When Breath Becomes Air Part 3

Yet openness to human relationality also carried a price.

One evening in my third year, I ran into Jeff, my friend in general surgery, a similarly intense and demanding profession. We each noted the other's despondency. "You go first," he said. And I described the death of a child, shot in the head for wearing the wrong color shoes, but he had been so close to making it...Amid a recent spate of fatal, inoperable brain tumors, my hopes had been pinned on this kid pulling through, and he hadn't. Jeff paused, and I awaited his story. Instead, he laughed, punched me in the arm, and said, "Well, I guess I learned one thing: if I'm ever feeling down about my work, I can always talk to a neurosurgeon to cheer myself up."

Driving home later that night, after gently explaining to a mother that her newborn had been born without a brain and would die shortly, I switched on the radio; NPR was reporting on the continuing drought in California. Suddenly, tears were streaming down my face.

Being with patients in these moments certainly had its emotional cost, but it also had its rewards. I don't think I ever spent a minute of any day wondering why I did this work, or whether it was worth it. The call to protect life-and not merely life but another's ident.i.ty; it is perhaps not too much to say another's soul-was obvious in its sacredness.

Before operating on a patient's brain, I realized, I must first understand his mind: his ident.i.ty, his values, what makes his life worth living, and what devastation makes it reasonable to let that life end. The cost of my dedication to succeed was high, and the ineluctable failures brought me nearly unbearable guilt. Those burdens are what make medicine holy and wholly impossible: in taking up another's cross, one must sometimes get crushed by the weight.

- Midway through residency, time is set aside for additional training. Perhaps unique in medicine, the ethos of neurosurgery-of excellence in all things-maintains that excellence in neurosurgery alone is not enough. In order to carry the field, neurosurgeons must venture forth and excel in other fields as well. Sometimes this is very public, as in the case of the neurosurgeon-journalist Sanjay Gupta, but most often the doctor's focus is on a related field. The most rigorous and prestigious path is that of the neurosurgeon-neuroscientist.

In my fourth year, I began work in a Stanford lab dedicated to basic motor neuroscience and the development of neural prosthetic technology that would allow, say, paralyzed people to mentally control a computer cursor or robot arm. The head of the lab, a professor of electrical engineering and neurobiology, a fellow second-generation Indian, was affectionately called "V" by everyone. V was seven years older than I, but we got on like brothers. His lab had become a world leader in reading out brain signals, but with his blessing I embarked on a project to do the reverse: to write signals into the brain. After all, if your robot arm can't feel how hard it's grasping a winegla.s.s, you will break a lot of winegla.s.ses. The implications of writing signals into the brain, or "neuromodulation," however, were far more wide-reaching than that: being able to control neural firing would conceivably allow treatment of a host of currently untreatable or intractable neurological and psychiatric diseases, from major depression to Huntington's to schizophrenia to Tourette's to OCD...the possibilities were limitless. Putting surgery aside now, I set to work learning to apply new techniques in gene therapy in a series of "first of its kind" experiments.

After I'd been there for a year, V and I sat down for one of our weekly meetings. I had grown to love these chats. V was not like other scientists I knew. He was soft-spoken and cared deeply about people and the clinical mission, and he often confessed to me that he wished he'd been a surgeon himself. Science, I had come to learn, is as political, compet.i.tive, and fierce a career as you can find, full of the temptation to find easy paths.

One could count on V to always choose the honest (and, often, self-effacing) way forward. While most scientists connived to publish in the most prestigious journals and get their names out there, V maintained that our only obligation was to be authentic to the scientific story and to tell it uncompromisingly. I'd never met someone so successful who was also so committed to goodness. V was an actual paragon.

Instead of smiling as I sat down across from him, he looked pained. He sighed and said, "I need you to wear your doctor hat right now."

"Okay."

"They tell me I have pancreatic cancer."

"V...okay. Tell me the story."

He laid out his gradual weight loss, indigestion, and his recent "precautionary" CT scan-a truly nonstandard procedure at this point-which showed a pancreatic ma.s.s. We discussed the way forward, the dreaded Whipple operation in his near future ("You are going to feel like a truck hit you," I told him), who the best surgeons were, the impact the illness would have on his wife and children, and how to run the lab during his prolonged absence. Pancreatic cancer has a dismal prognosis, but of course there was no way to know what that meant for V.

