How Little We Know
ON AN UNSEASONABLY MILD, sunny afternoon in early February 1999, I drive down from my home in Northampton, Massachusetts, to Guilford, Connecticut, 120 miles away, to spend an evening with my friend Jerry Friedland and his wife, Gail. Jerry is director of the AIDS programs at Yale-New Haven Hospital and the Yale School of Medicine, and he and I have known each other for nearly fifty years—since the fall of 1952, when we were both sophomores at Erasmus Hall High School in Brooklyn.
Early the next morning I leave my car at Jerry’s house and we head in to Yale-New Haven Hospital together. As I have also been doing for the past dozen or so years with another high school friend, Phil Yarnell, a neurologist living in Denver, Colorado, I take a break once or twice a year from my own work—my writing and teaching—to spend a day with Jerry at his work.
This time, however, I am traveling with Jerry to New Haven not to spend a day with him at the hospital and in his AIDS clinic, but because he has helped arrange an appointment for me with Dr. Henry Cabin, chief of cardiology at the hospital, to see what’s going on in my heart. Dr. Cabin, who will take an angiogram of my coronary arteries (injecting radio-opaque dye that makes blockages visible when x-ray pictures are taken), has told me that this is ordinarily an outpatient procedure. Even if he finds significant blockages and decides to perform angioplasty (threading balloons into one or more of my coronary arteries through a catheter to open the arteries), I should be able to drive back to Massachusetts following the procedure. Still, Jerry has insisted that I return home with him afterward and stay another night so I can rest up, and so we can have more time together.
Being with Jerry while he works with patients, staff, and medical students and talking with him about his work have given me great pleasure through the years—have inspired me, really. Jerry is one of my oldest and dearest friends; he is also a doctor whose work with AIDS patients and AIDS research has been literally life-changing and life-saving for thousands of people.
When we spend time together between my visits to Yale-New Haven, we continue the dialogues begun there—discussing patients I’ve met and how they’re doing, talking about his AIDS research and his public health projects, and—as in my ongoing talks with Phil—moving from the particular to the abstract and back again while speculating on the causes, prevention, diagnosis, and treatment of disease in general—about where, in things medical, we’ve been, about where we are, and about where we might be going.
Also, a true joy, knowing each other as we do across most of our lives, our talks have meandered—inevitably, always—along more personal paths as, without needing to impress or dissemble, we’ve tried, in matters having to do with things more private—family and friends, above all—to understand just who we’ve been, who we are, and where we might, in the years ahead, be going. When we are together, the time between visits—whether days, months, or years—disappears. Our conversations, at sixty, are as warm and stimulating—as rich, delightful, and filled with laughter—as were our conversations nearly a half century ago when we were teenagers taking walks together along Flatbush Avenue in Brooklyn.
At the hospital, Jerry walks me through admissions, and, although he regularly puts in seventy-to-eighty-hour workweeks (Gail maintains this is a very low estimate), he seems to have nothing else to do but to be with me, and he stays with me until I am in the room where the angiography is to be performed. Later on he will recall how astonished he was to find that when I undressed to ready myself for the procedure, I had to roll up my clothes and place them on the floor in a corner of the room. If I hadn’t been his friend, he said, he might not have noticed, and this was a reminder to him of how different things often seem, and are, from a patient’s perspective.
When I wake from anesthesia a few hours later, I’m lying on a gurney, and Dr. Cabin is smiling down at me. Although Dr. Cabin is a decade or so younger than we are, he too grew up in Brooklyn, where both his parents were high school teachers, and this, along with his warm, direct manner, puts me at ease. He has straight dark brown hair, is about five-foot-nine—two inches taller than me—and is fit and athletic-looking. I look up at him, my head a bit woozy, and he looks familiar suddenly, like one of the guys I played schoolyard ball with in Brooklyn.
“Let me show you what we found,” he says.
He points to a monitor hanging above me and explains that what I am seeing is film from the x-rays taken of my heart. The lines of colored fluid moving downward and outlining my coronary arteries—bourbon-colored squiggles, in my memory—come from the dye injected through a catheter he had inserted into the femoral artery in my groin.
On the screen I watch blood begin to flow into each of my three major coronary arteries, then stop. Dr. Cabin points to the spot where only a small amount of fluid continues to leak downward and says the angiogram tells us that only one of my three major coronary arteries is working and that no more than 10 percent of that artery is functional. Two of my three major coronary arteries (the right coronary artery and the circumflex artery) are 100 percent blocked, the third (the left anterior descending artery) 90 percent.
