Tuesday, October 19, 2010

Grossness in the Lab

There have been many, many books, articles, essays, and poems written about the cadaver.  There have been a similarly large number of writings about why death fascinates us.  I will try my best to avoid the obvious and cliched in this post.

Today marked the third day of dissection.  Every day, for the greater part of a month, we enter the gross anatomy lab at 8 am and spend the next two and a half hours palpating bodies, cutting through skin and subcutaneous fat, slicing fascia, probing superficial and deep muscle layers, and searching for nerves and blood vessels.  We started with the back, a relatively impersonal region with well-defined, thick muscles.  We then stayed with the donor prone, moving to the posterior upper and lower limbs during subsequent labs.

As expected, unexpected things have surprised me about anatomy lab.

Before our first day, our anatomy professor spoke briefly about the special (and privileged) experience we were about to undergo.  It sounded almost sacrosanct: "You will remember where you were standing.  You will remember where your lab partners were standing.  You will remember the first cut."

Though I write with less than week between that first cut and me, what I can say is that that cut was not our first interaction with the cadavers--and it was also not the most memorable one.  After we unzipped our body bag, we saw that our cadaver wasn't lying on its stomach, prepared for our incisions on its back.  We would have to flip it.  For several minutes, my labmates and I struggled to lift the heavy man--literally dead weight, and filled with gallons of embalming fluid--and carefully turn him onto his stomach.  I grabbed a left arm, a left leg, to steady the body, and I felt slightly sick.  Physically manipulating a dead body, feelings its contours, struggling with a rigid unmoving object, turned out to be much more crass and jarring than making restrained surgical incisions through his skin.

What I found throughout lab was that the worst, most disturbing moments were the most familiar ones--the ones when the body resembled a living human's.  To position the arm for cutting, I had to twist it carefully.  The elbow joint still worked, and the flexion resembled a living person's--not the stiff unbendable limb I had imagined.  Brushing against the man's fingernails--grime still underneath them--was unpleasant in its familiarity. Seeing toughened skin and hair on the man's arms and legs gave me the same feeling.

It was the new, the unrecognizable, that unsettled me least.  Never having seen anything beyond animal muscle, seeing human muscle and its surrounding fascia fascinated me.  Pulling on a certain muscle to move the cadaver's thumb felt like a surreal version of a marionette--but still too unnatural to elicit a strong reaction.  Cutting away human fat, an inherently unpleasant task due to its color and texture, only vaguely differed from cutting away animal fat during dinner.  Rolling up the skin and subcutaneous fat like a carpet after we had removed it was still too far removed from reality to make me shudder.

Before I entered the laboratory, I was fairly certain that the experience would feel laden with emotion and that I would not be comfortable if my labmates treated the situation with anything other than intense seriousness  Again, surprisingly, this attitude changed fairly quickly.  I realized that "respect" didn't stem from how we felt or what we said--it came from our deeper attitude towards the task at hand.

What would I want if I donated my own body to science?  What would upset me?  What would satisfy me?  I can't presume to know the donors' motives, but I can say that my own would be to teach someone something unique.  I wouldn't particularly care whether students put on a--perhaps artificial--air of solemnity during dissection.  I would rather they treat my body as a specimen, something they could learn a whole lot from.  The worst form of disrespect, in my view then, would be wastage--students rushing through procedures, not being prepared to identify structures, and worst of all, not caring about what was in front of them.

To help further classify my feelings, I divided them into several categories: 1) unpleasantness from something that would disturb me if seen on a living person, 2) unpleasantness from something that reminded me of death but wasn't directly related to the body's appearance, and 3) unpleasantness stemming from the appearance of the body itself.  I believe only category 3 is particularly sad and something I would like to lessen.

These classifications have helped me hone my idea of "respect" for the cadavers.  Our instructors talked quite a bit beforehand about this concept.  We were told not to give them names (they already have names; we just don't know them).  We were told nothing of their age or cause of death.  (There are many arguments about whether this dehumanizes the cadavers or protects their status and anonymity.)

Today, when we palpated the gluteal muscles, feces emerged from the cadaver's anus.  This happens sometimes, and it's not particularly common or uncommon.  Should I feel embarrassed that I was thoroughly disgusted?  I certainly would feel about the same way about a living person, and I'm not ashamed to admit it.  It is really any more respectful, then, to hide a feeling of disgust when the subject happens to be dead?  (This falls into category 1 of aforementioned unpleasantness.)

Similarly, I was fairly horrified the first time I held the cadaver's cold hand for an extended period of time.  Probing my feeling, I found that it wasn't the hand itself that repulsed me; it was that it very explicitly symbolized death.  It was inhuman.  This, also, I don't feel is particularly disrespectful--to have a visceral reaction against death.  (Category 2 of unpleasantness.)