He paused. "Paul," he said, "do you think my life has meaning? Did I make the right choices?"

It was stunning: even someone I considered a moral exemplar had these questions in the face of mortality.

V's surgery, chemotherapy, and radiation treatments were trying, but a success. He was back at work a year later, just as I was returning to my clinical duties in the hospital. His hair had thinned and whitened, and the spark in his eyes had dulled. During our final weekly chat, he turned to me and said, "You know, today is the first day it all seems worth it. I mean, obviously, I would've gone through anything for my kids, but today is the first day that all the suffering seems worth it."

How little do doctors understand the h.e.l.ls through which we put patients.

- In my sixth year, I returned to the hospital full-time, my research in V's lab now relegated to days off and idle moments, such as they were. Most people, even your closest colleagues, don't quite understand the black hole that is neurosurgical residency. One of my favorite nurses, after sticking around until ten P.M. one night to help us finish a long and difficult case, said to me, "Thank G.o.d I have tomorrow off. Do you, too?"

"Um, no."

"But at least you can come in later or something, right? When do you usually get in?"

"Six A.M."

"No. Really?"

"Yep."

"Every day?"

"Every day."

"Weekends, too?"

"Don't ask."

In residency, there's a saying: The days are long, but the years are short. In neurosurgical residency, the day usually began at six A.M. and lasted until the operating was done, which depended, in part, on how quick you were in the OR.

A resident's surgical skill is judged by his technique and his speed. You can't be sloppy, and you can't be slow. From your first wound closure onward, spend too much time being precise and the scrub tech will announce, "Looks like we've got a plastic surgeon on our hands!" Or: "I get your strategy: by the time you finish sewing the top half of the wound, the bottom will have healed on its own! Half the work-very smart!" A chief resident will advise a junior, "Learn to be fast now. You can learn to be good later." In the OR, everyone's eyes are always on the clock. For the patient's sake: How long has he been under anesthesia? During long procedures, nerves can get damaged, muscles can break down, kidneys can fail. For everyone else's sake: What time are we getting out of here tonight?

I could see that there were two strategies to cutting the time short, perhaps best exemplified by the tortoise and the hare. The hare moves as fast as possible, hands a blur, instruments clattering, falling to the floor; the skin slips open like a curtain, the skull flap is on the tray before the bone dust settles. As a result, the opening might need to be expanded a centimeter here or there because it's not optimally placed. The tortoise, on the other hand, proceeds deliberately, with no wasted movements, measuring twice, cutting once. No step of the operation needs revisiting; everything moves in a precise, orderly fas.h.i.+on. If the hare makes too many minor missteps and has to keep adjusting, the tortoise wins. If the tortoise spends too much time planning each step, the hare wins.

The funny thing about time in the OR, whether you race frenetically or proceed steadily, is that you have no sense of it pa.s.sing. If boredom is, as Heidegger argued, the awareness of time pa.s.sing, then surgery felt like the opposite: the intense focus made the arms of the clock seem arbitrarily placed. Two hours could feel like a minute. Once the final st.i.tch was placed and the wound was dressed, normal time suddenly restarted. You could almost hear an audible whoosh. Then you started wondering: How long until the patient wakes up? How long until the next case is rolled in? And what time will I get home tonight?

It wasn't until the last case finished that I felt the length of the day, the drag in my step. Those last few administrative tasks before leaving the hospital were like anvils.

Could it wait until tomorrow?

No.

A sigh, and Earth continued to rotate back toward the sun.

- As a chief resident, nearly all responsibility fell on my shoulders, and the opportunities to succeed-or fail-were greater than ever. The pain of failure had led me to understand that technical excellence was a moral requirement. Good intentions were not enough, not when so much depended on my skills, when the difference between tragedy and triumph was defined by one or two millimeters.

