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artemis2050

The Meaning of It All

or, There and Back Again


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MASH
artemis2050

*sigh* Hello, People...

...haven't posted much lately.

School started.

'Nuff said. See, those of you who don't know...I'm in med school, just started my second year about a month ago.

Today: four hours of lecture, a small group session, and then in the evening I had to run a meeting on "How to Ace Anatomy" for the first-years. Which was pretty much a big joke since I was...rather incompetent at anatomy. (Surgery is *not* an option, don't worry.) But I'm part of the school group that runs that session every year, so it was my baby. About half the first-year class showed up--they seem like an avid bunch. Just lookin' at them made me feel tired. And old.

*g*

Med school is weird. Once you pass through those doors, and particularly once you do anatomy lab...well...you're kind of in a different place from most of the human race. What's behind the LJ cut is kind of an exploration of part of that difference.

SERIOUS WARNING: The title says it all. If you find this kind of thing disturbing, please do not read. THIS IS NOT FICTION.

It looks like a laundry room.

That’s the first thing I think. There’s a large washer and dryer stacked one on top of the other against one wall, and there’s a sink, rubber gloves, and various bottles and cleaning implements. You have to look twice to notice that the sink operates on a foot pedal, so there are no taps to touch with your hands, and the bottles contain disinfectant and preservation fluid rather than detergent and fabric softener.

But there’s one thing that makes this decidedly not a laundry room, and that’s the body lying on a metal table in the center of the floor. Its head is swathed in an ordinary blue towel, faded with many washings—presumably in that very machine—and its lower half is draped with a sheet.

I’m a first-year medical student, and I’m here to watch my first autopsy.

The pathologist is a tall, ascetic northeastern gentleman in his seventies. He’s already gowned, or rather jumpsuited in a white coverall and ready to begin. I’m wearing scrubs I picked up at a local pharmacy. It’s not like I’ll have anything active to do, in all probability, but I was an actor before I was a medical student, and I like to look the part, I guess. I pull on a pair of latex gloves and join the doctor at tableside.

I look down at the body. There are two incisions already made; one a saggital fissure splitting the torso from sternum to navel, and another curved cut more or less in the transverse plane across the chest. The two cuts meet, forming a sort of Y, and the first thing I’m struck by is that I can see the red of muscle within the incision. Neither cut is deep enough to entirely split the muscle or reveal any deeper structure.

Cadaver muscle doesn’t look red. It’s grey, or white, or brown, or in some cases, bright artificial pink; the latter, we supposed, from the embalming process. One of the things that helps first-years to dissociate a bit from what it is that they’re actually doing—cutting up a dead body—is the fact that there is a difference between a corpse and a cadaver. A cadaver has been preserved, and in our case has also been stored for at least six months. The common description is that they look like mannequins.

This is a corpse. There has been no preservation, and it is approximately seventy-two hours from the time of death. I look down along what I can see of the body. The skin is rather pale, but not chalk-white; since the body is now awaiting autopsy and will not be embalmed, its blood has not been removed. I notice a couple of minor abrasions on the left hand, the one closest to me, and it seems strange that these cuts will never heal. My hand in its latex glove comes down over that hand.

When we began dissection in school, the first area that we worked on was the upper arm. In order to do that, you have to stretch the arm out to make the skin taut. I remember standing beside the table with it all feeling slightly surreal, holding the hand of the cadaver as my classmates figured out which end of the scalpel was the dangerous one.

She had pink polish on her fingernails, and I wondered who had done her manicure for her.

I look down the table. The feet extend below the sheet, still in socks, but both are twisted at an unnatural angle. I remember belatedly that the long bones of the legs were donated to a tissue bank; this is what is left. The corneas of the eyes were donated as well, but the towel is covering the face and I’m not entirely sure that’s something I want to see, anyway.

The pathologist has his instruments and receptacles ready: a couple of scalpels in different sizes, a pair of scissors, string, a large container for waste and a smaller one for tissue samples. He looks at me inquiringly and I nod. I’m ready when he is.

