When Breath Becomes Air by Paul Kalanithi

Foreword. I only knew Paul after his death. After he was diagnosed with cancer, he had a desire to write a book. We become aware of our own mortality after reading his book as well. Paul had a flair of writing, however, had a calling of being a physician. He would eventually be a neurosurgeon. Paul writes occasionally and was an excellent writer. Paul has been very vulnerable and revealed a lot about himself.

Prologue. The cancer had spread and was widely disseminated. I was the patient this time. Lucy was my wife and she was by my side. When I had back pain, I went for an MRI scan. X-rays aren’t good for detection of cancer. Weight loss became more common as the days went by. I was an outstanding surgeon and had a bright career ahead of me. A few weeks later, I had strong bouts of chest pain. My work and the demanding schedule had put a toll on our marriage. My wife wanted to leave me. The pain was getting more severe and I was in trouble. I also started to tell friends about my cancer. My wife learnt about it and promised not to leave me.

Part 1: In Perfect Health I Begin

I never thought that I would be a doctor. I didn’t know much about medicine when I was young. We had two dogs. Once, we went to the desert and found the insects there to be fascinating. My younger brother was Jeevan. My dad was the one who brought our family to the desert town of Kingman, in Arizona. The issue with Kingman was that the education system was bad and there were many dropouts. My mum instilled in us, a love of reading. I eventually got into Stanford University. I liked a girl named Abigail in school. In school, I was driven to understand what makes human life meaningful? One of my favorite authors, was T.S. Eliot. Literature was a form of moral reflection for me. Was the unlived life worth examining? I did an internship at Sierra Camp, which was very eye opening indeed. I studied both neuroscience and literature in school. Many of the caregivers will not even show up to pay the patients of severe brain problems. Some parents even abandon their kids. Brains indeed play a crucial role in our ability to form relationships. Language of life was a passion, hunger and a love. I studied the work of Walt Whitman. I wanted to find out how biology, morality, literature and philosophy intersected. I was contemplating medical school now. After I enrolled myself into the HPS program at Cambridge, I started to realize that only by practicing medicine, I could pursue a serious biological philosophy. I cut my first dead body and it felt alright. These were cadavers or donor corpses. I hardly ever felt like vomiting. The book by Shep Nuland on ‘How we die’ was very popular. It addressed the fact of existence. Although I read about the particularities of death, being a surgeon allowed me to understand them better. I was asked to deliver a child. I was educated on how to read the fetal heart rates etc. The twins were in distress and their only hope was a C-section. However, they didn’t survive as they were premature. On my next case, the baby was successfully delivered and I was very relieved indeed. Next on my rotation was surgical oncology. Many of the medical students chose to specialize in things like radiology or dermatology, which were deemed easier. Eventually, I chose neurosurgery as my specialty. Part of a doctor’s job is about to be emotionally attached to the patient and to calm them down. Brain surgery has a huge impact on the patient’s life. Would you trade your ability to talk for a few extra months of mute life? What makes life meaningful enough to go on living? Neurosurgeons have a huge responsibility. During the first year of residency, the workload was tremendous. The papers I file are narratives of risks and triumph. I finally lost my first patient. I saw a few people die in the course of my work. Sometimes, death has a suffocating weight on me too. In the second year of training, I was the first to arrive in an emergency. I was doing a lot of overtime work, which was very tiring indeed. It was so stressful that some left the profession. Some cases were beyond hope, where even surgery would not do much good. I did not think I was a doctor who missed the larger human significance. My dad was an inspiration to me and he even when to buy meals for his patients when they requested for them. I once persuaded a girl’s family that surgery was the best option for her. Announcing the bad news to a patient is very difficult indeed. Brain surgery for cases for cancer that metastases from other parts of body, can help to prolong life. In medical statistics, there is the Kaplan-Meier curve. This measures the number of patients surviving over time for any particular disease. It is a metric where doctors understand the ferocity of a disease. Instead of saying ‘You have a 95% chance of being dead in two years’, doctors can say ‘Most patients live many months to a couple of years.’. It is useful to hold a patient’s hand when announcing bad news. Sometimes, there can be an emotional cost as well. However, it can have its rewards too. For a neurosurgeon, it is also important to keep up to date on the latest technologies available in the market too. I loved talking to other scientists. Pancreatic cancer has a low survival rate. A patient can only be under anesthesia for that long. It is like finding the middle ground between the hare and the tortoise. Time flies in the OR. Technical excellence, was a moral requirement for me. For brain surgery, it is extremely important to be precise, up to the exact millimeter. The worst part of the brain damage is the cortex, the Wenicke and Broca area. These control one’s language abilities. I was excellent at my job and rewards and awards were coming naturally. My scientist friend committed suicide one day after he had a difficult complication. This made me contemplate the meaning of life even more.

