Lara-Rose Iredale MAAPT is a recently qualified APT, and reports on the afternoon session at Conference 2017
Chairing the afternoon session: Frances Ciardini MAAPT, a proud Welsh member and Frances introduced the first speaker of the session:
Dr Penney talked about something that APTs come across a lot in the mortuary – implantable cardiac devices. I should say that personally I have never really thought too much about their mode of operation, only whether or not I can remove one safely and not receive a nasty shock. Luckily, Andrew talked us through the history of using implantable devices, their indications for use, the implant procedure, how therapy is delivered, what happens when things go wrong plus the all-important deactivation of ICDs.
Talking about the history of electrical stimuli in medicine, resuscitation involving electricity was used all the way back in 1788. Fast forward to 1958 and the first implantable pacemaker was fitted in a human. Pacemakers are used to control abnormal heart rhythms and there are various ways they achieve this – some pacemakers work on-demand when they detect and abnormal rhythm and others work all the time to control the heart’s rhythm. They are used in the treatment of bradycardia, tachycardia, atrial fibrillation and can prevent arrhythmias caused by long QT syndrome.
In comparison, implantable cardioverter defibrillators (ICDs) use high energy electrical pulses to treat dangerous arrhythmias. Normally inactive (apart from monitoring), it is when the device detects a potentially life-threatening tachycardia that the ICD attempts to return pacing to a normal rhythm via low-voltage electrical impulses (known as ‘pacing’), using small electrical shocks to restore normal pacing (cardioversion), or it will deliver a larger electrical shock in order to ‘reset’ the heart’s rhythm back to normal (defibrillation). Patients who have survived MIs with poor LV function and have ventricular tachycardia. ICDs are particularly clever in that they ‘learn’ what tactic works best with their recipient and can be re-programmed by a cardiologist based on monitoring feedback.
Of course, there are always complications when in implanting a foreign body. Although rare, there is a risk of rejection, infection, pneumothorax and - one that I urge everyone reading to Google immediately – Twiddler’s syndrome.
It is important for and of us tasked with removing an ICD post-mortem to endure that it is deactivated so that it no longer poses a risk of delivering an electric shock. This is best done by a cardiac physiologist who can turn of this function. These devices still can deliver a shock even when they have been removed, so it really is better to be safe.
It was fascinating to see the evolution of these devices; I truly had no idea how large ICDs used to be. Pacemakers have also greatly reduced in size, with the next evolution including an implantable loop recorder. Resembling a USB stick, this is an implantable ECG monitoring device that does not provide any electrical stimulus to the heart, rather it is used for diagnosis in patients with unexplained episodes of syncope, a history of AF or post MI. Even smaller is the Micra, the smallest, leadless pacemaker that is inserted via a catheter into the femoral vein and implants in the right ventricle of the heart. These tiny, pill shaped devices are very expensive and currently rarely used, but I’m sure they will become more common within our APT lifetimes and present their own challenges for removal. In this instance, bigger is definitely better.
“This is the ICU speaking. I have a rather unusual question…”
A familiar face at AAPT Conference and part of the European contingent, Jaap delivered a light-hearted introduction to the serious topic of what happens when you encounter chemical, radiological, biological or nuclear contaminated patients in a mortuary, based on his own experience involving several case studies. I personally was particularly looking forward to this talk due to my own experience of individual chemical exposure (ICE) cases we have had through our mortuary doors. How do you prepare for such eventualities and mediate the risks when conducting post-mortems?
Jaap’s first experience of a CBRN fatality had him and his team effectively thrown in at the deep end. CBRN cases are very rare, which also means that SOPs, protocols and training for such events are pretty much non-existent. It became apparent during Jaap’s first experience just how much of a danger ICE cases pose to first responders, emergency services and mortuary staff. Having to plan on the fly, keeping safety as the first priority, the primary concern is off gassing of the deceased. Lesson 1: regular body bags are not suitable to handle such cases! Due to the danger posed, a flurry of phone calls and a lot of paperwork later, a cremation was arranged within 4 hours (4 HOURS!).
This first case was subject to a huge debrief and both shortfalls and good practice were highlighted. It is easy in hindsight to identify flaws, but working in a dangerous environment and having to respond to a rapidly developing and changing situation really emphasises that no matter how prepared you think you are, flexibility, quick thinking and co-operation are essential. In such scenarios, ‘protocols are guidelines’ The Erasmus MC, together with all the hospitals in region of Rotterdam has now developed uniform PPE, protocols and training for future events.
