OUTSIDE OF that incident, Anil settled into a comfortable routine at home. When their schedules aligned, he and Amber studied together in the evenings: he with his medical books and journals, she with her SAT preparation tome. She was planning to apply to the undergraduate program at a local university where she could take a part-time course load while continuing to work at the club. Although he was drained after a day at the hospital, Anil looked forward to these evening study sessions since they held the promise of falling into bed together at the end of the night.
For most of the summer it was too hot to run outdoors, but he and Amber went to White Rock Lake to walk or have a picnic. As they strolled around the perimeter, holding hands, they picked out the houses they would like to live in: combining the gray brick of one house with the black shutters of another, selecting planters of geraniums and a wooden swing for the front porch.
Occasionally, on the weekends, all four of them—Amber, Anil, Baldev, and Mahesh—went out together. Mahesh found an old theater nearby that played the latest Bollywood releases on Saturday nights. Anil was a little uneasy about two distinct parts of his life coming together, but they wound up fitting comfortably: Amber loved the film’s song-and-dance numbers and downloaded the soundtrack to her iPod before they left the theater. She was happy to go along when Mahesh suggested going out for chaat afterward. In furtive snatches of Hindi, when Amber got up to refill her cup numerous times during the spicy meal, Baldev teased him about getting serious with her and Mahesh warned him not to. But Anil was too happy to take either one of them seriously.
IN SEPTEMBER, as the oppressive heat of summer finally began to relent, Anil started his rotation in the Cardiac Care Unit. When he arrived in the CCU the first day, he was pleased to see Jennifer, the red-haired intern he’d worked with during the ICU disaster the previous year. She’d been shocked to hear Jason Calhoun died of a ruptured aneurysm, and Anil was grateful for her blameless reaction.
Anil and Jennifer were chatting, waiting for rounds to begin, when Jennifer stopped mid-sentence, her gaze traveling beyond Anil’s shoulder. A girlish smile crept onto her face and she held up one hand in a small wave. Anil turned around and his shoulders tightened.
“Hey, folks.” Trey towered over Anil by at least six inches, his broad chest and muscular arms filling out his crisp blue dress shirt. He offered them a roll of mints, and only Jennifer accepted one.
A larger crowd than usual was gathering in the CCU. “What’s going on here?” Anil asked. Two senior residents were huddled off to one side, studying their notes.
“Tanaka’s leading rounds today,” Trey said. “Department head. Heavy hitter.”
“I’ve heard he’s tough.” Jennifer smiled as she pursed her lips over the candy. Her demeanor left Anil feeling inexplicably betrayed.
Dr. Tanaka arrived precisely at seven o’clock. Anil noticed he was of mixed descent, his stiff dark hair and eye folds diluted by the Caucasian milkiness of his skin, making Anil feel something of a kinship. Morning rounds commenced without any preliminaries, and both senior residents seemed nervous. When Dr. Tanaka spoke, it was in a surprisingly low tone. Some attending physicians practically bellowed on rounds, as if standing in front of a lecture hall, but Tanaka spoke so softly everyone had to step or lean in to hear while they scribbled down notes. The rest of the team modulated their voices after Tanaka, so they all became part of the same intimate discussion.
SEVERAL WEEKS later on morning rounds, the team was standing outside a patient’s room when one of the senior residents asked Trey to present the case for him. Jennifer and Anil exchanged a glance at the unusual move.
Trey stepped forward. “Patient is a forty-six-year-old female, obese, with a history of type 2 diabetes and smoking, who presented to the Emergency Department yesterday with shortness of breath. I was called to the ER last night to admit her. The cardiologist on call was consulted by phone and recommended the patient get a ventilation/perfusion lung scan for suspicion of pulmonary embolism.” Trey paused until Dr. Tanaka nodded for him to continue. “Labs weren’t back yet, but my assessment was that the patient was experiencing an acute myocardial infarction and should be taken to the cath lab for a stent.”
