Pathoanatomical department. Pathologist: We see the last frame. Procedure in the morgue

The pathology department is one of the oldest departments of the hospital. On the basis of the department from 1962 to 1979. The Department of Pathological Anatomy of the Russian Medical Academy of Postgraduate Education was located under the leadership of Academician A.V. Smolyanikov. Currently, the Department of Pathological Anatomy and Clinical Pathological Anatomy No. 2 of the Pediatric Faculty of the Russian National Research Medical University is functioning. N.I. Pirogov under the guidance of Professor E.L. Tumanova.

The department includes 2 doctors of medical sciences, 3 candidates of medical sciences, 5 pathologists of the highest qualification category.
The staff of the histology laboratory are highly qualified specialists who put into practice the wealth of experience gained during internships and studies abroad. The employees of the department are members of the Russian and European Societies of Pathologists.

The main areas of work of the pathology department:

• Diagnosis of solid tumors in adults (tumors of the gastrointestinal tract, female and male genital organs, urinary system, chest, head and neck, soft tissues, bones, breast, etc.) and lymphoproliferative diseases;
• Differential diagnosis of tumors;
• Immunohistochemical studies.

PAO doctors, led by the head of the department, specialize in diagnosing surgical diseases of the pancreas using a modern dissection algorithm and research protocol.

The department provides advisory assistance and receives histological material for research. About 160 thousand intravital biopsies and 2 thousand autopsies of varying degrees of complexity are performed annually. The laboratory uses an automated system for recording material received for research, eliminating the possibility of errors.

Even when you ask the most advanced sixth-year students in the clinical pathology cycle: “Where are we now?”, they answer: “In the morgue - in the place where they dissect corpses.” The name “pathology department” doesn’t mean anything to them, says the head of the pathology department, Ph.D., to “Doctor Peter”. Vladimir Klechikov. - At least open an explanatory dictionary, which says: “A morgue is a room for receiving and storing corpses.” And we are in the pathology department of a multidisciplinary hospital.

- Vladimir Zakharovich, what is the difference between the pathology department and the pathology bureau?

Their field of activity is the same - research. But for these studies, the pathology bureau accepts material from different medical institutions, and the pathology department works only for its own medical institution. The City Pathological Bureau has several branches located throughout the city. Including those based in medical institutions, such branches work for the institutions in which they are located, as well as for other clinics.

Repairs are underway in the pathology department of Hospital No. 26

Recently, a new St. Petersburg channel told a terrible story about how the placenta was sold at the City Pathological Bureau.

This is a strange story in every way. Indeed, by order of the Ministry of Health, the placenta is necessarily sent from maternity hospitals to the city pathology bureau for examination. But pathologists cannot sell it - no one will buy it: the placenta is delivered in a fixed form - in formaldehyde. Apart from histological examination and disposal in the crematorium, it is not suitable for anything. It is impossible to obtain an extract, extract, or hormonal substances from it for the preparation of biologically active materials. The journalists were 20 years late with such revealing material - in the dashing 1990s, however, this was practiced. But not in pathological anatomy departments, but in maternity hospitals and large obstetrics and gynecology clinics. Medical institutions signed contracts and sold this biological material for pennies. Moreover, the practice of collecting pituitary glands still existed at that time. Extracts and extracts were also made from them to obtain hormonal preparations. To pick it up, you had to use a special preservative; no one needs it in its fixed form. But these are things of the past - everything has long been blocked, as well as the distribution channels that used to go through the Baltic states. There hasn’t been any of this for twenty years now.

The pathological service is still associated with death - autopsy of the dead, establishment of a post-mortem diagnosis. What diagnoses are found most often?

Mortality generally directly depends on morbidity: the more patients there are, the higher the mortality rate. Nowadays, most often people suffer from cardiovascular diseases, which means. Today, in general, there are three biggest modern problems in medicine - cardiovascular diseases, oncology, endocrine pathology (the latter is closely related to the first two). During different periods of medical development, the causes of mortality were different. For example, there was a time when cardiovascular pathology also prevailed in the Soviet Union. People died from acquired heart defects, rheumatism, endocarditis, myocarditis. A cardio-rheumatology service was created and the situation stabilized. But we still cannot cope with hypertension and atherosclerosis. But I believe that all this is connected not so much with health care, but with the socio-economic situation. In Finland, for example, about 30 years ago they adopted a national preventive program to promote and encourage a healthy lifestyle - the mortality rate from heart attacks and strokes has sharply decreased.

