This week’s other featured books, “The Silence in the Sound,” by Dianne C. Braley, (“ghost gesture”), by Gabrielle Civil and “Earning It,” by E.F. Dodd, can be found by scrolling down below this post, or by clicking the author’s name on our Authors page.
THE BOOK: South Eight.
PUBLISHED IN: August 23, 2022.
THE AUTHOR: Larry Atlas
THE PUBLISHER: Webatuck Press
SUMMARY: The emotionally-charged story of South Eight follows a young doctor’s collision with the demands and contradictions of modern acute care medicine, both its power and failings, and the moral questions it ultimately provokes.
For Dr. Abel Arkin, those questions reach back to his time as the spotter on an Army sniper team in Afghanistan, when the clarity of his training and skills converged with the uncertainty of mission outcomes and personal trauma. The old dilemmas and doubts join those of the present when a newly arrived patient tries to blackmail him with the threatened exposure of a wartime catastrophe, and simultaneously underlines Arkin’s increasing ambivalence about what he is actually accomplishing for his patients, what may be missing from the life-and-death calculations he makes everyday. In pitch-perfect language, Atlas builds suspense not simply around a disturbing medical and professional dilemma, but in troubling questions of individual trust and conviction. Both a literary mystery and love story, South Eight is also a piercing exploration of the reality of modern medicine, one with important insights for doctors and nurses, as well as for the patients they treat. Which is to say, for all of us.
THE BACK STORY: Like many of my physician/NP colleagues I experienced burnout, in my case after 14 years of hospital practice, first as a nurse, then as a hospitalist NP, providing medical care to acutely ill patients. When I took some time off to restore, I wrote this book, both to process feelings, and to consider solutions. It was also an exciting and challenging introduction to prose-writing, which I had literally never done before. In fact, I started out not once, but twice to write something along these lines for the stage. But the experience of working in the hospital, with patients at crucial moments in their lives, was simply too internal, for me at any rate, to examine in dialogue only.
WHY THIS TITLE?: While some units have real descriptions in their names, e.g. “Intensive Care Unit,” many more general hospital departments are often identified this way, geographical relationship to the whole, plus a floor number. One hospital where I worked had one building that topped out at South Seven. I came up with South Eight, as a sort of fictional extension for the fiction I was writing.
WHY WOULD SOMEONE WANT TO READ IT? We, collectively, have managed to isolate ourselves from the realities of aging and physical decline. The experience of those realities—a part of nature, and once a part of humanity’s daily existence—has been outsourced to doctors, hospitals and nursing homes, relieving us of fundamental questions about how we age and die, but placing an extraordinary burden on them. We need a new approach to aging and the illnesses that come with it. With a huge cohort of people just now entering their seventies, they are unlikely to be satisfied with the habits and practices of previous generations. Two questions arise from the reality of aging and death: when, and how. Almost always, we, both as patients and providers, ask only “when?” and answer “not now.” The vastly more important question for aging patients is “how.”
AUTHOR PROFILE: Larry Atlas is a former Drill Sergeant who served in the Army. After his service, he attended Bennington College, earning both bachelor’s and master’s degrees before declining admission to medical school—and moving to New York to begin a successful career as an actor, playwright, and screenwriter. Among his produced plays are Total Abandon and the award-winning Yield of the Long Bond which premiered at the Matrix Theatre in Los Angeles. He worked on multiple studio film projects including Sleepless in Seattle. He conceived and implemented the first nationwide online actors’ casting service, and then later co-invented and patented the first navigable nonlinear video architecture.In midlife, on impulse, he went to nursing school, then worked for four years as an acute care nurse while earning a master’s degree as a nurse practitioner at SUNY Stony Brook. He worked for a decade as a hospitalist NP and now practices at a subacute rehab. He has taught at Hunter, Bennington, and Vassar colleges, and is a former captain of the skydiving team Spaced Rangers. Larry lives in upstate New York with actor-turned-therapist Ann Matthews, and their dog Ruby.
AUTHOR COMMENTS: Some of the above, perhaps especially in the “Why would someone want to read it” section, might suggest that I set out to write a book about healthcare, or burnout, or the unintended consequences of advances in medical science. While I may indeed have been writing about those things, to some extent that only became apparent after the book was finished and others began to read it. The more immediate impulse, as I imagine is true for most writers, was simply to write, to uncover a story, to answer often vague and dimly understood questions of one’s own. That was certainly the case for me with South Eight.
