Forward

There is something different about a dead body. I usually relish the opportunity to cut -- as a budding surgeon, it is often a chance to cure, to heal, to save. Disturbing a lifeless body, though, even in the name of Science, evokes an uneasiness, a violation of the human form. I feel comfortable operating on the living; the dead is Someone else's realm.

This "violation" is not wrong, though I do wonder if it is right. Just as the hopeless coding patient enters a gray-zone -- not dead, but not quite alive either -- just as the medical team shocks, compresses, and forces air into her lungs, I wonder if we as clinicians too often cross this line. We push past the cancer and the fatigued heart, denying humanity's limits without pause or reflection. We push past the wishes of the patient and their family. For Science and Medicine, we move in one direction: forward.

In an autopsy, we disregard death entirely. Laying in front of me now was (is?) a person. Over the next hour or so, she will become unrecognizable, literal pieces of her former self. Her heart, brain, gut, lungs will all be weighed, measured, sliced, and cut into pieces to be examined grossly and under the microscope. The skin over her face will be peeled back; only her legs and arms will be left intact. A human being in jars of formaldehyde. What is left is splayed on a cold, metallic table. The soul already gone.

She happens to be a 280 lbs., 31-year-old female, approximately 5'6'' with no external deformities or obvious causes of death. Without pause, the cutting begins. There is no moment to consider her as who she is and was, nor a "timeout" as typical in the operating room. Unlike in surgery, there is room for error. She is already dead. We waltz across the line... forward.

I flash back to my first clinical experience with death. A woman similar to the lady in front of me, found on the floor of her bedroom by her 10-year-old son. The firefighters had already begun CPR when the paramedics and I arrived. Though I was a new EMT, I knew she was gone. We tried to sustain her life all the way to the trauma bay at the local hospital, to no avail. I watched quietly as the attending physician directed each of the residents to practice intubating her. When they were through with her, she was pronounced dead.

The woman in front of me overdosed on pain-killers, fully depressing her respiratory drive to the point of asphyxiation. Apparently this is a relatively common cause of death in the medical examiner (ME) domain. I watched. In less than an hour, the ME and nurses fully dissected the body. A kitchen knife was used to cut a "Y" shaped incision across her chest. The heart, lungs, and gut were removed, washed, examined, weighed, cut, palpated, placed in formaldehyde, and sent off to the pathology lab. The liver was chopped like a piece of meat. The heart was excised in sections to evaluate the patency of coronary and major vessels. Even the tongue and oral cavity were removed to look for obvious signs of choking and bruising.

In a typical medical case, one pauses to listen to the patient's story -- their history. The vast majority of diagnoses can be made from the history alone. I wonder what she would have told me. Was she depressed or angry? Who had hurt her? Was this her first and only attempt? Had no one heard her call for help? Did she have children? A partner? Who found her? I hope it was not a child.

This autopsy, however, is not a typical medical case. We investigate without the opportunity to ask questions. Forward. The ME splays open a dead body to discover the cause of death. In some cases, the diagnosis is simple and straightforward. In others, there is no answer. Either way, Science dissects the human form until it is unrecognizable, pronouncing final judgment -- Medicine's final word.

But this is training. No pause, no time for reflection. Patients await, and I must keep pace.