Writer, M.D.

by Leah Kaminsky

  My mother was grief-stricken. She became consumed by guilt and remorse, feelings that I would later learn often plague relatives of the recently dead. For my part, while I did mourn Agong’s death, I was unsure how to cope with this phase of life or with my mother’s overwhelming grief. I had not been witness to his actual dying, and seeing my grandfather alive during one visit and lying dead in a casket the next made his death unreal to me. The funeral was not particularly long, but the parade of mourners dressed in black and my own uneasy feelings seemed to last forever.

  I was surprised by how un-lifelike Agong looked lying in the casket. Despite all the efforts of the mortician, the figure in the coffin simply looked like a model of Agong, like a wax figure from Madame Tussauds’s famous museum. His face and body as I had known them were gone. Even his nose, famous in our family for its Jimmy Durante profile, had changed; the nostrils looked less fleshy and even droopy, like a once majestic sail that had lost its wind.

  The fact that even the professionals with all their makeup and tricks could not re-create my grandfather’s likeness only served to emphasize that he was really dead and gone from our lives. That funeral, the telephone call from my parents announcing my grandfather’s passing, and the memories of my mother’s grieving were the most direct experiences with death that I had prior to medical school.

  The majority of my 170 medical school classmates were no more experienced than I, and our first real exposure to death would be that semester in the human anatomy course. While one student had worked in a hospital morgue during college and another had worked in an Illinois meatpacking plant (subsequently becoming a strict vegetarian), those two classmates were the rare exception. Instead, the summer before starting medical school most of us privately dreaded and fretted about dissecting a human being.

  During my medical school orientation week, I was finally able to share my dissection fears with others who harbored the same uneasiness. Anatomy quickly became a major topic of discussion at social events. The classmate who had worked in a morgue was a prime source of information for the rest of us. I kept wondering if the cadavers looked alive or like wax figures. I secretly hoped that they would look at least as unreal as my grandfather had, believing that the less they looked like the living, the easier dissecting would be. We asked the second-year medical students about their experience the previous year. “Wear your old T-shirts and jeans,” they said, sipping their drinks nonchalantly at receptions for the new initiates. “You’ll want to throw out those clothes at the end of the semester because they’ll just reek.” Holding on to their words, I replayed their cavalier responses in my mind. What smell would cling to our clothes? Death?

  From the moment I had begun contemplating this career path some fifteen years earlier, I knew that I would want to use my profession to help people. Most of my classmates were no different. We were an odd group, idealistic but intensely obsessive and competitive enough to have survived the grueling premedical curriculum. While a few of us might have harbored goals of financial security or visions of a certain lifestyle, we were for the most part determined to learn how to save lives.

  What many of us did not realize was that despite those dreams, our profession would require us to live among the dying. Death, more than life, would become the constant in our lives.

  The dissection of the human body had fascinated me since I was seven years old. I had some idea back then that I might want to become a doctor. At the time my Agong had just been diagnosed with a brain tumor, and my mother took my younger sister and me back to Taiwan for the summer to be with him. The diagnosis, the operation, and the neurologic deficits resulting from the removal of a part of my grandfather’s brain would eventually color the rest of my grandparents’ lives together. Nonetheless, at the time I was enthralled by the way his neurosurgeon comforted my grandmother and family. He was a big, bald Taiwanese man, with a round face, hands like bear paws, and a demeanor that was at once humble and confident. When he came out to the waiting room to an audience of anxious family members, his words—“I got it all out”—fell on us like a great light from the heavens. That experience convinced me that medicine was the work of gods.

  An aunt who was in medical school at the time heard about my interest and offered to take me to her anatomy lab. I was fascinated by the idea that there might be secrets about life and death lurking there. At that age I already had come to believe that dissection was the greatest event that separated physicians from the rest of us. To be able to stomach such an experience, I thought, would prove my mettle, and to sneak a peek into the inner workings of a body—a dead body, no less—would put me in a league beyond any other second-grader I knew. My parents, however, quickly vetoed the idea, fearing that such a close-up and possibly gruesome experience might scar me permanently.

  Like all initiation rites, the dissection of the human cadaver poses several obstacles to the neophyte. First, the new medical student has to memorize a vast array of anatomical facts. Such rote memorization can be mindnumbingly dull, and the overwhelming amount of information makes the task seem Sisyphean. One of my college mentors, a brilliant psychiatrist and anthropologist, counseled me before I started. He had completed medical school some twenty years earlier. “It’s like memorizing a telephone book,” he said. “You just have to get through it.”

  Memorization, however, is probably the easiest obstacle to surmount, and it has until recently been the only focus of medical schools. The more difficult, and often unspoken, obstacle for medical students is accepting death and the violation of the human body. In the human anatomy course, cadavers are laid before fledgling physicians, and the familiarity of their form reminds us that each lived lives not unlike our own. For those of us who wince from simple paper cuts, running a scalpel against skin and definitively dividing the essential structures that once powered a fellow human are acts that require a leap of faith. While all premedical students fully expect to perform a human cadaver dissection in medical school, the expectation hardly tempers the brutal reality.