The secret is to know that the deck is stacked, that you will lose, that your hands or judgment will slip, and yet still struggle to win for your patients. You can’t ever reach perfection, but you can believe in an asymptote toward which you are ceaselessly striving. – Paul Kalanithi

Books become my closest confidants, finely ground lenses providing new views of the world. – Paul Kalanithi

Indeed, this is how 99% of people select their jobs: pay, work environment, hours. But that’s the point. Putting lifestyle first is how you find a job – not a calling. – Paul Kalanithi

Rushing a patient to the OR to save only enough brain that his heart beats but he can never speak, he eats through a tube, and he is condemned to an existence he would never want…I came to see this as a more egregious failure than the patient dying. – Paul Kalanithi

Amid the tragedies and failures, I feared I was losing sight of the singular importance of human relationships, not between patients and their families but between doctor and patient. Technical excellence was not enough. As a resident, my highest ideal was not saving lives – everyone dies eventually – but guiding a patient or family to an understanding of death or illness. – Paul Kalanithi

The call to protect life – and not merely life but another’s identity; it is perhaps not too much to say another’s soul – was obvious in its sacredness. – Paul Kalanithi

A resident’s surgical skill is judged by his technique and his speed. You can’t be sloppy, and you can’t be slow. – Paul Kalanithi

Neurosurgery requires a commitment to one’s own excellence and a commitment to another’s identity. The decision to operate at all involves an appraisal of one’s own abilities, as well as a deep sense of who the patient is and what she holds dear. – Paul Kalanithi

Cease Not till Death

The CT images were not good. My identity no longer mattered. It was life shattering and it hurt me. My potential would never be fulfilled. I was diagnosed with lung cancer. Emma Hayward was my oncologist. Emma was one of the best lung cancer specialist out there. She was also compassionate in nature. I felt weaker as the cancer spread. I couldn’t know my spot on the Kaplan-Meier curve. One option for me was chemotherapy and the other was therapy targeting at molecular defects. I had a PI3K mutation. Emma suggest carboplatin as chemotherapy for me. She refused to discuss the Kaplan-Meier curves. Lucy and I went to the sperm bank to preserve gametes. There is no point in depending or reading too much into statistics. I felt a drop of hope. After a drug, my appetite returned and I was happier. I had to figure out what is the most important for me. Cancer had helped to save my marriage with Lucy. I was also in physical therapy now. I was lifting my legs, but it was so exhausting and humiliating. I kept pushing myself. Finally, my condition improved. I could ride a bike for 6 miles and that was a massive achievement. Emma was a friend to me as well. I wanted a child, but the decision would ultimately lie with Lucy, because she would take care of the child. Life wasn’t about avoiding suffering. Life was about striving. We all need to carry on living. Only the best embryos would have a chance of survival. The tumor was reduced after a CT scan. It was good news. Life was looking up now. I started reading more about mortality. I pushed myself to return to the OR. Some patients could live for at least 10 years on the drug. I felt it was a moral responsibility to continue being a surgeon. Suddenly, halfway through the surgery, I felt faint and couldn’t continue. My junior resident took over. It was disappointing. Over time, my skills started to improve and I was getting better. However, it felt joyless as sometimes I would still be in pain. I wanted to be a doctor-scientist, but there were no vacancies. I overcame my pain and continued to see patients. I wanted to run a cancer lab as it would less demanding. I had to figure out what was the most important to me. God and meaning were linked, but it was also possible to believe in one and not the other. The problem is that science cannot reach some permanent truth. Hence, it might be incompatible with human life, which is more unpredictable. Science is cold, unlike the warmth of humans. I returned to Christianity as I found it to be compelling. Humans do not like blind determinism. A new tumour emerged in my latest CT scan. I was neither angry nor scared. I felt really tired after a grueling surgery. My last surgery was a big success and I could end on a high. Chemotherapy was the only way as localized treatment was out of the question. It would start on Monday. I felt very tired and the food was tasteless. I wanted to go for graduation but I started puking and it was horrible. I had to be placed on IV drip. My condition worsened. My kidneys were starting to fail now. I was placed in ICU now. Many specialists were now attending to me. Lucy was now 38 weeks pregnant. The problem was that the specialists could not come to a common consensus. No 1 party was willing to take responsibility. Some of them suggested ill-advised tests. I struggled to listen to them. Emma was now the captain of the ship. I was discharged from the hospital finally. I was very tired again, after the chemotherapy doses. Emma finally revealed that I could live for 5 more years. Lucy was in labour. My baby was finally born and it was a complete joy. Time began to feel static. The days of the week no longer to mean anything to me as I wasn’t working.

