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Summer Work in The Underworld
Cuimin Doyle

I'd just finished "Third Med" and I was delighted to get summer work in the Post Mortem department. My friend Danny, in fourth year, worked there last summer and said it was great.
He told me about the PMs, almost all of them coroners' cases "where", as he said, "you will see everything from strokes to stabbings". I felt sure he was exaggerating, but at least I'd earn money to help with the rent, and pay for the two-week holiday with Helen and the gang before the start of the academic year in September. We had the first module of the pathology course before the summer break, so seeing some pathology in "The Underworld" as Danny called it, would do no harm! Dr Hades, the Forensic Pathologist, put it more graphically when I met him to discuss the job: "There are no tutors like the dead", he said.

On my first day I was given a copy of the Department Protocols detailing how to deal with the police, undertakers, grieving relatives, phone calls from the press etc. The importance of respect for the dead was emphasised:  "Regard each case as you would your own father, mother, sister, brother, daughter or son".

By the end of the first week I was familiar with the routine - getting supplies, tidying up after PMs, washing the tables and floor, laying out the instruments and, of course, the banter over cups of tea in the day-room with the morticians and Margo, the secretary.

I couldn't believe the variety of cases going through almost every day; sudden deaths due to coronary artery disease, strokes, pulmonary thrombo-emboli, as well as the inevitable road traffic accidents, drug overdoses, suicides and others. Danny was indeed exaggerating when he mentioned stabbings; I wasn't allowed to have anything to do with suspected homicides; however, I assisted, however, in one way or another, with all the other cases.  

It took me a while to get used to life in the "Underworld" where death, its causes and circumstances are meticulously investigated. Dealing daily with death - sudden, accidental or intentional - was an entirely new experience. Like most of my friends, I knew what life was like out on the town at weekends, at football matches and the like, but somehow, I never imagined the stark reality of life and death as viewed from inside a morgue. It was a grim reminder of the fragility of life and many of the bodies going through were my age!

By the end of July I had enough experience to be able to assist Dr Hades when one of the morticians, Bill, was on holidays. Hands-on stuff this; I was really learning anatomy and pathology like I never imagined; I even put my hand into "the lesser sac"! When I mentioned this to my class mates, Kevin and Gerry, they didn't know what I was talking about. Vaguely I recall hearing the term "morbid anatomy"; now I knew what it meant.

Hades: in Greek mythology 'the underworld' ruled by Hades is the kingdom of the dead where Charon, the aged boatman, ferries the souls of the dead across the river of woe for punishment in Tartarus, or eternal reward in the Elysian fields.

That case the other day, a fifty year old male chronic alcoholic, who was brought to the Emergency Department in a coma.  He died the next morning in Intensive Care. There he was on the PM room table with a pale face, thin limbs, mild gynaecomastia and a distended abdomen. Dr Hades pointed out all these features to me as he noted them down as part of the external examination. Then the grand incision from sternal notch to supra-pubis, and a deluge of pale-yellow, watery, ascites that gushed from the peritoneal cavity. The liver was tawny, shriveled and contracted beneath the diaphragm which, Dr Hades said, was typical micro-nodular cirrhosis. The pictures in the textbooks and on Power Point at lectures are good but this was real, straight in front of me, I could feel the nodules. The spleen was big - at least four times normal size. When he opened the oesophagus, there they were; the collapsed, tortuous, dilated veins he said he was expecting, visible through the mucosa in the lower one-third. Now I understood the meaning of porto-systemic anastomosis and the risk of haematemesis.

Having removed the organs, Dr Hades showed me the heart: it was enlarged -almost twice the normal weight - and all the chambers were dilated; he called it dilated cardiomyopathy, apparently another finding in deaths due to chronic alcoholism. The other organs appeared normal enough and, as acting mortician, I had opened the skull for Dr Hades to remove the brain. As he did so he said it showed mild atrophy, because some of the gyri were thin and the sulci wide. Having weighed it he placed it upside-down on the bench and said, excitedly, "look at the mammillary bodies, they're haemorrhagic - this is Wernicke's encephalopathy!" It really is strange the things that excite pathologists! I had never seen real mammillary bodies before. I had read about them, but there they were, a pair of tiny haemorrhagic mini-breasts just in front of the pons. Dr Hades then made coronal sections through the cerebral hemispheres and showed me small haemorrhagic spots beside the ventricles that, he said, were also features of Wernicke's encephalopathy due to chronic alcoholism. I must find out something about Wernicke. I wonder was he related to that Bayern Munich striker of a few years back? The autopsy was now completed and I had seen "morbid anatomy" - I like that term - like nothing that textbooks or the most sophisticated imaging technology could ever impart.

