Sljmodiaries

This was a case of SPLENIC LACERATION in a 51year old who had met with a Road traffic accident.
The spleen which is usually situated on the left upper quadrant of the abdomen, is a highly vascular organ and it is the most commonly affected organ in blunt injury to the abdomen.
Spleen, if damaged can lead to massive blood loss and shock.
Such cases are very common in RTAs(Road traffic accidents), domestic violence, or even during sport related injuries.

An example of a domestic violence I saw around the same time was that a woman was struck with a broomstick onto the left side of her body and had sustained just one strong blow.
She came to the hospital with severe left sided pain and unstable vitals. She had to eventually undergo a splenectomy due to a massive splenic laceration.

RIGHT ELBOW DISLOCATION-

A 44year old man who had fallen from a height of 22 feet, while he was working at a construction site. Fortunately his head was spared but he had diverted all that force onto the right side of his elbow and shoulder. Impact was mostly on the right side of his body.

Usually posterior dislocations occur when the patient describes the falling on an outstretched hand or also known as a FOOSH Injury. (Fall Onto an Outstretched Hand)

In this case the neurovascular assessment is important as the brachial artery and ulnar and medial nerves are involved. Ulnar nerve injuries are the commonest in such dislocations.
In this case the person also had an associated ulnar nerve palsy.

Compartment syndrome must be considered in the differential diagnosis in the presence of persistent patient pain, particularly when exacerbations of pain occur with passive finger and wrist extension of the dislocated arm.

MUA (Manipulation under anaesthesia) was needed since this was a nonreducible dislocation.

Depending on the severity of the elbow dislocation, it may even take several months to heal. Early range of movement exercises and physiotherapy is recommended.

Severely Diseased Lung with Cavitations and a few bullae.

Incidental finding OF the lung in a man in his 60s who had succumbed to death following a myocardial infarction.

He was treated for TUBERCULOSIS 10years ago and had recovered following treatment. He was also known to be a chronic smoker.

What you see here is an extensive necrosis and cavitation of the left lung, most probably following TB.
He had probably survived, majorly dependent on his right lung.

*Cavitation is a distinguishing feature of postprimary TB.
In a chest Xray you would usually see cavitations in the Apical and posterior lobe of the lung, in the case of TB.

Emphysematous bullae is usually caused by COPD (chronic obstructive pulmonary disease), Alpha 1 antitrypsin deficiency and smoking as well.

A 22 year old mother of POA 9weeks was managed a few days ago for severe hyperemesis gravidarum. At that time she was also noted to have reduced urine output, with features of acute urinary retention which was immediately relieved after catheterization.
Her CRP, serum creatinine, and liver functions were found to be high. The culture reports weren't available but the rest of the investigations were normal, including serum electrolytes.
She was discharged after 9days, and the routine medical care was given.
On the way home she developed sudden onset Tonic clonic seizures and underwent sudden cardiac arrest, while at the ETU.

Post mortem features couldn't reveal anything definitive except for kidneys that were grossly enlarged and looked like AKI.
In such instances we usually give the cause of death as "UNDER INVESTIGATION" and send samples of desired organs for histology till something definitive can be ascertained.

So what you see here is a histology sample of the heart-
Showing an infiltration of neutrophils between the myocytes.
Swipe left to see the enlarged view. (The purple stained cells are the NEUTROPHILS, the predominant cell type in bacterial infections)

And hence her likely cause of death was BACTERIAL MYOCARDITIS, with the mostly likely source of origin being the kidneys

MACRO AND MICRONODULAR CIRRHOSIS OF THE LIVER.

Another person who had succumbed to complications of cirrhosis.
He is a 50 year old driver, who's also a chronic alcoholic for the past 20plus years.
He has tried to stop drinking for the past 3 months when he had already developed complications of cirrhosis. But unfortunately he developed sudden onset SOB (shortness of breath) while at home and had died.

He was also found to have massive ASCITES with bilateral lower limb, pitting oedema, upto knee level.

Patients with massive ascites may experience abdominal discomfort, depressed appetite, and decreased oral intake. Diaphragmatic elevation may lead to symptoms of dyspnea. Pleural effusions may result from the passage of ascitic fluid across channels in the diaphragm.

This is the case of a 74year old lady with a past history of DIABETES for almost 20years.
What you see here are features of BILATERAL CHRONIC KIDNEY DISEASE -
Irregular shaped kidneys with multiple scarring.
Some cystic appearance of the kidneys are noted as well.

