"Oxygen": Patients don't feel the pain, but main character does

In Carol Cassella's strong first novel, the protagonist, Dr. Marie Heaton, is an anesthesiologist in a fictional Seattle hospital whose life is turned upside down by the death of a child on the operating table on her watch. In "Oxygen" (Simon & Schuster, 288 pp., $25), a malpractice suit ensues; but when criminal charges are filed against Heaton, the stakes are dramatically raised.

Unmarried and childless, Heaton has a great career and a nifty condo overlooking Elliott Bay. On top of the lawsuit, criminal charges and the guilt and empathy she feels toward the dead child's mother, Heaton must face her own aging, cantankerous father in Texas who won't give up his independence. Heaton's best friend, fellow anesthesiologist Joe Hillary, is her ex-lover and perhaps future partner.

There is a medical mystery at the heart of the novel: Heaton cannot figure out why the child stopped breathing based on her anesthetic plan. The child's autopsy reveals a previously unknown condition, yet Heaton doesn't think that explains what happened. She loses her nerve in another child's surgery, and soon afterward takes a leave of absence, heading "home" to Texas to visit her married sister, Lori, and father.

The middle of the novel, set in Texas, is where Cassella hits her stride. The doctor observes Lori's chaotic household and her sister's "career choice" to marry and raise children, as well as her father's frailty. He is a retired, widowed professor who is resistant to change and yet prone to the vicissitudes of old age and entropy. The nearly blind old scholar made a living reading between the lines throughout his career; his well-drawn character is perfect for helping Heaton crack the medical mystery.

Unlike the silly voice-overs on the other fictional medical drama set in Seattle, television's "Grey's Anatomy," Cassella's musings on medicine are astute and probing. In one meditation on the art and science of anesthesiology, Heaton says, "I'm playing a psychiatrist as well as a medicinal artist, a chemical hypnotist beckoning the frightened and the uninitiated into a secure and painless realm of trust. It's a private world I build with my patient, a world the surgeon never sees, a secret pact that never makes it into the hospital record or onto an insurance billing form. I like to think it is where I can make the most difference ... "

The author, a Seattle anesthesiologist and medical writer, spends the opening pages describing the press and flow of various surgeries and preps, and how personalities and the pecking order in the hospital mesh. She knows her drugs, and invites the reader to pore over Heaton's planning for surgery. Readers who like medical details will enjoy the ease with which the doctor-protagonist gets down to business. Also impressive are Cassella's lively thumbnail sketches of various minor characters.

What work less well in this novel are minor elements that more practice may improve. Though we get Heaton's first-person voice and expert medical eye on everything, she is somewhat flat as a personality in a way that goes beyond being a busy doctor without a social life. Full advantage of the first-person narrative has not been taken.

There are a few passing romance-novel techniques at work that don't fit with the strong female character Cassella has tried to develop, such as when Heaton describes her ex-lover tracing her "vermilion" lips. These are minor anomalies in otherwise decent prose.

The ethics of the drama, and Cassella's portrayal of the very real and contemporary flaws in our health-care system, make this novel a promising debut.