When Breath Becomes Air
Page: 120, Location: 1837
Note: T.S Elliot
When you come to one of the many moments in life where you must give an account of yourself, provide a ledger of what you have been, and done, and meant to the world, do not, I pray, discount that you filled a dying man’s days with a sated joy, a joy unknown to me in all my prior years, a joy that does not hunger for more and more but rests, satisfied. In this time, right now, that is an enormous thing.
Page: 125, Location: 1908-1911
Note: The last lines
You that seek what life is in death, Now find it air that once was breath. New names unknown, old names gone: Till time end bodies, but souls none. Reader! then make time, while you be, But steps to your eternity. —Baron Brooke Fulke Greville, “Caelica 83”
Page: 5, Location: 71-76
(“If one day it happens / you find yourself with someone you love / in a café at one end /of the Pont Mirabeau, at the zinc bar / where wine stands in upward opening glasses…”
Page: 8, Location: 122-123
I was leaving this small Arizona town in a few weeks, and I felt less like someone preparing to climb a career ladder than a buzzing electron about to achieve escape velocity, flinging out into a strange and sparkling universe.
Page: 21, Location: 312-313
If the unexamined life was not worth living, was the unlived life worth examining?
Page: 28, Location: 422-423
Suddenly, now, I know what I want. I want the counselors to build a pyre…and let my ashes drop and mingle with the sand. Lose my bones amongst the driftwood, my teeth amongst the sand….I don’t believe in the wisdom of children, nor in the wisdom of the old. There is a moment, a cusp, when the sum of gathered experience is worn down by the details of living. We are never so wise as when we live in this moment.
Page: 30, Location: 449-451
She had been smiling, hadn’t she?
Page: 32, Location: 483-483
Only later would I realize that our trip had added a new dimension to my understanding of the fact that brains give rise to our ability to form relationships and make life meaningful. Sometimes, they break.
Page: 32, Location: 483-485
I had come to see language as an almost supernatural force, existing between people, bringing our brains, shielded in centimeter-thick skulls, into communion. A word meant something only between people, and life’s meaning, its virtue, had something to do with the depth of the relationships we form. It was the relational aspect of humans—i.e., “human relationality”—that undergirded meaning. Yet somehow, this process existed in brains and bodies, subject to their own physiologic imperatives, prone to breaking and failing. There must be a way, I thought, that the language of life as experienced—of passion, of hunger, of love—bore some relationship, however convoluted, to the language of neurons, digestive tracts, and heartbeats.
Page: 32, Location: 487-492
In anatomy lab, we objectified the dead, literally reducing them to organs, tissues, nerves, muscles. On that first day, you simply could not deny the humanity of the corpse. But by the time you’d skinned the limbs, sliced through inconvenient muscles, pulled out the lungs, cut open the heart, and removed a lobe of the liver, it was hard to recognize this pile of tissue as human. Anatomy lab, in the end, becomes less a violation of the sacred and more something that interferes with happy hour, and that realization discomfits. In our rare reflective moments, we were all silently apologizing to our cadavers, not because we sensed the transgression but because we did not.
Page: 38, Location: 574-578
Other times, the kinship was much simpler. Once, while showing us the ruins of our donor’s pancreatic cancer, the professor asked, “How old is this fellow?” “Seventy-four,” we replied. “That’s my age,” he said, set down the probe, and walked away.
Page: 39, Location: 587-589
“With what strife and pains we come into the world we know not, but ’tis commonly no easy matter to get out of it.”
Page: 40, Location: 609-609
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.
Page: 45, Location: 689-691
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.
Page: 46, Location: 701-704
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.
Page: 46, Location: 706-707
“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?
Page: 47, Location: 718-720
Putting lifestyle first is how you find a job—not a calling.)
Page: 50, Location: 753-754
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.
Page: 52, Location: 795-796
As my skills increased, so too did my responsibility. Learning to judge whose lives could be saved, whose couldn’t be, and whose shouldn’t be requires an unattainable prognostic ability. I made mistakes. Rushing a patient to the OR to save only enough brain that his heart beats but he can never speak, he eats through a tube, and he is condemned to an existence he would never want…I came to see this as a more egregious failure than the patient dying. The twilight existence of unconscious metabolism becomes an unbearable burden, usually left to an institution, where the family, unable to attain closure, visits with increasing rarity, until the inevitable fatal bedsore or pneumonia sets in. Some insist on this life and embrace its possibility, eyes open. But many do not, or cannot, and the neurosurgeon must learn to adjudicate.
Page: 56, Location: 856-862
As a resident, my highest ideal was not saving lives—everyone dies eventually—but guiding a patient or family to an understanding of death or illness.
Page: 60, Location: 913-914
acted not, as I most often did, as death’s enemy, but as its ambassador. I had to help those families understand that the person they knew—the full, vital independent human—now lived only in the past and that I needed their input to understand what sort of future he or she would want: an easy death or to be strung between bags of fluids going in, others coming out, to persist despite being unable to struggle. Had I been more religious in my youth, I might have become a pastor, for it was the pastoral role I’d sought.
