Dozens of gurneys with closed stainless-steel boxes greeted medical student Zain Alfankek on her first day of gross-anatomy class at the University of Arkansas for Medical Sciences.
Anxiety welled in her chest.
It wasn't unexpected. It's a rite of passage, a bridge all first-year medical students must cross on their way to becoming doctors.
Each August, 174 medical students file into the basement of the Daniel W. Rahn Interprofessional Education Building where they are divided into groups of five and assigned one of the stainless-steel boxes.
They are then introduced to their first patient.
"The purpose of being here is to learn about the human body, how to interact with people and how to treat the human body," Alfankek said. "The excitement for my first day of class was definitely there, but I was also very anxious. I had never interacted with a dead body before."
Each year, about 100 people sign up to donate their body as a whole to science upon their deaths through the UAMS Anatomical Gift Program. Administrators arrange for travel throughout the state as well as 50 miles into bordering states to retrieve the bodies that are usually bequeathed decades before the givers' demise.
From beginning to end, the practice is carried out with reverence and respect. Even the technical term of "cadaver" is forbidden in the UAMS program because it does not convey the totality of the contribution.
"We prefer 'body donors.' It just sounds better, more respectful," said David Davies, an associate professor in the UAMS Department of Neurobiology and Developmental Sciences. "It focuses more on their gift to humanity, to medical science and the training of future health professionals as opposed to the fact that they're just simply deceased."
The donors teach aspiring doctors the intricacies of the human body in a way that plastic models or atlases cannot, Davies said.
"While we're training them in anatomy, they're also learning things that are really not easily testable," he said. "They actually have to train their fingers for tactical sensation in terms of finding structures that they can't easily locate visually. By running their fingers across tissues, they can sometimes identify the nerves or tendons."
DIFFERENCE INSIDE
The biggest surprise for Alfankek was the intricate internal differences between one person and the next, and how the actual body varied from the precise illustrations in her anatomy textbook.
"There are some big variations that don't have any effect, maybe, that you can't tell on the outside, but once you're on the inside, there are a lot of variations among each of the bodies that we have," Alfankek said.
The students are not given any information about their donors, not even their names. But slowly, during the three hours per day for nine weeks that the students spend with them, the donors reveal bits of their life stories.
When the cover to the stainless-steel box is opened for the first time, students make an initial observation of the body -- which can be a jolting experience.
"You're thinking 'I'm going to go in here, and this isn't going to be a problem,'" said Kyle Standiford, president of the UAMS Class of 2021. "Then you uncover it, and you see, 'Well, actually this is a middle-aged female with painted nails and her hair is well-kept.' You think, 'What took someone so young away from the world?' or you think, 'This individual reminds me of my grandfather.'"
The donor for Standiford's group was an elderly male with a pacemaker and signs of a shoulder surgery. He had abdominal bruises that Standiford said he hypothesized were indicative of inpatient blood-thinner injections. The bruising on the patient's backside pointed to a long-term hospitalization. An examination of his lungs suggested pneumonia or lung cancer.
The future doctors get clues to the person's life by callouses on hands, hair that was colored, pieces of anatomy that are missing.
"This was nine weeks of hands-on work, and you get to know every aspect of this person," Alfankek said. "And some stuff definitely reflects the life experiences that they've had. For example, you see a woman who is missing a uterus. You can see that part of her life. I think we get to know them so well on a physical level."
There is no average profile of a body donor, Davies said.
Rich. Poor. Blue-collar. Professional. Male. Female.
"Adults from diverse economic, geographic, occupational and educational backgrounds have recognized that they can make a uniquely valuable and worthwhile contribution to the world they will leave behind sometime," Davies said. "As one might expect, mature adults are more likely to make this type of decision as they age and shift their perspective of life and personal goals."
WHO GIVES?
Celia McCaslin, the program coordinator for the UAMS Anatomical Gift Program in the Department of Neurobiology and Developmental Sciences, said she receives a lot of calls from retired doctors or people who have loved ones like a daughter or son going into the field.
"I tell donors when they call and they've made the choice to do this, that we couldn't run this program without the gracious donors of Arkansas," McCaslin said. "People are thinking of the students."
The contribution goes much further than the five students entrusted with the donor, Standiford said. He estimated that physicians see between 30,000 and 50,000 patients over the course of their careers.
