| A Medical Program With A Human Touch | ||||||||
| By Ye Wen-ying Compiled and translated by Tang Yau-yang Photos by Hsiao Yiu-hwa | ||||||||
“Behind every donated corpse is the concern and care of many loved ones. We mustn’t allow anything to go wrong or else we’ll let many people down,” said Tseng Guo-Fang, director of the Tzu Chi University Medical Simulation Center. He and center staff do their best to make the simulated surgery program at the university run as smoothly as possible. Tseng Guo-Fang, Ph.D., a professor of anatomy, leads the Tzu Chi University Medical Simulation Center. The center, which is Tseng’s brainchild, uses frozen cadavers for medical students and surgeons to learn and practice surgical techniques and skills. Tseng didn’t start out as an expert in the art of cold storage of human bodies. He knew that cadavers were frozen for future clinical exploration by physicians outside Taiwan, but there is more to freezing bodies than simply putting them in a freezer. How do you freeze a body so that it remains soft and supple after being thawed? He began his research by studying anything that might expand his knowledge base related to the field. He knew that the structure of things containing moisture can be significantly altered when they are frozen and later thawed. Vegetables, for example, become dehydrated and wilted after being stored in a refrigerator for some time. Tofu becomes porous when frozen and thawed. But these are relatively simple items. He needed to dig deeper. Based on his research, he explained the pores in frozen tofu. When tofu freezes slowly in a freezer, some of the water in it first solidifies into small ice crystals. These crystals are slightly colder than the surrounding water, which causes another layer of liquid water to freeze on the surfaces of the seed crystals. This incremental freezing continues, and the ice crystals in the tofu grow increasingly larger for as long as there is liquid water in the tofu. When the frozen tofu is thawed, the ice particles melt and flow from the place they once occupied, leaving empty spaces—pores—in the tofu. The larger the frozen particles, the larger the pores they leave behind. Tseng pointed out that a human body is 70 percent water, so slow freezing a human body would result in pores in the tissues after thawing, just like tofu. Such porous cadavers exude fluid and are not as supple as the original bodies, so they are not good for use in learning and practicing surgical techniques. “Rapid freezing, on the other hand, produces frozen particles so small that they are visible only under a microscope,” Tseng continued to explain. “When thawed, these minuscule particles leave only minuscule pores, rendering the body closer to what it was like when alive. Cadavers that are frozen quickly are suitable for simulated surgery after being thawed.” Tseng said that corpses are most ideal for use in simulated surgery if they are delivered to the Department of Anatomy at Tzu Chi University for processing within eight hours of death. Such corpses can then be rapidly frozen and kept at -30 degrees Celsius (-22 degrees Fahrenheit). However, there is more to keeping corpses at that constant temperature than meets the eye. A power outage, a tripped circuit breaker, or an equipment malfunction could interrupt the operation of the freezer, causing the freezer temperature to change. Tseng has bent over backwards to avoid such incidents. A change in freezer temperature may render the cadavers unsuitable for use in a simulated operation. “Behind every donated corpse is the concern and care of many loved ones. We mustn’t allow anything to go wrong or else we’ll let many people down,” Tseng explained. To that end, Tseng places small temperature probes inside the donated corpses and monitors freezer temperature closely. Whenever a temperature deviation is detected, whether on a workday or holiday, the system triggers an emergency notification mechanism that alerts the security guards and sends a message to the cell phones of two cadaver handlers.
Details, details Tseng and his team do everything they can to ensure that each frozen cadaver is in the best condition possible for use in training. Attentive care and special handling have made the human cadavers at the center a cut above those at other institutions. For example, freezing eyeballs require extra care. Because eyeballs contain water, they expand when frozen, and this expansion pushes the crystalline lens in the eyeballs out of place. Therefore, eyeballs require special handling before they can be used in simulated surgery. Laparoscopic surgeries are often simulated at the Medical Simulation Center. These are operations performed in the abdomen or pelvis through small incisions with the help of a camera. Some of these laparoscopic surgeries require air to be injected into the abdominal cavity—like blowing air into a balloon—so as to create enough space inside for the surgeon to conduct the surgery. If the skin of the cadaver is insufficiently elastic, the injection of air and increased pressure may cause the skin to crack, which results in deflating the abdominal cavity and hampering the procedure. Thanks to the efforts and body preservation skills of Tseng’s team, such deflation has never occurred at the center. Hsieh Mon-Hsian, a surgeon from National Taiwan University Hospital, has taken part in simulated surgery at the Medical Simulation Center. He has also participated in body dissections elsewhere, using imported bodies. Those bodies lasted only one day, compared to four days for corpses from the Medical Simulation Center. Once they even found that the side of an imported head had collapsed because the head had been placed on one side during the long transit to Taiwan. “Those corpses were clearly inferior to those used at Tzu Chi University,” Hsieh said. He affirmed that, of all the places he knew about, Tzu Chi does the best job in cadaver preservation.
