I recently marked my 23rd year of presenting at the Dodge Sunshine Seminars.  It has been a long and eventual relationship, and one that I am honored to write about today.

My first seminar for Dodge was held at the Sheraton Waikiki Hotel in Honolulu.  I was scared to death.  In fact I was so nervous that I blurted out the name of an embalming chemical in the middle of my talk that was manufactured by a chemical company other than Dodge.  The minute I blurted out the name of the “competing” embalming chemical I thought to myself “Well Todd, you dunce, you have done it again, so kiss off another invitation from Dodge.”  My fears, at the time, were only strengthened when Jake Dodge said absolutely nothing to me concerning my seminar presentation after it was over.  Jake said nothing, not one word.  I remember getting on the plane and thinking “Todd your family has been right all along, you are the ‘black sheep’ no question about it.”

One year later Jake Dodge called me and invited me back, and the rest, as they say, has been history, and what a marvelous history is has turned out to be. (I had to learn that not saying much was one of Jake Dodge’s character hallmarks.)

Over the past three decades it has been my experience, my fortunate experience, to have worked closely and at times at a far distance, with most every funeral/cemetery connected organization out in this big wide world.  The truth is that I have enjoyed almost all of my associations.   Of course not all of them have been a “love fest,” for some of the experiences have been a labor, in fact it would be better described as a “ill fated labor” which ended in hurt feelings, damaged egos, and the taking of the firm TVB oath that “I will never cross their paths again.”  Yes, this stuff has happened, but after giving seminars for over 35 years, to over tens of thousands of funeral professionals, clergy, hospice workers, cemeterians, mortuary science students, well this list goes on and on I have concluded that I just can’t be all things to all people, and people in turn can’t be all things to me.  You win some, you lose some, it is just the way of it – don’t you agree?

However, the truth is these unfortunate experiences that I have just described are far and away in the minority of my experiences.  Without question, the last 35 years have been filled with rich and meaningful work and associations, with countless people in our grand profession who really are great, decent and just kindhearted human beings, and nowhere in my myriad of speaking experiences have I found this to be more true and self-evident than when I work with a Dodge Seminar.

I would like to share some observations concerning the substance and literal panache of a Dodge meeting.  First and foremost, in my humble opinion, is that the history of the Dodge Company, both past and present, is a continuum of a genuine, literal, in-depth love of the funeral service profession.  I always felt that the generations of the Dodges since 1893, when the company was founded, well, they just seem to grasp the DNA of embalming and hence funeral service.

I found also that the Dodges were quiet people who have and had keen insights and were able in turn to discern the quality and content of the presentations that were given at the Sunshine and other seminars.  No formal evaluations were made, but most often it was clear enough which speakers hit the home run and which speakers flopped, simply based on whether you ever saw this or that speaker ever again.  Nothing was ever said, but the message was clear as a ringing bell and it depended upon the return invitation.

I remember very well one particular speaker – giving the location of the seminar is too risky, but here is what happened.  This person had presented themselves as a “grief expert.”  I have only known a couple of people who truly ranked in the realm of deserving the title “grief expert” and this speaker quickly taught the group that they were NOT a member of this exclusive club.  As my memory serves, this particular seminar started out in good order, but then the speaker shifted gears and started talking about taking care of a family who had experienced the tragic death of a loved one and the deceased had been severely mutilated in an industrial accident.  In a word, the dead body was literally in pieces.  This “grief expert” strongly suggested that in order for the bereaved family to “establish the reality of death” that the funeral director lay out a water proof canvas on the floor of a room in the funeral home, then set out the various pieces of the deceased person, and then have the family come in and look at the scene.  The “grief expert” in conclusion suggested that funeral professionals have the bereaved family “sit down Indian style so when they faint they won’t have so far to fall.”  I damned near fainted as well!

I was sitting in the back of the room when this happened.  The crowd was stunned into silence.  It is the only time I saw Jake Dodge’s expression change.  We never ever saw the “grief expert” ever again, anywhere.  The message was as clear as a ringing bell.

The Dodges have been risk-takers to be sure, but they have also been very savvy and insightful to be careful, prudent and cautious about what is put in print, what is said in their Sunshine and other seminars.  It appears clear to me after all these years that they just have the funeral knack, they always have had it, and it is clear to me that they still possess that greatly appreciated skill.

A couple of weeks ago I made another presentation in Maui at the 2011 Dodge Sunshine Seminar.  Of course over the passing of two decades the audience has changed.  Some of the old-time regulars are simply not with us anymore, and thankfully an entirely new group is attending which adds a fresh dimension to all of the proceedings.

The group in Maui once again reaffirmed my belief in and love for our great profession.  For the first time I moved from my historic ancient caveman approach and I actually used a PowerPoint presentation which I have to finally admit is much easier to maneuver than my old ancient Kodak slide trays which I lugged around on planes, trains and automobiles for a hundred years.

In this 2011 seminar I spoke of several themes.  They included a definition of success, an examination into a fascinating arena of thought which is called “Acres of Diamonds,” and of all things I included Newton’s physical laws of nature into the session.  It seemed things went well, and I finished up with sharing my new service concept which is called “Create Don’t Compete.”

While I was presenting I really was thinking and then publicly I shared in this 2011 seminar that the Dodge Company was a stellar example of just what I was talking about.  Their rich history is, in reality, in my humble opinion, a history of not competing, but is instead a history of creativity, which in the end is always much more influential and long-lasting.

As my sainted grandmother always used to say, “The proof is in the pudding.”  I actually never had any idea, and never understood, and still don’t really know what possible proof of anything can be discovered by looking into pudding, but it is of no matter, because everybody, I think, understands what that strange phrase really means: Just look at the results, and no question the results of the Dodge Company have been mighty impressive.

The Dodge Sunshine Seminars have been one of the fortunate experiences in my career.  In fact I knew that the Sunshine Seminars were of high quality many years before I was honored to be invited to be a part of them.  I knew this reality while reading about them in the old De-Ce-Co magazine while I was washing cars, delivering folding chairs and sweeping up the parking lot at the old Heafey & Heafey Mortuary on Farnam Street in Omaha.  Even a young funeral director wannabe could see the “proof in the pudding.”

Anyway that is one old undertaker’s opinion.
TVB 

This week I received a message from a former student of mine who today is a success in our profession (no thanks to me having been his professor). His message caught my attention and once again I sat in my office asking myself questions about the state of the state of this great profession.

Here is the situation my former student encountered.  In one week two former casket company sales representatives and executives from two separate casket companies died and my former student received the call to serve both families.  I gleaned from his message that these two men had worked in the casket world for decades, and between the two many decades of work had taken place, and I was of the thinking that thousands of casket had been sold to funeral directors who in turn sold them to bereaved families.

Both casket representatives were immediately cremated.  No casket, no embalming, no flowers, and no nothing save for the incineration of the dead human remains, and an instruction from the descendents of both families concerning the disposition of the cremated remains.  There you have it in a nutshell, and this made me start thinking.

I have the firm conviction that it is anyone’s absolute right to choose what they want.  No question, I mean this is American – freedom reigns supreme.  The funeral profession and cemetery activities will not fold up because two former casket sales reps, or someone else for that matter, decided to do what anybody finally decides to do.  Options and alternatives are quite popular in our society today and the insightful funeral profession offers scads of options and alternative.  This decision concerning the two casket representatives is not the end of the world.  There are many more important issues confronting the human experience than what happened to two casket reps who sold caskets thousands of times.

However this situation just started my brain thinking again about the state of the state of this world of death that we all live in.  Here are some unanswered questions that I have, and as I always like to learn stuff about my profession, so I openly ask for anybody reading this to jump in the deep end of the pool and educate this old fat grumpy undertaker as to why these things continue to go on.   Remember these questions come from Todd, so don’t expect too much sophistication.

Here are some questions:

1.  Why would someone who has sold caskets for decades to hundreds of funeral directors upon their own death would not utilize a casket? 

2.  Why would a funeral director, who has conducted hundreds and in some cases thousands of funerals in their career, upon their own death not have a funeral?  I remember several times in my own limited career that some mighty prominent funeral directors died and nothing was done.  No ritual, no ceremony, nothing.  Why?  Does this not strike anyone else out there funeral land as something to question?  When a funeral director does not have a funeral for themselves what kind of a message is sent to the community that they have served faithfully for years?  Is it not an oxymoron, the funeral director might just not like funerals?

3.   Why it is less expensive to cremate a dead human body than to dig a grave usually? Crematories require thousands and thousands of dollars of equipment and facility investments, and cremation requires certifications, training and expensive on-going maintenance,  and has significant liability and is a time consuming procedure, and then the post cremation activities are involved and requires meticulous attention to detail, but yet to dig a hole in the ground with a mechanical digger, which takes much less time than to cremate, and if the grave, God forbid, is dug in the wrong place the error can be quickly corrected (an error in cremation cannot be corrected), and there seems to be no certification and formal training to dig a grave, so why does this cost more money than to cremate?, And if you die and want a burial on a week-end the cost can be ten times what a cremation costs to accomplish.   So here is my question: why is digging a grave so much more expensive than cremating a dead body?

4.   Why is it that embalming a dead human body is cheaper than digging a grave?  A dead human body was alive, lived life, and influenced others.  In some religions the human body is sacred.   Learning the art and science of embalming is not a snap.  It takes time, several years of college education, mentorship, internships, study, examinations (tons of them) skill, knowledge and expertise.  Embalming a dead human body appears to me to be ten times more intricate and requires ten times more skill and knowledge than it does to dig a hole in the ground, no matter how important that grave might be.  Why is this?

These are four questions that just baffle me, and I ask for and am extending the right arm of fellowship to any reader that can help me fill in the blanks concerning this stuff.  I am obviously missing something here, but then missing stuff happens to me all the time.

I am asking for insight, for education, for your thoughts out there in the funeral/cemetery world, and please don’t give a thought if your answers establish that the person (me) who generated these questions is not the sharpest knife in the drawer, many people have concluded that fact years ago.  Your thoughts, honest candid thoughts, are welcomed, and at my stage of life and career, well, folks, when you have been shot with seventeen arrows the eighteenth one does not hurt very much.  I hope to hear from many of you good folks.

TVB

As I have gotten older I have discovered that in my beloved profession there seem to be some taboo subjects, some baffling issues which have dodged honest dialogue for years.

