In 2002 I applied for a work placement at Mid Staffs General Hospital Pathology Department and spent two weeks learning how to prepare tissue for display on slides, use a microscope and observe postmortem examinations. In my alternative life, the one where I got A’s in every subject and regarded study as a joy, rather than ‘what asshole’s did’. I would have been a pathologist. I am now way too old to pursue a career in medicine but fifteen years ago I gave it a shot. Medicine is a vast multi-disciplinary area but lacking anything resembling bedside manner, I was drawn to pathology. The peeling back of layers from macro to micro, in order to nail the culprit(s), scores very high on the job satisfaction stakes for me forcepsThe body on the gurney was that of an elderly woman who had been brought down to the morgue following a road traffic accident and a brief stay on the ITU. She had arrived covered lightly in a white sheet but that was gone now. The pathologist read the case notes, tutted, shook her head and then said, “Bless’. There was nothing empathic about the surroundings though. An eye-aching fluorescence bleached all humanity from the proceedings that and the combination of industrial white tiles and stainless steel. fst085039This wasn’t the first dead person I had seen, just the first that I hadn’t glanced away from. I had wondered when the last traces of her humanity would be lost. It wasn’t at the opening of the chest cavity. The woman’s indifferent expression to the violence made the process quite bearable but I found myself wincing at the snaps, cracks and slurps and as the viscera were removed the sulphurous compounds made me gag. I had been absolutely determined to not respond physically but controlling millennia of automated responses to death weren’t so easily fought off. I had been standing up to this point but surreptitiously dragged a stool forward and perched. The dissection of the organs and tissue sampling had been far quicker and more brutal than I’d anticipated and as I was shown the thickened heart muscles, the blackened lungs and damaged kidneys I felt as though I was back on solid ground. Intellectual curiosity is no slave to atavistic fears. If you haven’t had experience on how healthy tissue, organ and bone look like in comparison to unhealthy specimens, there is no glaring difference. I could see that her heart had a ‘toughened’ quality (Here I was only allowed to see not touch. I had been able to physically examine organs that had been preserved in formaldehyde in the histology labs but these chemical processes hardened the tissues, giving a false impression of texture and flexibility.) heart2The chambers of the heart were small, the walls inflexible and the superior vena cava narrowed. This must have compromised oxygen flow to her upper body. Her lungs were blackened and I would have suggested a smoker but apparently it was evidence of her age and a result of having always lived in an industrial city. The elderly lady had never regained consciousness after the accident and her kidneys had begun to fail very shortly after admission. They had probably been bruised on impact and, combined with her head injuries, had begun to stop producing sufficient urine, a notable jump in her blood pressure being the result. The spleen was undamaged, as were the intestines but when placed on the dissecting table directly below me, the smell was stunning. There had been no evidence, or possibly time, for bacterial infection to spread but the viscera was examined for integrity. One small puncture and septicaemia sets in quickly. The bowel contents were squeezed out during the examination and the smell of week old faeces hits the nose, palate and brain like a hammer drill. There was nothing so far to determine the exact cause of death but the chief suspect was next. lung tissueFor me the transition between a recognisable human being to cadaver happened the moment woman’s face was peeled back from the skull, rolled over on itself and tucked under the calvarium. The Stryker saw, which initially had been a clear monotonous shriek was becoming muted and thickened and the cold sensation that had started in my thighs was spreading like an anaesthetic. I felt heavy and cold and saw, through a ‘fish eye’ lens my unsuccessful lunge for the door. “How’re you doing up there?” said the pathologist, peering over the Perspex divide. “Good,” I replied optimistically. She nodded and smiled. brain sliceOnce down I felt fine. I lay for a moment or two, observing the ceiling, declined a call for help and then made it back onto the stool. I lay my head on my knees for a couple of minutes and then sat up. The moment had passed and I felt a sense of relief that the collection of systems arranged on the dissection table was now an object of study, rather than a reminder of one’s inevitable mortality. The brain had been removed and was being sliced laterally. It was a muted pink and seemed to have the consistency of blancmange. The slices cut through the pons, hippocampus, medulla and frontal cortex exposing the likely cause of death. A vessel had been ruptured, as the brain bounced between the front and back of the skull, forming a clot the size of a marble in the parietal lobe. Over the course of a few days the bleed applied pressure within the skull and combined with her failing kidneys and compromised respiratory system her elderly body could no longer fight on all fronts. Case closed. It was a privilege to witness a post mortem and its influence is always there when my story takes me into the autopsy suite. It is, for me, as important to understand how your victims die as to why they died.