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Medico-Legal Update

A study of hazards and risks in the autopsy centre

Author(s): Senti Toshi, S.K. Pandey, Manoj Kumar, S.K. Tripathi

Vol. 8, No. 2 (2008-07 - 2008-12)

Senti Toshi٭, S.K. Pandey٭٭, Manoj Kumar٭٭, S.K. Tripathi٭٭٭

٭Resident, Department of Forensic Medicine, IMS, BHU, Varanasi,
٭٭Lecturer, Department of Forensic Medicine, IMS, BHU, Varanasi,
٭٭٭Professor and Head, Department of Forensic Medicine, IMS, BHU, Varanasi.

Abstract

The present paper is a highlight of the hazards and risks, present in the autopsy centre and faced by the workers involved in the autopsy room. This study was conducted in the department of FORENSIC MEDICINE, IMS, BHU, Varanasi, during the year 2007. It was found that about one-fourth i.e. 502 cases (25.48%) of the total 1970 autopsy cases done were hazardous. Of which, infective risk contributed the highest (67.52%) and then followed by poisoning cases (32.47%).

There were also 43 cases of decomposed bodies autopsied. The other existing hazards were studied through a questionnaire put forward to the workers regarding physical injury, exposure to chemical hazards, infections and adverse psychological effects, secondary to stressful working environment of the autopsy room and presence of other occupational hazards if any.

Key word: hazard, risk, autopsy center, physical, psychological

Introduction

Health hazard and risk among health workers, is a well known occupational problem, but still it continues to be one of the biggest challenges faced till date. Worthwhile to mention is that, these hazards are directly proportional to the type of work done by the health workers, and thus the autopsy centre becomes one of the biggest health hazards place among the health departments. It has also been shown by studies that the postmortem examination room is one of the most potential sources for infections among all the areas of medical field. The persons at risk include the autopsy surgeons, the pathologist, technicians, potters, sweepers and others directly or indirectly involve in the postmortem examination3. The major risk is infections, which comes from sources of viral origin such as HIV, hepatitis B, hepatitis C, hepatitis D, non-B hepatitis, herpes, human T-cell lymphotropic virus type I etc, and bacterial sources as tuberculosis, staphylococcus, streptococcus, salmonella etc. 1,3,4,7,9,11.

Moreover, most of the time the dead bodies coming for autopsy have no past medical records or if at all present, contains inadequate informations. Special informations worth mentioning is information of drug abuse, prostitution, occupations such as truck drivers, army men etc, as individuals with such history are at high risk of acquiring infections which have long latent period of clinical manifestation of the disease, but are potential source of infections, such as HIV, tuberculosis etc3,8. So risk from these bodies is also unknown and hidden3,8. Also most of these dead bodies are cases of hospital admission, possible hospital acquired infections can be present, which are more virulent and resident to treatment. The medium through which these infective risks can be exposed to workers includes mainly blood and OPIM (means other potential infective materials and includes, pleural fluid, peritoneal fluid, CSF, semen, vaginal secretion, pericardial fluid, other body fluids etc)3,9.11.

The route of introduction of these potential infections happens, when the hazardous medium comes in contact with the body through following ways3:

  1. Inhalation of infective aerosolized particles.
  2. Splash of blood or other body fluid onto an open wound or area of dermatitis.
  3. Contact of blood or other body fluids with mucous membranes of the eyes, nose or mouth.
  4. Wound resulting from injury due to contaminated objects/instruments with blood or body fluids as needle, blade etc.

Exposure to poisons from poisoning death cases is another important hazard, as death due to poisons is a common occurrence in India. Biohazards to health as a result of exposure to decomposed bodies includes irrespirable gases as- Ammonia, Cadaverine, Putrescine, Carbon Dioxide, Hydrogen Sulfide, Methane, and Hydrogen as well as bacteria involved in decomposition3,10. The Other hazards includes physical injuries from needle prick, cut from scalpels, cutting saw, chisel and hammer and also cuts from broken sharp bonny parts of the victim while conducting autopsy, chemical hazards from formalin, absolute alcohol, phenol etc used as preservatives and disinfectants and adverse psychological effects as depression, mood swings, addiction etc secondary to stressful working environment in autopsy room7. Other possible risk of concern for autopsy workers includes- rabies, prion disease, plague, brucellosis, salmonella etc3,6.

