A few years back, I was just like most people in the western world alive this century – I’d never seen a dead body. Obviously since then I’ve seen a fair few. But they still freak me out a bit.
I remember my first day at medical school – when they took us down to the dissection room to be introduced to the cadavers. A funereal looking gentleman, with a voice from beyond the grave, slowly peeled the cover back, while talking us through what we’d be expected to learn in dissection. I spent the entire time repeating over and over in my head ‘don’t faint don’t faint don’t faint don’t faint’ and leaning against a metal chest of drawers for support. One by one a number of future doctors excused themselves to ‘get some air’, while I gritted my teeth. If I’d have known that the metal chest of drawers contained a selection of pickled limbs, I’d have keeled over there and then, but luckily I didn’t find that out till week 3. And by then I was a bit more hardy.
Anyway – this is how I felt when I first had to deal with a dead body as a doctor…
There is nothing a junior doctor remembers better than the first person they confirm dead. At morning handover a nurse tells you bluntly that there’s one less patient for the list, and ushers you towards a curtain-surrounded bed. You grit your teeth and go in. And there it is. Your first dead patient. They certainly look dead – they’re a sort of yellow-grey and their mouth is usually open, and their eyes closed. But you have to make sure, and in order to confirm someone has died there is a routine you have to go through –
1) Try to rouse the patient by voice and pain
2) Listen to the chest with steth for breath sounds for one minute
3) Listen to the chest with steth for heart sounds for one minute
4) Feel for a central pulse for one minute
5) Open the patient’s eyes and shine a torch in and check that the pupils remain fixed and dilated…
All of which is a bit pointless because when you see a dead body, you know it’s a dead body. It just doesn’t look the same – it just looks like an empty vehicle that ‘you’ drove around in for 80 odd years, and then abandoned.
Which isn’t to say it isn’t both freaky and scary. To be alone with a dead body when you haven’t yet had your breakfast is a bit odd. Then you add in the fact that there are plenty of times that you can’t hear breath sounds (e.g. on a fat patient, or one breathing very gently) or heart sounds (ditto on the fat patient), and there are plenty of times when someone doesn’t respond to voice or pain (not least the ortho SHO who overdoes it at the mess party and cannot be roused from the corner of the club for the night bus home). And central pulses can be a bugger to find (see fat patient). SO the only surefire way you can make sure this dead person is actually dead is to shine the torch in their eyes. And there’s nothing that feels more invasive than lifting a dead person’s eyelid and shining a torch into it. You feel like someone somewhere is going ‘OI – YOU! That body served me well for 80 odd years – can’t you just leave it in peace now?’
Once that’s done you write the time of death in the notes – which is actually the time that you see the patient and confirm their death – not the actual time of death. Which, if this patient dies in the night, can be some hours afterwards.
Then comes the tricky bit – death certificates. These are archaic old forms that require a PhD level of medicine to understand. But essentially you have to say why a person has died, and what other illnesses they had that contributed to this death. But, to be honest, a lot of the time you don’t actually know. An old person becomes breathless on the wards and dies soon after – have they had a heart attack? A clot in their lungs? Fluid on their lungs? Pneumonia? Sometimes, especially if the patient has just arrived on the ward, it can be difficult to tell. Now, in these cases you’re supposed to phone up the coroner to say you don’t know the cause of death, and the coroner then decides whether to hold a post mortem to find out why someone died. But for old, sick people this often seems a bit pointless, so you put what you think it might have been, and hope for the best.
Then it’s time for the cremation forms – and these are how most junior doctors pay their rent. Each time you fill in a crem form you get £73. It’s known as ‘ash cash’ and is highly prized. Unfortunately in order to get this ash cash it’s more form filling and a trip to the morgue to check that the patient doesn’t have a pacemaker – pacemakers can explode when cremated. So you pat the chest for a bit, and then run up to the wards to have a look at a recent chest x-ray – and check there’s nothing that will kill anyone working in a funeral parlour (what a way to go – death by dead body).
So basically a junior doctor is paid when a patient dies on their ward. Which isn’t the best way to incentivise someone to keep someone alive. Luckily no one likes new patients, as you have to get to know them, and do all sorts of work to understand what’s going on with them – which keeps you late at work. Everyone (except bed managers) prefers a patient who’s past medical history and latest blood results are on the tip of your tongue when your consultant asks for them. Which makes us want to keep patients alive. So all in all, your doctor prefers you alive to dead – happy day.