Tuesday, November 30, 2010

More and Less

It started with a simple question my classmate asked me while we were on the shuttle: "After taking anatomy, do you think you're more or less likely to want to donate your body to medical science?"  I paused, sat back.  It was--to borrow a cliché--really complicated.

How much did I know about the fate of a donated body before I stepped into the anatomy lab in scrubs with scalpel in hand?  On one hand, thinking of young aspiring physicians, I could have romanticized the role of a donor.  The invaluable experience of learning from flesh rather than books.  The indelible impact of feeling for organs, finding them, taking them out of their cavities, scrutinizing them, remembering them, and using the knowledge gained to cure others.

However, the past six weeks have been graphic.  Sterile donor consent forms are not sensual experiences.  They do not show the prodding of genitals and orifices with probes.  They do not replicate the sound of sawing the skull in two.  They do not convey the smell of rummaging through the bowels, or the feel of dry, leathery flesh.  Now that we are "informed"--in every sense of the word--would we want the same fate for our own bodies?

Or--now, do we even more acutely realize and appreciate the significance of such a gift?  Would this inspire us to want to give back to future generations of those like us?

Curiosity led me to send out a one-minute, five-question survey to my 200 classmates.  I received 75 responses.  The raw results are below.  In the next post, I will analyze these numbers further and discuss them.

Rather predictably, more students--nearly 50% more--began to think about their own body donation after taking anatomy.  No one who had answered "yes" for the former question answered "no" for the latter.

Before taking anatomy, about one third of students considered themselves "likely" or "very likely" to donate their bodies.  After taking anatomy, this fraction dropped a bit.

The more striking difference was the increase in students unlikely to donate their bodies after taking anatomy.  Fewer than half considered themselves "not likely" or "not at all likely" to donate beforehand.  After the course, that number grew to greater than half.

To note:

No one in any instance who had answered “yes” for the previous questions (they had thought about body donation) left these questions about likelihood blank.

Before anatomy: Since only 44 students claimed they had thought about body donation, I expected to receive this number of responses for the follow-up question.  However, 11 people most likely interpreted the question conditionally ("If you had thought about body donation, how likely would you have been to donate?") and thus answered.  I kept their responses for completeness.

After anatomy: Once again, based on the last question, I expected to receive 65 responses.  Similarly, I am including the extra 5 answers for completeness.

These results are consistent with the findings that taking anatomy caused more students to become less likely to donate their bodies.  Several questions remain.  How often did students experience complete changes-of-heart, such as switching from "likely" to "unlikely"?  Did students with stronger feelings about their likelihood of donating stick with them more steadfastly?  How did the 21 students who had not thought about donating their bodies before anatomy feel after it?

Since I have the individual surveys, I can be transparent and specific.  Next post coming soon.

Dear Third Space

Third Space Magazine is a student-run literary magazine for Harvard medical students, residents, and faculty. It publishes fiction, prose, poetry, and art biannually.

I am currently involved in the Chief Complaints section, a mock advice column.  My first contribution:

Dear Third Space,

I dislike my anatomy lab partner, but I dislike confrontation even more.  Do you have any suggestions about how I can passive-aggressively voice my displeasure? 

- Silent Rage Behind the Scalpel

Dear Silent,

The important thing to remember is, when donning the blue scrubs and gown, one must remain professional.  As we learned during Introduction to the Profession, being professional involves not raising your voice, not using your scalpel to nick your partner’s forearm, not burying fat in your partner’s hair, not naming your cadaver after your partner, not spraying formalin in your partner’s locker, not hiding your partner’s pants in the changing room, and not taking a hammer and chisel to your partner’s kneecaps.

It is also important to remember that every medical student in the anatomy lab is nervous and frightened to be there.  She may have had bad experiences in anatomy labs before.  Maybe she mistrusts the anatomy directors.  Maybe the anatomy labs here are not like the anatomy labs she is used to.  You must find out more about your partner as a person.  Instead of making assumptions about your partner’s expectations regarding anatomy lab, take the time to talk to her about them.

A good place to start would be to ask her what brings her into the anatomy lab today.  Try to obtain her explanatory model for why she thinks she is here.  It is also important to make empathic statements.  If she accidentally cuts the phrenic nerve, you may say, “This must be hard for you.”  Try to make your questions non-judgmental, and make the transitions natural but clear. Perhaps while she is dissecting the liver, ask her how many drinks she has each week.  While she is looking for the bulbospongiosus muscle, inquire “men, women, or both?"  While you both dig through fat, ask her if she is interested in exercising more.   Try offering advice about STD testing, AA meetings, or birth control in passing, just to let her know your door is open for additional questions.  Ask her how many children or grandchildren she has, and what she is most looking forward to doing when she leaves the anatomy lab.

No matter what, it is important to maintain an air of professionalism and understanding.  Remember, not all of this has to be accomplished in just one session.  Sometimes you may have to broach sensitive issues repeatedly on follow-up meetings until she eventually gives you satisfactory answers.  The partner-partner relationship is a unique, delicate, and long-standing one and should be treated as such.

Always Professional

Sunday, November 14, 2010

The Fifth Member

In this post, I am not going to be a hypocrite.  We have not called our "donor" "our donor" in a very long time.  In fact, I don't think we ever did.  He is "our body" and "our guy."  It doesn't feel right in writing.  It is jarring, but it is honest.  So I will call him that now.