One day, Matthew, the little boy with the brain tumor who had charmed the ward a few years back, was readmitted. His hypothalamus had, in fact, been slightly damaged during the operation to remove his tumor; the adorable eight-year-old was now a twelve-year-old monster. He never stopped eating; he threw violent fits. His mother's arms were scarred with purple scratches. Eventually Matthew was inst.i.tutionalized: he had become a demon, summoned by one millimeter of damage. For every surgery, a family and a surgeon decide together that the benefits outweigh the risks, but this was still heartbreaking. No one wanted to think about what Matthew would be like as a three-hundred-pound twenty-year-old.

Another day, I placed an electrode nine centimeters deep in a patient's brain to treat a Parkinson's tremor. The target was the subthalamic nucleus, a tiny almond-shaped structure deep in the brain. Different parts of it subserve different functions: movement, cognition, emotion. In the operating room, we turned on the current to a.s.sess the tremor. With all our eyes on the patient's left hand, we agreed the tremor looked better.

Then the patient's voice, confused, rose above our affirmative murmurs: "I feel...overwhelmingly sad."

"Current off!" I said.

"Oh, now the feeling is going away," the patient said.

"Let's recheck the current and impedance, okay? Okay. Current on..."

"No, everything...it just feels...so sad. Just dark and, and...sad."

"Electrode out!"

We pulled the electrode out and reinserted it, this time two millimeters to the right. The tremor went away. The patient felt, thankfully, fine.

Once, I was doing a late-night case with one of the neurosurgery attendings, a suboccipital craniectomy for a brain-stem malformation. It's one of the most elegant surgeries, in perhaps the most difficult part of the body-just getting there is tricky, no matter how experienced you are. But that night, I felt fluid: the instruments were like extensions of my fingers; the skin, muscle, and bone seemed to unzip themselves; and there I was, staring at a yellow, glistening bulge, a ma.s.s deep in the brain stem. Suddenly, the attending stopped me.

"Paul, what happens if you cut two millimeters deeper right here?" He pointed.

Neuroanatomy slides whirred through my head.

"Double vision?"

"No," he said. "Locked-in syndrome." Another two millimeters, and the patient would be completely paralyzed, save for the ability to blink. He didn't look up from the microscope. "And I know this because the third time I did this operation, that's exactly what happened."

Neurosurgery requires a commitment to one's own excellence and a commitment to another's ident.i.ty. The decision to operate at all involves an appraisal of one's own abilities, as well as a deep sense of who the patient is and what she holds dear. Certain brain areas are considered near-inviolable, like the primary motor cortex, damage to which results in paralysis of affected body parts. But the most sacrosanct regions of the cortex are those that control language. Usually located on the left side, they are called Wernicke's and Broca's areas; one is for understanding language and the other for producing it. Damage to Broca's area results in an inability to speak or write, though the patient can easily understand language. Damage to Wernicke's area results in an inability to understand language; though the patient can still speak, the language she produces is a stream of unconnected words, phrases, and images, a grammar without semantics. If both areas are damaged, the patient becomes an isolate, something central to her humanity stolen forever. After someone suffers a head trauma or a stroke, the destruction of these areas often restrains the surgeon's impulse to save a life: What kind of life exists without language?

When I was a med student, the first patient I met with this sort of problem was a sixty-two-year-old man with a brain tumor. We strolled into his room on morning rounds, and the resident asked him, "Mr. Michaels, how are you feeling today?"

"Four six one eight nineteen!" he replied, somewhat affably.

The tumor had interrupted his speech circuitry, so he could speak only in streams of numbers, but he still had prosody, he could still emote: smile, scowl, sigh. He recited another series of numbers, this time with urgency. There was something he wanted to tell us, but the digits could communicate nothing other than his fear and fury. The team prepared to leave the room; for some reason, I lingered.

"Fourteen one two eight," he pleaded with me, holding my hand. "Fourteen one two eight."

"I'm sorry."

"Fourteen one two eight," he said mournfully, staring into my eyes.

And then I left to catch up to the team. He died a few months later, buried with whatever message he had for the world.

