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Posts tagged ‘Marsh’

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

Book Club Spy: Do No Harm

Do No HarmDo No Harm – Henry Marsh

After a considerable hiatus, we reconvened to discuss this autobiographical account of neurosurgeon Henry Marsh’s career. The book is essentially a series of episodes spanning several decades of practise, and the most immediately disconcerting thing about a fairly unsettling book all round is Marsh’s tone. He veers between brutal honesty, peevish rebellion and didactic pomposity, and everywhere in between. The idea of an egotistical surgeon is as entrenched as our acknowledgement of the job as fairly technical and demanding: on Radio 4 on 30th June, he described himself as “jolly clever”, whilst at the same time being keen to debunk the idea of the surgeon as a solo “Michelangelo genius”.

He partially dispels the latter notion with his description of his entrance into the medical profession, which would be impossible now. He is quick to describe himself as middle class, but the story of him meeting one old boy and discussing fly fishing in order to gain a place at medical school (despite only two science GCSEs) suggests he is rather grander than that.

However, there are moments when he confirms every assumption surrounding the medical profession I have ever had, especially regarding his personal relationships, about which to be fair he is very discreet. I felt deeply sorry for his first wife – about whom he respectfully mentions very little besides the fact that his work contributed to the breakdown of the marriage – but his few explosions of temper/ego in the book are all compared to his younger episodes and found paltry by comparison, so he must have been a terror in the 90s. He refers to the nervous breakdown he had as a young man – necessitating a year out from Oxford – as silly. He glossed over it on the radio as he does on family matters in his book – as long as he is calling the shots on which episodes of his life to expose he is far more detailed, just very selective, as is his right.

Marsh claims the idea of surgeons needing to have steady hands is a myth, but the idea of an inexperienced wobbler operating on you or a loved one is not going to inspire many with confidence. Everyone is keen on training new doctors but no one wants to be the one experimented on, as it were, especially his story of a man being paralysed when a normally able, confident trainee snipped a vital nerve in his spine. The description of that white thread flopping where it is not meant to be is utterly desolate. It is one of the reasons Marsh hates training junior doctors.

He is not sentimental about his patients: he is gleeful when an outpatient has recovered sufficiently to say to him: “I hope I never see you again.” There is no Grey’s Anatomy schmaltz here. He claimed on the radio never to have had his mind changed by a patient – occasionally he has advised against operating in order to prevent spinning someone’s painful life out and has clearly expressed his views on avoiding a painful end for patients and families. He would, however, encourage patients to get second opinions on riskier surgeries – this is the culture elsewhere and he claims that in this country there is too much of a tendency to defer to a medical opinion rather than question it.

He has experienced surgery in Iran and Ukraine on several occasions and so is qualified to make some comparison. One reader questioned his motives for going to Ukraine to perform surgeries: was it because these extreme, neglected cases were interesting to him, and a coup if he pulled them off (he is much less accountable there if he doesn’t) rather than doing something genuinely altruistic? Another quibble was his account of bringing second hand medical equipment from England to perform these surgeries, as if everything provided for Ukrainians was second best. The ‘better than nothing argument’ is never sexy. He bought said kit with his own money. The patients he saw would certainly have suffered more without him, so on balance it seems to have been a good thing. The same sceptic questioned whether he should go back to Ukraine having retired to operate. Again, less than ideal to know an elderly gent is operating, but I would choose one of the most accomplished brain surgeons in the UK over none at all, personally.

His parting, reedy comment regarding his expertise on Radio 4 was that he finds neurosurgery crude. It is particularly interesting that he compares it to butchery when the practise is comared to the complexity of the brain, which no one completely understands. The book opens with his painfully vivid description of an exposed brain, with its jelly-like surface encased in silvery strands like a spider’s web. Brain surgery is only every chopping bits out of the brain – he is especially good at describing tumours: soft, uckable-out ones and hard ones that have to be collapsed in on themselves. Herein may lie the tension inherent in the profession at which he is so clearly proficient: he likes making things and admiring in them in their entirety, yet for thirty years he has had to remove and break things, never adding to the whole of the brain. Perhaps as a result, his retirement plans are to make things: furniture and houses while taking care of his own health. At the age of 65 he claims: “I am taking nothing for granted”. Except perhaps the publishing world, as he is planning a second book.

The Editors