When Breath Becomes Air (10 page)

The funny thing about time in the OR, whether you race frenetically or proceed steadily, is that you have no sense of it passing. If boredom is, as Heidegger argued, the awareness of time passing, 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 stitch 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 institutionalized: 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 assess 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 mass 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 identity. 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 fucking 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 fucking thing out of my head yet? Why are you slowing down? Go faster! I want it
out.
I can stay here all fucking 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 asshole? I told you I want the fucking 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 identity 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 finishing his surgical fellowship in the Midwest, and we were both so punishingly 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 passivity 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 assumed an onerous yoke, that of
mortal responsibility
. Our patients’ lives and identities 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”

L
YING NEXT TO
L
UCY
in the hospital bed, both of us crying, the CT scan images still glowing on the computer screen, that identity as a physician—my identity—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.