Critical Values Established in Isolation Without appropriate Escalation Policies or Sophisticated Algorithms can lead to Tragic Consequences

The purpose of this article is not to review the formulation of a critical value list, non-critical “critical values”, setting goals and measuring your laboratory performance, establishing up-to-date, clinically oriented algorithms, escalation policy and how outpatient critical values are reported, but to show what can occur when these goals are not well thought out or implemented, the consequences of which can have a negative impact on patient safety.  For laboratory values to be clinically meaningful an escalation policy and or a sophisticated algorithm should be in place, which interpret laboratory values, that on face are not themselves critical, but taken in concert with other values, and if provided, the patients underlying medical condition, will recognize these values are ‘critical’ for they portend a life-threatening situation for the patient.  The following case will illustrate what can occur when these goals are not met.  Click on the link to download the document.

Critical Values Established in Isolation Can Lead to Tragic Consequences

Nonsexual and Sexual Traumatic Injuries of the Perineum, External Genital Organs and the Breasts: Adult, Elderly and Pediatric

In this chapter we will review the anatomy and traumatic injuries of the perineum, external genital organs and the breast, both sexual and nonsexual in origin.  Although the breasts anatomically are not part of the perineum or the external genital organs, it is considered an accessory to reproduction function.  Also, when considering traumatic injuries to the breasts, especially those of a sexual abuse nature, they are not uncommonly subjected to trauma as are the external genitalia.

As in previous chapters the first part, pages 1 – 141, will cover the relevant anatomy of the perineum, external genital organs and the breasts.  The remaining portion of the chapter, pages 142 – 416, are devoted to traumatic injuries to these structures.  The purpose of this format is two fold: first, it will constitute a review of the anatomy of these structures for medical students, pathology residents, forensic pathology fellows, forensic nurses, emergency room residents and trauma residents, aiding them in understanding the pathophysiologic dynamics of traumatic injuries; secondly, since this educational blog may also be used by medicolegal investigators, emergency medical technicians, paramedics, law enforcement personnel and attorneys, such a review will help them to develop a better understanding of the effects of trauma on the victims.

As indicated above, there will be a discussion of traumatic sexual abuse injuries, which will include male and female, adults, elderly, children and infants.  Due to the nature of this subject the illustrations are graphic, which some may find disturbing to view.

Lastly, there will be a section addressing various pragmatic issues , which the forensic pathologist may face as a medical examiner/coroner

Traumatic Injuries of the Perineum,

Traumatic Injuries of the Organs of the Pelvis: Adult and Pediatric

In this chapter we will review the traumatic injuries of the organs of the pelvis, which will include the urinary bladder, the rectum, the anal canal, and the internal genital organs.  Although the rectum and anal canal represent the terminal portions of the gastrointestinal tract, only the rectum lies within the pelvis.  However, for the sake of continuity we will consider the two parts together.

As in previous chapters, the first part of this chapter will be devoted to the relevant anatomy of the pelvis and its contained organs.  As discussed previously, the purpose of a discussion of the relevant anatomy is two fold.  First, it will constitute a review of the anatomy for the medical students, pathology residents, forensic pathology fell0ws, forensic nurses, emergency room residents, and trauma surgeon residents, aiding them in understanding the pathophysiologic dynamics of traumatic injuries to the pelvis and its contained organs.  Second, since this educational blog may also be used by medicolegal investigators, paramedics, law enforcement personnel, and attorneys who have little knowledge of anatomy, such a review will help them to develop a better understanding of the affects of trauma on the victims.

There will also be a discussion of the mechanisms of injury to the pelvic cavity and its contained organs.

This chapter contains a discussion of sexual abuse, male and female, adults, children and infants.  Due to the subject matter, the illustrations depicting sexual abuse injuries are graphic by their very nature.

Traumatic Inuries of the Organs of the Pelvis- Adult and Pediactric

Traumatic Injuries of the Organs of the Pelvis: Adult and Pediatric

In this chapter we will review the traumatic injuries of the organs of the pelvis, which will include the urinary bladder, rectum, anal canal, and the internal genital organs.  Although the rectum and anal canal represent the teriminal portions of the gastrointestinal tract, only the rectum lies within the pelvis.  However, for the sake of continuity we will consider the two parts together.

As in previous chapters, the first part of this chapter will be devoted to the relevant anatomy of the pelvis and its contained organs.  As discussed previously, the purpose of a discussion of the relevant anatomy is two fold.  First, it will constitute a review of the anatomy for the medical students, pathology residents, forensic pathology fellows, forensic nurses, emergency room residents, and trauma surgeon residents, aiding them in understanding the pathophysiologic dynamics of traumatic injuries to the pelvis and its contained organs.  Second, since this educational blog may also be used by medicolegal investigators, paramedics, law enforcement personnel, and attorneys who have little knowledge of anatomy, such a review will help them to develop a better understanding of the effects of trauma on the victims.

There will also be a discussion of the mechanisms of injury to the pelvic cavity and its contained organs.

This chapter contains a discussion of sexual abuse, male and female, adults, children and infants.  Due to the subject matter, the illustrations depicting sexual abuse injuries are graphic by their very nature and some may find difficult to look at.