Dr. Tanaka held up his silver-plated pen, a gesture that was always his precursor to speaking. “This is very important. The symptoms and EKG results can look similar for an MI and a PE, but they have different management paths, and we may not have long to decide.” He turned back to Trey. “What led you to this assessment?”
Trey cleared his throat. “It was the combination of everything I observed—the EKG alone could have pointed to PE, but her chest pain, bradycardia, and diaphoresis, together with her risk factors, suggested an acute MI.” Trey shifted his weight from one foot to the other. “Also, as I was leaving, she . . . the patient grabbed my wrist and said, ‘Doc, please help me. If you don’t do something, I’m going to die.’”
A prickle traveled up the back of Anil’s neck. Dr. Tanaka’s eyebrows arched above the rim of his glasses and he looked around at the rest of the team. “Doctors, this is of great diagnostic value. Remember this: when a patient tells you she’s going to die”—he lowered his voice further—“pay attention.”
Anil was confounded by this guidance. How many times at Parkview had he been warned not to take a patient at face value? The addict who feigned back pain to secure narcotics, the prostitute who claimed she always used protection, the street teen who denied taking amphetamines. How many times had a patient come into the ER insisting he was having a heart attack when it was simply indigestion? Sound diagnosis was built on the objectivity of clinical assessment and inarguable test results, not a patient’s desperate utterings.
Tanaka nodded at Trey. “Please go on, Dr. Crandall.”
Dr. Tanaka hadn’t referred to anyone on the team by name until then, and Anil realized this was not an oversight but a sign of his indifference to the rest of them. Trey continued with the rest of the case presentation. He’d gone to the ER resident and suggested an alternative course of action, but no one was willing to overrule the first cardiologist. As a junior resident, he had little say in these matters. Anil would have followed the senior doctor’s instructions, and by Jennifer’s strained expression, he knew she would have done the same.
But Trey had been so confident in his own assessment that he’d hunted down another cardiologist in the hospital. “I showed him the EKG and told him I had a patient with a pile of risk factors who said she was going to die,” Trey said. “He grabbed the phone and told the cath lab to get ready. By the time we got there, the patient was arresting, but we were able to shock her back. Once she was stable, they put a stent in the RCA. It was touch and go for a while, but she made it.” Trey handed the chart back to the senior resident.
Tanaka held up his silver pen. “Doctors, sometimes we have to make decisions without all the information we’d like, without even seeing lab results. In these cases, you need to trust your instinct. But first”—he paused as he pointed his pen around the circle of listeners—“you need to develop your instinct, which comes from seeing many patients over many years. It’s rare for a young resident to make a call like this, but because Dr. Crandall did, he saved this woman’s life.” He aimed the pen in the direction of the patient. “Good work, Dr. Crandall.” And they all followed Dr. Tanaka in to see the patient who owed her life to Trey’s unrelenting confidence.
Trey’s case presentation served as a challenge to the rest of the team. Over the next few weeks, the other residents and interns began pushing to make their own diagnostic choices and fighting to defend them. Anil tried to get into the game, but making and defending assertive calls did not come naturally to him.
IN THE last week of his rotation in the Cardiac Care Unit, Anil finally had a chance to present a patient to Dr. Tanaka.
“So the EKG shows no abnormalities, but the patient is experiencing distress and chest pain,” Dr. Tanaka said. “Other considerations?”
&nbs
p; “High cholesterol and family history of heart disease,” Anil replied.
“Your recommendation?”
“Perform an angiogram to see if there are any blockages.”
“Yes, good.” Tanaka nodded. “Send her to the cath lab, and scrub in if you want to observe.” Anil was stunned by the invitation as junior residents were rarely allowed into the sacred chamber of the Cardiac Catheterization Lab.
Before entering the cath lab, which felt like an operating room, Anil donned a lead apron over his scrubs, surgery cap, mask, shoe covers, stiff plastic face shield, and sterile surgeon’s gown. Inside, the patient lay on the table, draped with sterile cloths so that only a small patch of skin near the groin was exposed. Prominently mounted above the table was an enormous monitor. A hushed intensity fell over the room when Tanaka issued instructions for the junior cardiology fellow to make an incision at the groin, insert a needle into the femoral artery, thread in the guide wire and the sheath. While he manipulated the catheter, every pair of eyes in the lab was trained on the monitor. Images began to emerge on the screen—grainy at first, then clearer. The artery became visible, a clear white branch against a black sky.