At the autopsy, pathologists should be able to see better than anyone else how large the risk group is for cardiovascular disease.

Here in front of me are the results of the autopsy of a 44-year-old deceased patient. Delivered with intestinal bleeding, chronic pancreatitis and liver cirrhosis. At 44 years old, the liver is almost double in size, varicose veins of the esophagus, exhaustion, protein deficiency. The cause of death is cirrhosis. But at the same time, we diagnosed atherosclerosis of the aorta and heart arteries. That is, if he had not died of cirrhosis, he would have had a heart attack.

This set of diseases is more common among heavy drinkers, as they say, maladjusted sections of society - the marginalized.

Social status is not written in the medical history. But we also see outright marginalized people, they die from AIDS, syphilis “slips through”, and even all together - AIDS, syphilis and hepatitis. There is a lot of tuberculosis, which is a paradox in the presence of specialized hospitals. But if the patient was brought by an ambulance, then the hospital cannot refuse him hospitalization, and once he has been hospitalized, then problems arise with transfer to another clinic - either they will not want to take such a patient or they will not have time to transfer him - he will die.

You see what the attending physician, say a therapist, does not see. Can you tell whether the body of a modern person is different from the one you dealt with 30-40 years ago? Say, deterioration of organs, pathologies not characteristic of the age of the deceased?

Medicine is the bottom of public health (disease, pain, death), and the pathology department is the bottom of medicine. We see the last frame. It is impossible to retrospectively judge how “worn out” the body is and how the condition of internal organs differs among people in different socio-economic conditions, especially considering modern methods of resuscitation and treatment. We can only state the presence of certain diseases and assess their impact on the outcome - lethal. Everything else is speculative. By indirect signs one can determine what kind of life a person led, nothing more.

In hospitals, autopsies are performed to monitor the quality of treatment and the correctness of lifetime diagnosis. How often does an intravital diagnosis differ from a postmortem diagnosis?

No, we rarely find discrepancies in intravital and postmortem diagnoses - 5.7% of all examined dead. In Soviet times, the normal percentage of discrepancies for a general somatic hospital ranged from 8 to 12 percent. If he was over twelve, a commission with a representative of the district party committee had to be sent to the hospital, she would find out why there were so many discrepancies in diagnoses. If it was less than eight, a commission also appeared, because the hospital had suspiciously good indicators.

- In what cases do pathologists most often find discrepancies?

Infections. Although there are few of them, they are often mistaken. Because it is assumed that the ambulance understands that it is taking the patient to a general somatic hospital, and not to an infectious diseases hospital, doctors, when searching for the cause of the disease, think about infections in the last place. And here, for example, there is one infectious disease specialist per thousand beds.

The second largest number of discrepancies in diagnosis is oncopathology. This is not only an undetected malignant tumor, but also an incorrectly identified one (for example, a tumor of unspecified localization). Third place - which is also explained by the complexity of diagnosis, as with infectious diseases. The situation is best with injuries and poisonings - 1.2% of all discrepancies.

- What else are pathologists researching?

The main work of the pathology department is not the dead, but living hospital patients - we conduct histological examination of surgical material and biopsies. Everything that surgeons remove from a person, from a wart to an entire organ, is subjected to histological examination via endoscopic biopsy (from the mucous membrane of the stomach, esophagus, duodenum, and all parts of the large intestine). It should be carried out especially carefully if oncology is suspected: we determine the nature of the tumor, the stage of its development, because all patient treatment tactics are based on this.
Oncology is the biggest problem, because it requires good modern diagnostic equipment, and in the city it is in very limited quantities. But there are low-grade malignant lymphoproliferative tumors, and on a simple preparation it is very difficult not to be mistaken in favor of a low-grade epithelial tumor, and the tactics of their treatment are different. In this case, the patient is not interested in why the diagnosis is incorrect. And the doctor is not interested in these explanations - he needs to treat the person.

