Writer, M.D.

by Leah Kaminsky

  We peeled away the rest of the skin and subcutaneous tissue to expose the muscles of the chest. The pectoralis major and the pectoralis minor were splayed like magnificent fans across each side. Underneath, the breastbone connected the two halves of the thorax like the hinge on a treasure chest, each rib’s tendinous connection like a joint of that hinge. We used another kind of electric saw to perform a median sternotomy, a maneuver that would divide the breastbone along its length, as surgeons do during cardiac operations. Using our index fingers in a technique appropriately referred to as “blunt dissection,” we cleared two small spaces just beneath the top and bottom of the sternum; these were the starting and finishing points for our little jigsaw. I revved up the humming motor of the saw, inserted its tip into the divot between our cadaver’s collarbones, and drew the vibrating blade along the length of the sternum.

  My lab partners and I pulled apart each side of the split breastbone. Underneath we found a pale sac, the pericardium, that enveloped our cadaver’s heart. I divided the sac with dissection scissors, thumb and fourth finger in the rings of the instrument. Underneath, a ball of muscle just barely the size of my fist squatted like a bulldog guarding a house. We removed the heart, cutting across its great vessels with large scissors similar to sewing shears, and then spent the rest of the day examining its anatomy. We dissected out the paperlike mitral valve, so named because its two leaflets resemble the pope’s miter. Sitting between the left atrium and the left ventricle, the mitral valve is tethered around its periphery by strands of muscle that look like the cords on a parachute. We dissected out the coronary arteries, each barely larger than a sharpened pencil tip. When these arteries are blocked, essential oxygen cannot reach the heart, and this ischemia can result in the death of heart muscle, otherwise known as a myocardial infarction or a heart attack. I stared at these crucial tiny vessels, amazed that people did not suffer heart attacks any earlier in life.

  On each side of the now empty pericardium were the lungs, deflated and still. According to our textbooks, each lung was made up of hundreds of millions of microscopic biological balloons called alveoli. Areas that were still inflated were particularly soft, almost velvety. A finger pressed into them left a small glistening depression and made a quiet wet sound, like the one made by a foot on the muddy banks of a pond. Our cadaver’s lungs were black and speckled with soot. Initially I thought that the formaldehyde had discolored them, but when I saw the other cadavers’ chests—our strapping neighbor’s lungs were full and pink—I realized that our cadaver had had a lifetime of cigarettes and some tough city living.

  We removed the lungs, cutting across the tubes and vessels that once supplied air and blood. The thoracic cavity, with puddles of formaldehyde settled on the dependent back side, now looked like an emptied, darkened fishbowl. From within we could follow several nerves that extended across the chest wall. The phrenic nerve, whose tiny electrical pulses innervate the muscular diaphragm, seemed hardly like the miserable perpetrator of intractable hiccoughs, but more like a long strand of spaghetti al dente. The imposing aortic arch, that magnificent muscular artery that once carried the oxygenated blood with a great kick from the heart, curved elegantly up toward the brain and then down again toward the abdomen; I could imagine blood jetting from its cavernous hollow into meandering and progressively smaller arteries throughout the body.

  We moved downward to the abdomen. We incised the skin, went through the subcutaneous fat, and then dissected out the abdominal wall muscles. Our cadaver’s belly was flat, but her abdominal wall hung strangely, given her fine bone structure. There was a looseness to her belly’s skin and musculature, as if it had once been round and full, and the muscles here were atrophied and stringy. An old surgical incision traveled in a fine long line from her breastbone to her pubis and distorted the tiny opening in her abdominal wall that would have been her navel.

  Once inside her abdominal cavity, we noticed that her intestines seemed oddly tangled. Other cadavers had bowels that were easily manipulated and could slide around freely, as they might have during peristalsis and digestion. My three lab partners and I found ourselves in a maze of bowel loops with no discernible beginning or end. We repeated the mantra of anatomic dissections: Go from the known to the unknown. Normally, there is enough consistency in human anatomy that one can recognize newly dissected structures by following the lines of those already identified. We each took a turn trying to make sense of the matted intestines, but the instructions of the anatomy textbook—Follow the small intestine down to the terminal ileum where you will find the appendix—confused us even more.

