PROCEDURE

PROCEDURE

1. At the table you will find your face shield to assemble along with nametag tape and a marker pen.

For a video on eyeglasses style face shield assembly...
                            ------- click here ------

Face shields must be worn whenever working with your donor for splash eye protection.

b) Place a strip of label tape on the front top.

c) Write your given or preferred name on the strip of tape with the marker pen.

d) Unclip the side rubber pins and insert one end of the shield to the glasses frame (clipping the pin in place holding the shield) then bend the shield around to the other side (clipping the pin back in place)

You will keep your face shield through all of your anatomy time, we suggest in your locker so it is available each day and for future classes.

If you lose, forget, or break your face shield there will be spares at PPE supply stations in the lab available in future sessions. 

At the end of the lab today, return the marker pen and any unused shields to the front supply station where the spare face shields are located.

During your medical career you will assemble many types of face shield and coverings, the ones we use are very common splash shields (impact shields have heavier polycarbonate).

If you find the eyeglasses style uncomfortable or difficult to fit, there are forehead foam styles available in the lab on request. However, we find the eyeglass style suffers less internal fogging during use than foam styles (i.e. less condensation formation).

Pause here for an introductory briefing

Do not start to uncover your donor or start the remainder of the steps below until after the introductory briefing is conducted.

2. Locate the Patient Chart on the bookstand and review the key information on your patient; their name, age, sex (and gender identity if different), cause of death.
    (Example Chart)

The Patient Chart serves as a record of the history and physical of your patient. Respect for your patient, and here your donor, involves knowing their name and maintaining an empathetic connection.

A list of common causes of death and abbreviations used are: --------------> click here

During the year you will be examining the anatomy of your patient in detail. This work may reveal prior surgeries or medical conditions the patient has.

If you determine they have had a past surgery or procedure add notes on what you have determined to that section on the Patient Chart. Similarly, if you find an anatomic variant in your patient add that detail to the Patient Chart.

During the semester there is a 'patient handoff' with the MS2 class.  For example, the MS2 class will examine the donors heart while the MS1 class is in the radiology small group next week. Later the MS2 will return to examine other organs/musculoskeletal systems while the MS1 class is undertaking the Blood & Host Defenses course.

The Patient Record serves as a detail of the patient for the MS2 team and, in turn, they will add additional details which you will be able to review upon return to the lab in the Brain & Behavior course.

3. Remove the blue drape and roughly fold it, then push the drape into the space between one of the legs of the table and the half wall.

The space keeps the drape held in a clean location preventing it from getting dirty due to any fluid spills that may occur on the shelf or under your table.

PROCEDURE - Surgical Instrumentation

4. Open the small tools draw at your table (the one with small tools sorted into white drawer organizers) and review the contents.
    (Photo0005)

Remove and return each type of surgical instrument one at a time to identify and review their use case.
     (Tools List)
Match each instrument to the list of instruments so that you become familiar with surgical tool names.

Verify that the number of each instrument in the drawer matches the count indicated in the draw photo.
     (Photo0005)
If a tool is missing, or during use breaks, spares are available at the front supply tables.

You are expected to maintain your tool drawers organization throughout your time in the lab. If you drawer is found disorganized, faculty will instruct you to correct the situation. Organized instruments are a key component of surgery and the lab is a training ground for good habits.

5. Remove one pair of scissors for each student and practice correctly holding the instrument.
    (Photo0007)

Holding surgical scissors (or other similar tool such as a hemostat or needle driver) is performed in a manner slightly different to household scissors and can feel unusual when starting out.

The most common holding method is the "tripod grip", which involves using the first, second and forth digits in a tripod-like arrangement.

Place your first (thumb) and fourth (ring finger) digits through the finger openings in the instrument. Note, the thumb is typically positioned only partway through the opening (i.e. not past the knuckle) to allow for more dexterity.

The second (index finger) digit is extended along the shaft of the instrument to enhance stability and control.

The third (middle) finger positions just in front of the instrument finger openings.

All use of scissors in the laboratory should follow a surgical holding style so that when you reach your surgery clerkship, holding the instrument in a correct manner is comfortable and familiar.

6. Open the large tools drawer at your table (the one with te larger and some specialty tools) and review the contents.
    (Photo0006)

Remove and return each type of surgical instrument one at a time to identify and review their use case.
     (Tools List)
Match each instrument to the list of instruments so that you become familiar with surgical tool names.

