A Swarm in May: A Novel

By Mark Anthony Powers

Dr. Phineas Mann has come a long way from the darkness in his past. He has a loving wife, two bright children, a lively interest in beekeeping, and a rewarding career in intensive care medicine.

And then a challenging case presents: an elderly man in the throes of full-blown tetanus. To make a difficult case worse, the patient'

• Language: English
• Publisher: Hawksbill Press
• Release date: May 6, 2021
• ISBN: 9781737032915

Mark Anthony Powers

Mark Anthony Powers grew up in the small town of West Lebanon, NH. At Cornell University, he branched out into Creative Writing and Russian while majoring in engineering. After receiving his M.D. from Dartmouth, he went south to the University of North Carolina for an internship and residency in Internal Medicine, followed by a fellowship in Pulmonary Diseases and Critical Care Medicine. After almost forty years in clinical practice and teaching, he retired from Duke University as an Associate Professor Emeritus of Medicine and began his exploration of other parts of his brain. Writing classes, writers' groups, and growing fruit and vegetables were some of the enjoyment that followed. A deep dive into beekeeping led to his presidency of the county beekeeping association and certification as a Master Beekeeper.Two cups of coffee and two hours of writing most mornings produced the medical thrillers in his Phineas Mann series: A Swarm in May, Breath and Mercy, Nature's Bite, and The Desperate Trials of Phineas Mann.

Book preview

A Swarm in May

Praise for A SWARM IN MAY

"Mark Powers’ suspenseful debut novel, A Swarm in May, utilizes his years as a physician and beekeeper to create a story that book clubs everywhere will compare to books like The Secret Life of Bees and Where the Crawdads Sing. Add the reality of racism in the South, and you have a story those readers will discuss late into the night."

Dawn Reno Langley, Author of The Mourning Parade and You are Divine: The Search for the Goddess in all of Us, and President of Rewired Creatives, Inc.

"Damn you, Mark Powers …. I settled in to begin reading the book last night at 9:30. Around 3:30 AM I finished it. If that isn’t an endorsement, then I don’t know what is! The last book I did that with was Where the Crawdads Sing. Overall, I loved it. It is truly a page turner."

Dr. Craig Rackley, MD, Associate Professor of Medicine, Duke University

"Hop on for a rollicking ride with Dr. Phineas Mann in this debut novel from Mark Anthony Powers! A Swarm in May is a gripping page turner you might have expected had John Grisham gone to medical school instead of law school. From bees to racism to ventilators in an ICU, Dr Powers shepherds us through the wonders and hazards of modern medicine—and life in general—in a troubled world."

Dr. Lake Morrison, MD, Associate Professor of Medicine, Duke University

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I loved, loved, loved the book. This novel was absolutely fabulous! I thought at first that this would be a story just for beekeepers, but it is so nice that it’s not. The ending was superb and so much fun! I think you have a winner here.

Cynthia Speed, Certified Master Beekeeper and Past President of Orange County Beekeepers

"Dr. Mark Powers’ debut novel is both tender and funny. This tightly woven and well-paced adventure teems with entomologic and medical wonder while offering a gentle portrait of human connection. A Swarm in May provides the reader entrée into the heart and mind of a committed intensivist who must navigate uncertain terrain as his many worlds collide."

Dr. Kim Talikoff, MD, Pediatrician, educator, documentarian, and beekeeper

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"As an insider in both the medical and beekeeping worlds, Mark Powers’ A Swarm in May is a fascinating novel that not only entertains but may teach you a few things!"

Randall Austin, Certified Master Beekeeper and Piedmont Regional Director of the North Carolina State Beekeepers Association

From the first day he steps into the intensive care unit, a cascade of events takes the reader on a thrilling adventure including medical mysteries, the ongoing legacy of racism, and the complex and fascinating lives of bees. It’s hard to put this riveting book down once you start it.

Tim Scialla, MD, Associate Professor of Medicine, University of Virginia

"While it is set in 1998, the racial themes explored are remarkably relevant today. I found myself empathizing with the characters, and the storyline kept me reading well past bedtime.

This novel reminded me that spending time in my garden and with my bees are some of the best ways to unwind and stay grounded, especially during challenging times."

Dr. Carrie Donley, PhD, University of North Carolina Department of Chemistry and 2021 President of Orange County Beekeepers

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"Fast-paced, captivating plot, great understanding of the world of beekeeping. A Swarm in May intriguingly explores the parallels between the often disorganized community of man and the seemingly chaotic, but well-ordered and selfless community of honey bees."

John Rintoul, Attorney and Past President of Orange County Beekeepers

"Mark Power’s A Swarm in May is a great read filled with characters you immediately like and a story line that keeps you turning the pages. It brings together details of medical care in a teaching hospital, beekeeping, and racial tensions in a book that is a delight to read. I am already looking forward to Mark Powers’ next book!"

