Demonstrate respect and follows the correct procedure when handling cadavers and other biologic tissues The Cadaver as our First Teacher (Module 1.5) Medical students shall be able to ¥ vvY Describe the role of biologic tissues and human cadaver in learning of anatomy. Describe the role of human cadaver as our first teacher in learning anatomy. Describe body donation and Anatomy act. Describe the Bombay anatomy act. Describe the process of preservation of human cadavers/ embalming. Describe method of embalming. Enumerate sources of human cadavers. Describe ethical aspects of cadaveric dissection. Demonstrate respect for human cadavers, tissues and donor families. Describe rules and regulations in the dissection hall. Enumerate safety guidelines in the dissection hall. Describe hazards of embalming fluid. Enumerate rules to minimize hazards of exposure to the embalming fluid. Define biomedical waste. ‘Describe categories of biomedical waste. Describe treatment and disposal methods of biologic tissues. conventional (Ga AETCOM Figure 4: Cadaveras A First Teacher.. Source: hteps://www.needpix.com/photo/1533338/ human-skeleton-muscles-bones-anatomy-grey- background @ Historical Account of Human Cadaveric Dissection ‘The most significant moment in the history of anatomy science is the introduction of human cadaveric dissection. In the early phase of 3rd century B.C. the ancient Greek physician started human dissection with the foundation of school of Greek Medicine in Alexandria, Herophilus of Chalcedon was one of the earliest anatomists, who performed human cadaveric dissections systematically. Herophilus was the one who contradicted with longstanding belief established by Aristotle (one of the founding Fathers of Philosophy) that the heart was the ‘seat of intelligence’. He disagreed with this philosophy of Aristotle, He entrenched the brain as the centre of intelligence, differentiated between arteries and veins, and made other acute observations within human body, especially nervous system.Figure 2: Herophilus Source: https://preai.com/ipqeebfagmkc/herophilus- of-chaleedon/ Many theories on human anatomy were described by Claudius Galen (129 - 199) which were based on the study of animals, dominated the medical science for over one thousand years. Towards the end of 12" century and early 13* century, with the foundation of universities all over the Europe, considerable advances were made in the field of science. In 1231 holy Roman emperor Fredric II (1194 - 1250) passed a law which ordered a dissection of human body at least once in every five years with compulsory attendance of all physicians and surgeons. Due to this initiative, people realized importance of human body dissection in learning of human anatomy and hence with the time, it got legalised around all over European countries (1283 - 1365), Mondino de Liuzzi (1275 - 1326) was the first to perform officially sanctioned systemic human dissection in full public display in 1315 at Bologna University, From this point of time, regular anatomy teaching sessions held once or twice a year where human dissections were conducted on the bodies supplied by the local authorities. These public dissections required the presence of lector (lecturer) who read the text (Galen's text) and ostensor who guided the sector (surgeon/barber) who performed the dissection. Instead of this there was no correlation between written text of Galen and real anatomy visible in human cadaveric Reese Source: https://www.qscience.com/content/fig. uure/'10.5339/gcsp.2015.66,F0004 Over the period of 14" and 15* century, there was a significant change observed in the interest of human cadaveric dissection in the learning of anatomy. This became more popular in 15" century especially in renaissance period of Italy. Antonio Pollainlolo (1431-1498), Leonardo da Vinci (1452-1519) and some other artists of Italy took interest in anatomical dissection and actually dissected many human bodies by illegal means for showing their antique art in the paintings of human body. eonardo da Vinci dissection, as the lecturer was fara way from the actual site of cadaveric dissection. Source: https://www biography.com/artist/leonardo- da-vineOver the later part of 16th century with increased demand of human cadavers for dissection purpose, malpractices (such as grave robbing, murder) became more common. From the 16" century onward, the great anatomist and surgeon Andreas Vesalius (1514-1564) highly contributed in the change of actual science of anatomy. Human cadaveric dissection was the most preferred method of teaching anatomy by Andreas Vesalius. He himself performed dissection of human bodies and also forced students to do the dissection. He described anatomy in such a way that, what he actually observed during cadaveric dissection which was contradictory to the Galen's anatomical theories. He also published a book “De humani corporis fabrica” in seven volumes with nice illustrations of his dissections. — = Father of the modern anatomy # https//todayinsci.com/V/Vesalius Andreas/ VesaliusAndreas-Quotations htm Souxe @ History of Human Cadaveric Dissection in India © Archaeological evidences about lifestyle of ancient societies in India reflect various methods, skills as well as exact sites on the body of animals during hunting. These proofs represent their knowledge about external and internal anatomy of various animals. Many paintings in caves depict their knowledge of comparative anatomy also. Ayurveda was evolved from 800 B.C. to 1000 A.D. which is said to be the golden period in Indian medicine. Charaka Samhita and Sushruta Samhita are two written evidences available in the Indian literature, which explain the comprehensive study of anatomy. It is mentioned in Sushruta Samhita that systematic method of human cadaveric dissection was practised in ancient India. He said that different part or members of the body including skin cannot be correctly described by one who is not well versed in anatomy. Hence, any one desirous of acquiring a thorough knowledge of anatomy should prepare a dead body and carefully observe it by dissection and examine its different parts. (Chattopadhyaya, 1933) Charaka Samhita also mentioned about anatomy, embryology of human body and techniques of dissection. (Porter 1998) Preparation of a dead body described in Sushruta Samhita Use of human cadavers was against the religious law in that era, so Sushruta developed the method for dissection. A cadaver should be selected which has all parts of body present of a person, not died due to chronic disease or Poisoning, not of more than 100 years of age and from which faecal contents of intestine removed. Such a cadaver, whose all parts are wrapped by munja (bush or grass), bark, kusa and flax etc and kept inside a cage, should be put in slowly flowing river and allowed to decompose in unlighted area. After seven nights cadavers should be removed and dissected slowly with brushes made up of roots of plants, hair, and bamboo and all internal and external parts should be examined directly (Singhal and Guru 1973).Figure 6: ‘Teacher of India; Acharya Sushruta Source: https://www.123rf.com/photo_105640442_ ancient-indian-medical philosophy sushrata-samhita kaneri-math-kolhapar-maharashtra.html The practice of dissection flourished during the 7th and 8th century. Pandit Madhusudan Gupta was the first student, who practiced dissection at a university level in 1827. The current state of dissection in India is more improving with legislation of Anatomy act. @ Role of Human Cadaveric Dissection In Anatomy: Cadaver as a First Teacher Anatomical dissection is a time honored part of the medical education across all over the world. It is a backbone of medical knowledge for medical students. Cadavers are the first teachers for medical students to reveal the complex structure of human body by allowing dissection on them. Human cadaveric dissection has been used as a most preferred method of teaching and learning anatomy since many years. «The practice of cadaveric dissection allows the medical students to grasp the three- dimensional picture of organization of human body (spatial appreciation) * Dissection of cadavers teach students about complex relationship of anatomical structures which cannot be achieved by other teaching methods. * Dissection of cadavers allows students to experience the feel and texture of human tissues (tactile appreciation). * Dissection helps students to understand the effects of any disease on the body (pathological condition) while learning normal anatomy and compare normal versus pathological which cannot be learn from models, textbooks or 3D programs. © Cadaveric dissection allows variability. Humans vary biologically at different levels: individually, according to sex, age and ancestry. © Dissection of cadavers is essential to achieve cognitive (knowledge) and psychomotor kills) levels of anatomy learning. © Dissection of cadavers is required for studying the human anatomy in all disciplines of medical sciences. * The good medical and surgical practice could only be based on adequate anatomical knowledge of human anatomy which can only be learned from cadaveric dissection. © Expert specialist in various fields such as orthopedician, _gastroenterologist, neurologists, ENT surgeons come back to their ‘First teacher’ (cadaver) to practice the various surgical procedures. * Dissection helps to impart a spirit of team work, patience and art to visualize various structures correctly which will be helpful for future medical practice. * It is also important to reinforce the respectful and compassionate attitude among medical students. * Human cadaveric dissections also play important role in sharpening the medical student's attitudes towards life and death. * Dissection helps to develop humanistic and ethical values throughout the life, which will be helpful in their carrier for practice of medicine. @ Sources of Cadavers Human cadaveric dissection is most routinely practiced method of learning anatomy across all over India. The human cadavers are obtained by: 1. Unclaimed