The Chick and the Dead

by Carla Valentine

  I spent a lot of time alone in that mortuary.

  I’m not completely socially inept, of course, and I did find time to chat with visitors, particularly the newer undertakers who came to collect the deceased and convey them to various funeral homes. And I was meeting other APTs every Thursday afternoon when I attended the lectures for my Diploma course. I even saw a few of those colleagues socially – just for a drink or a bite to eat, nothing romantic; just trying to make friends. To me, it didn’t seem like an odd thing to accept a night out with a person my own age in the same field of work, no matter what their gender, especially considering this was a new city for me and I didn’t know anyone. But nearly all undertakers and APTs at that time were male, and who knows, maybe my socialising rubbed up the team at the Metropolitan the wrong way? Maybe they thought I was going further despite having a boyfriend up north, and that explains what I felt was disrespect towards me? But I wasn’t after anyone’s heart – or any other part of their anatomy. I tried to keep that interest strictly in the post-mortem room! The long-distance relationship with my northern boyfriend was ending and I needed no further complications down south. I didn’t even have the basics yet: a home I wanted to live in, a good girl friend, a decent hairdresser and a favourite coffee shop. I was simply a functioning mortician who lived for work – lived for the dead and the dead only. I began to relish being alone and pulled even further away from the boys. I listened to music as I worked; these were patients who deserved care and attention to detail and music helped me relax and focus on my tasks, limiting any mistakes. I didn’t want to lose a finger.

  Another thing I didn’t want to lose was my heart. But when feeling so vulnerable and lonely, it was inevitable that I’d project that on to someone – the one person in the group who was mentoring me, showing me some kindness and highlighting a sensitive side. Josh, the youngest of the APTs, became the one and only person there I actually wanted to talk to. How much did I really like him? I’m still not sure. Perhaps I simply disliked the others so much he was the best option for companionship and camaraderie: there seemed to be an inverse correlation between how little I began to like the Terror Trio and how much I began to like Josh. With his floppy brown hair and gentle nature he was an inevitable magnet for someone who was hurting; someone like me. It was a closeness and friendship I needed there and then, and it went a long way towards comforting me.

  Often, when the Terror Trio were asleep or out and the day’s work was all done, Josh and I would sit and watch films together while we waited for the mortuary intercom to buzz.

  ‘What? You’ve never seen Labyrinth?’ he exclaimed, during one of our conversations, then acted out what I assumed was a pivotal scene: ‘I move the stars for no one!’

  I looked at him totally blankly.

  ‘Right, that’s it, I’m bringing it in tomorrow,’ he threatened – and he did. We sat side by side in the quiet office with the blinds drawn and the others dozing around us, knowing we’d be interrupted by an undertaker or two to collect a patient but that it wouldn’t wake them – we’d deal with that ourselves using the pause button. Then sometimes, when spending time with him, I began to wish that life had a pause button; that we could keep talking and be left in peace with everything around us not existing just for a short while.

  I suppose my feelings blossomed too much, not like a rose but like the Ipomoea alba, the moonflower, which only blooms at night – during the wrong time, a dark time. Their petals close when they eventually feel the sun. Given that Josh had been with his girlfriend for many years and I was rebounding, it was not a safe or healthy situation for me. I realised I needed to go off and ‘feel the sun’, to make London a happy home, but perhaps based somewhere else. I began to consider removing the heart of my problems and leaving, but even though there was never anything romantic between Josh and me, I will always be grateful for his friendship when I needed it the most.

