When Breath Becomes Air Part 5

Jack arrived quickly, and I excused myself. I sipped some orange juice in the lounge, lying on the couch. After twenty minutes, I began to feel better. "Neurocardiogenic syncope," I whispered to myself. The autonomic nervous system briefly shutting down the heart. Or, as it's more commonly known, a case of the nerves. A rookie problem. This was not how I'd envisioned my return to the OR. I went to the locker room, threw my dirty scrubs in the laundry, and put on my civilian clothes. On the way out, I grabbed a stack of clean scrubs. Tomorrow, I told myself, would be a better day.

It was. Every day, each case felt familiar but moved a little more slowly. On day three, I was removing a degenerated disc from a patient's spine. I stared at the bulging disc, not remembering my exact move. The fellow supervising me suggested taking small bites with a rongeur.

"Yeah, I know that's how it's usually done," I mumbled, "but there's another way..."

I nibbled away for twenty minutes, my brain searching for the more elegant way I had learned to do this. At the next spinal level, it came back to me in a flash.

"Cobb instrument!" I called out. "Mallet. Kerrison."

I had the whole disc removed in thirty seconds. "That's how I do this," I said.

Over the next couple of weeks, my strength continued to improve, as did my fluency and technique. My hands relearned how to manipulate submillimeter blood vessels without injury, my fingers conjuring up the old tricks they'd once known. After a month, I was operating a nearly full load.

I kept myself limited to operating, leaving the administration, patient care, and night and weekend calls to Victoria and the other senior residents. I had already mastered those skills, anyway, and needed to learn only the nuances of complex operations to feel complete. I ended my days exhausted beyond measure, muscles on fire, slowly improving. But the truth was, it was joyless. The visceral pleasure I'd once found in operating was gone, replaced by an iron focus on overcoming the nausea, the pain, the fatigue. Coming home each night, I would scarf down a handful of pain pills, then crawl into bed next to Lucy, who had returned to a full work schedule as well. She was now in the first trimester of pregnancy, with the baby due in June, when I would complete residency. We had a photo of our child as a blastocyst, taken just before implantation. ("She has your cell membrane," I remarked to Lucy.) Still, I was determined to restore my life to its prior trajectory.

Another stable scan six months after diagnosis pa.s.sed, and I reopened my job search. With my cancer under control, I might have several years left. It seemed the career I had worked for years to attain, which had disappeared amid disease, was now back in reach. I could almost hear trumpets sounding a victory fanfare.

- During my next visit with Emma, we talked about life and where it was taking me. I recalled Henry Adams trying to compare the scientific force of the combustion engine and the existential force of the Virgin Mary. The scientific questions were settled for now, allowing the existential ones full play, yet both were in the doctor's purview. I had recently learned that the surgeon-scientist position at Stanford-the job for which I had been heir apparent-had been filled while I was out sick. I was crushed, and told her so.

"Well," she said, "this doctor-professor thing can be a real grind. But you know that already. I'm sorry."

"Yeah, I guess the science that excited me was about twenty-year projects. Without that kind of time frame, I'm not sure I'm all that interested in being a scientist." I tried to console myself. "You can't get much done in a couple of years."

"Right. And just remember, you're doing great. You're working again. You've got a baby on the way. You're finding your values, and that's not easy."

Later that day one of the younger professors, a former resident and close friend, stopped me in the hallway.

"Hey," she said. "There's been a lot of discussion in faculty meetings about what to do with you."

"What to do with me, how?"

"I think some professors are concerned about you graduating."

Graduation from residency required two things: meeting a set of national and local requirements, which I'd already done, and the blessing of the faculty.

"What?" I said. "I don't mean to sound c.o.c.ky, but I'm a good surgeon, just as good as-"

"I know. I think they probably just want to see you performing the full load of a chief. It's because they like you. Seriously."

