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When Breath Becomes Air

whenbreathbecomesReading Paul Kalanthi’s book is bittersweet: its author wrote it knowing he would die soon and I read it hoping time would slow down. I forgot that racing awestruck to the end meant racing to a foregone conclusion.

The book is a sort of letter, the sender dead before the words reach us. The first and last words are dedicated ‘to Cady’, Kalanthi’s baby daughter, and to his wife, Lucy. There’s something spooky and poignant about text that reaches us from a person no longer there. Like Albertine’s conciliatory telegram that reaches Marcel after she has died falling off her horse in Remembrance of Things Past, a letter with no extant sender is like being shut in a room where the door has been rubbed out. The instability of ideas we’d like to convey in letters is highlighted by Maggie Nelson in her recent, excellent book The Argonauts where she teases out the bravery of writing letters, we commit them to another person’s safekeeping, as well as the suspicion that the letter writer is really addressing themselves (an angry girlfriend replies to one of Nelson’s love letters the puncturingly simple: ‘Next time, write to me’). So why is Paul Kalanthi’s last letter of interest?

Last year, one of the editors wrote here about Do No Harm, written by the neurosurgeon Henry Marsh. When Breath Becomes Air has much in common with Do No Harm: it’s also written by a neurosurgeon and deals with the crushing responsibility that comes with the job for the few that make it and it’s brilliant (arguably, more so). Marsh and Kalanthi reflect on their careers at different stages, of course: Marsh is towards the end of his; Kalanthi had only just completed his training. The difference in their accounts, however, is also attitudinal. Where Marsh bemoans the growing number of technological surgical interventions eclipsing a surgeon’s job and the impossibility of getting enough practice in the operating theatre as a junior, Kalanthi is passionate and always uncomplaining. Kalanthi castigates himself for mistakes made, most of them inevitable. Sometimes, he fights hard to save a life only for that life to be so limited by brain damage he wonders if saving it is the right way to look at it; decisions deferred not made.

Like Marsh, Kalanthi studied English before turning to medicine, a feat less surprising in America where students are encouraged to specialise later than in the UK, turning to medicine only after a first degree. Kalanthi’s writing shows how much literature meant to him and his style is lauded in the foreword. With infectious enthusiasm he tells us that ‘to burke’ meant “to kill secretly by suffocation or strangulation, or for the purpose of selling the victim’s body for dissection“, fuelled by medical schools’ demand for cadavers in “the bad old days“. We learn the root of the word ‘disaster’ means a star coming apart (the Greek for star is ‘astron’). According to Kalanthi, ‘no image expressed better the look in a patient’s eyes when hearing a neurosurgeon’s diagnosis’. Later, he tells us the word ‘hope’ first appeared in English about a thousand years ago “denoting some combination of confidence and desire“. His evident enjoyment in writing and choosing words deliberately is overdone only once. Expounding on how to communicate the immensity of an unbeatable brain cancer to a patient incrementally, he cautions: the “tureen of tragedy was best slotted by the spoonful“. The structure of the book is interesting: necessarily frustrating us as Kalanthi ran out of time. In the beginning of the book we race along hearing about his training, forgetting that the story is about to turn tragic. “Eat with your left hand. You’ve got to learn to be ambidextrous“, his boss tells him one day passing him at lunch in the canteen during his first year as a surgical intern.

Lessons learnt are hard won. “In the midst of this endless barrage of head injuries, I began to suspect that being so close to the fiery light of such moments only blinded me to their nature, like trying to learn astronomy by staring directly at the sun. I was not yet with patients in their pivotal moments, I was merely at those pivotal moments. I observed a lot of suffering; worse, I became inured to it“. At the end of part one, he’s just got to terms with how to live as a doctor: working 100 hour weeks; living with the responsibility of being a good doctor; working proximate to death and how to meet a patient “in a space where she was a person, instead of a problem to be solved“. Then, feeling he has learnt how to live, he then finds out at the age thirty six that he’s going to die of lung cancer.

“Be vague but accurate.”

Time, how it speeds up over a lifetime and how best to use it, is, is (unsurprisingly) a central concern. Accurate but humane uncertainty is promoted over the false satisfaction of giving a patient an exact amount of time to live (“I came to believe that it is irresponsible to be more precise than you can be accurate“).

Kalanthi returned to work after his tumour shrunk enough to hope more time may be meted out to him. He goes back in order to complete residency, resting between operations and swallowing handfuls of antiemetics and pain medication to get through his first week. Then he sleeps for forty hours straight.

“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…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.” This sense of values shifting would be familiar anyone who has lived close to someone terminally ill. It is well captured here and brought to mind Marion Coutts’s The Iceberg. Kalanthi wanted to spend 20 years working as a surgeon-scientist and 20 writing. In the end, he wrote for one year only and this book is his account of choices made and accepted.
Hannah Joll

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