Cadavers are vital to any medical student's existence, central, in fact, to the entire field of medicine. Yet, in what may come as a surprise to the uninitiated, the process of ordering cadavers for Virginia's public medical schools used to be highly casual.
Last year, Virginia Commonwealth University received only eight bodies — a mere fraction of the 32 it needs for first-year students taking gross anatomy classes. And now the medical examiner's office is lurching into action, trying to fix a system that for years was sorely in need of organization.
"The program needed some technical attention," says Dr. Leah Bush, the state's chief medical examiner, whose office oversees the Virginia Department of Health's State Anatomical Program. "The ordering was sort of hit-or-miss." Often a medical-school professor would call the examiner's office and leave a message ordering a certain number of bodies for the fall semester; this process worked fairly smoothly, but in 2009, its longtime supervisor fell ill and then retired.
That's when things broke down.
The rest of the cadavers that VCU needed for its gross anatomy class were obtained from Ohio. But Dr. Richard Krieg, who teaches the course, says the university encountered quite a bit of red tape when ordering the bodies. A Virginia health commissioner must give schools permission to bring bodies here from out of state, Bush says.
"It's not like you can drag a body across state lines," she says.
This year, Bush's office instituted a formal ordering form for schools that receive cadavers: Virginia Tech's College of Osteopathic Medicine, state-supported medical schools, graduate programs, dental schools and John Tyler Community College's mortuary-sciences program, where students learn about embalming.
Medical schools statewide conduct their gross anatomy classes in the fall semester. Many begin the class in August or September with dissection, but VCU starts its class with biochemistry and genetics, subjects the new medical students are more familiar with from their undergraduate studies, Krieg says.
If they're lucky, a team of first-year medical students will have a thin cadaver to dissect.
A leaner body allows easier access to the organs. The majority of body donors are elderly; one semester, Krieg calculated the average age of VCU's cadavers at 73.
Bush notes that most donors are older than 60 when they die, although some pass away prematurely. Each year, the number of donated bodies that come through the medical examiner's office varies between 350 and 600. Medical schools reimburse the state $1,500 for each cadaver; the state does not charge schools for delivery. The cost to schools is expected to rise in the next couple of years, however, because of increasing prices for gas and embalming fluids.
VCU students dissect over nine weeks, beginning with the cadaver's back, which allows them to cut with less risk of harming organs they'll later study. Then students work on a shoulder, a breast, an arm, a leg, the lungs, the heart, the abdomen, the pelvis, the genitals and finally the head and neck. VCU's class combines gross anatomy with embryology, a subject learned through lectures rather than dissection.
"There is a force promoting the idea of digital anatomy, and to this point, it hasn't got the advantages dissection supplies," says Krieg, a classically trained physician. He notes that the value of dissecting real bodies is their variability; his cadaver, a thin, older man, had a subclavian artery that took a more circuitous route than textbooks indicated.
"Models are quick and easy," Krieg says. "Dissection requires work."
Students often become attached to their cadavers, which many doctors remember decades later. Krieg's students learn about the people who donated their bodies, where they lived, their occupations and how they died. But because of privacy statutes, their names are not released. Most die of natural causes.
Cecilia Kye, a second-year medical student at VCU, says her cadaver — named "Gertrude" by her group — had "amazing muscles," no gall bladder and no uterus. She and her classmates often went around the lab, looking at other bodies, particularly those of the other gender, to glean more information.
"I remember my cadaver," says Bush, a graduate of then-Medical College of Virginia. "He looked like he was in the prime of life — good musculature, mustache, a little gray hair. Everybody was jealous." Bush shared the body with four other students; Krieg's teams are typically made up of six or seven students.
Some donors are doctors and nurses, although the largest group is made up of "good-hearted people with no medical background," according to Bush, who signed up to donate her body 20 years ago and had two aunts who were donors.
"You know, somebody did me such a favor," she says in explanation. Donors are not paid for volunteering their bodies, although cremation and burial is free. The ashes are returned to the medical schools if the family does not claim them, Bush says. Each November, VCU holds an internment service at Forest Hill Cemetery attended by medical and dental students and relatives of donors.
Kye went to last year's ceremony on a cloudy, drizzly day. "I was surprised how much comfort I drew out of it," she says. "I wouldn't mind going again."
Donors must be 18 or older, and cadavers cannot be used if they're under a certain weight or carry infectious diseases. Virginia's program deals strictly in whole bodies, not parts — which are typically used by private companies that train doctors in new laparoscopic surgery techniques. "We're only geared toward medical schools," Bush says. Tissue or organ donors cannot also donate their bodies to medical schools.
Some states have seen cadaver shortages in recent years, but Virginia has not, says Bush.
Just after a donor has died, the body must be refrigerated and embalmed in a soft cloth, and the coverings must be rehydrated from time to time. The bodies are treated with formaldehyde.
Once the anatomy classes start, the cadavers are not refrigerated but kept in body bags to avoid desiccation, and medical students frequently spray them with preservation fluids.
This sterilized environment is a far cry from 19th-century anatomy classes in Scotland and England, where grave robbers supplied fresh bodies for doctors in training. Between 1827 and 1828, two notorious Irishmen, William Burke and William Hare, smothered 17 people to death, selling their victims to an Edinburgh doctor.
And just six years ago, the University of California at Los Angeles weathered its own cadaver scandal, when two men, including the director of the university's Willed Body Program, were charged with selling almost 500 bodies for parts. Both were convicted.
Virginia has not earned such negative headlines, but Bush notes that there's room for improvement. Her office is working with the state of Maryland, which is at the forefront of long-term embalming technology. And the new process for ordering cadavers is designed to better organize the donation system. Bush and her colleagues also talk to medical students and professors, getting their input.
"We want all donors to get their wish, to help the community," she says.
For information about body donation, visit www.vdh.virginia.gov/stateanatomicalprogram.