When tumors or malformations abut these language areas, the surgeon takes numerous precautions, ordering a host of different scans, a detailed neuropsychological examination. Critically, however, the surgery is performed with the patient awake and talking. Once the brain is exposed, but before the tumor excision, the surgeon uses a hand-held ball-tip electrode to deliver electrical current to stun a small area of the cortex while the patient performs various verbal tasks: naming objects, reciting the alphabet, and so on. When the electrode sends current into a critical piece of cortex, it disrupts the patient's speech: "A B C D E guh guh guh rrrr...F G H I..." The brain and the tumor are thus mapped to determine what can be resected safely, and the patient is kept awake throughout, occupied with a combination of formal verbal tasks and small talk.

One evening, as I was prepping for one of these cases, I reviewed the patient's MRI and noted that the tumor completely covered the language areas. Not a good sign. Reviewing the notes, I saw that the hospital's tumor board-an expert panel of surgeons, oncologists, radiologists, and pathologists-had deemed the case too dangerous for surgery. How could the surgeon have opted to proceed? I became a little indignant: at a certain point, it was our job to say no. The patient was wheeled into the room. He fixed his eyes on me and pointed to his head. "I want this thing out of my f.u.c.king brain. Got it?"

The attending strolled in and saw the expression on my face. "I know," he said. "I tried talking him out of this for about two hours. Don't bother. Ready to go?"

Instead of the usual alphabet recital or counting exercise, we were treated, throughout the surgery, to a litany of profanity and exhortation.

"Is that f.u.c.king thing out of my head yet? Why are you slowing down? Go faster! I want it out. I can stay here all f.u.c.king day, I don't care, just get it out!"

I slowly removed the enormous tumor, attentive to the slightest hint of speech difficulty. With the patient's monologue unceasing, the tumor now sat on a petri dish, his clean brain gleaming.

"Why'd you stop? You some kinda a.s.shole? I told you I want the f.u.c.king thing gone!"

"It's done," I said. "It's out."

How was he still talking? Given the size and location of the tumor, it seemed impossible. Profanity supposedly ran on a slightly different circuit from the rest of language. Perhaps the tumor had caused his brain to rewire somehow...

But the skull wasn't going to close itself. There would be time for speculation tomorrow.

- I had reached the pinnacle of residency. I had mastered the core operations. My research had garnered the highest awards. Job interest was trickling in from all over the country. Stanford launched a search for a position that fit my interests exactly, for a neurosurgeon-neuroscientist focused on techniques of neural modulation. One of my junior residents came up to me and said, "I just heard from the bosses-if they hire you, you're going to be my faculty mentor!"

"Shhhh," I said. "Don't jinx it."

It felt to me as if the individual strands of biology, morality, life, and death were finally beginning to weave themselves into, if not a perfect moral system, a coherent worldview and a sense of my place in it. Doctors in highly charged fields met patients at inflected moments, the most authentic moments, where life and ident.i.ty were under threat; their duty included learning what made that particular patient's life worth living, and planning to save those things if possible-or to allow the peace of death if not. Such power required deep responsibility, sharing in guilt and recrimination.

I was at a conference in San Diego when my phone rang. My co-resident, Victoria.

"Paul?"

Something was wrong. My stomach tightened.

"What's up?" I said.

Silence.

"Vic?"

"It's Jeff. He killed himself."

"What?"

Jeff was finis.h.i.+ng his surgical fellows.h.i.+p in the Midwest, and we were both so punis.h.i.+ngly busy...we'd lost touch. I tried to recall our last conversation and couldn't.

"He, uh-he apparently had a difficult complication, and his patient died. Last night he climbed onto the roof of a building and jumped off. I don't really know anything else."

I searched for a question to bring understanding. None was forthcoming. I could only imagine the overwhelming guilt, like a tidal wave, that had lifted him up and off that building.

I wished, desperately, that I could've been walking with him out the door of the hospital that evening. I wished we could've commiserated as we used to. I wished I could have told Jeff what I had come to understand about life, and our chosen way of life, if only to hear his wise, clever counsel. Death comes for all of us. For us, for our patients: it is our fate as living, breathing, metabolizing organisms. Most lives are lived with pa.s.sivity toward death-it's something that happens to you and those around you. But Jeff and I had trained for years to actively engage with death, to grapple with it, like Jacob with the angel, and, in so doing, to confront the meaning of a life. We had a.s.sumed an onerous yoke, that of mortal responsibility. Our patients' lives and ident.i.ties may be in our hands, yet death always wins. Even if you are perfect, the world isn't. The secret is to know that the deck is stacked, that you will lose, that your hands or judgment will slip, and yet still struggle to win for your patients. You can't ever reach perfection, but you can believe in an asymptote toward which you are ceaselessly striving.