Can we make a quick list?  The issue of too many funeral homes is out there floating around; the issue of universal licensing has been out there floating around for a century – no solution; the issue of funeral service organizational fracturing is still floating around; the issue of cremation is still floating around. Well is just seems that there are a lot of issues, ancient issues, still floating around.  

However we have survived for years with these issues unresolved and I suspect we will survive for many years to come without any final resolution.  Can’t worry about things you can’t change.

When I do my travels, speaking, learning and talking with other professionals in the cemetery and funeral professions, one glaring issue seems to pop up its ugly head time after time but interestingly I have seen really nothing written per se about it, nor have I seen any seminars devoted to the topic, nor have I seen any study groups formed to address this issue and hence discover solutions. Hauntingly I have come to the conclusion that this one single issue might just be the number one challenge that our beloved profession is already facing – but facing in a cone of silence.

What is this monumental, all consuming, earth shattering issue you ask? Well here it is in a nutshell:  The unmistakable movement of our American culture from being body centered when a death occurs to being experience centered when a death occurs, and not in some isolated incidences, but today with a widening, ever-larger acceptance than ever before in death care history.

With all the talk and activities concerning catering funerals, memorial services at the shore and now green burials, the issue which has propelled these alternatives breaks down to one simple change – instead of being body-centered, many, many, many are embracing being experience centered.  

The consequences of this shift in funeral attitudes and values have been are profound.  Along with this shift, the “C” word, the corpse, has almost taken on pornographic proportions.  The word “corpse” upsets people, but that has not always been the case and we don’t have to return to ancient Egyptian funeral history to see this fact.

Let’s talk the old days for a moment.  There was a time, a not too distant past, when the dead body was at the epicenter of funeral activities.  Equal to the corpse was certainly the bereaved family but the dead body was right up there at the top also.  They seemed unquestionably to go hand in hand.

I remember, and am well aware this still happens today, that we literally spent hours upon hours restoring and beautifying dead people, and we were convinced (and I believe rightfully so) that a major part of the funeral homes reputation centered precisely on our abilities at color and cosmetics, embalming and restorative art.  This still happens, but I am going to make the proposition that it does not happen on the grand scale that it did just a few years ago.

During these years the funeral home had the ability – nay the duty – to tell families not to schedule any funeral times and/or activities until we knew when the dead body would be presentable for private and later public viewing.  It was a matter of course, it was matter of procedure, it was just the way things were done, and few if any questioned the practice.

Have things changed concerning the community's relationship with their dead?  It certainly has.  I have professors of restorative art who are remarkably skilled – artists in fact – tell me sadly that many of them think RA is becoming a lost art out in the field.  Many time I have been told that dead bodies that some years back would have been easy to restore now are behind the thickness of a closed casket lid, and you know my friends the thickest cosmetics you can put on a dead body is a closed casket lid.

This state of affairs has no blame connected with it, but it is a state of affairs which I would humbly suggest requires dialogue and exploration.

If the dead human body is today seen by many in the culture as not being important the fall out for our profession is profound.  Now as never before some terribly difficult questions are presented in light of this cultural kind of anti-corpse stance.  Here are some questions:

Are graves important?

Is the funeral coach important?

Is embalming important?

Are caskets and burial vaults important?

The list could well go on and on, simply because so much of the historical development of this great profession revolved precisely around taking care of the corpse. These are haunting questions, because it calls into question some of the most ancient and cherished precepts of our profession that have been held sacred for decades.

Everywhere I travel, people tell me they are selling fewer graves than ever before. I have friends in the embalming chemical profession tell me that if they had to survive today on selling preservative chemicals alone, they would not make it.

Yes, many thousands of bodies are embalmed, placed in caskets, cremation caskets/containers, urns, etc.  Yes, thousands of dead human bodies are restored and beautified and yes, thousands of embalmers still resource their unique talents and skills and create post-mortem miracles.  However, the numbers of such incidences seem all too clearly to dwindle every year.

I am really baffled by all this.  I understand all the demographic changes, the obsessions with staying young, being really happy and carefree and all that, but I am still baffled by the attitude of the culture toward the dead because it seems so evidently fickle and glaringly inconsistent.

Are dead bodies important or are they not?  I do not mean to imply that everybody who dies should be embalmed, casketed and buried in the earth – I am too old and too seasoned to think that way anymore.  However the growing evidence of abandonment of the corpse in favor of the party concerns me greatly.

As my good friend and famous author Tom Lynch said to me a dinner one night in New York, “we have traded in the funeral essentials for the funeral accessories.”  Well said, my good friend.

What is more authentically essential to wise and careful funeral practices that the essential significance of the dead body.  Without the dead body, there would be absolutely no need for funeral service in the first place, but that is a ridiculous position to take, given that everybody will in time become a corpse.  However the culture can and does fiddle and fiddle and fiddle with this notion and approach.

Interesting is it not that people, intelligent reasonable people, will say "dispose of Dad in the quickest way possible, burn him, or bury him quickly, and we want to remember him the way he was."  On the surface, this sounds so logical, rational, cool and contemporary, but grief is not an emotion that is logical, rational, cool and contemporary. It is raw, it is brutal, it is treacherous, and it has the power to drive people to kill themselves.  This subject goes way beyond cultural fads and contemporary attitudes.  

This shift from looking away from the dead instead of honestly confronting the reality of death, the visual, tactical reality of death, has already had unbelievable consequences for our profession.  The good suppliers and vendors in our profession have stepped up to this issue in a big way to come up with this and that product to help replace some of the lost memorialization accoutrements that for years were standard in community death rituals, but even these noble attempts appear to not be keeping up with the ever shifting attitudes of the culture that silently but by action proclaim that the dead are not important anymore.

Now, my friends, for the kicker, and if anyone can explain this to me, please let me know.

Today I picked up this month’s issue of the Smithsonian Magazine and on the front cover was this headline: “The Search for Herod’s Tomb.”  I have a 300 page book documenting the massive effort to locate the burial place and body of Alexander the Great, which has been lost for centuries but the search goes on. We all are well aware of how many dollars, time and expertise the Vatican spent digging under the Basilica of St. Peter’s for the actual true tomb of St. Peter.

Am I the lone ranger who finds this baffling, inconsistent and downright exasperating?

I am sure that the people/governments/religious bodies who are funding all these ancient digs are scholars of the first rank, or they also might be opportunists like some of the “Titanic” investigators who, when they hit pay dirt with artifacts, went on the world–wide tour and made millions.  I understand the entrepreneurial aspect of digging for dead people.

However this inconsistency cannot simply be explained away by the almighty dollar.  In the end, whose corpse is more important, that of my son who is dead in my own community, or that of Alexander the Great, wherever it may be?  This inconsistency worries me, because when one examines and explores this issue, the conclusions are somewhat unsettling, are they not?

Years ago I had good friends who lived in Cheyenne, Wyoming, where I was working – this was years ago.  One night after dinner my friend announced that he was going to cremate his mother upon her death, and try to remember her as she was alive.  He went on a diatribe, saying that funerals were a waste of time and money and that all this fuss and feathers over dead people was a waste of time.

I asked him, “Would it have been alright to cremate President Kennedy when he died and have his cremains immediately disposed of without any leaving-taking, ceremony or allowing people to express their feelings?”  My good friend responded immediately: “Of course not, he was the president of the United States, he was our president.”  I then asked, “Did you know President Kennedy better than your mother? Is President Kennedy’s body more important than your mother's? Why is a funeral OK for someone you only know from the newspapers, but not for someone you has been with you a lifetime?”

My friend looked at me and said “You are right. What am I thinking of; how could I make such a statement about my mother?”  

Cremation or any other method of disposing of a body is not the message and lesson of this case study involving my friend, but coming to grips with the reality and value of what any corpse represents to the living is, and I believe that it is still a major responsibility of every funeral professional to enter into these type of discussions and share the value and benefit of taking leave of the corpse.  

I know that I sound like an old, out-of-touch undertaker with this position, but I believe this with all my heart, and the absolute inconsistency people have about whether a corpse has value or not, I believe validates my thoughts.  

I am of the thinking, because I saw it happen, that when the corpse retained authentic significance, the experience for the bereaved was more thorough and complete.  As difficult as it was many times to confront the reality of death by viewing the restored and beautified corpse, in the end, in time good things happened to many bereaved people.

Today I worry that people are almost conditioned to think that not seeing the corpse means an easier time of it, that not having a funeral means lessening one’s grief.  My friends in funeral service, that is not true.

Could it be that replacing the essential role of the corpse with wind chimes, or the party, or you and I not taking time to explain the value and purposes of embalming, not attempting monumental restorative art challenges, could it be that if this continues the entire fabric, the thread, which has held our great profession together for centuries could well unwind?

Could it already be happening?

I have one last odd and unusual question to poise.  Why is it when a grave is robbed or disturbed or plundered say a day or week or month after the burial is it called the crime of grave robbing and there are legal consequences, an investigation and possibly a fine and jail time?  However when a grave is robbed or disturbed or plundered say 2,000, 3,000, 4,000, 5,000 years after the original burial took place, the activity is called archaeology, is given departmental status on university campuses, makes the cover of the Smithsonian Magazine and the academic archaeologist get financially sponsored by the National Geographic Society, then gets a television special on PBS and later in the year wins an honorary doctorate from, say, Harvard University?  

I know this is a ridiculous question, but I was just wondering.

Anyway that is one old undertaker’s opinion.  TVB

This condition, also called icterus, is not a disease, but is a symptom of a disease or condition. Jaundice is one of the most frequent challenges encountered by every embalmer.

Over the years, literally every conceivable concoction, formula, procedure and technique has been studied, developed and implemented to deal with it. There have been some successes and, as with all embalming processes, some cases where things did not work as planned, so embalmers always ask what to do in these cases.

In my own experience, I can remember following the instructions on "jaundice fluids" to the letter. When I was finished, I was pleased with the color, but as I left the preparation room I got that old embalmer's gut feeling that something was not right. Sure enough, by the day of the funeral I could detect some odor which ought not to have been present.

The next time, I put preservation first and used a trusted arterial fluid with predictable results in tissue preservation, yet I would again leave the preparation room with "that feeling." The next morning I would be pulling out the phantom cosmetics to cover over the dreaded green.

Jaundice is characterized by the yellow staining of the tissues of the body, including the blood volume, by bile from the liver. The bile's color is from the blood's hemoglobin that the liver has converted to bilirubin.