Dr. Cabin estimates my ejection fraction, which measures the heart’s ability to pump blood and which is the best general indicator of the heart’s overall functioning, at 30 to 35 percent; in a healthy heart, it would be between 50 and 70 percent.
“You’ve been going on nothing,” Dr. Cabin says to me, and then: “We’re going to try to get you into surgery tomorrow morning.”
“Great,” I say without missing a beat, and it is only later that Jerry makes me aware that my reaction—Hey, this is good news, so let’s go for it and do whatever we have to—is not typical. At the same time, I am, if optimistically, in a daze. I hear everything Dr. Cabin says to me but still seem to believe that in an hour or so I’ll walk out of the hospital with Jerry, get into his car, and drive back to Guilford. Instead of spending an evening with Jerry, however, I may instead—the possibility seems an ordinary piece of information—get to spend my last evening on earth alone in a hospital room in New Haven.
Dr. Cabin tells me that because the arterial occlusions are so massive, I am going to need a quadruple coronary bypass. (Like a bypass that reroutes cars and trucks around an avenue clogged with traffic, a coronary bypass graft, stitched in above and below an obstructed artery, reroutes blood through an unclogged artery and around the obstructed artery.) He tells me that he is putting me on several medications to minimize the possibility of a heart attack, that he has already conferred with Jerry about surgery, and that he has put a call in to Dr. Sabet Hashim, the man he and Jerry consider the best cardiovascular surgeon at Yale.* If Dr. Hashim cannot arrange to operate the following morning, a Friday, I will stay in the hospital over the weekend so that Dr. Cabin and his staff can keep an eye on me. The slightest exertion—or no exertion at all—might cause some arterial plaque to flake off, or to rupture, and block the narrow portion of my one coronary artery that is still working.
Open-heart surgery (or, more accurately, open-chest surgery) is, I know, a major event, a procedure that seems as astonishingly primitive as it is technically remarkable: They will crack open my chest then slice open an arm and a leg to harvest a vein and an artery that, after they shut down my heart for several hours while recycling my blood through a heart-lung machine, they will stitch into my heart before reattaching major incoming and outgoing arteries, jump-starting my heart with electricity, and stapling and sewing my chest closed. Even though I will be virtually dead for several hours—my body temperature lowered to 80 degrees (as with hibernating animals, cooling reduces the body’s need for oxygen, thereby giving the surgeon extra time for suturing) while a team of doctors and technicians retrofit me with new interior plumbing made up of spare parts taken from within my own body—the procedure itself, for all the drama and miracle of the fact that one can perform it on living human beings, has become commonplace. Hundreds of thousands of bypasses are performed each year (more than a half million in the United States), and—given my state of health—the possibility of failure, error, or distressing side effects seems minimal.*
Dr. Cabin talks with me about the surgery, and I ask if he was surprised to discover that my arteries are nearly 100 percent blocked.
“No. Little in my line of work surprises me,” he says, and he adds—something he will repeat when I see him for a six-week checkup following surgery—“But you are totally anomalous.”
True enough, I think, for despite the extent of the blockage, I have had few of the symptoms that usually accompany severe coronary disease: no chest pain or discomfort (no heaviness, pressure, tightness, or squeezing sensation), and no arm pain, dizziness, nausea, palpitations, faintness, or unusual fatigue. Luckier still, especially given the magnitude of the blockage, I do not seem, on the evidence of an echocardiogram, to have had a heart attack.
Nor do I seem to have had any of the classic risk factors for coronary disease. Until a week or so before surgery, I was swimming a mile a day, and at a good pace, as I had been doing for the previous twenty-five years, while also regularly playing tennis and half- and full-court basketball (sometimes with teenagers). I had never been a smoker, my cholesterol was normal, and so was my blood pressure. My resting pulse was fifty-eight. By all accounts I was in excellent physical shape and, at five-foot-seven and 150 pounds, I weighed perhaps 5 pounds more than I had forty-four years before when I was a senior in high school.
Genetics and family history? My mother was still alive at the age of eighty-seven, most of my thirteen aunts and uncles had lived well into their eighties, and some had survived into their nineties. My father, who died of emphysema at the age of seventy-two, had had a heart attack when he was fifty-nine, but he never exercised, had been overweight, and had smoked three packs of Chesterfields a day throughout his adult life.
