This year’s conference was held in Luton and once again was a credit to those organising the event. Lydia Judge-Kronis and her team delivered an excellent programme with a wide range of topics covered.
John Pitchers, Vice Chair of AAPT opened proceedings welcoming all the delegates before handing over to Zoe Rutherford to chair the morning session.
Infection risks in the mortuary
The first speaker was Dr Mike Lilley from the Health Protection Agency who gave a reminder to all of us about infection risks in the mortuary. The actual risk from the deceased is very low as most organisms are unable to survive long after the death and those responsible for decomposition pose no risk. In most cases if you take the appropriate precautions such as wearing the appropriate personal protective equipment and effective hand washing then you will have minimised risk.
Alcohol gels are no substitute for hand washing, which I shall certainly take on board! APTs are most at risk from infection by inoculation or Needlestick type injuries and even then the risk is lower than most people would probably expect. If there is an effective immunisation then APT staff should be offered this routinely and recommended vaccinations can be found in the ”Green Book” Hepatitis C infection is a 1 in 300 risk after one Needlestick injury whereas HIV infection carries a 1 in 3000 risk.
Ultimately the dead are less of a threat than the living but if you treat everyone as if they are a potential infection risk and take appropriate precautions you are extremely unlikely to contract any infectious disease.
Joining bereavement and mortuary services
The next topic was one of interest to many in the room and the presentation was very much based on personal experience. Tracey Biggs, Mortuary & Bereavement Services Manager at Guy’s and St Thomas’ Hospital Trust in London, along with Zoe took us through their journey from disjointed services to their award winning “one stop shop.” Some of the nightmares such as getting NHS and Local Authority IT systems speaking to each other were expected but getting staff to change their way of working and ensuring communication throughout the new team also provided their own challenges. Ultimately the vision of providing a top quality service for the care of the deceased and the bereaved ensured that the goals were met.
A Business Case to provide the new service managed to secure the team £200K and this enabled the plans to be rolled out. New dedicated space for the bereaved incorporating tranquil space and the opportunity for in house death registration with the “tell us once” service provided the basis for this forward thinking venture. All through the presentation the one word that continued to crop up was communication and the whole project relied heavily on good communication between everyone involved. As staff got used to the new venture other benefits have included provision of an improved Tissue Donation System and a Counselling Service. As the service continues there are further opportunities for staff education and service improvement.
A short break for refreshments allowed delegated to peruse the trade stands. Every year AAPT are very well supported by mortuary related trade.
CT Scanning and Post Mortems
Dr Amanda Jeffrey was next to give a presentation, one anticipated with mixed feelings, CT Scans and their role in the Post Mortem Examination.
Over the years we have had many presentations on imaging and its effectiveness post mortem, sometimes the hype surrounding the Virtopsy or Catopsy replacing the post mortem examination has meant the negatives have not been note. In reality did APTs know what is available and what are the limitations, we were about to find out!
Benefits in Forensics are often obvious when there is severe trauma or multiple fatalities. Other positives are the speed of the examination and there is much less handling so less contamination. Unfortunately radiographers can be traumatised! Papers published suggest that 87% confidence in providing an accurate cause of death from the Manchester studies but were they right? Unfortunately the Forensic and Mass Fatality Group in 2008 decided to investigate potential but forgot to invite an APT to the table.
A quick scouting image in 2D can be done in 8seconds and gives a heads up to potential trauma and followed by axial images a 3D reconstruction can be used to impress people with no PM knowledge! There is no disputing the usefulness where there is trauma or a need for reconstruction to provide an ID but what about the cause of death?
How good are images with natural disease such as enlarged hearts, air embolism or some tumours? Cause of death in a RTC may be head trauma but did the deceased have a myocardial infarction? There is a good deal which may be open to interpretation on images and ultimately imaging is an add on but not a replacement to the post mortem examination.
Dr Jeffrey suggested that if costs were not prohibitive then we may be able to adopt the Australian model where APTs do the imaging but logistical issues are also an issue. What would we do with bariatric patients or those with severe rigor or deformity? Any plans to use imaging must involve APTs as currently it’s the blind leading the blind. I think after the presentation it was good to see a balanced opinion which did not say imaging is the future and it’s here now!
