Home > When Breath Becomes Air(11)

When Breath Becomes Air(11)
Paul Kalanithi

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?

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