Jim Snapper, MD, Consultant Professor of Medicine, Duke University

Mark Powers delightfully captures the joys of medicine and medical education in this fast-paced story of disease and intrigue in North Carolina. An especially great book for nurses and doctors of all ages!

Joseph Govert, MD, Professor of Medicine, Duke University

A Swarm in May

A Novel

Mark Anthony Powers

Hawksbill Press

Copyright © 2021 by Mark Anthony Powers

All rights reserved. No part of this publication may be reproduced, stored, or transmitted in any form or by any means without written permission of the publisher or author, except in the case of brief quotations embodied in critical articles and reviews.

A Swarm in May is a work of fiction. Other than the actual historical events, people, and places referred to, all names, characters, and incidents are from the author’s imagination. Any resemblances to persons, living or dead, are coincidental, and no reference to any real person is intended. The author did his best to be rigorously true to honey bees including their biology and social behaviors.

Published by Hawksbill Press www.hawksbillpress.com

Edited by Dawn Reno Langley, President of Rewired Creatives, Inc.

Book design by Christy Collins, Constellation Book Design

Author photo by Amy Stern Photography, www.amystern.com

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ISBN (paperback): 978-1-7370329-0-8

ISBN (ebook): 978-1-7370329-1-5

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Printed in the United States of America

for Marco

Week One

A swarm of bees in May is like a load of hay.

A swarm of bees in June is worth a silver spoon. A swarm of bees in July isn’t worth a fly.

Anonymous, 17th Century

Opisthotonus.

This moment was the first time in Dr. Phineas Mann’s twenty years of medicine he’d seen a patient posturing in the way described by the medical term opisthotonus. The pale old man had suddenly arched into a human comma flipped ninety degrees left, his round, wrinkled head face up, anchored at one end, and his legs curled down, heels digging into the Medical Intensive Care Unit mattress at the other. His face was grotesque with lockjaw, his teeth clamped powerfully on a plastic bite block, the only impediment to his chomping through the life supporting tube in his windpipe. His eyes were taped shut. The gown had fallen off his raised white chest, now hoisted a foot above the bed by the spasm, revealing ridges of taut muscles.

The ICU team had just witnessed the student nurse fleeing the room, terrified, tears welling up. The jarring noise of her explosive sneeze had triggered the patient’s violent fit.

The room was kept as dark and quiet as an intensive care unit allowed. Any sudden stimulus could provoke the dangerous spasms induced by the deadly tetanus toxin. The only light came from partially dimmed vital sign monitors and the nurse’s flashlight, and all alarms had been uncharacteristically turned off. Mechanical breath sounds still interrupted the silence every six seconds.

The patient’s Registered Nurse, Lisa, showed Phineas a syringe. She whispered, Dr. Mann, how much vecuronium do you want me to give?

He was also whispering. Start with 3 milligrams. We need to paralyze him before he fractures his vertebrae. And how much Versed is he on?

"3 milligrams per hour. It had kept him well sedated."

Let’s help him sleep through this with an additional one-time dose of 3 milligrams.

Phineas leaned close to their patient’s ear. Sir, we’re going to give you something to stop the spasms and to help you relax and sleep.

The arterial line monitor’s blood pressure reading climbed to a frightening 240/120 and showed no sign of stopping. Phineas studied the flow chart. An hour before, blood pressure had been 70/40, and the nurse turned on a norepinephrine infusion to bring the reading up, but now the opisthotonus swung the man’s pressure the other way.

Standing beside Phineas along the near side bed rail, two young doctors were ghostly, their eyes wide open in the excitement and dim light. Looks like his BP is shooting up again. We better start nitroprusside to bring his pressure back down, Phineas murmured.

The nurse reached for the infusion pump controls. It’s a roller coaster. First, he’s in shock, the next minute, it’s accelerated hypertension.

Dr. Michael Downs, the Junior Resident in his second year out of medical school, sported a fresh blond crew cut that reflected the faint neon glow from the monitors. He shook his head slowly from side to side in awe. "Been like this since we came on service two days ago. After seeing him, I’ll never miss my tetanus shot." He and his team’s intern, Dr. Malcolm Carver, in his first year of internal medicine training, wore wrinkled scrubs, left over from the night’s battles.

Their counterparts, today’s on-call ICU house staff team, intern Dr. Ram Patel and resident Dr. Sadie Goldschmidt, both still in street clothes, watched from the even darker far side of the bed. Goldschmidt’s long curly, dark brown tresses were pulled back and restrained. Patel’s shiny black hair was neatly trimmed and combed. They nodded silent agreement.

They all watched the old man’s backbone sink to the mattress as the paralytic gained control. His blood pressure trended toward a safer level. Phineas felt his own tense spine relax in sympathy. He let out a sigh of relief through pursed lips, and then pushed open the half-glass door. Let’s all step into the hall, so you can tell me the whole story.

