When Breath Becomes Air: Part 1 Summary & Analysis

Paul jumps back in his narration to his teen years. He is sitting on a desert plateau above his house in Kingman, Arizona, weeks before leaving for college. Paul recalls that he had been certain that he would never be a doctor. He had believed that he might be a writer, but he was relatively unconcerned with his career path before college.

Paul recounts how he was familiar with medicine only because his father—a cardiologist—was so often absent from the house. At ten years old, the Kalanithi family had moved from Bronxville, New York, to Kingman, Arizona, to lower their cost of living. His father began a practice of his own and worked to put his sons through college, but at the cost of seeing them grow up.

In his childhood, Paul enjoys the freedom of the desert and grows familiar with the pantheon of wild animals around him. He describes how advice about how to handle these creatures lay in what he calls “country facts”—the rural cousin of the urban legend. One country fact explains “if you kill a rattlesnake on your doorstep, its mate and offspring would come and make a permanent nest there.” When Paul discovers a rattlesnake outside his front door, he and his brother Jeevan manage to get the snake into a pillowcase and hurl it back into the desert to avoid the vengeance of its family.

Paul gives a little more background on his family: his mother and father had eloped and moved from southern India to New York City. He was a Christian and she was a Hindu, and their marriage was condemned on both sides of the family.

Paul’s mother’s greatest fear is the lack of good education in Kingman, which had been identified as the least educated school district in America at the time. She finds a college prep reading list for Paul, and he describes how this list instills in him a deep love of language.

Paul elaborates on the books that sparked his passion for literature: Brave New World gives him a philosophical foundation; Hamlet helps him through adolescent crises; and “To His Coy Mistress” and other romantic poems lead him on many late-night escapades. Books become Paul’s “closest confidants.”

Paul’s mother also drives Paul and his brothers, Suman and Jeevan, to Las Vegas to be able to take their SATs and ACTs. She also joins the school board to demand that AP classes be added to the curriculum. Her work not only enables Paul to get a good education, but it also helps many other students in the school. One such student is his friend Leo, who is motivated to go to Yale despite being told by his guidance counselor that he should join the army. Leo becomes the class salutatorian and is accepted to Yale, and Paul is accepted to Stanford.

As Paul finishes high school, Paul’s girlfriend Abigail (who attends a local college) suggests he should read some lowbrow work. She gives him a five-hundred-page novel called Satan: His Psychotherapy and Cure by the Unfortunate Dr. Kassler, J.S.P.S. Paul admits that it’s not a good novel, but he is struck by its assertion that the mind is simply the operation of the brain, and that it is subject to scientific laws just like any other organ. Paul starts to mark biology and neuroscience courses in his Stanford catalogue in addition to the literature classes he had picked out.

Paul pursues degrees in both English literature and human biology at Stanford, his studies driven by the question of what makes life meaningful. He feels that “literature provided the best account of the life of the mind, while neuroscience laid down the most elegant rules of the brain.” He names a few more authors and works that are formative for him in his search for meaning, including T.S. Eliot’s The Waste Land.

Heading into Paul’s sophomore summer, he is torn between getting an academic internship at a primate research center and becoming a chef at a camp, which would allow him to explore the Eldorado National Forest. Weighing his decision, he thinks, “I could either study meaning or I could experience it.”

Paul chooses the camp. He describes the beauty he finds in the lakes and the mountains, and the rich connections and friendships he forges with others at the camp. He compares the dawn on Mount Tallac to the moment in which God declared, “Let there be light!” He is in awe of the expanse of the mountain and the earth, but also sees that his own presence is affirmed by his two feet standing on that mountain.

Back at Stanford, Paul continues to study philosophy, literature, and neuroscience. He also works in an fMRI lab and enriches his relationships with friends on campus through various escapades and pranks, such as raiding the school cafeteria dressed as Mongols and creating a fake fraternity.

Senior year of college, Paul visits a home for people who had suffered severe brain injuries for a neuroscience class. The guide explains that many of the residents had nearly drowned as young children, and that gradually the parents stop visiting them. Paul is upset to hear that parents abandon their children, especially after he sees one girl smile at him.

