Does This Mean You'll See Me Naked?

by Robert D. Webster

  On entering the room, we discovered the 350-pound decedent supine on the hardwood floor, clad only in jockey shorts and a T-shirt—which was thoroughly soaked in vomit. His stomach contents puddled around the entire body. I had never witnessed such a thing, and I was on the verge of involuntarily giving up the ham sandwich I had consumed only a half hour earlier.

  We placed the litter on the floor next to the deceased, and my older, wiser brother began to rattle off the game plan: I was to simultaneously take hold of the thin T-shirt and the waistband of the jockey shorts and then turn his body toward myself as my brother pushed the litter beneath him. A good-sounding plan—except that I was barely able to budge him. Plan B entailed both of us lifting the man onto the litter by brute force. Again, I was to grasp the T-shirt and my brother, the waistband.

  But this plan went awry as the thin, vomit-soaked shirt slipped from my grasp, and the deceased hit the hardwood floor with a resounding thud. Family members downstairs no doubt heard the commotion, but we hoped they thought we had knocked over a chair. Immaturity ruled as both my brother and I nearly collapsed in fits of muffled laughter, to the point that both of our young faces were red with shame.

  On our second try, we were finally able to position the deceased on the litter, cover him, and make our lumbering way down the steps to the waiting cot. Our faces still red, we prayed that the family would assume that our strenuous trek down the stairs with a 350-pound man in tow was the source of our breathlessness.

  THE TIME OF DEATH IS…

  These days family members are often present even when a death occurs outside the home, such as at a nursing facility or even a hospital. In the past, when I arrived at a nursing home at three o’clock in the morning, no one but the nurse on duty was available to help move the deceased out of the bed and onto the cot. Today the family is often waiting—I suppose because nursing home caregivers attend death education classes that stress that family members should be at a terminal patient’s bedside for end-of-life support. At hospitals this can be more complicated, because most hospitals still require that hospital personnel transport the deceased to the facility’s morgue, where the body is left in cold storage until the funeral director arrives.

  With the hospice movement having become so popular, however, more and more terminally ill people are choosing to die in their own homes or in those of family members, as opposed to in the antiseptic settings of hospital rooms. Hospice nurses and other caregivers are usually present when such a death occurs, or they are quickly summoned if needed. A death in hospice care at a private residence is not considered “death without medical attendance.” For example, when someone is found deceased at home and not under hospice care, the coroner or medical examiner almost always will examine the case. Some counties require a pronouncement of death by a physician. On many occasions I have had to transport a deceased loved one from his or her place of residence to a hospital, so that one of the doctors on duty could come out to the transport vehicle and pronounce the patient dead. Nine times out of ten, the doctor looks briefly at the deceased and then at his or her wristwatch and says, “Let’s call it 2:45 a.m.” That is declared the official time of death, even though the patient more than likely expired an hour or so earlier.

  Very rarely do doctors come out to a funeral home vehicle completely equipped to make a death pronouncement—no flashlight to shine into the eyes and no stethoscope to detect a heartbeat.

  It is important, though, to make sure that the patient is actually dead! I have heard of cases of nursing home patients being transported to funeral homes only to “come to life” during the trip. A colleague once told me that he had an elderly man on his preparation room table and was in the process of removing the man’s clothing when the “dead” man suddenly began to moan and move. After a few seconds of freaking out, my colleague called for an ambulance. The old man was very much alive; he was transferred to a hospital to stay overnight and the next day he returned to the nursing home.

  Sometimes I have been just about to roll up the cot to the wrong bed in a nursing home, only to hear the person still breathing. Obviously, I needed to attend the bedside of his or her late roommate. At some older nursing homes, patients are bedded in wards, and there are three or four non-ambulatory people in one large room, which is separated into sections by a floor-to-ceiling privacy curtain. Arriving in the dark in the middle of the night, a kindly nurse in charge once commented to me, “Take your pick,” as we surveyed a row of four elderly patients, all of whom appeared to be dead.

  Before the invention of the stethoscope, there were some interesting tests for death. The fire test involved holding an open flame to the skin of the potentially deceased. If the skin blistered, then the patient was not dead—skin cannot blister after death. For the mirror test, a small handheld mirror was positioned under the nose or mouth. If the mirror fogged, then there was obviously breath. The water test was administered by placing a glass of water on the chest to detect any motion in the water from the rise and fall of breathing.

  Even such fail-safe tests were not trustworthy; that is why the term wake came to be. Today a wake is a visitation period for offering sympathy and support, but originally a wake involved staying awake with the deceased to make sure he or she was in fact dead. If a moan, a twitch, or any other movement took place, then obviously the person was still alive. I imagine such things occurred quite frequently in the late 1800s and early 1900s, when a comatose patient or even someone who had fainted was often assumed to be deceased.

  INSIDE THE AUTOPSY

  An autopsy may be required for medical or legal reasons—suspected homicide, accident, suicide, or other probable unnatural death. Many teaching hospitals, such as those with a degreed nursing program, or hospitals owned and operated by a university, are required by hospital associations to conduct a certain number of autopsies for teaching purposes.