If I were a writer of books, I would compile a register, with a comment, of the various deaths of men: he would should teach men to die would at the same time teach them to live. – Michel de Montaigne (That to study philosophy is to learn to die)

The fact of death is unsettling. Yet there is no other way to live. – Paul Kalanithi

Only 0.0012% of 36 year olds get lung cancer. Yes, all cancer patients are unlucky, but there’s cancer and then there’s CANCER, and you have to be really unlucky to have the latter. – Paul Kalanithi

It’s easier when the patient is 94, in the last stages of dementia, with a severe brain bleed. But for someone like me – a 36 year old given a diagnosis of terminal cancer – there aren’t really words. – Paul Kalanithi

Many people, once diagnosed with cancer, quit work entirely. Others focus on it heavily. Either way is okay. – Emma Hayward, an oncologist

If the weight of mortality does not grow lighter, does it at least get more familiar? – Paul Kalanithi

If human relationality formed the bedrock of meaning, it seemed to us that rearing children added another dimension to that meaning. – Paul Kalanithi

I would push myself to return to the Operating Room. Why? Because I could. Because that’s who I was. Because I would have to learn to live in a different way, seeing death as an imposing itinerant visitor but knowing that even if I’m dying, until I actually die, I am still living. – Paul Kalanithi

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. – Paul Kalanithi

The way forward would seem obvious, if only I knew how many months or years I had left. Tell me 3 months, I’d spend time with family. Tell me 1 year, I’d write a book. Give me 10 years, I’d get back to treating diseases. – Paul Kalanithi

Human knowledge is never contained in one person. It grows from the relationships we create between each other and the world. – Paul Kalanithi

But at my back in a cold blast I hear the rattle of the bones, and chuckle spread from ear to ear. – T.S. Eilot

Part of the cruelty of cancer, though, is not only that it limits your time; it also limits your energy, vastly reducing the amount you can squeeze into a day. It is a tired hare who now races. – Paul Kalanithi

Epilogue by Lucy Kalanithi

Paul died on March 9, 2015. Chemotherapy stopped working a few months before his death. We still had our family dinners etc. Paul was focused on completing his book. At his late stages, he lost his appetite completely. At times, he would suffer from a really serious fever. Paul chose the do not resuscitate status at the very end. We chose comfort care at home as he didn’t want to die in hospital. His carbon dioxide levels were too high, indicating lung failure. Paul wanted to hold Cady, his daughter. Paul was really to remove the breathing support and die. His wish was for us to publish his manuscript. I hope that he would be resting in peace now. Our family continued to sing to him and look at his facial expressions. Soon, his breaths became more faltering and irregular. During his last years, Paul wrote furiously and wanted to complete the book. He was very determined to write. He was brave throughout his most difficult days. He did not avert his eyes from death and was strong. Our love stood strong and firm throughout his difficult days. Paul suggested that I remarry after my marriage. I was definitely very blessed to have known a man like him. He was an unwavering source of support to our daughter. Throughout his illness, he faced it with grace and authenticity and acceptance. He was fully alive and his life was full of meaning even in his darkest days. This book is his culmination of his life and love for literature. Paul had made great contributions in the area of neuroscience. Paul managed to face death with integrity, and I was as his wife, his witness.