From outside the old man’s room number 10, Phineas could take in the entire Intensive Care Unit working area at a glance, the central nursing station with its desks and banks of vital sign monitors, the surrounding circle of closed doors to patient rooms, and the lone doctors’ workroom, tucked behind the wall of illuminated screens.

It was Monday and Phineas’ first day of a month-long rotation supervising the ICU teaching service. He would be the faculty’s attending physician of record for May 1998, and the first two weeks would be without the usual pulmonary and critical care fellow to help with procedures and patient care. This month’s fellow, Dr. Gabriela Morales-Villalobos, had gone off and gotten married and was taking a honeymoon. It had been many years since he’d covered this service without the help of a hard-working fellow. He tightened his shoulders and spine, raising him to his nearly six-foot height. Phineas was confident he could do it. He just wouldn’t choose to. Homelife would suffer, and he’d hear about it.

The first day on service was the time for Phineas to impart important lessons young doctors might not think about. He began with, We should always make sure patients are adequately sedated when we paralyze them. It can be terrifying otherwise. And I always assume they can hear me when I am speaking in the room. He thought about what had been said in front of his elderly patient and wished he’d set a better example. Phineas had done enough of this over the years to do better, even on the first day.

Malcolm, please present his case for me.

Intern Malcolm Carver, a tall and lean young man, arranged his thin stack of index cards and stepped forward. His goatee was meticulously trimmed, and his shaved brown scalp reflected the bright overhead hall lights. Dr. Mann, again, welcome aboard. Should be an interesting month. First case of tetanus in UNC Hospital in more than twenty years. He paused to glance at the face of each listener. Enoch Jefferson is an 80-year-old Caucasian man, a semi-retired welder, who presented to the emergency room two days ago complaining of severe jaw and abdominal muscle spasms. While being assessed, he developed difficulty swallowing and shortness of breath. The senior surgeon they consulted for the abdominal tenderness astutely suspected tetanus, especially after he found inflamed and draining puncture wounds on an ankle. Mr. Jefferson reported that he’d been pecked there by a rooster.

Phineas couldn’t stop himself from interrupting. A rooster—and when was his last tetanus shot?

At that point he’d been in the ER for hours and could barely speak but managed to say that he’d never had one. Hadn’t seen a doctor in over fifty years. Word got out that the ER had a case of tetanus. No one, except the senior surgeon, had ever seen a case, so the trickle of fascinated students, residents, and even professors of medicine wanting a peek turned into a flood.

Phineas guessed what came next and winced. Not good.

Carver nodded vigorously. It got noisy around poor Mr. Jefferson, noisy enough to trigger his first episode of opisthotonos. They had to sedate, paralyze and intubate him in a crisis mode… He’s lucky he made it through it without any identifiable damage.

And for the tetanus behind all this? What’s been done for that?

"The ER team gave him antitoxin—and his first tetanus vaccination. Then they called the ICU team to admit him. When I came on service the day after he was admitted, we had to restrict access to him. Too much commotion around him triggered another episode. Seems like everyone around here still hopes to see him do his thing."

RN Lisa leaned closer to Carver. Don’t ever be the most interesting case in a teaching hospital.

Like everyone else at the University of North Carolina Hospital, Phineas had heard about Jefferson, so he’d read up on tetanus. This could go on for several weeks. We should request placement of a tracheostomy and a gastrostomy feeding tube.

Downs had been shifting his weight from one foot to the other. Surgery’s consulted. They should set those up for tomorrow or soon after.

Good. We’ll need to get consent from his next of kin.

Carver’s eyes were wide open, their whites expressing dread. I can try, but it should probably be you.

Why is he…? I can do that. Who’s his next of kin?

Jefferson’s a widower, so it’s his son, his only offspring. His son’s not the first to tell me he thought I was an orderly. Now, whenever I approach him, he walks away. Carver clenched and unclenched his empty hand. He has a stars and bars tattoo on his arm and wears an NRA hat.

I’ll talk to him, point out we’re a team, and you’re his father’s doctor. This could turn into an unpleasant task, but his intern needed to be able to do his job. Phineas cringed inside that his first reaction was about his workflow, the hassle for him, and not the cruel and unnecessary burden a freshly minted young doctor was forced to carry.

The grimace on Carver’s face suggested he hurt. A nurse on evenings said he made a racist comment about me and said he didn’t want me working with his ‘Daddy’.

I’ll talk to him.

Name’s Zebediah. Zebediah Jefferson.

Downs took a step closer to Phineas and whispered, The nurse said he used the N-word. Carver bowed his head. The muscle along his jawline clenched as if he, a stoic man, had absorbed a blow.

