Amongst the Angels
Submitted by Kathleen Keane
Tags: birth end of life infants pathology
I deal with parents on the very saddest day of their life. I keep dead babies in my refrigerator. Most hospital employees don't know my job even exists. I work amongst the angels.
I began my job like any normal person begins their job. I filled out an application on the internet and was lucky enough to get an interview at a hospital. It was a nondescript job, I would be working in a small office with two other women. We would be working near the pathology lab. Sounded rather routine and boring to me, but I was new in town and I needed the work. I vaguely remember one woman asking me if I minded working around dead babies. I thought about it for a moment and wondered just how close the dead babies were going to be. She then went on to say that the last person she hired for the job quit because she did not like dealing with the dead babies. I tried to imagine a clerical job involving dead babies, but I had actually never even entertained the idea, nor do most people I guess.
The lab office was situated between the pathologist reading office and the actual lab. The doors leading into the office were the doors from the 1950s with the small black face level windows with the black net material running through the glass. They were a faded brown color and had the metal plate across them which had various fingerprints and scratches etched across them. There was a push here sign right before them, but it was misleading as that particular button did not open the pathology doors but rather the surgery doors which were to the left.
Once passing through the pathology doors, there were more doors to the right wherein three techs and a physician's assistant were at work. The techs basically took the phone calls and requests for other labs who were interested in the tissue slides that we had prepared on different patients. It was a constant inflow and outflow of information. Slides coming in by mail and courier and slides going out for patients generally who were being treated for cancer. Basically, it is pathology's job to receive the tissue cut from a person who had surgery for a suspicious lump or suspicious tissue on a scan from radiology. We receive the tissue in a small plastic container and we cut it into very thin slices so that it can be read by the pathologist as cancer or as clear. That is in essence is pretty much what a pathology lab does.
There are two things you will notice about the lab when you walk in. One is that the floor has that white speckled lineoleum floor that was so groovy in the 60s. You will notice the white doors of the refrigerators. You will also be struck by the smell. It is a smell you will want to run away from because it goes against the human survival instinct. It is a mixture of blood, cut up tissue, xylene, formaldehyde and a few other gasoline-type smells. All in all it does not smell like anything it feels safe to be a part of. We work in it every day and we don't notice it, but my first day on the job the stench was almost unbearable. Besides for the smell, you will notice constant activity like a busy bee hive. Over at the wooden cutting block table you will often see a huge pool of blood with some lump of tissue, most likely a placenta (which looks like a slab of calves liver that you would see at the meat counter) or maybe an ovarian tube. You will hear the constant ringing of the phone and perhaps the deep bellow of "frozen" ringing out as a surgery tech walks in through the swinging doors holding fresh meat in his hands. Frozen means that the tissue has just been retrieved from a patient who may still be in surgery and the surgeon is awaiting the pathologist's verdict as to whether to cut out more tissue or stitch the patient closed. That tissue will be immediately cut and placed raw onto the slide for an immediate reading. I say immediate, but we do our best.
In the very back of the lab there is an old dank refrigerator which is hidden to the left of a room that contains various size jars and containers with tissues and specimens. It could be your grandmother's basement with pickled eggs and preserves, but the jars are bigger and instead of fruits and vegetables contain various body organs. It is a holding place of sorts as we hold tissues for a designated time period and then we dispose of them. In a dumpster. Labeled "biomedical refuse". This can be important, so keep that label in your hat.
Now I mentioned the dank refrigerator. I had been working my nondescript job for a month or so when my handsome pathologist (Dr. H) mentioned that we needed to retrieve fetal demise Anderson to send over to Hospital M for autopsy. I was not sure why I was being beckoned, but as he motioned for me to go with, I set my pen down and walked with him to the back. He grabbed for a pair of disposable gloves and swung open the refrigerator. Inside there were various-sized bright blue plastic-wrapped packages most about the size of a large loaf of bread. I could see that some of them contained white labeling. I stood back because I could imagine only mold, fungi, bacteria, and every other type of funky stuff growing in a petri dish from my university micro class. Dr. H squatted down and reached into the back of the frig and brought out a plastic blue package in his hands. He swung around and placed it on the waist-high brown plastic cart that was parked in a corner. "Okay. Anderson. Let's take a look." I had only seen a few dead bodies in my life at funerals and though I had seen a few fetuses in pickle jars, I had never actually seen a fresh dead small baby. I stood a few feet back and just peered over onto the cart as he unwrapped the blue plastic. The Anderson baby was fully formed but very small and had a peculiar red color to the tissue. The hand was frozen stretched up into the air and the eyes were closed. My eyes blinked as if the site were too painful for my brain to process. But then it was over. "Yep. Anderson". He traced the small plastic band with his finger and then Dr. H closed the blue tissue. "Tell Helena to send it to Hospital M." And that was that.