Every embalmer in the world knows this theory and knows that when bilirubin combines with HCHO (formaldehyde) the result is biliverdin and the dreaded green color.

I have found that massaging the face and hands with a quality massage cream and then wiping the cream away with a soft towel and applying more cream in a thick coating helps. A consistent massaging of the face and hands does contribute to removal of some stain and distribution of chemical.

Now the big question: What about chemical solution, jaundice fluids, dyes and the like? At my first job, I was taught by the embalmer at Heafey & Heafey to stimulate as much drainage as possible, and drain we did! We used water to make our solution and added drops of dye as we went. All in all, my memory of this approach was that it worked.

However, you have to consider the fact that in those days, funerals usually were held within a couple of days, so we did not keep the remains for an extended period of time. Since those early days of my career, I have encountered more and more instances where family members require several days to get together. Also, new medical drugs have altered the old embalming formulas.

Therefore, I have searched for an improved method of dealing with jaundice cases. Nathan Minnich, a former student of mine who has become a good friend and now teaches me things, has passed along the following method.

Instead of mixing consistent solutions of arterial fluid and dye, Nathan's approach is to use a great amount of dye (16-32 ounces) in the first gallon, and just a few ounces of preservative chemical. The rationale is that the jaundiced tissue gets dyed first before the HCHO can cause biliverdin.

Then, as additional half-gallon or gallon solutions are mixed, the formula is reversed, until, in the last gallon, just a few ounces of dye are used with a generous mixture of preservative chemical in order to thoroughly embalm the remains.

When I first heard this, I raised my eyebrows as all old embalmers do when a new idea comes to the floor. However, I have used the method on a dozen cases and the results are remarkable. It is much easier to cosmetize tissue that is pink rather than green, and much more pleasant to prepare well preserved remains.

If you have not tried this method of dealing with jaundice, I encourage you to give it a try. The results are truly remarkable and your families will be pleased.

As a matter of course, the location of the wound and parts of the remains punctured by the bullet or charge from the gun will be of greatest importance in determining the degree of difficulty in taking care of these situations.

If the heart is punctured, and the remains not autopsied, it will probably be necessary to do a six-point injection. In modem embalming, instant tissue fixation (otherwise known as "freezing the head") is a preferable method to ensure minimum swelling of the facial features.

It is suggested that both common carotids be injected with a high-index arterial fluid diluted with a quality pre- or co-injection chemical. When I was teaching embalming at the Cincinnati College of Mortuary Science, this method of "freezing" was used constantly.

Basically the injector is set at the highest pressure and highest rate of flow, and by intermittently injecting from the off/on switch at a ratio of on for 1 second and off for 15 seconds, the fluid is presented to the tissues so quickly that the chemicals literally fixate the tissues and hence stop swelling.

I realize that this method will shock many embalmers, but I have used it for years with good solid results.

If the gunshot entered the cranium, there will probably be black eyes and distention. In these cases, it is wise to turn the back eyelid, inside out and open the mucous lining inside the eyelids, then digitally remove the volume of clotted blood. This results in a reducing of the distention and removes some discoloration.

Also, injecting a bleaching agent will eliminate much of the discoloration.

One of the principal retrograde changes that takes place in a living body is gangrene. Gangrene means the "death of a part." It means that a certain area of the body's soft tissue has been deprived of one or all of the sources of elements that rebuild depleted cells. The result is the death and then decay of this area of tissue.

Gangrene is usually divided into two principal categories: dry and moist. Diabetic gangrene, which is very common today, and gas gangrene are in the moist category.

Basic mummification, which refers to local diminution in the blood supply due to an obstruction in the arterial system, is in the dry category. Dry gangrene usually occurs in the extremities. The tissues become dried out and eventually turn black.

With dry gangrene, the important point for every embalmer to remember is there is little, if any, chance that preservative chemicals used in the embalming process will reach areas that died because they have been deprived of the elements necessary for life.

Start by injecting the remainder of the body as you would do in an "average case."  It then will be necessary to either treat the gangrenous tissue by hypodermic injection or by applying cotton or gauze packs saturated with a penetrating preservative chemical and then wrapping the affected area in a plastic wrap such as Saran wrap.

Moist gangrene is a condition which can be found in almost any part of the body and is due to an invasion by saprophytic organisms. The invasion, which causes putrefactive changes, can be through a wound or from the respiratory or intestinal tract.

The embalmer needs to exercise great caution in personal cleanliness and safety in handling these cases. Furthermore, a liberal amount of disinfectant spray should be applied to the exterior of the body and a strong deodorant should be sprayed around the preparation room, as these cases generally produce a great and unpleasant odor.

A strong solution of embalming fluid (at least a 3 percent strength) should be used.  The common carotid artery should be the initial place of injection, and drainage should be taken from the internal jugular vein. However, these types of cases usually show little drainage. It is also advisable to use multiple injection sites to ensure tissue saturation.

Cavity treatment should be the regular aspiration of the cavities and the injection of two 16-ounce bottles of a quality cavity chemical.

Asphyxiation is a term applied to death starting with the lungs. Death due to asphyxia can be caused by several contributing factors: carbon dioxide, carbon monoxide, drowning, hanging or strangulation.

One interesting aspect of this type of death is that by the time the person has actually died, the heart has often undergone such intense effort to carry oxygen to the body that its muscular walls have broken down and it is dilated.

This can cause embalming problems. The aorta is dilated, the aortic valve is useless, and when embalming chemical is injected arterially toward the heart, the chemical flows into the heart through the aortic valve, filling the left ventricle. Then the chemical fills the left auricle and follows the pulmonary system to the lungs. This most often will result in a persistent lung purge.

If the right side of the heart is also dilated, the flow of chemical will return to the right heart, carrying a volume of blood ahead of it, and will be forced into the vena cava. The main course of this flow will take the course of the superior vena cava, and the face will become discolored and possibly distended.

There are a variety of procedures which can be used to prevent this, but one sure and safe process is to inject the head separately using both the right and left common carotid and drainage from both the right and left internal jugular veins. The injection should be slow; this is not instant tissue fixation. A low index arterial, mixed with a quality co-injection chemical to the embalmer's discretion is recommended.

Once the head is cleared of stain or blood congestion, the rest of the body can be embalmed in the normal manner. Also, little or no trouble should be encountered in carbon monoxide cases, since the blood is cherry red and will remain in a liquid state for a considerable time.

Deaths from alcoholism may be from causes that are either acute or chronic. In the acute cases, there has been an ingestion of sufficient alcohol to create poisoning sufficient to cause death. In deaths from chronic alcoholism, there has been a steady breaking down of the nervous system, the circulatory system and the digestive system or a complication has arisen from a combination of these conditions.

Carcinoma of the stomach, intestines or liver; stroke as a result of arteriosclerosis; jaundice; or even insanity which terminates in paralysis may be the direct or indirect result of alcoholism.

There is nothing unusual encountered in embalming these cases unless the terminal disease or complication presents specific problems, i.e., jaundice, edema, etc.

Massage thoroughly with a high-quality massage cream formulated by one of the embalming chemical companies. Cover the face and hands liberally and continue to massage throughout injection. Wash out the circulatory system with a pre-injection solution using 4 ounces of the solution to make a half-gallon solution. Half-gallon solutions do take more time, but the process helps in not over- or under-embalming the remains. Generally a low-strength fluid is recommended in sufficient volume to ensure complete distribution. (Specific concerns regarding edema and jaundice will be covered in future segments of this series.)

Alcoholism often dilates superficial capillaries. This is the reason so many people who use alcohol to excess have highly colored skin and, especially, colored patches of skin. In these highly colored areas, we may easily create desiccation or fluid burn spots unless we are careful in our massage techniques and embalming solutions. Use a gentle touch in these cases.

Thoroughly aspirate the cavities and treat with cavity chemical. Reaspiration may be necessary before casketing.

Addison's Disease is characterized by degeneration of the suprarenal capsules and a resultant bronze pigmentation of the skin. The change in the suprarenals is generally found to be tuberculous. In the latter stages of life we usually find anemia, general languor, feeble heart action, irritated stomach, diarrhea, rheumatic pains in loins and abdomen, and sub-normal temperature.

Above everything else we should thoroughly massage the skin with a quality massage cream to remove all the superficial discoloration possible and then thoroughly wash the circulatory system with pre-injection solutions of 4 to 6 ounce strength per half gallon of water.  It may be necessary to use a gallon or more of the pre-injection solution before starting arterial fluid injection.

Make fluid solution low in strength, but use an unusual volume. If these cases were to receive fluid injection over a period of several hours, even using a gravity system of injection or keeping the electric injector percolator as low as possible to send fluid into the body very, very slowly, the results will undoubtedly be far more satisfactory.  Thorough massaging with massage cream, thorough capillary wash, with co-injection and low-strength arterial fluid injected over a long period of time, is recommended for these cases. Cavities should be aspirated and treated with full-strength cavity fluid.

As far as I know this discoloration cannot be removed, but the above treatment will not exacerbate the problem, and after treatment, cosmetics may be satisfactorily applied.

Over the years there has been debate over preparing a body for viewing at the funeral in cases where the remains would then be sent to a medical college for dissection in the gross anatomy classes. Some medical schools flat out will not accept a body that has been embalmed by a funeral home. Certainly most medical schools will not accept a body that has been aspirated.

The medical schools' position is understandable, to be sure, but most embalmers get mighty nervous and uptight when a viewing is planned for a body without arterial embalming. And most embalmers come close to a mental breakdown at the thought of a viewing for a body that has not been aspirated. I always thought a body not aspirated was truly a ticking time bomb.

It seems like, lifetime ago, but I used to teach clinical embalming at the Cincinnati College of Mortuary Science. The old adage is true: A teacher who is not also a student isn't much of a teacher. I learned a lot while ''teaching'' embalming, and one of the subjects we tackled back then was preparing remains for viewing in cases where the body was to be donated to a medical school.

We developed a procedure for dealing with a "normal" case, i.e., one where the remains are in an ideal condition. In such a case:
•    The remains still retain body warmth.
•    Death occurred no more than 12 hours before.
•    The body has a normal protein content. When these criteria are met, the procedure as described below can be used.

Initial steps
The remains can be disinfected in the normal manner. The features may be set in whatever manner the embalmer normally uses.

Many medical schools require that the initial approach to injection be made via the right common carotid artery, and that drainage be taken via the right internal jugular vein.

In instances where additional drainage is desirable, some medical schools will accept one additional injection/drainage site, but most medical schools will protest the use of more than two sites.