Conversely, we knew that one trick to managing a terminal illness is to be deeply in love – to be vulnerable, kind, generous, grateful. – Lucy Kalanithi

Bereavement (of a partner) is not the truncation of married love, but one of its regular phases – like the honeymoon. What we want is to live our marriage well and faithfully through that phase too. – C.S. Lewis

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Boy by Roald Dahl

Tales of Childhood

Papa and Mama. My dad was Harald Dahl and was a Norwegian. My grandpa was a prosperous merchant. Dad suffered a fall when he was young and had his arm amputated at the elbow. For the rest of his life, he managed with one arm. However he was adept at using just 1 arm. His brother was Oscar. They wanted to head to England or France to set up shop there. Despite grandpa’s disapproval they left on a cargo ship. My dad stayed in Paris. Oscar was a rich man who entered the fishing business. My dad partnered with Aadnesen to form a partnership and became shipbrokers. My dad married a lady named Marie in Paris and headed off to Cardiff to start their business. The business performed well but Marie passed away after delivery of the second child. Later, Dad headed back to Norway and married Sofie Magdalene Hesselberg. With his second wife, she bore 4 children. I was one of them. We moved to a larger home. Dad and bro had a deep interest in beautiful things. They decorated the house with high quality furniture. Aside from this, dad appreciated nature and all its beauty.

Kindergarten, 1922 to 1923. My eldest daughter died from measles. My sister, Astri, died from appendicitis. Her death shocked my dad. My father gave up living after contracting pneumonia. It was my dad’s wish for us to be educated in English schools in England. We moved to a smaller home. I went to a kindergarten called Elmtree house. I loved riding to school in a tricycle. That’s all I could remembe

Llandaff Cathedral School, 1923 to 1925. I headed to a boy’s school. I was impressed by a guy on a bicycle one day and he wasn’t holding on the handlebars. Often, a group of friends and I would stop at a sweet shop. We often pulled funds together to buy sweets. We enjoyed Thwaites’ story about how the candy were made from rats. We liked Sherbet Suckers and liquorice candy. Gobstoppers could change colour and was lovely to eat too. Our spit made it change colour. There was also the tonsil tickler candy. We hated the shop owner, Mrs Pratchett. She was suspicious of us and thought we were thieves. Her apron was filthy and her hands were dirty all the time. However, we somehow didn’t mind as all we wanted were the sweets. We wanted to take revenge on her someday.

The Great Mouse Plot. We found a loose floor-board in classroom as a place to store our candy. I suggested placing the dead mouse in a jar so that Mrs Pratchett would get the shock of her life. We distracted her and then I finally placed the mouse inside the gobstopper jar. After that, I felt like a hero. We all ran out of the shop.

Mr Coombes. We wanted to see whether the mouse was still there the next day. Later, we realized the shop was closed. The Gobstopper jar was no longer there too. Later, we observed that the glass was on the floor and it was all smashed. She didn’t sweep the place. We felt guilty and puzzled. A while later, we suspected that she might have passed on due to a heart attack. All of a sudden, I was a murderer. Mr Coombes was the headmaster at school. That day, he ordered all the students to line up. I kind of expected policemen to come arrest me at any moment. Later, Mrs Pratchett appeared. Coombes allowed her to inspect all the boys. She identified Thwaites as one of the culprits. I was also identified. She managed to identify the five of us. She was really very sharp.

Mrs Pratchett’s Revenge. We would all be required to report to the headmaster. Mr Coombes held a cane in his hand. He was about to strike Thwaites’ bottom. He was whipped. We were all made to watch it. I waited for my turn. I was thrown violently forward when struck. The second stroke hurt even more badly than the first. I received 4 strokes and was told to get out. My mother noticed the cane marks and questioned me. She was pissed and went to approach the Headmaster in school. She vowed to take me away from the school the next year.