We will use these larger and specialty tools in a subset of sessions as directed by the dissection instructions.

Ensure tools are returned neatly such that the drawer closes without jamming on the tools.

7. Look at the shelf below the table and review the items stored upon the shelf which are used frequently throughout the anatomy program.
    (Photo0008)

In addition to your instrument draws, we expect the table shelf to be maintained in a neat and tidy organization as shown.

8. Examine the top of the half-wall by your station where this computer is attached.

Observer that there are two articulated LED procedure lights at each station with the on/off switch located on the upper side of the light heads. The switch is a rocker that goes from one light, off, two lights so that intensity of light can be adjusted from a single bulb to a double bulb (most of the time double bulb is best for maximum lighting).

Adjacent to the light is a Stryker battery charger with battery inserted. After a session using the Stryker saws, the battery should be firmly pushed back into the charger so that it is ready for next session.

PROCEDURE - Physical Examination

9. Uncover your donor by opening the various layered coverings, when finished for a session the coverings are replaced in the reverse order.

Unzip the white body bag. Be gentle with the zipper when opening/closing as the zip can break relatively easily.

Rather than let the unzipped excess plastic hang off the side of the table (which can drip fluid), roll the unzipped plastic sheet such that the rolled material can sit on the edge of the table. (Photo2000)

Unclip the hemostats from the inner plastic liner and open the liner.

Your donor is covered by moist cloth, which should always be left covering areas of the patient you are not dissecting or examining during a session. This is respectful of patient dignity and protects against dehydration. The cloth should be remoistened with wetting agent as needed to limit dehydration. 

The small cloth is for covering the donors face when you have drawn the body cloth down to work on the torso.

Remove, and discard in regular trash, the cord securing the wrists and ankles. This cord is to prevent limbs from being injured during donor transport and can be removed.

10. Examine the patient chart where you will enter the following demographic details in pen.
    (Example Chart)

Verification - begin by cross-referencing that the patient chart SAB# matches the number on the outer white bag and that the E# matches the number imprinted on the small metal tag attached to the donor ear.

If there are any discrepancies in labels let Dr. Puche know so that we can correct information on the Patient Chart.

Height - use the measuring tape (found in the small tools drawer) to measure your donor height and enter that onto the Patient Chart.

Weight estimation - In many situations it is difficult to measure the weight of an unconscious or seriously ill patient (not all gurney or hospital beds have weight sensors). In these situations, a mid-upper arm circumference (MAC) can be used to estimate patient weight. Measure and record the MAC (in centimeters) then apply the formula below to estimate the donor weight:

        Weight(kg) = (4 x MAC) - 50

        Weight(lb) = Weight(kg) x 2.2

Body Mass Index (BMI) - Body mass index is often derived from height and weight.

        BMI =  weight(kg) / height(m) x height(m)

While BMI has many flaws and erroneous assumptions in the application of the metric, it can serve a useful role in the context of an all-over review of patient health. By itself, it does not indicate healthy or unhealthy status of an individual.

11. Examine the anterior and lateral sides of your patient, head to toe, for scars that may be indicative of previous surgical interventions and note the location of those on the patient chart.

Do not turn your donor over, we will examine the posterior side in a later lab.

There will be an incision on the thigh and a second incision on the inside of one arm near the axilla (usually the right limbs). These incisions were made during the embalming process to access the femoral and brachial vessels. As these were not part of the patients prior medical procedures, you do not need to note them on the patient chart. 

Common incisions you may find include midline sternotomy (superior to inferior scar on the thorax for cardiac procedures), abdominal incisions (lower right scar for appendectomy or hernia repair, midline scar for hysterectomy, upper right abdomen scar for cholecystectomy), anterior or lateral hip scar (for hip replacement), and anterior scar on knee (for knee replacement). Pacemakers are also frequent, usually found on the upper left thorax and less commonly on the upper right thorax.

As we go through your studies, record on the patient chart any additional surgical interventions, pathologies or anatomic variant findings you may find during your lab sessions.

When complete with entering details on the Patient Chart, place the Patient Chart back into the protective plastic sleeve  to prevent liquid from damaging the page. 