  * * *

  Sometimes APTs need to remove the heart of a person who doesn’t need a post-mortem and is an organ donor. In this particular situation, when a patient is already deceased, the heart can’t be transplanted fully into a live patient who needs a whole heart: that can only occur when the donor is on life support. Basically, their body must be functioning but they will inevitably be what is known as ‘brain stem dead’. The family will make a decision to turn off the life support machine at a particular time, giving the recipient and surgeons a chance to prepare for the intricate procedure with a fresh heart. Instead, when the deceased has been dead a short while and received into a mortuary, the valves specifically can be removed for implanting into patients who may need valve repair or replacement. When human donor valves are used for this purpose they’re called homografts, but sometimes mechanical valves and even pig or cow heart valves can be used. This procedure, however, has to take place within forty-eight hours after death, as long as the deceased has been refrigerated within six hours of death. If no refrigeration has occurred, the removal must be within twelve hours. As long as we can remove the whole heart in time and pack it correctly, then courier it to the relevant tissue bank, a living patient can reap the benefits of the valves from the dead heart.

  Chris was experienced in heart retrievals and showed me how to do it one day, in an unusual fit of patient mentoring. To be fair, for all his faults he was the most knowledgeable APT at the Metropolitan and the most active PM-wise. He began by explaining that the instruments we were to use were set aside for this purpose only. After handing me the specific PM40, he said, ‘You can go ahead and do the cut as usual,’ so I cracked on with the straight incision then removed the sternum and ribs with the designated rib shears.

  ‘I’ll take over now,’ he said, but he didn’t take the PM40 from me once I’d finished. Instead, he opened a dedicated, single-use heart retrieval kit which had been provided by NHS Blood and Transplant Services (NHSBT) specifically for this point where the donor deceased had been opened. This was to minimise the risk of cross-contamination from the outside of the body.

  ‘Right,’ he continued authoritatively, talking me through his actions, ‘this is very different to removing the cardiorespiratory block. What you need to do is use these disposable scissors to cut the pericardium, being careful not to touch the lungs or anything else with the tip of them.’

  The pericardium, also known as the heart sac, is a double-layered serous and fibrous membrane that surrounds the heart and contains some fluid so that the beating organ within pulses across it repeatedly with ease. It protects the heart from infection and lubricates it.

  Chris gently sliced through the membrane and there in all its usual glory was the distinctive striated muscle of the heart.

  ‘Now, with this disposable scalpel we need to cut the vessels at the top of the heart as high up as we can to give NHSBT as much as possible to work with.’ He did so, and soon was holding aloft the heart in what had now become a familiar gesture. He didn’t change into He-Man though.

  ‘Right, grab them two swabs and take a swipe at two different areas of the cardiac tissue – I won’t move my hands.’ I did so, labelled them, and laid them gently down. This was to ensure the heart could be checked for infection at NHSBT.

  ‘Now we can rinse it in Hartmann’s solution,’ he said, to which I responded incredulously, ‘Heartman’s solution – are you serious?’

  He got the joke. ‘Hahaha. Nah, it’s just an aptly named infusion which closely resembles blood. It’s what you get in a drip.’

  ‘Ah.’ I realised what he meant. Hartmann’s solution is an isotonic fluid that was created by US paediatrician A. F. Hartmann, who was born in 1898. It’s so closely isotonic with blood – that is, it’s got the same osmotic or ‘liquid’ pressure – that it’s usually intended for intravenous administration via a hospital drip, replacing body fluid and mineral salts that may be lost for a variety of medical reasons. In this instance, it would keep the heart stable for transport.

  After rinsing, the precious organ wa
s placed in a single-use plastic bag and then Chris handed me a polystyrene box for it to go in with the bacterial swabs and a kilogram of ice to be stuffed in around it.

  ‘There you go,’ he said. ‘Get packing.’

  * * *

  It just so happened that later that evening I found myself packing again, this time my belongings … but things were actually looking up and I wasn’t packing to move far. One of my housemates, Mal, who rented the largest room of our three-bed house, had moved out. I’d met a friend, a lawyer named Denise, at my Amnesty International meetings and she needed a new place to live so I moved to the bigger room and she moved into my old one. Suddenly I was feeling more settled. I was living with someone I considered a friend, I was meeting other APTs at my course, and I’d even learned a new skill that day.

  My life began to feel like it was coming together.

