CAPÍTULO IV: SOLUCIÓN PROPUESTA
4. ENFOQUE DE SISTEMAS DE LA SOLUCIÓN PROPUESTA
The first element of an autopsy is the identification of the goals or purpose of the examination.
These goals may differ from case to case and depend upon the basis of the autopsy request. A coroner may have a different purpose in mind from that of the police, the family or a treating clinician. Each may be separately seeking answers to their own questions. It is up to the pathologist performing the autopsy to assure him or herself of the questions at issue so that he or she can orientate the examination appropriately.
Before commencing the physical examination of the body, the pathologist should be given access to all available information about the medical history of the deceased and the circumstances surrounding the death. Such information may well affect the way the autopsy is conducted and will determine in the pathologist’s mind whether or not to make particular observations. The experienced pathologist will, of course, always have in the back of his or her mind that, because of the informal nature of the information usually supplied, it will bear a variable relationship with the facts that subsequently emerge. It cannot be overstressed that the value of any particular autopsy is in direct proportion to the quantity and quality of information provided to the pathologist before he or she starts the examination. On occasions, it may be prudent to delay the autopsy until sufficient information about certain matters has become available.
[33.630]
Where the examination of the body is likely to involve many different specialists, the forensic pathologist must plan the autopsy in collaboration with the other investigators including the forensic odontologists, the forensic anthropologists/osteologists and the police.This will ensure that the technical procedures carried out are complementary and do not interfere adversely with each other. For example, in the case of procedures used in facial identification, it would be possible for some aspects of facial dissection to interfere with forensic radiology and photographic requirements. If the jaws are resected before skull or dental radiographs are obtained, the relationship of the dental and facial structures cannot be used as a point of comparison with radiographs that may have been taken in life. The sequence of examination procedures is therefore of considerable importance and should never be left to chance.
Whether the autopsy is being performed for medico-legal or clinical reasons, some universal basic goals exist. These include the identification of the deceased, the discovery of significant disease processes and the determination of the pathological states and injuries that have lead directly or indirectly to the death. In the case of hospital autopsies, most of the disease processes and the cause of death will be known in advance. (Indeed, if the cause of death is unknown the death must be referred to the coroner.) The main goal of the hospital autopsy is focused on determining the extent of the disease process and the effects of treatments provided in life. At the same time as investigating the death, the physical autopsy provides an opportunity for the collection of education material for medical teaching and research. These autopsies require that consent for the procedure is given by those having legal control of the body who in turn must ensure, in some jurisdictions, that relatives do not object. In practice these requirements are met by obtaining the consent of the next of kin. In contrast to this, a medico-legal autopsy can be performed on the instructions of the coroner and without consent
being obtained from the next of kin. This situation applies in the case of autopsies that are conducted principally to identify the deceased. There are instances where the next of kin or other relatives can object to a coroner ordering an autopsy, but these are rarely applicable where the identity of the deceased is unknown.
[33.640]
Prior to the examination of a body at a mortuary, the pathologist may have already carried out a superficial examination of the body in the place in which it was found.The scope of examination of a body at the scene of death depends on the circumstances, but in most cases, some initial information can be gathered from the position of the body, the presence or absence of rigor mortis or post-mortem hypostatic lividity (discoloration of the skin), and the temperature of the body. A body that is fully clothed, or otherwise wrapped and partly concealed, may be difficult to examine adequately at the scene, and no definitive conclusions regarding identity of the deceased or the nature of the death should be made until the body has been examined fully at autopsy and the necessary follow-up tests have been completed.
The next process involved in an autopsy is the retrieval and evaluation of information relating to the past medical history of the deceased. While this is important in all forensic autopsies, the collection of ante-mortem records is a specific phase in the processes involved in disaster victim identification and these proceedures are a good illustration of the principles involved.
[33.650]
Mass disaster involving loss of life can be conveniently divided into two types, open disasters and closed disasters. Open disasters refer to the situation where there is no record of the names of the individuals who may have been killed; an example of such a situation might be a major train crash. Anyone in the community might be on a particular train and it is not until friends and relatives report them missing that the investigators have an idea of who the deceased might be. In a closed diaster there is a record of all people who might be involved. An example of a closed disaster might be a plane crash where a list of passengers is immediately available from the airline. Clearly the task of identifying individuals involved in a closed disaster is much simpler as the ante-mortem investigation team know where to go to get their information. This ante-mortem information may include family and personal details such as information regarding last known activities as well as background information on, eg, work history, clothing and personal effects and family background. Medical details such as previous radiological examinations, drug history, and previous surgical or dental procedures are also important. While in many cases police investigators provide this information, it is often important for the pathologist and odontologist to be able to request particular information from or to speak with any dental or medical practitioners who have been involved with these suspected individuals prior to death. The ante-mortem information collected should include actual medical and dental practitioners’ files as well as photographs and radiographs of the suspected individuals taken in life.In routine coronial autopsies this collection of ante-mortem records is far more limited;
however, collection of medical notes and/or witness statements is essential if the pathologist is to be able to reconstruct the circumstances of the death.
Before the deceased’s body is physically examined, it is necessary to carry out a number of preliminary investigations. This may involve the taking of specialist radiographs, blood tests for infectious diseases and/or photographs. Where the body is not too severely damaged, the deceased may have their fingerprints recorded or an attempt may be made to have them visually identified by a friend or a member of their family. These preliminary matters may take some time to complete before the physical autopsy can be commenced and efficient co-ordination of the whole process by the coroner is essential.
