Because the med school application cycle takes eighteen months, I had a free year once my classes were over. Several professors had suggested I pursue a degree in the history and philosophy of science and medicine before deciding to leave academia for good. So I applied for, and was accepted into, the HPS program at Cambridge. I spent the next year in classrooms in the English countryside, where I found myself increasingly often arguing that direct experience of life-and-death questions was essential to generating substantial moral opinions about them. Words began to feel as weightless as the breath that carried them. Stepping back, I realized that I was merely confirming what I already knew: I wanted that direct experience. It was only in practicing medicine that I could pursue a serious biological philosophy. Moral speculation was puny compared to moral action. I finished my degree and headed back to the States. I was going to Yale for medical school.
—
You would think that the first time you cut up a dead person, you’d feel a bit funny about it. Strangely, though, everything feels normal. The bright lights, stainless steel tables, and bow-tied professors lend an air of propriety. Even so, that first cut, running from the nape of the neck down to the small of the back, is unforgettable. The scalpel is so sharp it doesn’t so much cut the skin as unzip it, revealing the hidden and forbidden sinew beneath, and despite your preparation, you are caught unawares, ashamed and excited. Cadaver dissection is a medical rite of passage and a trespass on the sacrosanct, engendering a legion of feelings: from revulsion, exhilaration, nausea, frustration, and awe to, as time passes, the mere tedium of academic exercise. Everything teeters between pathos and bathos: here you are, violating society’s most fundamental taboos, and yet formaldehyde is a powerful appetite stimulant, so you also crave a burrito. Eventually, as you complete your assignments by dissecting the median nerve, sawing the pelvis in half, and slicing open the heart, the bathos supersedes: the sacred violation takes on the character of your average college class, replete with pedants, class clowns, and the rest. Cadaver dissection epitomizes, for many, the transformation of the somber, respectful student into the callous, arrogant doctor.
The enormity of the moral mission of medicine lent my early days of med school a severe gravity. The first day, before we got to the cadavers, was CPR training, my second time doing it. The first time, back in college, had been farcical, unserious, everyone laughing: the terribly acted videos and limbless plastic mannequins couldn’t have been more artificial. But now the lurking possibility that we would have to employ these skills someday animated everything. As I repeatedly slammed my palm into the chest of a tiny plastic child, I couldn’t help but hear, along with my fellow students’ jokes, real ribs cracking.
Cadavers reverse the polarity. The mannequins you pretend are real; the cadavers you pretend are fake. But that first day, you just can’t. When I faced my cadaver, slightly blue and bloated, his total deadness and total humanness were undeniable. The knowledge that in four months I would be bisecting this man’s head with a hacksaw seemed unconscionable.
Yet there are anatomy professors. And the advice they gave us was to take one good look at our cadaver’s face and then leave it covered; it makes the work easier. Just as we prepared, with deep breaths and earnest looks, to unwrap our cadaver’s head, a surgeon stopped by to chat, leaning with his elbows on the corpse’s face. Pointing out various marks and scars on the naked torso, he reconstructed the patient’s history. This scar is from an inguinal hernia operation, this one a carotid endarterectomy; these marks here indicate scratching, possibly jaundice, high bilirubin; he probably died of pancreatic cancer, though no scar for that—killed him too quick. Meanwhile, I could not help but stare at the shifting elbows that, with each medical hypothesis and vocabulary lesson, rolled over this covered head. I thought: Prosopagnosia is a neurological disorder wherein one loses the ability to see faces. Pretty soon I would have it, hacksaw in hand.
Because after a few weeks, the drama dissipated. In conversations with non–medical students, telling cadaver stories, I found myself highlighting the grotesque, macabre, and absurd, as if to reassure them that I was normal, even though I was spending six hours a week carving up a corpse. Sometimes I told of the moment when I turned around and saw a classmate, the sort of woman who had a mug decorated with puffy paint, tiptoeing on a stool, cheerfully hammering a chisel into a woman’s backbone, splinters flying through the air. I told this story as if to distance myself from it, but my kinship was undeniable. After all, hadn’t I just as eagerly disassembled a man’s rib cage with a pair of bolt cutters? Even working on the dead, with their faces covered, their names a mystery, you find that their humanity pops up at you—in opening my cadaver’s stomach, I found two undigested morphine pills, meaning that he had died in pain, perhaps alone and fumbling with the cap of a pill bottle.