Page: 61, Location: 922-927
Before operating on a patient’s brain, I realized, I must first understand his mind: his identity, 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.
Page: 67, Location: 1017-1020
“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 hells through which we put patients.
Page: 69, Location: 1051-1053
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.”
Page: 70, Location: 1064-1067
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.
Page: 71, Location: 1085-1086
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?
Page: 73, Location: 1116-1117
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.
Page: 77, Location: 1167-1168
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.
Page: 77, Location: 1170-1173
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”
Page: 78, Location: 1183-1185
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
Page: 78, Location: 1192-1193
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.
Page: 79, Location: 1199-1202
her hair long and dark, but as is common to all those who spend time with death, streaked with gray
Page: 79, Location: 1207-1208
Before my cancer was diagnosed, I knew that someday I would die, but I didn’t know when. After the diagnosis, I knew that someday I would die, but I didn’t know when. But now I knew it acutely. The problem wasn’t really a scientific one. The fact of death is unsettling. Yet there is no other way to live.
Page: 85, Location: 1300-1302
Only 0.0012 percent of thirty-six-year-olds get lung cancer. Yes, all cancer patients are unlucky, but there’s cancer, and then there’s CANCER, and you have to be really unlucky to have the latter.
Page: 86, Location: 1311-1312
What patients seek is not scientific knowledge that doctors hide but existential authenticity each person must find on her own. Getting too deeply into statistics is like trying to quench a thirst with salty water. The angst of facing mortality has no remedy in probability.
Page: 87, Location: 1327-1329
I had passed from the subject to the direct object of every sentence of my life. In fourteenth-century philosophy, the word patient simply meant “the object of an action,” and I felt like one. As a doctor, I was an agent, a cause; as a patient, I was merely something to which things happened.
Page: 91, Location: 1389-1392
If human relationality formed the bedrock of meaning, it seemed to us that rearing children added another dimension to that meaning.
Page: 92, Location: 1398-1399
felt that life wasn’t about avoiding suffering. Years ago, it had occurred to me that Darwin and Nietzsche agreed on one thing: the defining characteristic of the organism is striving. Describing life otherwise was like painting a tiger without stripes. After so many years of living with death, I’d come to understand that the easiest death wasn’t necessarily the best.
Page: 92, Location: 1407-1410
I looked forward to the chance to reconnect with my former self. Yet being there merely heightened the surreal contrast of what my life was now. I was surrounded by success and possibility and ambition, by peers and seniors whose lives were running along a trajectory that was no longer mine, whose bodies could still tolerate standing for a grueling eight-hour surgery. I felt trapped inside a reversed Christmas carol: Victoria was opening the happy present—grants, job offers, publications—I should be sharing. My senior peers were living the future that was no longer mine: early career awards, promotions, new houses.
Page: 94, Location: 1436-1441
Lost in a featureless wasteland of my own mortality, and finding no traction in the reams of scientific studies, intracellular molecular pathways, and endless curves of survival statistics, I began reading literature again:
Page: 95, Location: 1450-1451
I got out of bed and took a step forward, repeating the phrase over and over: “I can’t go on. I’ll go on.” That morning, I made a decision: I would push myself to return to the OR. Why? Because I could. Because that’s who I was. Because I would have to learn to live in a different way, seeing death as an imposing itinerant visitor but knowing that even if I’m dying, until I actually die, I am still living.
Page: 96, Location: 1462-1465
Moral duty has weight, things that have weight have gravity, and so the duty to bear mortal responsibility pulled me back into the operating room.
Page: 97, Location: 1480-1481
The tricky part of illness is that, as you go through it, your values are constantly changing. You try to figure out what matters to you, and then you keep figuring it out. It felt like someone had taken away my credit card and I was having to learn how to budget. You may decide you want to spend your time working as a neurosurgeon, but two months later, you may feel differently. Two months after that, you may want to learn to play the saxophone or devote yourself to the church. Death may be a one-time event, but living with terminal illness is a process.
Page: 102, Location: 1560-1564
The truth that you live one day at a time didn’t help: What was I supposed to do with that day?
Page: 103, Location: 1572-1572
Even when the cancer was in retreat, it cast long shadows.
Page: 105, Location: 1600-1600
had learned something, something not found in Hippocrates, Maimonides, or Osler: the physician’s duty is not to stave off death or return patients to their old lives, but to take into our arms a patient and family whose lives have disintegrated and work until they can stand back up and face, and make sense of, their own existence.
Page: 105, Location: 1609-1611
Emma hadn’t given me back my old identity. She’d protected my ability to forge a new one. And, finally, I knew I would have to.
Page: 106, Location: 1615-1616
A physician’s words can ease the mind, just as the neurosurgeon’s scalpel can ease a disease of the brain. Yet their uncertainties and morbidities, whether emotional or physical, remain to be grappled with.