All measurements of the artery were within normal range. “I want to take a closer look at the LAD with the IVUS,” Dr. Tanaka said. He turned to Anil to explain. “The intravascular ultrasound catheter is a marvelous technology. It enables us to see from inside the blood vessels out.”
Moments later, Anil understood what Tanaka meant. The image on the monitor was the opening of a deep tunnel. Once the catheter was inserted, it looked like they were traveling down the artery, as though they were actually inside the body, with the ability to see into the corners of its life systems. Anil could not take his eyes off that view into a mysterious world. It must have been how Cousteau felt the first time he traveled to the depths of the ocean and saw what no one had seen before: vast expanses of life and nature functioning in all their beautiful complexity. Anil heard a weak moan and remembered the patient on the table.
“Look at that,” Tanaka said. “Significant plaque buildup in the left anterior descending.” The heart monitor began beeping loudly and bright red numbers flashed on the screen. Dr. Tanaka took a step forward, and Anil instinctively moved back. He deciphered the signals on the monitor as ventricular fibrillation. The patient was in cardiac arrest.
The team moved quickly, Tanaka conducting the players in the room like an orchestra. It was like no code Anil had seen. As the situation grew more stressful—the patient’s heart was losing oxygen and her brain, lungs, and kidneys were at risk of damage—Dr. Tanaka grew calmer and so did everyone else. Anil felt his own sense of panic slowly abate. Every one of his senses was heightened: he could hear the whirring of the machinery, smell antiseptic in the air.
After numerous tries with the defibrillator, the flatline finally responded with a jump to indicate that the heart had resumed its natural rhythm. Once the patient was stable, Tanaka inserted a new catheter to dilate and stent the blocked artery, which had caused the patient’s heart to stop. Anil watched on the monitor as the vessel was reopened and protected, and a pump was used to help stabilize blood flow to the heart. With his work finished, Dr. Tanaka moved to the head of the patient’s table and explained what had been done to repair the failings of her heart. “You’re better than new,” Dr. Tanaka said, smiling as he patted her shoulder.
“HE FOUND the blockage just in time and literally brought her back from the brink of death,” Anil said to Charlie as they sat in the Horseshoe Bar later that evening, pint glasses in front of them. For the first time in his residency, Anil felt like celebrating. He couldn’t contain the sense of exhilaration he’d felt, the thrill of seeing the inner workings of the body, the rush of adrenaline he’d experienced in that room.
Charlie emitted a low whistle. “Sounds amazing. But a fellowship in interventional cardiology is four or five more years. And you still get called into the hospital all the time. Why’d you want to do that to yourself?”
“Twenty years ago, that woman would have died on our doorstep,” Anil said, “and Tanaka just gave her ten or fifteen more years with that stent. Imagine being able to do that, do something, for everyone.”
Every day in the Cardiac Care Unit, Anil was surrounded by patients who’d suffered the symptoms of a heart attack. When someone described the crushing chest pain or feeling suffocated, he imagined what his father must have gone through in his final hours.
Anil had not looked closely into his patients’ eyes before, but now he found it impossible to look away. When the oxygen mask was applied or the cardiac monitor started beeping erratically, he saw bewilderment in his patients’ eyes and felt their silent trust planted like two ominous weights on his shoulders. Above all, he saw fear distilled to its purest form. While he still had to look up their dosage levels, the irrelevant details of their personal histories burrowed into his mind, like the MI patient who’d been an office janitor for forty-three years and met his wife at a school dance. And he could never forget his patients were the fortunate ones—in a world-class hospital filled with doctors and equipment, not an isolated rural village hundreds of kilometers from the nearest medical facility, which itself was years behind in technology. In that lab, with those catheters, stents, and balloons at his fingertips, Anil could be the kind of doctor who dealt in life rather than death. This was why he’d come to America.