About an hour after my talk with Dr. Cabin, when I’ve been moved to a hospital room and am lying in bed—the first time I’ve been hospitalized since I was operated on for Hodgkin’s disease at the age of eighteen, forty-two years earlier—Jerry comes by to visit.
“Hey Neugie,” he says, using the nickname all my old friends use. “How’re you feeling?”
I tell him I’m feeling a little groggy, and very lucky—lucky they found what they found and that, as I’ve just learned, they can get me into surgery in the morning. (Later, Jerry and Gail tell me they felt lucky too, since Dr. Cabin had suggested that if Dr. Hashim was unable to perform the surgery on Friday they might take me home for the weekend. “Oh my God—what do I remember about CPR?” Gail, a registered nurse, asked Jerry when he told her of this possibility.)
Jerry tells me that after Dr. Cabin saw the results of the angiography, he had paged Jerry and they had discussed what to do next. Jerry says that he was surprised—very much so—at what the angiogram revealed, but that he is pleased to learn that Dr. Hashim will be performing the surgery in the morning. The sooner the better, he says, and he tells me that my swimming and being in such good shape have probably saved my life.
“It seems you’ve been living on your collaterals,” Jerry says, and he explains that the collateral blood vessels I’d probably developed by swimming a mile a day for the past twenty-five years—hundreds of small steady-state blood vessels that lie between and connect the coronary arteries and that cannot expand and contract the way coronary arteries can—had been supplying the blood and oxygen to my heart and lungs that my coronary arteries were no longer providing.
Jerry then describes what he saw on the monitor. “A second or two after the blood stopped flowing into your heart, the entire bottom of the TV screen—the lower part of your heart—lit up, just blossomed with the glow of all those collateral blood vessels,” he says. “It was an amazing sight.”
We talk about telling my three children about the surgery, and this gives me pause—unsettles me for the first time since I arrived at the hospital. For a full half minute or more I cannot speak. Jerry smiles down at me. He is a strikingly handsome man, five-foot-eleven and about two hundred pounds, with a trim silver beard, a full and wavy shock of silver hair, and penetrating gray eyes that remind me of Jewish actors such as John Garfield and Paul Newman who have had the same captivating mix, in their looks, of toughness, intelligence, savvy, and tenderness. When, seeing my reaction, Jerry puts his hand on top of mine, I melt. Is this it? I wonder. Is the big basketball in the sky really about to fall on me?
Although Jerry’s presence comforts, it is also sobering, since he does not hide the seriousness of his concern, and when he asks if I would like him to call my children, I shake my head sideways and see myself, a small boy again, sitting on the floor of my office at home, sorting through my baseball cards and glancing up now and then toward my desk, where the light is on but nobody is working.
For more than a dozen years, I have been a single parent to my three children. By this time, however, the last of my children having left home the previous spring, I am, for the first time in three decades, no longer an on-site single parent. All three have graduated from college and are living on their own: Miriam, at twenty-nine, in the Washington, D.C., area; Aaron, at twenty-six, in Northampton; and Eli, at twenty-four, in Brooklyn, not far from where I was born and from where Jerry and I grew up.
I had told each of my children about driving down to New Haven for the angiogram but, not wanting to alarm or burden them, had minimized its importance: everything seemed fine, I’d said, and I was still swimming a mile a day, but some anomalies had shown up on an electrocardiogram, and we thought it best to check things out further, so I’d decided to have an angiogram performed at Yale-New Haven. That way, I explained, I could also spend some time with Jerry.
When I find my voice, I tell Jerry that I’ll telephone my children. Jerry says that he’ll call them also and that they can stay at his house (into which he and Gail moved two weeks before) for as long as they want.
Jerry also tells me he’s spoken with Rich Helfant and that Rich agrees about the need for emergency bypass surgery. Rich, too, is an old high school friend, and I’ve known him even longer than I’ve known Jerry, since, starting from a time when we were seven or eight years old, Rich and I went to the same Hebrew School (we later played together on our synagogue’s basketball team). Rich is a cardiologist now living in California—most recently he served as chief of cardiology at Cedars-Sinai Medical Center in Los Angeles; before that he was director of the Philadelphia Heart Institute and chief of medicine and cardiology at Presbyterian-University of Pennsylvania Medical Center—and these past few weeks he and I have been talking nearly every day. In the week to ten days preceding the angiogram, a fact I found both welcome and disquieting, he had been calling me several times each day.
