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Needle Exchange

The harsh overhead tube lights flickered, fading almost to darkness then sparkling back to life, as a bone-tired Vivek entered the inpatient ward.
On paper, Vivek was merely a trainee physician in his first year of residency. What this meant in the real world, however, was that he was one of only two in-house doctors managing forty-odd patients at the government hospital. Pritesh, the other first-year and his companion at the bottom of the hierarchy, was already at their shared work desk when Vivek walked in. (In later years, Vivek would humble-brag about the dilapidated “nurses’ station” he used to work at, but he was far from such Americanisms now.) The two had been together—as classmates and competitors, but never as friends—since the start of school. If pressed, Vivek could recall a time at the beginning that they may have felt for the lives entrusted to their care. Like a tiger’s tongue whittling flesh down to the bone, however, much of that altruism had been stripped away through their years of observing a system geared toward overexertion and cynicism. All that remained was the white-hot competitiveness that had gotten them this far.
Pritesh looked up, smirking as Vivek plopped his large pile of notes down across from him. Vivek steeled himself for a cutting remark, instantly regretting the few minutes he had spent getting chai at the tea stall, a choice that had apparently put him behind.
Chutiya, just getting started? I’m almost done!”  
Underneath the boastful tone, Vivek detected the same undercurrent of hostility that had strained him all year. There were a set of rumors and facts about Vivek well-known to Pritesh and all the other residents in his training program: that he had an uncle who ran a motel in Birmingham, Alabama; that he always carried a made-in-USA Littman cardiology stethoscope in sky-blue; and that he had clandestinely passed the two tests needed to get a U.S. medical license. Connecting these dots could lead to only one inescapable conclusion: like many trainees before him, Vivek planned to bolt for America at the first opportunity, leaving his fellow trainees to pick up the slack—more misery to add to an already miserable workload.
Vivek could sense the taunt coming next, but he pulled up a chair and sat down anyway. Pritesh leaned forward, wagging his finger, jeering in a mock American accent, “Such tardiness will not be tolerated at the University of Alabama!”
Bhenchod,” grunted Vivek in response as Pritesh cackled with glee on the other side of the desk. “I only got one chai. No way you wrote all these in five minutes.”
Pritesh smiled smugly, reaching into his backpack and pulling out a sheaf of papers. “My newest innovation—pre-written notes!”
Vivek looked at him, puzzled. “Pre-written? How can you write notes without seeing the patient?”
“Because, you fucking donkey, we admit the same types of patients every time we are on call. Five with malaria, five with tuberculosis, five pneumonia, couple strokes, couple diabetes. Right?”
“And they have basically the same history: fever and chills for malaria, cough and weight loss for tuberculosis. Right?”
“Why actually talk to the patient and get a history? Why not just recycle notes from the hundred other malaria patients we saw earlier in the year and add the face page for today’s patient? It’s not like any of our seniors have the time to double-check our work.”
Words failed Vivek as he stared at him open-mouthed. 
Pritesh was almost giddy in this moment of triumph.
“I’ve been doing it for a couple of months. Started with just malaria cases, then added the tuberculosis ones and then the rest. I keep a bunch in my backpack and then pull them out when no one’s around. Not one senior has found anything wrong with my notes.” He paused to catch his breath, then resumed. “This is why you’ll fail in America, Vivek. They prize innovation, and you have none.”
Vivek finally found his voice.“Fuck you, I’m not going anywhere. I’ve told everyone that. Residency interviews started two months ago. If I was applying, I’d have been gone by now.”
This last retort had a ring of truth to it—it was indeed very late in the application season to interview for American residency programs. Pritesh did not push the matter, still delighted with himself, shaking his head as he completed his final note and got up to prepare his procedure kits for the next day. 
Like any truth, however, it was also incomplete. What Vivek had conveniently left out was that he had, in fact, tried and failed to make his great escape two months ago. The main barrier to getting to residency interviews in the U.S. was obtaining a visa from the consulate in Mumbai, an overnight train ride away. He had delayed applying until the last minute. This was partly because he was overwhelmed by his intense workload and partly because he had been rendered irresolute by his ever-arguing parents: his mother pleading with him to stay, his father urging him to leave. This indecisiveness continued until some weeks ago, when he was brought down with a particularly nasty episode of malaria. His fevers were high enough that even his senior residents grudgingly agreed that he should take a few days off, the first time he’d had to himself all year. When he recovered more quickly than expected, Vivek viewed this as a sign that he should use these days off to apply for the visa. He took the night train to Bombay, getting in early enough the next morning to make his way to the line of assorted visa-seekers outside the American consulate. 