Diabetes and hypertension are at present the major causes of chronic kidney disease (CKD) and end-stage renal disease (ESRD) worldwide.

44year old male had been complaining of, on and off chest pain for the past 2 days. No proper medical attention was sought.

Possible cause of death- Acute MYOCARDIAL INFARCTION.
Severe degree of Coronary atherosclerosis was also present.

(NOTE the pale areas of the ventricle- which is due to necrosis of surrounding tissues.)

The earliest change that can be grossly discerned in the evolution of acute myocardial infarction (MI) is pallor of the myocardium, which is visible 12 hours or later after the onset of irreversible ischemia.

This was one of the most heartbreaking one I had to see💔

18day old baby girl, born at 33 weeks of gestation, with a birth weight of 1.6kg. She was the 2nd child of Mrs H.N, who also had a past history of 2 miscarriages.

She had been observed for a few days after birth and was discharged with no other complications.

She had been previously feeding well, no vomiting or fever. Good urine output and passage of stools.
On Day 18, She had developed a bit of nasal blockage and difficulty in breathing and by the time the mother brought her to the hospital, it was too late for resuscitation.Her on admission birth weight was 1.46kg.

The cause of death was found to be due to MILK ASPIRATION.

In the picture of the LUNG shown you can see a white frothy liquid oozing out of the bronchus which is milk that has been aspirated.
And the haemorrhage suggests possible infection going on- aspiration pneumonia can occur.

In premature babies its quite common as their reflexes are still developing.
Babies usually cough, choke or exhibit respiratory symptoms and may need immediate attention.

Silent aspiration may occur as a result of factors due to sensory and feedback deficits and could often go undetected.

This is the case of a 84year old lady, known patient with Diabetes and Hypertension, who has also been bed ridden for sometime, presented with sudden onset difficulty in breathing and had passed away on her way to the hospital.

On postmortem Examination she was found to have Underlying Congestive cardiac Failure.

The video shows how the lung has frothy fluid which is a feature of PULMONARY OEDEMA. (Excess fluid in the lungs)

The Gross pulmonary oedema oedema is suggestive of a LEFT HEART FAILURE. Since she was bed ridden, no ankle oedema had been present so probably couldn't have been detected early.

Her Liver is of "nutmeg appearance" which usually occurs secondary to RIGHT HEART FAILURE , as a result of hepatic vein congestion.
The right ventricular heart Failure causes transmission of elevated right atrial pressure to the liver via the inferior venecava and hepatic veins.
The darker areas are due to dilated and congested hepatic veins/venules and the paler areas are due to unaffected liver tissue.

She also had associated sepsis, possibly due to infected multiple bed sores that were present.

This patient was a chronic alcoholic who died due to complications of cirrhosis.

What you see here is a MICRONODULAR CIRRHOSIS of the LIVER - (Laennac's Cirrhosis or Portal cirrhosis)

Over time due to Liver parenchymal injury , there is change in liver architecture and fibrosis leading to formation of regenerative nodules. Nodules usually less than 3mm are called micronodular.
More than 3mm is usually classified as macronodular ( which is seen mostly in hepatitis due to post necrotic changes )

Some of the basics regarding medicolegal investigation into deaths -

SUBARACHNOID/ARACHNOID GRANULATIONS -

Those whitish lobule-like structures you see are the granulations which has been formed due to distended arachnoid villi , as a result of increased CSF pressure.

Arachnoid granulations are structures filled with cerebrospinal fluid (CSF) that extend into the venous sinuses through openings in the dura mater and allow the drainage of CSF from subarachnoid space into venous system.

Such patients are also found to have Underlying HYPERTENSION.

COVID-19 ALERT!!
Everyone's probably too tired of hearing, the rise in covid cases and deaths coming up again and some in the community refuse to believe this as well.

COVID is still AROUND!
Maybe not you, but you can be a carrier to a family member or someone who's immunodeficient than you.

Another case of sudden home death was witnessed yesterday -15/11/2021

MrS. A, mother of 2, 35year old, presented with worsening shortness of breath early morning , and was rushed to the hospital. She was found to be unresponsive on admission.

She was a known patient with Bronchial asthma for the past 3 years and was on inhalers on and off. So 3 days prior she has been having mild dyspnoea and exacerbations of asthma which had responded to her inhalers, so the family hadn't taken it seriously.