When the class returns to campus, Paul vents to his professor about the parents of the children in the home. The professor is sympathetic to Paul’s feelings, but also tells him that he sometimes believes it would be better if the children had died. As he leaves the classroom, Paul realizes that brains give rise to the ability to form relationships and make life meaningful, but sometimes that ability breaks.

As graduation looms, Paul wants to continue his studies, so he applies for a master’s in English literature at Stanford. He comes to see language as “an almost supernatural force, existing between people, bringing our brains, shielded in centimeter-thick skulls, into communion.” He aims to explore how language relates to the brain and other functions of the body.

Paul studies Walt Whitman for his thesis, a poet who also wanted to find a way to understand the “Physiological-Spiritual Man.” Though his thesis is well-received, he increasingly realizes that literary studies are not the field for him. The field seems averse to science, and Paul’s varying interests don’t quite fit together in the department. One day, he is struck with the realization that practicing medicine would allow him to get much more direct experience exploring the intersection between biology, morality, literature, and philosophy.

Paul begins to prepare his medical school application, loading up on chemistry and physics in his final year at Stanford. Discovering that he would have a free year once his classes were over because of the timing of applications, Paul pursues a one-year degree in the history and philosophy of science and medicine at Cambridge. During his time there, Paul realizes that words feel more and more inadequate, confirming his desire for more direct experience with questions of life, death, and meaning. He finishes his degree and returns to the U.S. to attend the Yale School of Medicine.

Paul describes the first time he dissects a dead body, and how strangely normal it feels. The scalpel unzips the body, an action that constitutes both a medical rite of passage and a “trespass on the sacrosanct.” Gradually the revulsion, exhilaration and awe are reduced to monotony by the repetition of dissection. He marvels at a professor’s ability to rest an elbow on his cadaver’s face without batting an eye.

Paul explains how cadavers end up on the table. They donate themselves to schools, unlike in the nineteenth century when students had to bring their own bodies. He wonders if the “donors” (the preferred term for cadavers) would have done so had they been more informed about dissection’s gory details. He recalls one son who requested his mother’s half-dissected body back in the midst of their lab.

Though a cadaver’s humanness is undeniable, Paul confesses that it is easy to forget that they are human when reduced to piles of flesh and bones. He realizes that doctors transgress against patients in many ways, seeing people at their most vulnerable, scared, and private. Even though anatomy professors are sometimes cavalier in dealing with the donors, at other times they retain a feeling of kinship towards the bodies on their table, as when one professor says that he is the same age as the man whose pancreas they are examining.

Medical students, Paul writes, experience death and suffering but are also shielded from the brunt of responsibility. But Paul’s girlfriend (and future wife) Lucy understands the subtext of the work. While studying EKGs, she identifies one which came from a patient who did not survive, and begins to cry.

Paul and Lucy attend Yale when Shep Nuland still lectures there. Nuland’s work How We Die is eye-opening for Paul in its head-on confrontation of the topic of death. Paul is particularly struck by Nuland’s description of the death of his grandmother, and how she gradually succumbs to congestive heart failure and also gains a shortness of breath because older blood is less able to take up oxygen from older lungs. Nuland describes how when she stops praying, she stops virtually everything else as well.

Another story of Nuland’s proves particularly important for Paul: when Nuland was a young medical student, he was alone in the OR with a patient whose heart had stopped. He then cut open the patient’s chest to try to pump his heart manually. Though the patient died, Paul views this action as the true image of a doctor: bearing a heroic responsibility amid blood and failure.

After two years of studying, Paul begins the next phase of medical school. The final two years, he explains, are spent in the hospital and clinic, putting theoretical knowledge to use in order to relieve concrete suffering. His first assignment is in the graveyard shift in the labor and delivery ward of an ob-gyn.

His first night in the hospital, Paul meets the resident he’d be working with, Melissa. Melissa tells him to keep an eye on a patient with preterm labor and twins who have only been developing for twenty-two and a half weeks. As Paul asks a nurse to explain a monitor that tracks Garcia’s contractions and the fetal heart rates, she becomes worried at signals on the monitors and begins to prepare for surgery.

Paul figures out that something has gone wrong, and the twins’ only shot at survival is an emergency C-section. The attending doctor cuts open the woman’s stomach and uterus with a scalpel, and pulls out the two babies. They are rushed to the intensive care unit.