"There are 174 of us, so that's roughly 9 million patients that this class alone will come in contact with. I stress that we're learning from these donors to benefit maybe 50,000 patients off of one donor," Standiford said. "Their life isn't over just because they're deceased. Their life is continuing on and could affect the lives of all of Arkansas possibly."
The donor qualifications are few. They must be at least 18, of sound mind, free of contagious diseases and meet certain physical requirements.
"We have to take the size of our tables into consideration," Davies said. "Basketball players may not be appropriate. They're too tall."
Organ donors -- those contributing specific parts of their bodies like hearts, lungs or livers -- cannot be whole-body donors.
"Concurrent registration in both programs [organ and whole-body donations] likely would result in some confusion at the time of death, and might be a potential source of additional distress for grieving family members," Davies said. "However, donation of one's eyes to the Eye Bank is acceptable and encouraged."
'BODY BROKERS'
Neither the donors nor their loved ones are paid for their service, which is against federal and state law. UAMS does not profit from the program, but does bear the expenses such as transportation, storage, cremation and final disposition.
As spelled out in the state's Anatomical Gift Act, Arkansas is one of the few states in the nation that strictly regulates the donation and disposition of bodies or tissue and prohibits profiting off a body or its parts.
In some states, such as Nevada and Tennessee, "body brokers" rake in millions of dollars by offering free cremation in exchange for bodies that are dissected into different parts and sold on the market by the piece -- usually for medical experiments or training.
The federal government does not monitor whole-body donations in the U.S., and regulations are few. A Reuters investigation published in the fall showed rampant abuse and neglect in the growing industry, making it difficult to "track what becomes of the bodies of donors, let alone ensure that they are handled with dignity."
While UAMS pays for the cremation after the donor's tour of service, the process from inception to final burial is strictly monitored and secured. Respect for the donor's body is stressed every step of the way, Davies said.
"We're very careful about making sure the privacy of the donor is maintained and respected," Davies said. "These are aunts, uncles, grandparents of fellow citizens of Arkansas. We want to make sure the only people that have access to them are the folks who are going to be learning from them."
Once a donor passes, a number is assigned and their identities remain private except to McCaslin.
"We keep everything in locked cabinets. If I'm not in this office, this office suite is kept locked," McCaslin said. "It's very important to us to make sure all of that is secure all the time. That's important information. That's somebody's life."
After the cremation, McCaslin contacts the donor's next of kin which is listed on the paperwork to ask if they would prefer to pick up the remains or have the program bury them in a plot at an Alexander cemetery.
IN MEMORIAM
Letting go is often emotionally difficult for the students.
"We've learned so much about them to just say 'goodbye' one day after your exam, then gather your stuff and leave seems kind of, almost, insulting to this individual who possibly put off the traditional religious aspects of maybe a funeral, or whatever their family may have had planned," Standiford said.
Every winter since 1999, first-year medical students at UAMS hold a private memorial service to express gratitude and to say goodbye to the donors. Students recite poetry, a keynote speaker offers advice and a piece of student-made art is presented for display in a hall gallery outside the anatomy class.
This year's piece, Botanical Heart by medical student Gelina Buslig, consisted of pressed flowers arranged in the shape of an anatomical heart and cast in resin.
The final process, the last day of class was surreal, Alfankek said.
"You close the metal box, and you think you're coming the next day, but you're not. And you get to know the person so intimately and it's hard to just let go so quickly. They were such a big part of our transition into med school," she said. "I actually didn't really fully come to terms with it being over, which was why I was very grateful for the service that we had."
During the service, one member from each of the groups placed a white rose on the stage.
"It was stunning. Really, really beautiful," Alfankek said. "It was closure for us, but also it was a way to honor and show our appreciation for the donors."
Standiford said the magnitude of the donor's gift hit home for him when a pacemaker, thought to be deactivated, kicked on during the silence of an exam.
"You could hear this pacemaker. It really sits in like, 'Somebody lost a grandfather or a father.' What we had done to keep them healthy and alive is still here," Standiford said. "It really hit home that this is not some meaningless process. This was somebody's family member who gave themselves to us to benefit as many people as possible."
A Section on 12/26/2017