Traumatic Inuries of the Organs of the Pelvis- Adult and Pediactric

Traumatic Inuries of the Organs of the Pelvis- Adult and Pediactric

Traumatic Injuries of the Organs of the Retroperitoneal Space: Adult and Pediatric

In this chapter we will review the traumatic injuries to the organs of the retroperitoneal space, which will include the pancreas, kidneys, ureters, adrenal glands, abdominal aorta, and the inferior vena cava.  Although, the abdominal portion of the esophagus is technically retroperitoneal, as is true of the distal portion of the first part of the duodenum, its second and third parts, and the fourth portion with exception of the most distal part, and the ascending and descending colon, they were discussed in the previous chapter, “Traumatic Injuries of the Organs of the Abdominal Cavity: Adult and Pediatric,” for the sake of continuity.  The first part of this chapter will be devoted to a discussion of the relevant anatomy of each of the organs.  The purpose of this discussion is two fold.  First, it will constitute a review of the anatomy for the medical students, pathology residents and forensic pathology fellows, aiding them in understanding the pathophysiologic dynamics involved in traumatic injuries to these organs.  Second, since this educational blog may also be used by medicolegal investigators, law enforcement personnel, and attorneys, who have little knowledge of anatomy, such a review will help them to have a bettter understanding of the relationships between trauma applied to the victim and their injuries.  There will also be a discussion, in a general sense, of the mechanism of injury to the retroperitoneal organs when they are subjected to trauma.

Traumatic Injuries of the Organs of the Retroperitoneal Space

Traumatic Injuries of the Organs of the Abdominal Cavity: Adult and Pediatric

In this chapter we will review the traumatic injuries to the organs of the abdominal cavity, which will include the esophagus, stomach, duodenum, jejunum, ileum, mesentery, appendix, colon, liver, gallbladder, and spleen.  Although, much of the esophagus is within the thorax, for the sake of continutiy, it will be discussed with the gastrointestinal tract, most of which is located within the abdomenal cavity.  There will also be a discussion, in a general sense, of the mechanisms of injury to the abdominal organs when the abdomen is subjected to blunt force trauma.  We will first review the surface anatomy, as well as the anatomy of the abdominal cavity.  The foundation of thought behind reviewing the anatomy is based on the fact that an understanding of the surface anatomy will give you some insight into what you can anticipate internally during your external examination.  It will also give you a grasp of the dynamics involved which produced the external and internal traumatic injuries. Since this educational blog may also be used by medicolegal investigators, police officers and attorneys, who for the most part have little knowledge of anatomy, such a review may help them in having a better understanding of the relationship between the blunt force trauma applied to the victim and their injuries.

Traumatic Injuries of the Organs of the Abdominal Cavity- Adult and Pediatric

Blunt Force Traumatic Injuries of the Chest

In this chapter we will discuss traumatic injuries to the chest wall and the thoracic viscera.  Chest wall injuries include the skin, subcutaneous tissue, intercostal musculature, ribs, sternum, and parietal pleura.  Thoracic visceral injuries include two main categories: (1) mechanical injuries of the respiratory system, which will include diaphragmatic rupture.  The inclusion of diaphragmatic rupture is due to the fact clinically it presents with symptoms analagous to pneumothorax.  (2) mechanical injuries of the cardiovascular system, which will include the mediastinum.  This is primarily due to the fact the most common cause of a widen mediastinum is aortic rupture.  We will also discuss the mechanisms of chest injury.  Prior to a discussion of the blunt force traumatic injuries of the chest and mechanisms of chest injury, we will review the anatomy of the thorax.

Blunt Force Traumatic Injuries of the Chest

The Oculomotor Systems-Cranial Nerves III, IV And VI

In this chapter we will discuss the organization of the ocular motor system and how visual information guides eye movements.  This review will inclucde the function of the six extraocular muscles, the neuronal control systems, which keep the fovea (that part of the retina responsible for sharp vision) on the object of interest, the neuronal systems for saccadic eye movements (they shift the fovea rapidly to a visual target in the periphery of the visual field), and the neuronal systems, which control smooth pursuit (keeps the image of a moving target on the fovea), vergence (move the eyes in opposite direction so the image is still and stablizes the image when the object moves or when the head moves), vestibulo-ocular movements (these hold images still on the retina during brief movements and are under the control of the vestibular system), and optokinetic movements (these hold images during sustained head rotation and are driven by visual stimuli).  We will review disorders of the neuromuscular junction and their effect on ocular muscles, as well as some of the myopathies which involve ocular muscles.  We will first review the morphogenesis of the CNS to gain some understanding of the origin of the cranial nerves (CN) III, IV, and VI and the extraocular muscles.

The oculomotor systems CN III, IV, & VI

Sharp Edged and Pointed Instrument Injuries

In this article we will discuss those injuries produced by sharp-edged instruments, incised wounds, and pointed instruments with a sharp-edge or edges, stab wounds.  This will be followed by a review of those injuries produced by instruments, which do not have a sharp-edge, but have a blunt point, such as found in barbecue forks, dinner forks, screwdrivers and scissors.  Chop wounds and impaled injuries will be discussed.  Mechanism and manner of death will then be reviewed.  Fundamental concepts such as cardiac tamponade will be explained, as well as the function of various cellular structures, such as neutrophils, monocytes and lymphocytes, in the inflammatory reaction to trauma.  There is a detailed review of the chronological histologic features of dating of incised and stab wounds, the purpose of which is to show there is sound scientific basis for the histologic dating of these injuries.

Sharp Edged and Pointed Instrument Injuries

Cranial Nerve II/Visual Pathway

In this article we will first discuss the embryology and anatomy of the visual pathway (the physiologic process by which we are able to see the world around us).  It is believed that once you have an understanding of the embryology and anatomy of the visual pathway, you will have a better comprehension of why some of the injuries produce the changes in vision they do.  You will note that there is some repetition in both the illustrations and written text.  This was done with the intent of the reader gaining a clearer understanding of the intricacies of the visual pathway.

FORENSIC NEUROPATHOLOGY