Phineas’ spine stiffened in sympathy. "I’m sorry, Malcolm. It’s hard enough taking care of really sick patients without difficult families." Oh man, I’ve got to deal with a throwback racist for the whole month?

The first day on a service always felt endless for Phineas, whether it was the ICU, the pulmonary ward, or the consult service. His default mode, the compulsive approach, pushed him to read all the chart notes on all ten patients and review the labs, scans, and x-rays of each patient. Phineas wanted to be able to speak intelligently to the rush of families who would visit at the end of the day, to show them that he knew their sick loved ones well—and cared about them—which he did.

There was also his dedication to teaching, but he tried not to interrupt the team’s daily work with too many comments and questions. They had a new patient to admit, procedures to perform, notes to write, and relatives to track down; and they were currently short their pulmonary fellow, Phineas’ most valuable support.

Gabby Villalobos had warned him several months ago of her plans to take her yearly allotment of vacation during these first two weeks of May, two weeks she had banked since July of 1997, two weeks during which her extended family would arrive from Mexico, and she would get married and escape UNC for a honeymoon. She’d pledged to him that she would soon begin work with him on his asthma research, an invaluable extra mind and pair of hands. He’d just have to grit his teeth and handle things in the ICU without her for the next two weeks.

Ada James, the 75-year-old matriarch of a large Black family from Durham, had consumed a disproportionate portion of his day. She’d been in the ICU for almost two weeks and remained on life support. Her adult-onset diabetes had ruined her kidneys years ago, making her dependent on thrice weekly hemodialysis. In recent months her heart function had deteriorated to the point where, the instant she became dehydrated, she’d go into shock, especially during dialysis; or if the least excess fluid or demand burdened her failing cardiac pump, her lungs would flood. Even the work of breathing, normally a passive act, could stress her heart if any extra respiratory impairment was added. Her x-ray showed that the pneumonia that led to her hospitalization was improving, and her white blood cell count had come down to normal. Phineas hoped the ICU team would have the opportunity to remove her endotracheal tube and let her successfully breathe on her own before a surgical tracheostomy was advisable.

The James family had requested Phineas meet with them that evening. And Malcolm Carver had relayed with a grin that Ada James insisted, early in her stay through notes and gesticulations, that despite her tenuous condition, her luxurious black wig was to be on her head and perfectly arranged before all visitations.

That afternoon, Phineas found her propped up in bed wearing glasses and the groomed shoulder-length hairpiece. She held the television remote in her hand. He stooped over the sink to wash his hands, and the chatter from her television ceased. As he approached her bedside, she held up a clipboard with nice to see you again penciled across the top sheet.

He nodded. You too. I believe I have some good news for you.

She raised her eyebrows.

He pointed at her ventilator. I’ve gone over your tests and I believe there’s a good chance you’re ready to come off that thing and breathe on your own.

The corners of her lips curved into as much of a smile as the endotracheal tube in her mouth would allow. Her nurse stepped through the door. Well, that’s the first time I’ve seen her do that!

Phineas gave her a moment to savor the happy news. I’d like to learn your feelings about what we should do after the breathing and feeding tubes come out. He pointed at the tube in her nose that provided her nutrition.

Creases formed across her forehead.

If we’re right, and you do well off the ventilator, we just move on to rehab for you to regain your strength.

She nodded and her brow relaxed.

Now the hard part. But if you start having breathing difficulties again, enough that we have to consider putting you back on the ventilator, then we have decisions to make.

She wrote, Such as?

You’ve been on the ventilator long enough, that if we have to put the tube back in anytime soon, we suggest an operation to replace it with a shorter tube in your neck. He lightly touched the skin over her trachea. Then you wouldn’t have to have a tube in your mouth, and it would be easier to have you on and off the ventilator.

She was grimacing as she carefully printed, You’d cut a hole in my neck?

A surgeon would, under anesthesia. At the same time, they could put a feeding tube directly in your stomach. He touched her left upper abdomen. So, you wouldn’t have to have it in your nose.

The tendons on the back of her hand stood out as she jabbed her finger at hole in my neck. She glanced up at Phineas before she wrote, permanent?

He shook his head. Usually not. Once you’re off the ventilator for a while and doing better, it can be removed.

She wrote, MY VOICE?

It can come back over time.

She shook her head and mouthed words Phineas couldn’t interpret. He pointed at the clipboard. She took up the pencil and stared at the paper before she printed, need it for singing in church. She looked up at him then back at her words and started writing again. and for words of wisdom for my family.

I understand. Think about it some more, and we can discuss it with them.

As she wrote this time, she pressed down hard enough that Phineas thought the pencil lead might break. NO Hole appeared.

He nodded. Decisions are yours. Now the harder part. So, if you needed the ventilator at some point in the future, you’d want us to replace the breathing tube to provide it? He pointed at the endotracheal tube again.

She hastily printed OR?. The forehead creases returned.

He considered