When Breath Becomes Air (6 page)

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.

For the next several hours, things progressed smoothly. Melissa slept in the lounge. I tried decoding the indecipherable scribbles in Garcia’s chart, which was like reading hieroglyphics, and came away with the knowledge that her first name was Elena, this was her second pregnancy, she had received no prenatal care, and she had no insurance. I wrote down the names of the drugs she was getting and made a note to look them up later. I read a little about premature labor in a textbook I found in the doctors’ lounge. Preemies, if they survived, apparently incurred high rates of brain hemorrhages and cerebral palsy. Then again, my older brother, Suman, had been born almost eight weeks premature, three decades earlier, and he was now a practicing neurologist. I walked over to the nurse and asked her to teach me how to read those little squiggles on the monitor, which were no clearer to me than the doctors’ handwriting but could apparently foretell calm or disaster. She nodded and began talking me through reading a contraction and the fetal hearts’ reaction to it, the way, if you looked closely, you could see—

She stopped. Worry flashed across her face. Without a word, she got up and ran into Elena’s room, then burst back out, grabbed the phone, and paged Melissa. A minute later, Melissa arrived, bleary-eyed, glanced at the strips, and rushed into the patient’s room, with me trailing behind. She flipped open her cellphone and called the attending, rapidly talking in a jargon I only partially understood. The twins were in distress, I gathered, and their only shot at survival was an emergency C-section.

I was carried along with the commotion into the operating room. They got Elena supine on the table, drugs running into her veins. A nurse frantically painted the woman’s swollen abdomen with an antiseptic solution, while the attending, the resident, and I splashed alcohol cleanser on our hands and forearms. I mimicked their urgent strokes, standing silently as they cursed under their breath. The anesthesiologists intubated the patient while the senior surgeon, the attending, fidgeted.

“C’mon,” he said. “We don’t have a lot of time. We need to move faster!”

I was standing next to the attending as he sliced open the woman’s belly, making a single long curvilinear incision beneath her belly button, just below the apex of her protuberant womb. I tried to follow every movement, digging in my brain for textbook anatomical sketches. The skin slid apart at the scalpel’s touch. He sliced confidently through the tough white rectus fascia covering the muscle, then split the fascia and the underlying muscle with his hands, revealing the first glimpse of the melon-like uterus. He sliced that open as well, and a small face appeared, then disappeared amid the blood. In plunged the doctor’s hands, pulling out one, then two purple babies, barely moving, eyes fused shut, like tiny birds fallen too soon from a nest. With their bones visible through translucent skin, they looked more like the preparatory sketches of children than children themselves. Too small to cradle, not much bigger than the surgeon’s hands, they were rapidly passed to the waiting neonatal intensivists, who rushed them to the neonatal ICU.

With the immediate danger averted, the pace of the operation slowed, frenzy turning to something resembling calm. The odor of burnt flesh wafted up as the cautery arrested little spurts of blood. The uterus was sutured back together, the stitches like a row of teeth, biting closed the open wound.

“Professor, do you want the peritoneum closed?” Melissa asked. “I read recently that it doesn’t need to be.”

“Let no man put asunder what God has joined,” the attending said. “At least, no more than temporarily. I like to leave things the way I found them—let’s sew it back up.”

The peritoneum is a membrane that surrounds the abdominal cavity. Somehow I had completely missed its opening, and I couldn’t see it at all now. To me, the wound looked like a mass of disorganized tissue, yet to the surgeons it had an appreciable order, like a block of marble to a sculptor.

Melissa called for the peritoneal stitch, reached her forceps into the wound, and pulled up a transparent layer of tissue between the muscle and the uterus. Suddenly the peritoneum, and the gaping hole in it, was clear. She sewed it closed and moved on to the muscle and fascia, putting them back together with a large needle and a few big looping stitches. The attending left, and finally the skin was sutured together. Melissa asked me if I wanted to place the last two stitches.

My hands shook as I passed the needle through the subcutaneous tissue. As I tightened down the suture, I saw that the needle was slightly bent. The skin had come together lopsided, a glob of fat poking through.