Now I knew what Dr Hades meant when he said "there are no tutors like the dead".

And so the days flew by, PM after PM, seeing and learning and being paid for it! Now it was Saturday, the end of my last week and probably my last case because Bill, the mortician, would be back on Monday, and I was off with Helen and the gang for a two-week break in Lanzarote on Sunday, and then back to college.

The case was routine enough: a twenty-eight year old drug addict found dead in a basement flat. He had been out "socialising" the night before with friends, and when one of them rang his mobile phone several times next morning, there was no reply. His friend then called to the flat but could not gain entry. The police were called and entered through a window. The deceased was found lying on a couch with vomitus about his nose and mouth. He was pronounced dead at the scene by Dr Bolster, the local GP. The body was removed to the mortuary accompanied by the policeman who had reported the case to the coroner. He identified the body to Dr Hades and gave him a written statement of the circumstances surrounding the death. The policeman confirmed that the deceased "was known to them" as an injecting heroin addict. Police-speak and PM room terminology now came naturally to me.

Having gone through all the preliminary procedures we were ready to get started, aware that special care was needed because of the risk of Hep C or HIV infection, so we had mesh gloves in addition to the usual face mask and other PM gear, and so we got started, anxious to get this last one out of the way before lunch.
I made notes of the clothing, the weight, height and external features for Dr Hades. A Caucasian male with a shaven head, a brown mustache and "goatee" beard and about the stated age etc. etc. And the tattoos: a man in a boat on the right shoulder with "Charon" underneath; a winged horse on the left shoulder with "Pegasus" underneath; a snake on the right forearm, a unicorn head on the left forearm, the word "sweet" beneath the right nipple, "sour" beneath the left nipple, and the inevitable ring in the left ear. A number of sclerosed venipuncture marks in the left antecubital fossa, and on the back of the left hand in keeping with chronic intravenous drug use, and three recent needle marks.   Also noted were fourteen parallel, thin, straight, transverse scars on the ventral surface of the left forearm and wrist, measuring from four to six centimeters in length, indicative of self-harm in the past. With all the external features noted, including post mortem lividity and rigidity, the internal examination commenced.

Nothing new so far: this must have been about the tenth PM on a drug addict at which I had assisted, and the external findings now flowed from my pen almost automatically.

Dr Hades was removing the heart and lungs but was having some difficulty. I was on the left side of the table and he asked me to hold the larynx and pharynx over to my side as he tried to free the right lung that was bound to the posterior chest wall by firm fibrous adhesions. As I reached to grip the pharynx and larynx I felt a slight scrape on the ventral surface of my right forearm, just above the glove margin. I looked, and saw a small sliver of bone projecting from the transected end of the left fifth rib.  "He's a drug addict", I thought, "he might be Hep C or HIV positive", but I said nothing. Dr Hades freed the right lung and removed the heart and lungs together. Now I had a chance to have a peep at my arm - maybe a slight blood-stained scratch. "It's ok" I said to myself. We completed the PM; gastric contents in the oesophagus, about the larynx and in the lower bronchi, with small areas of partial collapse throughout the very congested lower lobes of both lungs. "Almost certainly aspiration asphyxia but we'll have to wait for the histology to be sure", said Dr Hades. That was nothing new; I had seen it two or three times before in drug addicts and in at least two other cases, a male and female of about my own age, following a night out binge drinking.
So with my last case finished, and all the washing and cleaning done, I had a shower and prepared to leave. In the shower I had a look again at my arm: there definitely was a slight scratch. Should I mention it to Dr Hades? When I came out he was in the day room having a cup of tea. I showed it to him and mentioned the spicule of bone projecting from the rib. "It's a minimal abrasion", he said, and then, noting my anxiety, he tried to reassure me: "Even if the addict is Hep C or HIV positive the possibility of you becoming infected is very remote. For example", he said, "the chances of becoming infected from a needle-stick accident in a full blown HIV positive AIDS case is about 0.3 per cent and we don't even know if he is Hep C or HIV positive and you only have a slight scratch". He told me to go over to the Emergency Department and have it dressed. Meanwhile, he would contact Professor Sullivan in Microbiology and try to have the tests for Hep C and HIV expedited.