The plan was simple, the path trodden by many before him: sign up for a walk-in interview when the embassy opened at eight o’clock, charm the interviewer into granting a visa, fly to the U.S., interview at several residency programs, and match with one. If this all worked out, you were guaranteed to live happily ever after in the land of plenty and never, ever, even in the worst residency program, have to be on-call continuously for twenty-four hours a day for three hundred and sixty-five days.
On that surreal morning, however, none of this came to pass. For the first time in living memory (or so Vivek gleaned from the volubly anxious other visa applicants in line), the embassy failed to open on time. The crowd milled around uncertainly for another hour until a consulate official finally came out and made an announcement. Something had happened in Washington, a squabble between the Speaker and President Clinton. Government employees had been told not to report to work—indefinitely. When Vivek heard the phrase “first federal government shutdown in a hundred years,” he knew that he had misread the signs, that his destiny lay closer to home. He had procrastinated too long, the window had closed, and he had missed his opportunity to escape. There were only two-odd months left for residency interviews in the U.S., so this year’s application process was all but lost. By this time next year, he would be more than halfway through his residency, and he might as well complete it. And who knew what entanglements the future would bring. 
Strangely enough, Vivek felt relief rather than disappointment at this new development. He was one of the first to leave the sinuous line of distraught visa applicants, making his way back to the train station to find a ride home. He ignored the look of delight on his mother’s face and the muttered prayer of thanks that escaped her lips even as his father paced angrily in frustration at the news. He was back at the wards in time for evening rounds, his senior residents pleasantly surprised to see him show up a night early, burnishing his reputation for responsibility.
That was eight weeks ago, and his trip to the consulate had started to seem like some feverish malarial dream mistakenly registered as reality in his memory. Tonight, as Vivek wrote his notes, his thoughts drifted to the newspaper headlines he had seen at the tea stall earlier. He had been glancing at the papers, more out of morbid curiosity than anything else. The squabble between the American leaders was still unresolved, with federal workers “furloughed”—a new Americanism he had picked up—as the country was about to pass from fall headlong into the winter holidays.
Bhenchod!” Pritesh’s cursing jarred Vivek from his reverie. He looked up, only grunting in reply, awaiting an explanation.
“The liver biopsy needle is broken. And I have to do this liver biopsy tomorrow—it’s for the case presentation next week.”
Vivek had heard about this patient before, someone with findings of liver disease who had been tested for the usual suspects—hepatitis A and B—but every test had come back negative. Their senior residents loved mystery cases; wowing the faculty with an esoteric diagnosis could create a very positive impression, but only if the case was “solved,” which in this situation required Pritesh to conduct a liver biopsy. No wonder Pritesh was upset. Vivek shuddered at the thought of incurring the wrath of a senior resident by messing up his case presentation. 
“I don’t have any clean needles,” Vivek responded, preempting Pritesh’s anxious next question. “Just did one on Bed 12 yesterday, and you definitely can’t use that needle.”
Pritesh glanced over at Bed 12 from the window of the workroom, critically evaluating the older gray-haired man, clearly jaundiced, eyes and skin yellow as morning sunlight, belly bloated with ascites, scrawny legs jutting out from under the thin government-issued blanket. Over his head, a piece of paper was taped to the wall with the letters “HBsAg +” handwritten in red ink. The sign identified patients with an active hepatitis B viral infection, clearly marked so no medical equipment was reused, and the nurses knew to always wear gloves. 
“Autoclave’s not working either,” Vivek added helpfully, motioning to the machine behind Pritesh, the bath on top half-filled with water. One glance at the stillness of the water gave credence to Vivek’s claim. 
“This is chutiyatic, fucked up,” Pritesh snapped, staring at the patient in Bed 12. Nine months of continuous on-call had made him traverse the path from cold-hearted to callous fairly quickly, but tonight Vivek thought he detected more—a menacing resentment in his tone.  
“They want us to take care of all these patients, but they won’t provide us with two biopsy needles?” Pritesh’s voice was rising in pitch and anger. “Or a functioning autoclave? And tomorrow it’ll be my fault that the biopsy didn’t happen.”
