It Ends: On Caitlin Doughty’s Smoke Gets In Your Eyes by Andrew Bomback




I met my cadaver on the first day of medical school. This was 16 years ago. In the morning, my classmates and I sat through our first physiology lectures. After lunch, we assembled outside the anatomy lab to find our assignments (five students per cadaver), change into scrubs, and chat nervously while awaiting our professor to open the doors of the lab. I don’t remember anything he said in his introductory remarks other than a warning about how the smell of the preservative would stick to our bodies. “The only thing that gets the smell off your hands is cooking with garlic,” he said, “and then doing all the dishes afterwards.”



My team was assigned to a cachectic old woman whom we named Pearl. Every team named their cadaver. Some went for humor (the enormous black man lying on the table next to us was “Screech” to his medical students) while others tried to find a name that fit their person. We all agreed this tiny old woman looked like a Pearl, and we all agreed how lucky we were that she was so thin, because we wouldn’t have to dissect through layers and layers of fat to get to her organs. Of course, she was emaciated because she’d died of cancer. That seems obvious now but didn’t then to a team of five medical students with only four hours of lecture under their belts. We joked about how skinny Pearl was. We called her a waif and wondered about the modeling career she might have had if she were just a few inches taller. We predicted we’d be the first team to leave anatomy lab every Tuesday and Thursday afternoon.



I rarely think about anatomy lab because I’m a physician, not a surgeon. I sometimes reminisce about that class when I’ve been cooking with garlic and the scent lingers on my fingers, remembering that creepy anatomy professor’s attempt at a joke just before unlocking a laboratory that housed thirty dead bodies. But I’ve otherwise completely pushed aside what went on inside that lab until recently, when I read Smoke Gets in Your Eyes, a memoir from mortician Caitlin Doughty that covers her six months working at a crematorium in Oakland, her time in mortician school, and her evolving view of death from within these spheres. Doughty’s experience preparing bodies for cremation triggered a memory of the day we were dissecting Pearl’s colon and found a large mass that wasn’t in any of the anatomy textbooks we kept at our table for reference. We called over one of the assistant anatomy professors, who looked down and said matter-of-factly, “That’s a tumor,” before moving on to the next table that needed help. That memory spurred another, of the day we were dissecting Pearl’s oral cavity and pulled out her dentures. Her name was inscribed on the palate portion of the dentures, probably to ensure they were never mistaken for someone else’s in whatever nursing home she spent her final days wasting away from colon cancer. The dentures told us her name was Emma, not Pearl. We continued to call her Pearl after that day.



Physicians, like morticians, get used to death. At least most of us do. Recently, I was asked to consult on a middle-aged man who’d suffered a devastating head injury. He’d had six neurosurgeries to decompress what appeared to be a continuous source of intracerebral bleeding. Four weeks into the hospitalization, he demonstrated no evidence of any brain function other than the most basic drive to breathe. Around this time, his kidneys started to fail, and I was asked by his neurosurgeons to evaluate his candidacy for dialysis. The man’s wife and mother were at his bedside when I saw him. I explained to them that his kidneys were failing and that I didn’t expect them to recover. I advised against dialysis because I didn’t think it would change his overall trajectory. “If we put him on dialysis,” I said, “he won’t die from kidney failure, but he’ll still die from his head bleed. If we don’t put him on dialysis, he’ll die from kidney failure instead of from his head injury. The outcome is still the same.” I didn’t expect that I’d have to repeat this logic to the neurosurgeons a few hours later, who took my recommendations as hard as (if not harder than) the patient’s wife and mother. After a few minutes of back-and-forth about the patient’s kidney function, mental status, and overall prognosis, one of the neurosurgeons said, “You have to understand how hard it is to tell this patient’s family, after we’ve been operating on him for weeks, that now we just give up because his kidneys are failing. That’s hard to accept.” I asked, “Who’s having a harder time accepting that this man is going to die – his family or his doctors?” To my surprise, the chief neurosurgeon answered, “His doctors.” The next day the patient was started on dialysis, and about two weeks later, when the neurosurgeons had nothing left to offer the family, a mutual decision was made to take him off life support. He died within an hour.



