The Intern Blues (11 page)

I can't stay awake any longer. I'm going to sleep.

Monday, August 19, 1985

It's been a good week. I've been getting sleep, I've been coming home early, I've been spending time with Sarah and Larry. I can't complain.

The other interns on the team seem depressed, and I can understand why. There just aren't any normal children on this ward. Very few of these patients wind up being normal at any time during their lives. There's almost no hope here. On rounds yesterday, Janet said there were two kinds of patients at University Hospital: the ones who cry when you stick them for blood and the ones who don't. She said the ones who cry are bad because they make you feel guilty when you stick them. But the ones who don't cry are much worse because they're the ones who know that crying isn't going to do them any good.

I know what she meant and I know that if I were to hang around the hospital as much as she and Margaret do, I'd be depressed, too. But I can escape; I've got Sarah to run home to. And that makes everything a lot better.

Here's an example of what we have coming into this place: When I was on last Thursday, I got a five-year-old girl with intractable seizures who was coming in to have her anticonvulsant medication manipulated. She had metachromatic leukodystrophy
[a rare inborn error of metabolism caused by deficiency of the enzyme arylsulfatase; the disease leads to severe neurological abnormalities]
. Metachromatic leukodystrophy: You know how many of those there are in the world? Maybe a dozen. And one of them comes waltzing into University Hospital to have her seizure medication changed. She's still on the ward. She's on five separate anticonvulsants and we're raising one and lowering another. So far I haven't seen any real change in her. She could wind up staying in the hospital for months.

Her story's frightening. She was completely normal for the first year and a half of her life, and then her mother noticed she was getting clumsy. She started falling down a lot and losing her balance. She took her from doctor to doctor until she saw Dr. Rustin
[a pediatric neurology attending]
who made the diagnosis immediately. And now she's a GORK
[an acronym for “God only really knows”]
with an intractable seizure disorder.

The first thing I thought about when the mother told me the story was, Can something like that happen to Sarah? I mean, she seems completely normal now, but who knows what might happen next year or next month or next week? Who knows? Thinking about things like this can drive me crazy! I find myself doing it a lot. Every time I admit someone with something strange I think, Can Sarah get this? It usually doesn't stay with me for long, I can shake it pretty fast, but when it happens, it's like a wave of terror passing through me. I don't even want to think about it.

Ricky's much better. He had a pretty rough time last week but by Friday he was about back to normal. His kidney seems to be functioning well, and his BUN and creatinine came down to all-time lows today. He's been out of bed and walking around the ward, playing with some of the other patients. His mother's also calmed down a lot. Dr. White is pretty sure that no harm was done to the kidney but he says we'll still have to see what the future holds. He plans to send Ricky home either tomorrow or the next day.

Sunday, August 25, 1985

Today is Sarah's four-month birthday and we had a little party. My father came and so did Larry's parents. It was the first time we'd all been together since Sarah was born. My father was doing pretty well; he looked good and he seemed happy. Everyone was worried about me. They thought I looked pale and tired. I should look pale and tired; I'm working hard and I haven't exactly had a lot of time to go sunbathing, but I told them I think I'm doing okay. I think I am. I think I'm doing better than most of the other interns I've seen around.

Sarah rolled over for the first time last week. She did it first for Marie. Marie said she put her down in the crib on her belly and when she came back a few minutes later, she was lying on her back. So she put her back on her belly again and watched her, and sure enough, she flipped right over again.

I've been getting along very well with Marie. She really does love Sarah. I think she's been holding back on the feedings a little and not carrying her around as much. At least that's what she's been telling me. So things are going well on that front.

The renal team discharged Ricky on Friday. The nurses had a little going-away party for him. It was really nice. He was definitely my favorite patient of the month.

I finish this rotation on Tuesday. I'm on tomorrow night, the last night of the month, and then I start on 8 West
[one of the general pediatric wards at Jonas Bronck]
. Going to 8 West'll be like coming home. I did my subinternship and my third-year rotation there. I'm looking forward to it. But I know I'll never beat the hours I've been able to keep at University Hospital.

Mark

AUGUST 1985

Sunday, August 4, 1985

I started on Infants'
[a ward at Mount Scopus Hospital]
last Monday and so far this place makes Children's look like an amusement park! I was on yesterday; I worked my ass off all day long, running from one thing another; and at no time did I have any idea what the hell I was supposed to be doing. Usually, when you're on call on the weekend, you start with work rounds where you and the resident decide what needs to be done on each patient. It doesn't work quite that way on Infants'. First of all, when I got to work at eight o'clock, the resident who gave us sign-out was a cross-coverer
[a resident who works in another part of the hospital during the day and covers the particular ward at night only]
, and she didn't have much of an idea of what was going on with the patients. We didn't get any kind of intelligible sign-out, so we started off with one strike against us. And then when we finally got everything sorted out and came up with a plan of what we wanted to do for each kid, the private attendings starting calling to tell us what actually was going to be done. And then there were all these admissions coming in. I just wanted to say, “Okay, I'm going to go outside now and come back, and then we'll start the whole damned day over again.”

