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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
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
Seeing a live patient pass away is completely different. There
is no scientific curiosity, just a breathless sense of sadness and
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
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
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
Shohinee Sarma, MPH
McMaster University School of Medicine
Class of 2016
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.
December 2015 Issue of IMpact