“Okay, mate.” Charlie shrugged. “I hope you still feel that way when you’re camping out in a call room five years from now. It’s competitive, though, only five or six fellowship spots at Parkview. I’ve heard of a few people applying already. Not to mention Trey, and you know he’s in for sure.”
Anil took a long sip of beer. “Trey? Why?”
“His father? The legendary Dr. Crandall—cardiologist, swanky private practice in Highland Park, sits on the Parkview board.”
Anil stared into his sepia-toned beer. That explained Trey’s remarkable performance: always ready with his answers on rounds, never scrambling for a test result, never flustered like every other resident at one time or another. Trey had been bred for this job.
“Well, the department head invited me into the cath lab,” Anil said. “That’s got to be worth something.”
“You should try to work on a research project with Tanaka. Come up with a really great idea to take to him,” Charlie said with a thin smile.
“What about our project?” Anil said. He and Charlie had been making steady progress on their MRSA retrospective study. They were at a critical juncture where they’d have to complete the analysis of their data set soon, a big investment of time.
“Come on, I know that’s not really your cup of tea.” Charlie swirled the last inch of beer in his glass. He looked up and met Anil’s eyes directly. “Look, mate, you shouldn’t count on me right now. I might have to step away from the project for a bit. I don’t want to let you down. It might be good if you had something else going on, something you’re really into.”
“What? Why?” Anil said. “Charlie, what are you talking about?”
Charlie shrugged. “I’ve got some problems back home I need to take care of. I’m going to have to take a job in the evenings when I’m not at the hospital, at least for a few months,” he said. “My sister’s in a bit of money trouble. She’s pregnant with twins, and her husband was laid off a couple months back. Turns out there aren’t many jobs these days for a thirty-six-year-old miner. My parents are working-class folks, you know, don’t have much money to spare. I’m supposed to be the big earner in the family, the one everyone’s counting on.” Charlie signaled to the bartender for two more pints. “You know how expensive kids are? Twins!”
“So what are you going to do?” Anil asked.
“Between us, mate?” Charlie leaned closer. “I’m going to drive a gypsy cab in the evenings. This guy in the parking garage hooked me up. I can use my own car and set my own hours. He said I can make four hundred dollars a night on
the weekends.”
“At night, after your hospital shift?” Anil said. “When are you going to sleep, Charlie?”
He shrugged again. “Well, at least I’m used to being awake all night. Driving a car will be a breeze compared with running triage in the ER. And ten grand will make a big difference to my sister in the next few months.” He nudged Anil’s shoulder with his own. “Don’t worry, mate, it’ll be fine. But I won’t have much time for the research study for a while. I’m sorry.”
“It’s okay,” Anil said. “You do what you need to do. Take as much time as you need. I’ll keep things going with the data analysis, and you come back to it when you can.” Charlie cocked his head and began to protest, but Anil interrupted him. “No arguments. Mate.”
Charlie smiled in a way that was almost convincing.
14
LEENA HAD BEEN AT HER HUSBAND’S HOME FOR OVER A YEAR, but Nirmala still felt her absence anew every day. Early one morning, Nirmala awoke from a terrifying dream: she and Pradip were traveling to the market to sell their crops when giant black crows swooped down and tore open the burlap sacks with their beaks, scattering rice all over the road. She was watching herself sift white grains out of the dirt when the phone trilled in her ear, waking her from the nightmare.
When her husband went to answer the phone, Nirmala peeked out the window. The burlap sacks were still in the back of the truck, ready for their trip into town later that day. They were going to the market twice a week by then, to sell, in addition to their regular crops, anything of value they could muster: eggs from their chickens, milk from their cows. Nirmala hadn’t made Pradip’s favorite stuffed-eggplant curry in months. The additional dowry payments to Leena’s in-laws had crippled them. From the bedroom, Nirmala could hear only a few words on her husband’s end of the conversation, but from the tone of his voice, she knew something was wrong.