Fluids and embalming procedures
The basic key to the procedure is to make liberal use of a pre-injection solution. It's not unusual for it to require more than four gallons of a pre-injection solution to adequately "flush out" the vascular system, as well as expand and lubricate the body's vessels. Liberal use of the pre-injection solution is essential.

Inject the pre-injection solution under closed drainage via the right common carotid artery until you observe any distention of the superficial veins in the hands, feet or temples. At this point, drainage should be taken from the right internal jugular vein, or the other selected site, or both. It's up to the individual embalmer to decide whether to use a drain tube or forceps, or any drainage device.

The embalming machine should be set at a conservative pressure and rate of flow. Because of the wide variety of machines available (including one that sets its own pressure!), it is difficult to suggest a definite selling for the injector. I have found, however, that an actual pressure of four-six pounds, with a rate of flow one quarter open, should not cause adverse effects.

Following the pre-injection, I suggest you mix a low index arterial chemical at a solution of 8 ounces to one gallon of water, making a two-gallon solution. There is no "rule" or even opinion concerning the use of dyes, lanolin or any other accessory chemicals with the arterial solution.

If after you've injected the two gallons of solution the desired preservation has not been achieved because of the size and-or weight of the body, mix a third gallon according to the same 8 ounces to one gallon formula.

Do not inject more than three gallon, of arterial solution. Why? Because too much arterial solution actually causes rapid hydration of the vessels, making it difficult—if not impossible—to then inject the high potency anatomical solution.

By following the procedure as outlined above, I have generally noted good results. The hands and face generally are preserved and discolorations in these areas have usually been removed successfully.

Following the injection procedure, ligate the vessels in the usual manner and suture the incision(s). You may use cotton or powder sealant when closing the approach incision(s) unless the specific medical school with which you are dealing prohibits it.

Cavity treatment
All the embalmers reading this are going to have questions about cavity treatment. We all know that aspiration is basically taboo in cases of anatomical donation. But if the remains are in the ideal condition as previously described and the arterial injection has been successful, you can do a form of aspiration without puncturing the organs and anatomical structures.

I must reiterate that this only applies if those conditions hold. Certainly if death occurred more than 12 hours earlier, or if the remains are distended, dropsical or show signs of decomposition, the process I'm about to describe will not work and should not be attempted.

In my research for this article, I consulted an ancient embalming textbook that I have in my library, 'The Art and Science of Embalming," by Dr. Carl Lewis Barnes, published in 1877. Dr. Barnes was a pioneer in embalming education. In 1910, he sold his embalming school in Chicago, Illinois, to professor Albert Worsham. Worsham College of Mortuary Science is still educating funeral directors and embalmers today.

But I digress. In his textbook, Dr. Barnes addresses the problem of embalming in a home when the family has forbidden aspiration. He mentions having family members standing guard in the room as the work is being done, either giving permission for or vetoing each embalming procedure—certainly an awkward position in which to work!

It's hard for us to imagine doing an embalming in someone's house, never mind having the family supervise, but that scenario is not as far removed from today's challenges as we might believe. After all, don't families today have a legal right to permit or forbid embalming? And don't some medical schools prohibit aspiration?

So when I read Dr. Barnes' procedure for performing an aspiration without puncturing the organs, I wanted to try it out. Here is how the Barnes method works:

• First insert a flexible rubber drain tube into the trachea and, by gravity, inject as much cavity fluid as the lungs will absorb.

• Then take the same flexible rubber drain tube and insert it into the nostril. By raising the chin to enlarge the aperture of the epiglottis, work the flexible rubber tube down the esophagus to the stomach. Manually aspirate the gases and contents of the stomach, then reconnect the rubber tube to the gravity injector and inject as much cavity fluid into the stomach as possible. (Can you imagine the strength of this fluid in 1877?)

• Massage the stomach area, pressing as much cavity fluid as possible into the large intestines, then massage the abdomen to try to distribute the cavity fluid into the small intestines.

• Repeat using the external anal sphincter and rectum as the point of entry.

Dr. Barnes would repeat this process over and over again until the firmness of the cavities was satisfactory.

At the CCMC's clinical lab, the students and I tried Dr. Barnes' method many times (only on cases fitting the profile) with very positive results. In fact, in cases that fit the profile, the University of Cincinnati Medical College Anatomy Department allowed families to have funerals with viewing of remains that were going to be sent to the Gross Anatomy Lab.

Again, this is a special technique not suitable for all cases. But by using this old procedure developed by an embalming pioneer, I was able to witness firsthand the appreciation of families who wanted to honor their loved one's wish and donate the body to the medical school but also wanted a formal funeral with the body present.

The desire to help educate future physicians causes some people to leave their body to a medical school. In normal cases, embalmers can enable this to happen while still affording the bereaved family the comfort of a final viewing and presence at the funeral.

Can there be true personalization at a funeral if the person whose life is being remembered isn't even present?

Personalization. The last time I recall such mantra-like repetition of a single hot topic in the funeral profession had to be in the heyday of preneed.

At the onset, anyone could easily surmise the impact of preneed upon every facet of funeral service. Just a glance through any industry journal and the yield of articles and editorials, advertisements and how-to seminars served as testimonial.

The bottom line was that preneed had to be addressed by us personally, as business owners, and collectively, as a profession.

Fast forward to today. Personalization is the fresh buzzword. Of course, the concept is nothing new—astute and compassionate funeral directors have always encouraged individuality in the personal design of meaningful tributes.

We help client families express their beloved's lifestyle, career, hobbies, memberships, community or military service, etc. Together we endeavor to capture the essence of a life lived well. We thematically set the stage for the complementary rituals and ceremonies that follow.

In and around the casket are displayed artifacts that once belonged to that person. A golf putter, bingo card, remote control, hand-knit throws and cross stitched pillows, lapel pins—all serve to help tell the story of the decedent's life. Heirlooms of all sorts, photographs and letters and achievement awards all share an intimate connection with the person in the casket.

What is new is personalization for sale, which if we're not careful can make the funeral experience we offer families less rather than more personal.

Generic curios in mass production lack an historical connection to the deceased. The items are symbolic, but impersonal. They never belonged to the deceased. This trend toward personalization for purchase may also be upstaging the deceased and stealing the final bow.

Picture this: Funerals with no bodies
The video tribute does have real value and is significant and appropriate at the memorial service. But consider this: Today we can minimize or circumvent many of life's difficult experiences through avoidance or drug therapy. We can choose to not experience hard-to-handle emotions. A pill exists for every ill. We can choose to circumvent the funeral and/or viewing of the body, too!

A powerful video tribute may be less difficult for mourners to confront than the actual dead body. Could the video tribute eliminate the need for the body to be present at all?

Alan D. Wolfelt, Ph.D., director of the Center for Loss and Life Transition, Fort Collins, Colorado, speaks to this dominant model in North America: ''We as a culture appear to be forgetting the importance of the funeral ritual. While funerals have been with us since the beginning of human history, we seem to be rapidly moving toward minimizing, avoiding and denying the need for rituals surrounding death."

Can society choose to avoid the therapeutically painful rites of passage that define and validate death altogether? Will items of personalization serve as substitutes for the real physical form?

As Philippe Aries writes, "The change (in death's role in our society) consists precisely in banishing from the sight of the public not only death, but with it, its icon" (the dead body).

In the United States, from 1900 to 1960, over 90 percent of bodies were embalmed. Today, that percentage is significantly lower.

Can the funeral profession be truly effective providing funerals without bodies? Any garden-variety service/hospitality company can provide personalization and ceremony when the dead body is absent. Can we risk that?

The primary role of the licensed funeral director embalmer, according to the board of health, is to dispose of the dead human body and, concurrently, to protect public health. Ceremony is a separate, non-licensed function.

The successful survival of the funeral profession depends on ensuring that the public perceives the value we provide in handling both legal requirements and ceremonial rituals.

Death begins the process. The ceremony would not exist if death had not occurred. It is only logical that the decedent participate in his or her own final proceedings.

Back to the basics
I suggest we return to the basics and qualify ourselves to emphasize the most powerful resource we have for personalization. The subject we are to personalize is, after all, inherently the hallmark of our profession: the dead human body, which funeral directors-embalmers are granted exclusive license to handle.

The deceased person is the guest of honor and commands center stage. Despite a growing trend wherein the deceased is absent from his or her own final event, I maintain the dead human body in the casket for funeral visitation is still the public's expectation. Seeing is believing.

The increasing number of telephone inquiries asking if the "body will be available to view" suggests the public still needs and desires a viewing.
It is our professional duty to respond to the needs of our communities. The manner in which we help our client families fully understand the relevance of our services directly impacts how they ultimately value their own choices.

A good supporting foundation is necessary to the success of any endeavor. Embalming is the foundation of body presentation, and intensive and skillful embalming is critical, followed by impeccable grooming, cosmetic application and hairstyling.

A tailored fit for the clothing reflects meticulous care put forth in dressing and grooming. The decedent should rest comfortably in position and in facial expression.

In life, someone embarking on an important event—a first date, a job interview or any function where a poor appearance will have consequences—must look his or her best. So too in death, when the decedent is presented for approval to family and friends.

During the arrangements conference, emphasize the value of the decedent's farewell engagement here upon the Earth. Emphasize the family's "last look" at their loved one. Promise to dedicate your professional best efforts to that final appearance and invite the family to share in the commitment.

Encourage family members to discover items personally significant to their loved one, perhaps tucked away for safekeeping in a jewelry box or dresser drawer. Suggest a selection of photos and letters.

The simple act of reviewing these treasures, once held and dearly loved, offers the bereaved a starting point in the process of grieving and healing. These personal acts of the family reinvest the decedent in his/her own funeral, which in turn, reaffirms the bond between the dead and the living.

Personalization may exist in the tangibles, but it is much more. Personalization is the culmination of truly unique services that funeral directors can provide upon the person who has died and those who still live.

Consideration is given to a lifeless individual for the welfare of those who survive. The benefits are universal.

This quotation (often attributed to William Evart Gladstone, though Gladstone scholars say erroneously so), captures the benefits of what we do to society as a whole:

"Show me the manner in which a nation or a community cares for its dead and I will measure with mathematical exactness the tender mercies of its people, their respect for the law of the land, and their loyalty to high ideals."