  Seven

  Abdominal Block: ‘Pickled Punks’

  Bruises on the fruit.

  Tender age in bloom.

  —Nirvana, ‘In Bloom’

  The anatomical displays at Victorian medical museums and carnival freak shows which I alluded to earlier consisted of a melange of curios: incredible examples of ‘mermaids’, which were actually composites of monkey and fish skeletons, and, of course, bearded or tattooed ladies, the proverbial Strongman and individuals in the unfortunate position of having unusual deformities. In addition to these clichés, genuine human tissue specimens had laymen in awe, as they were preserved examples of their own, hitherto unseen, body parts. Those titillating female Anatomical Venuses, and smaller wax moulages of body parts, also had the general public attending these carnivals in droves. However, one of the biggest draws was the ‘pickled punks’, an old carny term for preserved whole baby specimens. Of course, we never use the term ‘pickled punks’ in a contemporary museum setting because it’s anachronistic and unethical. Yet despite the more modern way in which they are educationally referenced and displayed – as foetal or perinatal specimens – they still remain contentious and create a huge divide in opinion on the ethics of display.

  * * *

  The different methods of organ removal used in mortuaries meant that after the cardiorespiratory block had been extracted the APT would usually move on to the coeliac block – the pluck of organs containing the stomach, pancreas, liver and spleen. Then the genitourinary block containing the kidneys, adrenals, bladder and genital organs would be removed.

  I’ll never forget the first time I saw the uterus and ovaries of a normal, albeit deceased, woman during my early training. ‘That’s it?’ I’d shouted furiously, causing the heads of the other APTs and doctors in the room to turn towards me. I couldn’t believe how small they all were! After all the years of menstrual cramps and all the discomfort I’d experienced due to PMT, I imagined the uterus to be a bright red demonic entity covered in spikes which would bare its teeth at me as I attempted to remove it. Instead, it resembled a little pink plum, and the ovaries two matching fleshy almonds. They looked so harmless. I was shocked that something that insipid could cause so much woe! Of course, I (begrudgingly) got used to the uniformity of size and colour of these organs until the first time the uterus I exposed really was a lot larger than it was supposed to be and I had to alert the pathologist.

  ‘Doc, can you come and take a look at this?’ I’d asked, unsure how to proceed.

  He came over and palpated the organ before making a careful, long incision to reveal a tiny, angelic baby nestled inside the dead woman’s uterus. It was exactly like the final reveal of what Joanna Ebenstein described as the ‘tranquil foetus curled in the womb of the wax Anatomical Venuses of old’, their sex specifically used as a tool to teach students about the creation, development and even destruction of life.

  The womb can also be a tomb.

  Mortuary work, of course, involves the autopsy and dissection of foetuses and newborns, because it is a sad truth that babies die too, whether in utero, during birth or a short time after. Culturally, we don’t like to consider this: people don’t want to think about the miniature ‘dolls’ house’ set of autopsy tools reserved specifically for the perinatal bench, or the tiny rectangular coffins and petite plastic body bags mortuaries have to purchase in bulk. The coffins in particular, which come in an Ikea flat-pack-style cardboard, are a strange hybrid: on the one hand, a repository for the remains of someone’s dead child, on the other, a possible place to store shoes. Fears about the processes of neo- or perinatal autopsies abound because there is a natural, maternal sense of horror at the idea of such a delicate and innocent human being undergoing the ordeal.

  But it is necessary.

  For the most part, at the Metropolitan, the perinatal autopsies were not ordered by the Coroner but consented to by the parents. About 15 to 25 per cent of recognised pregnancies will end in a miscarriage and more than 80 per cent of miscarriages occur within the first three months of pregnancy. The shocked and devastated parents, when approached for their consent, usually agreed to (or often even independently requested) a post-mortem because they wanted answers. Was there something that caused the baby’s death that they could avoid doing in the next pregnancy? Was there a genetic issue that needed treatment to ensure successful future pregnancies?