Well-known pathanatomists in St. Petersburg say that in the city there is no one and nothing to do high-quality morphology.

It is difficult to disagree with this - there are not enough specialists capable of differentiating a tumor, and equipment that can be used to obtain a high-quality preparation for high-quality microscopic diagnosis. They are made on old microtomes, 30 years old. For example, we avoid mistakes only thanks to the skill of laboratory assistants - at the level of intuition. At the same time, we work with a huge volume. Imagine, in 2014, 10,925 patients were examined intravitally, and 77,000 samples of material for research were obtained from them. Several drugs are made from one sample, 82,379 of them were obtained. In terms of the number of studies, gynecology is in first place (53%), surgery is in second (28%), and endoscopic material is in third place (18%).

Based on these studies, we draw conclusions: in first place are various types of inflammation (41%). In second place is oncology (29%) - for a general somatic hospital this is a lot.

Why did the healthcare modernization program practically not affect hospital pathology departments if you work in conditions of the 20th, if not the 19th, century?

There is a tangled tangle of problems here: material, organizational and partly moral and ethical. Even advanced clinic managers either do not understand the importance of intravital histological diagnosis or pretend that they do not understand. For them, the main headache is organizing treatment in hospital departments. But the life of about a third of these patients depends on the histological diagnosis.

The pathological service in St. Petersburg needs to be modernized; this requires targeted funding, no matter whether it is city or federal. And now, except for the Mariinsky Hospital, which after renovation was equipped with really good equipment, and specialized clinics, for example, the oncology center in Pesochny, other hospitals were left with what they bought back in Soviet times.

Although, no - they opened a new clinical and morphological laboratory on the basis of the 109th clinic. She works under contracts with medical institutions - research must be paid for. But the city's budget hospitals have neither the right nor the money to pay for these studies.

Irina Baglikova

Doctor Peter

06.03.2015

Natalia

I ended up in the 3rd surgical department on a referral from the district clinic. Doctor Mikhail Borisovich Katkov convincingly convinced me of the need for surgery to remove the tumor. I was immediately given a referral for hospitalization with a list of necessary tests, and exactly two weeks later I was invited to hospitalization. In the department, my attention was immediately attracted by the information stand. It contained the internal rules of the department, a memo for new arrivals, a method of preparing for surgery, and even a seven-day menu. Most of the questions immediately disappeared. The work of the department staff is organized very clearly, for which I would like to express my gratitude to the head Mikhail Yurievich Shchupak. The patient, once in the department, feels like a part of a well-oiled mechanism. All stages of treatment: preparation for the operation, its implementation and the postoperative period were carried out clearly and without failures. My stay in the department left behind extremely positive emotions. For this I would like to express my deep gratitude to both the attending physician Alexey Borisovich Katkov and the entire staff of the department for their constant professionalism and sincere attitude towards the patients.

1. This job description defines the job duties, rights and responsibilities of the head of the pathology department.

2. A person with higher professional (medical) education, postgraduate professional education and (or) additional professional education and a specialist certificate in the specialty in accordance with the Qualification requirements for specialists with higher and postgraduate medical and pharmaceutical education in the field of health care, approved in accordance with the established procedure, work experience in the specialty of at least 5 years.

3. The head of the pathology department must know: the Constitution of the Russian Federation; laws and other regulatory legal provisions of the Russian Federation in force in the field of healthcare and sanitary and epidemiological welfare of the population; regulatory and methodological documents in the area of ​​professional activity; principles of labor organization; fundamentals of planning, economic and financial activities of a medical organization; the procedure for executing business and labor contracts; forms and methods of organizing hygienic education and upbringing of the population; procedure for maintaining primary accounting and reporting documentation; medical ethics; psychology of professional communication; basics of labor legislation; labor protection and fire safety rules.

4. The head of the pathology department is appointed and dismissed by order of the head of the medical organization in accordance with the current legislation of the Russian Federation.