Melissa sighed. “That’s uneven,” she said. “You have to
just
catch the dermal layer—you see this thin white stripe?”

I did. Not only would my mind have to be trained, my eyes would, too.

“Scissors!” Melissa cut out my amateur knots, resutured the wound, applied the dressing, and the patient was taken to recovery.

As Melissa had told me earlier, twenty-four weeks in utero was considered the edge of viability. The twins had lasted twenty-three weeks and six days. Their organs were present, but perhaps not yet ready for the responsibility of sustaining life. They were owed nearly four more months of protected development in the womb, where oxygenated blood and nutrients came to them through the umbilical cord. Now oxygen would have to come through the lungs, and the lungs were not capable of the complex expansion and gas transfer that was respiration. I went to see them in the NICU, each twin encased in a clear plastic incubator, dwarfed by large, beeping machines, barely visible amid the tangle of wires and tubes. The incubator had small side ports through which the parents could strain to reach and gently stroke a leg or arm, providing vital human contact.

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.

When I returned to work that night, I was assigned to a new mother. No one anticipated problems with this pregnancy. Things were as routine as possible; today was even her actual due date. Along with the nurse, I followed the mother’s steady progress, contractions racking her body with increasing regularity. The nurse reported the dilation of the cervix, from three centimeters to five to ten.

“Okay, it’s time to push now,” the nurse said.

Turning to me, she said, “Don’t worry—we’ll page you when the delivery is close.”

I found Melissa in the doctors’ lounge. After some time, the OB team was called into the room: delivery was near. Outside the door, Melissa handed me a gown, gloves, and a pair of long boot covers.

“It gets messy,” she said.

We entered the room. I stood awkwardly off to the side until Melissa pushed me to the front, between the patient’s legs, just in front of the attending.

“Push!” the nurse encouraged. “Now again: just like that, only without the screaming.”

The screaming didn’t stop, and was soon accompanied by a gush of blood and other fluids. The neatness of medical diagrams did nothing to represent Nature, red not only in tooth and claw but in birth as well. (An Anne Geddes photo this was not.) 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. What if I pulled too hard? (
Irreversible nerve injury,
my brain shouted.) The head appeared with each push and then retracted with each break, three steps forward, two steps back. I waited. 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.

I stood still, unsure when to act or what to do. The attending’s voice guided my hands to the emerging head, and on the next push, I gently guided the baby’s shoulders as she came out. She was large, plump, and wet, easily three times the size of the birdlike creatures from the previous night. Melissa clamped the cord, and I cut it. The child’s eyes opened and she began to cry. I held the baby a moment longer, feeling her weight and substance, then passed her to the nurse, who brought her to the mother.

I walked out to the waiting room to inform the extended family of the happy news. The dozen or so family members gathered there leapt up to celebrate, a riot of handshakes and hugs. I was a prophet returning from the mountaintop with news of a joyous new covenant! All the messiness of the birth disappeared; here I had just been holding the newest member of this family, this man’s niece, this girl’s cousin.

Returning to the ward, ebullient, I ran into Melissa.

“Hey, do you know how last night’s twins are doing?” I asked.

She darkened. Baby A died yesterday afternoon; Baby B managed to live not quite twenty-four hours, then passed away around the time I was delivering the new baby. In that moment, I could only think of Samuel Beckett, the metaphors that, in those twins, reached their terminal limit: “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?

“You think
that’s
bad?” she continued. “Most mothers with stillborns still have to go through labor and deliver. Can you imagine? At least these guys had a chance.”

A match flickers but does not light. The mother’s wailing in room 543, the searing red rims of the father’s lower eyelids, tears silently streaking his face: this flip side of joy, the unbearable, unjust, unexpected presence of death…What possible sense could be made, what words were there for comfort?

“Was it the right choice, to do an emergency C-section?” I asked.

“No question,” she said. “It was the only shot they had.”

“What happens if you don’t?”

“Probably, they die. Abnormal fetal heart tracings show when the fetal blood is turning acidemic; the cord is compromised somehow, or something else seriously bad is happening.”