Text copyright © Jeremy Hanson-Finger, 2017
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Library and Archives Canada Cataloguing in Publication
Hanson-Finger, Jeremy, 1987-, author
Death & the intern / Jeremy Hanson-Finger.
Issued in print and electronic formats.
ISBN 978-1-926743-91-2 (softcover).--ISBN 978-1-926743-94-3 (EPUB)
I. Title. II. Title: Death and the intern.
S8615.A575D43 2017 C813’.6 C2017-900453-0
C2017-900454-9
Edited by Leigh Nash
Cover design by Megan Fildes
Invisible Publishing | Halifax & Picton
www.invisiblepublishing.com
We acknowledge the support of the Canada Council for the Arts which last year invested $20.1 million in writing and publishing throughout Canada.
For Dr. Navraj S. Chima, good buddy since ’96
Doctors, as a rule, are the least curious of men. While they are still interns they hear enough secrets to last them a lifetime.
— Raymond Chandler, The Lady in the Lake
No, this is not a disentanglement from, but a progressive knotting into…
— Thomas Pynchon, Gravity’s Rainbow
prologue
The Delicate Art of Kneecapping – Blue Monday
Janwar will anaesthetize eight patients before he kills one.
This isn’t a probability; it will happen on Wednesday. The solution has been planned for a long time, planned before Janwar even applied to the placement at Civic. Janwar doesn’t know anything about his role. And he won’t until he has played it.
On Tuesday night, a man wearing a hooded sweatshirt holds a pungent dishtowel over Diego Acosta’s face while his partner smashes Diego in the knees with a bat. The two men then drag Diego behind an advertisement for MEC-brand dog backpacks, where they rifle through Diego’s pockets. They take his wallet and cellphone, although the theft is for show: later that night, the henchmen crush the cellphone and shred the cards from the wallet before they toss all the fragments into the Rideau Canal, not far from where a university student drowned himself a few months ago.
The henchmen do take the cash before they dispose of the wallet, however. Henching doesn’t attract the ascetic.
At the emergency room, the doctors say Diego is healthy aside from his fractured kneecaps, which is true, these thugs being professionals in the delicate art of kneecapping, among other body modifications both temporary and permanent. Diego’s knee surgery is scheduled for the next day.
Horace Louisseize supervises Janwar during Diego’s operation on Wednesday morning. As a medical student intern, Janwar is not allowed to perform anaesthesia unattended, so a senior staff member has to be present.
From the hallway, Janwar hears rubberized wheels squeak and Llewellyn Cadwaladr’s singsongy voice saying that a certain half-soaked fuck should watch where he’s going.
José Almeida rolls the anaesthesia cart into the OR, freshly filled at the dispensary.
Janwar draws 7 millilitres from a vial labelled “1% solution of lidocaine” into a syringe, enough for Diego’s 70 kilograms, followed by the appropriate amounts of fentanyl and propofol. He prepares another syringe of rocuronium and switches on the ventilator.
By then José has already departed to retrieve the materials that the surgeon, Victor Kovacs, and the attending, Karan Gill, need for surgery.
Rasheeda Mohammed is the scrub nurse assigned to the operation. Following Janwar’s instructions, she attaches the ECG leads, pulse ox, and BIS, and swabs Diego’s arm.
As Rasheeda performs her tasks, Janwar walks Diego through what is going to happen: Janwar will inject a mixture of drugs into Diego’s IV feed, and less than a minute after that, Diego will be out cold until the operation is over.
Janwar pats the BIS, a blue machine the size of a shoebox, and points at the display, which at that moment reads “97.” He explains that when he administers anaesthesia, Diego’s brain activity will slow and that number will drop, and once it drops enough, the surgeon will conduct the operation by peeling back the skin, drilling into the bone, and laying the latticework to brace Diego’s patellas as they heal. Janwar will watch the glowing number and adjust the IV drip to keep Diego unconscious, as well as monitor his vitals to make sure everything goes fine.
This is what Janwar says to Diego, and what Janwar believes—that everything will go fine.