5. The head of the pathology department is directly subordinate to the head of the medical organization or his deputy.

2. Job responsibilities

Manages the activities of the pathological department in accordance with the regulations of the department, its functions and objectives (improving the quality of medical care based on clarifying clinical diagnoses using pathological research methods; conducting pathological autopsies in accordance with the approved Procedure for conducting pathological autopsies; conducting histological and other types of laboratory analysis). Participates in pathological and clinical conferences. Improves the forms and methods of work, planning the activities of the pathology department, the placement of personnel at workplaces and their use in accordance with qualifications, the formation of a regulatory and methodological base, a base of material and technical means for laboratory and instrumental diagnostics. Coordinates the activities of the pathology department with other structural divisions of the medical organization, ensures their interaction in their work. Carries out regular monitoring of the work of doctors, paramedical and junior medical staff of the pathology department. Ensures compliance with labor legislation and labor protection requirements for workers in the pathology department. Takes measures to ensure that employees of the pathology department fulfill their job responsibilities and internal labor regulations, standardization requirements and metrological support for research, measurements, and tests. Develops long-term and current work plans for the pathology department and monitors the implementation of these plans. Analyzes the work of the pathology department for a quarter, half a year, year, and submits a report on the work of the pathology department in the prescribed manner. Monitors the quality of medical documentation. Helps to increase work motivation and professional qualifications of workers in the pathology department. Systematically improves his skills.

3. Rights

The head of the pathology department has the right:

1. give orders that are mandatory for execution by employees of the pathology department;

2. participate in the selection and placement of personnel in the pathology department;

3. make proposals to management for rewarding and imposing penalties on employees of the pathology department;

4. make proposals for the development and improvement of the activities of the pathology department;

5. request from management, receive and use information materials and regulatory documents necessary to perform their official duties;

6. take part in conferences and meetings at which issues related to the work of the pathology department are discussed;

7. improve your qualifications through advanced training courses at least once every 5 years;

8. undergo certification in the prescribed manner with the right to receive the appropriate qualification category;

The head of the pathology department enjoys all labor rights in accordance with the Labor Code of the Russian Federation.

4. Responsibility

The head of the pathology department is responsible for:

1. timely and high-quality implementation of the official duties assigned to him;

2. timely and qualified execution of orders, instructions and instructions from senior management, regulations on their activities;

3. rational and efficient use of material, financial and human resources;

4. compliance with internal regulations, sanitary and anti-epidemic regime, fire safety and labor protection;

5. maintaining documentation provided for by current regulations;

6. provision, in the prescribed manner, of statistical and other information about the activities of the pathology department;

7. compliance with executive discipline and performance of official duties by employees of the pathology department;

8. readiness of the pathology department to work in emergency situations.

For violation of labor discipline, legislative and regulatory acts, the head of the pathology department may be subject to disciplinary, material, administrative and criminal liability in accordance with current legislation, depending on the severity of the offense.

According to current regulations, the pathology department of a hospital is a structural unit of a medical and preventive institution. It is organized as part of multidisciplinary hospitals (including children's), infectious diseases, psychiatric, oncology hospitals and dispensaries, based on the number of autopsies and studies of biopsy and surgical material in each of these hospitals (dispensaries), which must be performed by medical personnel.

If there are several hospitals in the city, by decision of the relevant health authorities, a centralized department can be organized in one of the hospitals. Its staffing is established in accordance with the volume of work providing autopsies of the deceased and examination of biopsy material both in the hospital in which the centralized department is organized and in attached hospitals (dispensaries), as well as examination of biopsy and surgical material from attached clinics. In the capitals of republics, in regional and regional centers, centralized pathology departments, as a rule, are organized as part of republican, regional and regional hospitals.

In central district hospitals (CRH), pathological departments are organized taking into account the provision of all autopsies of the dead and studies of all biopsy and surgical material from the attached treatment and preventive institutions of the region.

To ensure the mandatory presence of attending physicians during autopsies of deceased patients, these autopsies, if the necessary conditions are available, can be carried out in the morgues of the relevant hospitals (dispensaries) by medical personnel of the centralized pathology department.

The organization of the work of centralized departments should include the performance of urgent biopsy studies in attached hospitals (dispensaries) upon their requests.

The centralized pathological department ensures timely collection of biopsy material from attached treatment and preventive institutions and delivery of reports to them.