  The first time I carried out an autopsy on a baby was at the Metropolitan, and it was a completely different process from what I was used to with adults. I welcomed learning this new skill in order to develop as an APT, and thankfully, of all the men there who could have been my mentor, it was Josh that I shadowed. He was a good buffer for the shock of seeing a dead baby laid out for autopsy for the first time: no teasing, no cleverness; just patience. And seeing a deceased child about to be eviscerated, no matter what age it is, is a shock, even for someone like myself who’d worked with the dead for over three years at this point and seen pretty much everything.

  The first baby we autopsied together was a male who had passed away in utero, meaning he wasn’t old enough to resemble a baby. At around seventeen to eighteen weeks’ gestation, his skin was delicate (or ‘friable’) and very red rather than pink because it was macerated, which means he had been soaking and softening in the live mother’s amniotic fluid after his death. (This tissue degeneration arises because of autolytic enzymes, just like adults have when they die, but because the fluid is a sterile solution there is no bacterial action and therefore no ‘proper’ decomposition.) Physically, his proportions were not the same as a full-term baby. His head-to-body ratio was more consistent with an adult’s, and the limbs were long and lithe, not chubby and peachy like a sweet-smelling newborn. As a result, he looked like a small adult who’d been scalded, some of the skin peeling off due to the maceration. He also had a slightly reptilian or alien appearance. As unusual as he looked in some respects, he was recognisably human: there were minuscule pale eyelashes around the closed eyes – eyes that hadn’t opened yet and never would – and there were tiny fingers which unbelievably already had fingernails the size of pinheads. He was still clearly a little miracle. I’ve never been maternal but I recognised it as a special thing, this child, and I didn’t like the way the perinatal pathologist picked him up by his feet and dropped him on to the weighing scales, as though she was a fishmonger with a sea bass. Was this the way all perinatal pathologists did it? I didn’t know – I didn’t know anything about the procedure at this point and was feeling confused as the doctor began to dictate and Josh took notes.

  The world of the perinatal post-mortem involves some unfamiliar vocabulary. For the first time I was hearing words like ‘vernix’ and ‘lanugo’: vernix is the white, waxy substance you see coating newborns (usually on TV, unless your hobby is hanging around maternity wards), and lanugo is the fine downy hair that develops on foetuses in the womb at about five months and sheds into the amniotic fluid at around seven or eight months. Wait, there’s more: because the foetus consumes amniotic fluid for nourishment it also eats the shedded lanugo hair, and this partly makes up the baby’s m
econium – that’s their first poo.

  What crazy new world was this? I already thought babies were freaky alive – I couldn’t hold them or feed them as I really didn’t have any experience with them, coming from a small family, and when I was out and about I didn’t want to hear or smell them – but I was discovering they were even more complicated in death.

  Thankfully, Josh talked me through the process as I watched, rapt. During a perinatal autopsy, after the weight and height of the tiny cadaver have been recorded to determine the exact gestation, it is the perinatal pathologist who carries out the delicate dissection, not us. We, the APTs, stand by to record measurements, hand over specific tools and help to place minuscule tissue samples into various pots and cassettes. The perinatal pathologists alone are familiar with the organs of a foetus, or neonate, which are so small the tissues are visually barely distinguishable from one another. In fact, we technicians aren’t even required to open the head as we would with adult cases. The pathologists can reflect the thin scalp skin back themselves then cut through the delicate skull bones with scissors. A saw is not needed on such fragile skull cartilage which has not yet had the chance to ossify into proper bone, particularly the soft open area at the top, the fontanelle.

  The main tasks we perform are taking notes and suspending the brain in formalin* to ‘fix’ it for about a week before it can be examined – it’s much too soft at this stage to be dissected by the pathologist, and I can really only describe it as delicate pink blancmange which barely has the markings of the brain images we are so familiar with. The other task we have is to reconstruct the tiny cadaver in the event that the parents would like to view their child, and of course we would let them do so as soon as physically possible.