When Breath Becomes Air

by Paul Kalanithi

  “C’mon,” he said. “We don’t have a lot of time. We need to move faster!”

  I was standing next to the attending as he sliced open the woman’s belly, making a single long curvilinear incision beneath her belly button, just below the apex of her protuberant womb. I tried to follow every movement, digging in my brain for textbook anatomical sketches. The skin slid apart at the scalpel’s touch. He sliced confidently through the tough white rectus fascia covering the muscle, then split the fascia and the underlying muscle with his hands, revealing the first glimpse of the melon-like uterus. He sliced that open as well, and a small face appeared, then disappeared amid the blood. In plunged the doctor’s hands, pulling out one, then two purple babies, barely moving, eyes fused shut, like tiny birds fallen too soon from a nest. With their bones visible through translucent skin, they looked more like the preparatory sketches of children than children themselves. Too small to cradle, not much bigger than the surgeon’s hands, they were rapidly passed to the waiting neonatal intensivists, who rushed them to the neonatal ICU.

  With the immediate danger averted, the pace of the operation slowed, frenzy turning to something resembling calm. The odor of burnt flesh wafted up as the cautery arrested little spurts of blood. The uterus was sutured back together, the stitches like a row of teeth, biting closed the open wound.

  “Professor, do you want the peritoneum closed?” Melissa asked. “I read recently that it doesn’t need to be.”

  “Let no man put asunder what God has joined,” the attending said. “At least, no more than temporarily. I like to leave things the way I found them—let’s sew it back up.”

  The peritoneum is a membrane that surrounds the abdominal cavity. Somehow I had completely missed its opening, and I couldn’t see it at all now. To me, the wound looked like a mass of disorganized tissue, yet to the surgeons it had an appreciable order, like a block of marble to a sculptor.

  Melissa called for the peritoneal stitch, reached her forceps into the wound, and pulled up a transparent layer of tissue between the muscle and the uterus. Suddenly the peritoneum, and the gaping hole in it, was clear. She sewed it closed and moved on to the muscle and fascia, putting them back together with a large needle and a few big looping stitches. The attending left, and finally the skin was sutured together. Melissa asked me if I wanted to place the last two stitches.

  My hands shook as I passed the needle through the subcutaneous tissue. As I tightened down the suture, I saw that the needle was slightly bent. The skin had come together lopsided, a glob of fat poking through.

  Melissa sighed. “That’s uneven,” she said. “You have to just catch the dermal layer—you see this thin white stripe?”

  I did. Not only would my mind have to be trained, my eyes would, too.

  “Scissors!” Melissa cut out my amateur knots, resutured the wound, applied the dressing, and the patient was taken to recovery.

  As Melissa had told me earlier, twenty-four weeks in utero was considered the edge of viability. The twins had lasted twenty-three weeks and six days. Their organs were present, but perhaps not yet ready for the responsibility of sustaining life. They were owed nearly four more months of protected development in the womb, where oxygenated blood and nutrients came to them through the umbilical cord. Now oxygen would have to come through the lungs, and the lungs were not capable of the complex expansion and gas transfer that was respiration. I went to see them in the NICU, each twin encased in a clear plastic incubator, dwarfed by large, beeping machines, barely visible amid the tangle of wires and tubes. The incubator had small side ports through which the parents could strain to reach and gently stroke a leg or arm, providing vital human contact.

  The sun was up, my shift over. I was sent home, the image of the twins being extracted from the uterus interrupting my sleep. Like a premature lung, I felt unready for the responsibility of sustaining life.

  When I returned to work that night, I was assigned to a new mother. No one anticipated problems with this pregnancy. Things were as routine as possible; today was even her actual due date. Along with the nurse, I followed the mother’s steady progress, contractions racking her body with increasing regularity. The nurse reported the dilation of the cervix, from three centimeters to five to ten.

  “Okay, it’s time to push now,” the nurse said.

  Turning to me, she said, “Don’t worry—we’ll page you when the delivery is close.”

  I found Melissa in the doctors’ lounge. After some time, the OB team was called into the room: delivery was near. Outside the door, Melissa handed me a gown, gloves, and a pair of long boot covers.

  “It gets messy,” she said.

  We entered the room. I stood awkwardly off to the side until Melissa pushed me to the front, between the patient’s legs, just in front of the attending.

  “Push!” the nurse encouraged. “Now again: just like that, only without the screaming.”

  The screaming didn’t stop, and was soon accompanied by a gush of blood and other fluids. The neatness of medical diagrams did nothing to represent Nature, red not only in tooth and claw but in birth as well. (An Anne Geddes photo this was not.) It was becoming clear that learning to be a doctor in practice was going to be a very different education from being a medical student in the classroom. Reading books and answering multiple-choice questions bore little resemblance to taking action, with its concomitant responsibility. Knowing you need to be judicious when pulling on the head to facilitate delivery of the shoulder is not the same as doing it. What if I pulled too hard? (Irreversible nerve injury, my brain shouted.) The head appeared with each push and then retracted with each break, three steps forward, two steps back. I waited. The human brain has rendered the organism’s most basic task, reproduction, a treacherous affair. That same brain made things like labor and delivery units, cardiotocometers, epidurals, and emergency C-sections both possible and necessary.

  I stood still, unsure when to act or what to do. The attending’s voice guided my hands to the emerging head, and on the next push, I gently guided the baby’s shoulders as she came out. She was large, plump, and wet, easily three times the size of the birdlike creatures from the previous night. Melissa clamped the cord, and I cut it. The child’s eyes opened and she began to cry. I held the baby a moment longer, feeling her weight and substance, then passed her to the nurse, who brought her to the mother.

  I walked out to the waiting room to inform the extended family of the happy news. The dozen or so family members gathered there leapt up to celebrate, a riot of handshakes and hugs. I was a prophet returning from the mountaintop with news of a joyous new covenant! All the messiness of the birth disappeared; here I had just been holding the newest member of this family, this man’s niece, this girl’s cousin.

  Returning to the ward, ebullient, I ran into Melissa.

  “Hey, do you know how last night’s twins are doing?” I asked.

  She darkened. Baby A died yesterday afternoon; Baby B managed to live not quite twenty-four hours, then passed away around the time I was delivering the new baby. In that moment, I could only think of Samuel Beckett, the metaphors that, in those twins, reached their terminal limit: “One day we were born, one day we shall die, the same day, the same second….Birth astride of a grave, the light gleams an instant, then it’s night once more.” I had stood next to “the grave digger” with his “forceps.” What had these lives amounted to?

  “You think that’s bad?” she continued. “Most mothers with stillborns still have to go through labor and deliver. Can you imagine? At least these guys had a chance.”

  A match flickers but does not light. The mother’s wailing in room 543, the searing red rims of the father’s lower eyelids, tears silently streaking his face: this flip side of joy, the unbearable, unjust, unexpected presence of death…What possible sense could be made, what words were there for comfort?

  “Was it the right choice, to do an emergency C-section?” I asked.

  “No question,” she said
. “It was the only shot they had.”

  “What happens if you don’t?”

  “Probably, they die. Abnormal fetal heart tracings show when the fetal blood is turning acidemic; the cord is compromised somehow, or something else seriously bad is happening.”

  “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.