  As an orderly during my college days, I witnessed hundreds of autopsies. As a result, I fervently hope that such a procedure is never performed on anyone in my family. Before proceeding, the pathologist would hand me a notepad and pencil, both already stained with blood from his earlier notations on height, weight, and general appearance. I was the designated stenographer, assigned to note the weight and condition of each organ and any abnormalities detected. I perused the initial notations of the pathologist so that I could be equally descriptive—I didn’t want to appear inexperienced. Standard initial commentary was already present: “A fifty-four-year-old white female, eyes brown in color, natural hair, streaked in gray. Well nourished, with all natural teeth present. Surgical scar on abdomen suggests past hysterectomy, with no other scars or anomalies noted.”

  First, a Y incision is made with a scalpel on the chest of the decedent. A large knife pares away the muscle and fatty tissue to expose the ribs. The ribs are cut away with a cast saw to expose the thoracic and abdominal organs for the pathologist’s inspection.

  The initial sight of exposed human organs always takes everyone aback. My first glimpse reassured me that there is a God, because all of those organs must work together in perfect synchronization to sustain life, and that’s something so complex that only God could make it possible.

  After the initial reaction to the sight comes the shock of odor. Blood reeks after death, as do stomach contents and the contents of the colon. Then you note the vivid colors of human organs: the mottled, black-specked appearance of a lung; the reddish-purple hue of a heart; the grayish-blue tint and the glistening wet appearance of a kidney; the three-lobed liver the color of any calf liver in a supermarket meat case.

  The pathologist then used a large knife to open the pericardial sac, the structure that surrounds the heart. With a qualified, deft slice, he released the heart from its moorings. The dripping heart was placed in a stainless-steel basket attached to a ceiling-mounted scale. The heart’s weight is critical; if a heart is heavier than normal, that’s an obvious red flag and probably the cause of death. An enlarged, and hea
vier, heart sometimes pinches off the nearby arteries, dramatically decreasing the blood flow.

  After being weighed, the heart was placed on a cutting board, where the pathologist sectioned it to meticulously search for any abnormality, such as scars from past or recent coronary disease.

  The remaining organs were removed and examined in the same fashion, with a few exceptions. The stomach was removed and the contents poured into a stainless-steel container for inspection. The first time I witnessed this procedure I was close to nausea. Stomach acids that had ceased working nonetheless carried the familiar odor of vomit. Certain foods do not digest quickly. Salad greens, broccoli, and baked potato skins are clearly recognizable among stomach contents, as are drug capsule remains. I was once instructed to use a screened ladle, much like a net used in fishbowls, to dip into the stomach of a patient who had potentially ingested many chloral hydrate capsules to commit suicide. It was amazing to know the death was on purpose, which I knew as soon as I scooped out more than forty capsules, some dissolved but some very recognizable.

  Probably the most unpleasant part of an autopsy is the procedure called running chitlins: several feet of intestines curled up in the abdomen are pulled out a foot or so at a time by an assistant (me) and then handed to the pathologist, who slices open the structures and inspects the interiors for tumors, restrictions, or any other abnormalities. Part of my duty was also to squeeze the exterior of the intestine to force fecal material out of the way so the pathologist could obtain a clearer view. That particular procedure took a little getting used to, but after a few times, I thought nothing of it.

  After witnessing many autopsies, all the sights and smells became commonplace. When I became a seasoned veteran, I have to admit that I enjoyed watching young nursing students entering the autopsy theater for the first time. Standing four across at the head of the autopsy table, the fresh-faced kids all wore looks of frightened anticipation. Once the scalpel made the first cut, and the body opened up in all its glory, the students’ countenances changed from nervous grins and smirks to mouth-dropping stares and curled upper lips.

  Death unmasks us all.

  CHAPTER FOUR

  Morbidly obese decedents pose some special challenges. Let me be clear in the beginning—I mean no disrespect to any folks who carry excess weight. But given that the death care of the morbidly obese occurs more frequently today than ever, so much so that casket companies now offer a specific line of caskets reserved for that increasing niche of decedents, talking about how we delicately handle these situations can shed some light on the state of death care.

  For example, several years ago, I was called to the residence of a deceased thirty-five-year-old female who weighed 660 pounds. Luckily, the local fire department was already on the scene—the firefighters had dealt with the woman’s medical problems before and knew the inherent problems of transporting her. She was found face-up in bed (“bed” was two twin-sized mattresses on two-inch sheets of plywood that had been glued together and were supported at each corner by concrete blocks). After reviewing the situation, I took the mortuary cot out of the hearse and left it in her front yard. There would be no way she could fit on something that was only twenty-two inches wide. The life-squad personnel and I pondered our dilemma for a few moments. Then I came up with the plan of the century.

  I drove to a nearby hardware store to purchase a large canvas tarpaulin to spread out on the floor next to the woman’s bed. Seven men assisted me in grasping the bed linens beneath her and gently pulling her onto the tarp. With four of us on each side, we gripped the tarp and slowly moved her to the front door and into the hearse.