Instead, everything goes fine according to the solution, which is not the same as going fine for Janwar, since Janwar does not come out of the solution looking good. And it’s definitely not the same as going fine for Diego, who doesn’t come out of the solution at all: the permanent removal of Diego is the solution.
Diego doesn’t know any more about the solution than Janwar does—although, being the problem, he does possess information concerning the series of events that have led to his forthcoming negation. He doesn’t flinch as the IV goes into his vein. Diego thinks the hospital is a safe space. But he is wrong. The hospital is a much less safe space for him than the street.
Rasheeda tapes the IV down. Janwar slides the first syringe into the port in the tubing and depresses the plunger.
Diego’s ECG spasms into the twisted party-streamer shape of torsades de pointes. Before any of the staff can intervene, the display flatlines.
Janwar shouts that Diego is in cardiac arrest and orders José to page for a crash cart.
José snatches up the intercom and makes the request, but by the time the cart thunders down the hallway and screeches around the corner, Janwar and Horace and Victor and Karan and Rasheeda and José all know Diego is not coming back.
But right now it’s Monday morning. Diego is still asleep in his own apartment. He is a consultant; he has no meetings scheduled. He can sleep in.
And Janwar is about to anaesthetize his first patient.
PART I: THE WINDUP
CHAPTER 1
Grime – Boys from Brazil – Nursing Rebellion – Supplies – The Mixers – Chthonic Breakthroughs – Pimp and Fail – Contingency – Moonboots – Spray Tan – A Simpler Way – Hardball
Monday, July 7
Batman bandana over his hair, scrub mask over his nose and mouth, gloves on. Syringes laid out. Janwar’s own pulse and breathing steady. Dr. Carla Welrod, the senior staff anaesthesiologist who showed Janwar around, sits in the corner with her tablet, but Janwar can tell she’s paying more attention to him than to the condo interiors she’s swiping through.
The operating room, OR II, is pretty much the same as the operating rooms at UBC, where Janwar spent most of his third year of medical school. At UBC everyone in the OR wore green scrubs, but here the staff wear a light blue-purple Carla called “mauve,” which Janwar thought until now referred to a much more vibrant colour between magenta and fuchsia. This colour shift is just one of the many changes Janwar must accommodate.
Nothing about this OR is vibrant. Grime has infiltrated the room the way it does all ORs. Only the site of the operation itself needs to be sterile, where the patient’s skin peeks out through the hole in the surgical screen. Sanitizing the entire operating room would be impossible; pathogens ride in on the soles of needle-resistant Crocs, dally in the crevices between computer keys, bloom underneath the sink’s grout. Plus nobody wants superbugs around, so sanitizing is done only where necessary.
Nurses get divided into two types for the same reason. A scrub nurse wears sterile clothing and can touc
h only items that have also been sterilized. A circulating nurse, in comparison, does not, and can go anywhere in the room and touch anything.
The OR griminess also stems from the building’s age. The Civic’s walls have shifted since it was completed in 1924, and its equipment and furniture come from every decade between then and now. Hospitals stop looking brand new very quickly. Surfaces get scratched or rubbed or warped or discoloured, or plain go out of style, like beige computers and wood-finish televisions, both of which Janwar’s father still has in his home office.
Unlike Ajay Gupta’s Compaq desktop (and, across the room, the Zenith Solid State Chromacolor II, knobless but perma-tuned to cricket), the hospital equipment isn’t any less effective because of its age, but patients who watch TV medical dramas are often uncomfortable with the lack of shine on the steel, the cracks in the vinyl, the mottled, yellowed, uneven floors. The occasional fly turning lazy circles.
The nurses have strapped Mrs. Bradford’s limbs to the cross-shaped table. She stopped talking about her grandchildren a while ago, when Janwar inserted the IV into her arm.
Now she’s waiting with the zen patience of the elderly, her mind blank. If she’s filled with a private terror beyond words, Janwar can’t tell. She seems at peace, her fingers and lips still, her vitals all within the normal range.