Following on from the first chemical incident, Jaap described how lessons learned were implemented when a patient suspected to have Ebola was brought into his care. This time, appropriate PPE was present and staff were confident about how to proceed with the case. An important part of preparing for any eventuality is APTs having full confidence in their ability to respond. As such, it is recommended that training via table top exercises, and simply performing routine post-mortems in full CBRN PPE is carried out and recorded for teaching and evaluation regularly to ensure all staff are competent.
Contaminated fatalities due to suicide are the most common case type seen in mortuaries in Europe, but the potential for a mass fatality scenario is not entirely out of the question. As Jaap identified, incidents involving chlorine gas poisoning at swimming pools, petrochemical spills and of course the recent Ebola outbreak are potential sources of CBRN fatalities. It is important for mortuaries to know what to expect (and what is expected of you as an APT) when presented with such patients – full post-mortem vs toxicology only, how to work in restrictive and uncomfortable PPE, who to call for advice etc. And of course in the midst of all of this, there are grieving relatives who will need to be informed and updated, often with many usual expectations (i.e. viewings) and timeframes being impossible to accommodate. How well prepared are you?
Next up was a new addition to the Conference format – abstract presentations from APTs on a subject matter important to them.
In this presentation, Deborah ran us through two types of dysplasia that you might encounter in a mortuary setting, their causes and characteristics on imaging and macroscopically.
Firstly, an all-important definition of ‘thanatophoric’ – a word of Greek origin meaning ‘death bearing’. Deborah explained that although skeletal dysplasia presents in many forms with differing levels of severity, it is Type I and Type II thanatophoric skeletal dysplasia that are fatal. Children with thanatophoric dysplasia are usually stillborn or die shortly after birth.
With the aid of photographs and x-ray imaging, Deborah illustrated the differences between Type 1 and Type II dysplasia. Type I typically presents on imaging with disproportionately shortened limbs, bowed long bones, relatively large head with a normal trunk length with platyspondyly of the spine (to name a few). Type II characteristics include short, straight long bones with a ‘telephone handle’ shaped long bones that were impressively demonstrated on the associated x-ray imaging.
Thanatophoric dysplasia affects around 1 in 60,000 births and is caused by a mutation in the fibroblast growth factor receptor gene 3 and can occur in families with no history of the disorder. I will definitely keep an eye out for such cases in the future and feel a lot more confident being able to point out anomalies on x-ray imaging now.
This is such a hugely important topic for any workplace, but APTs are exposed on a near daily basis to scenarios that may have a negative impact on mental health (also events outside a workplace setting may be detrimental to mental health which ca have an impact on work life).
1 in 4 of us will experience a mental health problem and workplaces have a duty under the Health and Safety at work act to support those who need help, and the Equalities Act states that no one should be discriminated against due to mental health issues in the work place. Ruth gave us some definitions of stress and how it can affect you physically and mentally. Each of us will have a different stress level tolerance, but once that level is breached, what support do APTs have?
Back in August, Ruth put out a survey looking to capture what APTs felt about their work, its impact on their mental health and what support systems (if any) were in place:
Some answers that were given regarding challenging aspect of the job perhaps were not that surprising – dealing with bereaved families, child deaths and particularly violent deaths were top of the list. Solutions to this were given as spending time with family and friends, exercise and meditation/self-reflection. Many of these are acts of self-care that do not involve accessing help via the workplace. Ruth brought up an excellent point that I had not realised before – there is not really any support or signposting at a professional level via the AAPT (compared to advice and signposting available to doctors and nurses via the GMC/RCN etc.) Is this something that the AAPT should consider offering, even if it is a series of links on the website that are accessible to everyone?
I know that personally speaking, and anecdotally, APTs have often been left out of any offer of help in the aftermath of mass fatality incidents. I have felt that outsiders may think that APTs are hardened to these scenarios and are simply facing yet another day in the mortuary.
For those of us employed in the NHS, occupational health can be approached but, just like other services, there can be a lengthy wait and I’ve often wondered if the support they can offer would be suitable for APTs given the pretty unique work we do. Approaching managers regarding occupational health appointments and referrals may also be another obstacle in people accessing help. It is this lack of support that leads me to agree with Ruth that maybe there should be some form of professional support network within the AAPT, even if it is just providing a safe space for people to vent and signposting resources for people to access out of work if necessary.
With that in mind, here’s one link to start off with:
I would love to hear an update on this topic, Ruth!