As they waited for the elevator, Anil examined Mr. Calhoun’s abdomen again, gently palpitating the area around his navel. Just as before, there were no signs of a rupture: no mass in the abdominal area, no rigidity, no pulsating. What had he missed? Inside the elevator, Anil watched the floor numbers light up in descending order, and silently repeated one of his mother’s mantras to himself.
A MIX of relief and shame washed over Anil when the elevator doors opened on the basement level and he saw Sonia Mehta waiting there. The nurse rattled off stats as they rolled out the gurney. “Abdominal aortic aneurysm. Pressure’s seventy-four, down from ninety a few minutes ago. Gave eight milligrams morphine and opened fluids. Going to CT to check for a rupture.”
Sonia ran alongside the gurney. “Dr. Patel, anything to add?”
“No . . . I mean, I don’t know how I mi-missed it. I checked for signs of rupture. I checked t-t-two times with a f-f-f-full examination.”
The cardiac monitor alarm sounded. “Too late for a CT now,” Sonia said. “Did you call the surgeon?”
“Yes,” Anil said, hoping to prove some level of competence. “We paged him from the ICU.”
Sonia swung the front end of the gurney down the next corridor. “We’ll have to go straight to the OR and hope the surgeon gets here in time.” They traveled through the bowels of the hospital, along dimly lit corridors that snaked their way around the basement. By the time they reached the operating room, the patient’s breathing was ragged.
“Pressure’s down to sixty.” The nurse’s eyes were locked on the blood pressure monitor.
“Deanna, go look for any surgeon inside,” Sonia said to the nurse. “Tell them we have a ruptured triple-A bleeding into the retroperitoneal space.” She reached for the patient’s wrist. “And get a crash cart!” she called as the OR doors swung behind the nurse.
Sonia stepped up onto the lower railing of the gurney. “Starting compressions.”
“Sh-should I get the crash cart?” Anil asked.
“No.” Sonia pressed down on the patient’s chest in an even rhythm. “You stay here.”
Deanna reappeared with the crash cart, shaking her head. “No one inside, but they’re paging another surgeon in the hospital.”
“Patel, get up here and take over,” Sonia said from her perch on the gurney. Anil stepped up and counted the rhythm of his compressions while Sonia charged up the defibrillator. “Stand back.” Anil raised his hands. She placed the paddles on the patient’s chest, and his limp body jumped in response, then flatlined again. Anil resumed compressions, alternating with Sonia’s use of the defibrillator. They tried for several more minutes to resuscitate Mr. Calhoun, until Sonia shook her head, paddles in hand. “It’s no good,” she said. “I’m calling it.” She glanced down at her watch. “Time of death, 5:29 a.m.”
Anil stepped back from the gurney and bumped into the cement block wall. Sonia turned to him, her voice rising. “Why didn’t you call me earlier? When did his pressure start falling?”
“I di-di-didn’t”—Anil struggled to get the word out—“I didn’t sus-suspect a rupture. The intern last night said his angiogram went fine, he was just uncomfortable from lying on the table.” His face flushed. “He didn’t show any signs of rupture. No rapid decrease in pressure, no pain in the abdomen, no rigidity or masses. I examined him twice.”
Sonia picked up the chart from the end of the gurney and flipped through it. “Morning labs show a drop in hematocrit.” She handed him an unfamiliar yellow lab slip and continued to read from the chart. “His pressure was up to one-seventy after the angiogram at 3 p.m. yesterday, and fell slowly through the night until it was eighty this morning.” She nodded to the nurse. “When I was finally paged.”
Anil shook his head slowly. He could feel sweat patches at his armpits. “I-I-I didn’t see those labs. He was fine after the procedure, he was stable. I just didn’t suspect . . . there wasn’t a sudden drop in pressure to indicate a rupture—”
“No, there wasn’t a sudden drop,” Sonia interrupted. “There was a gradual drop because it was a slow leak.” She pointed to a spot in the chart. “His aortic wall was thinned to less than a millimeter. Anything could puncture it. Like a catheter.”