Harder! Stitch ‘im up! Make it sting! Tickle him up good and prper! Warm his backside for him! Go on, warm it up, Headmaster! – Mrs Pratchett

Going to Norway. It was the summer holidays and I headed back to Norway. It was going home and I was delighted. My mum was amazing and co-ordinated everything. It was an ardous trip which lasted more than 4 days. We headed to my grandparent’s house. Bestemama was my grandma. There would be a huge feast and we were all elated. Following which, we had ice cream. By 10, I was involved in drinking ceremonies and would always end up very tipsy.

The Magic Island. There would be another day on our trip. The boat ride was incredibly peaceful . Norwegian children were all very adept swimmers. The toilet was simply a hole. Breakfast was a luxury and there was a huge spread. Almost everyone in Norway had a boat. My mum was an expert at rowing. As kids, we all loved to play in the water. The island was our regular destination. There were plenty of cool places we could explore. My mum enjoyed the rough seas. She was skillful enough in controlling the small boat to make sure it wouldn’t capsize. Later, we enjoyed fishing and reeling the fish in. Those were the enjoyable days.

A Visit to the Doctor. I had to visit the doctor because I was suspected of having adenoids one day. The doctor seemed to performing a surgical procedure on me. I refused to open my mouth initially. Later, the blade in my mouth was twisted and flesh and blood came out. Huge red lumps came out. Those were the adenoids. They all came out and were placed in a basin. That was the procedure at that time without anesthetic.

St Peter’s 1925-1929. First Day. I was nine and headed to my first boarding school. It was situated near a seaside resort with a sandy beach. I placed my belongings in a wooden tuck-box. It was my secret-house. The box contained some of my treasured possessions as well. I was apprehensive for my first day of school. Similar to my previous school, this Headmaster was a giant. I began to cry when my mum left me.

Writing Home. I wrote a letter to home from St Peter’s. I often wrote to my mum and it was at least once a week. Later on, I would fly with the RAF. My mum compiled all my letters I sent and this was incredibly touching. We could not complain about school in the letters. The letters would be vetted by the school staff. If there were spelling mistakes, we would have to write the same thing 50 times.

The Matron. Matron told care of the doms and was incredibly strict. She was extremely mean and caned people on the spot. She was like a tyrant. She scolded me at times too. If we made noise at night, we would be caught too. Everyone was ordered to wake up and stand in a line. They banned us for eating during canteen breaks. She made life very miserable for me. To the Matron, snoring was a crime and one would be punished for doing it.

Homesickness. I was homesick during my first term at St Peter’s. I wanted to pretend to have appendicitis so that I could go home. Nanny said when you swallow a toothbrush bristle, it would appear in your appendix and cause appenditicitis. I complained to the Marton that my appendix hurt. I feigned illness. My mum would be coming to pick me up. He forgave me for feigning it and told me not to do it again.

Everybody is homesick at first. You have to stick it out. And don’t blame your mother for sending you away to boarding-school…Life is tough, and the sooner you learn how to cope with it the better for you. – Dr Dunbar

Unless you have been to boarding-school when you are very young, it is absolutely impossible to appreciate the delights of living at home. It is almost worth going away because it’s so lovely coming back. – Roald Dahl

A drive in the motor-car. I got though the first semester. Our family bought a motor car. At that time, no one took driving classes. My ancient sister would drive too. The car had a retractable hood. Traffic was very light. Unfortunately she was involved in an accident. No one was hurt except for me. My nose had been partially cut off my face. She placed the dangling nose back on my face. Later, my sis continued driving. My mum was insistent to get to the doc as soon as possible. Finally she drove us to Dr Dunbar. The doctor sewed my nose back again. I would be sedated for this operation. Later I vomited. Luckily, it went well and I was okay again.