The doctor takes a scalpel and quickly, easily, cuts through the muscle layers of the torso, skinning it back to either side, and then extending the cut across the chest so that skin can be reflected back as well. I find myself murmuring names of muscles that he’s cutting as he goes: “Pectoralis major and minor, external, internal and innermost obliques, transversus, rectus abdominus…” The anatomy staff would be proud. Inside, everything is red, red, red, and the layer of fat perhaps half an inch thick under the skin is a vibrant yellow.

The doctor picks up a different instrument and begins cutting at the ribs, and a moment later I have an entirely new vision of a ‘breastplate’—he’s simply cut out a piece resembling nothing so much as a part of a suit of armor, ribs still connected by muscle and fascia and connective tissue, and he lifts it away and sets it down at the foot of the table. I am now staring into the chest cavity; as he clears away pericardium, blood flows freely, and I am looking at a heart and lungs that look like a heart and lungs, not blobs of grey matter. The heart is streaked with white—“That’s not abnormal,” he says—and the lower lobe of the left lung looks shriveled and almost dried up. I point to it and the doctor nods. “He had asthma, I understand. Could be from that, could be postmortem changes. We’ll see.”

Now he reflects back the abdominal fascia, and I am completely transfixed. The heart and lungs were shock enough, and the red of muscle and yellow of fat, but the colors here are incredible. I suddenly understand why the pictures in Netter’s look the way they do. I feel honestly reverent as I lean over. Greater omentum, yellowish-green and pearly. The stomach, curving up. The liver is smooth, light burgundy, and looks just like the illustration.

The doctor cuts away some of the greater omentum and then lifts out part of the small intestines. He begins to tie it off just beyond the duodenojejeunal junction. “You see how distended this looks,” he says, and I nod; the coils of intestine look like fat little sausages. “That’s from gases expanding after death. It wouldn’t normally look like this.” He ties off the lower end as well, then cuts the cordoned section free and slides it into the disposal container. “Everything looks normal here, and there’s no suspicion of gastro-intestinal problems, so this might as well be out of the way.” I nod again. As he makes the cut, there is a trace of something fetid, and I suspect I now know what surgeons mean when they talk about getting a “whiff of bowel”.

That’s another difference, by the way. The anatomy labs stank of formaldehyde, a scent so permeating that it was almost impossible to get out of any clothing worn down there. Here, except for a background antiseptic odor, this is the first even vaguely noisome aroma.

With the small intestine out of the way, the pathologist begins examining other abdominal organs. “I’m leaving the heart for last, since that’s our most serious candidate, but I do want to get some sample of other tissues, just in case anything looks unusual.” I watch as he expertly fishes out one kidney and turns it over in his hand. I remember how hard it was for us to find this simple structure, and of course he has years of experience, but I can’t help thinking We’d have found it that easily too, if it had looked like that! It looks completely normal to me, and he seems to concur. “I’ll take a slice just in case, but this doesn’t look out of the ordinary.” He takes a bit of tissue and puts it into a container at his side. He touches the liver and merely remarks, “Normal size and consistency. He certainly wasn’t a drinker.” I shake my head, and for the first time I ask something directly.

“Can I see the gall bladder?”

He lifts the lobe of the liver and there it is, and damn, yet another color: it is green, just like in the books. “No problem there.” He takes a sample of tissue from the liver and then lifts the stomach and slits it open. I brace myself for another foul odor, but there’s nothing much. “Stomach contents emptied; he hadn’t eaten for a couple of hours at least. What was the time of death?”

“Eleven-oh-four AM,” I answer, and feel a little med student thrill at having the answer for the doctor.

“So a while after breakfast. All right, let me just check the spleen.” He’s on the right side, so he has to lean over toward me to pull it out. And this time even he looks surprised; it’s huge. I mean, larger than the stomach. It’s speckled purple and white, a lobular, bulbous mass.

“Splenomegaly,” I squeak, and he nods.