One night, alone in the anatomy lab, I was reviewing our body's abdominal and pelvic organs.  I knew that the next time I saw him, I would be dissecting his face and neck.  There would be little time for reflection.  I lifted the sheet that had covered his face for the last month.

Our guy was entirely dissected, in some places far less than perfectly.  During lab, I no longer mused about the now bloated, skinless hand while I was wrist-deep in intestines and embalming fluid.  I no longer thought about "the person" or "the patient" while I cursed the smell--an unfamiliar and unpleasant mixture of embalming fluid and bodily contents--that strongly emanated from our body, particularly when we dissected near the rectum.  (I had long given up trying to breathe through my nose.)  I often wished that our guy weren't so darn moist, and yellow, and fatty--that, like our classmates, we could easily distinguish among arteries, veins, nerves, and ducts.

It is amazing what a difference a face makes.  I looked at his face, completely intact, feeling a combination of awe and shame.  His eyes weren't completely closed.  His nostrils flared a bit.  He had strong, gray stubble.  Who was this person?  What would he think if he knew what we were doing to him?  How much worse was it than what he'd imagined?

I thought about this man with the metal knee replacements, the hardened coronary and femoral arteries, the strong tan arms, the large amounts of visceral fat.  Sometimes during lab, we would hazard guesses about who our guy used to be: a fisherman?  A construction worker?  A park ranger?  We were probably horribly, offensively wrong.  My three labmates and I knew him in ways that no one else, including he, ever would.  Yet at the same time, we knew nothing about him at all.

If this were a movie, we would probably we treated to flashbacks about this man's life while we puzzled over his innards.  Maybe he would be shown at the dinner table, eating a hearty meat-and-potatoes meal while his arteries slowly calcified.  Maybe we could see how he developed such strong muscles, surprisingly well-formed even years after death.  Perhaps we would see him contemplating what he wanted to do with his body after death, having deep discussions with his wife and children.  Was he ever in a hospice, on a "death bed"--or did he die suddenly, perhaps of a heart attack?

Who was this man?  Would he have laughed along with us as we surreptitiously tried to get our instructor's attention with some well-placed coughs?  Would he too have flinched at the smell?  Been frustrated by the layers and layers of fat?  Felt disappointment when we accidentally cut a major nerve instead of preserving it?  Felt that same awe when we held his heart and lungs in our hands?  When he donated his body to science, how much did he know what the aftermath would look like?  That he would be groped deeply in cavities he probably never knew he had.  That he would get a circumcision.  That he would be seen every day by at least forty students--but not really seen so much as "looked past," as though he were part of the decor. This sounds more like a horror story than a gift.

The moment I stared into his face was oddly sad.  In some way, I felt as though he were witness to our work all along, a fifth member of our group.  I wished I could have a conversation with him.  I wished I could tell him what he looked like inside.  I wished I could tell him that we are just kids, to ignore our pouts and moans when we can't find what we're looking for and when we're tired of digging.  I wished I could tell him that holding his heart was the most humbling experience of my life.  Throughout lab, I sometimes imagined I could find a clue as to who he was by searching through his body, that physical signs could somehow magically impart answers.  Of course, this was fruitless.

If this were a movie, perhaps we would be rewarded with a final scene, a culmination of our efforts and his.  A meeting, of sorts.  A brief but meaningful conversation that would change how we viewed each other.  A videotape delivered by his family.  A hand-written letter.  A spiritual epiphany.  But there are no such endings here.  Our reward is learning anatomy.  This is the psoas muscle.  Sometimes I wish it were all bit more Hollywood.

Thursday, November 11, 2010

Internal Happenings

There was a certain ignorance I had about the body before dissecting it from shoulder to foot (head and neck are up next and last).  Some of what I've learned was surprising, disconcerting, and fascinating:

1. The female urethra is very, very short.  I was aware that it was only a few centimeters in length, but seeing the bladder so close to the outside world (and the anal opening) made me wonder why every woman doesn't always have a UTI.

2. The body is almost entirely shades of brown, yellow, gray, and red.  The gallbladder and its contents are the only exception: a stunning bright olive-green (in live people, it is robin's egg blue).

3. We have an internal apron: a layer of visceral fat, several inches thick, that hangs from our stomach.  It helps protect our stomach, accessory digestive organs, and small and large intestines.  This is different from subcutaneous fat, which is what we usually think of when we put on weight.  The female "apron" is thicker than the male (she has more internal organs to protect)--which unfortunately leaves the door wide open for sexist jokes.

4. Even if you do not smoke, your lungs will probably end up black and speckled from what you've breathed in over a lifetime.

5. The appendix elicited a large amount of anger from my labmate.  It looked puny, flat, and unnecessary.  Since it is at the beginning of the large intestine, it easily gets infected.  Appendix pain has been said to be the most agonizing pain there is.

6. Our bodies can differ substantially, with apparently no impact.  There are certain things we'll never know about ourselves unless a careful anatomist dissected us.  Some arteries, veins, and nerves run in different directions, taking tortuous routes--and some simply do not exist.  Sometimes the right kidney is higher; sometimes the left is.  A thigh can have a large benign mass, made entirely of fat.  Cysts are very common, sprinkled throughout the body.

7. Your body gets hard when it ages.  Calcifications develop in the cavity holding your lungs, coronary arteries harden, cartilage disappears and leaves rough bone in its wake.

8. In one day, our kidney filter 150-180 liters of blood.  We can survive with reduced kidney function or just one kidney.  One kidney is only about the size of a computer mouse.