Anil put his fingertips to his temple and rubbed.
“The angio procedure yesterday must have created a small perforation in the aneurysm,” Sonia explained. “He was slowly bleeding into his retroperitoneal space, beneath the gut. That’s why you couldn’t feel it in the belly. He was bleeding out slowly, all night long. Twelve hours, maybe more. Ruptured aneurysms don’t always have a classic presentation. That’s why it’s important to do a CT if you suspect one. It’s simple, takes ten minutes.” She handed the chart to Anil and turned to the nurse. “Deanna, you’ll call the morgue? We’ll head upstairs and start the paperwork.”
Anil stared at the unmoving figure of Mr. Calhoun. Sonia pressed his elbow and led him away. “Let’s go.”
They didn’t speak in the elevator as others filtered in and out. Back on the ICU floor, Anil followed, numb, as Sonia walked briskly to the break room. She pointed to the olive-green couch where they’d sat hours earlier. Anil sat. She remained standing. “What the hell, Patel? Why didn’t you page me when you were in trouble?”
“I should have caught it,” Anil said. “I should have ordered a CT earlier.”
“Yes, but you’re not always going to catch everything the first time you see it. You need to learn when to ask for help. As your supervising resident, I need to trust you’re being completely straight with me.”
“I wasn’t keeping anything f-f-f-from you,” Anil protested, “I-I was just trying—”
“To handle it all yourself. I know,” she interrupted. “Rookie mistake.” Sonia jabbed thumb into her chest. “These patients are my responsibility. When something goes wrong, it falls on me. Listen, Patel, you think you’re the first smart guy to walk in here? Every single intern at this hospital was top of their class in med school. Everyone is used to having the right answers. No one gets this far otherwise.”
Anil rubbed at his forehead, shielding his eyes.
“This is different from school,” Sonia said. “You can’t know all the answers yet, and you won’t find them in your books. The only way you’re going to learn here is by watching and doing.” She leaned toward him. “Anil, in this place, the consequence of your not knowing the right answer isn’t a bad grade. The consequence is somebody dies. You’ve got to check your ego at the door, and change your goal from having the right answer to learning everything you can. Understand?”
Anil nodded without looking up. He was desperate for her to leave the room.
Sonia sat down on the far arm of the couch. “Look, this was a tough case. It wasn’t the normal presentation of a rupture. It’s not easy to identify a small perforation, especially where he was bleeding. But you’ve got to know when you’re in over your head. I didn’t call you out in front of Deanna because these nurses can sniff out incompetence a mile away, and if you lose their respect this early, you’ll never make it.”
Sonia stood up. “I’ll page you when Calhoun’s family gets here. They’ll have questions about his final hours, if he was in pain, so think about what you’ll say.” When she reached the door, she turned back. “Listen, it’s tough to lose your first one. Don’t beat yourself up too much. Just make sure you learn from it.”
ANIL GLANCED up at the clock over the door after Sonia left. Rounds began in an hour. He hadn’t yet checked morning lab results or seen any of his patients, yet he’d already managed to kill one. And there was no doubt in his mind that he had killed Mr. Calhoun, no question it was his fault. If only he’d checked the hematocrit, ordered a CT earlier, recognized the pattern as a slow leak, not the big rupture described in his textbooks.
If only.
Anil had seen other patients die at Parkview, many others, but Jason Calhoun was the first who was his fault. Sonia could have berated him publicly, yelled at him
for not telling her about Calhoun’s falling pressure, for allowing his pride to lead to a fatal mistake. She had been kinder than he deserved, and it was worse this way. Now she recognized he was stupid and worthless.