I picked up some real terrific patients when I came over to Infants'. I've got this incredible specimen named Hanson, who's four months old and has never been out of the hospital. When we went into his room on Monday morning, he was lying there in his crib, weighing all of about two pounds, with these wasted, shriveled arms and legs that were stiff as boards. He wasn't able to suck on a pacifier, and it seemed like he was having these little seizures. He looked like warmed-over death, and the senior actually said he was looking good that day compared to how he looked last week. My God, he must have looked like rotting hamburger the week before! It turned out he had crumped before we changed services and when they worked him up
[in this case, the workup consisted of blood cultures, a spinal tap, and urine cultures]
they found he had a disseminated fungal infection. A fungal infection! Now, there's a common cause of a crump. But I guess it wasn't so strange in this kid: He's had chronic diarrhea for the past two months and he hasn't gained an ounce in all that time. Since his mother's an IVDA
[intravenous drug abuser]
, we're sure he'll be a candidate for admission to the AIDS clinic.

Anyway, he's being treated with amphotericin
[a drug for systemic fungal infection]
, which is so toxic that even if the infection doesn't kill him, there's a good chance the treatment will. It's got to be given by IV. He has a central line
[an indwelling catheter passed through the skin into one of the major veins in the chest]
, but we're giving him his TPN
[total parenteral nutrition, a treatment in which a large number of calories are provided by vein]
through that, so we have to give him the amphotericin through peripheral lines
[normal IVs]
. His IVs usually last only about twenty minutes, and most of the veins in his arms and legs are already blown, so I can see this kid is going to take up a lot of my precious time this month.

The people on my team seem pretty good. There's Elizabeth, of course. She already told me she doesn't like Infants' and that if it were all the same to the chiefs, she'd rather be back on Children's. And then there's the other intern, Valerie Saunders. I don't know about her, she seems kind of depressed. Our resident is Rhonda Bennett. She's smart, but she treat us like we're real morons. I mean, on rounds in the morning, she makes sure to go over every little detail two or three times, and then makes us repeat what she says and write it all down. It's like being in first grade or something. Elizabeth said something to her like, “C'mon, Rhonda, we promise we won't forget, cross our hearts and hope to die,” and she got real defensive and said she was just trying to help us and make it easy for us. Well, I'll tell you, if she keeps it easy for us, I might have to murder her.

Wednesday, August 7, 1985

I'm going to kill them, I'm going to kill them all! I was on last night and today was the worst day of my internship. It's bad enough spending the night running from room to room trying to keep twenty-eight babies from dying, but to do that and to have to spend the next day being nice to Rhonda
and
putting up with all the shit the chief residents are handing us, that's a little too much. So it looks like I'm going to have to kill everybody to get any peace.

The first one I'm going to kill is that Hanson. He crumped again last night. He stooled out
[developed diarrhea]
and got acidotic
[built up acid in his blood, a sign of deterioration]
and shocky. I had to do a whole sepsis workup including a spinal tap and pull out his old IV and start a new one; the whole thing took over four hours. And then I had to call the ID fellow
[the fellow covering the infectious disease service]
and argue with him about what antibiotics to start him on. He told me to use three drugs, two of which I'd never even heard of before!

The second one I'm going after is Rhonda. She's so damned cheerful all the time, it's disgusting! At two o'clock in the morning, after I got off the phone with the ID fellow, I went to tell her what antibiotics he had suggested and she smiled and said, “Well I don't know about that, Mark, I don't know if those antibiotics give adequate coverage against enteric gram negatives
[bacteria that normally inhabit the intestinal tract]
. You did tell him that Hanson had chronic diarrhea, didn't you?” Of course I hadn't mentioned the kid's diarrhea. It was late and the kid had been trying to die on me all night and I can't be expected to think of everything! So, still smiling, she ordered me to call the ID fellow back and rediscuss the case with him. Of course the guy knew Hanson had diarrhea; he had suggested the drugs just for that reason.

The thing about Rhonda is if you go and tell her she's a pain in the ass and that she's making your life miserable, she takes it personally and starts to get teary-eyed. So even though she is a pain in the ass who's making my life miserable, I have to be nice to her anyway. I don't think I can take this for a whole month. So I'm pretty sure I'm going to have to kill her.

And the third one I'm going to have to kill is Arlene, the chief resident. There I was, sitting in the residents' room at noon today, minding my own business, trying to catch my breath; I'd made it through the night; I'd worked up six admissions. I had managed to keep Hanson and all the rest of them alive; I had even managed to make it through work rounds and attending rounds without falling asleep or complaining much. All I wanted to do was finish my scut, write my progress notes, and get my ass out of there. But could I do that? No! Arlene came in, saw us interns sitting there, and she said, “Aren't you guys going to the noon conference?” Well, Elizabeth said she had to start an IV on a kid who was supposed to go to the OR at one and Valerie said she had something else to do, and I just sat there unable to move. So Arlene said, “You know, these conferences are for you guys, not for us. It's just more work for me to schedule them. If you interns don't want to come to them, maybe we shouldn't schedule them anymore.” None of us said anything back to her. I just glared. Here I was, having killed myself all night, having killed myself for over a month now. Maybe you'd think the chief resident ought to come up to us and compliment us every once in a while, tell us we're doing a good job and that we should keep it up, but no, all we get told is that if we don't come to conferences, they're going to cut them out! So if she ever says anything like that to me again, I'm definitely going to kill her.

