The smell was all over the hospital hall. She could sense it in the air, and wondered if anyone else could—the smell of neurotransmitters and hormones exhaling from bodies losing the fight for sanity.
That smell was not strange for Karina, but she never wanted to get used to it. The freaked out biochemistry of patients’ family members would cling heavy on her. How unusual it was to realize that dead patients, fresh corpses, had a scent and feeling about them that was far less intense. In this way, to her, the smell of the living was far more sickening than the smell of the dead.
She had lost the will for a strong coffee, knowing she still needed it, when she saw his big smile ending in large dimples. Two coffees in his hand, straight from the machine next to the nurses’ lounge where she saw him adding sweetner.
This doc doesn’t waste time, Karina thought. Doctor Adam’s smile would have been charming if she didn’t know there were three spoons of sugar added in her coffee. Ugh! You’re not doing this right, she thought while smiling back.
“Thank you,” she said and took the hot cup in both hands.
He noticed the small stone shining on a necklace low on her throat and his smile broadened. “I did the ICU release prescription for that car accident patient. He’s in orthopedics now. I increased his heparin dose because of a pulmonary embolism.”
Can’t wait to see all the harmful interactions in the prescription and call you to change drugs and adjust doses, she thought then said, “That’s great! I didn’t think he would be released from ICU so soon.”
“I was thinking he would be released to the 11th floor a month ago.”
She nodded. The hospital only had 10 floors. It was hospital slang, an expression to make it all less painful. She looked up at Doctor Adam and squinted. The way he tilted his head and studied more than her eyes, she would find him attractive if she didn’t know he was just looking for a blow job in a dirty bathroom stall, and she thought of her friend who committed suicide two months ago after coming out of that dirty stall to tell her, “Don’t do it, girl. Listen to me, Karina. Wrong guy. Wrong time. Don’t think it will be different with you because of your pretty face and tight white coat. You’re needy, and coming to the hospital needy is just like going to the supermarket when you’re hungry—you grab the first thing you see in front of you.”
How she missed her friend every time she saw a fucking ketamine. Always the kidder, always zipping by with a quip whispered to keep the mood upbeat on their long shifts. Now, the humor was gone. A whole vial, intravenous, and her friend’s life ended on a toilet. Why didn’t she just quit and start over?
“What time will you have lunch?” Doctor Adam said. “I just found out about a new Italian place near here.”
Maybe he could be more than a cheap smile and expensive coffee and wanted to really know her. But she was so tired and too lazy to dig into his soul in search of something good hidden behind three spoons of sugar.
“I won’t have lunch today. Thanks, anyway.” Her dark eyes looked down the hall as she took a small sip from her cup. A man and his wife let go of each other, crying, to hug two teenagers.
He made a face. “That’s the family of the motorcycle guy. He died this morning. His condition seemed to improve, but it was just the famous improvement before dying.” He took a long pull from his coffee. “At least his family saw him.”
There goes the family, exhaling the painful smell all around, she thought, feeling their pain like it was her own. She knew she was not crazy. She wanted to ask if he could feel the smell, but she was too sleepy for an introspective conversation, especially with someone she was unsure about.
“I’ll be here until lunchtime. Then Doctor Martina will take over the shift. Be patient. She didn’t sleep all night because she wanted to be on the phone, knowing about every patient. Her mood is wishy-washy.”
That was the kind of bad news to destroy her day. Everyone’s day, actually. But she smiled, thanked him for the coffee again, and said she would talk to him again later.
At the Pharmacy, she took a quick look at all the prescriptions and the higher heparin dose that was already on her desk.
“Two syringes of 20mg instead of one of 40mg,” Karina said to an assistant who passed by without looking.
“The night pharmacist said heparin of 40mg ended at night,” the assistant answered.
“No way. I’ll call another hospital and borrow some of them. We still have some hours to get it before his next dose. Fewer pricks and less trash. We need to borrow other drugs for now and catch the opportunity to get some 40 mg heparin,” the pharmacist decided, while walking around with drugs in her hands and talking quickly.
***
Joanna was responsible for the day shift in the ICU. She smoothed the wrinkles from her dark green scrubs top and reached for the phone on the desk and called the Pharmacy. She needed to know which pharmacist was working in the morning. She imagined the phone ringing on her friend’s work desk on the 8th floor.
“Karina! Thank God you’re there. Some patients coded last shift and Doctor Martina is being totally crazy. Will you help me with the paperwork?”
“They died?” Karina froze while closing the door of her office.
“Two of them.”
“What were the doses of ketamine, thiopental and fentanyl?”
“Not necessary to check. I got them from the emergency trolley,” Joanna said, and hoped the pharmacist didn’t hear the nervousness in her voice.
The pharmacist’s long hair cast an almost noir shade on the prescription as light came in through the unopened glass window. “I mean, there is no solution prescribed to dilute these drugs. You know… Sedatives have always been common for all the patients in the ICU, and lots of ketamine, thiopental and fentanyl are handled every day, but they must be diluted in solutions and run during certain hours. From time to time, I see a prescription of sedatives in high doses without a solution to dilute them.”