Anil’s temples were throbbing. The coffee pot in the break room was nearly empty. He poured himself the last muddy dregs and drank it straight, wiping the residual grounds of coffee from his tongue with a paper napkin. Through the window, he could see the first glow of morning sun illuminating the sky. The same warm light was slowly fading into darkness over the fields of Panchanagar. The cook would be shuttling back and forth to the table with platters of food. The scent of chapatis, served piping hot from the flame, reached out from Anil’s memory. Papa would be sitting at the head of the table, consecrating the meal with a prayer. Anil struggled to retain the image of Papa last year, sitting with his impossibly straight back and holding his chin high as he listened to the mealtime banter at the table. A more recent picture of Papa, with stooped shoulders and sunken cheeks, crept into his thoughts, and Anil tried to banish it. In this place, surrounded by illness and disease, it was easy to think of everyone in terms of their ailments.
The door to the break room opened and a nurse poked in her head. “Dr. Patel, Mrs. Jimenez’s son is here.” She lowered her voice. “Dina Jimenez, the DNR?”
Anil pressed his eyes closed and saw the image of Mr. Calhoun’s still body. “Be there in a minute,” he said. After the door closed, he removed his specs and rubbed his eyes before standing up. He’d already killed one patient today, and now he would have to persuade this man to let him kill another.
7
THE PATTERN OF COMMUNICATION BECAME ETCHED BETWEEN Leena and her husband. Girish barely spoke to her unless he needed something; he did not seem curious about her the way she was curious about him. Other than when they lay together at night, Leena spent little time alone with him. While her husband went off with the other men, Leena spent her days under the direction of her mother-in-law, who managed the house, and Rekha, who was in charge of the kitchen.
Leena had never been afraid of hard work. At home, she and her mother did everything themselves. Leena had always taken pride in performing a job well: rolling a stack of perfectly round chapatis, polishing the furniture until it gleamed, scrubbing the stains out of the wash. In her new house, it was different: no matter how hard she tried, she could derive no satisfaction from her work. Leena did all the cooking, but under the control of her sister-in-law. Rekha told Leena exactly what to do, standing over her shoulder to watch. If Leena failed to chop the vegetables in precisely equal pieces or missed one tiny stone in the dried lentils, Rekha would strike her hand with a rolling pin.
Leena prepared every meal like this, under a threatening hand. When everyone came to the table, it was Rekha who served the food and accepted their compliments on the cooking while Leena remained in the kitchen, preparing hot chapatis. Once everyone’s bellies were full, Leena was allowed to join the family at the table and eat from what was left. Many times, she did not even get to taste all the food she’d cooked. After the meal, Leena cleaned the dishes and scrubbed the kitchen by herself.
With nine people in the house, it took at least two hours to prepare and clean up after each meal, but even then Leena was not allowed to rest. In the few hours between meals, Rekha sent her to Mother, who put her to work washing and hanging clothes on the lines outside, sweeping the floors, and making the beds. Although it was hard work, it was also somewhat of a relief for Leena. Whereas Rekha was bitter and mean, Mother was simply blind in her devotion to her sons and her belief that their wives should serve them. In this way, at least, she treated Leena and Rekha with equal disdain. Mother often grumbled about all she had done for her own husband when she was a young bride, though their relationship appeared to be nothing like Leena’s parents’, the way Sahib spoke to her like a servant or dismissed her with a flick of his hand.
From the moment her feet touched the floor in the morning, until the end of the day, when her back ached and her feet were sore, Leena worked and worked. In the afternoon, when the house needed to be quiet while everyone else napped, she was sent out to the fields to collect cotton under the hot sun. She tried to accept her duties without complaint, but she couldn’t understand why she was being treated in such a way, as if she were not a member of the family, not even allowed to share meals with them. Perhaps it was a test of her will. If she worked hard enough, cooked well enough, scrubbed the clothes clean enough, one day they would invite her to join them at the table. Every day, as Leena waited in the kitchen, she listened for the voice of her father-in-law or husband. But the only time she heard her name, it was someone asking for a fresh chapati, or telling her to bring the rice.
The only people in the family who treated her kindly were the children, Ritu and Dev. Ritu was nine years old, a serious girl with thick hair that was always tangled; Dev was a spry five-year-old with mischief in his eyes. They often played together in the small cellar next to the kitchen. Rekha chased them away when she found them there, but when Leena was alone in the kitchen, she gave them small steel bowls and tumblers to play with. She enjoyed hearing the sound of their laughter, and even their bickering, while she worked. Although she was their aunt, they called her didi, elder sister.