I'm worried about all of us, but I think Val's in a lot more trouble than Elizabeth or me. She's really depressed. She says she'd rather be hiding under her bed than working in the hospital. Now I'm no psychiatrist, but that sounds pretty abnormal to me. She was on Sunday and spent the whole day trying to start an IV in Hanson and doing a lot of other technical scut. To hear her tell it, she missed every single time. And then the senior resident would come along and plop a needle in and get it on the first stick. Val got so frustrated that by Monday morning she couldn't even get blood from the veins of the easy kids. She walked around like a zombie most of the day. Rhonda had to tell her to go home in the early afternoon because she wasn't doing anybody any good. I think Rhonda felt better about Val leaving. I get the feeling Rhonda would be happiest if we all would leave. That way, she'd just take care of all the patients herself without anybody to bother her. Have I mentioned yet that I'm going to have to kill her?

Well, all this may not make much sense, but it sure as hell made me feel better to get it off my chest. I can now go to sleep without worrying about tearing my pillow to shreds.

Thursday, August 8, 1985

Maybe Rhonda isn't so bad after all. At the end of attending rounds today, Claire, the other chief resident, came into the residents' room and said, “It's come to my attention that maybe we haven't been paying enough attention to you guys.” That's an understatement! She told us how sorry she was about it and that she wanted to find out what the chiefs could do to make our lives easier. And before anyone could say anything else, Rhonda yelled, “This makes me so damned mad!” and immediately broke into tears. She caught her breath and said, “Here we are, working our rumps off. I had eleven admissions the other night
[on nights on call, Rhonda was responsible for all patients admitted to both the Infants' and the Children's ward]
and Arlene knew it but not once did I get a ‘You did a good job last night, Rhonda' or anything. All she gave me was, ‘If you can't get your interns to conferences, we just won't have them anymore.' ”

Then Claire got a real concerned look on her face and asked, “Rhonda, what's wrong?” and Rhonda yelled back, “You want to know what's wrong? You treat us like dirt! It wasn't so long ago that you were doing this! You can't tell me you don't remember what it's like to be the senior on Infants' with all these sick kids and all these admissions and all the attendings coming around to bombard you with demands every second of the day! But neither of you seem very sympathetic. All you can do is complain that we're not coming to conferences. You know I'd love to be able to go to the conferences, I'd like to learn something. But I don't see you or Arlene volunteering to cover the ward for me so I can go!”

I wouldn't have believed it if I hadn't seen it. Elizabeth felt the same way. Neither of us thought Rhonda had it in her to stand up for herself like that. She seems like too much of a robot to show that much emotion. I mean, she's feeling as rotten about working on this ward as we are.

The rest of the exchange was pretty amazing, too. After Rhonda finished yelling, Claire said, “Rhonda, you know what we think of you. We might not always say it, but you're the best we've got. Whenever I see your name on the schedule, I breathe a sigh of relief because I know you're never going to do the wrong thing.” And then Rhonda said, “You sure have a strange way of showing it. I don't expect a pat on the head just for taking night call, but I don't expect to be yelled at either.” They talked a while longer after that, but it wasn't as good as this first part. It was pretty amazing. It made me feel a little better about working with Rhonda. Who knows? Maybe I won't have to kill her after all.

Tuesday, August 13, 1985

What a calm, relaxing night last night was! I got four admissions, all of them in the middle of the night, all real simple: a kid with congenital heart disease that's so complicated I need a medical dictionary, an anatomy textbook, and a road map just to get through the old chart; I also got a ten-month-old who had GE reflux
[gastroesophageal reflux, the reflux of acidic stomach contents back into the esophagus]
that was corrected surgically when he was a couple of months old, who got diarrhea over the weekend and got himself pretty dehydrated; a straightforward meningitic who happened to be seizing; and a three-year-old with meningomyelocoele
[a congenital defect of the spine that causes paralysis of the legs, bowel and bladder incontinence, and hydrocephalus; also called spina bifida]
who came in with a high fever and looked like shit. We thought he probably had meningitis, too, but it turned out he probably only has a UTI
[urinary tract infection, a common problem in children with bladder incontinence]
. I managed not to get any sleep again. And then today my pal Hanson, who was getting better, decided to get a fever. He looked pretty good so I didn't make too much out of it. I figured he had the virus that's going around but then Rhonda heard about it and took a look at him and said, “Well, it may be the virus, but I don't like the look of those IVs”
[fever in a child with IVs can be caused by infection of those IVs]
. I was planning to spend the day writing my notes and getting the hell out of there. But did I do that? Of course not! I wound up spending the afternoon sticking needles into Hanson's body, trying to start new IVs. I must have stuck him ten times before I got one in. The kid's totally aveinic
[internese for “without veins”]
.