Excerpted from Chapter 1 of South Eight by Larry Atlas
Kate, a day shift RN on South Eight, wears a flowered scrub top over a t-shirt at the top of which Arkin can just make out the word, “Relax.” Because he’s seen it on other nurses, he knows the rest of the message is: “I’m a nurse, I’ve seen worse.”
“Dr. Arkin?” He nods. “Do you have Mrs. Warren today? In 868, post op with C-diff?
“I saw her yesterday. What’s up?”“
“She doesn’t look good to me. Worse than yesterday.”
Arkin exhales, considers some long ago advice that when a skilled nurse tells a doctor something’s wrong with their patient, or that something’s changed, the doctor should pay attention. This nurse stands in front of him comfortably, no more cowed by this one doctor than by the hundreds of others she’s met, waiting for a response, her hair pulled back into a practical pony tail held in place by a red plastic bow. Arkin can smell the lavender in the shampoo she’s used that morning, and tries to remember if he’s ever seen her alarmed or angry.
“There was nothing overnight in report, but she’s in a lot of pain, nausea, vomiting. Held her oral vancomycin just now, don’t think she could keep it down; belly looks bad. Could you see her first?”
Arkin hesitates only a moment, the nurse watching him, her gaze steady, the eyes gray and direct. He notices her name tag, the last name in smaller letters, Maddox, over a picture of her, smiling into the HR camera.
“Let’s get some fresh vitals, I’ll check her labs, be right in.”
The patient is eighty-four, overweight; but even in pain she manages a wave as Arkin comes through the door:
“Hey, handsome,” she grunts.“
“Hello, Sylvia – what’s going on?”
Arkin walks to the bed, touches her arm.
“I look like hell, that’s what,” the old woman says. “Why couldn’t we meet when I was just seventy?”
“That would’ve been cruel, Sylvia – I’m already your slave.”
The old lady grins, then grimaces. “My belly hurts. A lot.”
He gently palpates her abdomen; it’s hard as a drum, a tabletop. He puts his stethoscope to it, listening in all four quadrants, hearing no bowel sounds whatever, not even the trilling, tinkling wheeze of partial obstruction
“You having any diarrhea?” he asks, though he knows the answer:“No. Nothing since yesterday.”
“That’s pretty personal. No.”
Arkin has moved the bell of his stethoscope up to the heart, listening to the steady rhythm there, the sound of valves slamming shut, first mitral and tricuspid, then pulmonic and aortic, the tandem jazz of life – only now far too fast, around a hundred thirty beats a minute. And even without listening specifically, he can hear the lungs, too, expanding and contracting, he guesses thirty times a minute, more, the wild rapid gale of sepsis.
“Am I going to die?” she asks him. “I feel like I’m going to die today.”
“We’re all going to die,” Arkin says gently enough, hoping the old lady will accept the cliché, the vapidity of his evasion, and spare them both not just the bad news of his diagnosis, but of her prognosis.
She doesn’t: “But is it today that I’m going to die?”
He takes a breath and tells her, “It could be,” keeping his voice even, direct, empty of alarm; he’s holding her hand. “It could be today. But, Sylvia, it could also be next week, it could be next year.”
Arkin catches in his own voice the shaky vibration of words repeated too many times, hopes the old woman hasn’t heard it too. She just blinks at him, her expression unchanging, unsurprised.
“I’ll be with you,” he tells her.“
“If it’s today?”
“I’ll be with you,” he says again, and turns to Maddox: “We’ll start normal saline, bolus two liters, then two fifty an hour, let’s get another line in. Start Flagyl I.V., give her Cefepime, 2 grams Q12, get a blood gas, EKG. Frequent vitals.”
“Hourly?” she asks, taking notes on the back of her sign out sheet.
“Let’s do every fifteen minutes for the next couple hours, look for mean arterial pressures greater than 65. Let’s get a lactate, CT of the abdomen with I.V. contrast, don’t bother with P.O.; CBC with diff, procalcitonin, CMP. Blood cultures times two. Switch the NG tube to continuous suction. NPO. Low bar for ICU transfer, very low. Can you start Levophed here if she needs it, through a peripheral line?”
“Good, then if she drops below MAP of 65 we’ll do that, and transfer. I’ll put it in the orders.”
She’s still writing but takes a moment to look up from her notes, smile at the patient, relaxed and direct, as much woman-to-woman as nurse-to-patient, Arkin thinks. To his surprise, it makes him feel, for a moment, like an outsider.
“And call Dr Bennett, acute abdomen.”