I realized it was true: For the past few months, I had been acting merely as a surgical technician. I had been using cancer as an excuse not to take full responsibility for my patients. On the other hand, it was a good excuse, d.a.m.n it. But now I started coming in earlier, staying later, fully caring for the patients again, adding another four hours to a twelve-hour day. It put the patients back in the center of my mind at all times. The first two days I thought I would have to quit, battling waves of nausea, pain, and fatigue, retreating to an unused bed in down moments to sleep. But by the third day, I had begun to enjoy it again, despite the wreck of my body. Reconnecting with patients brought back the meaning of this work. I took antiemetics and nonsteroidal anti-inflammatory drugs (NSAIDs) between cases and just before rounds. I was suffering, but I was fully back. Instead of finding an unused bed, I started resting on the junior residents' couch, supervising them on the care of my patients, lecturing as I rode a wave of back spasms. The more tortured my body became, the more I relished having done the work. At the end of the first week, I slept for forty hours straight.

But I was calling the shots: "Hey, boss," I said, "I was just reviewing cases for tomorrow, and I know the first case is booked interhemispheric, but I think it will be much safer and easier if we come parietal transcortical."

"Really?" the attending said. "Let me look at the films....You know what? You're right. Can you change the booking?"

The next day: "Hi, sir, it's Paul. I just saw Mr. F and his family in the ICU-I think we'll need to take him tomorrow for an ACDF. Okay if I book it? When are you free?"

And I was back to full speed in the OR: "Nurse, can you page Dr. S? I'm going to be done with this case before he gets here."

"I've got him on the phone. He says you can't possibly be done yet."

The attending came running in, out of breath, scrubbed, and peered through the microscope.

"I took a slightly acute angle to avoid the sinus," I said, "but the whole tumor's out."

"You avoided the sinus?"

"Yes, sir."

"You got it out in one piece?"

"Yes, sir, it's on the table so you can have a look."

"Looks good. Really good. When did you get to be so fast? Sorry I wasn't here earlier."

"No trouble."

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.

It struck me that I had traversed the five stages of grief-the "Denial Anger Bargaining Depression Acceptance" cliche-but I had done it all backward. On diagnosis, I'd been prepared for death. I'd even felt good about it. I'd accepted it. I'd been ready. Then I slumped into a depression, as it became clear that I might not be dying so soon after all, which is, of course, good news, but also confusing and strangely enervating. The rapidity of the cancer science, and the nature of the statistics, meant I might live another twelve months, or another 120. Grand illnesses are supposed to be life-clarifying. Instead, I knew I was going to die-but I'd known that before. My state of knowledge was the same, but my ability to make lunch plans had been shot to h.e.l.l. The way forward would seem obvious, if only I knew how many months or years I had left. Tell me three months, I'd spend time with family. Tell me one year, I'd write a book. Give me ten years, I'd get back to treating diseases. The truth that you live one day at a time didn't help: What was I supposed to do with that day?

At some point, then, I began to do a little bargaining-or not exactly bargaining. More like: "G.o.d, I have read Job, and I don't understand it, but if this is a test of faith, you now realize my faith is fairly weak, and probably leaving the spicy mustard off the pastrami sandwich would have also tested it? You didn't have to go nuclear on me, you know..." Then, after the bargaining, came flashes of anger: "I work my whole life to get to this point, and then you give me cancer?"

And now, finally, maybe I had arrived at denial. Maybe total denial. Maybe, in the absence of any certainty, we should just a.s.sume that we're going to live a long time. Maybe that's the only way forward.

- I was operating until late at night or into the early morning, fixated on graduation, my diagnosis nine months in the past. My body was taking a beating. I was too tired to eat when I got home. I had been slowly upping the dose of Tylenol and NSAIDs and antiemetics. I had developed a persistent cough, presumably caused by scarring from the dead tumor in my lungs. I only had to keep up this relentless pace for a couple more months, I told myself, and then I would graduate from residency and settle into the comparatively calmer role of a professor.

