Skydiving: or How a Humanities Degree Makes Me a Different Kind of Doctor

At the beginning of clerkship, I did a family medicine rotation in the North. During the cold and snowy months of November and December, a lovely couple took me in as a guest and supplied me with a place to stay. They lived in a log cabin, tucked away within a group of tall hills that were carpeted in trees and snow and silence. The cabin had originally been a barn. The couple had hand-chinked the logs together to transform it into their home, adding a green tin roof and a veranda around 3 of the exterior walls. It was heated by a lone wood burning stove and it was the most beautiful place I think I've ever lived.

The wife was a bright eyed, humble woman who had all the features that I associated with living in a perpetual state of joy. She was quick to laugh and gentle in her seriousness. Having a conversation with her was like receiving a warm hug.

One day, she shared with me an insight that was so brilliant I felt like I had just been given a treasure. I took it, giddy as a child who has just been given candy, and tucked it away in a pocket of my mind to examine and covet when I had more time to indulge in such leisure.

Today, I had that time. And now I will share it with you.

The woman was a practicing buddhist and her insight was about death - she stated, rather matter-of-factly, that the only thing we can ever count on in life is our final exhalation. For in death, the last thing we do is release that one, final sigh.

It's funny to think about all the things we do through exhalation. Exhaling is our means of communication - to create speech, we must exhale. And let it be noted that so often, our primary means of connecting to one another is through speech. Exhaling is also our means of relief and comfort – whether we sigh in contentment with an “ahhhh” or scream in pain and terror with an “AGGHHHH” – we do these actions instinctively.

-       While inspiration is an active process (you must contract your diaphragm and intercostal muscles to create a zone of negative pressure that will pull air into your lungs), exhaling is physiologically passive. With every inhale we actively assert our vitality… but we cannot continuously inhale. For every inspiration, we must exhale – to accept our finitude – in order to create room for more life. It's a yin and yang. Thus, while we can actively do things to keep ourselves alive (breath in, jump out of the way of a car, or eat our veggies), when it is our time to die, it will be a passive act. Something over which we have no control. Every exhale is a potential death.

Now, this is all very philosophical, so here's the practical side. As physicians, we are overwhelmed with claims of various drugs or procedures as "life-saving" but I am always reminded of what my grandmother's boyfriend said to me when I found out that I was accepted to medical school, "Why would you ever want to go into a profession where you will always fail?" Doctors don't save lives. They forestall deaths, and only temporarily.

Recently, I have witnessed a number of deaths while working at the hospital. Most have been of the "ahhhh" variety, where an elderly person acknowledges the immanence of their death and breaths out in a sigh of relief. On the flip side, I have also recently witnessed the death of a very young woman who left this life literally screaming for more air.

When I think about what it must feel like to die, I am reminded of a line from the novel The Cobra Event by Richard Preston. Early in the book, a young girl dies from an infection. To describe this exact moment, Preston wrote, "And then, she fell away."

I always thought that this was the perfect description of the experience of death. However, the line brings to mind certain questions:

Fell away from what?

I think he means, her consciousness fell away from her body.

Was she aware of this?

I think so. At least, she is conscious of it for as long as we are - and that is a mere instant. Maybe just the same amount of time it takes to read a 5 word sentence.

How far does she fall?

Far enough that we can't imagine it. Maybe forever.

Does she know she's still falling?

Probably not. I imagine that this is very much like skydiving. The moment you jump out of the plane, you feel a sudden lurch as you plummet through space. It is a terrifying moment but it's only half a heartbeat in time before you reach terminal velocity (where you stop accelerating because the force of gravity becomes equal to the resistance of air against your body). At terminal velocity, you're still falling (in fact, you're falling faster than you were when you first just jumped out of the plane) but it no longer feels like it. You just exist in space. It is the most beautiful, exhilarating feeling.

Now, some of you will know that this is no idle analogy. I recently went skydiving for the first time and I remember my skydiving instructor giving me this advice just before we jumped: "It will help if you exhale. Scream, shout, laugh, whatever. But breathe out. Here we go!"

And in that terrifying moment of falling away, I did yell. Because I was scared. Because my stomach decided to take up residence in my throat and there was no more room for my lungs to have air in them. But after that feeling of falling passed, I don't remember inhaling the way someone would if they had just been choking. I don't remember being greedy for more air - more life. I just remember breathing out again and again and again, saying over and over "Yay! Yay! Yay! Yay! This is fun!"

I think that this is, from now on, how I will think of the experience of death. On our side, we only see that moment of terror. The initial drop. The knowledge that the person is falling away from us. We have all the points of reference from our side. We can measure their velocity and we know that it is accelerating beyond our control. An instant later, and the patient is gone. But in my mind, I think that I will believe that they are skydiving. They reach terminal velocity the moment after they leave our presence in this world. After that, they are floating in space, feeling beautiful and exhilarated and free. And while, in the here and now, we might pull off our gloves and masks and gowns, letting out our collectively held breaths in sighs of frustration or sadness- I will think that the patient is still falling, exhaling again and again saying "Yay! Yay! Yay! Yay! This is fun!"

At least, that's how I hope it will go when I die.

PostScript:

A friend asked me how I came up with this idea, so I figured to keep the conversation in one place, I'd write my response down here:

This afternoon, I was reading about meditation and this sanskrit mantra Ham-sa. Which, incidentally, is the noise you make when you breath (try it, I did). Inhale: Haaahm; Exhale: saaaaa. The mantra translates into "I am That."

Now, let's fit that into my everday working paradigm. "I am" --> creativity in the 21st century is based on individuality. These days, we typically define something as creative when it is unique, authentic, one-of-a-kind. The emphasis in Ham is on the individual... it is an active (inhale = intentional action) construction of our selfhood.

Ham, however, is immediately followed by Sa, or That. In this context, I think That means God, or The Oneness of All Beings, or whatever you think of divinity. Now, since exhaling is passive, this must mean that God lies within us and there's nothing we can do about it. I don't think that it's unusual at all that most people consider dying as a "return to God" or The One or whatever - and how elegant is it that our last act in life is to exhale? To return to God. To acknowledge the Oneness of All Beings. Whether we like it or not.

See, that's what I like about philosophy and religion. It's so TIDY. It all makes sense. And it makes you feel better. Every moment of every day you are both inspiring as an individual and at one with with universe - so just keep breathing. And when it's time to stop breathing, you'll be ok.