ONE MORNING, a few months into the marriage, as Leena was cleaning scalded milk from the bottom of a pot, her eyes filled with tears. Her mother-in-law had chided her for letting the chai boil over while she was busy slicing mango. She had called Leena a stupid girl, worthless. As Leena scrubbed at the brown residue with steel wool, the odor of burned milk rose around her and those names echoed in her ears. She saw her hands, the skin no longer supple but cracked now, calluses on the palms, knuckles covered in scabs. Tears slipped down her face.
“Didi, why are you crying?” Ritu asked. Leena shook her head and wiped her face on her arm. When she turned back, both children were standing at her elbow. “Don’t cry, didi,” Ritu said.
“Do you want a chocolate biscuit?” Dev asked. “I know where the jar is. I can reach it if I climb on Ritu’s back.” He made the wild motions of a monkey climbing with his hands, one of which had a large, dark birthmark on the back. Leena had tried to look at it once, gently taking his hand and outlining the jagged egg shape, but Dev had pulled his hand back and run away.
At his offer, Leena laughed. “It’s okay, monkey, I don’t need a biscuit,” she assured Dev, but he remained skeptical, ready to pounce on his sister’s back if she changed her mind.
Ritu took Leena’s hand and rested her head against Leena’s arm. “Don’t go away, didi,” she said. “Please don’t go away.”
Leena kissed her disheveled hair. “Don’t you worry, sweet girl. Now, go play outside while I finish the dishes.” After the children had left, the sounds of their laughter continued outdoors, but tears kept sliding down Leena’s face.
NIRMALA WAS applying almond oil to her hair when she spotted the vehicle through the sunlit bedroom window. Three men emerged from the car. She was filled with excitement, quickly followed by panic, at the sight of Leena’s new husband, his elder brother, and their father. Since she was not dressed for guests, Nirmala called out for her husband, Pradip, to greet them while she quickly tied up her hair. When a daughter’s in-laws made their first visit after the wedding, it was customary to have a celebratory meal and exchange gifts. She thought of what she might have in the kitchen to serve them.
It had been a few months since Leena’s wedding, such a joyful occasion for all of them. On the morning of the wedding, she and Pradip had proudly presented the dowry to the groom’s father. It was more money than they had ever seen in their lifetime, and it graced their hands for only a few moments. After counting the bills, the groom’s father nodded. This will give our happy couple a good start in life, he said and gave the signal for the marriage ceremony to begin. For the rest of the night, Nirmala did not worry about money or any other concerns that had weighed on them before the we
dding day. Now, she missed Leena’s daily presence, but she took comfort in knowing they had sent their daughter to her new home with pride.
By the time Nirmala came out to the drawing room, the men were already seated and Leena’s father-in-law was speaking. They were disappointed in Leena, he was explaining. She was not carrying her share of work in the family, was not enough of a help to her elder sister-in-law and mother-in-law. Her cooking skills had been overstated, he said, when in fact she was slow and sloppy in the kitchen and needed to be told how to do everything. Leena showed no interest in household responsibilities as a good wife should, preferring instead to spend her time playing with the children.
Listening from the edge of the room, Nirmala felt a hollow space expanding inside her, as she’d felt after Leena had been born, when her taut belly was deflated of the life it had carried. Who were they talking about? This girl didn’t sound like her daughter. Then again, Leena had a strong mind, which could sometimes veer toward disobedience. She remembered her daughter as a young girl staying out late to play in the fields for hours after she should have been home.
And marriage was hard. Nirmala recalled her own early days of marriage: the sudden intimacy of a man of unfamiliar scent moving on top of her, the confused unlearning and learning of the ways of her husband’s family. For months after her own wedding, she’d ached to return to the comfort of her parents and siblings at home. But in time, this yearning had dulled. At some point, though she couldn’t say exactly when, it had been replaced by the ease she came to feel in their home, the companionship she found with her husband, the creation of their own family.