Autumn Leaves

Would there be an autopsy deemed “sufficient” for a group of medical school students to see this morning? This question raced through my mind. As second-year students, we were required to travel to the Chief Medical Examiner’s office in Raleigh, North Carolina to watch an autopsy. There a general sense of uncertainty among my classmates about this requirement. A fundamental cause of this discomfort centered on the fact that it was completely and utterly unpredictable. You might not have to see an autopsy at all that morning—even though you had been dreading it. Before embarking on the 40-minute drive to Raleigh, we were asked to call the Chief Medical Examiner’s office at 8:00am on the morning of our scheduled autopsy. During the call, we would be told whether or not we would be able to view the process. If the bodies in the autopsy suite were deemed not “suitable” for a group of nervous, jittery medical school students to see, then it would be canceled. If we did receive approval, we had to be in Raleigh by 9:00am—breakfast or no breakfast.

A few students in my class had been forced to reschedule their autopsy experience two or three times because of the unforeseeable cancellations. I wondered what criteria were used by the pathologists or technicians to decide a body was “unsuitable” for viewing. Were we not supposed to see a body that was mangled, decomposing, or brutally murdered? Part of me felt offended that they thought we could not handle seeing an autopsy where the body was not in the “best” condition. I had gone through eight solid weeks of dissecting a formaldehyde-infused body head to toe (literally). On the other hand, I am sure they have their reasons for only wanting to show us certain bodies. Maybe the pathologists were not so concerned with our bravery and strong stomachs as much as they wanted to give us a solid educational experience. What organs could we see in a mangled body anyway? And, after some thought, I reflected I probably did not have the tenacity to stand and watch the autopsy of a person who had died horrifically. I could barely look at pictures of dead people without feeling nauseous and uncomfortable.

During the first week of our second-year medical school courses, the Chief Medical Examiner gave a lecture on forensic pathology entitled “Force Injury.” It was almost like I had jumped straight into an episode of Cold Case, CSI: Crime Scene Investigation, or maybe Night of the Living Dead. Her lecture was gruesome, horrifying, yet oddly fascinating. It was teeth-clenching, stomach-churning, headache-inducing, but I could not look away from the images that flashed on the screen during her presentation. In addition to being the Chief Medical Examiner of North Carolina, Dr. R. is also the director of the North Carolina Child Fatality Prevention Team. I believe it was her experience in both of these realms that led to her decision to put pictures of dead children in the presentation. Dead babies, dead kids, dead teenagers. All sorts of dead young people. And I mean brutally dead: pictures of babies that were shaken by frustrated, angry caregivers; bodies that had been whipped by belts or electrical cords; and a young woman who had committed suicide by hanging herself in jail. Death seemed to be a violent affair.

My thoughts wandered during Dr. R.’s lecture to the body that I had dissected as a first-year medical school student. I had spent two months getting intimately acquainted with the body of an approximately 80-year-old woman who had died of natural causes. She had suffered from severe dementia. I did not know her name, her history, or anything else about her other than this fact. We kept her face covered with a cloth for most of the dissection. One of my most vivid memories of anatomy was coming into lab late one night to study for an exam. The next week, we would begin to dissect the head of the bodies…including the face. I lifted up the cloth to look at her figuring it was better to see it now than later. Face my fear. The body’s face looked so unnatural in death. Her eyes were half open and eyeballs sunken into her head. Her skin was wrinkled and pale white—hard like marble. Her mouth was open and completely dry. Her cheeks sunken as if she had lost a significant amount of weight before her death. Her hair was chopped very short.

Propelled by morbid curiosity, fright, and some dread, I begin to pull away the cloths covering the faces of the other bodies in my room. They all looked the same in death. Women looked like men. The eyeballs sunken into the head. Same wrinkled, marble-like, pale cold skin. The size and shape of each head and face were slightly different, but overall they were almost indistinguishable. Most of the bodies that were donated were bodies of older individuals which was one reason why they might have seemed the same. Would a younger cadaver look different than an older cadaver? Or maybe the chemically-based embalming process muted the distinct features of each face? Or perhaps that was just death? Death makes us all the same in some way. It washes away the life, the “be,” that makes us human beings. Death, the ultimate loss of individuality and the mysterious, inescapable fate for all.

On that bitterly cold winter morning, approval had been given to my group to proceed with the autopsy viewing. Filled with a strange mixture of relief and trepidation, I walked to a neighbor’s house to join a carpool of fellow students to the Chief Medical Examiner’s Office. The traffic was terrible which compounded my anxiety. Stop and go, sudden braking and acceleration. Finally, after 44 minutes of travel, we had arrived. After checking in at the front desk, we were quickly ushered back to the locker rooms and told to change into green scrubs, respiratory masks, hairnets, surgical shoe covers, gloves, plastic aprons, and protective eye glasses. It felt like gearing up for battle, yet you were strangely armed with nothing. We were waved into the autopsy suite, “Good morning! The body is over here. Come on, folks! We will be examining this one, and there are three other autopsies that will be going on at the same time. Try to focus only on your autopsy. This is the pathologist and pathology technician.”

