Kelly Esposito, Stephen Vance, Eric Golike, and I were presented with a 280 lbs. 31 year old female. She was approximately 5'6'' with no external deformities or obvious causes of death. It was surreal to see someone so young rest limp and lifeless. But there was no time to delve into questions of the soul or God. A differential diagnosis was to be formed. After changing into scrubs, gowning, gloving, and shoe-/eye-protecting, the four of us assembled in a semi-circle before the attending. I proffered the possibility that drugs were the etiology of death. Seeing our patient (person? specimen? patient? yes, patient) laying there on her back reminded me of my first overdose call working EMS. A woman in her upper-30s was found on the floor of her bedroom by her 10 year old son. The firefighters had begun CPR when we arrived, but the paramedic I was working with called it off immediately Blood had pooled to the posterior trunk and legs. It was my first clinical experience with death.
Turns out this picture was similar. Our patient had overdosed on pain-killers, fully depressing her respiratory drive to the point of asphyxiation. Apparently this is a relatively common occurrence in the medical examiner (ME) domain. Someone so young makes one reflect on one's own mortality Yet again, there would be time to reflect later. In less than an hour the ME, nurses, and fourth year medical student dissected the body; it had only taken us eight weeks in anatomy. Just like in the movies, a Y-shaped incision was cut into the anterior chest. Unlike in the movies, the ME didn't use a scalpel. Instead, a kitchen knife of the CUTCO variety was the instrument of choice. Within the first few minutes, the heart, lungs, and gut were removed, washed, examined, weighed, cut, chopped, felt, excised, placed in formaldehyde, and sent off to the pathology lab. The liver was chopped into slices like a piece of meat (I won't name any meats specifically so dinner is not ruined). The heart was examined in sections to evaluate the patency of coronary and major vessels. Even the tongue and oral cavity were excised to look for obvious signs of choking and/or bruising. In a moment of lucidity (or "awakening" from my clinical state), I remember thinking, "Damn, this man is holding a person's tongue and trachea in his hand! WTF?!" But again, I had to snap back into my desensitized state.
In retrospect, what snapped me back was most likely the smell. It was unlike the comfortable formaldehyde aroma of the anatomy lab. Thank Jesus for the windows in that building. Even though none of them were open, they at least allowed my eyes some escape, but by the end of the hour the fetid odor was the status quo.
If the smell didn't get me back in clinical form, my anatomy-recall deficiency (ARD) did. While our attending held the tongue/former breathing apparatus, he quizzed us briefly on the anatomical structures. Fortunately Kelly saved us with her AR thyroid knowledge. This ARD reminded me that I definitely should do some sort of anatomy rotation in my fourth year; it seems "high yield" for the rest of my life. A number of fourth years, preparing for their general surgery residency, spend a couple of weeks under the medical examiner's tutelage to refresh their anatomical acumen (e.g. our fourth year assistant). Come to think of it, I wouldn't mind doing a radiology rotation for this same purpose.
As far as learning goes, our patient had pristine anatomy despite her death and her BMI. Her aorta had minimal fatty streaks (the beginning of atherosclerosis that can be seen even in teenagers these days) and her heart lacked hypertrophy.Yet there she lay. Dead. In most cases, one hears the patient's story, but our lady had nothing to say. Before they cut into her face and scalp, I wondered what would she have told us. Was she depressed or angry? Who hurt her? Was this her first and only attempt? Had no one heard her call for help? Did anyone care? Did she have children? A partner? Who found her? I hoped it wasn't her children. It is unfathomable, even after seeing it happen in real-life while working on the ambulance: You're a fourth grader getting off the bus after school, walking across the street to your house, up the stairs, and there is your mother on the floor, a bottle of pills beside her, half of them gone, she's cold and lifeless, she doesn't respond to your call. Mom?? Wake up. WAKE UP! You run to the phone and dial 911, police officers, EMS, firefighters, dozens of people in your house, they tell you your mother is dead. You are too young to comprehend your own mortality.
I guess now is the time to reflect, and yet I don't want to. They say there are two types of medical students: those that think they have every disease, and those that deny their own morbidity and mortality. Before, I have thought I was in the former category, but it is scary to think of everything that could happen to you. One in 1000 get this, 1 in 500 get that. It's amazing that anyone is even born "normal" with all the possible genetic mutations and deletions that could occur in utero. Every disease I see that says it "affects males more than females, more common in people of northern European descent," that could be me. And some of the diseases are truly horrible diseases. What if today I was diagnosed with ALS? What if I had a year left? This woman was 31 years old. Thirty-one! I won't even be out of residency then. I'm not ready. I need more time, but that's not my choice. This, like gross anatomy or the autopsy, also provokes a visceral reaction, one that I'm not ready to confront. And yet it is one that I will confront almost every day as a physician. Will I push it away? Will I become so desensitized to death that I will forget my own mortality?
An autopsy is an investigation. With a short history, a physician examines a dead body to discover the cause of death. In some cases, the diagnosis is simple and straightforward. In others, you need a microscope and tissue samples to narrow down your differential. And many times you never find out why your patient died. In today's culture we separate science and religion. So who does our spiritual autopsy? At the end of the day, who dissects our soul? I don't know, but as we were standing there observing man's final judgment, I couldn't help thinking...
God, are you waiting?
(Note: some details concerning our patient were subtly changed for her privacy.)
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