Chapter 15 #2
“It comes with practice,” Laurie explained.
“I’ve never stopped to try to figure out just how many autopsies I’ve done over the years.
It’s a lot even though I haven’t been doing that many recently.
And Jack has done even more than I, a lot more.
He’s a glutton for punishment when it comes to autopsies.
He does more than anyone else at the OCME, hands down. ”
“That’s because I make it a point to arrive early every day and cherry-pick the best cases,” Jack explained from where he was standing over at the autopsy table.
After finishing with the examination of the GI system, Laurie and Bob left the laundry-like sink and returned to the autopsy table.
She went on to examine and remove all the abdominal organs except the pancreas, which she left in place after carefully palpating it and taking a tissue sample, continuing to explain every step as she went along.
Each individual organ was weighed, meticulously examined, and dissected.
The only abnormalities she encountered were an enlarged spleen, which she thought was otherwise normal in appearance, and a single stone in the gall bladder.
Then, taking a new scalpel, Laurie carried out a neck dissection to expose the thyroid gland and carotid arteries.
“That part’s done,” Laurie said, straightening up to stretch her back. “Any questions before I close up?”
“I don’t think so,” Bob said. He glanced at the clock, amazed at how fast Laurie had been able to proceed despite her ongoing commentary.
He then watched with equal respect as she returned the organs to their approximate original locations, replaced the sternal flap, and then very rapidly sewed up the body using a running suture.
“All right,” Laurie said, hyperextending her back for a moment before placing the needle holder back on the instrument tray. She rubbed her gloved hands together in anticipation. “Now for payoff time, at least for this autopsy: the brain. Do you have a head block?”
“Yes, we do,” Bob said. “Let me get it.” He disappeared for a moment into the changing room.
“We’ve never bothered to use the head block,” Melanie explained.
“It makes the removal of the brain at bit easier,” Laurie said.
Bob reappeared almost immediately with a sizable block of wood.
While Jack lifted Stanley Kramer’s head and shoulders with Melanie lending a hand, Laurie inserted it under his neck, adjusting his head up at a forty-five-degree angle.
“There are a number of ways of removing the brain, but I’ll show you how we generally do it at the OCME,” she said.
Then, explaining as she did it, she took a scalpel and made an incision from ear to ear around the back of the patient’s head.
Using the same scalpel and a pair of forceps, she created a large flap of scalp, which she folded over the face, exposing the entire boney top of the cranium.
Without even being asked, Melanie handed Laurie the electric Stryker saw, which made a high-pitched raucous sound, especially as it cut into bone.
“You have to be very careful along the temples,” Laurie explained, nearly shouting.
“The bone is significantly thinner in those areas, and it is easy to damage the underlining dura or, worse yet, the brain itself.” At that point everyone was glad they were wearing face shields, as tiny bits of bone flew in all directions.
After having circled the head 360 degrees, Laurie handed Melanie the Stryker saw and then carefully teased off the boney skullcap with her gloved hands, exposing the brain’s dural cover.
“So far so good,” she said as she again picked up the scalpel and forceps.
“Now I’ll make a longitudinal cut through the dura from one end of the opening to the other, followed by transverse, relaxing incisions to expose the entire dorsal surface of the brain.
” The moment she finished, she pulled her hands back and straightened upright, so all four of them could look down at the brain.
“Whoa!” Jack murmured. “That brain appears a bit worse for wear. What do you think, Laurie?”
“I’d have to agree, although I’m not sure if my mind is playing tricks on me,” Laurie said. “I wish I had a known normal brain photo right here for comparison. It’s subtle, but I think it’s not normal. Let’s be sure to get some pictures even at this stage to compare.”
“Sure,” Bob said agreeably. He picked up the camera and took a number of photos, just as he’d been doing during the entire case.
“With as many brains as I see, I have a good idea of what a normal one looks like,” Jack said.
“And this one looks abnormal to me, not overly so, but I’d say consistent with an early Alzheimer’s brain.
I get the impression that some of the sulci, or the valleys between the convolutions, are more open than usual. ”
Once Bob had finished with his in situ photos, Jack pointed to which sulci he was referring to, namely those along the sides of the brain just above the ears.
“Right along here is what I’m talking about.
And on top of that, I sense that the convolutions, or gyri, themselves are flatter than normal. ”
“I certainly haven’t seen the number of brains you guys have,” Bob said. “So, I’ll take your word for it. But after we’re done here, I can show you the photos I took of the brains of the two other cases, so you can compare them.”
“That would be helpful,” Laurie said. “But let’s move on with this case by getting the brain out of the cranium, so we can examine it closer. There’s a bit of technique involved.”
“Tell me about it,” Bob said. “It’s been a struggle for me on more than one occasion.”