dead bodies from the forensic mortuary of government hospitals or 2. Donated bodies which are voluntary donated during life or thereafter by family members@ Body Donation and Anatomy Act Body donation is the donation of a whole body after death for medical research and education purpose. The anatomy act, enacted by various states in India provides for the supply of unclaimed dead bodies for the purpose of anatomical teaching and learning in the medical institutions. In India, Anatomy Act was enacted in 1948, Accordingly, it provides for collection of dead bodies for teaching purpose. If death occurs in a state hospital or in a public place within the prescribed zone of the medical institution provided the police have declared a lapse of 48 hours with no claimants for the body and could be used for medical purpose. In Maharashtra, the Anatomy Act was adopted as Bombay Anatomy Act 1949. It was further amended by Legislative Council in 2000 to permit donation by a person before his death to a hospital or medical institution for medical education and research, Body donation in Maharashtrais governed by the Bombay Anatomy Act, 1949 - Anactto provide for the supply of unclaimed bodies of deceased persons and for donation before death by a person of his body or any part thereof after his death to hospitals and medical and teaching institutions for therapeutic purposes or for the purpose of medical education or research including anatomical examination and dissection. [Bombay High Court, India. Bombay Anatomy Act, 1949http://bombayhighcourt.nic.in/libweb /acts/1949.11 pdf (accessed 10 October 2014)] Unclaimed body: It means the body of deceased person who has no near relative or whose body has not been claimed by any of his near relatives within prescribed period. Near relatives: Any of following relatives of deceased namely a wife, husband, parent, son, daughter, brother, sister and includes any other person who is related to deceased. Approved institution: It means a hospital or a medical or teaching institution approved by State Government. Authorized officer: The act, the State Government may notify in official Gazette, one or more officers to whom report shall be made for area in which the act comes into force. This authorized officer is known as ‘Coroner’. So, Coroner is Government official officer who confirms and certified death of an individual within a Jurisdiction, A Coroner may also conduct or order an investigation into the manner and cause of death (Refer chapter of “Anatomy act” for details) Criteria for Non Acceptance of a Dead Poa Postmortem bodies. Decomposed body. - Extreme obese or emaciated ody, Body of a medico legal case (e.g, suicide, homicide, accidental death etc.). Body of a person having contagious ‘or communicable diseases eg. AIDS, ce C, Gangrene ee organs removed (except eyes). Body of a person with skin diseases like psoriasis, bedsores etc. @ Preservation of Cadaver ‘The human cadaver is the first teacher for learning anatomy in any medical college, who draws the maximum attention so needs to be preserved well. Embalming is a well known technique for preservation of cadavers with chemicals for duration of many years. Embalming is the process of preserving human body by treating them with chemicals to prevent decomposition. The intention is usually to make the deceased suitable for public or private viewing as part of funeral ceremony or keep them preserved for medical purposes in an anatomical laboratory. Embalming fluid is used to fix the tissues of the cadaver and kill microorganisms by cross linking proteins. Embalming fluid contains variety of preservatives, disinfectants and sanitizing agents to prevent decomposition of body.‘ommalin (5%) 37% aqueous formaldehyde ‘igure 7: Embalming Fluid ‘This formula is subject to change according to climatic condition of different places. Effects of embalming: * Prevent the dead body from decomposition. © Structural preservation of organs and tissues with minimal shrinkage or distortion. © Prevention of over hardening, while maintaining flexibility and suppleness of internal organs. ‘Help the tissues to retain their natural colour and softness. © Prevent biological and environmental hazards. ‘© Preserve the anatomical structures in their natural forms. Methods of carrying outhuman embalming Natural Method a) Mummification b) Preservation in cold oricy condition * Non natural Methods a) Conventional method of embalming b) Refrigeration ©) Plastination Conventional method of embalming: This process normally involves following four steps: 1, Arterial embalming: The modern practice ofembalming utilizes the arterial embalming technique because arteries remain open after death and are relatively free from obstruction and permit the circulation of embalming fluid all over the body, usually via common carotid artery or femoral artery. Perfusion of fluid: To avoid entering of air in the body, rubber tube linking the anatomical bottle of embalming machine and the cannula mustbe filled with theembalming fluids before the