Page: 106, Location: 1614-1615
Science may provide the most useful way to organize empirical, reproducible data, but its power to do so is predicated on its inability to grasp the most central aspects of human life: hope, fear, love, hate, beauty, envy, honor, weakness, striving, suffering, virtue.
Page: 108, Location: 1642-1644
Nobel Prize–winning French biologist Jacques Monod, belies this revelatory aspect: “The ancient covenant is in pieces; man at last knows that he is alone in the unfeeling immensity of the universe, out of which he emerged only by chance.”
Page: 108, Location: 1649-1650
In the end, it cannot be doubted that each of us can see only a part of the picture. The doctor sees one, the patient another, the engineer a third, the economist a fourth, the pearl diver a fifth, the alcoholic a sixth, the cable guy a seventh, the sheep farmer an eighth, the Indian beggar a ninth, the pastor a tenth. Human knowledge is never contained in one person. It grows from the relationships we create between each other and the world, and still it is never complete. And Truth comes somewhere above all of them, where, as at the end of that Sunday’s reading, 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.
Page: 109, Location: 1663-1669
Damyata: The boat responded Gaily, to the hand expert with sail and oar The sea was calm, your heart would have responded Gaily, when invited, beating obedient To controlling hands
Page: 120, Location: 1835-1837
Emma was now the captain of the ship, lending a sense of calm to the chaos of this hospitalization.
Page: 120, Location: 1833-1834
My thoughts were clouded. I needed that oracle to scry again, to gather secrets from birds or star charts, from mutant genes or Kaplan-Meier graphs.
Page: 121, Location: 1852-1853
There we were, doctor and patient, in a relationship that sometimes carries a magisterial air and other times, like now, was no more, and no less, than two people huddled together, as one faces the abyss. Doctors, it turns out, need hope, too.
Page: 122, Location: 1860-1862
Looking out over the expanse ahead I saw not an empty wasteland but something simpler: a blank page on which I would go on.
Page: 123, Location: 1877-1878
Time for me is now double-edged: every day brings me further from the low of my last relapse but closer to the next recurrence—and, eventually, death. Perhaps later than I think, but certainly sooner than I desire.
Page: 123, Location: 1881-1883
Part of the cruelty of cancer, though, is not only that it limits your time; it also limits your energy, vastly reducing the amount you can squeeze into a day. It is a tired hare who now races. And even if I had the energy, I prefer a more tortoiselike approach. I plod, I ponder. Some days, I simply persist. If time dilates when one moves at high speeds, does it contract when one moves barely at all? It must: the days have shortened considerably.
Page: 123, Location: 1884-1888
You left me, sweet, two legacies,— A legacy of love A Heavenly Father would content, Had he the offer of; You left me boundaries of pain Capacious as the sea, Between eternity and time, Your consciousness and me. —Emily Dickinson
Page: 125, Location: 1916-1926
Warm rays of evening light began to slant through the northwest-facing window of the room as Paul’s breaths grew more quiet. Cady rubbed her eyes with chubby fists as her bedtime approached, and a family friend arrived to take her home. I held her cheek to Paul’s, tufts of their matching dark hair similarly askew, his face serene, hers quizzical but calm, his beloved baby never suspecting that this moment was a farewell. Softly I sang Cady’s bedtime song, to her, to both of them, and then released her.
Page: 133, Location: 2031-2035
That’s what I’m aiming for, I think. Not the sensationalism of dying, and not exhortations to gather rosebuds, but: Here’s what lies up ahead on the road.” Of course, he did more than just describe the terrain. He traversed it bravely.
Page: 134, Location: 2050-2051
“Always the seer is a sayer,” Emerson wrote. “Somehow his dream is told; somehow he publishes it with solemn joy.” Writing this book was a chance for this courageous seer to be a sayer, to teach us to face death with integrity.
Page: 134, Location: 2054-2056
At home in bed a few weeks before he died, I asked him, “Can you breathe okay with my head on your chest like this?” His answer was “It’s the only way I know how to breathe.” That Paul and I formed part of the deep meaning of each other’s lives is one of the greatest blessings that has ever come to me.
Page: 135, Location: 2070-2072
he wrote, “The good news is I’ve already outlived two Brontës, Keats, and Stephen Crane. The bad news is that I haven’t written anything.”
Page: 137, Location: 2099-2100
What happened to Paul was tragic, but he was not a tragedy.
Page: 139, Location: 2122-2122
The Pilgrim’s Progress: “Who would true valour see, / Let him come hither…/ Then fancies fly away, / He’ll fear not what men say, / He’ll labour night and day / To be a pilgrim.” Paul’s decision to look death in the eye was a testament not just to who he was in the final hours of his life but who he had always been. For much of his life, Paul wondered about death—and whether he could face it with integrity. In the end, the answer was yes. I was his wife and a witness.
Page: 140, Location: 2138-2142