Of course, the cadavers, in life, donated themselves freely to this fate, and the language surrounding the bodies in front of us soon changed to reflect that fact. We were instructed to no longer call them “cadavers”; “donors” was the preferred term. And yes, the transgressive element of dissection had certainly decreased from the bad old days. (Students no longer had to bring their own bodies, for starters, as they did in the nineteenth century. And medical schools had discontinued their support of the practice of robbing graves to procure cadavers—that looting itself a vast improvement over murder, a means once common enough to warrant its own verb: burke, which the OED defines as “to kill secretly by suffocation or strangulation, or for the purpose of selling the victim’s body for dissection.”) Yet the best-informed people—doctors—almost never donated their bodies. How informed were the donors, then? As one anatomy professor put it to me, “You wouldn’t tell a patient the gory details of a surgery if that would make them not consent.”
Even if donors were informed enough—and they might well have been, notwithstanding one anatomy professor’s hedging—it wasn’t so much the thought of being dissected that galled. It was the thought of your mother, your father, your grandparents being hacked to pieces by wisecracking twenty-two-year-old medical students. Every time I read the pre-lab and saw a term like “bone saw,” I wondered if this would be the session in which I finally vomited. Yet I was rarely troubled in lab, even when I found that the “bone saw” in question was nothing more than a common, rusty wood saw. The closest I ever came to vomiting was nowhere near the lab but on a visit to my grandmother’s grave in New York, on the twentieth anniversary of her death. I found myself doubled over, almost crying, and apologizing—not to my cadaver but to my cadaver’s grandchildren. In the midst of our lab, in fact, a son requested his mother’s half-dissected body back. Yes, she had consented, but he couldn’t live with that. I knew I’d do the same. (The remains were returned.)
In anatomy lab, we objectified the dead, literally reducing them to organs, tissues, nerves, muscles. On that first day, you simply could not deny the humanity of the corpse. But by the time you’d skinned the limbs, sliced through inconvenient muscles, pulled out the lungs, cut open the heart, and removed a lobe of the liver, it was hard to recognize this pile of tissue as human. Anatomy lab, in the end, becomes less a violation of the sacred and more something that interferes with happy hour, and that realization discomfits. In our rare reflective moments, we were all silently apologizing to our cadavers, not because we sensed the transgression but because we did not.
It was not a simple evil, however. All of medicine, not just cadaver dissection, trespasses into sacred spheres. Doctors invade the body in every way imaginable. They see people at their most vulnerable, their most scared, their most private. They escort them into the world, and then back out. Seeing the body as matter and mechanism is the flip side to easing the most profound human suffering. By the same token, the most profound human suffering becomes a mere pedagogical tool. Anatomy professors are perhaps the extreme end of this relationship, yet their kinship to the cadavers remains. Early on, when I made a long, quick cut through my do
nor’s diaphragm in order to ease finding the splenic artery, our proctor was both livid and horrified. Not because I had destroyed an important structure or misunderstood a key concept or ruined a future dissection but because I had seemed so cavalier about it. The look on his face, his inability to vocalize his sadness, taught me more about medicine than any lecture I would ever attend. When I explained that another anatomy professor had told me to make the cut, our proctor’s sadness turned to rage, and suddenly red-faced professors were being dragged into the hallway.
Other times, the kinship was much simpler. Once, while showing us the ruins of our donor’s pancreatic cancer, the professor asked, “How old is this fellow?”
“Seventy-four,” we replied.
“That’s my age,” he said, set down the probe, and walked away.
—
Medical school sharpened my understanding of the relationship between meaning, life, and death. I saw the human relationality I had written about as an undergraduate realized in the doctor-patient relationship. As medical students, we were confronted by death, suffering, and the work entailed in patient care, while being simultaneously shielded from the real brunt of responsibility, though we could spot its specter. Med students spend the first two years in classrooms, socializing, studying, and reading; it was easy to treat the work as a mere extension of undergraduate studies. But my girlfriend, Lucy, whom I met in the first year of medical school (and who would later become my wife), understood the subtext of the academics. Her capacity to love was barely finite, and a lesson to me. One night on the sofa in my apartment, while studying the reams of wavy lines that make up EKGs, she puzzled over, then correctly identified, a fatal arrhythmia. All at once, it dawned on her and she began to cry: wherever this “practice EKG” had come from, the patient had not survived. 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.
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.
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 week
s 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.
When Breath Becomes Air Page 4