When Breath Becomes Air (15 page)

the sower and reaper can rejoice together. For here the saying is verified that “One sows and another reaps.” I sent you to reap what you have not worked for; others have done the work, and you are sharing the fruits of their work.

—

I hopped out of the CT scanner, seven months since I had returned to surgery. This would be my last scan before finishing residency, before becoming a father, before my future became real.

“Wanna take a look, Doc?” the tech said.

“Not right now,” I said. “I’ve got a lot of work to do today.”

It was already six
P.M.
I had to go see patients, organize tomorrow’s OR schedule, review films, dictate my clinic notes, check on my post-ops, and so on. Around eight
P.M.
, I sat down in the neurosurgery office, next to a radiology viewing station. I turned it on, looked at my patients’ scans for the next day—two simple spine cases—and, finally, typed in my own name. I zipped through the images as if they were a kid’s flip-book, comparing the new scan to the last. Everything looked the same, the old tumors remained exactly the same…except, wait.

I rolled back the images. Looked again.

There it was. A new tumor, large, filling my right middle lobe. It looked, oddly, like a full moon having almost cleared the horizon. Going back to the old images, I could make out the faintest trace of it, a ghostly harbinger now brought fully into the world.

I was neither angry nor scared. It simply was. It was a fact about the world, like the distance from the sun to the earth. I drove home and told Lucy. It was a Thursday night, and we wouldn’t see Emma again until Monday, but Lucy and I sat down in the living room, with our laptops, and mapped out the next steps: biopsies, tests, chemotherapy. The treatments this time around would be tougher to endure, the possibility of a long life more remote. Eliot again: “But at my back in a cold blast I hear / the rattle of the bones, and chuckle spread from ear to ear.” Neurosurgery would be impossible for a couple of weeks, perhaps months, perhaps forever. But we decided that all of that could wait to be real until Monday. Today was Thursday, and I’d already made tomorrow’s OR assignments; I planned on having one last day as a resident.

As I stepped out of my car at the hospital at five-twenty the next morning, I inhaled deeply, smelling the eucalyptus and…was that pine? Hadn’t noticed that before. I met the resident team, assembled for morning rounds. We reviewed overnight events, new admissions, new scans, then went to see our patients before M&M, or morbidity and mortality conference, a regular meeting in which the neurosurgeons gathered to review mistakes that had been made and cases that had gone wrong. Afterward, I spent an extra couple of minutes with a patient, Mr. R. He had developed a rare syndrome, called Gerstmann’s, where, after I’d removed his brain tumor, he’d begun showing several specific deficits: an inability to write, to name fingers, to do arithmetic, to tell left from right. I’d seen it only once before, as a medical student eight years ago, on one of the first patients I’d followed on the neurosurgical service. Like him, Mr. R was euphoric—I wondered if that was part of the syndrome that no one had described before. Mr. R was getting better, though: his speech had returned almost to normal, and his arithmetic was only slightly off. He’d likely make a full recovery.

The morning passed, and I scrubbed for my last case. Suddenly the moment felt enormous. My last time scrubbing? Perhaps this was it. I watched the suds drip off my arms, then down the drain. I entered the OR, gowned up, and draped the patient, making sure the corners were sharp and neat. I wanted this case to be perfect. I opened the skin of his lower back. He was an elderly man whose spine had degenerated, compressing his nerve roots and causing severe pain. I pulled away the fat until the fascia appeared and I could feel the tips of his vertebrae. I opened the fascia and smoothly dissected the muscle away, until only the wide, glistening vertebrae showed up through the wound, clean and bloodless. The attending wandered in as I began to remove the lamina, the back wall of the vertebrae, whose bony overgrowths, along with ligaments beneath, were compressing the nerves.

“Looks good,” he said. “If you want to go to today’s conference, I can have the fellow come in and finish.”

My back was beginning to ache. Why hadn’t I taken an extra dose of NSAIDs beforehand? This case should be quick, though. I was almost there.

“Naw,” I said. “I want to finish the case.”