“Certainly is. Was he aware of this, any condition he had that might have caused it?”

All I know is blood disorders where corpuscles are being destroyed tend to enlarge the spleen. I think frantically back through CBLs. “Not that I can think of.” And suddenly he turns med school teacher on me.

“What would cause that?”

“Um…sickle cell anemia. Any anemia, really. Leukemia. Lots of blood disorders, in fact. And sarcoidosis! We studied that, in fact I think that was my topic…” I trail off, feeling faintly ridiculous.

He nods. “And he was on antibiotics?”

“Not right when he died, but he’d had a bad sinus infection about a month before that he’d had trouble shaking.” I look at the enormous organ, which the doctor is now sampling. “That could do it? Could that happen that fast? That looks like it would take a while.”

“Probably not, but I’ll look at it histologically.” He puts the sample away and then turns back to the thoracic cavity. “All right. Now we’ll look at the main suspect.”

The first thing he does is to lift the heart out of its place without cutting anything, turning it as far as he can and examining it more or less in situ. Blood has pooled in the pericardium and more drains out of the heart when he severs the great vessels and lifts it free of the body.

“There’s no obvious clotting.” He turns the heart over in his gloved hands, and I’ve managed to reduce my med school soliloquy to an internal monologue: LAD, right and left coronary arteries, circumflex artery…He pushes a finger into the aortic valve, and I think Try pulling my aorta; are these mnemonics going to follow me forever? “No adhesions. Let’s see what we have inside.” He picks up a scalpel and easily, effortlessly, slices open the right ventricle. I peer into it and I can’t see a thing that looks out of the ordinary. I see cusps and thready things, the name of which has escaped my memory and which I have to look up later: chordae tendinae. The doctor scrapes the scalpel down the wall of the ventricle, sluicing blood away, and then he looks alert. “There we are.”

“What?” I still can’t see a thing.

“Look. See where there are grey areas?” I look and I don’t, and he amends his statement. “All right, areas where it’s less pink.” Okay, with that I can in fact see what he means; there are slightly mottled areas here and there.

“Those are dead cells?” I ask.

“Damaged areas, yes.” He turns the heart over and does the same thing with the left ventricle, and this time even I can see it. “So which arteries do we suspect?”

“Right coronary artery and the LAD?”

“Let’s look.” He turns the base of the heart up and cuts through the right coronary artery near its beginning. “It’s elastic, no obvious atherosclerosis.” He continues to make cuts, making very thin slices, very even, revealing circle after circle of white. I’m fascinated, but even more, I’m astounded at his technique: he’s slicing right down onto his index finger, using it to support the artery as he makes cut after cut. I can’t help remarking on it.

“You’re braver than I am—those things are sharp.” I wince as he makes yet another cut.

“Been doing this quite some time,” he observes dryly, and then he stops. “There’s something. Not completely occluded, approximately seven or eight centimeters down the right coronary artery. Normally I wouldn’t expect something like this to drop someone, but you never know.” He cuts away a sample and it’s added to the collection. Then he turns the heart over and begins doing the same thing to the LAD, which he’s calling something else, anterior interventricular, I think.

And this time, I can see it even before he points it out. There’s a mass, and a greyish blob in the center of it. Presumably, we have our answer: the partial blockage in the right coronary artery might not have helped, but this is the real guilty party.

“It’s a shame,” the doctor says. “If he’d been diagnosed, he’d probably have been a perfect candidate for a bypass.” I nod numbly and hold out my hand; he gives me the heart. I open the cut ventricles, touch the arteries—he’s right, they are flexible, and they feel totally different from the ones in the cadaver. Apparently we’re done now; the doctor takes the heart and replaces it in the chest cavity, sets the breastplate over it, layers the fascia back over the whole thing. The entire procedure has taken less than half an hour. I go to strip off my gloves and wash my hands—it takes a second to figure out how to operate the foot pedal on the sink—and then I come back to the table. Below the blue towel I can see thick grey hair, just tinged with brown. I’m tempted to remove the towel, but somehow that doesn’t seem right. I put out my bare hand and just brush it over his head.