Melissa sews up the woman’s wounds, and asks Paul if he’d like to place the last two stitches. Paul’s hands shake as he does it, and his stitches are uneven. Melissa pulls out his stitches and redoes his work, demonstrating the proper technique.

Paul explains that the twins are considered to be on the edge of viability and that their organs are not quite ready to sustain life. Paul thinks to himself that he also feels unready for the responsibility of sustaining life.

The next night, Paul returns to work and helps with a more routine pregnancy. Melissa pushes Paul to the front of the action, and he helps deliver a baby for the first time. He realizes that learning to be a doctor in practice is a very different education from the one he acquired in classrooms and textbooks: knowing that one must use judgment when pulling on the head during birth is not the same as doing it. Pulling too hard would cause irreversible nerve injury, and he marvels at how the human brain has rendered reproduction such a dangerous task.

Paul informs the baby’s family of the good news. Afterwards, he asks Melissa about the twins from the night before. She says that both babies had died during the day. Paul is at a loss for words, imagining the contrast between the family of the baby that had just been born and the reactions of the parents whose newborns had just passed away.

Paul asks Melissa if doing an emergency C-section was the right thing to do. She responds that if they hadn’t, they probably would have died from a multitude of different complications because abnormal fetal heart tracings show up when something is going seriously wrong. When Paul asks how a doctor knows when the heart tracings look bad enough, she tells him it is a judgment call. Paul wonders how he could learn to make such calls.

Paul’s ob-gyn rotation ends, and he is next placed in surgical oncology. A fellow med student named Mari is on the same rotation as Paul, and a few weeks into a grueling schedule she is assigned to a particularly complex operation during which she must stand still for up to nine hours straight. The surgeon begins by inserting a small camera to look for metastases, because widespread cancer renders the operation useless and causes its cancellation.

Standing by, Mari has a small thought, hoping for metastases so that the operation will be cancelled. The surgeons discover metastases and the procedure is called off. At first Mari is relieved, but when she leaves the OR she confesses her guilt to Paul.

Paul jumps to his fourth and final year of medical school. He watches as his classmates elect to specialize in less demanding areas in order to have jobs with more humane hours, higher salaries, and lower pressures. As graduation approaches, the students sit down to write a collective commencement oath, borrowing from the words of medical forefathers—a Yale tradition. He is shocked when several students express desire to remove language insisting that they place patients’ interest above their own. Paul treats his work not as a job, but instead as a calling, and he refuses to see the language taken out.

Paul chooses neurosurgery as his specialty. This decision is cemented for him when he listens in on a pediatric neurosurgeon explaining to parents that their son has a large brain tumor. The neurosurgeon explains not only the clinical facts, but the “human facts” as well, providing guidance to the parents and making them able to face the operations and treatments that lay in their son’s future.

Paul is also drawn to neurosurgery because of the brain’s relationship to patients’ sense of self, as every operation on the brain is a manipulation of one’s identity. He poses questions about what makes life meaningful enough to live: “Would you trade your ability—or your mother’s—to talk for a few extra months of mute life? Your right hand’s function to stop seizures?”

Paul and Lucy marry just after they finish medical school, and then head to California to begin their residencies: Paul at Stanford; Lucy at UCSF. Paul’s first year of residency is concerned mostly with paperwork, which is not without its challenges. Paul doesn’t leave the hospital for the first two days, but he is able to quickly reduce mounds of paperwork.

Paul’s paperwork, however, reveals fragments of patient’s narratives, such as the story of an eight-year old named Matthew. Matthew has a tumor pressing against his hypothalamus, which regulates basic drives: sleep, thirst, hunger, and sex. Removing his tumor would avoid the cancer consuming his childhood, but would risk damaging his hypothalamus and rendering him a slave to his appetites. The surgery goes successfully.

Paul describes the first patient he loses—an eighty-two-year-old woman named Mrs. Harvey who is admitted for bowel obstruction. After a minor operation, Mrs. Harvey is doing fine, until Paul returns home to get some rest. Around midnight, Paul’s phone rings—Mrs. Harvey is struggling for air, her heart is racing, and her blood pressure is collapsing. Paul rushes back to the hospital. That night he is the only general surgery intern on call, and his pager buzzes relentlessly. Paul feels as though he is drowning, and the next day, Mrs. Harvey dies.