As a routine procedure, all sudden deaths undergo a mandatory PCR test and she was found to be COVID POSITIVE.
She has also had both her vaccinations during the past year.

Contact history was traced and her son(10yrs) who had gone to school had contracted it. A fellow classmate had been found to be covid positive last week.

Anyways the cause of death was concluded as covid pneumonia which probably worsened as a result of her underlying past medical history.

NOTE-

Do not ignore if any covid symptoms are present (cough, fever, shortness of breath on exertion), especially if there are any underlying risk factors or cormorbidities like diabetes, caridac diseases or lung conditions. Get advice from a GP atleast.

Despite Vaccination you can still get COVID-19.

Follow the safety guidelines of washing hands and wearing masks in public.

This patient was brought to the hospital following a near drowning incident at home.
On admission his GCS was 3/15, BP - 200/120mmHg, BL pupils sluggish on Examination.
He was managed as possible Cerebral oedema in the ward, and was awaiting NCCT brain while he went into sudden cardiac arrest.

Cause of Death-
SPONTANEOUS INTRACEREBRAL HAEMORRHAGE -
The bleeding was noted more medially and arising from within the brain involving the thalami as well- and hence we could say the cause of death was likely due to spontaneous ICH
If it was found to be more lateral and towards the edges a possibility of trauma or head injury may have to be excluded.

Intracerebral hemorrhage accounts for 8-13% of all strokes and results from a wide spectrum of disorders. Intracerebral hemorrhage is more likely to result in death or major disability than ischemic stroke or subarachnoid haemorrhage. Intracerebral hemorrhage and accompanying edema may disrupt or compress adjacent brain tissue, leading to neurological dysfunction. Substantial displacement of brain parenchyma may cause elevation of intracranial pressure (ICP) and potentially fatal herniation syndromes

This patient came to the hospital following a 3rd degree burn injury. A tragic accident where, she had apparently been cooking by the gas stove and her shawl had caught fire. She had started running around after ( which apparently fans the flames and makes them burn faster). Her husband had tried to put it off and meanwhile sustained injuries too.

So following admission to the hospital, she was given ICU care, intubated and ventilated and the usual burn care.
Due to complications of Flame burn injury she didn't survive .

The first picture shows- SOOT PARTICLES IN THE TRACHEA AND BRONCHI
-usually if present below the vocal cords it indicates that the person was ALIVE before/during the burn. (Important to forensic medics to decide if the person was killed and burnt otherwise)

PS - NEVER RUN AROUND WHEN YOUR CLOTHES CATCH FIRE 🔥
Instead, STOP! DROP! AND ROLL!

DROWNING
Majority of the deaths witnessed yesterday were between the age group of 25 to 40s and all being consequences of the recent flooding.

Postmortem results revealed typical drowning features.
(Not all are mentioned here- these were some of the main stuff that were looked into)

1)Lungs are voluminous, edematous and usually pale.

** (EMPHYSEMA AQUOSUM)**
A term describing hyperexpanded lungs due to " waterlogged" lungs.
Lungs are squeezed out to observe the oozing out of frothy liquid which is another feature as well.

The 2nd picture shows how the medial margins of the lungs come together and the typical (heart in between the lungs) sign is absent.

2) Paltauf's haemorrhages- subleural petechiae as seen in the pic too.

3)The 3rd picture shows water in the stomach, which can also be usually present
(pic taken by me :P)

4) Washer womans hand/feet appearance (usually occurs if been immersed for about 4hours )

10/11/2021
JMO!!
Is what I saw on my phone few weeks back when I got my RHO placement.
Denial, Frustration and Total dissent was my first reaction.
Took me a few days for acceptance and after having met my Consultant JMO and senior, thought of giving it a go. Anyways I had no option of leaving either.

Penning this down on Day 3 of my duty, thought of starting my version of Srilankan JMO diaries.
Kind of Learning a whole lot of new and ugly stuff and maybe writing might help me survive.

It's day 3 today and Due to adverse weather conditions in srilanka and the floods we have had several drowning deaths today and postmortem to be done. Waiting for PCR results before we could start.
Hoping it wouldn't be as bad as I expect.

( PS : I didn't think I could handle postmortems till I had to be the photographer for the ones we did yesterday 🤢😐)