cannula is inserted into the artery. The cannula is inserted in to the artery pointing {in upward direction and the embalming fluid begins to enter common carotid or femoral artery. As the embalming fluid circulates, the skin becomes pallid. The extent of this change indicates the extent at which the fixatives have circulated. In case of poor circulation other injection points are used. Figure 8: Arterial embalming with (@) common carotid artery or () femoral artery 2. Cavity embalming: In this method, the internal fluid of the corpse is being suctioned Ceoand thereafter embalming chemicals are injected into the body cavities using an aspirator and trocar. The embalmer makes a small incision just above the umbilicus and pushes the trocar in the chest and stomach cavities to puncture the hollow organs and aspirate their contents. The cavity is then filled with embalming fluid. 3. Hypodermic embalming: This involves injecting the embalming fluid under the skin as needed. 4. Surface embalming: This method is additional to other methods especially for visible injured body parts. 1 Ethical Concern Towards Cadaver : Respect For Cadavers The use of human tissue for research, teaching and training purposes are surrounded by ethical jssues, The main ethical concern of cadaveric dissection lies in respect to human life, The process of teaching and learning anatomy with the help of human cadaveric dissection should be done with proper ethical consideration. © The main ethical concern towards the cadaver is the respect for cadaver as first teacher and as a first patient which later translate into respect for human beings as teachers anda lifelong respect for learning. Students should treat the human tissue with dignity and confidentiality. ¢ Mutilation of body parts of cadaver should be strictly avoided which shows disrespect towards cadavers. © Cadaveric remains should be properly disposed of in proper way without affecting the social, religious and spiritual beliefs of the society. «All tissues, organs and body parts removed from cadavers must be collected and preserved properly. Respect for the cadavers Certain rules, ethics and safety measures should be followed while doing cadaveric dissection in dissection hall. By holding formal ceremony such as “cadaveric oath” at the beginning of course promotes professionalism and medical ethics. Also, this helps to develop new relationship between students and their first teacher (cadaver). ‘Across all over India, medical students have been started paying respect for the cadavers by taking, cadaveric oath. CADAVERIC OATH Twill always treat you with respect and dignity of highest order, as you are my first anatomy teacher. Twill always respect your privacy and confidentiality. Twill use this knowledge for the service of society. Inall my deeds from now onwards, I will do justice to your great sacrifice. My heart fills with gratieude, as Trealize your kind and courageous act of donating your body for the purpose of our learning. Twill be grateful to you and your family for this act of ‘Living After Death’ Figur Photograph: Cadaveric oath ceremony at Terma medical college, Navi Mumbai (with ethical permission) The medical students of Thailand have given the name to the cadavers as “Ajarn Yai” which means great teacher. These students show respect for the cadaver by celebrating two ceremonies called “Dedication ceremony” and “Cremation ceremony”. In the dedication ceremony students, faculty members and relatives of deceased assemble in the dissection hall to pray, chant and offer floral tribute to cadavers: In cremation ceremony, students carry their cadavers to the cremation building, Booklets showing donors pictures, their address, words of condolence and gratitude from students and teachers are published and distributed. This feeling of gratitude helps to inculcate humility, caring, attitude, sympathy and love in the emerging doctors.In the University of Taiwan, students identify family members of person whose cadaver it is. They visit family members to thank them and to pray their respects along with family members to the cadaver which allow them to learn anatomy. Student’s words of condolence for the cadaver asa first teacher The cadaver is laid down Deprived of its clothes and dignity Preserved in formalin Nobody knows the story Behind it’s eyes-open and lifeless But it's contribution is immense And itis priceless, It isa teacher, a guide Areminder that we are the same Made of just flesh and bone The same nerves and tendons Ie shows us the truth Ie teaches us to be humble And how fickle is youth Truly, the cadaver Isthe greatest teacher And the most honest one Because to serve a purpose even after Death has madi its call Isworthy of utmost respect Itis the noblest act of all Tushar Sharan Ullrd MBBSstudent Terna Medical College, Navi Mumbai @ Rules and Regulationstobe Followed in the Dissection Hall (Ethics in the Dissection Hall): Medical students should be aware of their responsibilities while handling with human material which help them to