I was surprised by the chief neurosurgeon’s answer, how honest the reply was and how much it betrayed a fear of death that doctors try their best to hide. One of my fellows was with me during that discussion in the neurology intensive care unit. When we were out of the unit, going over the logistics of starting this dying man on dialysis, my fellow chided the neurosurgeon for a “god complex.” I disagreed. The surgeon’s refusal to let his patient die that day wasn’t rooted in a belief that he had the power to save the man’s life. He just wasn’t ready for death. He wasn’t prepared. The patient’s relatively young age clearly played a role in the surgeon’s reluctance to accept the inevitable, along with the acuity of the downfall (one morning, a 51-year-old man wakes up, eats breakfast with his wife, goes to work, and within hours, a traumatic head injury has eliminated any semblance of brain function). If Pearl, an elderly woman from a nursing home dying of colon cancer, had an intracerebral bleed, this neurosurgeon would have never even brought her to the operating room, let alone ask a nephrologist to put her on an artificial kidney machine.



Readers of Smoke Gets in Your Eyes probably will focus on the behind-the-curtain details that Doughty spills about the “death industry,” as she calls it. I get it – the reveals are interesting in a this-is-how-the sausage-is-made way, with eyelids propped open using crazy glue and staples planted into the palate and cheekbones to force away the default frown of dead skin. I wasn’t shocked by the dark humor that Doughty and her co-workers employ throughout their days, because doctors do the same thing for the same reasons, but I suppose readers who work in saner professions will find some of the jokes and lightheartedness jarring. What struck me, though, were the rare moments when Doughty or her bosses were forced to pause, when they cried, when they mourned over these anonymous corpses spread out before them. The 11-month-old who died of a heart defect. The unclaimed suicide whose body had already decomposed from days floating beneath the Golden Gate Bridge. The old woman whose family asked if she could hold a candy bar when she was cremated.



Why do some cadavers affect the morticians and others elicit no emotion? Why did the neurosurgeons decide that day that they weren’t going to lose their patient to kidney failure when surely at least one or more other patients in their intensive care unit died within hours of our discussion? Why did my anatomy classmates and I keep calling Pearl by that fake name when we knew from her dentures that she was an Emma, and why didn’t any of us talk about that colonic tumor we simply resected and tossed in a biohazard bag along with the little fat we’d removed from Pearl’s abdomen that day?



Early in her memoir, Doughty relays the story of watching a toddler jump out of her mother’s arms and fall to her death in a shopping mall. Doughty was only a few years older than the dead girl, and this horrific event – the sight of the girl plummeting, the thud of the infant’s body smacking into the floor, the screams of the child’s mother, the hush that fell over the entire mall – instilled a fear in Doughty that, she believes, led her into a death-oriented career. By working so close to death, she seeks a comfort level with the inevitable. And she wants to share this comfort with others. She dreams of demystifying and personalizing the death experience for families of the deceased. She describes an ideal of spouses and children and parents preparing the dead bodies themselves and then performing a natural burial process in which the corpse’s decomposition enriches a soil from which fruits and vegetables can emerge.



This is nice but unrealistic, as Doughty herself concedes towards the book’s end when she quotes Kafka: “The meaning of life is that it ends.” We all, to some extent, live with a daily fear of death. There’s a spectrum, from Woody Allen-types on one end to Keith Richards-types on the other end, but all of us plod through our days knowing, at some level, that tomorrow is not guaranteed. There are moments when that knowledge rises to the fore, like when a doctor doesn’t want his patient to die, because that means someday another doctor will let him die. Or when a medical student refuses to acknowledge the person who is his cadaver, because then his scalpel is dissecting away skin and fat and lethal tumors that someday could be his own. I don’t know a better definition for the meaning of life than the one Kafka proposed.



Doughty claims that the funeral industry is cheating us of a “realistic interaction with death.” I don’t think she has to worry, at least not when it comes to doctors. She also argues that the modern, hospital-situated, professionally handled version of death dilutes “the chance to face our own mortality.” She’s talking about my patients and their families, yet I can’t shake the feeling that she’s talking about me and my colleagues, too.


Andrew Bomback is a physician and writer in New York.