In order to carry out the corresponding work with the attached medical institutions, the centralized pathological department of the hospital must have an assigned ambulance transport, the use of which for other purposes is strictly prohibited.

The management of the hospital, which has a centralized pathology department, bears full responsibility for ensuring the necessary operating conditions for the department, including staffing with medical personnel, material and technical equipment, economic support, etc.

The management of attached hospitals (dispensaries), in cases of autopsies in the hospital, is obliged to provide the necessary conditions for autopsies, as well as urgent studies of biopsy material in the conditions of their hospitals (dispensaries), having for these purposes appropriate premises, equipment, apparatus, tools, etc.

According to the regulations on the pathological department of the treatment and prophylactic department, the main tasks of the pathological department of hospitals (centralized pathological department) are to improve the intravital diagnosis of diseases through the study of biopsies and surgical material and according to autopsy data; ensuring the receipt of reliable data on causes of death for state mortality statistics.

In recent years, independent pathology bureaus have been organized and are successfully operating, serving the city, region (territory), and republic.

According to our data [Avtandilov G.G. et al., 1991] the modern structure of sectional and biopsy material, per year per pathologist, is characterized by the following results of the analysis of 500 questionnaires (see Table 1).

Despite the great variability of indicators, sectional work predominates in the pathology departments of hospitals and is small in oncology dispensaries, where it constitutes only 25% of the annual workload of the prosector of a general somatic medical institution. On the contrary, biopsy work predominates in the departments of regional (regional, republican) hospitals and oncological dispensaries. Converting the number of biopsies to the number of autopsies (1 autopsy according to the standards is equivalent to the examination of 20 biopsies), these data look as follows. Currently, the annual workload of one pathologist in regional (territorial, republican) hospitals reaches 253, city hospitals - 257, in the central district hospital - 295 and oncological dispensaries - 170 (the norm is 200).

Table data 1 indicate that the main part of the work of a pathologist in a city hospital is occupied by the study of malignant and benign neoplasms of various localizations (about 30%), diseases of the circulatory system (20%), and the digestive and genitourinary systems (25%).

Analysis of the structure of sectional material showed similarities in the profile of nosological units that are the primary cause of death of patients in general somatic hospitals. Autopsies of those who died from myocardial infarction and other forms of coronary artery disease, as well as from cerebral hemorrhages and cerebral infarction (up to 30% of all sectional material) significantly predominated. Cancer patients accounted for 15% of the autopsied deaths.

Table Structure of generalized annual biopsy and sectional material (in equivalents) of the pathology department of a city hospital

In oncology dispensaries, as a rule, they autopsy those who died from malignant neoplasms of the stomach, intestines, and lungs (more than 50% of sectional cases).

The structure of the biopsy material examined by the dissector varies significantly both in hospitals and oncology dispensaries. Oncology dispensaries (3386 biopsies per year) and pathoanatomical departments of regional, regional, republican hospitals (3272), providing advisory assistance in the region, are close in terms of the volume of biopsy examinations. In the departments of city hospitals, on average, fewer samples are examined - 2685, in the Central District Hospital - 2117 biopsies and objects of surgical material annually.

In the pathoanatomical departments of hospitals, the number of diagnosed malignant tumors is: in the regional 42%, in the city 40%, in the Central Regional Hospital 32% and in oncology dispensaries 66% of all biopsy material.

The structure of the material received for pathological examination is interesting. These are mainly objects of the female genitourinary system. Among malignant tumors in the material of hospitals, neoplasms of the cervix and uterine body, ovary, and mammary gland predominate; in cancer clinics - tumors of the skin and soft tissues, stomach, rectum, lymph nodes and kidneys.

In the structure of biopsy specimens and non-tumor surgical material examined by hospital pathologists, diseases of the uterus (29%), appendix (20%), and stomach (8%) are in first place, and in oncology clinics - diseases of the uterus (48%), stomach ( 16%) and lymph nodes (16%).

The presented data make it possible to judge the typical structure of the material examined by a doctor in the pathology department during the year and accordingly rearrange the training and advanced training of a specialist. At the same time, the morphological diagnosis of the most common tumors and diseases is being improved, and the publication of manuals and manuals on these sections is also expanding.