PROCEDURE - The Thorax

12. In the steps below we will attempt to palpate bony landmarks and correlate their palpable position with how they appear on an X-ray of the chest.
    (Figure240) (Netter187) (Netter192) (Netter250)

We will use a skin marker pen to indicate the bony landmarks (mark both left and right sides unless the instruction says otherwise).

Send a member of your team to the front supply table for several of the purple disposable skin marker pens to use in the steps below.

Dry excess moisture from the skin on the torso with paper towel, as skin markers do not apply well to wet surfaces. 

The disposable skin marker pen tips can become 'clogged' with moisture or skin cells. If the pen does not make a mark, wipe/clean the marker pen tip on dry paper towel and wipe/dry the skin surface further with fresh paper towel.

The landmarks examined below do not need to be perfect, they serve primarily as a pre-surgical guide and need only be approximate.

Also, do not worry if you cannot feel all the landmarks, make your best guess. It may be helpful later to try palpating these landmarks on yourself or a willing partner later as landmarks are easier to palpate on the living compared to an embalmed donor.

An understanding and ability to identify landmarks are a key component of making a correctly positioned incision during surgery. Of particular use are the palpable landmarks, meaning those bony landmarks that can be readily felt during physical examination of the average patient.

Identification by palpation is more difficult in donors due to higher tissue density following embalming. Palpation may also be more difficult in individuals with a larger body habitus due to musculature and/or subcutaneous tissue.

13. At the base of the anterior neck palpate for the sternal notch at the superior end of the sternum and place a marking on the skin at the notch.
    (Figure240) (Netter187) (Netter192) (Netter250)

The sternal notch is also commonly known as the jugular notch, these terms are used interchangeably.

Less commonly used you may come across the formal name of the suprasternal notch.

Radiology - On chest X-ray (a CTX, aka chest plate) note that the position of the sternum and sternal notch is obscured by the density of the more posterior vertebral column. (Rad2001a)

9. Palpate laterally from the sternal (jugular) notch on each side to follow the clavicles out to the shoulder, where it connects to the acromion on the clavicle, drawing a line along the trajectory of the clavicle.
    (Figure240) (Netter187) (Netter192) (Netter250)

The clavicle attaches to the sternum just lateral to the sternal (jugular) notch at the sternoclavicular joint. The clavicle extends laterally out to the shoulder where the lateral end attaches to the acromion on the scapula.

Radiology - The clavicles are readily visible to each side on a CTX (remember X-rays are viewed as though you are standing in front of the patient for left/right).  While we cannot readily palpate the sternoclavicular joint on a person, CTX shows the 'flared' (wider) end of the clavicle with a distinct hypodense (dark) line that is the joint space. The space is darker than the bone since there is a gap between the bones a synovial joint. (Rad2001b)

10. Draw a line extending from the clavicle over the pectoral region to the front of the axilla (armpit).
    (Figure240a)

This is approximately the line between the deltoid and pectoralis major muscles, referred to as the deltopectoral groove.

11. On the chest palpate inferiorly from the sternal (jugular) notch to the sternal angle.
    (Figure240a) (Netter187) (Netter192) (Netter250)

The sternal angle (or "sternal angle of Louis") is a 'ridge' at the manubriosternal joint where the manubrium makes a 160 degree angle to the body of the sternum giving rise to the 'sternal angle' terminology.

This can be difficult to palpate through embalmed skin or if a donor has extensive subcutaneous tissue. The location is approximately 5-6cm below the sternal (jugular) notch and if you cannot feel the ridge place a best guess mark at that location. You will be able to feel the distinct ridge/angle when the skin is opened in the next laboratory session.

At a later time, try palpating the sternal angle on yourself or a willing partner when you are not wearing gloves.

Radiology - On a CTX the position of the sternal angle is obscured by the density of the more posterior vertebral column. (Rad2001a)

12. On the chest palpate for the inferior end of the sternum (the xiphoid process) and place a marking at that landmark.
    (Figure240a) (Netter187) (Netter192) (Netter250)

The body of the sternum and xiphoid process are connected by a cartilaginous joint (the xiphisternal joint). This joint has somewhat more movement than the manubriosternal joint though often fuses with age.

13. Draw a mid-sternal line from the sternal notch to the xiphoid process.
    (Figure240a) (Netter187) (Netter192) (Netter250)

This line is a common thoracic surgery incision location used to perform a midline sternotomy. If your donor has had cardiac or other thoracic surgery there may be a scar running along this location.