Joanna thought for a second before cautioning, “Oh. I don’t know how these drugs were administered. I’ll ask Doctor Martina to correct the prescriptions. She should prescribe 500 mL or 1000 mL solutions to dilute those drugs, correct?”
The shadow over the prescription got darker. “Not just prescribe. She should use them. You know these drugs are fatal if they are not diluted and infused precisely over several hours. I saw she declared these patients deceased less than 30 minutes after these prescriptions.”
“Oh. Huh. I don’t know how she did that. I’ll talk to her about that,” Joanna said, and she imagined the pharmacist could hear her lips press together.
Another pharmacist must have arrived, Joanna, thought, her ear beginning to ache from pushing the phone tight against it. She heard the office door open slowly, then, “Good morning,” she heard Karina say hanging up the phone.
***
“Two more for the count, Clara. Doctor Martina has opened space in the ICU, for sure. Why the hell is she prescribing these sedatives pure? High doses in bolus, like a signed confession? I mean, it’s written! Everyone knows it’s fatal.”
“Not everyone knows that. Maybe she cares about hospital finances. The hospital needs to get paid for every drug, even when it’s harmful. That’s why she does illegal prescriptions like signed confessions. It’s euthanasia, plain and simple. She enjoys thinking she can do anything she wants,” Clara said while pulling a bit of skin off her finger, and Karina looked at it with horror.
“Is it possible… no. A medical auditor would catch ketamine, thiopental and fentanyl injected in bolus, and the immediate deaths.”
Clara spat the piece of skin. “Hey. Brazilian Universal Healthcare System. What auditor?” She raised her voice and looked around the empty nurses’ station. “Anybody see an auditor here?” She grinned as Karina looked around. Clara continued, “Two new patients just came, and she definitely opened space in the ICU for them, releasing those in worse condition to the 11th floor. Those previous patients would have died anyway.”
“Clara… I think we need to… I don’t know… Call the police?” Karina said.
Clara spat another piece of skin. “Are you crazy? She might get indicted, sure, but that cunning bitch would get the best lawyers… the police and the judge and the prosecutor won’t understand anything about these prescriptions, and what should be dead-to-rights proof won’t be worth anything. I think most of us would want to drink and dance because her career would be over, but all that would be short-lived and you know it. The hospital administrators would want to crucify us after Doctor Martina’s lawyers hit them with a million dollar lawsuit.” She put a palm on her head as if that would cool her off. “There’s no winner here.”
“I just can’t stand with all that,” Karina insisted, while she was analyzing an enormous prescription of an intensive care patient.
“So write a book, or maybe a short story about it all. But don’t lose your whole life doing something with consequences you can’t handle. This will be bad for everyone! There has to be a better way. Just don’t.”
“My hands are clean. If they don’t have it all on the emergency trolley in the ICU, and ask for these drugs specifically with no dilution, I won’t send it to them. But I would like to do something for these patients. It’s not fair. And it’s not legal. I mean, it’s obvious that these families have no idea when something like this happens.”
“If you write it someday… it would be funny if it wasn’t tragic. People would say these things never happened. That it was sensationalism,” Clara laughed.
“Life is worse than fiction.”
***
Six floors down, in the ICU, Doctor Martina was giving everyone hell. “The patient is dying! What are you doing there?” said a woman with extravagant hair and makeup. Her scrubs jumped on her small frame as she slammed the telephone against the table.
“Do you need something, Doctor Martina?”
“Jo-a-anna… with an A. Joanna, go to your place and teach your cattle how the patient of bed 03 must lay with his head up. He just came back from a complicated surgery. A craniotomy, for Christ’s sake! Cra-ni-o-to-my. I don’t know why his head is not propped up as it should be.”
Joanna looked at the patient without saying a word. She washed her hands in minutes, while praying to have a good day of work in the ICU.
The Pharmacy sent the drugs to the ICU just in time: 10 am. Joanna heard Martina’s voice and felt something cold in her stomach. Martina was asking for a dose of dopamine for the patient in bed 07. Up until lunch time, the doctor visited every patient several times, intubated one, reintubated another, prescribed for them all, and updated their records, screaming with nurses and residents.
Doctor Martina’s prescriptions just shined. No harmful drug interactions. No wrong doses. The pharmacists didn’t like her but couldn’t complain about the professionalism of her prescriptions.
Martina left the hospital for her lunch break, looking for a cigar in her black purse. Her long purple skirt and flowing yellow blouse were designer, but it was likely no one noticed because it was hard to see anything but the deeply serious expression on her face, as if she was constantly thinking about how incompetent the ICU staff was. Several times, when the hospital didn’t have resources, she paid for expensive equipment out of her own pocket. Her no compromises management of the ICU made her a queen of that hospital, she felt. She demanded respect, enforcing her own rules. Even the infectology doctors, who visit all the patients to help with antibiotics and antifungals, were forbidden, by her, to enter the ICU. They could only go there when another doctor was present.
