Solving Complex Clinical Puzzles: A Memorable Autopsy Experience

I walked into the autopsy suite, trembling and drenched in sweat, even though the atmospheric temperature was as cool as it could ever be. It was my second autopsy experience as a pathology resident and I could not make out exactly how I was feeling. My first session had exposed me to the critical role of pathologists in solving complex clinical puzzles and had left me shaken for days. And, I still wasn’t sure how the second session was going to be. But, one thing I was sure of was the fact that I still felt uncomfortable.

Not uncomfortable because of the task that had been given to us to find out the cause of death of the person I was going to meet. But I felt very uneasy with the fact that I did not know what to expect, yet again. The first session had been that of a middle-aged woman. This was going to be a case of a young man. Two different scenarios and diagnoses. I did not know what to expect. My stomach turned and churned and I could also feel my heart thumping loudly in my chest.

I looked up at my senior resident, with my attending physician observing our every move. He looked very comfortable with what we were about to do. He seemed to approach the entire situation like it was a routine procedure for him. I questioned myself, “would I ever get comfortable with doing autopsies like him?”

I listened attentively as the senior resident walked me through the process of performing an autopsy and what our duties as pathologists was supposed to be. I tried to listen as my senior colleague who was obviously very familiar with the process gave me a detailed lecture. I felt my mind wandering away, even though it seemed as though I was paying attention to what he was saying. My attention drifted back and forth as I couldn’t help thinking about so many other things including the complexities surrounding life and death.

As we went through the organs and finally began working on the lungs and heart were his primary pathologies were supposed to be, I was amazed at the pathology I was being exposed to. His bilateral lungs were severely fibrotic, encased with numerous calcified nodules that eventually turned out to be non-caseating granulomas. He also had calcified hilar nodules also confirmed histopathologically as non-caseating granulomas and his heart was markedly enlarged, with hypertrophy of biventricular walls, more prominent on the right side. His pulmonary arteries also showed signs of severe vascular disease with hyalinization and fibrosis. He had disseminated sarcoidosis, with his heart and lungs more severely affected. The sarcoid granulomas had spared the other organs and had domiciled in the lungs, with downstream effects on the heart. He fit the stereotypical case of cor-pulmonale-right sided heart failure from severe lung disease. The facts of the case suddenly began to make a lot of sense to me. I thus had a better understanding of why the patient had progressed so rapidly with his disease course with a fatal outcome.

I realized later that all my prior apprehension about performing the autopsy had been replaced by an interesting curiosity to find out more about his disease. My initial trepidation about performing that autopsy was quickly replaced by a determination to answer the “why” question. I became more involved and present with the procedure that by the time we left the autopsy suite, I thought I had learned something new that day.

That experience of being able to solve a clinical puzzle from autopsy findings made a huge impact on me. Therefore, the role of pathology and laboratory medicine in the advancement of medicine and patient care can never be overstated.

-Evi Abada, MD, MS is a Resident Physician in anatomic and clinical pathology at the Wayne State University School of Medicine/Detroit Medical Center in Michigan. She earned her Masters of Science in International Health Policy and Management from Brandeis University in Massachusetts, and is a global health advocate. Dr. Abada has been appointed to serve on the ASCP’s Resident’s Council and was named one of ASCP’S 40 under Forty honorees for the year 2020. You can follow her on twitter @EviAbadaMD.