He started to pace up and down in the small space next to the desk as Vivek watched his rage build, slightly alarmed. He stopped abruptly, staring at the autoclave. 
“No. You live in your American dream, Vivek, I’m going to fucking live in our reality. Where’s the contaminated needle?”
“I’m not… dreaming… American…” Vivek started to protest, but his voice faltered as he watched Pritesh slide a glove over his right hand and sort through the dirty equipment. “What are you doing?”
“This is it, right?” 
He held up the long needle Vivek had used a day earlier in his gloved hand, dried blood and remnants of diseased tissue still on its gleaming steel surface. Vivek didn’t feel the need to respond to what was clearly a rhetorical question—they both knew what a liver biopsy needle looked like.
“Why is it still dirty, Vivek?” Pritesh affected a condescending tone, like one of their senior residents or professors. “Why, Vivek?”
“Because the ward orderlies are too lazy to…”
“Because the ward orderlies are too lazy to take the equipment to central sterilization!”
Pritesh completed the sentence for him, jaw clenched, teeth set to edge, his neck veins palpating furiously, visible three feet away where Vivek sat across from him. “And whose fault is that, Vivek? Ours? No––it’s the government’s fault. You did your job; you completed the procedure and placed the needle in the dirty instruments tray. But the government didn’t do its job: the government’s employees failed to sterilize the equipment properly.”
Vivek’s alarm grew by the minute as he tried to follow Pritesh’s relentlessly twisted logic.
“And if central sterilization hasn’t happened, Vivek, what is our backup?”
“The ward autoclave,” Vivek replied reflexively, like a Pavlovian dog trained to respond to supercilious tones.
“The ward autoclave,” Pritesh repeated slowly and with some relish. “So I will be a good junior doctor and sterilize this needle that I need tomorrow in the ward autoclave.” 
With a flourish, Pritesh dropped the dirty needle into the unheated bath of the non-functioning autoclave. The clang of the metal needle against the metal bottom gently resounded through the room. Despite himself, Vivek stood up to look, watching the small ripples in the cold bath diluting the blood on the needle until the red was no longer visible.
“There! We have now sterilized this needle to the best of our ability, using the resources our government provides our patients, Vivek,” Pritesh continued, still with a slightly unhinged tone to his voice. “We will now place this needle in the sterile procedure kit, and we will be able to complete the liver biopsy procedure for our most esteemed patient tomorrow, on time!”
“But… the needle, it’s not…”
“It’s not sterile? The hepatitis B virus is still on it? Is that my fault? Is that your fault? Is it the patient’s fault? No––this is none of our faults!” Pritesh hissed. “Maybe my patient will get hepatitis B from Bed 12 over there. Maybe the next patient who has a liver biopsy will get it too. And maybe if we have a fucking epidemic of hepatitis B”––here his voice took on a genteel news reporter’s tone––“caused by procedures in the hospital, the government will think about properly funding us.”
Vivek sat back down, unsure of how to respond to this outburst, unconvinced that Pritesh was serious, although he certainly seemed to have every intention of carrying out this plan. He decided to ignore him for now, wordlessly starting to write out his notes as Pritesh silently and determinedly completed preparing the “sterile” liver biopsy procedure kit and walked out. 
Vivek might have said something later that night, but as it turned out, he would not see Pritesh again for a while. Just a half hour into writing notes, his father called on the ward phone, beside himself with excitement. The radio newscast was reporting that there had been a rapprochement in Washington and the federal shutdown was over, which meant the consulate would open the next morning. The last night train to Bombay left in an hour; he had to catch it to beat all the backlogged visa seekers of the past two months. There was still a month left in the residency interview season; the timeline was tough but not impossible. There was a decision to be made, but really, it had already been made.