New APT qualifications - update from the RSPH
The morning’s final presentation was by Dr Richard Burton from the RSPH and concerned the new APT Qualifications. We must thank Richard for stepping in at the last minute as Garth Dineen had to pull out after being involved in the Sheppey pile up. We wish Garth a speedy recovery.
Richard explained the long and often torturous route that had led to the new qualifications being introduced. RSPH have supported the profession and with input from RSPH, AAPT and the MSC team from the Department of Health developed a new qualification which comprises of modules and is much more practically based. No-one likes change but after 50 years APTs need to recognise that their professional aspirations must be backed by qualifications which represent hard educational currency and are recognised by educational bodies.
The Level 3 Diploma has been published and the level 4 Diploma will follow shortly and finally there will be a BSc in Anatomical Pathology Technology.
Richard explained that the new course would be comprised of taught modules and also practical modules. The Level 3 Diploma has been Ofqual accredited (Qualifications and Credit Framework) and in total is 60 credits in size. Evidence will be required for the workplace units and there will be practical assessments as well as assignments to carry out. All ten units in the Course will require to be passed prior to the Diploma being awarded.
It is great news that finally APTs are going to have new qualifications 50 years after the old ones were introduced. Amazingly there were no questions at the end of the presentation!
After a welcome break for lunch and another chance to speak to the trade representatives Michelle Lancaster introduced Dr Michael Ashworth, Consultant Paediatric Pathologist at Great Ormond Street Hospital who invited us to “Look at the Heart of the Autopsy.”
The heart of the autopsy
Many APTs are unfamiliar with paediatric hearts so have no exposure to congenital heart disease or cardiac abnormalities. The one important point is that the dissection is completely different and babies and children are not “little adults” The different dissection techniques allow different views of the heart and great vessels. Artefacts are quite common and 30-40% of people may have to three accessory right coronary arteries and blood cysts on the mitral valve are common but of no significance.
Different dissection and scanning techniques were demonstrated with reference to red peppers and different chamber views and which was best for demonstrating different conditions such as Tetralogy of Fallot and its four common anomalies and hypolplastic left ventricles. From the presentation it was very clear that paediatric pathology and the specialist knowledge needed for describing cardiac anomalies alone marks this out as a very special specialism.
Professor Steve Gentleman and his colleague Dr George Gveric from Imperial College London were next to give a talk on tissue banking, especially brain banking, and why it is important.
Unlike most organs the only way the brain can be properly examined is after death so it does mean that examining the brain is really the ultimate audit for neuropathology. Imperial College deals mainly with Parkinson’s and Multiple Sclerosis Brain Banks and they facilitate research by organising tissue retrieval 24/7. From the time that death has been confirmed the whole process of getting the deceased to the mortuary, paperwork completed, tissue retrieved and transport arranged can be done within 24 hours. Unfortunately logistically some of us live to far away from London for this to be possible but we can still retrieve the tissue within 24hours and fix it for transportation later. Once the tissue is at Imperial then 22 areas are sampled and 60 slides examined to give the full diagnostic picture.
When people are diagnosed with Parkinson’s diseased then often it is not pure Parkinson’s but a mixture of degenerative disorders which are common in older people. The research conducted on donated tissue is to help understand pathology within the brain, it is unlikely we will find a way of reversing degenerative disease but stopping it before it causes damage is the aim. In most people it is estimated that the disease process has been working for 15-20 years before it is detected. It is still not clear what the neuropathological substrate of cognitive change is in PD whereas in Alzheimer’s it is recognised as two proteins.
In America there are a lot of chronic traumatic encephalopathy’s many related to American Football where players ask to have their brains examined after death, boxing has similar statistics.
As a result of the research tissues being available many drug therapies have gone to trial and then some have been made available on prescription.
Unfortunately many patients are classified as DLDH or Dementia lacking distinctive histology but post mortem examination of brain tissue is the only way we can learn more about dementias and degenerative brain disorders. For many of us it was the first time we got a change to meet these people we speak to regularly on the telephone during our normal working routine.