If you observe a scar, make a note in your Patient Chart under past surgeries that they had a midline sternotomy.

14. On the chest palpate laterally from the xiphoid process to follow the costal margins drawing a line demarcating the costal margin on each side as far as the mid-axillary line.
    (Figure240a) (Netter187) (Netter192) (Netter250)

The axilla is the anatomic term for the armpit. The mid-axillary line is an imaginary line separating the body into an anterior and posterior half centered on the middle of the axilla (i.e. the middle lateral point on the chest).

Observe that the costal margin is more inferior laterally compared to anteriorly.

It is typically not possible to palpate the ribs directly in donors due to embalming making the skin more rigid. On yourself, or a willing partner try to follow a rib at a later time when you are not wearing gloves.

Radiology - On a CTX the costal margin is obscured by the soft tissue densities of the abdominal organs (e.g. liver on the right). Since the costal margin anteriorly is all cartilaginous the densities are quite similar to soft tissue and the margin can only be estimated on the image. However ribs show up readily on CTX. The horizontally orientated density of the ribs is actually the posterior part of the ribs while the indistinct anterior cartilaginous portion has a sharply inferiorly directed trajectory. (Rad2001c)

15. With your fingers demarcate the position of the 'cardiac box'.

The cardiac box is a roughly square region demarcated between the left and right mid-clavicular lines and between the sternal notch and xiphois process

Penetrating trauma within the cardiac box region can potentially cause life-threatening cardiac injuries.

 Radiology - On a CTX it is easy to see why the cardiac box has heightened risk of major vascular or cardiac injury from penetrating trauma. The great vessels such as the aorta and pulmonary trunk along with the heart itself are centrally positioned within the box. (Rad2001d)

PROCEDURE - The Pelvis

15. On lateral torso, palpate inferiorly along the mid-axillary line until you find the arch of the iliac crests.
    (Figure240a) (Netter187) (Netter192) (Netter250)

Press firmly and follow those arches anteriorly to the front where there is a 'point', the anterior superior iliac spine (ASIS).  Place a marking on this landmark and the arch of the iliac crests.

Note if the spine is laterally flexed, the left and right anterior superior iliac spines may not line up precisely (as shown in Figure240a).

The anterior superior iliac spine can be difficult to palpate in an embalmed donor and in individuals with larger body habitus. Thus, you may need to make a 'best guess' mark. If you are unable to palpate these effectively, try palpating on yourself when not wearing gloves.

Radiology - On a plain film of the pelvis the arch of the iliac crest is a prominent feature. The ASIS forms a distinct 'bump' or point to the and of the iliac crest. (Rad4001)

16. On the pelvic region palpate at the midline just superior to the external genitalia for the pubic tubercles and pubic symphysis.
    (Figure240a) (Netter250)

The pubic symphysis is a cartilaginous joint 'fusing' the left and right pelvic bones together. The pubic tubercles are bumps of bone just lateral to the pubic symphysis.

Radiology - On a plain film of the pubic tubercles are inferior and at the midline with a hypodense (dark) region between the bones. That represents the cartilage of the pubic symphysis, which due to the lack of calcification has low density similar to soft tissue.  (Rad4001)

PROCEDURE - The Breast

17. Observe the nipple, surrounding areolar tissue, and the breast itself.
    (Figure241) (Netter188)

The main body of the breast, where the glandular tissue resides, is typically from the 2nd to 6th rib laying on the anterior surface of the pectoralis major muscle. There is also an axillary tail of glandular tissue which runs along the inferolateral edge of the pectoralis major into the axilla.

When performing a breast examination it is important to palpate the full extent of the breast tissue so as not to miss a mass.

The breast is clinically described using either a quadrant system or as a clock-face. (Figure245)

Quadrants are four regions described as upper-outer, upper-inner, lower-outer, and lower-inner with the intersection centered on the nipple.

The clock-face terminology uses the nipple in the center of an imaginary clock face with hour hand and distance from the nipple determined (e.g. right breast mass, 2 o'clock, 4 centimeters).

Breast cancer spread will typically follow the lymphatic drainage pattern. The bulk of lymph drainage from the breast (~75%) proceeds laterally to the level one axillary lymph nodes (lateral to pectoralis minor), which in turn drain to the level two nodes (deep to pectoralis minor), and then the level three (medial to pectoralis minor).

