floor

I love them with diagrams. The more diagrams the better. A diagram for postmortem changes, another for medical interventions. One for the tattoos, scars, and other identifying marks. One for each gunshot wound. A summary diagram for all the gunshot wounds put together.

I love them with my ruler. I measure everything about the wound that I can think of-- everything that looks like a thing that can be measured. I measure the distance from an extra landmark when there's one around (the nipple, the umbilicus...) and from the table surface so that I have three dimensions. I measure the defect in four quadrants, I orient it to the hands of a clock.

I love them with my knife. Anyone can make a single cut through the liver and throw it in the stock jar-- I slice it thin, one smooth motion per cut (which takes practice) and slide the flat of the blade over the surface to wipe the blood away each time (it's a habit by now to be honest) and peer at it looking for some tiny difference in anatomy. (I caught a liver hemangioma yesterday!) That sort of stuff will never end up in court and it isn't the cause of death but it only takes another minute or so and it looks so nice in the report-- I looked, I really looked. His life mattered, his death matters, he means something. He may be a really rough guy but he's somebody's baby and his mother may well read this someday and while I don't know if she'll see it for what it is I'm leaving her a little note in the chart in a way that says that her baby was important and deserving of the best care I could give.

A couple of weeks ago, I did an overdose where the family was worried about a heart murmur he had as a kid. There's a really common little extra sound that kids make that's technically a "murmur" but isn't dangerous at all and that's what he must have had because his heart valves were perfect and there's this little place in the protocol where you say that but I added another couple of sentances about all the things that can go wrong with valves that he specifically did not have. I did that for his mom. Okay, probably she won't but maybe she would know that I wasn't just checking off boxes on a sheet of paper: I listened to her and I looked for an answer for her-- really looked-- and I found the answer. Even though we do just gobs of overdoses, even though they are so common as to be disappointing when you discover that you've been assigned yet another one, she matters, her son matters, his life matters, and I gave him the best care I could.

You can tell from my knife.

Reading list so far

Done:
Safferstein's undergraduate criminology textbook: a breezy tour through the basics

In progress:
Geberth's Practical Homicide Investigation: very, very readable with lots of stories and color scene photos.

And, of course, the DiMaio Forensic Pathology and Gunshot Wound texts and Spitz and Fisher's Medicolegal Investigation of Death (required, working through them at a year-long pace...)

Story time with the boss

Cautionary tale:

There are people in this world who get shot a surprising number of times before they make it to you. There are a huge number of different ways to approach numbering the wounds. The boss today told the very, very sad story of a shootout involving two officers and a suspect that resulted in a bunch of ricochet and, in essence, a bloody mess. In short, it was pretty hard to tell which bullet belonged to which wound and, well, he made the rookie mistake of trying to figure it out anyway rather than admitting that this was beyond normal human capacity and-- of course-- he ended up getting them swapped, which results in a very long and tedious de-pantsing in court (never pleasant) followed by a very long mourning period.

So, while you have to try your best, it's okay to admit defeat and dictate it as such. In fact, it beats the alternative by far.

Random Case

Had a drowning today.

So, in my review of the literature (good resident, good resident!) there are a few things you tend to see in a drowning, none of which are specific and none of which are always there:Heavy lungs (80% of the time)Pleural effusions (40% of the time)Froth in the lower airways (also 40% of the time)And if there's a resuscitative effort-- no matter how brief-- it tends to blow away the froth.You can also see:water in the sphenoid sinus and, possibly, microscopic changes in the sinuseswhich I was all gung-ho to see but my tech is likety-split fast and closed the head about fifteen nanoseconds after showing me the pituitary. (I had informed everyone involved individually and more than once that I wanted to do the sinuses.) (... fail to see what I should have done short of flinging myself over the body and shouting "Wait! Wait!")

Also, be on the lookout for secondary causes of drowning, like heart attacks, strokes, seizure disorders, myocarditis (especially in kids: take micros!)

My guy had bad coronary disease, which sort of explains how when he got in over his head he couldn't manage to extricate himself.