What about making small jokes, at no one's expense (including, and especially, the cadaver's)?  I surprised myself by laughing during lab.  When we dissected down to the trapezius muscles, I mentioned that it was cool to see the muscles that felt so good when they were massaged.  My labmate gently squeezed them and said, "Yeah, it's like he's getting a really deep massage."  It felt okay.

So what wouldn't I want if I donated my body to science?  It's not an easy question to answer.  Clearly, we want our sacrifice to be taken seriously--though not to the extent that emotion renders us less effective learners.  I realized that I would be bothered if people were disgusted by my remains.  Not of my feces, not of my cold hand, but of the natural processes that my body undergoes as a result of being dead--that is, category 3.

It would sadden me, for instance, if someone saw my long toenails, or squished backside, or flaking skin, and as a result, saw me as less than human.  I don't mind if people see my feces as disgusting, or as death itself as disgusting.  I suppose I do mind if people see what I've contributed as repulsive.  It's a dehumanizing feeling--to repulse someone--and it would put me on a separate plane from my dissectors.  We are no longer the same species; I am alien.  They cannot see themselves in me.  Understandable, of course, but sad nonetheless.

Tomorrow we dissect at 8 am.  It may be serious, but hopefully not too serious.  It may be enjoyable, but hopefully not distracting from all we need to accomplish.  It may even be disgusting--but hopefully for "better" reasons.

Tuesday, October 12, 2010

More on Mortality

This past weekend I attended a course--Practical Aspects of Palliative Care--held by palliative care physicians and specialists from Harvard's hospitals.  It was attended by physicians, nurse practitioners, nurses, managers, social workers, and chaplains from across the country.  I was very different.  Greener than green, I have not yet taken part in the dying process, much less the process on a regular basis.

Apart from seeing glimpses of cadavers in various anatomy labs while interviewing at medical schools, I have only seen a dead body once in my life.  It was in the basement of a hospice I had volunteered at in college, and what struck me was how lonely it looked.  Fewer than 24 hours ago, that same figure had been surrounded by doting loved ones whispering tearful expressions of affection.  She had been the center of attention, of love, of comfort care.  She had appeared almost identical to how she looked now, but everything else had changed.  She was alone on a cold metal gurney.  When the volunteer coordinator turned off the light and closed the door to the basement, I had an instinctual reaction--wait, are we just going to leave her there?

Later, outside the confines of the hospice, I probed my discomfort over leaving, and I realized how difficult it was for me to separate a body from the person who had occupied it.  For better or for worse--despite rational mind-body dualism--we are our bodies.  When our bodies fail, who we are is profoundly affected.  When we're in pain, our relationships with others change.  When we don't have energy to speak or to move, some priorities shift to the forefront while others fade into the background.  Health is a foundational good that we can take for granted until its status changes.

During the conference, there was a workshop on how to avoid burnout and fatigue.  Participants listed the "perfect storm" of events that could cause them to hit an emotional wall.  For some, patient-related issues contributed: seeing particularly young people die, or seeing people who bore striking resemblances to themselves.  Professional dissatisfaction was a cause too: feeling a lack of control over the system or over resources within the system, or not being able to help as much as one would like.  Personal life certainly played a role, as well as general challenges unique to working in palliative care.  Who do you turn to when you need to share something particularly challenging or frustrating?  Do those outside the field understand--and even if they do, how often can they hear about it?

I waited to hear answers along a particular line of thought.  Loss of faith.  Spiritual questioning.  Seeing so much suffering as to feel as though life itself were unfair and meaningless at times.  Existential anguish.  These were noticeably absent; answers were fairly grounded.  I'm not sure what that means.

I wonder if it takes a particular type of person to go into this field.  Does the special emotional resilience--the ability to transition from distancing to empathizing--stem from deeper beliefs about life?  Do you have to have some sort of spirituality or religion to give events a greater meaning, so as not to become disillusioned by the physical fragility of the human condition?  I would very much like to know if palliative care professionals are more spiritual/religious than other health care professionals, and if so, if it's correlative or causative.  At a certain point during the course, I began to see all of us as the walking future dead.  How could these professionals see such tragedy and still function despite these continual reminders of their own fate?  I think this is something I am wholly unprepared for and will have to learn gradually.

Death isn't carved out neatly into palliative professionals' hands simply because they have more experience with it.  Most doctors will have to face it.  I will be facing it during my third year of medical school.  I will be facing it in two days, in seeing my first "patient," a cadaver.

It seems like a great juxtaposition to go from a palliative care conference--focusing on transitioning from the living to the dying--to the anatomy lab--focusing on learning from the dead.  It seems like an odd backwards cycle, but I'm glad for it, emotionally.  There will be no suffering, no unmitigating symptoms, no difficult decisions.  Our learning takes place after all this, from the great gift left behind.