  That was the first time I ever placed a body directly on the floor of a hearse, and there was little room to spare. I asked the life-squad personnel to follow me back to the funeral home so they could help me transfer her into the building. At the funeral home, I had to make some adjustments: because the decedent was forty-three inches wide, she couldn’t possibly fit onto a standard embalming table. I placed two tables side by side and latched them together at the legs with nylon rope. The eight of us took baby steps with the tarp and its cargo into the funeral home, down a short hallway, and into the preparation room. Then, after a brief rest, we counted to three and hoisted the decedent onto the joined embalming tables.

  Later, since I could not hold the mass of fatty tissue away from her neck to locate the carotid artery or jugular vein, I opted to find and raise the right femoral artery and vein, located in the upper thigh near the groin. After making the femoral incision, I had to ask an assistant to hold open the incision with his hands and some strategically placed duct tape. I was nearly up to my elbow in fatty tissue before I finally could delve deep enough in the femoral space to locate the selected vessels. Arterially embalming a decedent of average weight usually consumes from three to five gallons of formaldehyde-based chemical. In this case, I injected fourteen gallons through the decedent’s arterial system before I finally started recognizing some positive results.

  When I received her burial clothing the next day, I pondered the sheer size of the black dress she was to be buried in. My wife styled her hair, I applied cosmetics, and we awaited the arrival of my seven assistants to move the woman into her substantial casket. I had ordered a custom-made forty-five-inch-wide, eighteen-gauge steel version, which had been delivered that day.

  The next hurdle was coming up with a proper device on which to place the casket. A standard bier, a wooden pedestal-like device on wheels, would not be strong enough to support her weight. I called around to inquire about the price of having a special bier constructed on short notice—but to no avail. During one fruitless call, however, a gentleman referred me to a welding shop known to have rolling carts on which they mounted equipment. The owner invited me to come over and take a look at a steel cart that sported heavy-duty steel wheels. He agreed to deliver the cart to me, and after a good scrubbing and applying black bunting around the top edge, it was perfectly serviceable.

  Throughout the entire process, I made one serious blunder. I had placed the casket on the floor of the preparation room and removed the lid, so that we could get around both sides as we lifted it. Removing the lid was an excellent idea; laying the casket on the floor was not. We hoisted the decedent into her casket and positioned her as well as possible so that she would look comfortable in her repose. But that’s when my blunder sank in. We would need to lift her again—this time with the added weight of the casket in which she was lying! I apologized to my hoisting partners and admitted that I should have placed the empty casket into position on the welding cart and then situated the decedent. I also vowed never to make such a mistake again.

  Since a forty-three-inch-wide casket will not fit into a hearse, a standard burial vault, or standard grave, I had to devise a mode of transportation to the cemetery and then arrange for oversize accommodations there. The burial vault company offered its flatbed truck, which was also equipped with a hydraulic crane, for use as a hearse. Following the funeral, the truck backed up to the chapel door, and two canvas-strap slings were slid underneath the casket. With little strain, the hydraulic lift gently swooped the casket onto the truck for its short journey to the cemetery.

  I’m sure the sight of a white flatbed truck with a very large blue casket on the back leading a funeral procession down the street is not very common. When we arrived at the cemetery, I noticed that an inordinate number of gawkers had staked their claims near the grave site to catch a glimpse of what they had heard was a woman with a very large casket.

  The bottom part of the vault was twice the normal size. The vault company also made concrete septic tanks, so with such a large grave opening, it had used an actual septic tank. For the first time, I witnessed a graveside ceremony standing next to a minister and a vault truck, with the honored decedent resting on the truck’s bed rather than on a lowering device above the open grave. With a twist of a lever, the casket was raised and gently cranked down to its final resting plac
e.

  CASKET TECH

  Expensive caskets, such as those of sixteen-gauge steel, stainless steel, solid copper, and solid bronze, are sometimes urn shaped rather than rectangular. The urn shape is not only more attractive and more expensive but also serves a practical purpose for funeral directors. The extra inch or so of width inside allows us to position a heavier person in a more comfortable repose. With arms crossed across the abdomen, the elbows rest against the interior sides of the casket. Without that extra room, the deceased appears, and is, stuffed uncomfortably into the casket.

  For decedents who weigh 350 pounds and up, oversize caskets must be used. A standard casket’s interior dimensions are twenty-three inches wide and seventy-eight inches long. Oversize caskets are available in widths of twenty-seven, thirty, and thirty-four inches. For the morbidly obese, custom-made caskets must be specially manufactured and are usually available in two or three days.

  Many midrange and high-end caskets are equipped with a plastic tray underneath the dead body—a fail-safe liner. Embalming and other fluids frequently ooze from the deceased even if an expert and thorough embalming job has been done. Incisions that have not dried properly or have not been stitched tightly enough have also been known to leak, as does the site of the trocar, where embalmers insert a thin, tube-like instrument just above the belly button to aspirate the thoracic and abdominal cavities. Obese decedents present an additional problem in this regard because of the immense pressure on the abdomen from their weight and the weight of their arms and hands resting on the belly.