The attending scrubbed in, and together we completed the bony removal. He began to pick away at the ligaments, beneath which lay the dura, which contained spinal fluid and the nerve roots. The most common error at this stage is tearing a hole in the dura. I worked on the opposite side. Out of the corner of my eye, I saw near his instrument a flash of blue—the dura starting to peek through.

“Watch out!” I said, just as the mouth of his instrument bit into the dura. Clear spinal fluid began to fill the wound. I hadn’t had a leak in one of my cases in more than a year. Repairing it would take another hour.

“Get the micro set out,” I said. “We have a leak.”

By the time we finished the repair and removed the compressive soft tissue, my shoulders burned. The attending broke scrub, offered his apologies and said his thanks, and left me to close. The layers came together nicely. I began to suture the skin, using a running nylon stitch. Most surgeons used staples, but I was convinced that nylon had lower infection rates, and we would do this one, this final closure, my way. The skin came together perfectly, without tension, as if there had been no surgery at all.

Good. One good thing.

As we uncovered the patient, the scrub nurse, one with whom I hadn’t worked before, said, “You on call this weekend, Doc?”

“Nope.”
And possibly never again.

“Got any more cases today?”

“Nope.”
And possibly never again.

“Shit, well, I guess that means this is a happy ending! Work’s done. I like happy endings, don’t you, Doc?”

“Yeah. Yeah, I like happy endings.”

I sat down by the computer to enter orders as the nurses cleaned and the anesthesiologists began to wake the patient. I had always jokingly threatened that when I was in charge, instead of the high-energy pop music everyone liked to play in the OR, we’d listen exclusively to bossa nova. I put
Getz/Gilberto
on the radio, and the soft, sonorous sounds of a saxophone filled the room.

I left the OR shortly after, then gathered my things, which had accumulated over seven years of work—extra sets of clothes for the nights you don’t leave, toothbrushes, bars of soap, phone chargers, snacks, my skull model and collection of neurosurgery books, and so on. On second thought, I left my books behind. They’d be of more use here.

On my way out to the parking lot, a fellow approached to ask me something, but his pager went off. He looked at it, waved, turned, and ran back in to the hospital—“I’ll catch you later!” he called over his shoulder. Tears welled up as I sat in the car, turned the key, and slowly pulled out into the street. I drove home, walked through the front door, hung up my white coat, and took off my ID badge. I pulled the battery out of my pager. I peeled off my scrubs and took a long shower.

Later that night, I called Victoria and told her I wouldn’t be in on Monday, or possibly ever again, and wouldn’t be setting the OR schedule.

“You know, I’ve been having this recurring nightmare that this day was coming,” she said. “I don’t know how you did this for so long.”

—

Lucy and I met with Emma on Monday. She confirmed the plan we’d envisioned: bronchoscopic biopsy, look for targetable mutations, otherwise chemo. The real reason I was there, though, was for her guidance. I told her I was taking leave from neurosurgery.

“Okay,” she said. “That’s fine. You can stop neurosurgery if, say, you want to focus on something that matters more to you. But
not
because you are sick. You aren’t any sicker than you were a week ago. This is a bump in the road, but you can keep your current trajectory. Neurosurgery was important to you.”

Once again, I had traversed the line from doctor to patient, from actor to acted upon, from subject to direct object. My life up until my illness could be understood as the linear sum of my choices. As in most modern narratives, a character’s fate depended on human actions, his and others.
King Lear
’s Gloucester may complain about human fate as “flies to wanton boys,” but it’s Lear’s vanity that sets in motion the dramatic arc of the play. From the Enlightenment onward, the individual occupied center stage. But now I lived in a different world, a more ancient one, where human action paled against superhuman forces, a world that was more Greek tragedy than Shakespeare. No amount of effort can help Oedipus and his parents escape their fates; their only access to the forces controlling their lives is through the oracles and seers, those given divine vision. What I had come for was not a treatment plan—I had read enough to know the medical ways forward—but the comfort of oracular wisdom.

“This is not the end,” she said, a line she must have used a thousand times—after all, did I not use similar speeches to my own patients?—to those seeking impossible answers. “Or even the beginning of the end. This is just the end of the beginning.”