In February, I flew to Wisconsin for a job interview. They were offering everything I wanted: millions of dollars to start a neuroscience lab, head of my own clinical service, flexibility if I needed it for my health, a tenure-track professorship, appealing job options for Lucy, high salary, beautiful scenery, idyllic town, the perfect boss. "I understand about your health, and you probably have a strong connection with your oncologist," the department chairman told me. "So if you want to keep your care there, we can fly you back and forth-though we do have a top-notch cancer center here, if you want to explore it. Is there anything else I can do to make this job more attractive?"

I thought about what Emma had told me. I had gone from being unable to believe I could be a surgeon to being one, a transformation that carried the force of religious conversion. She had always kept this part of my ident.i.ty in mind, even when I couldn't. She had done what I had challenged myself to do as a doctor years earlier: accepted mortal responsibility for my soul and returned me to a point where I could return to myself. I had attained the heights of the neurosurgical trainee, set to become not only a neurosurgeon but a surgeon-scientist. Every trainee aspires to this goal; almost none make it.

That night, the chairman was driving me back to my hotel after dinner. He stopped the car and pulled over. "Let me show you something," he said. We got out and stood in front of the hospital, looking over a frozen lake, its far edge luminous with specks of light leaking from faculty houses. "In summer, you can swim or sail to work. In winter, you can ski or ice-skate."

It was like a fantasy. And in that moment, it hit me: it was a fantasy. We could never move to Wisconsin. What if I had a serious relapse in two years? Lucy would be isolated, stripped of her friends and family, alone, caring for a dying husband and new child. As furiously as I had tried to resist it, I realized that cancer had changed the calculus. For the last several months, I had striven with every ounce to restore my life to its precancer trajectory, trying to deny cancer any purchase on my life. As desperately as I now wanted to feel triumphant, instead I felt the claws of the crab holding me back. The curse of cancer created a strange and strained existence, challenging me to be neither blind to, nor bound by, death's approach. Even when the cancer was in retreat, it cast long shadows.

When I'd first lost the professorship at Stanford, I'd consoled myself with the idea that running a lab made sense only on a twenty-year time scale. Now I saw that this was, in fact, true. Freud started his career as a successful neuroscientist. When he realized neuroscience would need at least a century to catch up with his true ambition of understanding the mind, he set aside his microscope. I think I felt something similar. Transforming neurosurgery through my research was a gamble whose odds had been made too long by my diagnosis; the lab wasn't the place I wanted to plunk the remainder of my chips.

I could hear Emma's voice again: You have to figure out what's most important to you.

If I no longer sought to fly on the highest trajectory of neurosurgeon and neuroscientist, what did I want?

To be a father?

To be a neurosurgeon?

To teach?

I didn't know. But if I did not know what I wanted, I 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.

My own hubris as a surgeon stood naked to me now: as much as I focused on my responsibility and power over patients' lives, it was at best a temporary responsibility, a fleeting power. Once an acute crisis has been resolved, the patient awakened, extubated, and then discharged, the patient and family go on living-and things are never quite the same. 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.

Emma hadn't given me back my old ident.i.ty. She'd protected my ability to forge a new one. And, finally, I knew I would have to.

- On a crystalline spring morning on the third Sunday of Lent, Lucy and I went to church with my parents, who had flown in from Arizona for a weekend visit. We sat together in a long wooden pew, and my mother struck up a conversation with the family sitting next to us, first complimenting the mother on her baby daughter's eyes, then quickly moving on to matters of greater substance, her skills as a listener, confidante, and connector fully evident. During the pastor's Scripture reading, I suddenly found myself chuckling. It featured a frustrated Jesus whose metaphorical language receives literal interpretation from his followers:

Jesus answered and said to her, "Everyone who drinks this water will be thirsty again; but whoever drinks the water I shall give will never thirst; the water I shall give will become in him a spring of water welling up to eternal life." The woman said to him, "Sir, give me this water, so that I may not be thirsty or have to keep coming here to draw water."