The pathologist introduced herself as Dr. S. and began to explain to us what happens in an autopsy. I tried hard to listen and focus, but the room was a beehive of activity. The other pathologists and pathology technicians were already setting up their bodies and beginning the autopsies. Surprisingly, there were only three autopsies happening this morning. Our group was standing right in front of one of the supply cabinets, so we were frequently asked to get out of the way (verbally and nonverbally asked) and accidentally stepped on or whacked with boxes if we did not move quick enough. It was a fast-paced environment. The body would be eviscerated organ-by-organ to figure out the cause of death. The only information that Dr. S had about the body was that she was a 40-year-old woman who had been found dead in her home by her husband. The woman’s husband was a truck driver and discovered her the day before we came to view the autopsy. She had probably been dead for a few hours by the time he found her body. He reported that she had been complaining of headaches. All other information about her case was a mystery.

Like us, almost every inch of the pathologists and pathology technicians was covered with personal protective equipment. The pathology technicians wore two pairs of gloves and taped the ends of their gloves to their plastic aprons with biohazard stickers. They used ventilated surgical hoods that covered their entire head. Filtered air was pumped through the hoods by a box strapped to their waists. No Darth Vader noises coming from the boxes, but it eerily reminded me of pictures I had seen of clinicians in Sierra Leone treating individuals affected by Ebola virus disease. Abby, the pathology technician working with Dr. S., moved quickly and efficiently setting out her tools for the day’s work: scalpel, forceps, clamps, scissors, cloths, and buckets. She pulled the body from the cart to the autopsy table. A photographer wandered over to the table and snapped a picture of the woman’s face after an identifying card was carefully placed on her chest.

Throughout Dr. S’s introductory remarks, my gaze would flicker toward the body. There was a cockroach in her hair. Abby also noticed it around the same time. She shuddered, “I hate bugs.” She attempted to pick it out of the hair. I almost jumped when I saw it move. It was still alive. “Ew. Ew. Ew,” she muttered, pulling it free and washing it down the drain. As she adjusted the body on the table, Dr. S. began her inspection of the outside of the body. “What do you notice about her? Look for anything abnormal. See any bruises or marks?” she asked us gently. A fellow student pointed out some bruises on the woman’s shoulders and legs. I moved to the other side of the table to get a closer look. There was a series of purple marks from the woman’s left shoulder to the center of her chest just above her sternum. Dr. S nodded, “Yes. These are post-mortem marks. Insect bites. Since the body was lying on the floor for a few hours, the insects started to nibble on her.” I shuddered. Apparently, it is common for cockroaches and other household scavengers to hastily take advantage of a new food source. This category of scavengers also includes pet cats. Although most dogs will go hungry for days before resorting to eating their owner’s body, cats will wait only 1-2 days before chowing down.

Dr. S waved to more bruises on the back of the woman’s calf, “These are also post-mortem bruises. Blood tends to pool toward the feet because of gravity, and there is no movement of the muscles to carry blood toward the head.” I nodded mechanically, my mind still preoccupied with various cockroach-feasting-on-my-dead-body scenarios. After inspecting the head and neck thoroughly to rule out strangulation or other foul play, Dr. S decided that the cause of death most likely was from a natural incident. If there was any possibility that this woman could have been murdered, the photographer would need to take more pictures. Since this was not necessary in this case, we moved painstakingly onward.

Dr. S. and Abby worked together to shove a rubber block underneath the torso. This makes the cutting easier since the body is arched upward. Abby smiled, “Okay. So there should be only one hand in the body at a time. This is a very sharp scalpel. I don’t want to take your finger off too.” Without the slightest hesitation, she began cutting into the chest, slicing from the clavicles to the bottom of the abdomen. As soon as the abdomen was open, a foul smell permeated the air. The body cavity was full of brown fluid which Dr. S quickly suctioned. She shrugged, “There must be something going on in the gut.” I felt nauseous and tried to adjust my respirator mask to block the aroma. I squeezed the area at the tip of my nose and pushed the edges around my face. No luck at getting a seal. I started breathing through my mouth. The smell was not constant. It would be present for a few minutes then would disappear, but it came back each time the body was moved. It was actually not too bad. I had imagined much worse.

Dr. S. grabbed two needles with syringes and gestured to the body, “We take two blood samples and send them to toxicology. We will take one sample from a vessel near the heart. The other sample would normally be taken from a vessel further down in the body, but since there is a lot of contamination down there, we are going to take it from a vessel above the diaphragm.” That odd sense of fascination was coming back to me. I watched as Abby pushed on the woman’s liver to squeeze blood into the vials. It was a gruesome process with red sticky liquid going everywhere. Blood from the liver gushed out with each shove. “Do you worry about keeping the instruments sterile?” one of my classmates asked. Abby laughed, “Nope.”

