By Neela JanakiramananUnpublished Manuscript

On a Knife’s Edge

Judges' comments

On A Knife’s Edge is a contemporary novel that follows Emily, a first-year trainee orthopaedic surgeon as she navigates the politics and bureaucracy of the modern hospital, bringing into sharp, urgent focus the state of the working conditions of those whose job it is to look after our health.

Utterly readable, the writing shifts registers between amusing workplace antics to the darker side of hospital jobs. This is a novel about work, but it’s also a novel about the human experience. Janakiramanan’s ability to extract questions about human character shows a great nuance and perception that underlines the story while maintaining a strong narrative drive. The writing shows an ear for dialogue, especially between colleagues and family members, and without giving away spoilers, the ending packs a punch. On a Knife’s Edge is a remarkable work of fiction.

Portrait of Neela Janakiramanan

Neela Janakiramanan

Neela Janakiramanan is a Melbourne surgeon who has difficulty saying ‘no’. She combines a busy clinical practice with teaching, mentoring, research, public speaking and commentating, and writing. She has undertaken pro bono work in the areas of health equity and the welfare of both patients and clinicians.

As a writer, her commentary has been published in Women’s Agenda, The Age, Sydney Morning Herald and The Saturday Paper. On a Knife’s Edge is her first work of fiction.

Extract

The anaesthetic machine whirs quietly, and the blip blip blip as it registers Jacqui’s heartbeat fills the room. 

‘Hey, you, anaesthetics!’ Prof says, even louder. At this, Jyothi, lifts her eyes, an expression of total calm on her face. 

‘Hello, I’m Jyothi, we have worked together on a number of occasions,’ she says, coolly, and I want to cheer inside. 

‘Did you hear me? I was expressing my frustration at today’s unacceptable delays.’ Prof is not letting up. 

Jyothi stands and smiles thinly. 

‘Well we better go outside and talk about it in a civil manner, hadn’t we?’ she asks, picking up her coffee mug. 

Nic has walked into the room, and she stops. We catch each other’s eyes and remain still. I once read that predators are highly attuned to movement, but that when they are in an alert or aroused state, their attention is so focussed that stillness may appear to them as the equivalent of invisible. 

Prof finally turns on his heel and stalks outside, and Jyothi follows after a few short instructions to Tom. The room breathes a sigh of relief. It is not over, but at least ‘it’ will not be conducted in front of everyone. 

Jyothi has clenched teeth and Prof is purple when they return. The tension has boiled over to a point where the silence is no longer discomfiting but actually welcome; at least they are not being openly hostile. On the operating table, in the middle of the room, Jacqui’s chest rises and falls in time with the whirring of the machine, oblivious. 

Fortunately interpersonal discord has not gotten in the way of the two theatres teams getting ready and before we know it we are assembled, tools in hand, on either side of Jacqui - Prof and I ready to remove the tumour from her leg, and Nic and her boss ready to borrow a piece of tissue from her other leg to fill the hole. 

Jacqui is not a large woman and we are upon the rubbery mass before we know it. I am in charge of the suction, and the whirring gurgling noise fills the room as I help suck the pooling blood out of the way as Prof works his large hands around the irradiated, shrunken tumour, trying to deliver it from her thigh. As his fingers get deeper and deeper, his scowl deepens too. The Plastics team have been chatting away about some TV show, and he eventually silences them with a glare. His fingers are around Jacqui’s femur, and the tumour is clearly attached to it. 

‘This tumour seems to have progressed,’ he mutters. Nic looks up at me, her eyes darting from one to the other of us, her long eyelashes flickering at me, blinking as she tries to communicate something silently.

I think about Jacqui’s life on the farm and two children hoping for three and suddenly understand Nic’s gestures. She cannot raise what she pointed out to me last night because of long-embedded silos and hierarchies, but I can.

I weigh up my options carefully. If I say nothing and he thinks the tumour has gotten worse despite radiation, he may consider a radical operation like amputating her leg. If he knows that actually there was evidence that the tumour was attached to the bone all along, he will be grumpy for having missed it, but more likely to try and preserve her leg. 

‘Prof, there was one image on her original scan which seemed to show that the tumour was growing into the femur?’ I blurt it out quickly and end it with an upward inflection which turns my statement into a question. Andy used to tell me off for this, but I feel it is an important strategy in this moment. 

Prof pauses, squints at the screen across the room, and then walks over to look closer. The scout nurse scrambles to work the mouse. I grab a cotton pack from Lorraine’s trolley, and push it into Jacqui’s leg to quell the oozy bleeding, and then another to cover the wound altogether; Nic keeps operating, but her boss has stopped and watches us both, an eyebrow raised. 

‘Image seventy-six, on the coronal,’ I remember, hoping this is correct. Nic looks up imperceptibly, and nods. Phew. 

Prof jerks his head at the coronal view, and watches as the nurse enlarges it and scrolls though the images to land on number seventy-six. Prof studies it carefully, and then with a nod of his head he turns back towards us and surveys the scene - a patient asleep on the table, an operation half done, a reconstructive plan in progress, none of it quite addressing the problem at hand. His long blue gown is streaked with blood, and he folds his equally bloodied hands together across the top of his pot belly. He closes his eyes, thinking, the image of Jacqui’s thigh magnified and glowing behind his head, clearly showing the tumour growing into the bone.  

‘Emily, you should have shown me this earlier,’ he finally says flatly, but I have known my father well enough to know that this is only the slightest chiding, and behind it is an acknowledgement that I – we, because it was really Nic, though he will never know – have pointed this out now. 

The plastic surgeon finally speaks and asks if this will require us to remove a part of her femur, because he has not planned to reconstruct that. Jacqui cannot be left with a six cm gap in her leg bone. 

Prof closes his eyes again, and taps his foot, the rubber of the gumboot dull on the ground, and out of time with the regular blips from the anaesthetic machine. Finally, he snaps his gloves off, pulls his gown away, tearing the paper straps that hold it on. 

‘I’ll be back,’ he mutters, and walks out. 

The Victorian Premier’s Literary Awards shortlist