Paul resolves to treat his paperwork as patients, and not the other way around. Paul describes a few other patients he loses: an alcoholic who bled to death, a pathologist, dying of pneumonia, and many, many cases of head trauma—suicides, gunshots, and car accidents. At times, Paul feels suffocated by the weight of stress and tragedy in the hospital.

In his second year of residency, Paul is the first to arrive in an emergency. The schedule takes its toll on him: he works as many as one hundred hours a week, even though regulations cap doctors’ hours at eighty-eight. Not all residents are able to withstand the pressure. Paul describes a fellow resident who refuses to accept blame or responsibility for his mistakes, and Paul knows that this person will not survive a career in neurosurgery.

Paul admits that he also made mistakes. He comes to believe that saving only enough of a patient’s brain to confine a person to life support for the rest of their time is a more egregious failure than if the patient were to die.

Paul worries that being so close to death only blinds him and dulls him to it. He tries to keep lightness in his job when he bonds with a fellow resident, Jeff. One day Jeff asks Paul for his prognosis on a patient’s head trauma, and Paul jokes that he could only be a senator from a small state. From then on, state population becomes their barometer for the severity of head injuries.

Paul describes another instance in which he rushes to the trauma bay with an ice cream sandwich, which he sets down behind a computer. After he is unable to save the patient, he must return to the trauma bay while the patient’s family says goodbye in order to save the ice cream sandwich before it melts all over the desk.

Paul hears that his friend, Laurie, has died in a fatal car crash. These words conjure up gory images for Paul, and he fears that he has become desensitized and unempathetic when dealing with patients. He worries he is losing sight of the importance of taking care of patients and their families emotionally as well as physically, knowing that the family’s first conversation with a doctor can color how they view the death of their loved one. He realizes that “When there’s no place for the scalpel, words are the surgeon’s only tool.”

Paul remarks that if he had been more religious in his youth, he might have become a pastor, and he renews his focus on being a more empathetic doctor. He makes an inner vow to earn patients’ trust and guide them through their decisions, not just drily inform them of risks and benefits.

Paul draws a connection to his father, who brought comfort and levity to his own patients. For example, his father once told a patient that he would make sure she got lobster and steak before joking that it might look more like a turkey sandwich upon arrival. The easy human connections his father formed inspired Paul to do the same.

Paul describes the guidance he provides to a thirty-five-year-old woman who is rushed to the hospital after experiencing a seizure. He sees that she is terrified of the idea of brain surgery, even though he knows that her surgery would have little operative risk and would almost certainly eliminate her seizures. Instead of simply giving her all the possible risks, he gathers her family and calmly talks through her options. She chooses surgery, which goes successfully, and she never seizes again.

Paul speaks about how brain diseases are often strange and somewhat incomprehensible to people. Often news of brain diseases is so shocking for patients that the brain suffers an electrical short. One of his patients, upon being diagnosed with brain cancer, falls suddenly into a coma. After a battery of inconclusive tests, Paul realizes that the patient is simply in shock—the cure for which is speaking reassuringly until the patient awakens.

Paul moves to the topic of brain cancer, describing its two varieties: primary cancers, which are born in the brain, and metastases, which come from another part of the body. Surgery usually prolongs life, but most people die within a year or two. Paul recounts a patient named Mrs. Lee, who has an aggressive brain cancer called glioblastoma. She obtains an MRI from her ER and is passed on to him because the doctors in the ER did not want to break the bad news to her.

Paul informs Mrs. Lee of her prognosis and of the surgery and treatments that she will undergo. Paul explains to the reader that detailed statistics are usually not explained to patients. One statistic, the Kaplan-Meier curve, measures the number of patients who survive over time. For glioblastoma, only five percent of patients are alive after two years. He reasons that doctors must be accurate but must also leave room for hope. A nuanced description, like “most patients live many months to a couple of years,” proves more helpful than giving a finite number of months someone will live.

Paul says that there is also a price to empathy and bearing responsibility for patients. In his third year, he runs into Jeff, and they note each other’s sadness. Paul explains that a patient of his—a child shot in the head for wearing the wrong shoes—had been so close to making it, but had ultimately died. Jeff remarks that he should always go to Paul when he’s feeling down about his work, in order to cheer himself up.