Post-mortem radiology
Radiographic studies play an important part in the forensic autopsy and are particularly relevant in injury cases, firearm-related deaths or where the identity of the deceased is unknown. Comparison of post-mortem radiographs with clinical radiographs taken in life can result in identity being established with a very high degree of certainty. The shape of the frontal sinuses and dental structures are highly individual features and make post-mortem radiography of the head almost mandatory in autopsies on unknown individuals. It is important to co-ordinate the radiological examination with the remainder of the autopsy procedures in order to minimise the risk that one process will interfere with another. For example, if the head is first opened with a saw, later radiographs of the frontal sinuses of the skull will be much more difficult to interpret. Similarly the process of embalming a body may cause artefactual trauma and introduce air and fluids into body cavities, changing the radiological appearance (as well as interfering with toxicological analysis of body fluids).
As commented on above ([33.430]) radiological procedures are an important preliminary investigation in the forensic autopsy. Radiographs are useful when attempting to identify the presence of foreign material in a body or when trying to identify the extent and location of injuries that may require detailed analysis during the internal examination of the body.
Health and safety
Taking part in autopsy procedures necessarily involves some personal risk. This is particularly true when the identity and background of the deceased are unknown. Both physical injury and communication of infectious agents are potential hazards. Individuals infected with one of the types of infectious viral hepatitis, HIV or tuberculosis pose special risks. However, it should not be forgotten that commensal organisms (common bacteria present in every body) can pose a threat to the operators if these organisms are inoculated into their body tissues via a cutaneous injury. In deaths that have occurred as a result of major trauma, foreign materials present on or in the body may puncture protective clothing including surgical gloves and represent a significant hazard to the examiners. Any object, whether a part of the body or foreign material, that can cause a cutaneous injury needs to be identified in advance and countermeasures instituted. Working with bodies that are very cold or frozen poses a particular risk, as the operator’s sense of touch and fine movement may become impaired. Control of the production of fluid splashes and aerosols during the autopsy should be given similar attention as these can also transmit infectious agents.
As well as physical injury being associated with the risk of transmitting infectious agents to the operator, other physical hazards can occur. The very act of moving heavy bodies and body parts can cause back and limb injuries and these need to be avoided by the use of appropriate equipment and assistance. Chemical injuries to an operator can also occur if the body is contaminated and this can occur in a number of major disaster incidents and industrial deaths.
Hydraulic fluids, caustic and corrosive chemical as well as gas and radiation hazards must be anticipated and countermeasures instituted at the appropriate time during the investigation.
Deaths occurring in a setting of military action or terrorist activity may also involve complex, highly toxic chemical contamination as well as explosive hazards from retained weapon projectiles and other explosive devices.
Post-mortem radiology
Radiographic studies play an important part in the forensic autopsy and are particularly relevant in injury cases, firearm-related deaths or where the identity of the deceased is unknown. Comparison of post-mortem radiographs with clinical radiographs taken in life can
result in identity being established with a very high degree of certainty. The shape of the frontal sinuses and dental structures are highly individual features and make post-mortem radiography of the head almost mandatory in autopsies on unknown individuals. It is important to co-ordinate the radiological examination with the remainder of the autopsy procedures in order to minimise the risk that one process will interfere with another. For example, if the head is first opened with a saw, later radiographs of the frontal sinuses of the skull will be much more difficult to interpret. Similarly the process of embalming a body may cause artefactual trauma and introduce air and fluids into body cavities, changing the radiological appearance (as well as interfering with toxicological analysis of body fluids).
As commented on above ([33.430]) radiological procedures are an important preliminary investigation in the forensic autopsy. Radiographs are useful when attempting to identify the presence of foreign material in a body or when trying to identify the extent and location of injuries that may require detailed analysis during the internal examination of the body.
Health and safety
Taking part in autopsy procedures necessarily involves some personal risk. This is particularly true when the identity and background of the deceased are unknown. Both physical injury and communication of infectious agents are potential hazards. Individuals infected with one of the types of infectious viral hepatitis, HIV or tuberculosis pose special risks. However, it should not be forgotten that commensal organisms (common bacteria present in every body) can pose a threat to the operators if these organisms are inoculated into their body tissues via a cutaneous injury. In deaths that have occurred as a result of major trauma, foreign materials present on or in the body may puncture protective clothing including surgical gloves and represent a significant hazard to the examiners. Any object, whether a part of the body or foreign material, that can cause a cutaneous injury needs to be identified in advance and countermeasures instituted. Working with bodies that are very cold or frozen poses a particular risk, as the operator’s sense of touch and fine movement may become impaired. Control of the production of fluid splashes and aerosols during the autopsy should be given similar attention as these can also transmit infectious agents.
As well as physical injury being associated with the risk of transmitting infectious agents to the operator, other physical hazards can occur. The very act of moving heavy bodies and body parts can cause back and limb injuries and these need to be avoided by the use of appropriate equipment and assistance. Chemical injuries to an operator can also occur if the body is contaminated and this can occur in a number of major disaster incidents and industrial deaths.
Hydraulic fluids, caustic and corrosive chemical as well as gas and radiation hazards must be anticipated and countermeasures instituted at the appropriate time during the investigation.
Deaths occurring in a setting of military action or terrorist activity may also involve complex, highly toxic chemical contamination as well as explosive hazards from retained weapon projectiles and other explosive devices.