When Breath Becomes Air (7 page)

“But how do you know when the tracing looks bad enough? Which is worse, being born too early or waiting too long to deliver?”

“Judgment call.”

What a call to make. In my life, had I ever made a decision harder than choosing between a French dip and a Reuben? How could I ever learn to make, and live with, such judgment calls? I still had a lot of practical medicine to learn, but would knowledge alone be enough, with life and death hanging in the balance? Surely intelligence wasn’t enough; moral clarity was needed as well. Somehow, I had to believe, I would gain not only knowledge but wisdom, too. After all, when I had walked into the hospital just one day before, birth and death had been merely abstract concepts. Now I had seen them both up close. Maybe Beckett’s Pozzo is right. Maybe life
is
merely an “instant,” too brief to consider. But my focus would have to be on my imminent role, intimately involved with the when and how of death—the grave digger with the forceps.

Not long after, my ob-gyn rotation ended, and it was immediately on to surgical oncology. Mari, a fellow med student, and I would rotate together. A few weeks in, after a sleepless night, she was assigned to assist in a Whipple, a complex operation that involves rearranging most abdominal organs in an attempt to resect pancreatic cancer, an operation in which a medical student typically stands still—or, at best, retracts—for up to nine hours straight. It’s considered the plum operation to be selected to help with, because of its extreme complexity—only chief residents are allowed to actively participate. But it is grueling, the ultimate test of a general surgeon’s skill. Fifteen minutes after the operation started, I saw Mari in the hallway, crying. The surgeon always begins a Whipple by inserting a small camera through a tiny incision to look for metastases, as widespread cancer renders the operation useless and causes its cancellation. Standing there, waiting in the OR with a nine-hour surgery stretching out before her, Mari had a whisper of a thought:
I’m so tired—please God, let there be mets
. There were. The patient was sewn back up, the procedure called off. First came relief, then a gnawing, deepening shame. Mari burst out of the OR, where, needing a confessor, she saw me, and I became one.

—

In the fourth year of medical school, I watched as, one by one, many of my classmates elected to specialize in less demanding areas (radiology or dermatology, for example) and applied for their residencies. Puzzled by this, I gathered data from several elite medical schools and saw that the trends were the same: by the end of medical school, most students tended to focus on “lifestyle” specialties—those with more humane hours, higher salaries, and lower pressures—the idealism of their med school application essays tempered or lost. As graduation neared and we sat down, in a Yale tradition, to rewrite our commencement oath—a melding of the words of Hippocrates, Maimonides, Osler, along with a few other great medical forefathers—several students argued for the removal of language insisting that we place our patients’ interests above our own. (The rest of us didn’t allow this discussion to continue for long. The words stayed. This kind of egotism struck me as antithetical to medicine and, it should be noted, entirely reasonable. Indeed, this is how 99 percent of people select their jobs: pay, work environment, hours. But that’s the point. Putting lifestyle first is how you find a job—not a calling.)

As for me, I would choose neurosurgery as my specialty. The choice, which I had been contemplating for some time, was cemented one night in a room just off the OR, when I listened in quiet awe as a pediatric neurosurgeon sat down with the parents of a child with a large brain tumor who had come in that night complaining of headaches. He not only delivered the clinical facts but addressed the human facts as well, acknowledging the tragedy of the situation and providing guidance. As it happened, the child’s mother was a radiologist. The tumor looked malignant—the mother had already studied the scans, and now she sat in a plastic chair, under fluorescent light, devastated.

“Now, Claire,” the surgeon began, softly.

“Is it as bad as it looks?” the mother interrupted. “Do you think it’s cancer?”

“I don’t know. What I
do
know—and I know you know these things, too—is that your life is about to—it already has changed. This is going to be a long haul, you understand? You have got to be there for each other, but you also have to get your rest when you need it. This kind of illness can either bring you together, or it can tear you apart. Now more than ever, you have to be there for each other. I don’t want either of you staying up all night at the bedside or never leaving the hospital. Okay?”