I am not sure what I was expecting. Dr. H had been tender with the package and had shown the proper respect that the situation demanded. But it still seemed so factual, so non-emotional, so, just another tissue specimen.
That was my introduction to the dead babies that we keep in the dank refrigerator in the back of the lab. And had that been my only contact with these blue packages, I could have kept my distance and viewed them as packages that needed to be identified and shipped out to either a funeral home or Hospital M for further processing. However, there was much more to learn. Much more.
Seated at my desk and preparing to go home for the day, the phone rang. "Pathology" I eeked out, hoping to God it was an easy request and not Hospital H calling to ask for tissue to be retrieved from our off-site storage. I didn't hear anyone on the line. "Pathology" I repeated. Then I heard an odd sound and some shuffling as if someone had dropped the phone. I waited. "Hello"? It was a woman's weak voice. "Hello" I responded. "Is this the lab"? "Yes, it is. The Pathology Lab." I replied, trying to distinguish "the lab" from the other lab, which would be the lab as the general public saw it, the lab where you had blood drawn. "Okay. Well, this is Barbara Slay. I had a baby there last week and they said it was being sent to Hospital M. But I called Hospital M and they did not have her. Can you tell me where my baby is?" That popped the air out of me like a rubber balloon. I leaned back into my chair and thought about the question she had posed to me. "I'm sorry, ma'am, but I did not catch your name. Can you repeat that for me and tell me the baby's name?" my voice slower and with all the compassion I could muster after a very long day. "Well, you are the first person at the hospital to ask me that question. Her name was Cecelia Morris Slay. She was named after my grandmother and mother's side of the family." "What a beautiful name" I offered. "Thank you. No one at the hospital ever asked her name". "Well", I replied, "names are very important, aren't they? Let me go look and see if we still have Cecelia here or if she has already been transferred by Compassionate Care Transport. GIve me one moment." I set the phone down and walked to the back to peer into the darkness of the "fetal demise" frig. I did not see any "Slay" package at first, so I turned around and donned gloves. With my gloved hands I could move the various blue packages around to locate one with the proper "Slay" label. Yes, Slay was still there.
I picked up the phone. "Mrs. Slay, we still have Cecelia here. I will check to see why she has not been sent to Hospital M and let the social workers know. You can call them back in the morning and they can give you a better status. I do not mind giving you the information, but it is really their job to communicate with you and keep you informed of what is going on and where Cecelia is at any given time." This seemed to satisfy her and the call ended.
I made a note on my paperwork that the mother had called requesting status. I was never asked to do this, but coming from a nursing background where if it is not written down it did not happen I documented everything with time/date and my initials.
I was confused about the issue of sending fetal demises for autopsy. Sometimes we would have requests from parents to do an autopsy on a baby that was eight weeks gestation. You can look it up in your anatomy and physiology books, but there is not enough tissue in the very tiny demises or very early demises to do an autopsy. It is basically a clump of cells and there is no way for the pathologist to look at it and tell what went wrong. One day I asked the pathologists exactly how far along a baby would have to be before an autopsy would actually be useful for any reason. Their reply was 18 weeks. I guesstimated that at between 4 and 5 months.
Dealing with the dead babies was much more work than one would think. It would appear on the surface to be pretty cut and dried. A lady has a baby that for whatever reason did not live. The nurse puts identification bands on the arms and ankles and wraps the baby in blue plastic and sends it to pathology. The baby is placed into a refrigerator and then one of four things takes place.
The first thing that can take place is that the parents can designate a funeral home and the funeral home can be called and they will send a person out to pick up the baby. This can be interesting for a few reasons. The first reason is that sometimes it is a question of the parents being able to pay the funeral home. Generally the parents were not expecting to lose their baby and certainly not thinking about paying a funeral home. Depending on what type of funeral they want it can be expensive. Anything is expensive when you are living paycheck-to-paycheck and have the misfortune of losing a baby and having to pay a funeral home a substantial down payment before they will retrieve the baby from Pathology. Some parents or grandparents will ask many questions to me trying to determine the cheapest route to getting the baby from the hospital to the funeral home for burial or cremation. Sometimes they will ask if they can pick up the baby directly from the hospital (no, they cannot). The hospital policy is that we release the baby either to a funeral home or transport to another hospital. Period. The reason they ask if they can pick up the baby themselves is that they have to pay the funeral home expenses for picking up the baby and sometimes they may live in a rural area which is many miles from the hospital and thus the expense of mileage comes into play.