And just like that, Vivek, the most responsible of first-years, walked out on his patients, on his half-done notes, shedding all his responsibilities, taking nothing but his sky-blue Littman with him. He made no phone calls, alerted no one to cover him. In a few hours, his absence would be discovered, the obvious assumptions made, his responsibilities quickly divided between the second- and third-year senior residents, all of their lives and careers affected by having to do the work of the missing first-year, patients harmed and ignored as workloads grew even more crushing. But Vivek would not be there to see any of this, to know or even care if the ward and his patients were better or worse off without his steady presence. Even his mother’s plea of desperation as she bid him goodbye—But what will happen to me?—was steely ignored. In twenty-four hours, he had the visa stamped on his passport; in forty-eight hours, he had landed on an icy runway in Queens, New York; in one month, he had crisscrossed this gleaming new world on Greyhound buses and Amtrak trains, making up for all the interviews he had missed; in two months, he had matched into a residency program in an imposing steel-and-glass hospital building near Boston. Now, it was the long period of first-year drudgery in the underfunded government hospital serving people no one cared about that seemed like a fevered malarial dream. This new land of promise, Vivek reassured himself, was the real real world.


Vivek returned home, briefly, before the start of his new American residency program to say a more proper goodbye to his family and collect his belongings. The visit was meant to be discreet. Too many bridges had been burnt by his quick getaway, and he studiously avoided anything to do with his former training program.  
On his last night at home, however, Vivek felt a twitch of nostalgia, an urge to reconnect. The inpatient ward was out of the question, but he thought the sidewalk tea stall he and the other first-years used to frequent would be safe—his seniors never went there late. He delayed for a bit, riding his two-wheeler up and down the dimly lit street outside the hospital a few times before finally taking the plunge. He need not have worried. The chaiwallah barely remembered him, and the stall area teemed only with a cluster of tired faces that he did not know and that clearly did not recognize him. A batch of new first-years must have started, he realized belatedly. Vivek was hurriedly drinking his cup of chai when he felt a friendly smack to the back of his head.
Chutiya! Here for the memories?”  
It was Pritesh, grinning from ear to ear. The two sat down on a makeshift bench underneath the jaundiced light of a streetlamp, the space hastily and deferentially cleared by Pritesh’s new junior residents. Behind Vivek, the chaiwallah’s crackly transistor radio played music from movies he had missed in the past few months. It did not take long for the two to get back into their old, familiar talk. Pritesh filled him in on ward gossip and the reactions to his sudden departure. Pritesh had a cheerier outlook on life now that he had new first-years to boss around. Neither of his new trainees had taken the U.S. licensing exams as far as he knew, so he was safe from upheavals, Pritesh joked. This awkward reference temporarily paused their conversation. The silence sat uneasily between them until the song on the radio switched, and the haunting new melody Pardesi pardesi jaana nahi reverberated in the warm night air. The irony of the lyrics—Don’t leave, stranger from another land—was neither lost on them nor remarked upon. 
Something jogged Vivek’s memory, and he turned to Pritesh.
“Remember that night, before I left? The liver biopsy needle? What did you end up doing?”
Pritesh glanced at him slyly. 
“Oh, you remember that?” 
He paused, then resumed in a tone suddenly dripping with animosity.
“You’re no one to judge, you know… you left everyone in a lurch.”
Another hesitation.
“I used your dirty needle the next morning.”
Vivek nodded, then asked the obvious question.
“The patient… did he end up getting…?”
“Hepatitis B?”
Pritesh’s tone was suddenly wistful.
“No, he didn’t. Checked the blood test twice afterward, to be sure. Some fuckers are lucky.”
Vivek nodded, somehow unsurprised. Some fuckers are lucky, he repeated in agreement.
Another, easier silence sat between them until the tender chorus for Pardesi punctured the night air: Mujhe yaad rakhna kahin bhuul na jaana—keep my memory, don’t forget me. 
A couple of the new first-years hummed along cheerfully. Vivek and Pritesh bobbed heads contentedly to the tune, almost in unison, until Vivek broke the rhythm, tipping his head back and emptying his cup to get the last dregs of chai.

Alok A. Khorana

Alok A. Khorana is a writer-physician in Cleveland, Ohio originally from Vadodara, India. His creative fiction and nonfiction has been featured inBellevue Literary Review, JAMA, Literary Hub, The Bombay Review, and TheBest American Medical Writing. His works-in-progress include a biographical memoir and a linked short story collection.


Alok A. Khorana is a writer-physician in Cleveland, Ohio originally from Vadodara, India. His creative fiction and nonfiction has been featured in Bellevue Literary Review, JAMA, Literary Hub, The Bombay Review, and The Best American Medical Writing. His works-in-progress include a biographical memoir and a linked short story collection.