He turns back to the old woman in the bed, Sylvia, a traveler in life: a mother and grandmother, a child in World War II, a bride in the Fifties, a widow for ten years, a garden club member, bridge with the girls for thirty years; he sees the lines and creases in her face, the heavy jowls, the thick quivering pads of flesh there, the puffy hands, the swollen legs and arms, the thin chain around her neck, its plain silver cross to one side and just touching the pillow, small and tarnished with the years, a gift, he thinks, of her childhood, and the stoic companion and witness to the years since, their disappointments, dreams, losses, laughter, tears, pain, grief, age.
“Sylvia, it’s possible we’ll need to operate again.”
“No,” she says, barely a pause, not even a breath – or perhaps she has no breath, just the remaining conviction of: “No.”
Arkin looks for a chair, then thinks better of it and sits again on the bed; he again takes the old lady’s hand.
“Sylvia,” he begins, the words forming in his mind, the points assembling themselves automatically within, as if running on ahead of: “It’s possible that you have new problems in your belly, maybe something called toxic megacolon. And it’s even possible, likely, that you have some perforation, so that some of the contents of your gut are getting into your blood. This happens.”
The old eyes, only slightly rheumy, with only the slightest glitter of fear, hold his, attentive yet somehow not, drifting off on the unfamiliar language of medicine as well as the oceanic undertow of completion.
“And when it happens, you get infected, ‘sepsis’ we call it, and that can kill you. We’re giving you antibiotics, and that’ll help, but there’s a chance if we don’t find the source of the infection and repair it, we won’t be able to stop it, even with the antibiotics. Do you understand?”
Sylvia nods, agreeable now, even placid.
“So we’ll get a CAT scan – is that OK?”
“And we’ll have Dr Bennett look at the CAT scan.”
She only nods at this, minutely.
“And…” Arkin hesitates, hoping the air between words will soften her resistance to the final phase of his assault on her spirt: “And if it doesn’t improve, he’ll go in and fix it. He might have to take out part of your colon. And you could have a pouch, at least for a while. You understand?”
A hint of a smile, the ghost of a once-young woman who’d been cajoled, or allowed herself to be cajoled, by men before – a few, a dozen, a hundred, who would ever know? Now? – and then: “No.”
Almost gently, as if sparing… him.
“I don’t want that. I’ve lived long enough. No.”
Arkin looks into her face, peaceful now, almost cherubic, in contrast to the hard red furrow the nasal cannula have dug into her plump, sagging, sweaty, cheeks; the nasogastic tube emerging from the tape abrasions on her nose.“All right.” It comes out a whisper. He tries again:
“All right,” though no stronger, just more precise, as if diction could approximate control over something likely to spin out of it. “If you don’t want surgery then I’m not putting you through the CAT scan – is that OK? Do you understand? We’ll get a plain X-ray up here.”
Sheila closes her eyes now, takes a deeper breath through the nasal cannula, centering perhaps.
“And…” Arkin begins, pauses, says: “I’m gonna be really direct, and honest. We’ll focus on making you comfortable now. We’ll continue antibiotics, and fluids, I think that’s reasonable and right, but we won’t do anything aggressive. No ICU. If something should happen, if your heart should stop we won’t shock you. We won’t put you on a machine if you can’t breath. If that should happen, we’ll let nature take its course.” Although he uses it often, Arkin hates that phrase, a cliche that diminishes nature, life, God or whatever else his patients may happen to believe in; there should be a study to devise better. “But I’m gonna take away your pain, OK?”
The old lady just nods now, adjusts her hand in his, squeezes briefly; her grip is still surprisingly strong, a lifetime of practiced and habitual comfort in her touch, even now, comforting him. He allows himself a smile, too, and he covers her hand with his other, presses gently in return, a slight, unmistakable, irreducible, and almost certainly unsupportable, reassurance.
Arkin can also feel there, at her wrist, among the plastic name ID and blood bank and Fall Risk bands, and the purple Do Not Resuscitate identifier, the racing, rampaging pulse. He stands at last, looks to the nurse, watching him from across the bed, over by the window, the Hudson River beyond, bucolic. A train rolls south on the Western bank, toylike and silent at this distance.
“Then… we’ll get the flat plate, portable; we’ll do the rest, no pressors. I’ll let Bennett know where we are, what Sylvia’s decided. Ativan, 1 milligram I.V. q4 PRN, Dilaudid the same, q4H as needed, but give 2 milligrams now. No ICU. More palliative. OK?”
