What’s it like to attend a cadaver dissection?

I’d finally decided to do it. After a long time thinking about it and talking about it with my partner, this was it. A 6 day dissection class. With real cadavers.

Ascending the lift, I was apprehensive. I had dissected animals as part of my degree but I had never seen a cadaver, let alone used one as a teaching tool.

In a locker room, with other students, we were all quiet. Some were returners, others were, like me, new to this. After locking our phones and valuables away, and putting on our white coats, we were led into the lab.

As we walked into the lab, it was impossible not to notice all of the 5 shiny humidors that contained our bodies. The lab was large and cold, with specimens persevered in formaldehyde on workbenches.

We sat on stools in a circle, introduced ourselves and were off on an incredible journey.

Once we had discussed what was about to happen, we gloved up and were led over to the humidors, which were now open, revealing linen wrapped forms. The coverings were removed and we were invited to look carefully at each and make a choice as to the one we were drawn to work on. I chose a man – I couldn’t honestly say why. He was an elderly gentleman, well built.  He was lying face up. There was a line of stitches in his groin – the closure of the hole to get to the femoral artery to input the embalming fluid. His head was shaved and his arms and legs were freckled.

Now it was crunch time. You think about death abstractly. You know that it is the absence of life. You know that there will be no warmth. You’ve heard about rigor mortis but nothing can prepare you for actually laying your hands on an embalmed cadaver. I was, oddly, surprised by how stiff and cold it was. Note here that I say ‘it’ and not ‘he.’ My initial reaction was that whatever had made this form ‘human’ was no longer there. This thought would change as the dissection progressed.

Having been shown how to use the forceps  and scalpel, we were now asked to remove the skin. Yes, you read that correctly, remove the skin. This conjures up pictures of flaying, of Silence of the Lambs but no, it was nothing like that. Skin is attached very firmly to the superficial fascia layer beneath. At one point we had to turn the body over to remove the, much thicker, skin on the back. I now appreciate the term “dead weight.”

Many blunted scalpels later, we could look at our form without his skin – barring his hands, feet and face; the superficial fascia or adipose layer is so thin in some areas, that it takes a degree of skill to dissect it beautifully.  The colour was most shocking – yellow – especially when all 5 of the cadavers were placed side by side on their gurneys. But they were still recognisable as male or female, the rounded curves of the women, their breasts and hips given form by this superficial fascial layer.

Day 2 was the removal of this layer. It was soft and oily – a result of the fat cells breaking down as we cut through them with our scalpels. Careful not to cut too deep and hence into the deep fascia underneath, we began to peel back this blanket. One group of more experienced dissectors managed to remove the whole of the superficial layer in one go. They laid it on a gurney next to the body from which it was removed – a woman.  Apart from her genitals, she was no longer recognisable as a woman; this covering had given her form and now it was gone.

The  layer of deep fascia is one of the most difficult to dissect. It clings to the muscles, wrapping around each, separating them. It is strong, pliable, criss-crossed like a matrix and it is everywhere!

Muscles next; now we were into more familiar territory, but even this was far removed from the conventional anatomy in books like Netter or Grays. Each muscle was wrapped in superficial fascia, but when this was removed, the muscle just came apart in our hands. It made us realise that what we think of as knots in our muscles, couldn’t possibly exist. So what are we doing when we massage or treat someone as a therapist? Bearing in mind the layer of superficial fascia over the top of the muscles, are we actually doing anything to them?

Nothing about this experience is normal, yet it has become routine. On into the viscera; I held the heart in my hands, shone a light through the diaphragm, watched as the teacher used a bag to inflate the lungs, amazed as they ‘pinked up.’  One group removed the brain and the central and peripheral nervous system, laying it out like an ethereal skeleton.

And finally, when our week was done – there was not enough time I can tell you now – we laid everything in a body bag in a coffin and held a moving ceremony where we thanked the donors for what they had allowed us to see and learn. I admit, it was emotional and I shed a few tears. The camaraderie in the room had been fantastic and we had participated in something very few people have had the privilege to do. I would be back!

Evidenced Based Medicine. The Mythical Holy Grail

Evidenced Based Medicine. The Mythical Holy Grail

“Absence of evidence is not evidence of absence.” – Carl Sagan

Complementary medicine seems to some, like a dirty word.   Fuelled by some idea that all Complementary and Alternative (CAM) therapists are shamans and quacks, frothed and indignant bloggers flood cyberspace in the name of science to scoff and sneer at anything which might not be found in the annals of the BMJ, not that they have ever read it.  This is the pseudo-scientist, who happily lumps his conveniently dim witted  and proudly ‘sceptical’ views into two categories: those things that have been proven according to science and everything else which is junk, bogus and a scam, peddled by charlatans.

