When Breath Becomes Air(12)

Lucy and I attended the Yale School of Medicine when Shep Nuland still lectured there, but I knew him only in my capacity as a reader. Nuland was a renowned surgeon-philosopher whose seminal book about mortality, How We Die, had come out when I was in high school but made it into my hands only in medical school. Few books I had read so directly and wholly addressed that fundamental fact of existence: all organisms, whether goldfish or grandchild, die. I pored over it in my room at night, and remember in particular his description of his grandmother’s illness, and how that one passage so perfectly illuminated the ways in which the personal, medical, and spiritual all intermingled. Nuland recalled how, as a child, he would play a game in which, using his finger, he indented his grandmother’s skin to see how long it took to resume its shape—a part of the aging process that, along with her newfound shortness of breath, showed her “gradual slide into congestive heart failure…the significant decline in the amount of oxygen that aged blood is capable of taking up from the aged tissues of the aged lung.” But “what was most evident,” he continued, “was the slow drawing away from life….By the time Bubbeh stopped praying, she had stopped virtually everything else as well.” With her fatal stroke, Nuland remembered Sir Thomas Browne’s Religio Medici: “With what strife and pains we come into the world we know not, but ’tis commonly no easy matter to get out of it.”



I had spent so much time studying literature at Stanford and the history of medicine at Cambridge, in an attempt to better understand the particularities of death, only to come away feeling like they were still unknowable to me. Descriptions like Nuland’s convinced me that such things could be known only face-to-face. I was pursuing medicine to bear witness to the twinned mysteries of death, its experiential and biological manifestations: at once deeply personal and utterly impersonal.

I remember Nuland, in the opening chapters of How We Die, writing about being a young medical student alone in the OR with a patient whose heart had stopped. In an act of desperation, he cut open the patient’s chest and tried to pump his heart manually, tried to literally squeeze the life back into him. The patient died, and Nuland was found by his supervisor, covered in blood and failure.

Medical school had changed by the time I got there, to the point where such a scene was simply unthinkable: as medical students, we were barely allowed to touch patients, let alone open their chests. What had not changed, though, was the heroic spirit of responsibility amid blood and failure. This struck me as the true image of a doctor.

—



The first birth I witnessed was also the first death.

I had recently taken Step 1 of my medical boards, wrapping up two years of intensive study buried in books, deep in libraries, poring over lecture notes in coffee shops, reviewing hand-made flash cards while lying in bed. The next two years, then, I would spend in the hospital and clinic, finally putting that theoretical knowledge to use to relieve concrete suffering, with patients, not abstractions, as my primary focus. I started in ob-gyn, working the graveyard shift in the labor and delivery ward.

Walking into the building as the sun descended, I tried to recall the stages of labor, the corresponding dilation of the cervix, the names of the “stations” that indicated the baby’s descent—anything that might prove helpful when the time came. As a medical student, my task was to learn by observation and avoid getting in the way. Residents, who had finished medical school and were now completing training in a chosen specialty, and nurses, with their years of clinical experience, would serve as my primary instructors. But the fear still lurked—I could feel its fluttering—that through accident or expectation, I’d be called on to deliver a child by myself, and fail.



I made my way to the doctors’ lounge where I was to meet the resident. I walked in and saw a dark-haired young woman lying on a couch, chomping furiously at a sandwich while watching TV and reading a journal article. I introduced myself.

“Oh, hi,” she said. “I’m Melissa. I’ll be in here or in the call room if you need me. Probably the best thing for you to do is keep an eye on patient Garcia. She’s a twenty-two-year-old, here with preterm labor and twins. Everyone else is pretty standard.”

Between bites, Melissa briefed me, a barrage of facts and information: The twins were only twenty-three and a half weeks old; the hope was to keep the pregnancy going until they were more developed, however long that might be; twenty-four weeks was considered the cusp of viability, and every extra day made a difference; the patient was getting various drugs to control her contractions. Melissa’s pager went off.



“Okay,” she said, swinging her legs off the couch. “I gotta go. You can hang out here, if you like. We have good cable channels. Or you can come with me.”

I followed Melissa to the nurses’ station. One wall was lined with monitors, displaying wavy telemetry lines.

“What’s that?” I asked.

“That’s the output of the tocometers and the fetal heart rates. Let me show you the patient. She doesn’t speak English. Do you speak Spanish?”

I shook my head. Melissa brought me to the room. It was dark. The mother lay in a bed, resting, quiet, monitor bands wrapped around her belly, tracking her contractions and the twins’ heart rates and sending the signal to the screens I’d seen at the nurses’ station. The father stood at the bedside holding his wife’s hand, worry etched on his brow. Melissa whispered something to them in Spanish, then escorted me out.