Abby wiped her gloved hands on a rag and readied the bone saw. She expertly cut ribs and sternum making a door into the chest and ripped it off. The heart was first organ to be removed and placed on a cloth. “Anybody want to hold it?” Abby asked. She dropped it into the first hands that opened. We passed it around trying to figure out which vessels were which. After a few minutes of oogling, the heart was handed to Dr. S who sliced it into sections and gave it back to us. She used a knife and cutting board that reminded me of one in my own kitchen. One by one, Abby took out the organs from top to bottom: lungs, diaphragm, stomach, duodenum, ileum, jejunum, colon, rectum, liver, gallbladder, kidneys. It became a cycle. Plop. Someone would get the organ. They would pass it around. The last medical school student would drop the organ in the scale a.k.a. the holding tank. Dr. S grabbed it when she was ready and would cut it into sections. It would be passed back to us if there was something interesting. Tossed into a bucket if there was nothing to note. I was awestruck at our efficiency and how easy it was to forget that this was from a person who was alive and well the day before yesterday.

In the moments when I was not oohing and ahhing over a whole lung or sliced gallbladder, I found my gaze wandering back to the woman’s face. At the beginning of the autopsy, Dr. S had opened her eyes to see if there were any hemorrhages. She explained that petechial hemorrhages in the eyes or mouth could indicate that the woman had been strangled. After seeing none, Dr. S closed the eyelids. Unlike the murder victims pictured in Dr. R’s presentation and the body I dissected in anatomy, the woman’s face looked peaceful almost as if she was sleeping. This image was in stark contrast to the rest of her body which was now open, agitated, red, and glistening.

Peaceful was not a word I had associated with death before seeing this woman. As I contemplated this thought, my mind wandered to crisp fall day in Chapel Hill. Walking home after a long day of studying in the library, I was awestruck by the trees. The leaves had transformed their appearance from summer green to coruscating gold, magnificent red, warm yellow, husky magenta, and burnished orange. The profusion of color was illuminated by the last rays of a breathtaking sunset. I was struck with the realization that the leaves are most beautiful in their first moments of death. The green color of a leaf comes from a pigment called chlorophyll which dominates all other pigments. With cooler temperatures and shorter daylight hours, cork cells form at the base of each leaf preventing fluids from flowing into and out of the leaves. Chlorophyll degradation occurs and hidden pigments transform the color of the leaves—the yellow xanthophyll, orange beta-carotene, and red anthocyanin. In their death, the brilliance of the colors is spectacular.

Like the fall leaves, this woman was radiant in death. Death came too soon for her. Yet she laid here on the table serene, beyond suffering or struggling. Finally at rest. Dr. S called for our attention, “Ah-ha. See this. She had a perforation in her stomach. Looks like it is near the pylorus.” She showed us an opening approximately the size of a soda-bottle cap which had formed in the stomach. Its location and smooth edges provided evidence that this woman most likely had a peptic ulcer which had not been treated. “Wouldn’t she have been in pain from this ulcer?” a student quietly asked Dr. S. “Yes. But since she had gallstones, she may not have realized she had another problem going on,” replied Dr. S. She shook her head and murmured, “Poor lady.” The stomach was arranged on a cloth with the perforation easily visible and the photographer was called over to take a picture of the specimen.

To be sure that the stomach perforation was the cause of death, we had to rule out other causes. There was a report that this woman had been having headaches, so she may have had an aneurysm. After moving the rubber block to a new position under the woman’s neck, Abby started slicing the skin at the base of the scalp. Using a tool that looked like a metal spatula, she carefully scraped away the skin from the skull, peeling back face from bone. The bone saw was used again cutting into the skull as if it were butter. Like unscrewing a jar of tomato sauce, the skill popped right off. We did not see any blood around the brain immediately, meaning that an aneurysm probably did not occur. The woman’s brain was cut out and passed around. It was huge and squishy like a gigantic jelly fish. We put it into the holding tank to await examination by Dr. S. “All normal here,” she told us as she picked up and then dropped one cerebral hemisphere at a time.

We were almost finished. Abby put the body mostly back together and squirted Joy dishwashing soap on the body’s face and legs. She scrubbed the woman, washing away the grime, blood, and body fluids. We all worked together to put the lady back into her body bag. She would be soon on her way to a funeral home. Abby scrubbed the table with soap as Dr. S patiently answered our lingering questions. Once finished, Abby asked if we were ready to go. We all said a relieved and grateful “Thank you” to Dr. S. and were quickly led out of the autopsy suite. We tossed our blood stained aprons, shoe covers, hairnets, masks, and gloves into a biohazard container. Back in the locker room, I blew my nose for the first time in two hours trying to rinse out the smell of dead body. It took a few hours for the aroma to leave me.

In a few minutes, we were back in our street clothes and on our way returning to the land of living bodies, civilization, home, and school. Our drive back to Chapel Hill was a quiet one. As soon as we were in town, our group split to fulfill the rest of the day’s obligations. Over the next few days, I often thought about the woman’s halcyon slumber and her closed eyes. Will my future patients look like this if they die? Will I look as peaceful in death? In an article about facing death, Joseph Meszler writes, “Death is disconcerting, upsetting, humbling and invigorating. It is as natural as it is inevitable. And it can be liberating to name our fears and say, ‘One day that will be me.’” I felt similar emotions and thoughts when viewing the autopsy of this woman. It was meant to be an educational experience but perhaps also a step forward in the process of making peace with death.