• Alyse Gray

Question Everything

If there's anything I've learned from working in pathology, it's that physicians make mistakes like every other human being. In my practice, I've encountered a myriad of medical errors. Most of them are trivial, but some can be serious. Because of this, I've learned to question everything.

As a rule, medical professionals should question themselves and their colleagues to ensure patients get the best care. It's important to do this respectfully without being rude or insulting(which causes negative conflict). It's equally important to understand the value of being questioned and not take offense when this occurs. Without internal and external questioning, we cannot achieve excellence.

I had a hospital autopsy recently where a question was posed by a physician, that contradicted the diagnosis of another physician. While I don't know the details behind the question, the autopsy definitely provided an answer.

The patient had been treated for cervical cancer, and had been declared cancer free. Another doctor challenged this diagnosis, with the opinion the patient still had cancer in their body, and that it had spread to other organs, particularly their lungs. The physician requested that we perform a limited autopsy, removing only the lungs to determine the presence or absence of cancer.

When I performed my external exam, I noted that the patient had a curved needle inserted in their chest, something that should never happen outside of certain forensic cases, where the needle may become an important detail in determining the cause of death. Needles in dead bodies are hazardous to those who come into contact with the corpse, and are typically removed as a matter of protocol if someone dies in the hospital.

I was immediately concerned, and thought, "Why would they leave a needle in this patient?"

Further examination showed the needle was inserted into a device implanted in the patient's chest called a Port-A-Cath(port for short). Ports are small triangular-shaped metal and silicone devices used to administer chemotherapeutic drugs to certain cancer patients. A catheter attached to the device runs directly into the subclavian vein-a large vessel close to the heart. Many chemotherapeutic agents are so toxic that they will destroy a smaller veins and surrounding tissues if administered by typical intravenous route in the arms. The direct line from the port into a large vessel like the subclavian vein helps dilute the drugs so they won't cause local tissue destruction. Ports have the additional advantage of being less likely to become infected than a typical IV line. Specialized curved needles are used exclusively with these devices, which is what I was looking at.

I don't know why this needle was left in the patient, but removed it gingerly with a pair of hemostat forceps. It occurred to me that there was a possibility the patient had been receiving chemotherapy the moment they died. This was concerning, because it meant I would be exposed to any toxic drugs still within the patient's bloodstream when the body was opened. A waterproof, disposable gown, and double gloving with nitrile gloves should be sufficient to protect me from any lingering poisons, but if any of these barriers were permeated, I could be at risk.

When the chest cavity was opened, I didn't observe much beyond a few plaques in the lungs, which can be caused by a number of things, and aren't necessarily indicative of cancer. I placed the lungs in a bucket, filled them with formalin, and sutured up the body. Typically, my group hires autopsy techs from an outside company to do the evisceration and suturing, but I figured this time I would do it myself since it was a quick and simple procedure.

Everything went well with the autopsy, and I did not experience any sharps injuries or needlesticks during the procedure that would have compromised my glove and gown barriers. But when I took my gloves off at the end, I saw blood on my hands that was not my own. My heart sunk. Somehow, the patient's blood had gotten onto my skin. I had no idea how. I started to freak out and discussed it with my pathologists. They assured me that if the patient were getting chemo, the drugs would be so diluted that I would not likely suffer any ill effects, but I was not reassured until I saw in the patient's record that their last chemotherapy treatment had been 9 months ago. They had also received antibiotics in the hospital. I didn't realize until now that other drugs could be administered though ports, which explained the presence of the needle.

A big part of my concern stemmed from personal experience. Nine years ago, I watched my mother suffer through chemotherapy for breast cancer. She had a port too. I went with her to every single oncology appointment and held her hand as she was stuck with those needles. Everything I associate with ports is related to that. Just like the physician who posed the question of a cancer diagnosis in this autopsy case, I will boldly question physicians when it comes to my health, the health of those I love, and the health of my patients, whose specimens I handle, that will never even know I exist.

The next day, when I examined the lungs, I found a few spots in the lungs indicative of pneumonia, and some other areas suggestive of infarction-which is caused by a blockage of blood flow in the lungs. I didn't see anything that appeared outright cancerous, but took sections of these areas, along with additional representative lung samples to be made into slides.

A few days later, the pathologist examined the slides to discover that there was indeed cancer present-and it was everywhere. The patient's cervical cancer had spread throughout the blood vessels in their lungs. I took a look at the slides with the pathologist and was surprised to see so many spots of cancer that were not obvious at all when I sectioned the lungs. I wondered if this is why the diagnosis was disputed.

I may never know why this question was raised, but do hope that our work helped provide the family with some sort of closure by answering the question of their loved one's physician.

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