derive the maximum. benefit from the dissection hall. Working with human material requires respect and sensitivity. Here are some rules and regulations must be followed by medical students and teachers while handling human material in gross anatomy laboratory setup. I. Handling with human cadavers: Human Anatomic gift: Cadavers should be treated with respect and dignity at all times. Some of these cadavers are unclaimed but many of them are truly anatomic gift by them and their families. Hence it is imperative that proper respect is to be paid to the cadavers, donor families and tissues. Any disrespect for the cadaver shows disgraceful behavior as a human being, Donation of body is truly a precious gift as the person donating his body does not receive any financial compensation for that, Cadaver care: The cadaver has to be kept moist by keeping wet cotton gauze pieces or by spraying with INFUTRACE preservative (1 infutrace: 4 distilled water) solution. Cadavers should be kept immersed in formalin tank if not used for dissection purpose. * Keep identification tag with the cadaver at all times, * All tissues removed from the cadaver must be collected and placed in the designated container (yellow container). ‘* All organs and body parts removed from cadavers must be collected and stored in designated sealed container. ¢ Human cadaver material should not be removed from laboratory under any circumstances. * Keep cadavers and work area as clean as possible. * A professional attitude is expected during laboratory session as well as outside the lab, while discussing the dissection hall experiences in public place. * Intentional destruction or incomplete dissection is considered as an unprofessional behavior. * No photographs or videos in dissection hall without prior permission. * Laboratory access: Only students enrolled for the course are permitted to enter in the dissection hall. Visitors should not be allowed to dissection hall without permission.Potential hazards of embalming fluid: The embalming fluid is the primary source of fumes and odour in dissection hall. We should be aware of hazards and protection against the components of embalming fluid. Formalin: It is 37% of formaldehyde in water. It fixes the cadaver tissue and kills microorganisms by cross linking proteins. It is highly toxic, mutagenic and carcinogenic. Exposure to formalin causes irritation of mucous membrane, upper respiratory tract irritation, contact dermatitis, tearing of eyes, runny nose and headache Phenol (Carbolic acid): It is considered highly toxic and corrosive, It is used as a mold inhibitor. Tt can be absorbed through the skin. Glycerin: It is wetting agent, miscible with water and alcohol add prevents water loss from body. Itis used to keep the joints of the cadaver flexible Ethyl alcohol: It is germicidal agent and fixes tissue by drying, Itis extremely volatile therefore has inhalation hazards. It causes upper respiratory tract irritation and may dehydrate skin after prolonged exposure. Thymol: It is very strong antimicrobial and antifungal agent. It is highly corrosive and causes burns and upper respiratory tract irritation. Il. To minimize hazards in dissection hall: Following safety measures will protect from irritating effects of embalming fluids and from other hazards in the dissection hall. ‘* Allstudents must wear NITRILE or LATEX gloves. NITRILE gloves should be preferred because they are less porous and more puncture resistant than latex. ttf Figure 10: Hand Gloves Source: https://www.amazon.com/AMMEX- GWN1OPK-S-Nitrile-Gloveworks-Disposable/ép/ BO7MC3XHZX © All students must wear white coat while dissection. «All students must wear shoes which cover their entire foot. No open toed shoes or sandals are allowed. * Allstudents must wear safety glasses when operating with saws and bone splitting instruments. © Physical contact of one’s skin and clothing with the cadaver should be avoided. «It is not permissible to wear soft contact Jenses in the dissection hall because it may absorb the chemicals used in lab and cause eye irritation, * Do not touch the bones, models and any other learning materials with gloved hands. * Soiled gloves are to be rinsed in the sink before removing them from hands and then thrown into proper disposal container (red container). © Remove excess fluid from the table with sponge and container provided, so that area around the dissection table will remain free of fluid and tissues. © Eating and drinking should be strictly prohibited in the laboratory.