Transparency Tzu Chi has advocated body donation for medical education for more than 20 years. Many people have donated their bodies in response, leading to an adequate supply of cadavers for use in anatomy classes and simulated surgeries at Tzu Chi University. Corpses donated to the university are treated with the utmost reverence. Tzu Chi handles donated bodies with respect, keeping in mind how family members might feel if they witness how their loved one, the body donor, is treated after being delivered to Tzu Chi. Because the silent mentors are treated with such care, a donor family can inspect the body donation program at any stage, from the moment the body of their loved one is delivered to Tzu Chi, to how it is stored, to when the body is inaugurated for use. Once delivered to the Department of Anatomy at Tzu Chi University, a body is processed according to whether it will be used in anatomy class or simulated surgery. For use in anatomy class, corpses are injected intravenously with preservatives, as opposed to being soaked in formalin for preservation. For simulated surgery, corpses are rapidly frozen as described earlier. Eight simulated surgery sessions a year are conducted at the Medical Simulation Center, with each session lasting four days. A ceremony is held to inaugurate the bodies for use before the beginning of each session. Each time, Tseng explains to families of the silent mentors before the inauguration ceremony how things will unfold in the simulated surgery session, much as a surgeon talks to his patient and family before surgery. “We are transparent enough for families to supervise us directly,” Tseng said. Tseng makes a point of explaining to families the extent of cutting that the bodies will undergo. “The cutting will be more thorough than in a typical anatomy class for a third-year medical student,” he says. He explains why this is necessary: “Thanks to your loved ones, physicians and medical students can learn and become more experienced with surgical techniques. They won’t need to practice on living patients to gain experience, and so they will minimize the potential damage that they may cause their patients in the future.” Family involvement To the students and physicians who use the cadavers donated to Tzu Chi, the corpses are not nameless objects. Instead, they are revered as “silent mentors.” In fact, participating students and physicians even visit the silent mentors’ families to learn more about the donors themselves, and they compose brief biographies about them. These actions connect students and physicians with their silent mentors, and inspired respect and gratitude when they practice on them. Such visits also make family members feel that they and their deceased loved ones are valued and respected. Li Hui Er (李慧兒), a medical student from the National University of Singapore, took part in a simulated surgery class at Tzu Chi University. She said, “In Singapore, we don’t know anything about the corpses we work on. As a result, we have no feelings for them. But here at Tzu Chi University, we meet the donors’ families before working on the silent mentors. The families even thank us and ask us to make the best use of this opportunity to learn from their loved ones. They hope we can become better doctors by practicing on their loved ones.” Li was also impressed by how much everyone involved—medical students, physicians, Tzu Chi volunteers, and staff at the Medical Simulation Center—respect silent mentors and their families. Yu Liang Lim (林宇亮) was another medical student from the National University of Singapore. He was awed by the fact that body donors are willing to give away their bodies and allow them to be dissected and practiced on by utter strangers, learners like Lin and himself, in the hope of advancing their surgical skills. “I may forget some of the surgical techniques I learned here if I don’t use them for a long time,” Lim said. “But I’ll never forget the selfless giving shown by the body donors and their families.”
