Your airway is the width of your smallest finger: you can see how things can go wrong.

“Airway first. Breathing next. Medicine is life caring for itself. To me, it’s the greatest story.”

James Maskalyk’s story is structured from “A is for Airway” through “XY is for a man” and “Z is for ze end”.

The story begins with a scene with his grandfather, but is populated with a rapidly changing set of scenes, unfolding from Toronto to Sudan to Ethiopia.

His grandfather’s life hunting and trapping in northern Alberta brings matters of mortality to the fore immediately. But the focus shifts quickly from the life and death of four-leggeds to the life and death of two-leggeds.

It is both a story of one man’s life and approaching death and, simultaneously, many people’s lives and approaching deaths.

Sometimes he writes lyrically, of these forces: “Like a great magic, electricity arrives spontaneously in the heart and holds us together.”

Sometimes pragmatically: “It can be difficult to rest from the worry.”

“Write hard and clear about what hurts”: This advice from Hemingway, shared in “P is for Practice”, drives Maskalyk’s prose style.

Quick scenes of trauma are intertwined with more lyrical, reflective scenes.

The ER itself is in constant motion. It’s on the ground floor because sometimes waiting even a minute, to transport someone further into the building, for instance, can make a difference between their living and dying.

In “F is for Flow”, Maskalyk reminds readers that the burnout rate for ER doctors is higher than for any other physicians.  Working in this environment takes a toll; but, simultaneously, it’s “hard to leave, even if you know you should. It feels good to be surrounded by those who know what you do, to whom you don’t have to explain.” And to cope? A variety of intoxicants is always on hand.

There are ethical and litigious complications in this business. Maskalyk discusses the fact that drugs prescribed in an instant can have unintended effects, especially given that there are more bacteria in a person’s body than cells, and that what is not known or understood about reactions to those drugs is massive. Staff also face a risk when prescribing opiates for pain, as patients could later sue a long line of caregivers for contributing to their opiate addictions.

“A drug’s means to facilitate lasting change is often disappearingly small because a body is in constant flux with its environment, external and internal, emotional, social, and genetic, each so intimately connected that you couldn’t draw a line where one starts and the other ends.”

Not all hospitals have an ER and Maskalyk was part of the training process for the group of four doctors responsible for the new ER in Addis Ababa, Ethiopia. Under such conditions, the concern for foreign medical personnel used to be how to reach as many people in need as possible. Now the concern is to avoid being someone’s proxy, either in a political or economic conquest.

Details about hospital work in Addis Ababa are relayed in scenes. Readers learn that this city of five million people has grown into a metropolis over only one hundred years. The country’s population remains 80% rural and the city was founded on the availability of water; now Ethiopia hosts more refugees in its borders than any other African county.

Maskalyk recognises his contribution as being only one small part (and temporary) of a broader program; Ethiopia intends to be a middle-income country by 2025 and is working to train 10,000 post-graduates over the next ten years (compared to 100). In the past, only a small number of those who left the country to study overseas returned to practice their trade; after they gained accreditation elsewhere, they usually settled elsewhere. Educating more people at home suggests that a greater percentage of professionals will remain and work in Ethiopia.

Some elements of the ER practice do not vary, whether in Ethiopia or Toronto. “Even if you aren’t sure what’s wrong, you do what you can.”

It’s clear, however, that Maskalyk has been profoundly changed by his experiences, in and out of medicine, within and without national borders:

“Once you see through the lie that the worth of a person’s life depends on where they were born, or how close to money, you can never go back to being the same person.”

This narrative seems to suit both a busy writer and a busy reader; one can imagine it being composed in moments of in-betweenness, rare moments of calm, and it seems designed to be consumed in small portions, to allow the short scenes to resonate more fully and dramatically between reading sessions.

Although I read it straight through, from beginning to end, I wondered halfway through if it mightn’t be possible to read it in a true sampling manner. If I had it to read over again, I would choose a disorderly version of the alphabet, perhaps even ending with “A is for Airway”.

“Endings, beginnings, who can tell?”

Toronto Book Award 2017

One of five books nominated by this year's jury

Life on the Ground Floor

“Dr. Maskalyk has a gift for distilling a pivotal life moment into almost painful clarity, capturing heartbeats of intermingled triumph and tragedy from a career that spans decades and continents.”

Read the rest of the jury’s comments by clicking on the image above.