Monday, October 11, 2010

I'm Starting to Get It

From Ellen Lerner Rothman's book, Becoming a Doctor at Harvard Medical School (she graduated from our program about a decade ago, and her book chronicles her experience):
At times it felt as if death were everywhere.  In anatomy lab we finally uncovered the facial shroud and opened the skull to dissect the brain, and that was okay.  I talked to a patient who had nearly died the previous evening and would certainly die within the next months, and that was okay.  I came home, and my goldfish had died, and that wasn't okay.  I sobbed for half an hour.
This past week culminated in a similar sense of emotional drain that is very new to me.

On Monday, I met a 48-year-old patient who had been in and out of the hospital for severe abdominal pain for the last five years.  He had been forced to retire, lived alone, and had only his dog for company.  After the interview, he didn't want me to leave the room.

On Tuesday, I shadowed a neurologist for several hours.  I saw a 29-year-old man who had just been diagnosed with multiple sclerosis and couldn't feel his legs, a confused elderly gentleman who had had a series of seizures resulting in his increasing levels of incapacitation, and videotapes of two patients suffering intense seizures.

On Friday, Saturday, and Sunday, I attended a conference on palliative care, with physicians, nurse practitioners, nurses, managers, social workers, psychologists, and chaplains from all over the country.  Every person there experienced dying on a regular basis.  They shared details about basic mechanistics and interventions during the actual dying process, how to communicate prognoses and do emotional "damage control" after a patient has exhausted treatments, how to support families, ethical and legal dilemmas on withdrawing or withholding care, and how to deal with fatigue and burnout.

This Thursday we start dissecting cadavers.

Suddenly academic rigors do not seem like the hardest part of medical school anymore.

Tuesday, October 5, 2010

"Do You Want to Listen to my Heart or Lungs or Something?"

We have a weekly course called Patient-Doctor, in which we interview patients at our school's teaching hospitals to learn how to take a medical history and present clinical cases orally and in writing. We also try to incorporate the idea of "patients as people," inquiring about their social support networks, hobbies, work, or other meaningful components of who they are.
What we can't do in the least is help them medically. They know more about their illnesses than we do.
On one of my first sessions, I interviewed a middle-aged man who experienced acute episodes of debilitating pain in his abdomen, most likely from complications stemming from his gastric bypass surgery a decade ago. The pain was bad and always there, he said. When it was particularly severe, he couldn't do much other than lie down, and his dog would lick his hand until he'd feel better again (he lived alone). He had been forced to retire from a job he loved.
I had twenty minutes to take a brief history: his present symptoms, what he thought caused them, how long they lasted, and how they affected his life. He opened up to me in a way that even surprised my preceptor, freely admitting that he had been a heavy drinker and smoker.
As our minutes together ran out, I thanked him for his time and sharing his story. My hand was proverbially on the doorknob when he asked me, "Do you want to listen to my heart or lungs or something?"
I'm not sure why he asked. Did he think I had more authority or qualifications than I actually did? Did he want to help me learn better? Or did he just want me to stick around longer, to talk, to listen, to understand?
When I told him unfortunately I couldn't do that, he said he understood and told my preceptor that he should send other students in if he wanted.
At the time, I was too wrapped up in my own thoughts about how I would present the case to think much about the patient after I left his room. Later, when I presented his case, I was concise. I stuck to the organized structure of a medical history, throwing in a few personal facts as per the formula to make this patient come alive to my audience. Then my assignment was over. My brief relationship with this man was over.
Hours later, I couldn't sleep. I wondered how he was doing. He was still probably experiencing some form of pain right then. Quality? Severity? Worse? Better? How? Why?
I felt an intense sadness that I would probably never be able to know how he felt again. I couldn't listen to his heart or lungs, but could I... "something"?  The thought flitted through my mind that perhaps I could email my preceptors and ask if I could visit this man again. No interview pad, no scripted questions, no rigid time restraints. But a mixture of timidity, discomfort, and a fear of doing something outside protocol got the best of me. Would such a request sound inappropriate and naive? I wrote a draft of this blog post and tried to get back to sleep. Perhaps writing that email instead would have been a more fruitful and less self-indulgent endeavor.
When the gentleman asked me that question, he needed help. He was looking directly at me, earnestly, waiting for me to do something. I thought I couldn't do anything. I was not qualified.
Now I wonder if I could have qualified in a different way, had I seriously explored possibilities beyond strictly medical help.  Maybe my attempts would have failed; maybe there was policy prohibiting me from visiting again. I still do not know. I should know now though, because I should have asked then. Next time I will. I'm just sorry it will not be for this particular man with this particular pain.