Service of Gratitude and Remembrance, 6 June 2017

The annual Emory School of Medicine Service of Gratitude and Remembrance for the Human Anatomy body donors was held on 6 June 2017 at Cannon Chapel and I was this year’s Anatomy Faculty speaker. My remarks are below:

Last week, Peyton invited me to speak at today’s Service of Gratitude and Remembrance. My first reaction was to say no. After all, for something like this, it’s nearly impossible to come up with something simultaneously new, something tidy, something universal, something profound, something satisfying and something moving. Those are not my strengths, I’m more of a Kahoot man, as you well know.  Besides, others have already said the appropriate things and said them better. But I feel that I owe you, my students, my surrogate children, my future colleagues, and our donors something for your sacrifices, so I will offer up something untidy and personal.

We’ve worked together now for almost 10 months, so you know that I don’t have all of the answers, especially when it comes to little nerves that may in fact be cunningly disguised bits of fascia. The older I get, the more I struggle with even understanding the meaning of the big questions, let alone trying to answer them. Some of us have a gift for thinking and writing and speaking about big thoughts like Love and Justice, Life and Death, but I am not one of them. I am an ant who builds a modest but sturdy structure one hard grain of fact at a time.

Now, lucky for me, ant behavior is foundational to being a good doctor. All of you engaged in ant behavior during your human anatomy course. You have to. You must understand anatomy to have any chance of correctly diagnosing and treating diseases. And you do understand, thanks to your own hard work and the generosity of our donors. Let’s consider a patient who is short of breath because of a large pleural effusion, compressing the underlying lung. It happens, just ask Bill Eley. What will you do? You may advance a hollow needle into the fluid, draw the fluid out of the pleural space and allow the lung to reexpand. But where will you place the needle and what complications do you want to avoid? It makes sense, right, to stick your needle where most of the fluid lives. Well, where is that? The posterior costophrenic angle. Some of you may not remember what that is, I know that the half-life of this information is often maddeningly brief, but the posterior costophrenic angle is where the posterior tip of the lung sits on top of the back of the diaphragm, with the pleural space in between. It is the lowest, or in doctor-speak, the most dependent part of the chest in the upright position, and that is where pleural fluid will collect.

You get out the thoracentesis tray, prep and drape the patient’s back in the usual sterile fashion, numb up a generous swath of skin and get ready to slide the needle in. But wait, do you place the needle above or below the rib? As you no doubt remember from dissection #7, objective #3, you go above the rib because the intercostal artery runs below the rib and you want to avoid puncturing said artery. Take it from someone who has stuck sharp objects into arteries hundreds of times, mostly on purpose.

Now, I know that you know this anatomy. I saw almost all of you place your hands into the posterior costophrenic angle of your donor’s chest cavity, so you literally have a visceral feel for where the most dependent part of the pleural space is in the upright position. Many of you also showed me the intercostal arteries arising from the internal thoracic arteries, running inferior to the ribs. You can thank your donors for this knowledge and this experience that you will call on for the rest of your life. You will rely on similar knowledge gained because of your donor’s generosity when you do other procedures. Each of you will eventually do a spinal tap. I was lucky, I did something like 10 my first month of Internal Medicine.  Where did I, and where will you insert the needle to avoid the spinal cord? If you don’t remember the answer, go back and look at dissection #1, objective #6.

Let’s move on to the untidy, messy part, where the answers aren’t hard grains of fact like, “Advance the spinal needle between L3 and L4 to avoid the conus medullaris.” Can we learn one more thing from our donors? We can. I’m an atheist, and my atheist “go to” Bible passage is the Sermon on the Mount, parts of it anyway. The fourth line of the sermon is: “Blessed are those who mourn, for they will be comforted.” Who will comfort those who mourn? You will, you will comfort your patients and sometimes comfort each other. Medical school is hard, being a doctor is hard and being a patient is even harder. Think back to your donors. Many of them had heroic medical or surgical interventions: bowel and liver resections, craniotomies for brain tumors, one patient even had a heart transplant. Ultimately, though, those interventions failed; these patients died and became our donors. But they and their families must have received some measure of comfort from the doctors, nurses and others who cared for them, otherwise, they would never have given you the gift of their mortal remains.

You will comfort those who mourn. I know that you will do it well, because I have watched you closely during the most stressful part of many of your lives. The human anatomy lab is a tough place with harsh lights, terrible smells, actual dead bodies being cut up, (often with power tools, but some of you liked that!) and high expectations. Despite all of this, I was impressed by how respectfully and even lovingly you treated your donors, your dissection partners and your fellow students. I remember one day coming by to “help” Daniel and Bryce hunt for some little nerve, unsuccessfully, of course. After 5 minutes of futility, Daniel sighed and said, “Well Brycie, it’s back to the drawing board.” I thought that was sweet, in a totally manly and testosterone-laden way of course. I won’t embarrass any of the rest of you, but I could.

I cannot give you tidy advice on how to provide the comfort your patients will surely need, it’s a messy process that you will learn through your own experiences and by emulating others more skillful than me. Ants don’t do comfort. But comfort is often the most important thing we can offer and sometimes the only thing we can offer. And that’s our donors’ final lesson.


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Stefan Tigges

I am an academic Radiologist who uses comics to teach medical students and residents.