To Joanna, it always seemed like Doctor Martina came back after lunch in a far worse mood. And so it was that day. The doctor entered the ICU and started screaming, “Joanna. Come here. Tomorrow is the day of the big cleaning in the ICU, including the walls. Do you know what that means?”
“Patients released?” Joanna tried to hide her wide eyes while injecting the medication into an elderly woman’s access.
“Yep! But not only releases. Also releases to the 11th floor,” Martina whispered.
Joanna pretended she didn’t hear and went to wash her hands so she could see to another patient. She knew that nineteen patients were getting better, and they would probably be released. One was getting worse. But terminal was not the same as dead.
Who does she think she is? Screaming and deciding people’s fate? Joanna thought, trying not to blow her mood with evil thoughts. Other patients needed her, after all. Maybe she doesn’t mean she will… do something… about him. Maybe she just thinks he could die soon, she concluded.
Doctor Martina started to prescribe for the patients who would be released. The prescriptions were automatically printed at the pharmacy—papers and more papers. “Only release prescriptions,” Clara said. “Day to clean the ICU for sure.”
***
At the ICU, Doctor Martina sent the patients to their new places, most of them went to Nephrology, Cardiology, and Oncology.
“Joanna, come here, please,” Doctor Martina, who never says “please,” said in a slow voice.
Joanna left the computer immediately, without finishing the round of nursing, to know what the evil woman wanted. She came to bed 18 praying in silence.
“Let’s open the emergency tool kit, please. Inject a whole vial of fentanyl,” said the doctor.
Joanna pretended she didn’t understand that the fentanyl would be injected pure. She got a normal saline solution of 1000 mL, to dilute the drug.
“Joanna, leave it pure. You know he’s about to die. He will die today or tomorrow, and you know that. The ICU needs to be disinfected, and it can’t be done with 20 patients inside it. You are well aware of the problems we’ve had with MRSA. The ICU is always at overcapacity. We can’t properly clean it. Some patients are going to be killed by bacteria. Do you think it’s fair? We can’t hold a patient who is about to leave this world and risk the lives of others who have a chance. Do you understand?”
“Yes, doctor.” Joanna was nauseous.
Martina saw Joanna’s upset face but continued, “So, fentanyl. And we can aspirate a whole vial of ketamine too, in another syringe. We need to make sure he will not feel pain. I don’t believe in God, but I believe in life. And I’m doing this for the good of all. You’re doing the right thing, Jo. And don’t worry, if you don’t agree, this is on me entirely. You know nurses have to administrate what the doctors ask. Just do it, and it’s my call. Good, Joanna,” said Martina while slowing down the patient’s oxygen.
Joanna started to cry.
“We did all that we could, but the patient is deceased. The time of death is 2:22 pm,” Martina said with a sad voice and tried to breathe. “I hate to do this, Joanna. And that’s why I ask for your help. Don’t think that it’s easy for me. It’s a lot of responsibility to run this ICU. I’m doing my best, even when I have to do something that will steal my sleep tonight,” Martina said, and Joanna thought she saw the corner of the doctor’s mouth turn up.
Doctor Martina put her left hand on Joanna’s back, and then she kept walking to the medical staff room.
The end of a hospital shift in a developing country can be anything but ordinary. To enter it praying and go back home crying is nothing but routine, Joanna thought, pretending she didn’t notice her colleagues’ judgmental faces. And so another shift was over, on the Friday night of a Holiday.
***
It was Monday. The ICU was clean and full again. No free bed. 20 new patients had been received over the weekend, most of them because of car accidents. A young man who suffered an overdose with cocaine was waiting in the Emergency Unit for a place in the ICU. They needed to clear at least one bed today.
Joanna looked at the patient’s chart and her eyes glanced over Doctor Adam’s orders. “That bitch Doctor Martina,” she heard Karina tell Clara at the hall station when she clocked in. “She was still wearing the designer skirt and loose yellow blouse when she was brought in.”
“Good luck to whoever inherits them,” Clara snickered. “Those blood stains aren’t coming out.”
Joanna’s eyes narrowed, then relaxed as she shrugged and followed the orders of Doctor Adam. Fentanyl. Tyopenthal. Ketamine. Done. She slowed the oxygen down for the patient marked as terminal by the doctor. She’s here because of a car accident, of all, things.
Oh well…
“Patient: Doctor Martina,” Doctor Adam said without wearing his big smile. “Deceased at 6 am. Please take note.”
“Yes, doctor.” Joanna said.
Doctor Adam crossed paths with Karina when he left the ICU for a coffee break. Karina smiled and kept walking. She glanced in the direction of the waiting room, having just spoken to Doctor Martina’s family. She looked back at the doctor and her nose wrinkled. Can he smell that? Can he feel their stink?
by 
Carola Schmidt
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Good build up and twist at the end.
Seriously chilling!