  Aspiring physicians face death directly in the form of the cadaver. And then they tear it apart. Each detail of the cadaver—every bone, nerve, blood vessel, and muscle—passes from the world of the unknown into the realm of the familiar. Every cavity is probed, every groove explored, and every crevice pulled apart. In knowing the cadaver in such intimate detail, we believe that we are acquiring the knowledge to overcome death.

  To complete the initiation rite successfully, however, we need to learn to separate our emotional self from our scientific self; we must view this dead human body not as “one of us” but as “one of them,” a medical case to be understood but not embraced. This ability to distance the self, I was to learn later, would be called upon again and again in my medical training. It was as if such separation would provide me with a greater sense of objectivity, a modicum of strength, and thus an enhanced ability to care for my patients. But this first lesson in disengaging from the personal was the most radical: it required suppressing the fundamental and very human fear of death.

  My medical school, not entirely unaware of the anxiety we harbored, did make some attempts to lessen the impact of working with a cadaver. We spent a week in lectures preparing for the first day of dissection. While none of these lectures directly addressed our mounting anxieties, they did give us the tools we needed to begin to detach ourselves emotionally from the experience. One of our first anatomic lessons was on vocabulary used to describe the body. These words, so different from our usual descriptive terms, would serve as directions on the map of the human body. We learned the difference between “distal” and “proximal,” “abduct” and “adduct,” “transverse” and “sagittal.” We learned that “left” and “right” no longer referred to our left and right but to the patient’s.

  The day before our first dissection lab, we toured the laboratory facilities. There were eleven rooms connected by a long hallway, and each room had four large stone lab benches with sinks and enoug
h workspace for four students. A large enclosed cavity within the lab benches held a sliding metal bed not unlike the metal beds used by coroners or pathologists. These cavities would be where our cadavers would be stored. We would spend every weekday afternoon for the next twelve weeks in these rooms, and all of us, either in small groups or alone, would spend many of our free hours there trying to memorize the minutiae from each cadaver.

  Formaldehyde, the preservative used for cadavers, has an unmistakable odor—sharp, rancid, piercing—like the olfactory version of a high-pitched shriek. The faint smell of formaldehyde present in each of the eleven rooms was left over from years past, as the cadavers for our class had not yet arrived. Over the years the smell had managed to work its way into the rooms’ marble and concrete, lingering and reminding us of our place in the school’s history.

  Our professor was not the wizened sage I had always envisioned would take me through this rite. Instead, he was just a few years out from his own graduate work in physical anthropology and anatomy. His youth and strong Hoosier twang demystified the whole ritual and made many of us more relaxed. He informed us of the overwhelming power of the scent of formaldehyde and reminded us that the smell would permeate our gloved hands, clothes, and hair. Indeed, I would soon discover that it would be strange eating with my hands that semester. While tasting some chicken wings at a reception later that fall, I realized that the smell of the cadavers from my fingers was mingling with the taste of barbecued chicken in my mouth. “Lemon dishwashing detergent helps get rid of the smell,” our professor advised us the afternoon before we were to embark on our dissections. That night each of us pulled out clothes that we were willing to toss at the end of three months—frayed jeans, “borrowed” hospital scrubs, and T-shirts with high school emblems—and there was a run on lemon dishwashing detergent at the local grocery stores.

  The next afternoon an intensified odor assaulted each of us as we entered the labs; overnight, the laboratory technicians had placed fresh cadavers in their respective stone enclaves. For that afternoon’s work I had replaced my contact lenses, susceptible to the fumes of formaldehyde, with my chunky glasses, and I remember being mildly surprised by how many of my fellow classmates were as blind as I. All of us had also carefully put on thin yellow paper masks, more to blunt the penetrating formaldehyde than to protect ourselves from any biohazards. Over the weeks, as we became more absorbed in our work, we eventually neglected to wear these flimsy barriers. Some of us even occasionally forgot to put on our gloves.

  The class was divided alphabetically into groups of four students, and each group was assigned to a cadaver. These groupings were used over and over again during the next two years whenever our education required more intimate instruction. With the same three classmates, we clumsily attempted to draw blood, learned to do pelvic exams, and performed our first rectal exams on patients. Most notably, however, we dissected together in anatomy lab.

  I worked with three other women. Mary was from California, the daughter of a family practitioner and the middle child in a large Irish-Italian Catholic family. She was preternaturally calm, a characteristic that would give her an outstanding bedside manner, and she eventually followed in her father’s footsteps. Peg was from Chicago. She was the most reticent of the four but made up for her shyness with a generous spirit and a sharp, dry wit that helped give the rest of us perspective during more difficult times. She later became a pediatrician. The third woman, Lara, was the youngest and the most boisterous of the four of us. The daughter of immigrants, she was born and raised in Chicago and now practices pediatrics in that city. I was from New England and set at the time on becoming a psychiatrist or geriatrician and pursuing an academic career in medical anthropology. However, as gruesome as it all seemed to me that first week, the experience of the cadaver dissection—the concise and efficient beauty of human anatomy, the pleasure of using my hands as an extension of my mind, and the spirit of teamwork—became the foundation of my decision to become a surgeon.