Captain Hardcastle. He was a slim man. We were very afraid of him. He had an awful moustache. He had a strange twitch all the time. In school, he often picked on me. We were forbidden to look around or to talk. These masters were very tough. There was once when I broke my pen nib in class. I wanted to get an extra nib from a friend. However, it was seen by Captain Hardcastle. I was given a stripe. It meant a beating from the Headmaster. I could never win against the Headmaster. I would receive 6 strokes of the cane. Every boy feared the cane. I grabbed hold of my butt and clutched it in pain. A boy named Highton promised to report this incident to his father.

Little Ellis and the boil. Ellis had a boil on him and was being treated by the doctor. The doctor took out a long steel handle with a blade attached to the end of it. Ellis screamed in pain.

Pain was something we were expected to endure. Anesthetics and pain-killing injections were not much in those days. Dentists, in particular, never bothered with them. But I doubt very much if you would be entirely happy today if a doctor threw a towel in your face and jumped on you with a knife. – Roald Dahl

Goat’s Tobacco. My half sister got engaged. Her partner was a heavy pipe-smoker. One day, the family and the couple headed to some island because we saw goats on them. The goats weren’t friendly. Later, I inserted goat’s droppings into his tobacco pipe while he wasn’t looking. My family didn’t object to what I did. Later, he began choking and admitted his lungs were on fire. When he realized it was his pipe, we all ran away.

Repton and Shell, 1929 to 1936. Getting dressed for the big school. I chose Repton over Marlborough. I had to take the train. I was exactly 13 when I had to go to Repton. It was troublesome to wear the butterfly collar of the uniform. Later, I crept downstairs. The uniform was indeed very elaborate and difficult to don on.

Boazers. The prefects were called Boazers and they were scary. Williamson was the one who caned people.

The Headmaster. He could not speak coherently at all and it was very embarrassing. Later, he became the Bishop. Everyone was surprised by this. Eventually, he became the Archbishop of Canterbury. Despite this, he had horrible mannerisms and didn’t treat the kids well. Did they preach one thing and practice another? It was then that I had my doubts on religion and God.

Chocolates. Once in a while, we received chocolates from Cadbury. Cadbury were actually testing out their inventions. It was then that I realized that the chocolate companies had laboratories and factories. This formed the plot for Charlie and the Chocolate Factory.

Corkers. Corkers was an old man who was interested in boys. He kept teaching us other stuff than mathematics. However, he kept everyone thoroughly entertained. When someone farted, everyone would rush to open the windows.

Fagging. I was the servant of the studyholder while in Repton. Carleton was an arrogant dude. I had to clean the place well every Sunday. Carleton would inspect our cleanings. He would purposely try to seek out any dust. The school had extremely complex rules for disciplining people. I became Wilberforce’s bog-seat warmer.

Games and Photography. I was exceptionally good at fives and squash-racquets. I was soon made captain of the Game ‘Five’. This made me more conspicuous among my peers. Being captain, it also entailed other duties. However, I was not Boazer material. School was fun especially since I was good at the games. Playing games made the days seem to pass faster. The other thing which interest me was photography. I often developed my negatives and then enlarged them. In the past, technology was not good and the photography business was challenging. I won trophies before.

Goodbye School. I got accepted into Imperial Chemicals. However, I wanted to work for Shell Company. I surprised myself and cleared the Shell interview despite intense competition. This would be followed with 2 years of intensively training. I enjoyed working in Shell. Later, I got posted to Egypt but I didn’t want to go. Later, they changed my posting to South Africa instead. I was 20 then. It would be a 3 year stint overseas. It was a wonderful experience. During the WWII in 1939, I joined the RAF to fight the war. This would be a tale for another time.

I began to realize how simple life could be if one had a regular routine to follow with fixed hours and a fixed salary and very little original thinking to do. The life of a writer is absolute hell compared with the life of a businessman. The writer has to force himself to work. He has to make his own hours and if he doesn’t go to his desk at all there is nobody to scold him. If he is a writer of fiction he lives in a world of fear. – Roald Dahl

It happens to be a fact that nearly every writer of fiction in the world drinks more whisky than is good for him. He does it to give himself faith, hope and courage. A person is a fool to become a writer. His only compensation is absolute freedom. He has no master except his own soul, and, I am sure, is why he does it. – Roald Dahl

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