* Dissection tools must not be left loose on the table or on the cadavers. ‘© Theventilation system in the dissection hall should remain on at all times which removes air at the level of cadavers and reduces exposure to embalming fluid chemicals and odors. * Itis not advisable to work in dissection hall if you are pregnant because the risk of foetal malformations appears to be increased in ‘women who exposed to embalming flitid. * Scalpel blades must be handled with care and disposed properly in white SHARP CONTAINERS. ¢ Report any injuries toa member of the staff and a first aid box should always be there in the dissection hall ll Biomedical (Hospital) Waste Definition: “Bio-medical waste” means any waste, which is generated during the diagnosis, treatment or immunization of human beings or animals or in research activities pertaining there to or in the production or testing of biologicals or in health camps Waste Generated in Hospitals In developing countries, the waste generated in hospitals falls into following categories: * General waste (80%): This is harmless to the humans, can be disposed with usual domestic and urban waste management system, * Pathological and infectious waste (15%): This is more hazardous and may infect health care workers through inhalation, ingestion or direct skin contact © Chemical and pharmaceutical waste (8%): This is toxic, explosive, flammable, corrosive. « Sharp waste (1%): This should be handled ‘more carefully as transmitting blood borne pathogens like HIV, Hepatitis B and C etc. © Less than 1% accounts for special waste such as cytotoxic drug, radioactive waste, broken thermometers and used batteries. All the health care professionals should be aware of proper management of biomedical waste, as this waste is a potential health hazard to the health care workers, public and environment too. The government of India has promulgated the Medical waste (Management and handling) Rules, 1998 for the management and Handling of biomedical wastes generated from hospitals, clinics, other institutions for _ scientific management of Biomedical Waste. These rules were further revised in 2016 and published in the Gazette of India, Extraordinary, Part II, Section 3, Subsection (i), Government of India, Ministry of Environment, Forest and Climate Changes as ‘notification on 28 March 2016. (hetp://mpeb.gov.in/biomedical/pdf/BMW_ Rules_2016) Differences between Biomedical Waste (Management and Handling) Rule 1998 and 2016: m "BMWitie1958——~=~*~*CM WeDo aeeysiied dee ‘Ten Four Overlapping of category Yes No ey Incinerator May have only one chamber _Upgxade to have secondary chamber ‘Chlorinated Bags Using it Phase out in two years Cytotoxic drugs Black colour bag Yellow bag Majority of idea Discarding the BMWs For recydling Table 1: Biomedical Waste Rules Eee aa arig Red 1 ‘Non-chlorinated plastic Bio-medical waste has been classified in to 4 categories instead of 10 to improve the segregation of waste at source (as per 2016 rule) (Category [Type of Bag/ Container | ‘used ‘Type of Waste Treatment/ ‘Disposal options @ bags or containers bags or containers w White | Translucent, Puncture, | Leak, tamper proof containers Blue Cardboard boxes with blue coloured marking Yellow ‘Non-chlorinated plastic | Human anatomical waste Incineration or deep ‘Animal anatomical waste burial Soiled waste Expired or discarded medicines Chemical waste (Chemical liquid waste Microbiology, biotechnology and other clinical lab waste | Contaminated Waste [Autodaving/ (recyclable) like tubing’s, microwaving / bottles, plastic bags, syringes | hydroclaving and (without needles) and gloves __ | then sent for recycling not be sent to landfill ee ‘Waste sharps including metals | Auto or dry heat Sterilization followed by, shredding or ‘mutiation or encapsulation ail Glassware Disinfection orautoclaving, microwaving, hydroclaving and then sent for recycling ‘Table 2: Segregation of Biomedical WasteYELLOW BIN: 1, Human anatomical waste: a) Tissues, organs, body parts b) Fetus, Umbilical stump, placenta 2. Animal anatomical waste: Tissues, organs, body parts 3. Soiled waste: Items contaminated with blood and body fluids a) Dressings, sponges, gauze b) Plaster casts ©) Cotton swabs 4) Blood bags e) Infected gowns, mask, shoe covers, cap £) Expired or discarded medicines including antibiotics (except cytotoxic) 4, Allyellow waste that are generated from labs. 5. Chemical waste . a) Discarded disinfectants, Cleaning agents b) X-ay film developing liquid, Infected secretions ©) Aspirated body fluids, Liquid from laboratories Yellow bin with cytotoxic label: 1. Used, discarded and expired cytotoxic drugs whether in plastic vacutainers, syringes, glass vials, ampoules, glass bottles. The container is not the determining factor in the case of segregation of cytotoxic wastes. 2. Allitems used during preparation and administration of cytotoxic drugs (e.g.: glass and plastic bottles, ampoules, vials, IV sets, gloves, syringes without needle, dressing, cotton swabs, etc.) RED BIN: All infected plastic recyclable waste: 1, Endotracheal tube/Tracheal tubes, Nasogastric tubes 2. Transparent dressing sheet 3. Ventilator/ nebulizer tubing’s 4. Ostomy bags 5, Tracheal tubes 6. Suction/ oxygen tubing’s 7. Diagnostic kits All plastic and rubber infected waste generated from laboratories BLUE MARKED CARDBOARD BOX: 1. Broken, discarded and contaminated glassware including slides, vials and ampoules (except cytotoxic waste) 2. Metallic body implants 3. Disposable laparoscopic instruments All glassware generated from laboratories Roe