At life's curtain call, the "star" appears one final time to give family and friends one last look, for laughter's release at a remembered anecdote, or one last tearful memory. One last moment is suspended before the audience can let go of the main character. No one is absent; no one is overlooked. And then, as in life, there is a definitive end.

Absent the person from the funeral, personalization becomes the understudy that takes center stage.

Even when effective and powerfully symbolic, it's not quite the same.

The contemporary reader will say WHAT? Vibration and embalming—what is he talking about? Let me begin at the beginning. One of the greatest aspects of my life and career has been my good fortune in observing, working, learning and being friends with highly skilled embalmers.

One of those embalmers was a man named C.  Wayne Livingston. He was connected for years with the old Woodring Funeral Home in Council Bluffs, Iowa. Wayne's son, Vaughn, and I were close friends, and I used to hang around the Woodring facility regularly.

Wayne Livingston was a great embalmer. He had great skill and technique in all aspects of embalming, but the one which stands out in my memory is that he had a vibrating embalming table. It's true! Some of the veteran embalmers who read this will well remember this piece of preparation room equipment.

I had the honor of watching Mr. Livingston embalm many cases on this particular table, and I would like to reflect for a moment on the superior results that I witnessed at the hands of this skilled professional.

Let's review some basics in embalming circulation. We know that during life, the application of vibration to any part of the body will produce hyperemia, which is an excess of blood in a part of the body. In addition, any type of vibration is also a form of massage.

However, with a vibrating embalming table, the massage affects the posterior of the body, the entire body—and is continuous.

All embalmers are familiar with the favorable effects produced by the judicious use of gentle massage with the hands on certain parts of the dead human body before and during the arterial injection.

It is a definite aid in clearing discolorations and at the same time emptying the tissues so as to obtain better fluid distribution.

Then too, embalmers are familiar with the possible adverse effects—over dehydration and swelling—that can occur when the hand massage is too aggressively used during arterial injection.

With this background, let us now examine the "how" of table vibration. First of all, how do you make an embalming table vibrate?

Mr. Livingston rigged up his own vibration system by attaching two barber vibrators (the type which barbers use to massage head and shoulders) to the head and foot underneath the table.

This type of vibrator has a regulator on it so you can control the degree of intensity of the vibration. Sometimes Mr. Livingston would use one device, either at the head or feet. In other cases, he would use both simultaneously.

As I watched this master embalmer at work, it was clear that the same degree of vibration would not be satisfactory on every embalming operation. It was also evident that far more blood and other body fluids were drained than in cases where vibration was not used.

When the potential existed for over dehydration, Mr. Livingston would add 8 ounces of a quality humectant chemical to the last half-gallon and inject this under closed drainage to seal in the humectant effect.

Today I do not know of any manufacturer of embalming tables making one that vibrates. However, I suspect that a few embalmers reading this article just might become another Wayne Livingston and rig one up in order to further ensure quality embalming. In the end, is this not the vision for which we strive?

No longer is the frozen body a problem unique only to states and countries that suffer from harsh winters.  Today, freezing can be a challenge for the embalmer simply because of the escalation of refrigeration in almost every hospital and coroner's office in the country.

Freezing creates problems for the embalmer. One important fact is that the embalmer needs to know whether the death occurred immediately and while the body was in a frozen state or whether only one part or several parts of the body were frozen and death occurred later as a result of the freezing or complications.

If death did not occur until some time after the freezing, there will probably be severe gangrene at the point of the freezing. If death occurred because of the freezing and the body was turned over to the embalmer in a frozen condition, the first step will be to thaw the body.

The remains need to be completely thawed before injection is begun. I have been exposed to the theory that you can inject frozen remains, and if my memory serves correctly one of the chemical companies even formulated an embalming preservative which was promoted as extremely effective on frozen cases. However, I never tried this approach. If you have, please call or e-mail me with your experience and outcome.

My thawing method
I have used the following method for thawing a body: place a sheet over the body and allow cold water to continuously saturate the sheet for several hours. Tepid water can be used, but I am cautious about using anything but cold water. Certainly one should never use hot water, because as most embalmers already know, if hot water is used, skin slip will invariable result.

I knew an old embalmer in Omaha who swore by another method of thawing. He would use a tank filled with ice water and submerge the body in this water. Within a short time the tank would appear to be filled with slush. He would remove the body, empty and refill the tank with cold water and replace the body, repeating the procedure until the tissues were thawed. I never used this method, and frankly it sounded like a lot of work back then and it still sounds like a lot of work today.

If cold water is used for thawing, it will be possible to remove the blood and to properly disinfect and preserve the body. Blood remains liquid under the influence of low temperature, but begins to decompose and clot immediately under high temperatures.

While the tissues are frozen, the skin will usually be a creamy color, but this light yellow shade will disappear as the tissues thaw and the skin bleaches.

Two important points need to be made. First, in my experience (others surely have had better outcomes), once frozen and then thawed, tissues will not become rigid under the action of many embalming chemicals.

Second, the action of many embalming chemicals on tissue that has been frozen usually results in a pink coloration that resembles the coloring we find in cases where death was caused by suffocation from carbon-monoxide poisoning.

I recommend that a pre-injection fluid not be used, but a coinjection fluid can be used. Though we can expect some drainage, I have not seen very much drainage in the cases I have embalmed. Discolorations are common and often there will be a postmortem stain that cannot be removed.
After thawing the body, you should massage the face and hands with a quality massage cream. A film of cream should be left on during embalming.

Because of tissue damage, the arterial solution should be strong, 2.5 percent to 3.0 percent HCHO to make half a gallon. I am old fashioned and still use the Slocum method of one-quarter to one-half gallon solution. I have found it takes more time, but I can control the fluid activity much better, so I don't over-or under-embalm the remains and I also don't waste chemicals.

Also, I have discovered that while I can hope for a one- or two-point injection, I usually end up doing an eight-point injection. (I use the radials.)

Pressure is in such flux today that I dare not make any suggestions, but I have heard nothing but praise for the new Dodge machine which sets the pressure automatically. What will they think of next?

The application of proper restorative art materials will serve to mellow the pink/red coloring of the skin and give splendid results.

When I started embalming I was often frustrated with my inability to get the correct mouth closure. I would fiddle and fuss for literally hours at time, with the constant pressure of being told time after time that "if the mouth is not correct, nothing will be correct on the funeral." Pressure!

As usual, I studied all the pertinent literature on the subject, became familiar with terms like weather line, needle injector, tack, lip cream, adhesive, lip wax, mandibular suture, phenulum suture, etc, Still I had cases which seemed to defy the theories and procedures, and every embalmer I spoke to assured me that their method was the best and that they had never once had a complaint from a family. This information did not help my confidence at all.  Of course today I realize that those embalmers who claimed absolutely 100 percent family satisfaction were either exaggerating terribly or had not done much embalming in their careers.

One day while I was working to get the right mouth closure I realized that while working with the lips and mouth, I could literally feel a type of tissue resistance when I was attempting to position the lips to the natural weather line. Finally I had a hunch (which I learned to trust in embalming, more than theory) that the tissues, muscles and structures which made up the mouth area needed to be stretched. So I took a dry paper towel and rolled the towel under the bottom lip of the mouth and very gently stretched it upward over the top lip as far as it would go.

Then I rolled the paper towel under the top lip and very gently stretched the top lip down as far as it would go covering the bottom lip. Be prepared for the fact that if you decide to implement this procedure the lips will look terribly misshapen for a while.

Next, take a reasonable amount of regular massage cream and cover the lips, top and bottom, with the cream. Then simply purse the lips together and the tissues will fall naturally into the weather line closure.

I was amazed and often relieved at the amount of elasticity I created by using the paper towel technique. Be careful not to press and push on the lip tissue too much, for it can damage the tissue, and upon injection the damaged tissue will swell.

This technique also offers additional centimeters of lip extension when attempting to correct prognathism.

Give it a try on your next case and let me know how it works. Call or e-mail me—I am always interested in learning new and improved embalming techniques.

As every funeral professional knows very well, hanging can be and often is one of the most disturbing death scenes to be called to. I have seen many such cases, and it amazes me the ways in which the trauma to the head and neck can vary. Of course I am not talking about capital punishment cases here, only about accidental hangings and intentional ones (suicide).

Both accidental and intentional hanging can result in significant problems for the embalmer. But often the hanging victim can be embalmed by using a restricted cervical, injecting both left and right carotids and taking drainage from the left and right jugular veins.

The principal problem frequently found with hanged victims is blood congestion in the face and the neck. In older individuals with sclerotic arteries, complete severance of the arteries has been known to occur.

As mentioned above, the carotid approach is best in these cases. I have used a small amount (6 ounces) of a quality pre-injections fluid to assist in removing the discoloration due to the congestion of blood in the head. Following this I inject a waterless embalming solution made up of 16 ounces of a coinjection chemical, 8 ounces of a 25 index arterial fluid and 4 ounces of a humectant for rehydration of the tissues.

I sometimes will hypodermically inject a small amount of a bleaching agent, but usually the action of the preinjections chemical will suffice to handle the discoloration. After dealing with that, tie off the left common carotid artery and left internal jugular vein and start injecting the rest of the body.

In treating the cavities, be very careful to thoroughly aspirate the thorax. If the noose of the rope ruptured the circulation, there may be accumulations in the upper thorax of blood that flowed out under pressure at the moment the noose injured the arteries and veins.

When the cavities are thoroughly relieved and then treated with a quality cavity chemical, one bottle up and one bottle down, there should be no more trouble. However, as all embalmers are aware, there are no guarantees in the art of embalming, so regular monitoring of these cases is a necessity.

After several hours, a quality tissue-building injection may be introduced beneath the traumatized area where the noose did damage to properly reestablish the normal appearance of the neck, which may have been compressed by trauma. Cosmetics can generally conceal any discoloration or marks that may remain at the end of the procedure.

One effective method of infant embalming utilizes a thoracic incision and hence a direct injection into the heart or the arch of the aorta. This method can only be implemented if the infant has not undergone a post mortem examination.

The arterial injection takes place directly into the left ventricle of the heart; drainage is received from the right atrium. Make a standard post mortem "Y" type of angular incision just below the clavicle toward the median line so that the two incisions meet on the median line at the level of the fourth rib.

Continue the "Y" incision down the median line to the lower border of the sternum. Here the tissue from the sternum and the ribs needs to be dissected.

