The cadaver looked just like me
It was the 83rd time I had harvested organs, and making transplants possible made me feel alive. Not this time.
By PAULINE W. CHEN Special to the Times
Published March 11, 2007
Editor's Note: This essay is adapted from the recently published book Final Exam: A Surgeon's Reflections on Mortality.
Procuring organs was part of the job description during my transplant-surgery fellowship, and the operation was like any other. There were patients who required more care, others who seemed made for a surgeon's hands. And though brain-dead, they all seemed remarkably alive. They bled bright red, and their chests rose and fell regularly, albeit with the aid of medications and life-support machines.
We often worked in the middle of the night, keeping the body functioning for as long as possible. The less time we exposed the organs to the stillness of death, the greater the chances of success in waiting recipients. But every operation ended the same way. The senior surgeon cross-clamped the aorta, the anesthesiologist disconnected the medications and breathing tube and I snipped across the vena cava, letting blood drain into tubing connected to clear wastebasket-size canisters on the floor.
I always emerged from those operating rooms feeling more alive than when I had entered. I became energized by the act of operating, the hope of transplantation.
That was until my 83rd procurement. She was a 35-year-old Asian-American woman, like me. She was driving on a Southern California road when a drunken driver collided with her car. Three days later, brain-dead, on my operating table, she looked merely asleep. Her warm skin was taut, with few blemishes, and her full hips and thighs suggested a metabolism beginning to slow. Her toenails were painted pink.
Hasan, the senior surgeon that night, began working on her abdomen. I was to open her chest.
As I placed the pencil-like electrocautery instrument at the top of her breastbone, the surgical drape covering her right breast fell away. I pulled it up again but noticed the undulations of each rib and the gentle fall of breast tissue to her side. Her nipple and areola peeked through; they had a coloring and shape that I had seen on only one other person: myself. In fact, the very shape of her breast, the thinness of her chest and the texture of her skin reminded me of my own upper body. It was as if I were standing naked after a shower, looking in a mirror.
I stopped for a moment, unable to put my instrument back to her chest, and my nose suddenly filled with the smell of flesh burned by Hasan's cauterizing pen. It was a familiar odor - surgeons use electrocautery in almost every operation - but this time, it found its way into the pit of my stomach. I stepped back, tasting the smell in my mouth, and looked away to try to breathe in anything but what was wafting up into the air.
"Are you sleepy?" Hasan asked gently. The clock read 3 a.m.
"I'm all right," I replied, trying to recover.
"Come here and feel her liver." He took my hand and plunged it into the woman's upper abdomen. "It's perfect."
The abdominal incision closed around my forearm. Her liver - soft, smooth, well formed - was perfect, but my fingers felt lost in the warm sponginess of organs. Loops of bowel slid by, and her pulsating aorta persistently nudged my palm.
Hasan asked me to hold her abdominal incision open. I tried to pull the edges apart, but her abdominal wall had a vibrant elasticity that resisted. I looked closer at the cut edge and noticed that her dermis, the layer between the fat and the outer skin, was particularly thick. It was white, pearly.
I remembered that as an intern I let medical students practice placing intravenous catheters in my arms. They always noted how difficult it was to drive those needles through. "Thick skin," I'd say, trying to make a joke about internship. But then I would add, "My dermis is probably pretty thick."
Looking at her dermis now, I felt as if I were looking at my own. As we snipped away at the organ attachments, about to take her liver, pancreas and kidneys, I tried to ignore the aliveness of her body, to believe that she was only a cadaveric reflection of myself. But then, in my sleep-deprived state, I found I could not bear to think of her - of myself - as dead.
The drape across her chest continued to slip, and I would have to see her breast yet again. Her thick dermis kept resisting our attempts to keep her belly open, making it difficult to take my eyes off that strong layer below the skin. And in the end, as I watched her blood fill those canisters on the floor, I felt as if my own life force were draining away.
When we finally closed her stone-cold body, the warm blood replaced by preservation solution, my mind felt as emptied as she was. The muscles in my palms ached, and my legs were numb. I was profoundly exhausted, from sleep deprivation, overwork and an unbearable grief.
Final Exam: A Surgeon's Reflections on Mortality
By Pauline W. Chen
Knopf, 288 pages, $23.95
[Last modified March 11, 2007, 01:25:12]
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