The center In the early days, there used to be just two corpse handlers and a staffer in charge of funeral and memorial services for body donors at the Department of Anatomy at Tzu Chi University. After the simulated surgery program was launched, two senior nurses from the operating room of Hualien Tzu Chi Hospital—Lin Zi-ling (林姿伶) and Ou Ting-fang (歐庭芳)—were recruited to help the program run more smoothly. They were experienced professionals, intimately familiar with running an operating room. Their experience would come in very handy for the program. Cadavers are used as fully as possible in the program. Therefore, each cadaver is usually operated on by participants from different medical specialties, each working on their respective area of the body. Lin and Ou schedule and arrange the order of simulated operations by specialties and according to the body parts to be worked on so that the surgery sessions run better. “Treat silent mentors like living patients in every way,” Lin reminds medical students who are about to start a simulated surgery course. “Pay attention to patient positioning on the operating table. If the surgery is lengthy, take special care to avoid damaging the corpse from extended compression.” She adds that if the corpse is laid on its side, care must be taken that it doesn’t fall off the table, even though the silent mentor won’t cry out in pain if it does drop to the floor. Before trying their hand at simulated surgery, these students have had no prior experience in an operating room, so Lin, like a mother, patiently talks to them about things to pay attention to. Surgeons who take part in simulated surgery at the Medical Simulation Center are also reminded, among other things, to suture all parts of a cadaver back together at the end of a session so the silent mentor is kept whole. Suturing a cadaver together is another gesture of respect for the silent mentor. The center currently has a staff of eight working under Tseng. They take care of everything during a simulated surgery session, such as organizing food and lodging for the families of body donors, filming the surgeries, and arranging hearses for the silent mentors. They also edit video footage to be shown at the memorial service, which is attended by participating students, physicians, and donors’ families. The staffers also clean up the operating room during recess. Cleaning duties outside of the surgery sessions are outsourced to cleaning companies. Tseng praised his team: “Were it not for their willingness to cover for each other in doing all the things that have to be done, we could not have such a strong team. Our staffers are inspired by the spirit of giving that is demonstrated by the body donors, so they do their very best in doing their jobs.” Tseng also thanked nuns from the Jing Si Abode and Tzu Chi volunteers for helping out. “We couldn’t have done it time and again without their support,“ said a grateful Tseng. ● The Medical Simulation Center offers a valuable service unavailable in many other institutions around the world. Participating learners include medical students and physicians within or without the Tzu Chi medical system, from Taiwan and other countries. Tseng points out that many doctors in other countries may not have access to the type of training offered at the center, or they may not be able to afford it. That’s why they come to benefit from the center’s service. But he believes that what is offered here surpasses mere technical training. The human touch of the program, for example, provides an experience completely different from what a physician goes through in their dissection courses when they are training as doctors. “Although a doctor may appreciate the meaning and value of life,” said Tseng, “it’s not uncommon for them to become burnt out after practicing for a long time. But when he experiences how much human lives are respected here at the center, it might touch a chord in him and trigger a change, [helping him rediscover his original aspirations].” Altruism is at the core of the Medical Simulation Center, Tseng added. “Through June 2018, 80 percent of our body donors were Tzu Chi volunteers. They gave of themselves to the service of others when they were alive, and when they passed on, they gave their bodies to the service of medical education.” He lauded the spirit of these silent mentors. Because of them, the center is not simply a place for medical learning but also a place where acts of love and altruism unfold. Dr. Diderot Parreira is a Brazilian physician who took part in simulated surgery at the center in August 2016. He resonated with the spirit of giving of the silent mentors so much that he donated money to the center. He said that he was even willing to volunteer at free clinics that Tzu Chi offers in Brazil. Dr. Christian Dinu, from Klinikum Oldenburg, Lower Saxony, Germany, served as a course instructor at the center in April 2017. Moved by the spirit of the silent mentors, he also donated the fees that he had received for his instruction to the center. Such a cycle of goodness is exactly what Tseng hopes to see.
SILENT MENTORS A cadaver that is slated to be used for an anatomy class needs to be delivered to Tzu Chi Univer-sity within 24 hours of death. Bodies donated first are used first. Generally, they will be used within four years after donation. Each corpse is used for one semester and is then cremated. To be used for simulated surgery, a body needs to be delivered to Tzu Chi University within eight hours of death. Like bodies used in anatomy classes, those donated first are used first. Generally, they will be used the year following donation. Each corpse will be used for four days—the duration of a simulated surgery session at the Medical Simulation Center—and be cremated on the fifth day. The anatomy class is for third-year medical students. The simulated surgery program is for sixth- and seventh-year medical students and surgeons. Of the eight simulated surgery sessions held at the Medical Simulation Center every year, four are for medical students and four for surgeons.
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