Later that afternoon Rich calls and says he is not at all surprised at what the angiogram revealed and that, based on his talks with Jerry, he has every confidence in Dr. Hashim and the people at Yale. He reminds me that he had been urging me into the hospital—gently, gently, so as not to scare me—for several weeks.
When my family practitioner, while not excluding the possibility of coronary disease, thought the symptoms that had made me call for an appointment—some occasional shortness of breath while swimming—were due to adult-onset or exercise-induced asthma, and when a local cardiologist, finding some anomalies in an electrocardiogram and an echocardiogram, while also not excluding coronary disease, thought the problem was probably viral, Rich had exploded. “It’s not viral, goddamnit!” he had exclaimed, in the first burst of exasperation I’d heard from him since I’d begun talking with him about my concerns. “I want you in the hospital as soon as possible.”
The local cardiologist had recommended that I have an angiogram done at Bay State Hospital in Springfield, but when I called his office to make an appointment, the colleague who performed the angiograms was booked for several weeks. I was persistent and secured a “brief office visit” a week later, not for the angiogram, but to confer about setting up an appointment for the angiogram. Then I had telephoned Rich, Jerry, and Phil.
“Listen,” I’d said to Rich, as I had to Jerry the day after I’d received the results of the EKG and the echocardiogram, “why don’t you guys all talk with one another and then just tell me what to do?”
On Sunday morning, Jerry phoned to say that he and Rich had decided I should come down to Yale and that Dr. Cabin would be calling me at home (as he did) to arrange for the angiogram.
Now, less than a week later, Rich says that, barring the unforeseen, he feels certain that the bypass surgery and the recovery from the surgery will go swiftly and smoothly. He asks about my children, and I tell him I’ve spoken with each of them and that they will all be arriving at the hospital before surgery the next morning.
Aaron is already on his way down from Northampton by bus; Eli is on his way from New York City by train; and Miriam and her fiancé Seth will be taking a three A.M. train from Washington, D.C., and will arrive early the next morning. I tell Rich I was surprised that they didn’t hesitate, and will be with me—I note that I didn’t ask any of them to come—and Rich tells me he is surprised that I was surprised. Why wouldn’t my children want to be with me at a time like this?
After supper, Dr. Hashim stops by and talks with me for a while. Dr. Hashim is Lebanese and therefore, I expect, speaks French. I tell him I lived in France for two years some thirty years ago, before and after my first child, Miriam, was born, and Dr. Hashim and I proceed to talk with each other in both French and English. Although he describes the surgery and explains the possible risks attendant to it, such as stroke, retinal damage, cognitive losses, and infection, and says that, given the excellent state of my health, he sees no cause for concern, it is our conversation about things ordinary and familial that calms my fears and reassures.*
When I comment on his name and its possible biblical origin, he tells me that yes, he believes he is a descendant of families that inhabited the ancient Hashemite kingdom. He asks about my name and I tell him my father’s family came from Ryminov, a shtetl in the Carpathian Mountains—from a region now part of Ukraine—and that they had been in the butter-and-egg business there, as they were after they came to the United States. When, in the Austro-Hungarian Empire, civil servants assigned family names to Jews, probably at the end of the eighteenth century (so that we would no longer be Jacob-son-of-David, or Jacob-Mordecai-of-Ryminov), a state official, seeing thousands of baby chicks running around the family property, according to family lore, gave us the name Neugeboren, meaning, in German, “newly born.”
Dr. Hashim says something about the appropriateness of my name, and then, to my surprise, reaches down, lifts the bedsheet, and takes my hand in his.
“Twenty or so years ago,” he says, “I could not have done anything for you.”
Phil Yarnell, with whom I’ve been talking regularly, and who has been offering me diagnoses by phone and conferring with Rich and Jerry about me, telephones from Denver. Phil started out as a neurosurgeon but switched to neurology early in his career. Before moving to Denver and becoming chief of neurology at Denver General Hospital and of the Neuroscience Division at St. Anthony’s Hospital there, he taught at the University of California at Davis; since 1993, in addition to being in private practice, he has been clinical professor of neurology and neurosurgery at the University of Colorado School of Medicine.