The nurse, Kate, nods once, gray eyes as calm and steady as ever.
“Any questions?” he asks her.
She shakes her head slowly, expert, understanding the implications, and the plan.
“Good. I’ll put it all in, call if you need me – here’s my cell.”
He scribbles his phone number on the back of a business card, hands it to the nurse, then turns back to Sylvia: “I’ll come back.”
The old lady, eyes closed now, manages a brief wave of dismissal, half salute.
A few others of Arkin’s hospitalist medical group relax around their conference room table. Some eat, almost all complain. The talk is of billing codes and an atypical pneumonia in the Respiratory Care Unit (memories of COVID are still fresh in everyone’s mind); paid time off has been unilaterally cut.
Apart from all that, Arkin sits at one of the group’s computers reviewing sepsis of gastrointestinal etiology. Of course he’s thinking of his patient on South Eight, but Arkin can’t help recalling a similar experience from his pre-professional past: a Special Forces E6 in Kandahar, who’d returned from three weeks with his A-team at the Parrot’s Beak with a perforated appendix, ashamed (as he lay gray with shock in the aid station) that his team had been forced to evacuate him for this non-combat-related illness, a non-wound, trivial except for the liquid feces with its armies of bacteria pouring into his bloodstream, as he tried to laugh and joke away his embarrassment and fear, and couldn’t, and died.
Such memories are part of what’s brought Arkin to medicine, he supposes; and for a moment, lost in memory, the words on the monitor before him refuse to focus.*
*When the page comes, delayed as usual by the overloaded hospital wifi, and Arkin reaches Sylvia Warren’s room, he finds Kate Maddox still there.“
Does the family know?” Arkin asks.“
I called her daughter, the POA.”
Maddox sits in a chair by an open closet; inside, Arkin sees a worn old housecoat, a pair of terrycloth slippers. A silvered heart-shaped “Get Well Fast!” helium balloon is tied to the closet door, floating anemically, two days old and barely aloft.
“She coming in?”
Maddox just shakes her head. At last Arkin goes to his patient, her body already shrinking, or seeming to, as corpses will; her eyes are open but not staring, not windows to the soul, not alight with pain or intelligence, or humor or weariness, not anything, not even sightless, as though sight had not just ceased but never was, eyes as artifact.
There’s music softly playing on the patient’s iPad, Arkin recognizes Billie Holiday singing “I’ll Be Seeing You,” a tune from the patient’s disappearing past, the Forties of her girlhood, Holiday singing I’ll always think of you that way.”
Arkin shuts off the music, puts his stethoscope on the woman’s chest and listens for a long while, perfunctorily, to nothing. In his head he can still hear Holiday: and when the night is new.
He straightens, looks at Maddox.
“This sucks,” she says.“
“I’m sorry,” he says, and turns to look out the window, now open, its view of the unused and decaying piers and industrial sites along the river.
“Did you put on that music for her?” he asks the nurse, although he knows she did.
She ignores the question: “You weren’t here. You said you would be.”
“I didn’t get the page.”
“I called you first. Check your phone.”
Arkin pulls pulls the phone from his lab coat pocket, thumbs through the voicemails, one unidentified.
“Is this you, the two-nine-six number?”
She doesn’t bother answering, instead rises, begins pulling more clothes from the closet shelves, packing them into a plastic belongings bag. Arkin realizes that his phone, jammed into his pocket, had once again self-muted.
“Did you open the window?”
“What?” she says, stopping.
“Did you open the window?” The room’s window is open; it wasn’t earlier.
“I know… nurses sometimes open a window when a patient dies. Or they used to.”
“To let the soul out,” she says, almost weightless, uninflected.
“Do you believe that?” he asks. “Did you do it?”“
“I don’t believe it,” she says, and hesitates, looking down at the sweater Sylvia Warren brought to the hospital three days before she died. “But I did it,” Maddox says.
Knit into the front of the sweater is the image of two Labradors, one brown, one yellow. Slowly, as if the stronger original impulse has abandoned her, she pushes the sweater into the plastic bag along with the dead woman’s shoes, her slippers, robe, skirt, compact, hairbrush, mouthwash; cards from her children; cards from her grandchildren; her rosary. A single tear slides down the nurse’s face as she turns away from Arkin, and back to work.
WHERE TO BUY IT:
PRICE: Paperback: $15.95, eBook $9.99,
CONTACT THE AUTHOR: Connect with Larry at www.larryatlas.com.–
Olivia McCoy (she/her) | Publicist & Marketing Associate