Cut the ribs on both sides of the sternum with a sharp pair of scissors and be sure not to cut the upper end of the sternum loose from its articulation with the clavicle bones.  Then, grasping the lower ends of the sternum, lift it up and bend it backwards toward the infant's face.  Lift the exposed heart and carefully open up the pericardial sac so that you can free the heart from the confines of the sac.

While holding the heart, insert a curved medium sized arterial tube through the wall of the left ventricle in the direction of the aorta so that the end of the arterial injection tube lies within the chamber of the left ventricle.

No incision is necessary in the heart muscle to insert the arterial tube, because the muscular tissue will naturally fit tight around the arterial injection tube. It will not be necessary to ligate the arterial injection tube into the heart.

Drainage is obtained from the right atrium. You will not need to insert a drain tube, merely to make a small incision in the right atrium with a scalpel or sharp scissors and insert a pair of small spring forceps to hold the incision open.

To avoid swelling, you must be extremely careful to make sure that the amount of arterial fluid does not greatly exceed the amount of drainage. Inject 1 quart to 3 pints of mild arterial solution strength.

When using 2 concentrated ounces of a 5-index cosmetic-based arterial fluid, you should dilute this solution with a quality pre- or co-injection fluid to make 1 quart of fluid. Basically this is a waterless embalming technique.

Injection pressure should not exceed 1 to 1.5 pounds, and the rate of flow should be at a minimum. The procedure is simply a trickle effect injection.

It is not necessary to close the incision in the right atrium or the puncture incision in the left ventricle after arterial injection in completed.

Following completion of the arterial treatment, carefully place the heart back into its correct anatomical position in the thoracic cavity, return the sternum to its normal position and close the incision.

Your next step should be aspiration using an infant trocar and cavity treatment via injection of 8 to 12 ounces of concentrated low-odor cavity fluid.

I have used this method throughout my entire career. In the early years, we used these procedures and techniques without any consideration given to obtaining special permission from the family.

Times have changed. Since this technique creates an incision which closely resembles the "Y" type of incision used in performing thoracic autopsies, the liability risk to the funeral home is greatly increased.

Therefore, I strongly suggest that when you seek permission to embalm from the person executing the rights and duties of disposition, you include full procedural disclosures.

One effective method of infant embalming utilizes a thoracic incision and hence a direct injection into the heart or the arch of the aorta. This method can only be implemented if the infant has not undergone a post mortem examination.

The arterial injection takes place directly into the left ventricle of the heart; drainage is received from the right atrium. Make a standard post mortem "Y" type of angular incision just below the clavicle toward the median line so that the two incisions meet on the median line at the level of the fourth rib.

Continue the "Y" incision down the median line to the lower border of the sternum. Here the tissue from the sternum and the ribs needs to be dissected.

Cut the ribs on both sides of the sternum with a sharp pair of scissors and be sure not to cut the upper end of the sternum loose from its articulation with the clavicle bones.  Then, grasping the lower ends of the sternum, lift it up and bend it backwards toward the infant's face.  Lift the exposed heart and carefully open up the pericardial sac so that you can free the heart from the confines of the sac.

While holding the heart, insert a curved medium sized arterial tube through the wall of the left ventricle in the direction of the aorta so that the end of the arterial injection tube lies within the chamber of the left ventricle.

No incision is necessary in the heart muscle to insert the arterial tube, because the muscular tissue will naturally fit tight around the arterial injection tube. It will not be necessary to ligate the arterial injection tube into the heart.

Drainage is obtained from the right atrium. You will not need to insert a drain tube, merely to make a small incision in the right atrium with a scalpel or sharp scissors and insert a pair of small spring forceps to hold the incision open.

To avoid swelling, you must be extremely careful to make sure that the amount of arterial fluid does not greatly exceed the amount of drainage. Inject 1 quart to 3 pints of mild arterial solution strength.

When using 2 concentrated ounces of a 5-index cosmetic-based arterial fluid, you should dilute this solution with a quality pre- or co-injection fluid to make 1 quart of fluid. Basically this is a waterless embalming technique.

Injection pressure should not exceed 1 to 1.5 pounds, and the rate of flow should be at a minimum. The procedure is simply a trickle effect injection.

It is not necessary to close the incision in the right atrium or the puncture incision in the left ventricle after arterial injection in completed.

Following completion of the arterial treatment, carefully place the heart back into its correct anatomical position in the thoracic cavity, return the sternum to its normal position and close the incision.

Your next step should be aspiration using an infant trocar and cavity treatment via injection of 8 to 12 ounces of concentrated low-odor cavity fluid.

I have used this method throughout my entire career. In the early years, we used these procedures and techniques without any consideration given to obtaining special permission from the family.

Times have changed. Since this technique creates an incision which closely resembles the "Y" type of incision used in performing thoracic autopsies, the liability risk to the funeral home is greatly increased.

Therefore, I strongly suggest that when you seek permission to embalm from the person executing the rights and duties of disposition, you include full procedural disclosures.

Babies are not supposed to die. Well, not in 2006; the brutal fact of death history is that babies used to die all the time. Thanks to the great advances of medical care in the 20th century, for the first time in human experience certain cultures live with the expectation that babies will not die. But, of course, as every funeral director knows, this expectation is not always met.

Each year in the United States, approximately 37,000 children die within the first 28 days of life. Another way to look at this reality is to say that one neonatal death occurs every 15 minutes somewhere in this country. And in some countries, infant mortality rates are still similar to what they were 100 years ago in America.

Embalming babies, infants and even older children is especially difficult and challenging for the professional embalmer, both psychologically and technically, but the value of embalming our "little ones" is enormous.

This value is best attested to by the famous case my friend Glen W. Davidson did many years ago called "Death of the Wished-For Child." Dr. Davidson's pioneering study provided proof of what anyone knows in his or her heart: In cases of infant death, the parents have very special needs.

Some of the findings from Dr. Davidson's five-year study of mothers who suffered stillbirths or lost their babies within 24 hours of birth:
•    When an infant dies, the mother and significant people around her become vulnerable and disoriented.
•    The mother very much wants to hold the infant.
•    A significant number of times, this request to hold the dead infant is denied.
•    Parents who were able to see and/or hold their dead infant were able to reorient themselves much more quickly than those who did not do so.
•    Parents find it difficult to get the emotional support they need from people close to them when an infant dies.
•    Professionals have their own problems or anxieties about accepting the death of an infant, making them less able to help the parents.
•    When given little or no accurate information concerning what happened to her and her baby, a grieving mother tends to imagine the worst, creating in her mind the image of an infant horrible in appearance.
•    Seeing her dead child almost instantly drives out those horrible images the mother's imagination has conjured up.
•    Viewing the body can be psychologically helpful to the people significantly affected by the death as they try to work through their deep grief.

In this series of articles devoted to infant embalming I will cover seven embalming techniques:
1.    Fluid pack approach.
2.    Heart approach.
3.    Thoracic aorta approach.
4.    Umbilical vein approach.
5.    Abdominal aorta approach.
6.    Normal arterial embalming injection approach.
7.    Angiocath/syringe approach.

Pre-embalming analysis
There are two problems embalmers frequently encounter in the embalming of infants. First, they often experience difficulty in securing satisfactory blood drainage because of the minute size of infants' veins. Second, they have to beware of the possibility of and tendency to over-embalm an infant.

Because of these challenges, a careful case analysis consisting of, but not limited to, the following points needs to be made:
•    vessel selection,
•    body positioning,
•    injection cannula size,
•    presence of liquid blood,
•    size/location of incision(s),
•    rate of flow,
•    pressure,
•    solution strength,
•    intensity of refrigeration, and
•    unautopsied cases vs. autopsied cases.

The pre-embalming and post-embalming procedures are general and might not be applicable to every technique selected by the embalmer.

In cases where there was no autopsy, any of the seven embalming techniques may be used. If there has been an autopsy, only three of the techniques can be considered: fluid pack, normal and angiocath/syringe.

Before embalming by whatever method, you need to take care of the following pre-embalming measures:
1.    Perform a case analysis as outlined above.
2.    Wash the infant and disinfect all orifices.
3.    Place the infant on a bed of nonabsorbent cotton, as this prevents the flattening of the back, buttocks and legs. Such flattening will feel unnatural if the mother holds the infant. Note: I have filled a small receptacle about half full of water and floated the infant in it while I injected the remains and found that the legs, back, buttocks, etc., fill out naturally from the pressure of the injection.
4.    Never remove any facial hair without the written permission of the person exercising the rights and duties of disposition.
5.    Set the features. Methods vary, but I usually simply held the mouth while injecting. Sometimes a slight opening of the mouth causes the face to truly resemble how infants look when they are sleeping. Eye caps are unnecessary, massage cream on a small piece of cotton works very well.
6.    Use massage cream to prevent dehydration.

Approach No.1: Fluid pack
I am ashamed to admit this, but it's true: When I started embalming 38 years ago, this was the only method used to embalm infants. It did not work particularly well in terms of providing a good appearance, but it did accomplish preservation. It has been my experience that few viewings are held when the fluid pack approach has been used.

Basically the infant is wrapped in several layers of cotton, which is then saturated with a concentrated arterial or cavity fluid solution. Next, the infant might be placed in a closed box or container and covered with embalming powder or hardening compound. This embalming approach is also referred to as embalming by osmosis.

The result of placing the concentrated fluid on an infant's fragile tissues are not desirable. There is usually excessive dehydration, intense wrinkling of the skin and little or no change in the color of blood discoloration. In addition, fluid penetration is usually minimal, so there is a risk of premature decomposition if the body is held for an extended period of time without refrigeration.

Next month: No.2, Heart approach.

The appearance of the hands is an important part of the overall visual presentation of the deceased. At the visitation, family members and friends will generally hold, clasp or pat the hands of their loved one. Seeing their loved one's hands holding a rosary, a cherished photo or some other memento, or wearing a ring with sentimental value can be comforting for family members.

Beautiful, well groomed fingernails are an important part of the overall look. Many women (and some men) take pride in the appearance of their hands, especially their nails. People who spent a significant amount of time and money properly caring for their fingernails would not want to be viewed with their hands looking anything but their best.

Recently I had a colleague ask me if there really is a difference between doing a professional manicure and simply polishing the nails. The photos I was able to show him proved that yes, there is a big difference, and today's consumers are sophisticated enough to notice when the nails have not been professionally done.

Funeral directors who are responsible for the final appearance of the deceased are expected to provide professional cosmetology work. People will notice if the hands are not properly "finished," and family members may have specific requests for how their loved one's nails should look.