Phil grew up on the same block in Brooklyn where I lived until I was two years old—across from Prospect Park—and though neither Phil nor I have clear memories of having done so, we like to imagine we played together back then: in front of our apartment houses, in the park, and in the sandbox and on the monkey bars in the playground that was directly across from my parents’ building.
Phil moved to Denver in 1971, the same year I moved to Northampton, and has lived there ever since. He and his wife Barbara also own a 160-acre ranch in Kiowa (“That’s one-quarter the size of Prospect Park,” Phil says), a small town an hour east of Denver, where they keep cows, horses, and llamas. At a lean five-foot-ten-inches tall, with a full head of white hair and a broad white mustache, and wearing a bolo tie at home and at work, Phil could pass for sheriff of a Western frontier town. His accent and blunt, slangy way of talking about things, however, remain pure Brooklyn.
He tells me he was surprised to hear from Jerry that I have heart disease and that it is so far advanced, but he’s glad I’m in Jerry’s hospital, where Jerry can keep an eye on things. This, he says, is very important, agreeing with why Rich and Jerry have decided upon Yale instead of Massachusetts General, where Rich originally wanted to send me. Given the routine and often lethal miscommunications and other slip-ups that prevail in hospitals, Jerry wanted me at Yale, where he could monitor matters and where doctors and staff involved in my care would be accountable to him.
My friends had seen a lot of hospitals and doctors, and until you had, they said, you could not believe the difference there was between excellent care and care that was less than excellent. It was, more frequently than anyone dared acknowledge publicly, the difference between life and death. (And this was ten months before revelations appeared in front page articles around the country, based upon a report from the Institute of Medicine of the National Academy of Sciences, that as many as ninety-eight thousand Americans die every year in hospitals from preventable medical errors—a figure Rich thought grossly underestimated the reality.* “That figure is just the tippity-tip of the iceberg,” Rich said, “and includes only the most gross and undeniable errors.”)
Early that evening my son Eli arrives (Aaron arrives an hour or so later), and while he is with me another old friend from Erasmus, Arthur Rudy, calls. I considered Arthur my closest friend in high school and have been talking with him regularly in recent weeks. Eli, who remains close with many of his high school friends, says something about how lucky I am to have remained friends with guys like Arthur—smart, successful, menschy guys who grew up rooting for the Dodgers and who have turned out to be delightfully quirky: Where’s the downside? he asks.
Arthur was vice president of Erasmus when we were juniors and, when we were seniors, in a class of more than twelve hundred students, was voted Boy-Most-Likely-to-Succeed. (Jerry Friedland was elected our senior class president.) Arthur, too, is a doctor, though not an M.D. He is a psychologist, formerly chief of psychology at Roosevelt Hospital in New York City and now in private practice. He tells me that Jerry called him with the news. Jerry and Arthur, good friends at Erasmus, roomed together for a year in an Upper West Side apartment during our college years (the three of us went to Columbia together), and though both acknowledge they made lousy roommates, they have remained close friends ever since. (Arthur was best man at Jerry and Gail’s wedding.) Arthur and I talk for a while, and—as with Phil, Jerry, and Rich—though I’m happy to have him calling to wish me well, what pleases more than anything we say is the knowledge that, before and after our talk, he, Rich, Jerry, and Phil will be talking with one another about me. How’s Neugie doing? I hear them ask. And: The Neug seemed in such great shape, and things seemed to be going so well for him…
Given that, unlike my four friends, I have been living without a wife or companion for the past dozen years, the thought that while I am asleep in the operating room, my chest open and my heart disconnected, these four guys who have known me, and one another, for nearly a half century will be taking care of whatever needs to be taken care of, provides more than comfort. Largely because I cannot know but can only imagine what they will think, feel, and say, my sense of their concern and affection enables me, even before my heart is emptied of blood, to see myself in a life that will be mine after my heart is repaired. Among other pleasant fantasies, I picture myself at Miriam’s wedding, scheduled eight months hence; and, too, I watch myself at my desk, alone in my third-floor office after my return home, going through notes and sketching out scenes for a new novel.
