In my hand lie the fingers of a dead man, blanched white and icy cold, awaiting my dissection. This morning in gross anatomy lab, we are studying the tissues of the forearm and hand. I have body 1: a man who died 6 months ago. I don't know the cause of his death, but as I examine his body, I see lungs coated black, a heart stitched with blue, fingers clubbed and yellow. I formulate a diagnosis, imagining diaphoresis, Levine's sign, and tombstones. I cut the skin shoulder to hand, revealing a delicate cobweb of tissue and a swath of musculature. I examine the muscle layers of his posterior forearm. I marvel at the multitude of tendons running wrist to hand. When I pull on his abductor pollucis, he gives me the thumbs up and I wonder if he is happy with my work. I hope so. I have found gross anatomy difficult: I held this man's brain, tried to see the soul in the mush, and placed the grey matter in a Ziploc bag. I determined not to forget that moment. He left a legacy that I intend to honor; my brain studying his brain, his right hand in mine, guiding my future practice as a PA.

MORNING

Later that morning, I see tombstones on an ECG. In clinical medicine we are studying cardiology. The instructor is a cardiothoracic PA from a local hospital. He is passionate about his subject: first-degree, second-degree, third-degree block. Wenckebach and Mobitz are my soul mates, helping me decipher the heart's cryptic code. As a class we are learning to trace life. The PA teaches us segment by segment, wave by wave, building our knowledge and future potential: ventricular depolarization is QRS, repolarization is T, and ST elevation with downward concavity creates a frown. I think about body 1: what was his expression? The class continues and the PA starts to quiz us, searching for proof of our knowledge rather than the heart's reflection. The room pulses with energy as we call out the answers to the instructor's questions. No one wants to be pimped—not now, not ever at the end. We learn about dysrhythmias: couplets, salvo, and torsades de pointes. I think of ballet as the points of my ECG calipers skip from P to R and jump the QRS. The dance stops at asystole: we check the leads, the connections, the monitor, the power, and the patient's pulse. CPR begins; we call the code, but it is noon and time has run out.

EARLY AFTERNOON

At 1:10 PM, I watch my preceptor pronounce death. I am on a site visit at a nearby hospital. My plan was to perform a history and physical examination on a patient in the ICU. I was ready to practice my newly acquired skills, but instead I am examining death again. I met my preceptor (an ICU PA) 10 minutes ago; she flew through the doors of the ICU, instructing me to follow her as she had a death to pronounce downstairs and a patient coding upstairs. I ran down the stairs with her, listening as she explained the status of her two patients. When we arrived on the lower floor, she slowed her pace, signaling to me to wait by the entrance of her patient's room.

The room is bright, lit by the midday sun. A man lies propped on pillows in the bed. The etchings of time mark his face; vaults and niches have replaced muscle and fat. Three women stand guard over the patient, anxiously watching and waiting. My preceptor pulls out her stethoscope to auscultate the patient's chest, moving as if she has an infinite amount of time, searching aortic to mitral, listening for tones in a silent heart. I look away for a moment, thinking that this asystole is death run amok; naivety and classroom squashed in favor of a direct line to the ultimate solution. No medicine for this. No hope of curing. The monitor is off, CPR was never started, and I am powerless. I had not considered this possibility when I studied the physical examination of the cardiac and pulmonary systems. Did I miss this section of the checklist?

When I look back, my preceptor nods to the women, confirming that this is indeed the end of life. They crumple. She speaks to them of beginnings and endings, birth, life, and death. The sun shines on. The women cry silently, listening to my preceptor and visibly soothed by the meaning she instills in the moment. One by one, the women approach, thanking her for her work and rewarding her kindness with their hugs, tears, and words of admiration. I watch as a woman strokes the hair and then caresses the face of the body, as women do and will do to infinity. She whispers in his ear, speaking of love, life, and times immemorial. My preceptor moves slowly out of the room, stopping to tuck the blankets up under her patient's chin. I follow her out of the unit. She breaks into a run. We ascend the stairs two at a time. At the top, the phone rings in her pocket. It is the neurosurgeon: no more CPR for the patient upstairs; his brain has collapsed, leaving no structure to examine or lines to trace. This end is precocious, transcending the boundaries set by both medicine and culture. At 30 years old, this man has defied expectations and disintegrated beyond the form of even body 1.

Young death looks quite different. No etchings on this face, just a scattering of pale brown macules across the nose. I see the bulk of the biceps, triceps, and temporalis and then think about the atrophy of bodies 1 and 2. This face is ashen, but the chest moves and the fingers are warm. With eyes half shut, this young man looks as if he is caught between waking and sleeping. The monitor, the power, and the ventilator are still on. A flat line runs across the screen. Shock and surprise govern the experience.

Moments ago, my preceptor had told the family that their son, brother, father had reached the end of his life. She told the mother first, bringing her forward in her wheelchair away from the family group in the waiting area. As she spoke of hypoxia, irreversible brain damage, and asystole, the rest of the family tiptoed forward to listen. They whirled back, their brains in turmoil as they rejected the diagnosis; only to advance again as if wanting, yet not wanting, to know the truth—a danse macabre. My preceptor gathered the family together, ushering them to the patient's room and motioning to me to wait by the door.

Again, I watch death from the wings. The choreography differs slightly: a nurse exits the room, sinks against the wall, and sighs, “I feel so bad for this family.” The patient's sister looks over at me and whispers, “I cannot believe this is happening.” I nod to both. The family fills the room, all standing at least 6 feet from the bed. Eventually, the mother rises from her wheelchair, steps forward, and reaches for her son. Her movements are tremulous; muscles quivering, hands shaking, yet her spirit holds. My preceptor rushes to support her, placing her hand on the mother's arm, guiding her safely towards her son. The rest of the family follows her, forming a body of unity around the man in the bed. My preceptor leaves quietly; stopping to inform me that now it is time for me to meet my patient. It is 3 PM and I feel exhausted.

LATE AFTERNOON

My patient looks tired too. He gives me a weary smile as I walk into the room. My preceptor introduces us, and I start my history and physical exam. I carefully establish my patient's chief complaint and history of presenting illness. Once I have listened to his story, I pull out my stethoscope, listening aortic to mitral, hearing murmurs of the days to come. I think about my patient's 80 pack-year history, wondering if his lungs are already coated black. Fine crackles and expiratory wheezes confirm my suspicion that this man's tissues are already succumbing to disease. I know his story: a virus is destroying his immune system, creating havoc where there was once order and synchrony. His CD4 count is 111, his lungs are awash with PCP, and his heart is failing.

When my patient tires, I settle at the desk in his room and examine his charts. The sun is setting and the day is coming to an end. The room is dimly lit, but I work by the light emanating from the hallway. After a short while, my patient stirs from his sleep and calls me to his bedside. As I stand by him, he reaches his hand out and says, “Alexandra, I am not ready to die.” I pause, stopping to think about the hand of body 1, the face of body 2, and the sudden death of body 3: each human a mystery but each teaching me a little more about medicine and its practice. I look at my patient's monitor and see the QRS hop-skip across the screen. I think about my preceptor—words spoken, hands touched, sheets tidied. I take my patient's outstretched hand, wrap his fingers in mine, and say, “I know.” JAAPA

Acknowledgment: This piece of writing is dedicated to the memory of Lara Rutan, a PA whose kindness, compassion, and generosity brightened the lives of so many.

Alexandra Godfrey is a second-year student in the PA program at Wayne State University, Detroit, Michigan.