He went on to describe the planned operation, the likely outcomes and possibilities, what decisions needed to be made now, what decisions they should start thinking about but didn’t need to decide on immediately, and what sorts of decisions they should not worry about at all yet. By the end of the conversation, the family was not at ease, but they seemed able to face the future. I had watched the parents’ faces—at first wan, dull, almost otherworldly—sharpen and focus. And as I sat there, I realized that the questions intersecting life, death, and meaning, questions that all people face at some point, usually arise in a medical context. In the actual situations where one encounters these questions, it becomes a necessarily philosophical and biological exercise. Humans are organisms, subject to physical laws, including, alas, the one that says entropy always increases. Diseases are molecules misbehaving; the basic requirement of life is metabolism, and death its cessation.

While all doctors treat diseases, neurosurgeons work in the crucible of identity: every operation on the brain is, by necessity, a manipulation of the substance of our selves, and every conversation with a patient undergoing brain surgery cannot help but confront this fact. In addition, to the patient and family, the brain surgery is usually the most dramatic event they have ever faced and, as such, has the impact of any major life event. At those critical junctures, the question is not simply whether to live or die but what kind of life is worth living. Would you trade your ability—or your mother’s—to talk for a few extra months of mute life? The expansion of your visual blind spot in exchange for eliminating the small possibility of a fatal brain hemorrhage? Your right hand’s function to stop seizures? How much neurologic suffering would you let your child endure before saying that death is preferable? Because the brain mediates our experience of the world, any neurosurgical problem forces a patient and family, ideally with a doctor as a guide, to answer this question: What makes life meaningful enough to go on living?

I was compelled by neurosurgery, with its unforgiving call to perfection; like the ancient Greek concept
arete,
I thought, virtue required moral, emotional, mental, and physical excellence. Neurosurgery seemed to present the most challenging and direct confrontation with meaning, identity, and death. Concomitant with the enormous responsibilities they shouldered, neurosurgeons were also masters of many fields: neurosurgery, ICU medicine, neurology, radiology. Not only would I have to train my mind and hands, I realized; I’d have to train my eyes, and perhaps other organs as well. The idea was overwhelming and intoxicating: perhaps I, too, could join the ranks of these polymaths who strode into the densest thicket of emotional, scientific, and spiritual problems and found, or carved, ways out.

—

After medical school, Lucy and I, newly married, headed to California to begin our residencies, me at Stanford, Lucy just up the road at UCSF. Medical school was officially behind us—now real responsibility lay in wait. In short order, I made several close friends in the hospital, in particular Victoria, my co-resident, and Jeff, a general surgery resident a few years senior to us. Over the next seven years of training, we would grow from bearing witness to medical dramas to becoming leading actors in them.

As an intern in the first year of residency, one is little more than a paper pusher against a backdrop of life and death—though, even then, the workload is enormous. My first day in the hospital, the chief resident said to me, “Neurosurgery residents aren’t just the best surgeons—we’re the best
doctors
in the hospital. That’s your goal. Make us proud.” The chairman, passing through the ward: “Always eat with your left hand. You’ve got to learn to be ambidextrous.” One of the senior residents: “Just a heads-up—the chief is going through a divorce, so he’s really throwing himself into his work right now. Don’t make small talk with him.” The outgoing intern who was supposed to orient me but instead just handed me a list of forty-three patients: “The only thing I have to tell you is: they can always hurt you more, but they can’t stop the clock.” And then he walked away.

I didn’t leave the hospital for the first two days, but before long, the impossible-seeming, day-killing mounds of paperwork were only an hour’s work. Still, when you work in a hospital, the papers you file aren’t just papers: they are fragments of narratives filled with risks and triumphs. An eight-year-old named Matthew, for example, came in one day complaining of headaches only to learn that he had a tumor abutting his hypothalamus. The hypothalamus regulates our basic drives: sleep, hunger, thirst, sex. Leaving any tumor behind would subject Matthew to a life of radiation, further surgeries, brain catheters…in short, it would consume his childhood. Complete removal could prevent that, but at the risk of damaging his hypothalamus, rendering him a slave to his appetites. The surgeon got to work, passed a small endoscope through Matthew’s nose, and drilled off the floor of his skull. Once inside, he saw a clear plane and removed the tumor. A few days later, Matthew was bopping around the ward, sneaking candies from the nurses, ready to go home. That night, I happily filled out the endless pages of his discharge paperwork.