Now, and later on during my recovery, when I once again rely on these friends to get me through matters both medical and personal, I will find myself seeing us as boys, back again in Brooklyn and doing what we loved most of all: playing basketball. I see us in our favorite place—Holy Cross schoolyard on Church Avenue—and I imagine that we are a team: Phil and Jerry at the forwards, Rich (who is six-foot-two and played college basketball and baseball) at center, me and Arthur (who once scored 59 points in a league game when he was thirteen) in the backcourt. Four Doctors and Neugie, I think—five pretty good ballplayers ready to take on all comers: five guys who loved nothing more than to be away from our homes, sweating it out on a baseball field, or in a gym, or a fenced-in schoolyard—five guys who loved nothing more, win or lose, than to hang out together afterward, talking and laughing about shots made and missed, about passes threaded and passes gone wild, about girls we were going out with or dreamt of going out with—five guys who would have loved nothing more than to have gone on talking forever about those things—sports, girls, the Erasmus basketball team, and the Brooklyn Dodgers chief among them—that mattered most in the world to us in those days.
The next morning I telephone my brother Robert, who has been a patient in state mental hospitals for most of the last thirty-seven years and for whom I’ve been primary caretaker. I tell him (and the chief of psychology at Bronx Psychiatric Center, where Robert is this time) about the surgery. Robert is silent for a few seconds, then asks if my children will be at the hospital and who will be taking care of me at home after the operation. He says he will say a prayer for me.
Miriam and Seth arrive in the morning and, with Eli and Aaron, stay with me until I am taken to the operating suite. According to them, the last thing I say before I am wheeled away is that they should use my credit card when they go out for lunch.
The surgery lasts six and a half hours, and my heart is stopped, my blood processed through a heart-lung machine (during what physicians refer to as “pump-time”) for one hour and fifty-five minutes. Dr. Hashim and his team perform a quintuple bypass (five grafts, one more than planned; when I tell this to Arthur, he laughs: “You were always an overachiever,” he says), and there are no complications. When Rich calls after he has received faxes of Dr. Hashim’s postoperative report, he is very pleased and tells me the surgeon was absolutely first-rate.* But that’s based on his own report, I say. How do you know how good he was? “Several things—but most of all, the pump-time,” Rich replies, referring to the amount of time my heart was detached and my blood cycled through a heart-lung machine. “One hour and fifty-five minutes for five grafts is incredible. The man is terrific.”
When I wake the next day, tubes and wires protruding from my chest, stomach, arms, neck, and mouth, my children and Seth are there, and I am able to get out of bed and take a walk with them along the hospital corridor. I feel very sleepy—and very happy. I fade in and out, and at noon I watch a nationally televised UMass basketball game. I have taught at the University of Massachusetts as writer-in-residence since 1971, and for most of those years my children and I have had season tickets to UMass games. We have also traveled to other cities—Albany, Worcester, Boston, Philadelphia, Washington, D.C.—to see games, and our home, where my friends and my children’s friends would gather when the UMass team was on TV, was dubbed “Hoop Central” by the sports editor of the local newspaper.
“When I told you the game was on TV,” Eli later tells me, “you got very intense and excited suddenly—as excited as anyone could be, given where you’d been less than twenty-four hours before. You’d fall asleep during commercials, but when the game came back on, your eyes would snap open.”
It is only now, the operation over and successful and my children seeming so happy—and relieved—to be with me (none of us upset, as we ordinarily would have been, to see UMass lose a crucial end-of-season league game), that I realize just how frightened they had been, and—but why the need for such reassurance?—how much they do love me. The depth of their affection, like that of my friends, seems an unexpected revelation.
“We were pretty relieved your children were staying with us for the weekend—and that you weren’t” Jerry says. “Your children were lovely, but they were walking into walls, they were so stunned. I remember that Gail made this great minestrone soup, with tons of fresh vegetables, and Miriam warned us that Seth had a very funny, quasi-religious thing about vegetables—he never ate them—but he just kept spooning the stuff in, one bowl after the other.”
On the afternoon after the UMass game, walking back and forth by myself from one end of the cardiac care unit to the other while my children have gone off to eat lunch, and feeling a bit stronger, though still groggy from the anesthesia and pain medications, I think of how lucky—and happy!—I am to be alive, of how good it feels simply to be walking (“Listen, Neugie—keep breathing in and breathing out,” Arthur advises. “It’s the secret of staying alive”), and of how dear my children and friends are to me, and then of how strange, swift, and mysterious the entire experience has been: of how little we know about how and why I nearly died.