Three lights illuminate her with a perfect white halo. Past the table, the two IV trees cast skeletal shadows against the wall, but the overhead fluorescents wash out their edges.
The shadows are more unsettling for their lack of distinction, or maybe Janwar’s already unsettled, this being a new experience for him, in a new city, among strangers, even if he has anaesthetized a number of people back in BC and received glowing reviews from supervising physicians. Most memorably, one of his preceptors wrote in his evaluation, “It’s a rare pleasure to see Janwar Gupta intubate a patient,” although a masked man shoving a tube down someone’s throat isn’t a pleasant thing for anyone to see, no matter how efficiently done.
Mrs. Bradford has a multipage chart of drug contraindications and allergies. If Janwar induces anaesthesia using the standard drugs in the standard sequence, she could go into anaphylactic shock. Her throat could swell up and strangle her, shutting off her supply of oxygen. While in an operating room, doctors have ways of preventing anaphylaxis from becoming fatal. But if you can avoid it in the first place, you probably should, is Janwar’s thinking in this respect.
The anaesthetic machine and the anaesthesia cart form a V by Mrs. Bradford’s head, and Janwar feels comforted by the right angles and cold metal. No matter what he does, the machine’s components will perform according to the instructions baked into their circuits.
If he mixes all the drugs to put Mrs. Bradford to sleep together with a serious antihistamine and injects them into the IV at the same time, he will need to inject only one other syringe—the one with the paralytic. That way he can have the breathing tube down Mrs. Bradford’s sedated, relaxed, and paralyzed throat as quickly as possible, in case the antihistamine doesn’t stop her airway from closing fast enough. He weighs the pros and cons and decides on blending the drugs together.
His technique matters here, and not only because Mrs. Bradford needs to stay alive throughout the operation. Janwar is on his first placement outside of med school, and also his first placement after setting his sights on anaesthesiology, so he has to make a good impression on his colleagues. From here on, every move he makes will impact his career. What Janwar likes most about anaesthesiology is how the goal is to keep the status quo. To maintain homeostasis. As long as the patient’s vital signs remain steady and she doesn’t wake up during the operation, the anaesthesiologist has done his job.
Sometimes he has to solve drug interaction or allergy problems like Mrs. Bradford’s, but they’re always problems within certain boundaries. He has all the tools at his disposal to keep someone alive, even if they’re not always shiny. The anaesthesia machine is already breathing for them, so the anaesthesiologist can leave the heroics to the surgeons. If a surgeon is a surly detective making great leaps of intuition and following serial killers into catacombs without backup, an anaesthesiologist is good old Constable Gupta patrolling his beat by bicycle and making sure all is as it should be. A boring day for an anaesthesiologist is a good day.
And there’s also the money. Anaesthesiologists can monitor several operations at once, meaning they can also bill hours concurrently. This is a trick surgeons can’t pull off. Which is why surgeons resent anaesthesiologists, even to the point, on occasion, of manslaughter, even of manslaughter in the operating room, which Janwar read about in a recent news story from Rio de Janeiro. Some boys from Brazil took their professional feud really, really far, and, despite the stabbing happening in the one place you most want to find yourself if you’re in a life-threatening condition, the anaesthesiologist was pronounced dead less than five minutes after the fight started, because of two factors in the surgeon’s favour: amphetamines, heavy intake of, and knives, dexterity with.
The Civic surgeons have been civil to Janwar so far, but then again, he’s not making any money yet, let alone the $500K of a mature anaesthesiologist. He’s still paying for the privilege of being here. Plus, he’s not bossing them around.
Both the senior staff surgeon, Dr. Victor Kovacs, and the attending, Mildred Zhang, are studiously ignoring Carla, as if her rhythmic tablet swiping is merely the pendulum of a grandfather clock, marking time until they can leave this room and spend their money. In return, Carla hasn’t acknowledged their existence either. She looks right through them at Janwar, in between condo floor plans.