The second thing that can happen to the fetal demise is that it can be transported to a different hospital for autopsy. The reason most parents ask for an autopsy is that somewhere in the baby's development something went wrong. It can be many things, but the thing I noted most was a nuchal cord around the neck. Unfortunately I noticed that this happens most of the time at full term and sometimes even the day before the baby was scheduled for c-section or would have delivered. There is not a lot of room for the baby to move around towards the end of the pregnancy in the uterus and the umbilical cord somehow gets wrapped around the neck and the baby turns wrong and strangles with a cord wrapped around its neck. Many babies go for autopsy because of this and many fetuses go for autopsy because the maternal doctor and parents want to know if there was something wrong with the baby that could possibly be wrong with their next pregnancy.
The third option for the fetal demise is that the baby can be picked up by the nurse and brought back to the floor for the mother and family to visit with the baby for the last time. This does happen and there have been times when the nurse did not sign the baby out or at least leave a note that the infant had been retrieved to be taken back to the mother. I began a process of checking on the babies each morning to see if I had any new arrivals which lacked the necessary documentation. It was a shock to see blue plastic still in the refrigerator with no infant inside. At that point calls had to be made to the nursing supervisor and to the floor to see if perhaps the infant was with mom. When you are responsible for being sure of the location of the infants you are charged with this can be frankly scary. Nurses cannot know all the rules and regulations and when you are dealing with mothers who are in a fragile state mistakes can be made. This one happened too frequently.
The fourth option is my not-too-nice option. Some fetal demises are kept for medical disposal. This means that after a certain period of time the parents have elected that the hospital dispose of the fetus. So in a nutshell the baby is put into the medical waste container and carted off with other tissue and biohazards.
So that is basically the processes, aside from the paperwork, of what happens to a fetal demise after birth or delivery.
There are many things to be learned in dealing with fetal demises and I will reflect on those things. The first thing I learned is how easy it is to slip into a mental state that they are no longer precious million-dollar babies, but rather tissue that has to be dealt with properly. In order to get through our days and do our jobs properly we develop a thick skin you may call it so that we can properly index and transport these babies to their ultimate destination. We have to have rules and regulations to protect the parents of these children from further emotional upheaval. Therefore we have written documentation such as logs and state paperwork that tells us what the doctors and parents have elected as far as what will happen to the babies. There are also regulations in place as to how the funeral homes will deal with the infants at transfer. We ask that the funeral homes go through a certain gate and require that security escorts them to pathology. Even though we specifically mention this when we call the funeral homes, some funeral homes have old-timers who have dealt with the hospital for years and who still think that they can do it their way. They will just show up unannounced from a phone call that the parents made and demand to pick up infant X. This means that I have to fast-track my paperwork process and first locate the infant and then prepare the infant to be transported. The other problem with funeral homes is that some operate on a tight budget apparently and will show up to retrieve one of my infants with a ziplock bag for transport. Yes. This is rare, but it does happen. After seeing the ziplock bag funeral home guy, I began to specify when I called the funeral home for transport that they would bring an appropriate carrying bag to transport the infant out of the pathology lab and into their funeral home car. Most funeral homes have an appropriate leather body transport bag that looks like a rather large bowling bag for lack of description. The nicest one that I noticed was a large leather satchel which looked like a doctor's bag. However, it had clasps that opened from the top and inside you could see a soft pink blanket and a pink pillow for the infant's head. This told me a lot about the compassion and care of the that particular funeral home. I always wondered what would happen to the ziplock funeral home guy if an accident happened and somehow the ziplock bag got separated from the funeral home guy. It made me shudder to think about it.
Another thing I learned while I was in charge of the dead babies was that once a baby leaves Pathology the mother in theory will not get to hold the baby again. When I first started working with the dead babies I was under the impression that the faster I got the baby to the funeral home the faster the mother and family could be reunited and she could hold her infant and perhaps rock the infant in a wooden rocking chair and process the loss and mourn. This is what I would want to do . However, I was wrong. The time for holding the baby is in the hospital. Once the baby leaves the hospital the funeral home under mortuary law is not to allow close contact because of contamination issues. This may be a state-by-state law, but there is a whole body of law designated "mortuary law" and the issue of physical contact with corpses falls under that body of law. So in esssence the time to dress the baby and rock the baby is in the hospital room and not at the funeral home.
Most of the time when I would check the baby's identification to facilitate transport to either another hospital or to a funeral home I would find simply a naked body with name bands on either the feet or tiny hands. Yet sometimes there would be other items such as IV lines or tubes still in. Some babies would be dressed. It made me sad to think that they were dressed in the very outfits that they were meant to be taken home in. Some babies would have a stuffed bear or items wrapped with them. I felt that these items were sacred and made sure that everything that came in to Pathology with the baby traveled with them when they left my care. I still remember chasing down the funeral home representative with a tiny lamb in my hand and including it for transport in his leather bag with the infant. I still recall the surprise of seeing an infant dressed in a tiny white silk suit and silk shoes I witnessed when I peeled back those blue plastic sheets to properly ID them.