...Meanwhile, the disciples urged him, "Rabbi, eat." But he said to them, "I have food to eat of which you do not know." So the disciples said to one another, "Could someone have brought him something to eat?"

It was pa.s.sages like these, where there is a clear mocking of literalist readings of Scripture, that had brought me back around to Christianity after a long stretch, following college, when my notion of G.o.d and Jesus had grown, to put it gently, tenuous. During my sojourn in ironclad atheism, the primary a.r.s.enal leveled against Christianity had been its failure on empirical grounds. Surely enlightened reason offered a more coherent cosmos. Surely Occam's razor cut the faithful free from blind faith. There is no proof of G.o.d; therefore, it is unreasonable to believe in G.o.d.

Although I had been raised in a devout Christian family, where prayer and Scripture readings were a nightly ritual, I, like most scientific types, came to believe in the possibility of a material conception of reality, an ultimately scientific worldview that would grant a complete metaphysics, minus outmoded concepts like souls, G.o.d, and bearded white men in robes. I spent a good chunk of my twenties trying to build a frame for such an endeavor. The problem, however, eventually became evident: to make science the arbiter of metaphysics is to banish not only G.o.d from the world but also love, hate, meaning-to consider a world that is self-evidently not the world we live in. That's not to say that if you believe in meaning, you must also believe in G.o.d. It is to say, though, that if you believe that science provides no basis for G.o.d, then you are almost obligated to conclude that science provides no basis for meaning and, therefore, life itself doesn't have any. In other words, existential claims have no weight; all knowledge is scientific knowledge.

Yet the paradox is that scientific methodology is the product of human hands and thus cannot reach some permanent truth. We build scientific theories to organize and manipulate the world, to reduce phenomena into manageable units. Science is based on reproducibility and manufactured objectivity. As strong as that makes its ability to generate claims about matter and energy, it also makes scientific knowledge inapplicable to the existential, visceral nature of human life, which is unique and subjective and unpredictable. 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.

Between these core pa.s.sions and scientific theory, there will always be a gap. No system of thought can contain the fullness of human experience. The realm of metaphysics remains the province of revelation (this, not atheism, is what Occam argued, after all). And atheism can be justified only on these grounds. The prototypical atheist, then, is Graham Greene's commandant from The Power and the Glory, whose atheism comes from a revelation of the absence of G.o.d. The only real atheism must be grounded in a world-making vision. The favorite quote of many an atheist, from the n.o.bel Prizewinning 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."

Yet I returned to the central values of Christianity-sacrifice, redemption, forgiveness-because I found them so compelling. There is a tension in the Bible between justice and mercy, between the Old Testament and the New Testament. And the New Testament says you can never be good enough: goodness is the thing, and you can never live up to it. The main message of Jesus, I believed, is that mercy trumps justice every time.

Not only that, but maybe the basic message of original sin isn't "Feel guilty all the time." Maybe it is more along these lines: "We all have a notion of what it means to be good, and we can't live up to it all the time." Maybe that's what the message of the New Testament is, after all. Even if you have a notion as well defined as Leviticus, you can't live that way. It's not just impossible, it's insane.

About G.o.d I could say nothing definitive, of course, but the basic reality of human life stands compellingly against blind determinism. Moreover, no one, myself included, credits revelation with any epistemic authority. We are all reasonable people-revelation is not good enough. Even if G.o.d spoke to us, we'd discount it as delusional.

So what, I wonder, is the aspiring metaphysician to do?

Give up?

Almost.

Struggle toward the capital-T Truth, but recognize that the task is impossible-or that if a correct answer is possible, verification certainly is impossible.

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.

- 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 a.s.signments; 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, a.s.sembled 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 pa.s.sed, 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 st.i.tch. 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.

"s.h.i.t, 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.