“The best way to start is to work your fingers under the frontal lobes,” Laurie began as she demonstrated.
“And then blindly lift the olfactory bulbs off the cribriform plate. Following that step, you go back to working around the edges of the brain to isolate and cut the various cranial nerves and carotid arteries.” Laurie quickly followed her own directives.
“Next go back and lift the occipital lobe to expose the fibrous tentorium separating it from the cerebellum and transect it.”
“What do you use to cut the tentorium?” Bob asked.
“These long-curved dissecting scissors that Melanie just handed me,” Laurie said, holding them up for a moment before using them on the tentorium.
“And now for the last step. Carefully push the cerebellum forward with the flat of your hand to get the same scissors down as far as you can into the cervical canal to cut the spinal cord. You want the cut to be as low as you can manage.”
“You make it look so easy,” Bob complained.
“It is easy once you get the hang of it,” Laurie said, handing the scissors back to Melanie.
“Now for the final maneuver, we have to go back under the frontal lobe with your right hand and work the tips of the fingers down into the ventral side of the cervical canal. And now, supporting the brain stem, lift the brain out of the cranium.” As she spoke, she gently hoisted Stanley Kramer’s brain out of its boney sanctuary and carefully placed it on a baking sheet Melanie extended toward her.
Laurie then took the pan down to the foot of the autopsy table, where she placed it so all four of them could have direct access to it.
Jack, having brought a bread knife from the dissecting table, bent over and proceeded to make a series of through-and-through coronal slices.
“Hmmm,” he voiced while studying several of these.
“To my eye I’m seeing more hints of early Alzheimer’s disease,” he said, straightening up.
Using the very tip of the knife as a pointer, he motioned toward a slightly shaded area beneath the floor of the lateral ventricles on a number of the slices.
“This is the hippocampus area. Its cross section is supposed to be more flat or oblong than round. To me it’s looking round. Would you all call it round or flat?”
Bob laughed. “I’ll take your word for it. It’s so indistinct and obviously a judgment call.”
The others agreed, admitting there was room for interpretation.
“Well, I think it’s more round than flat,” Jack said, “meaning, for me, another suggestion of early Alzheimer’s.”
“Clinically I was also convinced,” Bob said.
“But I’ll be willing to make a bet, NMS Labs are going to report it as Alzheimer’s negative if this case is like the other two, which it has clinically matched.
The problem is, we’re going to have to wait for NMS Labs and that’s going to be more than a week for certain. ”
“We haven’t been able to do the autopsy on Ethan Jameson with his body disappearing,” Jack said.
“The obvious result is that no one is going to be driving his specimens down to the OCME like we planned, at least for the time being. But there’s no reason it couldn’t be done with Stanley Kramer’s samples.
If we did and with an ounce of pressure from Laurie, we’d get results overnight.
We could even have microscopic slides rapidly made by our superb histology team. Who makes the slides for you here?”
“Both Melanie and I give it a go,” Bob said. “We’re not very good at it, but we’re getting better.”
“As you can imagine, ours are first rate,” Jack said. “I presume you made slides of the other patients’ brains.”
“Of course we did.”
“Obviously we’ll want to see them,” Laurie chimed in. “And if samples from this autopsy are being sent down to the OCME, we should include some of the brain slides from the previous cases and direct them to Christine.”
“Excellent idea,” Jack responded.
“Who is Christine?” Bob asked.
“Dr. Christine Skinner is our relatively new neuropathologist,” Laurie said.
“What about the other various tests from the previous autopsies?” Jack asked. “Do you have all the results? What are the names and the ages, by the way?”
“Harold Barker, age fifty-two, and Susan Hughes, age thirty-nine,” Bob said.
“Wow, that is young for Alzheimer’s,” Laurie said. “This certainly is a scary situation. How about the other nine patients? Are they all on the young side?”
“Most would be considered young for Alzheimer’s,” Bob said. “Only two are over sixty-five. As for tests on Barker and Hughes, all we have available at the moment is that they are negative for Alzheimer’s.”
“So, we are back to considering whether to send Stanley Kramer’s samples down to New York City,” Jack said, his voice reflecting some impatience.
“What do you think, Melanie?” Bob asked. “Can we find someone to drive down to the city this afternoon?”
“I should think so,” Melanie said. “It is the middle of the summer. People aren’t all that busy. I’d be happy to take the job myself if you could do without me for an afternoon.”
“Hell, no!” Bob said with a shade of humor. “I’m not facing an afternoon of patients without you. But otherwise, I agree. It shouldn’t be that difficult to find someone. Carol might even be willing to do it if she can combine it with a stopover at Macy’s.
“All right, here’s the plan,” Bob continued. “We’ll finish here and clean up, and then we’ll head down to Ted’s Diner for a deserved lunch. Over burgers, we’ll decide the next step.”