I lost my first patient on a Tuesday.

She was an eighty-two-year-old woman, small and trim, the healthiest person on the general surgery service, where I spent a month as an intern. (At her autopsy, the pathologist would be shocked to learn her age: “She has the organs of a fifty-year-old!”) She had been admitted for constipation from a mild bowel obstruction. After six days of hoping her bowels would untangle themselves, we did a minor operation to help sort things out. Around eight
P.M.
Monday night, I stopped by to check on her, and she was alert, doing fine. As we talked, I pulled from my pocket my list of the day’s work and crossed off the last item (post-op check, Mrs. Harvey). It was time to go home and get some rest.

Sometime after midnight, the phone rang. The patient was crashing. With the complacency of bureaucratic work suddenly torn away, I sat up in bed and spat out orders: “One liter bolus of LR, EKG, chest X-ray, stat—I’m on my way in.” I called my chief, and she told me to add labs and to call her back when I had a better sense of things. I sped to the hospital and found Mrs. Harvey struggling for air, her heart racing, her blood pressure collapsing. She wasn’t getting better no matter what I did; and as I was the only general surgery intern on call, my pager was buzzing relentlessly, with calls I could dispense with (patients needing sleep medication) and ones I couldn’t (a rupturing aortic aneurysm in the ER). I was drowning, out of my depth, pulled in a thousand directions, and Mrs. Harvey was still not improving. I arranged a transfer to the ICU, where we blasted her with drugs and fluids to keep her from dying, and I spent the next few hours running between my patient threatening to die in the ER and my patient actively dying in the ICU. By 5:45 
A.M
., the patient in the ER was on his way to the OR, and Mrs. Harvey was relatively stable. She’d needed twelve liters of fluid, two units of blood, a ventilator, and three different pressors to stay alive.

When I finally left the hospital, at five
P.M.
on Tuesday evening, Mrs. Harvey wasn’t getting better—or worse. At seven
P.M.
, the phone rang: Mrs. Harvey had coded, and the ICU team was attempting CPR. I raced back to the hospital, and once again, she pulled through. Barely. This time, instead of going home, I grabbed dinner near the hospital, just in case.

At eight
P.M.
, my phone rang: Mrs. Harvey had died.

I went home to sleep.

I was somewhere between angry and sad. For whatever reason, Mrs. Harvey had burst through the layers of paperwork to become my patient. The next day, I attended her autopsy, watched the pathologists open her up and remove her organs. I inspected them myself, ran my hands over them, checked the knots I had tied in her intestines. From that point on, I resolved to treat all my paperwork as patients, and not vice versa.

In that first year, I would glimpse my share of death. I sometimes saw it while peeking around corners, other times while feeling embarrassed to be caught in the same room. Here were a few of the people I saw die:

1.  An alcoholic, his blood no longer able to clot, who bled to death into his joints and under his skin. Every day, the bruises would spread. Before he became delirious, he looked up at me and said, “It’s not fair—I’ve been diluting my drinks with water.”

2.  A pathologist, dying of pneumonia, wheezing her death rattle before heading down to be autopsied—her final trip to the pathology lab, where she had spent so many years of her life.

3.  A man who’d had a minor neurosurgical procedure to treat lightning bolts of pain that were shooting through his face: a tiny drop of liquid cement had been placed on the suspected nerve to keep a vein from pressing on it. A week later, he developed massive headaches. Nearly every test was run, but no diagnosis was ever identified.

4.  Dozens of cases of head trauma: suicides, gunshots, bar fights, motorcycle accidents, car crashes. A moose attack.

At moments, the weight of it all became palpable. It was in the air, the stress and misery. Normally, you breathed it in, without noticing it. But some days, like a humid muggy day, it had a suffocating weight of its own. Some days, this is how it felt when I was in the hospital: trapped in an endless jungle summer, wet with sweat, the rain of tears of the families of the dying pouring down.