The family may simply request a particular nail lacquer color, or may expect you to handle something as complex as camouflaging a fungus condition or removing artificial nails. Are you prepared to handle such requests professionally?

A good embalmer always must have a fingernail care kit which should include at least the following items:

•    nail scissors and clippers,
•    polish remover,
•    emery boards of various textures,
•    a cleaning implement,
•    cuticle remover,
•    Birchwood manicure sticks,
•    liquid ridge fillers,
•    buffing wands,
•    a few neutral lacquer colors,
•    individual finger separators (to prevent smudges in your polish work) and
•    a professional quality shiny top coat.

The first step in preparing the nails is cleaning them, since people will notice dirty nails—and they'll talk about them. No matter how impeccable your facilities and service, presenting for viewing a body with dirty fingernails sends a bad message about the care you provide.

Start by lightly spraying under the free edge of each fingernail with a bottle filled with a bleach and water solution. This will help loosen dirt and debris, which can then be removed with a professional cleaning implement.

Next, check the nail plate. Are the nails stained yellow from nicotine or old fingernail polish? A good quality nail polish remover or the bleach solution can generally lighten this discoloration.

After the nails are clean and free of stains, dirt and old polish, analyze the shape. There are generally four basic fingernail shapes: round, square, pointed and oval. Shape accordingly using an emery board with a fine grit. Emery boards are great for smoothing ragged nails.

If the cuticles are thick and overgrown—a common occurrence in the elderly—use a cuticle remover. If ridges are present on the nail plate, a ridge filler or buffer generally will hide or remove them. At this point, the nails of men or of women who will not be getting a coat of polish can be buffed to a shine.

When color is called for
During the arrangement process, the funeral director should inform the family that a professional manicure will be included in the preparation of their loved one, ask for any specific requests and record them. The family may simply request a color or shade of polish, or may bring in a specific bottle of polish they want you to use. It is important to make sure the family's wishes are clear.

Before applying color to the cleaned and shaped nails, make sure you have removed all traces of old polish. Use foam finger separators to keep the finders spread apart as you work. This is especially helpful when dealing with arthritic fingers.

First, apply ridge filler to the nail plates and allow it to dry before applying nail color. To prevent smudges, the separators should be left in place until the lacquer is dry. Apply two coats of lacquer. Do not apply thick coats, since this will prevent the lacquer from drying and two thin coats generally work fine.

After the color has dried, apply a shiny top coat for a professional and finished appearance. You can reapply a shiny top coat the day of the viewing or service to freshen up the manicure.

With proper training and practice, you will be able to provide this important but sometimes overlooked service that communicates to the family that even the smallest of details has not been overlooked.

It is the embalmer's worst nightmare, the ticking time bomb which can explode at any time, under any conditions. Nothing can spread panic in a funeral home like having a family member come to the office and announce that "Something is running out of Mom's nose" or "There's stuff coming out of Dad's mouth."

Throughout my career, when I have been confronted with a family member announcing that "Something is running," I have seen calm, confident, competent embalmers hit the floor running to correct the problem. I have washed white shirts, washed casket pillows, taken remains out of the casket for reaspiration and, on a few occasions, replaced the mattress. Once I had to replace the entire casket.

Purge: The bane of the preparation room. Purge:  The tormentor of every embalmer on the face of the earth. Purge: The subject about which the public knows nothing, but has a definite psychological reaction to when confronted with it.

Purge can occur at any point in the body where an orifice exists—mouth, nose, ears, urethra, rectum or an artificial orifice such as a wound. Purge can be due to a number of factors, including hemorrhage, gas pressure or both, or excessive embalming pressure with unregulated rate of flow.

Purge from the mouth and nose usually originates in either the stomach or lungs, or both. The color of the purge will usually identify its origin. For instance, stomach purge usually is yellow to brown and can be semi-solid. Lung purge will usually be red to rust brown in color with a foamy texture. Ear purge is usually hemorrhagic in nature, or caused by putrefaction, both of which create intercranial pressure. Purge from the rectum and/or urethra is often due to gas in the hypogastric region. Nasty stuff!

After this unattractive and somewhat offensive but realistic description of the nature of purge, and before we examine the treatment for it, I need to quickly add that sometimes purge is a necessary and good aspect of embalming. But certainly not when it appears after the remains are placed in the casket.

I well remember one evening embalming deceased human remains which started to purge. I immediately turned off the injector and went to fetch my employer. When my boss arrived, he told me to start the injection again, and so I did. The purge continued in a variety of places, but there was no swelling or distension. My boss told me to continue injecting, clean everything up and then aspirate the remains.

Everything turned out wonderful and the family was well pleased. My boss' approach was to let the body respond naturally to the injection and allow the discharge from the case to take its natural course. Sometimes purge during embalming can be desirable.

Treatments
Stomach purge. All purge eventually will be conquered by aspiration and reaspiration. However, in the instance of stomach purge, 6 to 8 ounces of cavity fluid can be poured down the esophagus while the arterial injection continues. The action of the cavity fluid can solidify the stomach contents.

Also, a liberal amount of cotton soaked in cavity fluid and inserted down the throat in addition to the cavity fluid poured into the stomach can retard stomach purge. It is very important that if you pack the throat with cotton soaked in cavity fluid you also liberally apply massage cream to another portion of cotton and place this on top of the cotton/cavity fluid pack. This will ensure that the deceased's lips will not dehydrate from the astringent action of the HCHO fumes.

It is risky to aspirate the stomach with a sharp pointed trocar while the arterial injection is taking place. The pointed trocar can damage the mesenteric vessels even though the aorta and vena cava are not damaged.

Lung purge. When the cause and/or mode of death have resulted from disease or injury to the lungs or bronchial tree, the purge is usually going to be hemorrhagic in nature.

Six to 8 ounces of undiluted cavity fluid can be poured down the trachea, and a cavity pack can be placed into a throat soaked in cavity fluid. The reaction of the cavity chemical when in contact with blood is rapid coagulation. Hence, when lung purge occurs the cavity fluid not only will coagulate the blood, but also will help in the preservation of the lung tissues.

Ear purge. A purge from the ears is usually hemorrhagic and is usually of short duration, since generally it will stop once the intercranial pressure has been relieved. Brain aspiration is an effective way to relieve this type of pressure. The use of a trocar button will prevent leakage.

Gas purge. Urethral or rectal purges are easily taken care of in the preparation room. This is not pleasant work, but it needs to be done nonetheless. Packing and ligature ties are the most effective way, but the chemical companies have recently invented devices to be used in these instances which are much more sophisticated that the old-fashioned method of packing. However, a novice embalmer who does not or will not pack these private areas has not truly been baptized in the real world of embalming procedures.

How likely is bird flu to be a major problem in North America?
What do death care professionals need to do to protect themselves if they handle cases where the deceased had bird flu?

Speculation regarding bird flu and its worldwide repercussions is running rampant in the world press. Numerous predictions of a pandemic with worldwide devastation are common.

What actually are the facts and interrelationships of bird flu to human influenza viruses and the consequences of interaction and infection among the global human population? What do the embalming industry and individual embalmers need to know and do in the event that the worst case predictions come true? These topics will be discussed and analyzed in depth in our current article.

Bird flu is not human viral influenza, but they are closely related. Closely enough, in fact, that mutation and co-infection or cross-infection can and does occur, with potentially deadly consequences.

What history tells us to expect
The current Asian bird flu was first spotted in Hong Kong in late 1996-1997 and determined to be a new and virulent strain, designated H5Nl. It reemerged in Hong Kong again in 2003 and began its global march in 2004- 2005. Tens of millions of birds have been infected and died in these two years.

Asian bird flu has been found mostly in South Korea, Turkey, Southeast Asia, Ukraine, Romania, Russia and Karzakhstan. It is currently in the process of migrating allover Europe. Roughly 200 infections in humans have been documented and close to a hundred deaths attributed to this deadly H5Nl strain.

Symptoms of profound infection include: high fever (greater than 100.5), diarrhea, vomiting, bloody gums and nose, abdominal and chest pain, breathing problems developing in five days with respiratory distress, hoarseness, and cracking of voice, pneumonia quickly develops with bloody sputum and multi organ failure as the ultimate cause of death.

Approximately 200 people have been sickened worldwide, with close to 100 deaths reported. Looking at these statistics might lead one to believe of an imminent danger and maximum lethality (apparently at least 50 percent) from this virulent strain. Given the massive number of infected birds worldwide, the documented human infections are minuscule. Regular seasonal human flu kills 250,000-1 million people worldwide every year. Thirty-six thousand Americans die every year from regular seasonal flu.

The lethality of human strain viruses has historically been only a few deaths per 10,000. It is unlikely the H5Nl strain would be much above this, and the apparent high lethality would not play out in a worldwide pandemic, at not least in the developed countries.

The incubation period of H5Nl appears to be relatively longer than usual—two to eight days typically, possibly as long as two weeks. This compares to regular flu viruses that have incubation periods of two to three days. High-risk exposures would be handling of infected bird carcasses, drinking of duck blood (common in Southeast Asia) and long-term proximity to infected birds and their droppings.

Direct human-to-human transmittals are very rare and all occurred from close, long-term intimate contact. Healthcare workers, for example, do not appear to become infected despite the constant contact with patients. Some supposedly high-risk groups actually have low incidence of infection, such as slaughterhouse workers and other poultry workers.

On the other hand, some apparent low-risk groups have higher incidences, such as children playing in back yards with mixed wild and domestic fowl running loose (also typical in most infection areas). This is in stark contrast to poultry farming in the United States, where strict controls, sanitation, disinfection, inoculations and isolation techniques are typical.

The ability of the H5Nl virus to survive in the environment is relatively good, with survivability at six days at 98.6 degrees in carcasses and surfaces and up to 35 days in bird feces at only 39 degrees. This survival factor no doubt contributes to the tenacity of the strain and its ability to continually reappear despite efforts at eradication.

There have been deadly flus in the past, with the Spanish flu of 1918 being the most famous and lethal. The Spanish flu was an H1N1 strain of human flu that originated in the United States in 1918 and ended up killing between 20 to 50 million people worldwide. It was a typical strain that turned virulent when it literally marched into WWI through the trenches, battlefields and generalized overcrowded and unsanitary conditions of war. Its virulence, however, waned considerably within 18 months and it exists to this day as a normal flu strain that can still be found in some parts of the world.