Even with the job’s hardships, Paul never questions the value of his work. Before operating on a patient’s brain, Paul knows that he must first understand the patient’s mind and what makes the person’s life worth living.

In the middle of residency, doctors train in additional fields. Paul chooses “the most rigorous and prestigious path”—that of a neurosurgeon-neuroscientist. He begins to work in a lab developing technology that would allow paralyzed people to mentally control a computer cursor or a robot arm.

The head of the lab is a professor of electrical engineering and neurobiology and a fellow second-generation Indian affectionately called “V.” With V’s permission, Paul sets out to develop technology that could write signals into the brain (not just read signals from the brain), allowing the possibility for treatment of various neurological disorders.

Paul meets with V weekly and comes to respect him deeply for his avoidance of the politics and competition that plague many scientific careers. One day, V confesses that he has pancreatic cancer, which has a dismal prognosis. V asks Paul if his life has meaning and if Paul thinks he has made the right choices. Paul is shocked by these questions, because he believes V to be a “moral exemplar.”

V undergoes surgery, chemotherapy, and radiation treatments. They are successful, and V returns to work a year later, just as Paul returns to his clinical duties at the hospital. On his first day back, V confesses that this is the first day the suffering seems worth it. Paul thinks about how doctors so rarely understand the suffering of their patients.

Paul is now in his sixth year in neurosurgical residency, which he describes as a black hole for his time. His day begins at six A.M. and lasts until the operating is done, which depends on how quickly he operates. He describes the conflict between being precise and being fast as the race between the tortoise and the hare: take too long with precision, and nerves can be damaged, muscles can break down. Too fast, and work needs to be redone or mistakes are made.

The intense focus required in surgery, Paul says, makes the clock feel arbitrary—two hours can feel like a minute. He feels that time only restarts when the surgery is finished.

Now a chief resident, Paul acknowledges that responsibility rests primarily on his shoulders. Technical excellence, he says, is a moral requirement, because being one or two millimeters off can represent the difference between tragedy and triumph. This is clear when Matthew, the little boy with the brain tumor, is readmitted to the hospital. His hypothalamus had in fact been slightly damaged by his surgery. He never stops eating and throws violent fits. Eventually he is institutionalized, all because of one millimeter of damage.

Paul provides other examples in which his precision is crucial. One day, he is performing surgery on a patient with a Parkinson’s tremor, and when they turn on an electrode, the patient becomes overwhelmingly sad. They reinsert the electrode two millimeters to the right, the tremor goes away, and the patient’s mental health is undamaged. In another surgery, the attending doctor points to Paul’s incision and tells him that if he had cut two millimeters deeper, the patient would be paralyzed except for the ability to blink—which had happened the third time he performed the surgery.

Paul tells the reader that certain parts of the brain are considered off-limits to surgery because the cost of damaging them is considered too great. These are primarily the regions that control language. If a patient has experienced destruction in these areas, surgeons are sometimes more hesitant to save the patient’s life, as Paul questions what kind of life exists without language.

Paul describes a patient, Mr. Michaels, who experiences this kind of damage to his language centers. He is only able to speak in streams of numbers, though he is still able to emote. Paul is deeply saddened, as no one is able to understand the meaning of the numbers.

Surgeries that involve these language centers involve many precautions, and the patients are often awake and talking during the surgeries. Another of Paul’s patients insists on having surgery to remove his tumor even though the board of doctors at the hospital advises against it because it is so close to his language centers. The patient swears through the entire surgery, and Paul realizes that the size and location of the tumor may have only left the patient with profanity, because profanity runs on a slightly different circuit from the rest of the brain than language.

Paul draws near the end of his residency, and he fields job interest from all over the country. He is satisfied that he has developed a coherent worldview for himself, and has a sense of his place in the world.

Paul receives a phone call from his friend and co-resident, Victoria. She tells him that Jeff committed suicide the night before. One of his patients died after experiencing a difficult complication, and Jeff had then jumped off the roof of a building.

Paul wishes that he could have spoken with Jeff and offered some comfort with what he had come to understand about being a doctor. Paul knows that death always wins out, but it is still valuable to struggle for one’s patients.