Material and methods

The study data of potential hazards and risks were collected from the 1970 dead bodies coming for medicolegal autopsy in the department of Forensic medicine IMS, BHU, Varanasi in the year 2007 and a questionnaire was designed to assess the hazards and risks faced by the autopsy workers. The presence of hazards and risks from the dead bodies were noted based on presence of infective features (as presence of pus, abscess, fibrosis and adherence of lung to chest wall, features of gangrene, putrefied bodies) and poisons in the cases of poisoning. These data were correlated with gender, type of case, presence of any health problem, Results Of the total of 1970 cases of autopsy, 502(25.48%) cases (278 male and 225 female) were noted to be source of risk and hazard to the health of the autopsy workers, of which infected samples were the commonest 339 cases (17.20%) followed by 163 poisoning cases (8.28%) as shown in fig:1. Of the infective source, the most common case was of burn with sepsis of 179 cases (52.802%), followed by 132 cases (38.93%) of pneumonic lung with septicemia (here most of the cases were of unknown individual of 72 in number, 44 diagnosed infected cases and 16 cases of prisoners), other infected cases included, 2 known tuberculosis cases, 6 accidental cases with sepsis (of which 3 of them had gangrene), 3 infected gunshot cases, 2 cases of congestive heart failure with sepsis, 2 cases of peritonitis(one was a case of illegal abortion and other one of penetrating abdominal injury), and a single case of known HIV infection, as shown in table 1. The remaining 12 cases were of decomposed bodies (7 suicidal cases of hanging and 5 homicide cases).

Though, total cases of decomposed bodies were 43 in number, but for the remaining 31 cases apart from above mentioned, could not be categorized separately as they were associated with already categorized hazardous cases of infected unknown individual dead (23 cases) and poisoning dead cases (8 cases).

It was also found that of all the hazardous cases of autopsied bodies, the presence of hospital admission and treatment was found in 330 cases (65.73%). From the questionnaire’s, the information obtained about the exposure to hazards and risks includes – In physical hazards, there were three incident of needle prick injury to hand, one incident of cut injury by scalpel blade to hand, and presence of body pain, fatigue, mild burn and irritations from chemicals were a frequent occurrence. Regarding psychological adverse effects, substance abuse to alcohol and tobacco, stress, fatigue, depression, moody personality, frequent leaves and absenteeism from work etc were present among autopsy workers. Also two of the autopsy workers had history of been diagnosed with tuberculosis and had treatment, in the course of their work in autopsy room.

Hazards and risks observed in the autopsied bodies

Fig. 1: Hazards and risks observed in the autopsied bodies, in department of forensic medicine, IMS, BHU, 2007

Table 1: Showing the types and numbers of infected autopsy cases

  Infected cases Number of case
1 Burn with sepsis 179
2 Pneumonic lung with septicemia 132
3 Accident with sepsis 6
4 Gunshot with sepsis 3
5 tuberculosis 2
6 CHF with sepsis 2
7 peritonitis 2
8 HIV 1

Note: Decomposed bodies are not included in above table.

Table 2: Showing overall observations of hazards and risks in forensic department, IMS, BHU

no hazards risk observations
1 Infections Septicemia, pneumonic lung,
tuberculosis, HIV, and others.
339 cases of autopsied bodies plus
History of tuberculosis infection
and treatment in two autopsy workers.
(decomposed poisoned cases excluded)
2 Poisoning Poisons from Poisoning cases 163 cases
3 Biohazards Irrespirable gases and bacteria’s
from Decomposed bodies
43 putrefied cases
4 Physical Cut, needle pricks backaches,
muscle pain and other injuries to body.
2 case of needle prick injury,
one case of cut injury,
and presence of body pain a common feature.
5 Chemical Burn, irritations, sore eye, lacrimation, pain etc. Frequently present.
6 Psycholo-gical Stress, depression, mood swing, absenteeism etc. Common occurrence.
7 addictions Smoking, chewing tobaccos, intake of alcohol Present as habitual activity, especially among potters,
dissectors and sweepers.

Overall observations of hazards and risk in the study have been shown in table 2.

Discussion

From the above observations, it is clear that autopsy room is a high risk room for medical workers. The degree of risk faced among the workers involved in autopsy work differs, the highest infective risk is faced by those who are directly involved with the dissection of the body7, which is followed by those involved in examination and documentation of the observed information into reports (the doctors and the technical assistants), the others exposed to risks includes the potters involve in shifting the bodies, the accompanied police personals and the sweepers.

In the department of forensic medicine, IMS, BHU, Varanasi about 1500 to 2000 autopsies are conducted every year and on an average daily about 5 to 6 autopsies are conducted. The working team for an autopsy in our hospital consists of two doctors on duty having the facility for expert assistance when needed, one technical assistant, one worker helper for dissecting the body, four potters for shifting the body, one sweeper and two police constables on duty. Personal protections as gloves, apron, rubber boots etc are provided to this team but sad to say of the inadequacy of the material provided, mainly due to inadequate funding to the department. The practice of strict universal precaution is also questionable one. Also the department is understaffed as per the sub-committee report (Bureau of Police Research and Development of 1975)5 and also fails the MCI norms regarding a hospital with autopsy facility.