The remaining 25% of lymph drains to the closest other lymph nodes. Thus, lymph from tissue close to the midline can go to the parasternal nodes or across to the contralateral (other side) breast. Lymph from inferior breast tissue can progress inferiorly to abdominal nodes. Lymph from deep tissue can drain through the pectoralis major muscle to interpectoral nodes (between pectoralis major and minor) which continue in turn to level two/three axillary nodes.  (Netter191)

CLINICAL EXERCISE - Breast Examination

18. In this clinical exercise, you will perform a breast examination on your donor and mark areas of concern detected for potential a biopsy.

For the steps to take:
                               ------ click here ------

19. When the breast examination is complete, proceed with the steps below under Donor Care.

The Donor Care procedure should be followed at the conclusion of any session where you are working with a donor.

DONOR CARE

20. Proper care of your donor is training for patient care and a display of respect for the donation that this individual has given to provide you this unique anatomy opportunity. At the end of each dissection session:

a) Moisten dissected surfaces with wetting agent as required to keep the surfaces from dehydrating. Since we have not dissected any area today moistening should not be needed. However, over the course of the coming week you should use approximately a half bottle of wetting agent and a full bottle each week thereafter.

Dehydration will significantly increase the difficulty of your dissection and may destroy the structures you have carefully exposed.

Extra wetting agent is present in the tank at the rear of the lab you to refill your spray bottle as needed. After filling your spray bottle, make sure to close the tap on the main tank fully so that it does not drip (which would empty the tank overnight).

b) Replace any skin tissue flaps you may have reflected or removed.

c) Cover the donor face/head with the small moist cloth and the body with the large moist cloth sheet.

d) Bring the edges of the inner plastic lining together and clamp them closed with several hemostats (usually three or four works well) to hold the edges together.

e) Check that excess fluid hasn't accumulated in corners of the white bag that may have hung over the edge of the table. If this is the case, lift the corner to return the fluid to the central drain.

f) Zip the white outer bag closed. Close the zipper slowly as they can break if too much force is applied.

g) Cover the donor neatly with the blue drape cloth.

21. Check the stainless steel drainage bucket under the table and if it is half full empty the bucket.

To empty the bucket, first head to the rear of the lab where there are spare buckets on the shelving beside the 55 gallon fluid disposal drum.

Bring one of the empty spares back to your table and at your table swap out the half full bucket for the empty bucket. Then, carry the half full bucket back to the disposal drum and using the funnel at the drum empty the bucket into the disposal drum. Leave the now empty bucket on shelving for the next group.

There is a 2" slit in the plastic liner above the drainage point in the table. If you move or turn a donor over, the alignment of the hole can become shifted. If you notice the drainage is blocked in later labs, use a sharp tool to punch a small additional slit through the plastic liner and body bag directly above the drainpipe or in the area where you notice pooling liquid under the donor.

22. A neat and tidy work area shows respect for the patient and is a good practice for avoiding error or sterility break when you are in surgery.
    (Dissection/Surgical Tools)

In general, when working and putting a tool down the best location is to place it onto the bookstand surgical tray. That keeps control of where the tools are and positions them for ready access.

After a lab session, all tools should be placed into their labeled locations in drawers or under the table at the completion of every dissection session.

It is the responsibility of your team to return the instruments to their respective locations in the draws.

You do not need to wash instruments at the end of a session (unless there is tissue present on the tools). The tools are stainless steel, so a sheen of fluid will not affect their function or longevity

23. Take your face shield with you and keep it in your locker, you will need the face shield for this course, along with other MS1 and MS2 courses.

Return the marker pen and any unused shield parts to the boxes at the supply station at the front of the lab.

Should the shield become dirty, there is Windex cleaner at the supply stations at the front of the lab.

Should the shield become lost or damaged, spare shields are available at the supply stations.

Post-Lab Daily Clinical Review Cases

Each lab has several multiple choice practice cases to reinforce understanding of the material within the lab and associated lectures. These are optional to review at home for consolidating and testing understanding.

Case 01

Case 02

CHECKLIST

Skeletal Structures

Sternum
    Manubrium
    Body of the sternum
    Xiphoid process
    Sternal (jugular) notch

Clavicle

Scapula
    Acromion

Ribs
    Costal margin

Pelvis
    Anterior superior iliac spine
    Pubic symphysis
    Pubic tubercle

Soft Structures

Breast
    Nipple
    Areola