Thank you for the lesson, I say silently, and then we’re through. The body is wheeled away, and the doctor goes to take off his jumpsuit. I walk out through a different door, through a garage, and out the open garage door into the parking lot of the funeral home.

My father died on April 25th, 2005, of a heart attack that probably began twenty-four to thirty-six hours prior to the fatal event. This is a reasonably faithful account of the last time I saw him. This is what I learned, what I discovered, what I witnessed.

He had no prior history of heart trouble; whatever symptoms he had—the most common ones exclusive of pain, which he presumably did not have, are fatigue, shortness of breath and heartburn-like symptoms—were likely masked by his known medical conditions: he had asthma, he could single-handedly have kept Tums in business, and he had been suffering from a sinus infection and had been working long hours at work and, over the weekend prior to his death, rebuilding the autopilot system of his plane.

He was at work when the fatal attack occurred. His workplace had trained first responders and a doctor and nurse on-site; AEDs and people trained in CPR were with him within minutes. It didn't matter. And today—this was the way it finished.

This is the end of life, which cannot always be prevented.

Just another step on the road to becoming a doctor.

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Thank you for reading it.

I wasn't sure anyone would want to, it not exactly being my usual thing.

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(Deleted comment)
Heh. Icon is not a problem. Smiles are always good.

And if you want to be a doctor, you can be a doctor. (If *I* can get in, believe me...I am so *not* the typical med student.)

Though there's a saying around med school: If you really just want to do good and take care of people...be a nurse.


I'm so sorry about your mom. That's a whole different level of difficult, at the age you must have been then. I don't know how I'd have handled this if it had happened earlier. Not that it's much fun now.

It really is amazing, what you take for granted from day to day.

Wow. That was a truly awesome piece.

And I could see everything in my head, too - even the bright green on the gallbladder. Weird little thing, isn't it?

Very definitely a weird little thing. And *green*. I always thought they just colored it green in the books so you could tell it from the liver!

Thanks so much for reading and commenting. It really is wonderful to see such a positive reaction.

Subtle and powerful. Well done.

Thanks, Kid! *g*

Glad to see you around LJ.

I think it is the overlying respect for the subject that makes this such an awesome piece of writing - a sincere, simple, and honest reflection of the very end of someone's story. Thank you for sharing.

Thank you so much for saying that--it's hard to know how to write about a subject like this, and I'm glad that that was the impression it made.

One problem with med school is that the way doctors are trained does tend to lead to a certain...dissociation, perhaps, is the right word, though some people would say "callousness". There's no question, as I said in the piece, that you have to find a way to mentally deal with the strange things you have to do, but the schools these days are very good about emphasizing taking a serious attitude towards all patients, including dissection subjects. They have a whole part of our curriculum called "Essentials of Clinical Medicine" that focuses on understanding the process of becoming a doctor, including ethics and consent issues and that sort of thing.

I sent this to one of the two doctors who were in charge of ECM last year. His response was that though he thought it was well-written, "that kind of distance is nothing to be proud of." Made me worry about the whole course. I know I designed the piece so it wasn't clear until the end that it was my father, but...I couldn't believe that anyone could read this and come away with the idea that I wasn't very involved and moved by the whole thing.

I loved my dad very much, but one thing I do know is that if he thought I could learn anything from what happened, he would have wanted me to do it.

*hugs*




I'm glad that that was the impression it made.
It did. My brother, a physician, would agree with you on the 'callousness' term. And as for the doctor who wrote you back, he's right that distance is nothing to be proud of, but neither is being incapable of helping your patients because you are 'too involved'. I'm glad to see schools are addressing this in a compassionate manner both for you, as the student, and your future patients. You'll all come out ahead.

if he thought I could learn anything from what happened, he would have wanted me to do it.
Now that I'm a parent, and have been for a few years, I definitely agree.

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