When Breath Becomes Air

by Paul Kalanithi

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Part 1, Section 2 Summary

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In his first year of medical school, Paul is surprised by how easy it is to get used to carving up human bodies, though one dissection exercise gives him pause: when cutting open a stomach, he sees two undigested morphine pills, suggesting that the deceased was in great pain when he died. Sometimes, others have similar realizations, such as when Paul’s seventy-four-year-old professor is surprised to find one of the cadavers died at seventy-four of pancreatic cancer.

Paul also meets his future wife, Lucy, in the first year of medical school; her sensitivity appeals to him. He recalls her weeping over the EKG of a patient who must, based on the fatal arrhythmia presented on the strip, have died:

The squiggly lines on that page were more than just lines; they were ventricular fibrillation deteriorating to asystole, and they could bring you to tears.

One of Paul’s greatest influences is the “surgeon-philosopher” Shep Nuland. Though Nuland is a lecturer at Yale during Paul’s period as a student, Paul only knows him as a reader of Nuland’s seminal work How We Die. Reading this book makes Paul realize that despite his years of medical school, he still knows little about death. “Descriptions like Nuland’s,” he writes, “convinced me that such things could be known only face-to-face.” Nuland’s description of himself as a student, unable to save a patient’s stopped heart by cutting his chest open and attempting to pump it, strikes Paul as “the true image of a doctor”: responsible and active even in the face of failure.

After finishing the first two years of medical school, Paul comes to witness death firsthand when he works the late shift in the delivery ward. Only in her twenty-third week of pregnancy, Elena Garcia is experiencing preterm labor, which the doctors hope to keep under control through drugs until her twin children are developed enough to survive outside the womb. Paul is unsure how to read the results on Elena’s monitor, so he asks the nurse for help. However, just as the nurse is teaching him, she realizes something is wrong: the twins are not doing well. An emergency C-section is their sole, slim chance for survival. Paul witnesses the operation. The twins are extremely small; their skin is see-through. The doctors offer to let Paul sew the last two stitches on Elena’s belly, but his nerves cause him to put them in unevenly, forcing Melissa, the resident doctor, to fix them.

Later that night, Paul is assigned to care for another expectant mother. This time, though, everything goes right. Paul is stunned by how different (and difficult) birth is in real life as opposed to within the clinical confines of a textbook. After he delivers the good news to the mother’s family, Paul inquires after the premature twins, only to learn that both died. Melissa does not regret performing the C-section—it was the only option that gave the twins a chance at life—and Paul learns that being a doctor does not mean one is always certain about what to do in an emergency situation.

Soon after this, Paul’s rotation in obstetrics and gynecology ends, and he moves on to surgical oncology with Mari, another medical student. Mari is chosen to assist with a Whipple operation, a complicated procedure for pancreatic cancer patients in which the abdominal organs are rearranged. When it turns out that the operation will not be necessary, Mari weeps from relief in the hallway.

In his fourth year of medical school, Paul watches as many of his classmates ultimately choose to specialize in “less demanding” areas so that...

(This entire section contains 1421 words.)

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they can live more comfortably and have more free time away from work. Many students even claim that they should not always place their patients’ needs before their own. Paul’s feelings about these classmates’ choices are complex—he calls the prioritization of one’s own life “egotism” and “antithetical to medicine,” but also “entirely reasonable”—and ultimately concludes that such decision-making is characteristic of how one chooses a job, not a “calling,” as he considers medicine to be.

Paul’s determination to become a neurosurgeon is “cemented” when he overhears a pediatric neurosurgeon speaking to the parents of a child with a brain tumor. They are devastated, but the doctor’s gentle manner in preparing them emotionally for the days and weeks ahead makes Paul realize how influential doctors can be in helping people face traumatic situations. He is also “compelled” by neurosurgery’s “unforgiving” nature; the neurosurgeon, he explains, seems to be closer than any other physician to the cruxes of human life, death, and identity.

After medical school is finished, the newly married Paul and Lucy start their residencies in California: Paul’s at Stanford and Lucy’s at the University of California, San Francisco. Paul makes several friends at the hospital, notably Victoria, his coresident, and Jeff, a general surgery resident. Paul’s initial workload involves giant masses of paperwork. One of the patients during this period is an eight-year-old boy named Matthew, who has a tumor by his hypothalamus, the part of the brain which regulates “basic drives: sleep, hunger, thirst, sex.” The surgeon must choose between possibly damaging the hypothalamus and subjecting Matthew to years of grueling operations. He opts for the former, though a few years later, Paul learns that Matthew has extreme problems regulating anger and hunger due to a millimeter of hypothalamus damage.

The elderly Mrs. Harvey is the first patient Paul loses. Unlike Matthew, Mrs. Harvey only suffers from a bowel obstruction, and it is believed an operation will have her home in no time. However, Mrs. Harvey begins to lose blood pressure after the operation. Paul desperately pumps drugs and fluids into her body in the ICU. She reaches a stable condition for a while but dies hours later. The following day, Paul realizes that Mrs. Harvey is the first patient to have really become “his,” despite the “layers of paperwork.” After his experience with her, Paul resolves “to treat all [his] paperwork as patients, and not vice versa.”

Residents in their second year of training, Paul says, are first to respond in an emergency. Some residents are unable to handle the stress, such as a surgeon who blames his mistakes on everyone but himself. Paul fears he is losing compassion as he and the other professionals make jokes about the operations, or when he is able to enjoy an ice-cream sandwich after an accident victim dies in surgery. When his friend Laurie dies from car accident injuries days later, Paul suddenly realizes that he is beginning to lose empathy for both the patients and their grieving families, and resolves to do better.

Paul recalls his father’s easy manner in putting patients at ease, and he emulates his father when a thirty-five-year-old woman with a brain tumor comes to him for surgery. She is terrified of the operation, and Paul gathers her with her family to discuss her options. Reassured, she goes through with the surgery, and all goes well. Unfortunately, Paul also deals with hopeless causes, such as a woman with severe brain cancer.

In his fourth year, Paul works with a scientist everyone calls “V.” V helps develop neural prosthetics. Paul respects V’s dedication to excellence and enjoys their frequent discussions. However, V is diagnosed with pancreatic cancer and comes to Paul to ask,

Paul, do you think my life has meaning? Did I make the right choices?

Luckily, V’s grueling treatments garner success, though his “hair had thinned and whitened, and the spark in his eyes had dulled.” Yet V claims that now that he is back at work, it all seems worth it, despite the pain.

After Paul returns to the hospital full-time as chief resident, he takes on even more responsibility, and toward the end of this period—what he calls “the pinnacle of residency”—Paul receives multiple job offers as a result of his skill. However, Paul also loses his friend Jeff, a surgical fellow, to suicide. Evidently, Jeff had lost a patient in surgery, then killed himself. Paul says that if he had been there, he would have told Jeff what he’s learned about life from his work:

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.

Part 1, Section 1 Summary


Part 2, Section 1 Summary