PART II.

Cease Not till Death If I were a writer of books, I would compile a register, with a comment, of the various deaths of men: he who should teach men to die would at the same time teach them to live.

-Michel de Montaigne, "That to Study Philosophy Is to Learn to Die"

LYING NEXT TO LUCY in the hospital bed, both of us crying, the CT scan images still glowing on the computer screen, that ident.i.ty as a physician-my ident.i.ty-no longer mattered. With the cancer having invaded multiple organ systems, the diagnosis was clear. The room was quiet. Lucy told me she loved me. "I don't want to die," I said. I told her to remarry, that I couldn't bear the thought of her being alone. I told her we should refinance the mortgage immediately. We started calling family members. At some point, Victoria came by the room, and we discussed the scan and the likely future treatments. When she brought up the logistics of returning to residency, I stopped her.

"Victoria," I said, "I'm never coming back to this hospital as a doctor. Don't you think?"

One chapter of my life seemed to have ended; perhaps the whole book was closing. Instead of being the pastoral figure aiding a life transition, I found myself the sheep, lost and confused. Severe illness wasn't life-altering, it was life-shattering. It felt less like an epiphany-a piercing burst of light, illuminating What Really Matters-and more like someone had just firebombed the path forward. Now I would have to work around it.

My brother Jeevan had arrived at my bedside. "You've accomplished so much," he said. "You know that, don't you?"

I sighed. He meant well, but the words rang hollow. My life had been building potential, potential that would now go unrealized. I had planned to do so much, and I had come so close. I was physically debilitated, my imagined future and my personal ident.i.ty collapsed, and I faced the same existential quandaries my patients faced. The lung cancer diagnosis was confirmed. My carefully planned and hard-won future no longer existed. Death, so familiar to me in my work, was now paying a personal visit. Here we were, finally face-to-face, and yet nothing about it seemed recognizable. Standing at the crossroads where I should have been able to see and follow the footprints of the countless patients I had treated over the years, I saw instead only a blank, a harsh, vacant, gleaming white desert, as if a sandstorm had erased all trace of familiarity.

The sun was setting. I would be discharged the next morning. An oncology appointment was set for later in the week, but the nurse told me my oncologist was going to drop by that night, before leaving to pick up her kids. Her name was Emma Hayward, and she wanted to say h.e.l.lo before the initial office visit. I knew Emma a little-I had treated some of her patients before-but we had never spoken beyond pa.s.sing professional courtesies. My parents and brothers were scattered about the room, not saying much, while Lucy sat by the bed, holding my hand. The door opened and in she walked, her white coat showing the wear of a long day but her smile fresh. Trailing behind her were her fellow and a resident. Emma was only a few years older than I, her hair long and dark, but as is common to all those who spend time with death, streaked with gray. She pulled up a chair.

"Hi, my name is Emma," she said. "I'm sorry to have to be so brief today, but I wanted to come by and introduce myself."

We shook hands, my arm entangled in the IV line.

"Thanks for stopping by," I said. "I know you have kids to pick up. This is my family." She nodded h.e.l.lo at Lucy, at my brothers and parents.

"I'm sorry this is happening to you," she said. "To all of you. There will be a lot of time to talk in a couple days. I went ahead and had the lab start running some tests on your tumor sample, which will help guide therapy. Treatment may be chemotherapy or not, depending on the tests."

Eighteen months earlier, I'd been in the hospital with appendicitis. Then I'd been treated not as a patient but as a colleague, almost like a consultant on my own case. I expected the same here. "I know now's not the time," I proceeded, "but I will want to talk about the Kaplan-Meier survival curves."

"No," she said. "Absolutely not."

A brief silence. How dare she? I thought. This is how doctors-doctors like me-understand prognostication. I have a right to know.