When Breath Becomes Air(16)

I was compelled by neurosurgery, with its unforgiving call to perfection; like the ancient Greek concept arete, I thought, virtue required moral, emotional, mental, and physical excellence. Neurosurgery seemed to present the most challenging and direct confrontation with meaning, identity, and death. Concomitant with the enormous responsibilities they shouldered, neurosurgeons were also masters of many fields: neurosurgery, ICU medicine, neurology, radiology. Not only would I have to train my mind and hands, I realized; I’d have to train my eyes, and perhaps other organs as well. The idea was overwhelming and intoxicating: perhaps I, too, could join the ranks of these polymaths who strode into the densest thicket of emotional, scientific, and spiritual problems and found, or carved, ways out.

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After medical school, Lucy and I, newly married, headed to California to begin our residencies, me at Stanford, Lucy just up the road at UCSF. Medical school was officially behind us—now real responsibility lay in wait. In short order, I made several close friends in the hospital, in particular Victoria, my co-resident, and Jeff, a general surgery resident a few years senior to us. Over the next seven years of training, we would grow from bearing witness to medical dramas to becoming leading actors in them.



As an intern in the first year of residency, one is little more than a paper pusher against a backdrop of life and death—though, even then, the workload is enormous. My first day in the hospital, the chief resident said to me, “Neurosurgery residents aren’t just the best surgeons—we’re the best doctors in the hospital. That’s your goal. Make us proud.” The chairman, passing through the ward: “Always eat with your left hand. You’ve got to learn to be ambidextrous.” One of the senior residents: “Just a heads-up—the chief is going through a divorce, so he’s really throwing himself into his work right now. Don’t make small talk with him.” 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.

I didn’t leave the hospital for the first two days, but before long, the impossible-seeming, day-killing mounds of paperwork were only an hour’s work. Still, when you work in a hospital, the papers you file aren’t just papers: they are fragments of narratives filled with risks and triumphs. An eight-year-old named Matthew, for example, came in one day complaining of headaches only to learn that he had a tumor abutting his hypothalamus. The hypothalamus regulates our basic drives: sleep, hunger, thirst, sex. Leaving any tumor behind would subject Matthew to a life of radiation, further surgeries, brain catheters…in short, it would consume his childhood. Complete removal could prevent that, but at the risk of damaging his hypothalamus, rendering him a slave to his appetites. The surgeon got to work, passed a small endoscope through Matthew’s nose, and drilled off the floor of his skull. Once inside, he saw a clear plane and removed the tumor. A few days later, Matthew was bopping around the ward, sneaking candies from the nurses, ready to go home. That night, I happily filled out the endless pages of his discharge paperwork.



I lost my first patient on a Tuesday.

She was an eighty-two-year-old woman, small and trim, the healthiest person on the general surgery service, where I spent a month as an intern. (At her autopsy, the pathologist would be shocked to learn her age: “She has the organs of a fifty-year-old!”) She had been admitted for constipation from a mild bowel obstruction. After six days of hoping her bowels would untangle themselves, we did a minor operation to help sort things out. Around eight P.M. Monday night, I stopped by to check on her, and she was alert, doing fine. As we talked, I pulled from my pocket my list of the day’s work and crossed off the last item (post-op check, Mrs. Harvey). It was time to go home and get some rest.



Sometime after midnight, the phone rang. The patient was crashing. With the complacency of bureaucratic work suddenly torn away, I sat up in bed and spat out orders: “One liter bolus of LR, EKG, chest X-ray, stat—I’m on my way in.” I called my chief, and she told me to add labs and to call her back when I had a better sense of things. I sped to the hospital and found Mrs. Harvey struggling for air, her heart racing, her blood pressure collapsing. She wasn’t getting better no matter what I did; and as I was the only general surgery intern on call, my pager was buzzing relentlessly, with calls I could dispense with (patients needing sleep medication) and ones I couldn’t (a rupturing aortic aneurysm in the ER). I was drowning, out of my depth, pulled in a thousand directions, and Mrs. Harvey was still not improving. I arranged a transfer to the ICU, where we blasted her with drugs and fluids to keep her from dying, and I spent the next few hours running between my patient threatening to die in the ER and my patient actively dying in the ICU. By 5:45 A.M., the patient in the ER was on his way to the OR, and Mrs. Harvey was relatively stable. She’d needed twelve liters of fluid, two units of blood, a ventilator, and three different pressors to stay alive.



When I finally left the hospital, at five P.M. on Tuesday evening, Mrs. Harvey wasn’t getting better—or worse. At seven P.M., the phone rang: Mrs. Harvey had coded, and the ICU team was attempting CPR. I raced back to the hospital, and once again, she pulled through. Barely. This time, instead of going home, I grabbed dinner near the hospital, just in case.