I was recently reading a review of prominent English neurosurgeon Henry Walsh's memoir Do No Harm.  He reflects on the mistakes during his surgical career that resulted in irreparable damage or death. He quotes, "Every surgeon carries within himself a small cemetery, where from time to time he goes to pray." 
Atul Gawande, at the forefront of North American modern med-lit, suggests that he "learned about a lot of things in medical school, but mortality wasn't one of them."  In my initial stages of medical school, I would concur.
Medical school is a grueling few years that tax the body and mind. We choose medicine with a perceived sense of purpose, a desire for compassion and justice (sometimes translated as prestige and job security). We set aside these supposed humanitarian tendencies for the first couple of years, focusing our energies on being little medical sponges. We memorize large textbooks, sleep through early morning lectures, and regurgitate the causes of hyperkalemia. Somewhere between memorizing the formula for correcting calcium and failing to palpate the elusive liver, we begin to wallow in the depths of our incompetence.
But this incompetence generally relates to the technical aspects of medicine. We do not always push ourselves to delve deeper into the other human feelings that medicine provokes. This avoidance is perhaps related to a lack of time, or so we tell ourselves. But it is likely also due to the embarrassment we feel in acknowledging our acute discomfort.
I remember walking into the anatomy lab nearly two years ago with knotted anxiety, and the mild nausea that I kept hidden. The idea of cutting into a dead human body was disturbing, but it did raise my intellectual curiosity. I remember once unknowingly leaning against a trolley full of female human pelvises and my horror when I opened it. But over time, the nausea dissipated, and I soon became focused on extracting the necessary knowledge from this incredible educational privilege. This growing level of comfort, however, only came by dissociating the human aspect from the scientific curiosity. As soon as I pictured the family member behind that grotesquely beautiful dissection, the nausea returned.
Seeing a live patient pass away is completely different. There is no scientific curiosity, just a breathless sense of sadness and confusion.
My first medical encounter with death occurred last summer in a tertiary government hospital in northeast India. I was visiting the pediatrics intensive care unit (PICU) for an international elective, unknowingly during a Japanese encephalitis outbreak. My grandmother says that all events in life are predestined. It was perhaps destiny then that my first encounter with death occurred in the same hospital where I was born.
I had walked into the PICU just as a code was called. There she was lying, a tiny bundle with a puffy blue face and large listless eyes. My staff noticed the dwindling heartbeat on the cardiac monitor and the code blue was initiated. Watching cardiopulmonary resuscitation (CPR) performed on anyone is difficult; seeing it performed for the first time on a two-month old child is excruciating.
The scene was a classic humdrum of puzzled residents, beeps and cries, misunderstanding and confusion. At the end, all that remained were questions, and a father comforting a dead child.
The biggest source of confusion stems from not being able to define death in the twenty-first century. Is a person actually dead because their heart has stopped and not responding to epinephrine? Can we put more ice packs around the brain to attempt to preserve neurons while CPR continues? If we artificially ventilate the patient and keep them hemodynamically stable, is that life? When we extract organs without anesthesia from a brain-dead individual, are we certain their pain circuits are not the least bit activated? So many questions that medical education does not always adequately address. We often walk into clinical situations naïve and unprepared.
Two summers ago, I was travelling through rural Quebec and stopped at a quaint Francophone village on the north bank of the St. Lawrence. While touring the village, we noticed that each historic house had a stone edifice outside for storing produce in the winter. The tour-operator jokingly remarked that these structures were often used for storing dead family members when the winter ground was too hard to dig. "So sometimes you had to reach past Uncle Jean's elbow to reach the carrots and 'taters for that night's dinner." Everyone chuckled at his flippant comment, but what he described was morbidly natural.
I remember a family friend from Mumbai telling me a similar story about Zoroastrian end-of-life rituals. The Zoroastrian community has a unique rite of placing the dead in Towers of Silence, raised circular structures for vultures to excarnate. My friend commented that you could be standing on a high-rise balcony enjoying the evening when a vulture overhead could drop half a human limb next to you. He spoke about it calmly, almost humorously. The humor was not jarring though, it reflected desensitization and acceptance.
Knowing that birth and death are the only two certainties of life, it is interesting how the modern western world has so easily removed both from our daily consciousness. We are preserved from the physical realities: the raw assaults on our senses. There is an entire lucrative industry that will now perform the rites traditionally performed by family members, presenting a clean respectable body for farewell wishes. I am grateful for the privilege of being allowed to witness the personal yet universal sights, sounds, and smells of end-of-life. Without being irreverent, there is an immense dignity in being able to accept death for itself. The more we see death, the more we talk about it, normalize it, perhaps the less we fear it. At the very least we might be able to find some meaning in our otherwise seemingly insignificant lives.
Shohinee Sarma, MPH
1. "When Brain Surgery Goes Wrong." The New Yorker. 18 May 2015. Web. 13 Sept. 2015. http://www.newyorker.com/magazine/2015/05/18/anatomy-of-error.
2. Marsh, Henry. Do No Harm: Stories of Life, Death, and Brain Surgery. New York City: St. Martin's, 2014. Print.
3. Gawande, Atul. Being Mortal: Medicine and What Matters in the End. Doubleday Canada, 2014. Print.