Margo, the secretary, came with me - she knew Mary, a senior staff nurse there.  My mind was now in a tizzy. What if I became Hep C or HIV positive, or both? This was the stuff of fiction. How could this happen after all the cases I helped with this summer and never a problem? And so we hurried along the corridors to the ED.

The place was in chaos, trolleys with bodies everywhere. It was Saturday mid-day and there was a match on Friday night, - "a local  derby" with, apparently, a brawl between opposing drunken supporters, not to mention the usual RTAs, coronaries, strokes and falls.

I got a chair and waited. Margo had a word with Mary, the staff nurse, hoping to have me seen quickly. She then had to rush back to the office. Three hours later I was seen by a very-stressed junior doctor, David Hand. He was in fifth year when I was in first year but he wouldn't remember me. He treated me with a rub of antiseptic and a piece of Band-Aid. When he heard what happened he said I'd have to come back on Monday for blood tests. He scribbled some notes and rushed off to attend to an elderly man with chest pain. Come back on Monday! I am supposed to be at the airport at 8.00 a.m. on Sunday for a ten o'clock flight to Lanzarote with Helen and the others.

Back in the PM Department Dr Hades had sent blood from the case to Microbiology for viral screening as well as blood and urine to the Toxicology Laboratory. He had been on to Professor Sullivan who said preliminary results should be available "soon". When I mentioned about having my own blood taken for screening on Monday he said "Not at all, relax Pat, everything is all right, forget about it, off you go, enjoy your holiday. If there's a problem I'll give you a call. I have your mobile number".

As I cycled home to the flat I was thinking how this could happen at my last
case after a great summer in the PM Department. I had enjoyed every minute of it - until today. Suppose I had taken that job "shelving" in the supermarket. Sure, it would have been deadly boring, but at least I wouldn't have had this problem! On the way I stopped at "Joe's Diner" for a burger and chips. Back in the apartment, my flat-mates Brendan and Neil were watching a match on TV while I rang home. No mention of my problem, of course, just the usual upbeat talk, "great now, looking forward to the break and to seeing you all when I get back - we've a lot to catch up on, I've been busy these last few weeks etc. etc." I also texted Helen to say I couldn't meet her tonight, too tired, packing to do, see her at the airport. Then the packing and I was ready for bed but first I just dipped into "Medline" on "the net" to find out something about Hep C and HIV.

In bed, my mind was still on that PM. Suppose I was positive for HIV? How would Helen react? Going out with her now for over a year; she's in "Third Med", a year behind me and she'd know something about Hep C and HIV. Should I tell her? And then there's Dad and Mum, Colette, John and Louise as well as the lads! Would they all believe I picked up the infection in the PM room? Might they think I got it from a prostitute? But hold on, I thought, you're jumping to conclusions; this is ridiculous: Dr Hades told you the possibility of being infected was extremely remote. Yes, but there is the possibility, however remote.
I drifted into turbulent sleep; now I felt weak, no energy - I'd have to give up football; I'm losing weight and sweating, and that fungal infection in my mouth is getting worse, and now I can't breathe. I probably have pneumonia and TB, and those flat blue tumours on my legs named after someone called Kaposi. Now I'm jaundiced and I've got cirrhosis, ascites and oesophageal varices just like that chronic alcoholic, and maybe liver cancer. Dad and Mum are crying beside my bed and Helen is going out with Josh Collins who borrowed my lecture notes last year and lost them.

And there's my mobile ringing; Dr Hades phoning to say the tests for Hep C and HIV are positive? He said he'd give me a call if there was a problem. I sat up with a start, it's morning, I grabbed the mobile, it's the alarm. I'd been dreaming. I shouldn't have gone on "the net" and read all that stuff about AIDS and Hep C. Just then my mobile rang; a text from Dr Hades - tests on blood from the case negative for Hep C and HIV.  Wow! I jumped out of bed with delight.

Hurry, shave, shower and get dressed, I have to be at the airport by eight, Helen will be waiting! What a summer in the PM department! The autopsy - seeing it yourself - nothing beats it! Pathological, you may say, sure and it's for me!

Cuimin T. Doyle, MD., FRCPath.                    

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