Book Review — When Breath Becomes Air by Paul Kalanithi

Three days ago, I finished When Breath Becomes Air: A Memoir by Paul Kalanithi. Kalanithi was an American neurosurgeon who died in March 2015. The book was posthumously published by Random House in January 2016.

This 228-page book is a profoundly moving memoir of 36-year-old Paul, who was diagnosed with stage IV metastatic lung cancer just as he was about to finish his last year of neurosurgical residency at Stanford University. What was he to do? How was he supposed to navigate this? Should they have that baby with a girlfriend he was devoted to, who was fortunately devoted to him? What is the meaning of life?

The last question had plagued him as a doctor and then as a patient. From a young age, he made books his friends. In fact, he had never considered becoming a surgeon. He wanted most to read and write and explore. He graduated with a Bachelor of Arts and a Master of Arts in English Literature and a Bachelor of Science in Human Biology. It was while considering going for a Ph.D. in English Literature that he changed his mind and put in for the Yale School of Medicine.

As he delved around, sampling his interests, I could not help thinking that there is great fulfillment in allowing a child the freedom to wander. While some of his closest friends from his time in college pursued a life in the arts — some in comedy, others in journalism and television — the burning question in his mind about the intersection between biology, morality, literature, and philosophy led him into medicine, specifically neuroscience. For a person whose father, uncle, and elder brother were all doctors, medicine had never occurred to him as a serious possibility, and he had not been pressed. Alas, medicine called him.

And it’s no surprise that he became interested in neurosurgery branch of medicine. It became less of a job and more of a vocation. Why do doctors hold the hands of the patients after delivering especially tragic news to them? Do you know that one of the early meanings of the word “patient” is “one who endures hardship without complaint”? Why do anatomy professors advise students to take just one good look at the cadaver’s face and then leave it covered as they begin the dissection? In easy, plain language, Paul takes the reader through what the life of a neurosurgeon entails. He tells us how doctors invade the body in every way imaginable. How they see people at their most vulnerable, their most scared, and their most private. The reader feels his shock as Paul realizes that the neatness of medical diagrams does nothing to represent nature. With blood everywhere during surgery, the surgeon not only has to train their minds but their eyes, too.

#WILT: Psychogenic syndrome. This syndrome is a severe version of the swoon some experience after hearing bad news. For example, while alone at college, after his mother heard that her father had finally died after a long hospitalization, she had a psychogenic seizure — which continued until she returned home to attend the funeral. One of Paul’s patients went into a coma after being told they had brain cancer. All it took to wake her up was to raise her arm and speak some comforting words to her still body.

The book’s sheer graphic details could make the reader shudder at times. An alcoholic bleeding to death into his joints and under his skin looking up at Paul and saying, “It’s not fair — I’ve been diluting my drinks with water.” Paramedics pushing the gurney into the theater, reciting the details: “Twenty-two-year-old male, motorcycle accident, forty miles per hour, possible brain coming out his nose…”. An 8-year-old boy who had to be institutionalized because he had become a monster as a result of slight damage to his hypothalamus during an operation to remove a tumor in his brain. A man was reduced to saying only a series of numbers because his brain tumor had interrupted his speech circuitry. With something to tell the doctors, only figures like “fourteen one two eight” came out. He died a few months later, buried with whatever message he had for the world. Driving home one night, tears streamed down Paul’s face. Why? A few minutes earlier, he had told a mother that her baby was born without a brain and would die soon.

As a result, it was no surprise when he recounted the death of a fellow surgeon who climbed onto the roof of a building and jumped off. He apparently had a difficult complication during an operation, and his patient died. It should not be underestimated the crazy hours these professionals work. As resident doctors, they were working as much as one hundred hours a week; though regulations officially capped their hours at eighty-eight, there was always more work to be done. And duty dictates that they do as much as they can. Paul remembers often staggering through the parking lot and napping in his car before driving home to bed.

“Science may provide the most useful way to organize empirical, reproducible data, but its power to do so is predicated on its inability to grasp the most central aspects of human life: hope, fear, love, hate, beauty, envy, honor, weakness, striving, suffering, and virtue.”

Nonetheless, Paul would have preferred the arduous work ethic of his chosen profession to the unexpected and sudden diagnosis of lung cancer. The news so derailed his plans that even when the cancer receded at some point and he was wooed to take a posh job in Wisconsin, he could not. Millions of dollars to start a neuroscience lab; head of his own clinical service; flexibility if he needed it for his health; a tenure-track professorship, appealing job options for his fiancé; a high salary; beautiful scenery; an idyllic town; the perfect boss. He had to turn the job down because he knew that if he had a relapse, which he eventually did, his fiancé would be isolated, stripped of her friends and family, and alone, caring for a dying husband and a new child.

Cancer is a terrible disease. He encountered deep fatigue; a profound boneweariness set in. Eating, which was normally a source of great pleasure for him, became to him like drinking seawater. Suddenly, all of his joys were salted. Reading, one of his great loves, became exhausting. Even writing this unbelievably inspiring book became a chore. The narration of how the disease made a once vibrant, deep-thinking man deteriorate was tear-inducing, but just as his wife said, what happened to Paul was tragic, but he was not a tragedy.

You should read this simple, straightforward, eloquent, and unflinchingly honest book because, even though it is soul-wrenching, Paul has so many things to tell us from his own experiences. It is philosophical, beautiful, and moving.

As an additional push for you to read this book, the book spent 68 weeks on the non-fiction bestseller list on the New York Times bestseller list. It was a finalist for Pulitzer Prize, Biography or Autobiography. It was named one of Paste’s best memoirs of the decade.

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