  On that first day I unlatched the door on the side of our stone lab bench and gently slid the metal bed out of the inner compartment. All the cadavers were sheathed in white plastic body bags. Some bags were large; others were smaller. There was no question, however, given the frozen forms, what was within these zippered shrouds. Several provisions had been made by the medical school to decrease the shock of starting our work. The lab technicians had placed all the bodies facedown so that we could see only the back of their head. We started our daily dissections with the arms and legs, and our cadavers’ faces were kept covered until the final two weeks of the course. Those who organized our anatomy course believed that such a progression would be a gentler introduction to working on a dead human being.

  We learned anatomic principles, dissection techniques, and ways to hold the dissecting instruments with greater precision. We learned that in medicine, “tweezers” were called “forceps,” and those who fancied a future career in surgery used the more specialized jargon, “pickups.” We learned to change blades efficiently on a scalpel without ever touching the blade’s sharp edge, to hold the scalpel like a pencil for finer work, and to grasp it with the tips of four fingers and the thumb apposed, as if holding a violin bow, for more dramatic slices and cuts. We began to manipulate scissors with the thumb and fourth finger, as surgeons do, not the thumb and index finger as we had once learned in nursery school. “Using the fourth finger allows the index finger to rest on the joint of the scissors and gives greater control,” stated one of the teaching assistants, a fourth-year medical student planning on a surgical career. Hairdressers everywhere, I would later note, hold scissors in a similar fashion.

  The only information that we had on our cadavers was a card attached to the bag indicating their gender and approximate age at death. My cadaver was a woman who had died at seventy-two. Other than those two pieces of information, there was nothing else: no name, no address, no story. It was unsettling to be presented with so little history, and it became more so as we allowed ourselves to become intimately familiar with every detail of these bodies. My lab partners and I would know our cadaver’s body better than any patient we would ever take care of; yet in her book of life, we were to begin with the epilogue and attempt to read backward.

  Despite all the precautions taken by my medical school, my cadaver hardly remained an impersonal corpse with anonymous extremities. I remember unzipping the white bag that held her and being surprised by her thin arms. Her fingers were long and slender, with delicate, pointed tips; her nails had been filed into fine ovals and painted with coral nail polish. It was probably time for another manicure, as just above her neatly maintained cuticles were slender little half-moons of bare pink nail. While the skin around her forearm seemed to wrap tightly around her muscles, the skin on her upper arm was looser. It was wrinkled and hardened, like old leather. I figured that the hardening must have been from the time spent in a vat of formaldehyde.

  My lab partners and I took scalpels to the skin of our cadaver, making long incisions along the length of the hand and forearm. In so interrupting the tension of the skin, we released the dermal tissue and muscles from their epidermal cocoons. We then gently stripped and separated that tissue with fine scissors and forceps, traveling along the axes of the vessels and nerves. Moving our cadaver’s arm, now free of any skin covering or sinewy attachments, we saw the muscles function with each action and wondered how much more animated they might have been in life.

  Aspects of that life were apparent from our cadaver’s slender arms. She had loved the sun; the tanned background of her skin betrayed the jewelry that had once adorned her. On her left fourth finger I could see the white imprint of a wedding band. On her wrist I could make out the pale outline of a watch, probably one of those fine old-lady watches with the delicate chain across the latch for security. As we dissected into her hand, encountering the small muscles—flexor pollicis longus, abductor pollicis brevis—I could imagine how each of these bundles of ti
ssue once worked in her hands. The pink flesh, now a grayish red in death, would have contracted, each fiber shortening and swelling with the exertion, the muscle strands pulling on their attachments to her fingers, flexing the fingers around the hand of her husband or the brush she held to her hair.

  Trying to memorize the Latin names with no intrinsic meaning to me, I would think of my cadaver’s muscles and then imagine my own muscles while waving my arms and legs in front of the bathroom mirror. Brachioradialis, I would say to myself as I rotated my forearm and imagined my cadaver doing the same. Sartorius, I would think as I sat on a chair and crossed a leg over the opposite knee, imagining this graceful and delicate muscle in my cadaver’s thigh and the Roman tailors who gave it its name. The laboratory experience we were struggling with in the afternoons would reinforce, then and forever, the didactic anatomy lectures we heard in the mornings; and to this day, I see my cadaver’s body when I envision human anatomy.

  We spent two weeks dissecting the arms and legs and began the third week of anatomy with our first exam. During the written portion I spied classmates waving their arms and legs around to jog their memories; they, too, had danced in front of their mirrors. After the written exam we took the practical portion of the test in the laboratories. At various stations our professor displayed dissections from class cadavers with plastic question marks pinned to different structures. The cadavers had been covered so well, except for the vessel or nerve or muscle in question, that it was difficult to figure out what was an arm or a forearm, a leg or a thigh. A timer in the labs went off every two minutes, and as the alarm sounded, each of us scrambled to the next station and struggled to make sense of the disconnected body parts.

  In the midst of these cadaveric displays I spied those slender fingers with the coral nail polish and felt a wave of pride. I was pleased with the meticulous work my lab group had done and proud of the beauty of our cadaver’s anatomy.