Generally speaking, these people represent the type of reasonably intelligent but naive buffoon, who whilst holding forth on science, perhaps even reading the summary of a paper or two, has never actually considered how you go about proving, or for that matter disproving anything scientifically.

The mistake they make is demanding that all CAM based therapies should be ‘evidenced based’ with most of them having not the slightest clue what this means, or what the comparison is.  It is a commonly accepted principle amongst most medical practitioners, nurses, surgeons and clinicians, that a big chunk of daily medical practice often has little in the way of evidence to back it up and as much as 50% of general practice work is not evidenced based.

Most of it is based on what has been always done, hunches, ‘best practice’ and so forth.  Pharmaceutical intervention fairs even less favourably and the US hosts thousands of deaths per year from drug overdoses and medical negligence.  A lot of pharmaceutical testing has hidden outcomes and there are lots involving combinations of older drugs, that just don’t get tested at all.  ‘Proof’ is not all it’s cracked up to be.

Now comes a study in the current issue of the Journal of Patient Safety that says between 210,000 and 440,000 patients each year who go to the hospital in the USA for care, suffer some type of preventable harm that contributes to their death.

The starting point for CAM therapies is to understand that however useless the sceptics might claim them to be, they tend to be generally harmless, as long as they do not attempt to convert the recipient away from their conventional treatment.  Jumping through the hoops to demonstrate efficacy is no easy matter however.  I am not for a minute supporting those who make wild claims to cure cancer with crystals, or generally talk unscientific bollocks to big up their own nonsense.  What I am saying is that there is other stuff out there that we don’t understand and that it is foolhardy and arrogant to assume that we know it all.  ‘Science’ should help more to develop ways of helping CAM to demonstrate efficacy instead of snidely sniping from comment pages in the Guardian.

To validate a physical therapy approach for instance, requires a treatment protocol to be written which sets a standardised approach and has everyone treated the same way.  For most, this flies in the face of what CAM is all about, which is to treat the person presenting with the disease or problem, rather than treating the disease itself.

This presents a problem in itself, but this is only the start.  The research paper might have to be submitted to an ethics committee (check here), to decide that the protocol being used is appropriate and does not adversely affect any control group.  Then the study itself needs to be undertaken and funded, followed by this paper being written up, with statistics, a literature review and couched in a language which is generally not very accessible. There is a big disconnect between the academic designing a study and a therapist who, whilst having a good practical knowledge of their technique is not trained or equipped to undertake a serious piece of research.

But then surely once I’ve proved my theory/practice/lotion works everyone will accept it?  Not a bit of it.  Why the hell not?

“Ahh you see, you’re biased.”
“What do you mean I’m biased?”
“Well you had a vested interest in proving the outcome.”
“Of course I bloody well did, who else is going to do it?”
“No-one, but that’s not the point.  It’s still first hand research and doesn’t really count.”
“What does then?”
“Well someone else has to do it again.”
“So I ask someone to do it again?”
“Oh no you can’t do that.  You’d be influencing them.”
“What so I just have to wait around until someone decides to test out whether what I found out was true?”
“So until then can’t say it was?”
“Oh you can say it was, it’s just that no-one will take you seriously. Because you introduced a bias.”
“I give up.”
“Yes well that’s to be expected.”

The paper then has to find a publisher which will peer review it.  Invariably the publication itself will be subject to derision or criticism, simply because it is publishing research papers which address CAM outcomes, irrespective of the quality of the research or the writing.  The goal posts are hardly equal.  The baseline is this: all CAM is effectively shit and if you go out and try and prove its not, then you are biased and your research isn’t valid.  Tim Minchin, a funny and famous sceptic echoes the naive view of the majority of those of his religious persuasion, when he says “There is a name for alternative medicine that works.  It’s called medicine.”  It’s a sweet idea, but bears no resemblance to the complex and difficult arena which is called proof and is a bit like saying “If everyone laid down their weapons there would be no more war.”  It’s true, but a bit more complex than that.

With hundreds of thousands of treatments being conducted every year and millions of pounds being spent, it seems backward to sit on the sidelines and scoff, even suggest that it’s rubbish, when a pro-active investigation could perhaps shed some light and help the so called victims of CAM.

It behoves us to understand that the things that define us as humans: love, sexual attraction, love of spinach, loneliness, fear, sexual orientation, even pain, have no consensus when it comes to defining them scientifically. Lack of evidence is not the same as evidence of lack.