Our final coffee break gave us a chance to ask those last minute questions from trade before having two of our most entertaining talks of the day!
The Death of Marilyn Monroe
Professor Atholl Johnston always entertains and this time his presentation regarding the death of Norma Jean, topical due to it being the 50th anniversary of her death last year. Marilyn is one of those people, like another young blonde, whose death has caused no end of conspiracy theories, was it suicide, murder or accidental death?
Marilyn Monroe was born on June 1, 1926, her mother Gladys was schizophrenic and so much of her childhood was spent in care. In 1941 Norma Jean married her first husband Jim Docherty but divorced in 1946 after the war, she was 20 years old and had aspirations of being a movie star!
We worked through all the history but it would appear that there were two key facts; Munroe’s psychiatrist was prescribing her chloral hydrate for insomnia, which was in effect the Rohypnol of its day as it was both a sedative and hypnotic. Probably the most famous reference is the Mickey Finn which was most likely named after the manager at the Lone Star Saloon and Palm Garden Restaurant, who was ordered to close on December 16, 1903.
Secondly Dr Engleberg was prescribing Munroe pentobarbital, one of the world’s most popular barbiturates. Legend has it that it was named after a Munich barmaid, Barbara, when it was first synthesised in 1864. By 1960 8% of prescriptions were for barbiturates and Nembutal had 15 million prescriptions alone, overprescribed and over used.
On the 4th August 1962 Eunice Murrays, the housekeeper, called Greenson as Marilyn’s door was locked. At 1am he gained access to her room visa the French windows and called Engleberg. It was only at 0425 that the LAPD were called and told death had occurred at 0350 even though there was established rigor mortis. Neither of the men endeared themselves to the LAPD and the housekeeper was found washing sheets at 0430.
There was no obvious trauma; no pill residue and toxicology gave pentobarbital levels at the lower end of fatal but Chloral hydrate levels were high. The death was deemed the result of an overdose, possibly suicide. Unfortunately all the samples disappeared before a second opinion could be sought. Over the years much has been made of conspiracy theories, was it murder, were the Kennedy family involved and one other high profile case comes to mind with a similar fascination. Diana Spencer’s sudden death also had a botched toxicology, occurred in August and has endless conspiracy theories. They also have Elton John’s 1973 record in common!
Servants of the Reaper
In the “Graveyard slot” we had Kristoffer Hughes who as well as being a fully qualified APT is the founder and Head of the Anglesey Druid Order and studies with the Order of Bards, Ovates and Druids. His presentation entitled Servants of the Reaper: Living a life in death was a fast moving trip through death starting 24000years BC. We now know that prostitution is not the oldest profession, serving the dead considerably predates it.
From religious preparation in the Gower peninsula through Egyptian rituals to the modern day we were highly entertained. 150 years ago there was public outcry when APT work, or mortuaries in the more modern sense, can first be identified but in reality it was just a continuation of the old practice of looking after the dead. Stonehenge was the precursor of modern day cemeteries with stone traditionally signifying death.
Since 1843 when a sanitation report in London suggested a “mortuary” to put the 20,000 deaths, 75% of which occurred in single room homes and it took up to three weeks to organise a funeral, it was 1852 when St Ann’s dead house in Soho came into being.
Kriss took us from Queen Victoria, professional mourner through world war two to the present day where the funeral industry has once again mystified some of the rituals surrounding death. Kriss also talked about how APTs are visceral insulators helping insulate others from “bad things” but expected to cope when they themselves, the consummate professionals, need a little visceral insulating. Just because we deal with death every day does not mean we are impervious to grief. Kriss has his own experiences of being in this situation and as we laughed and cried through his presentation I think his presentation really resonated with many in the room.
This brought the academic programme to a close and Dr Mike Osborne, the AAPT President proposed a vote of thanks to Lydia, John and David as well as their team of helpers was well deserved.
As always we have to thank the excellent speakers for their time and trade for supporting us so magnificently once again this year.
We will have high expectations for the Newcastle 2014 AAPT Conference next year.
Ishbel Gall AAPT Chair