  Unlike her orderly arms, back, and chest, our cadaver’s abdomen was in disarray. She had no gallbladder. Her omentum, the fatty bib that usually covers the bowels, was gone. Adhesions, scar tissue, distorted her intra-abdominal anatomy, coalescing the delicate individual organs into a big, ugly block.

  It was obvious that our cadaver had had surgery of some kind, but what operation could have left her abdominal contents so decimated? My lab partners and I finally went to look at our classmates’ cadavers, where the anatomy was more clearly discernible. Each of us was silently disappointed, feeling as if our cadaver had betrayed us and kept the secrets of abdominal anatomy hidden from our probing hands and minds.

  By the eighth week of anatomy class, we had dissected our way down to the pelvis. I was immensely curious about the uterus and ovaries. I wanted to see and feel them. What were the organs that held babies and created menstrual periods really like? I remembered my sixth-grade Family Life teacher, Miss Goodwin, explaining menstruation and ovulation. As one of the youngest teachers in my elementary school, Joanna Goodwin had likely been unwillingly corralled into the job of teaching sex education to fifty prepubescent girls. Nonetheless, she managed to be both creative and entertaining. When asked to describe the uterus and ovaries, Miss Goodwin paused momentarily from her fast-paced presentation. Finally, she held both arms up in the air and placed balled-up newspaper in each hand. “Do you see?” she asked us. “My body is the uterus, my arms are the fallopian tubes, and the newspapers are the ovaries.”

  I half expected to see Miss Goodwin in our cadaver’s pelvis, her arms outstretched and her hands grasping two crumpled balls of newspaper. As we delved deeper, my lab partners and I began instead to find balls of hardened tissue. Eager to see the female reproductive organs, we proclaimed the first two balls to be the ovaries. Our cadaver, however, kept bringing forth more balls of tissue, some as small as marbles, others as big as limes. The numerous balls were stuck together, stuck to intestine, stuck to her inner pelvic wall. Some were smooth, but many were like rocks with craggy faces. We called our professor over. He peered into our cadaver’s abdominal cavity. “Oh my,” he said. “I think she had ovarian cancer.”

  The ovaries that produced the estrogen that gave our cadaver the feminine features and qualities she cared for so dearly were the very organs that would put an end to her life. At one unknown moment in her life, one of her ovarian cells contorted and mutated and then began to reproduce with unchecked fervor. The anomalous ovarian tissue grew and infiltrated her intestines, causing them to mat together and obstruct. The cancerous tissue produced fluid, ascites, in her belly, which caused the once flat waistline to stretch and bloat and robbed our cadaver of her delicate figure. In death, in that vat of formaldehyde, her ascites had disappeared, so now her stretched abdominal wall hung loosely over her slender frame. The chemotherapy she received in an attempt to hold on to life had left her scalp bare except for a few soft, downy strands. The tumor that had greedily robbed her body of nutrients in its maniacal race to grow had left our cadaver wasted and thin, so that even her back muscles had degenerated into a few measly strings.

  Our classmates took a particular interest in the findings in our cadaver’s abdomen. As physicians who are meant to cure the ill, we are lifelong students not of the normal but of the abnormal, the anomalies and curiosities of human physiology. Here was a chance to see ova
rian cancer in the flesh; for some students it would be their only chance to see the end stages of this disease process. During that long afternoon the anatomy instructors pointed out the irregular agglomerations of tumor in our group’s cadaver, and our classmates wandered by and marveled at her intraabdominal contents. In many ways this scene was a preview of our future as clinicians, when we would, in large groups on clinical rounds, visit living patients. Our preoccupation as medical students with seeing and touching abnormal findings in cadavers already reflected this voyeuristic aspect of our art. Even at the beginning of our schooling, we realized that great clinicians are not just born; they are trained.