The Asian flu of 1957-59 was an H2N2 derivative strain that was particularly deadly, with at least 70,000 dead in the United States alone. The China flu of 1968-69 was an H3N2 virulent strain that killed 34,000 in the United States (twice the normal number at that time). New strains are constantly appearing and targeting the worldwide human population, the most recent being an H7N7 strain that caused a limited outbreak in the Netherlands in 2003 but was contained.

The problem with the H5N1 bird strain is that there is no good treatment and no vaccine. The only effective way to control a flu epidemic is through vaccination. There is an experimental H5N1 vaccine that was based on an early 2004 variant. The United States has a few million doses of a partially effective vaccine and a new vaccine based on a much later mutated variant is in the works. At this point, however, there is no effective, hard hitting vaccine.

Relenza (zanamivir), a nasal inhalant and Tamiflu (oseltamivir), a capsule or oral suspension, are moderately effective in lessening the symptoms of typical strains of flu and reducing the virulence. Both are antiviral agents that target the viral protein neuraminidase (the N in strain typing) that allows the viral migration from infected to healthy cells. Both antiviral agents are for types A and B human strains, but some strains have shown unilateral and cross resistances, thus limiting their effectiveness.

Bird flu can and has jumped, in the past, from birds to humans. Bird flu viruses only infect ciliated epithelial cells, while human viral strains infect both ciliated and non-ciliated cells. The H5N1 strain that has been found in humans has been isolated deep in lung tissues, making it less likely for aerosolization and transmittal to other humans.

Millions of individuals, worldwide, handle chickens and other poultry, yet few, up to now, have contacted disease. At this point, it appears the H5N1 strain has some difficulties in human infectivity; however that can change. Avian flu viruses can go lethally transmissible to humans by gene swapping through a coinfected human (simultaneous avian and human strains) as in the 1957 and 1968 outbreaks, or by evolving into a lethal human strain, as in the 1918 outbreak. Fortunately, H5N1 does not appear to be progressing in either of these directions, from gene and strain monitoring for two years now. H5N1 has, however, learned how to become infective in rodents, cats and a very few humans.

Wild birds migrating are causing the worldwide spread with poultry smuggling, the fighting cocks trade and the illegal exotic bird trade contributing to cross-border failures at containment.

H5N1 does exhibit one unusual trait that has not been seen before. This strain is apparently capable of traveling from wild fowl to domestic poultry and then can back transmit from domestic poultry to wild fowl. This has never been observed before, as all other strains have dead-ended in domestic poultry and been eradicated by various measures.

There is no H5N1 strain in the United States, but no doubt it will show up. The problem will be migrating ducks, swans and geese. The impact will probably be limited due to our modem high tech poultry farming conditions and safeguards. The rest of the world's poultry farming is archaic compared to that in the United States.

How the U.S. has handled avian strains
Outbreaks of other avian strains have occurred over the years and been effectively eradicated. The latest outbreak was in Texas in 2004, which was an H5N2 strain that was quickly controlled by extermination and quarantine of chickens. The United States learned many of its lessons from a costly outbreak in Pennsylvania in 1968 which took two years to control and forced the destruction of 17 million chickens.

The U.S. poultry industry is set up for rapid response to future outbreaks, with swift and effective eradication and disposal of infected birds and inoculation of healthy stock. I concur with the analysis of some experts that the worst-case scenario would probably mimic the 1957 outbreak in the United States, as that strain also carried avian-derived variants of both the hemagglutinin (H) and neuraminidase (N) viral proteins and was new to human hosts at that time.

H1N1 variants of the 1918 Spanish flu still circulate and reappeared in 1977 in Southeast Asia, and may provide additional protection during a pandemic and prevent maximum lethality of the H5N1 strain.

Disinfection and sanitation measures are easy and effective. The viruses are very susceptible to sanitizing and disinfecting agents that are readily available. Thorough cooking of poultry destroys the virus and makes the meat safe to eat. Careful hand washing and use of hand sanitizers minimizes transmission and infection. Typical measures to control common flu viruses are effective against H5N1 bird flu.

Embalming room precautions
Despite doomsday predictions, embalming procedures utilizing universal precautions and the elimination of inhalable aerosols by the use of HEPA masks will provide effective protection to the embalmer during the embalming of these cases.

Disposal of embalming garments and HEPA masks is advised, as well as the use of disposable instruments or the thorough disinfection of all instruments after embalming with the use of a glutaraldehyde-based high-level disinfectant, with a pre-cleaning by a medium-level disinfectant. This coupled with the use of a highly effective disinfecting surface spray will ensure disinfection, sanitation and safety.

Selection of arterial and cavity chemicals should focus on maximum effectiveness of sanitation, with glutaraldehyde and phenolic based chemicals being the preferred choices, as they deliver, ounce-for-ounce, the maximum amount of sanitizing ability of available embalming chemicals.

No other unusual or extraordinary measures would be necessary in embalming and preparation. Normal post-embalming procedures would be unaffected and traditional viewings and funerals could be conducted, along with transport of bodies for final disposition.

So there you have it. A potentially deadly and troublesome situation, if and when it occurs, but not the doomsday scenario that has been painted by pop culture and the media.

References: Information about bird flu is voluminous on the Internet. Just Google it and a vast array of articles and information will appear from multiple sources, some excellent, others not so. WebMD is a good place to start, as well as some of the news sources. Discover magazine and New Scientist also have excellent and relevant articles concerning bird flu and related infectious topics.

Don Douthit
From our point of view, the person is a donor; from your point of view, that's the decedent.

A lot of the same things are going on in both of our worlds. The celebration of life: That's what people are doing when they donate organs and tissue. They are celebrating life and giving life to the next group of individuals.

Both our missions are time driven and time sensitive.

We in tissue banking and the organ procural world, we get it. And more and more tissue banks are hiring funeral professionals for this very reason, so they can help educate and make sure everybody understands we're all there.

It's real important to keep your folks up to date on all the technologies. Send them to schools, embalming seminars. Make sure you have the products you need to do the job. There is technology that must be kept up with.

Yes, it's invasive. Yes, it takes a lot of tissue out of the body that you're used to having there that causes additional work for you. But when you understand the grand scheme, remember two things:

1. It's about the mission, your mission and our mission.

2. It's about the donor, the deceased.

There has to be a balance we can get to.

Melissa Williams
What we hear a lot from funeral directors is, "Organ donation, that's OK, but that tissue thing, that doesn't save anybody's life." That's in the eye of the beholder. What if it were your child in need?

Generally speaking, preparation is no different than an autopsy or a trauma case, and the outcome is always under our control. Think outside the box. People call me all the time and say, "I have to have an artery; you didn't leave me any artery."

Well, if you had someone who had arterial sclerosis of the femoral artery and they got no fluid down to the leg, what would you do? You wouldn't just walk away and say, "He's going to be buried in a couple of days; I'm not going to worry about it."

No, you'd either have to hypodermically inject that leg, or you would have to go in and try to find another artery if one that were available.

This article compiled from an address presented by the authors at the 2006 ICFA Annual Convention

(Editor’s note: This is No.3 in a regular column by funeral director, embalmer and educator Todd Van Beck, who aims to promote high standards in embalming and restorative arts by sharing information about how to handle challenging cases.)

For years, this vascular condition has been a problem for most embalmers. This disease begins in the inner coating of the walls of the artery and results finally in a hardening and deterioration of the artery walls.

The vessel loses its elasticity and hence is easily broken. This has to be one of the greatest frustrations to embalmers when one of these normally elastic vessels breaks. In fact, sometimes the result of this condition is that the vessel is entirely obliterated.

Causes of arteriosclerosis are well known to embalmers. They include chronic alcoholism, gout, overeating, stress and kidney disease.

Bodies with this condition are usually not out of the ordinary so far as external appearances are concerned. Often the person finally died from a stroke and/or heart condition. Sometimes the sclerosis continues into the capillaries and then the embalmer is confronted with a condition resembling phlebitis.

The body should be massaged with a high quality massage cream, one manufactured by a trusted embalming chemical company. I have seen embalmers use Vaseline or other petroleum-based creams, resulting in an increased dehydration of the tissues, which is the opposite of what you want to achieve with the massage cream.

Quality massage treatments usually result in improved quality of embalming, because the cream helps remove the external film of discoloration and also soften and prepare the skin to receive the embalming chemical. A light film of massage cream should be left on the hands and face to prevent the dry air from coming into contact with the skin of these exposed areas, further contributing to dehydration.

To raise the artery, instead of using the arterial injection tube, use a child-sized arterial tube—not necessarily a radial tube, but a normal child-sized injector cannula. There are two good reasons for doing this. First, it will prevent breaking the inner coating of sclerotic material and pushing this up ahead of the cannula. Second, it will prevent too rapid injection, which would result in a rapture of the artery's inner coat, completely blocking the injection process.

I also suggest that when ligating the vessel to the child-sized injection tube the embalmer use regular gauze instead of regular ligature to tie the vessel to the injection tube. The gauze is wider, thus it distributes the sealing action of the ligature without cutting the fragile vessel.

Also, it might be necessary to "snake" the injection cannula in and between the sclerotic materials. It is well worth the time to carefully manipulate the cannula into place. Of course, there are no guarantees, and in some advanced and complicated cases multiple injection and drainage sites will need to be used.

I once knew a veteran trade embalmer who used the axillary with a child's injection cannula as the injection site and drained from the femoral vein with profound results.

Use a quality pre-injection solution of 4 ounces per half gallon and inject slowly at approximately a gallon every 15 minutes. Then formulate your arterial solution according to your own judgment and desire. Remember that today one of the major problems in embalming is using an arterial solution that is too weak or at a volume that is too low to saturate the tissues.

These cases can be very challenging, but if we use precautions, time and patience, the results can be very satisfactory.
 

Is Embalming Reguired?

Embalming requirements vary from state to state. Some states do require it for all deceased bodies. Some require it if there is going to be a viewing period of more than a specified period of time, for example 36 hours. Some mausoleums require all bodies entombed in above-ground crypts be embalmed. Some religious faiths do not allow embalming (ex. Judaism, Muslim). If the body will not be buried within a day after death, many states require the body be refrigerated until it is transported to the cemetery or other final place of rest or cremation.

NOTE: contrary to popular idea, embalming does not provide perfect, perpetual preservation. It merely slows the decomposition process. All bodies will eventually decompose to some degree. Depending on conditions in the grounds, they may more mummify than decompose.