Though rapid advancement and modernization is taking place in all the field of medical sciences in India during this present century, the autopsy center remains an exception. The basic concept of health “womb to tomb” clearly indicates that in a health care set up the duty of a doctor is not only to care the living but also the patients who die, but practically the later is less adopted5.

All these drawbacks and inadequacy of facilities are common problem all over India and results in inadequate output of quality of work, thus forensic department in India has become just a death house instead of becoming the law facilitating center of modern medicine5, bringing serious adverse impact on the work of justice department and the ultimate sufferers are the common people and the community. The eye opening catch from this study for the forensic medical people is how to create a safe and healthy working environment in the autopsy centers. To do so, in brief, safe and healthy practice should be adopted starting from the dead bodies, as washing the bodies, plugging all orifices and protecting the rest of the body with clothing’s etc, soon after death1,3. Regarding the autopsy centers, it should be adequately staffed, have adequate space with good ventilation, lighting, exhaust and sterilization facility along with good practice of cleaning and disinfecting the autopsy center especially the autopsy room. The practice of strict universal precautions of using gloves, face mask, goggles, protective aprons and head cap should be followed. In few cases as HIV, an extra care like using double glove, HIV autopsy kit, generously using disinfectants as bleaching powder in contaminated areas with adequate sterilization of instruments and finally careful and safe disposal of these bodies, preferably incinerating them1,2,3,5,7,11.

All these above practices should be strictly followed as “Safe Life” is not only our right but also a responsibility.

Conclusion

High prevalence of hazards and risks poses a great threat to autopsy workers in India. Thus Periodic training and education in safe postmortem procedures should be practiced and also integrated teaching and learning between different departments of medical field to help forensic workers to understand and identify potential infectious materials and diseases and follow preventive measures as per “the standard universal precautions”. Also first aid management in cases of exposure to any hazard should be incorporated. Vaccination against infection especially hepatitis, tetanus and others vaccine preventable disease should be strictly practiced. Finally but not the least the employees should also be educated on the awareness of the workmen’s compensation act 19231, so that it will help the workers feel more secure, as work without fear results in best and most effective outcome, which in turn would help in providing efficiently the purpose of our forensic work i.e. “social and legal justice”.

References

  1. Modi.N.J, Medical Jurisprudence and Toxicology, 23th edition, pp 202-205, 408, 762.
  2. Green.G.B, Harris.I.S, Lin.G.A, Moylan.K.C, Washington Manual of Medical Therapeutics, 31st edition, Appendixes G. Infection control and isolation recommendation pp-36.
  3. Vij.K. and Krishan. K., Risk fators and prevention of infection in autopsy room- a review, IIJFMT 1(1) 2003.
  4. Kasper.D.L, Braunwald.E, Fauci.A.S, Hauser.S.L, Longo.D.L, Jameson.j.l, Harrison principles of internal medicine. 16TH edition, pp-959, pp-1081.
  5. Singh.S, Sinha.U.S, Kapoor.A.K, Verma.S.K, Singh.D, Sharma.S, Guidelines for set up Mortuary Complex: planning and designing of modern mortuary complex in tertiary care.
  6. S.Suguna Hemachander, Shaikh Khaja, Suma Kaza, Occupational hazards with “PRIONS”- in autopsy workers, journal of Indian academy of forensic medicine 2008, vol- 30, January-march, pp 26-28.
  7. B.L. Meel, Risk assessment of the Utama general hospital’s mortuary, in the former Republic of Transkei, Utama, Eastern Cape.http://www.geradts.com/anil/ij/vol-002-no- 001/papers/ paper 002.html.
  8. DRAFT DGAFMS MEMORANDUM ON- Autopsies on cadavers infected with HIV.
  9. Occupational safety and health administration. Bloodborne pathogens. Final standard federal register 1990; 46:64175-79.
  10. Special need cleaning services, http:// www.special needscleaning.com/faqs.htm
  11. Forensic magazine: the safety guys: blood, sweat and fears BBP- PART 1-2, VOL 4-5, April-May and June-July 2006, http://forensic.texiterity.com/, http://www.forensicmag.com/newsletter/.

Address For Correspondence:
Dr. Senti Toshi

Resident, Department of Forensic Medicine, Institute of Medical Sciences, B.H.U., Varanasi-221 005
E-mail: dr.senti (at) yahoo.co.in
Mobile: 09889198236

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