  By the time my lab partners and I finally uncovered our cadaver’s face, we had spent every day for the previous ten weeks in and out of her body. A clear plastic bag encircled her head, and a white muslin cloth, moistened with formaldehyde, clung to the contours that were her eyes, nose, and mouth. I lifted the cloth slowly, starting at the corner that covered her chin. Somehow I felt that seeing her face—her eyes, her lips, and her final expression—would confirm the life I had tried to re-create in my mind. Unlike her abdomen, our cadaver’s face was smooth and the skin tight. Her chin appeared exquisitely chiseled, and her lips, still stained with a burnt-orange lipstick, were thin. Despite all the work we had done to the rest of her body over the previous two and a half months, our cadaver looked peaceful, asleep even.

  Her eyes were closed. I lifted her right eyelid, wanting to know the color of her eyes, the windows through which she looked out into her world. The eyes, I hoped, would finally tell me the rest of her story. I would be able to look upon her as those who surrounded her during her life had. But there were no eyes under either her right or her left lid, just empty sockets. I had never seen enucleated bare sockets; and instead of being shocked, as I would have imagined, I felt a profound sadness, a kind of void, as if I had been robbed of closure to the imagined life of my cadaver. “She probably donated her corneas after death,” said my professor.

  Her eyes were not the only things that were taken away before her arrival to us. Her brain, the control center of her soul, had also been removed. “It’s being saved for later,” said our anatomy professor. “You’ll dissect it next semester in neurology lab.” The empty cranium, like the hollow eye sockets, looked like a room that had been hastily vacated.

  We peeled away the skin on her face, uncovering the nerves and muscles that controlled the expressions she had used over a lifetime. I asked my lab partners to allow me to do this part of the dissection. Holding the small scalpel like a pencil, I separated and lifted the thin facial skin from the underlying muscles, a technique similar to that used in facelifts. The dissection had to be done meticulously so as not to cut inadvertently any fine facial nerves or vessels. I found the work soothing; over the previous ten weeks I had come to enjoy this technical work of dissection, particularly the finer parts. Moreover, I wanted to spend more time with her face to see if I could piece together other parts of her life.

  Unlike many of her other muscles, my cadaver’s facial muscles turned out to be beautifully developed. I came to believe that she, even as she approached her death from ovarian cancer, embraced living; the strong muscles of her smile and around her eyes reflected someone who relished life’s emotions. While the cancer had eaten away at the rest of her body, these muscles of facial expression survived and even flourished despite the hardships she surely faced.

  Unbeknownst to me at that time, my cadaver, my very first patient, was much like my living patients that would follow. Pushed to view their own mortality directly, they too would live the remainder of their own lives that much more fully than the rest of us.

  Our final anatomy exam came two weeks later. By this time, dissecting had long since become routine. We spent our free moments at night up in the labs with our cadavers, looking at parts and committing them to memory. If time was short, we ordered pizza after working for a couple of hours, ate quickly in the lab halls, then went back to dissect. The smell of formaldehyde had become a part of life, a badge of pride as we walked by other graduate students who recognized the smell and thus our place as students of medicine. For a brief moment during those twelve weeks we felt like true descendents of our medical forefathers, a part of the history of medicine that has remained unchanged for centuries. We were performing dissections similar to those that had been performed by Vesalius over four centuries before and documenting them within our brains. We came to believe that even in death, the human body contains the secrets of life. And like those great forefathers of medicine, we learned to suppress our instincts of fear and even of repulsion. We pushed those emotions out of our consciousness in order to further medical knowledge.

  We had become initiated.

  The afternoon after our final exam, I returned to the lab for one last visit with my cadaver. Laboratory technicians had spent the day preparing our cadavers for shipment, but the rooms were now quiet and empty. I opened the familiar latched door underneath the lab bench and pulled out the metal bed.

  She was covered neatly in white plastic, ready to move to her final resting place. Through the plastic I touched her forehead, her shoulders, and her hands. I sat in my old jeans and high school T-shirt, thumbing through my memories of her body and the story it told us. I closed my eyes and envisioned her anatomy, referring to it as I would again innumerable times in my future practice. Thank you, I thought, feeling at that moment the strong and regular beats at the center of my own chest. Thank you for your final gift.