Different types of mourning that I witnessed were very interesting to me along with the different cultures and their ways of dealing with death. My conversations with the social workers were compelling. One of the issues was the process of grief. In the process of retrieving the appropriate paperwork there were times when the parents could not or would not sign off on paperwork. I would email the appropriate social worker asking for the state paperwork on baby A which basically consisted of consents for autopsy or designation of a funeral home or both. After a few emails I would get a phone call with a response. On one infant the response from the social worker was that the parents did not and would not sign paperwork because they could not accept the baby's death. It was interesting to me also that it seemed to me that the mothers did accept fully that the baby had passed away perhaps because they had carried the baby and felt the movement each day and then accepted that the baby was no longer moving. It was the father's reaction to infant death that was more surprising to me. Many fathers tended to completely deny that it happened at all. I recalled going up in the elevator one morning with a new father. I begin to recognize the new-father look by a few designated signs. They all seemed to look the same, with the been-up-all-night fatigue on their faces and various items in their arms and hands. They had shifted into the staying at the hospital routine. This particular father had slits for eyes, a puffy face, unkempt hair and a particularly-haggard appearance. To my "Good morning" he simply nodded. I noted the security tag on his chest with the name "Agarwal." I bounded off the elevator and used my elbow to swing open the door and into my office I went to grab an already-ringing telephone. Once I had handled that call, I cruised on in to the back of the Pathology lab. As I did my routine of checking on my babies I stopped and bit my lip. There I noticed a new tag with "Agarwal" on it. Oh no. I recalled the face of the unkempt young father huddled inside the elevator earlier. Indeed he had most likely been up for days. I wanted to reassure him that his infant's soul was with the angels and his body would rest with me just until I could get it on its way as soon as I possibly could. Some things don't make any sense.
Another thing that was of particular interest to me was the fact that in some cultures a huge funeral was held when a baby demised at even six or eight weeks. There was a scale from one to ten. One was that the mother miscarried and the tissue was sent to pathology and held for the appropriate number of days and discarded into medical waste. On the end of that scale was the full funeral for a tiny clump of tissue no bigger than a fingernail. Same fact. Hugely different interpretations. Humans are funny that way.
But I think the hardest thing I learned in Pathology was this. Different cultures grieve in different manners. And there is a culture that does not allow any grief whatsoever. None. One day I received the paperwork for a particular fetal demise and noticed something crossed out and something added and some initials. It was checked that the baby was to be disposed of by cremation and had the number of a crematory filled in. I went to the back to be sure I indeed had the infant and I did. So I returned to my desk to phone the crematorium. When the representative answered he replied that he had not been able to contact the parents to come in and have them sign the paperwork that they would not be picking up the cremated remains. It took me a moment to understand what he was saying, so I asked him to repeat that. "Yes, I said that" he replied. "There are some people who want to drop off the bodies for cremation and will not be picking up the ashes. At all. Ever." That was a shock to me. When I finished the call with the crematorium, I phoned the social worker who was responsible for that infant and explained what the crematorium employee had said to me about NOT picking up the remains. The social worker's reply was even more shocking and sad to me than the crematorium clerk's explanation. She replied that in some cultures when a mother miscarries a child it is deemed that there is something wrong with the mother, not with the child. And in that culture, it is a huge deal if a mother cannot properly care for her unborn child to the point where the child leaves her body prematurely and dies. Thus in that culture when a child is stillborn or dies in the womb the body is whisked away to be disposed of and the infant is never allowed to be mentioned again by anyone thus ensuring that the mother will be allowed to remain active in their culture and not ostracized for being unfit. I closed my eyes and stood still for a moment imagining the grief that the mother had to have felt and then the worry that someone may discover her secret and to add to the grief she would then be ostracized from her husband and culture. Not being able to grieve and have the support of relatives and friends after losing a child, it seemed unbearable and unfair. What people do to other people in the name of customs and culture can be devastating.
Most women enter the hospital and leave with wonderful pictures and memories. Their infant bundled tightly in their arms and their vehicles await them to whisk them away to the sleepless nights as the parent of an infant which all too soon turn into the sleepless nights of the parent of a teenager. But there are those few mothers who are wheeled to their vehicles whose arms are empty and whose infant spirits reside in the arms of the angels and whose bodies rest in Pathology awaiting their final destination. It is my job to receive these infants and let them rest until they are transported. I work amongst the angels.