And I felt better.

A week after the biopsy, Alexis, the nurse practitioner, called. There were no new targetable mutations, so chemotherapy was the only option, and it was being set up for Monday. I asked about the specific agents and was told I’d have to talk to Emma. She was en route to Lake Tahoe with her kids, but she’d give me a call over the weekend.

The next day, a Saturday, Emma called. I asked her what she thought about chemotherapy agents.

“Well,” she said. “Do you have specific thoughts?”

“I guess the main question is whether to include Avastin,” I said. “I know the data is mixed and that it adds potential side effects, and some cancer centers are turning away from it. In my mind, though, since there are a lot of studies supporting its use, I’d lean toward including it. We can discontinue it if I have a bad reaction to it. If that seems sensible to you.”

“Yeah, that sounds about right. Insurance companies also make it hard to add it later, so that’s another reason to use it up front.”

“Thanks for calling. I’ll let you get back to enjoying the lake.”

“Okay. But there’s one thing.” She paused. “I’m totally happy for us to make your medical plan together; obviously, you’re a doctor, you know what you’re talking about, and it’s your life. But if you ever want me to just
be
the doctor, I’m happy to do that, too.”

I hadn’t ever considered that I could release myself from the responsibility of my own medical care. I’d just assumed all patients became experts at their own diseases. I remembered how, as a green medical student, knowing nothing, I would often end up asking patients to explain their diseases and treatments to me, their blue toes and pink pills. But as a doctor, I never expected patients to make decisions alone; I bore responsibility for the patient. And I realized I was trying to do the same thing now, my doctor-self remaining responsible for my patient-self. Maybe I’d been cursed by a Greek god, but abdicating control seemed irresponsible, if not impossible.

—

Chemotherapy began on Monday. Lucy, my mother, and I went to the infusion center together. I had an IV placed, settled into an easy chair, and waited. The drug cocktail would take four and a half hours to infuse. I passed the time napping, reading, and sometimes blankly staring, with Lucy and my mother next to me, interrupting the silence with occasional small talk. The other occupants of the room were in various states of health—some bald, some well-coiffed, some withered, some sprightly, some disheveled, some dapper. All lay still, silent, with IV tubing dripping poison into outstretched arms. I was to return every three weeks for treatment.

I began to feel the effects the next day, a deep fatigue, a profound bone-weariness setting in. Eating, normally a source of great pleasure, was like drinking seawater. Suddenly, all of my joys were salted. For breakfast, Lucy made me a bagel with cream cheese; it tasted like a salt lick. I set it aside. Reading was exhausting. I had agreed to write a few chapters on the therapeutic potential of my research with V for two major neurosurgical textbooks. That, too, I set aside. The days passed, television and forced feedings marking the time. A pattern developed over the weeks: the malaise would slowly ease, normalcy returning just in time for the next treatment.

The cycles continued; I shuffled in and out of the hospital with minor complications, which were just enough to preclude any return to work. The neurosurgery department determined that I had met all national and local criteria for graduation; the ceremony was scheduled for a Saturday, about two weeks before Lucy’s due date.

The day arrived. As I stood in our bedroom, dressing for graduation—the culmination of seven years of residency—a piercing nausea struck me. This was unlike the usual nausea of chemotherapy, which washed over you like a wave and, like a wave, could be ridden. I began uncontrollably vomiting green bile, its chalky taste distinct from stomach acid. This was from deep in my gut.

I would not be going to graduation, after all.

I needed IV fluids to avoid dehydration, so Lucy drove me to the emergency department and rehydration began. The vomiting gave way to diarrhea. The medical resident, Brad, and I chatted amicably, and I relayed my medical history, covering all my medications, and we ended up discussing advances in molecular therapies, especially Tarceva, which I was still taking. The medical plan was simple: keep me hydrated with intravenous fluids until I could drink enough by mouth. That evening, I was admitted to a hospital room. But when the nurse reviewed my medication list, I noticed Tarceva was not on it. I asked her to call the resident to correct the oversight. These things happen. I was taking a dozen medications, after all. Keeping track was not easy.