  Intensive Care

  DANIELLE OFRI

  The patient was a routine alcoholic, hauled off the streets of Manhattan on a warm June evening and brought to the Bellevue emergency room. Or maybe he staggered into the ER. In either case, when his dose of Thunderbird or Mad Dog wore off, he slid into alcohol withdrawal. The ER staff probably gave him ten milligrams of Valium to stop the shakes and racing heart rate. Then twenty milligrams, then forty. Apparently they’d been unable to calm the tremors and agitation at even the highest doses of Valium, and so started giving him barbiturates—the “big guns.” Eventually, they did silence his tremors and, in the process, his breathing. So by the time he arrived in our ICU, he was intubated with a breathing tube down his throat and a heaving ventilator at his side pushing in the oxygen. There was nothing else to do except wait out the days until the barbiturates wore off so we could extubate him and allow him to breathe on his own.

  Now we stood in front of our patient in Bed 12, his disheveled street looks frozen in place by the barbiturate coma. Lauren was presenting the case. She was a shy, petite intern with a mousy demeanor. Dr. Sitkin, our lanky six-foot attending, slouched against the IV pole as she spoke, a derisive half-smile on his face the entire time. He shook his head slowly when she finally finished. “Jeez,” he said, in his Tennessee drawl, “where do they unearth these ER docs? Haven’t they ever read a textbook in their lives, or do they still use garlic cloves down there?” Lauren reddened and looked down quickly. “I’m serious now,” Dr. Sitkin said, standing up and straightening out the slight hunch of his shoulders. “It’s like hauling in a John Deere tractor to knock off a pesky moth. Now this guy ain’t gonna be whistling Dixie for some time.”

  “What day is it today, anyway?” He glanced down at his watch. “June third? This guy ain’t gonna wake up this week.” His hands began to gesticulate in the air. “This guy ain’t gonna wake up this month. This guy ain’t gonna wake up until at least Rosh Hashana.” He pointed to the ventilator. “In fact, why don’t we just park a shofar on this ol’ ventilator. When he starts blowing the shofar, we’ll know it’s time to extubate him.”

  I didn’t want to do it. I didn’t want to laugh in front of a patient. I didn’t want to laugh at a patient. Again. But the image of our homeless alcoholic blowing the ram’s horn in Bed 12 of the ICU just rocked my funny bone and, to my embarrassment and annoyance, I once again found myself laughing uncontrollably on rounds with Dr. Sitkin. I thoug
ht his humor was off-color, inappropriate, and sometimes downright insulting to the patients or the staff. But the combination of his dry Jewish humor and his Southern drawl just overpowered my self-control. In between his jokes, he freely peppered us with educational pearls. His breadth of knowledge extended way beyond his field of infectious diseases—he was always impressing us with arcane fungi and protozoa—to all of general internal medicine and critical care medicine. But he was equally free with his biting criticism for anyone who wasn’t as smart or fast as he, which was most of the world.

  Dr. Sitkin looked around at our team, which was a healthy mix of ethnicities and colors. His lean face screwed up in a smirk and his bushel of wiry salt-and-pepper hair cascaded over his brow. He eased his tiny wire-rimmed glasses low down on his bony nose and his eyes darted over the tops. “For the goyim amongst us, there’s a copy of the Talmud in my office next to my other bible, Mandell’s Infectious Disease. You can consult either one if you need a refresher on Rosh Hashana ritual.” He shoved his glasses back up and sauntered on to the next patient.

  “This one’s dead,” he said passing by my patient with metastatic esophageal cancer in Bed 11. “What’s he doing in our ICU?”

  “His daughter hasn’t signed the DNR yet,” I said.

  “Rubbish. There’s no rule about having to administer critical care to a corpse just because there’s no DNR in place. You don’t have to give medical care that’s not warranted. Ship this guy out.” On Dr. Sitkin marched, and our team jogged to catch up with his long strides.