Dear colleague,
As a young pathologist, my teachers stressed me: "You have to dictate findings at real time - formulate what do you see - do not construct definitions and do not think about it much". I commemorate this advice every day.
There are probably three main methods how to create autopsy protocols:
1. Direct dictation of findings while performing an autopsy (to a secretary, to a colleague, on a Dictaphone, etc.).
2. Delayed stylization after the autopsy (by heart with a help of notes, sketches, photographs, etc.).
3. Usage of checklists and pre-printed autopsy protocols.
In my opinion, the method number one is the best, as you directly convert perceptions into inner speech and formulations. It may be demanding on your concentration and vocabulary, but it is the most direct and reliable method. I think...
Well, it all depends on the quantity of autopsies and the building characteristics and work techniques.
For example, in the first semester of the year we have performed 2170 autopsies, the autopsy room have four Morgagni tables, with 3 forensic pathologist working at the same tame, 4 or 5 morgue technicians, in short, very noisy surroundings, so I choose 2 and 3 combined methods
Please see our paper. Sorry, it is in German. http://www.ncbi.nlm.nih.gov/pubmed/24619530
I think it is necessary to take many photographs to keep track of every detail. At the same time, go describing the findings in real time. To make the report, it is necessary to compare both records. The pre-printed sheets have inevitable limitations. The photographic record is particularly useful in forensic cases, which should show exactly what you saw.
In Vilnius we use sketches to mark all the measurements of injuries (bruises, wounds, scars), taking photos for important findings. The dictaphones appeared to be not very comfortable due to surrounding noise in autopsy room. For pathologic findings on external and internal examination we have specific protocols where all the measurements, weights and other important facts of internal organs are being written down by lab (autopsy) assistant during autopsy. Direct dictation of pathologist's thoughts to a lab assistant is the best way to keep your final pathology report accurate.
we use sketches and assistants as well. as for dictaphones, I used in the past voice activated one and had no problem with the recording. on the other hand, later transcription of voice record was something i was not satisfied with. when i was trying to dothe transcript by myself, it proved to be more time consuming than describing the finding from sketches and photos.
Dear Dr. Bytautaite
Perhaps you can share with us that specific protocols where all the measurements, weights and other important facts of internal organs.
Thank you in advance
Herbstein
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