Janwar swirls his syringe around to mix the drugs together before inverting it and squeezing out a couple of drops, which fall onto the tiled floor, dosing any microscopic organisms in the area. Fentanyl, ketamine, propofol, and dimetindene—the analgesic, the coinduction agent, the induction agent, and the antihistamine, respectively—will all hit Mrs. Bradford at the same time.
The nurses, Henry Wilshire and José Almeida, scrub and circulating, respectively, take this moment to voice their disagreement with the method Janwar has chosen in order to put his patient to sleep. They are anti-mixing.
Janwar looms over them, but he isn’t tall in an imposing way, just tall in an awkward way, with a size 29 waist and a size 34 chest. He straightens his spine and puts his hands in his pockets, in case he starts fidgeting.
Henry leans against the wall as he elaborates on his reasoning re: mixing. His shaved head shines. “This is no place for experimenting.” Henry’s voice is so deep Janwar can feel it in his own chest.
“Yeah, who do you think you are? Dr. Mengele?” José adds.
Henry’s jaw hangs slack for a moment, and then he holds his hand up for a high-five, which José doles out with a crack that echoes throughout OR II like a gunshot.
Janwar doesn’t know who Dr. Mengele is, but from the context he can guess that the comparison doesn’t make Janwar look good.
“I’ll take that into consideration,” Janwar says. He smiles, but the nurses aren’t buying it.
Mixing induction agents and other drugs in a single syringe is not the traditional approach, but as long as Janwar induces sleep before paralyzing Mrs. Bradford with a separate injection, his technique is still kosher. The nurses must know that, and in this case, Mrs. Bradford’s chart of drug contraindications makes mixing the best option.
The nurses don’t move to stop Janwar as he aims his rainbow-labelled syringe at the port in the IV tubing connected to Mrs. Bradford’s elbow.
Janwar inserts the syringe and depresses the plunger. The milky white solution disappears from the barrel and joins the saline flowing into Mrs. Bradford’s median cubital vein.
Henry and José could have restrained him and prevented him from going ahead with his plan if they believed he was making a dangerous mistake, but they let him proceed. Carla doesn’t say anything either.
“Now count backwards from sixty,” Janw
ar says.
Mrs. Bradford reaches fifty-three before her voice lurches into a last-call slur. Her vital signs remain steady after thirty seconds, and Janwar can see no signs of swelling—the antihistamine has done its work—so he picks up a second syringe from the anaesthesia cart, this one labelled in red, and administers the paralytic, rocuronium, which his fellow med students at UBC referred to as “the roc.” When it takes effect, he snakes an endotracheal tube down Mrs. Bradford’s throat to maintain the flow of oxygen to her brain now that all her muscles, including her diaphragm, are immobilized.
Mrs. Bradford’s gall bladder needs to be removed via laparoscopic cholecystectomy. She suffered several rounds of biliary colic—gallstones—and taking the whole organ out is the best option. Janwar fires up the anaesthesia machine, which wheezes and sucks and blinks and burbles. He monitors it while over the next hour Victor, with Mildred’s assistance, makes four one-centimetre incisions in the square of Mrs. Bradford’s abdomen visible through the cutout in the sterile drape. Through the different openings, Victor inserts an insufflator, an irrigation tube, a fibre-optic camera with a light attached, and a hook cautery.
Janwar is proud of himself for fidgeting only a little, interlocking his knuckles from time to time. Mildred also fidgets when her hands aren’t busy, and her breathing is fast under her mask. Victor doesn’t stop accomplishing tasks long enough to fidget.
Mrs. Bradford remains immobile, the LED lights on the display showing her brain activity is below conscious levels. “First sleep, then paralysis” is one of the cardinal rules of ethical anaesthesia. If Janwar paralyzed a patient before inducing sleep, she would “get stuck in the boogeyman’s closet,” as Janwar’s preceptor Benjamin Rausch put it, awake and aware of everything going on but unable to move, communicate, or breathe. Patients usually survive a trip to the boogeyman’s closet unless they have a pre-existing condition—such as a brain aneurysm—that the intense anxiety of the experience could push into the danger zone, causing rupture and almost certainly death.
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