The Intern Blues (19 page)

Then Larry yelled at me for yelling at Marie, and I let him have it, too. I told him I wasn't a superwoman, I couldn't do everything. I can't be expected to work and take care of the baby and do the shopping and the cooking. I told him he was going to have to pitch in more and do some of the things that needed to be done around the house. Then after I let him have it, I felt even worse because I hate fighting with him. He's one of those people who just doesn't fight back; he never seems to get mad. He's so calm, it drives me crazy! So we've been fighting a cold war since then.

And things are terrible at work. I hate my patients, except Lisa
[the young woman with choriocarcinoma]
; I hate the house staff I'm working with, except for Susannah, who's had the flu herself; but most of all, I hate the medical students. They're terrible. I've never seen anything like it. I've got this third-year student who's been assigned to me the past two weeks. He actually deserves to fail. He's an M.D.-Ph.D.
[a special track in which college graduates are accepted for a course of study that will ultimately grant then both an M.D. and a Ph.D. degree; Schweitzer accepts a handful of these students each year]
, and he's got this attitude problem. He thinks he doesn't have to do anything, all he has to do is show up. I ask him to go and check labs and do other scut and he actually refuses. He says it's not in his job description.

And the subinterns are big pains also. I asked one to switch with me so I don't have to be on the last night of the month. At first she said she'd think about it. Then a few days later she said she'd do it. Then this week she told me she'd decided she couldn't switch for some reason. She didn't tell me why, but it doesn't matter. It was the one time this whole year I really needed somebody to help me out, and nobody would do it. So now I don't know what I'm going to do. Maybe I'll just walk out of the hospital early the next morning. I mean, I'm not going to miss my flight.

My patient with the brain tumor died last week. He had been in a coma for about a week. After talking it over with his parents, we all agreed to make him a DNR. I don't think he was in much pain; his heart just stopped one night and they declared him dead. I never got a chance to talk to him. He was always so angry when he was conscious.

At least Lisa's doing much better. I'm glad about that. She's the only patient I care about right now. Her mouth sores are better and she's able to eat again. She finished her first course of chemo and she's not nauseous anymore. She's actually improving; she's about the only patient all month who has gotten better.

I told Lisa about Sarah on Friday. She asked me if I was married and I told her about Larry and the baby. She said she was happy for me and that she was really sorry that she wasn't still pregnant because she really wanted a baby of her own. She said she thought I must be a good mother because I'm a doctor and I know what to do when children got sick. I don't know about that, but it was a nice thing for her to say. She said she'd like to meet Sarah sometime, so maybe tomorrow, when I'm on call, I'll have Larry bring her over to the hospital.

Well, a week from tonight I'll be on call for the last time on Adolescents. And a week from tomorrow, we'll be on our way to Israel. I can't wait.

Saturday, October 26, 1985

I can talk for only a minute. I'm very busy tonight, but I wanted to get this down on tape before I left on vacation. This is a terrible story.

Tuesday I admitted this seventeen-year-old named Wayne who'd had leukemia in the past but had been in remission for years. He came to the hospital because of shortness of breath, and as soon as he hit the floor, it was pretty clear that his leukemia had recurred. His shortness of breath was due to his enormous spleen. His white count
[while blood cell count in the peripheral circulation]
was over a hundred thousand
[normal is between five thousand and ten thousand]
, and he was anemic and thrombocytopenic
[thrombocytopenia: low platelet count; platelets are factors that aid in clotting of blood]
. The hematologists jumped on him right away. They gave him all sorts of poisons to bring his white count down. He was sick, but he was in pretty good spirits, considering what was happening.

Then yesterday morning, we were on work rounds and Wayne's mother came to tell me he was acting funny. I didn't think much of it, but I went to check him anyway. He was acting really strangely. He was shifting around in bed making gurgling sounds; he didn't respond to questions; it was like he was in a coma, but his eyes were open and he was moving around. I got him to respond to pain, but he didn't respond to anything else. I called for help, and everybody came running. The resident noticed that his right pupil was fixed and dilated
[a sign of an acute and serious change in neurologic function]
. Then he arrested.

We all worked on him for about an hour. We were never able to get anything back. Everybody was in there: Alex George
[the director of the intensive-care unit]
, the chief residents, everybody.

That was my first death. All I kept thinking about through the whole thing was Sarah. A patient's death always bothers you, but when you've got a baby, it means a lot more. I went home after work and just hugged her and hugged her. She'll never understand it. I don't think I'll ever forget it.

We're in the middle of packing. I've got to get everything done tonight because I'm on call tomorrow and there's no other time to do it. I explained the situation to the chief residents and they told me they were sorry but there was no way they could force anybody to switch with me against their will. They at least said that if everything was under control, I could sign out to the senior who was covering at 7:00
A.M
. and leave. I'll still never have enough time to get home. So it looks like I'm going to be going on a twelve-hour plane trip after being on call. If it's a busy night, I may not even get a chance to change my clothes or take a shower. I'm really pissed off.

The fact that nobody'd switch with me when I really needed it has made me incredibly angry. It may be a little thing, but I'll tell you, I'm never going to help anybody around here. Except for Susannah, maybe.

Mark

OCTOBER 1985

Friday, October 4, 1985

They're trying to kill me. I know they're trying to kill me. I'm just surprised I've survived this long. I've been at Jonas Bronck since Monday, and so far everyone's tried to kill me, the chief residents, the nurses, the elevator operators, the lab technicians, and especially the patients, but no one's managed to finish me off yet. They're all trying, so I know it's only a matter of time.

See what a vacation will do for you? It clears your head, makes you see things in a new light.

Actually, my vacation wasn't exactly what I'd call wonderful. No, wonderful is definitely not the word I'd use. How would I describe it? What word would I use? Lousy; lousy is definitely a word I'd use, lousy bordering on shitty.

It started off with my brother and me in my car driving south as fast as we could to escape from the Bronx. We didn't have any real end point in mind; I was just trying to reach a place where cockroaches don't exist. Actually, that's not true. We were heading for Cincinnati. We both have friends there, and we decided to go visit them. Yes, there's nothing more romantic than spending a week with your younger brother visiting friends in Cincinnati in late September. The whole experience almost made the Bronx seem nice.

Okay, so it wasn't romantic, but Carole and I sure made up for that in the second week of my vacation. We went to the romance capital of the East, Pocono Castle, a resort hotel catering to the honeymoon crowd. What a place! I knew we had made a big mistake when the first thing the bellboy showed us was the heart-shaped bathtub in our room. Carole said she liked it; I thought I showed great restraint by keeping myself from puking right there on the spot. But that wasn't the worst of it. We went down to the dining room for dinner that first night and discovered that everybody there, every last couple, was there on their honeymoon. It was Carole and me and four hundred newlyweds! The place was disgusting; the food was horrible, the decorating job was ostentatious, the rooms were dirty, and it rained all week. All for two hundred bucks a day! Just the kind of relaxing environment I needed.

In the dining room, they put us at a table with another couple. These two were great: They had just been remarried for the second time. They were reformed drug addicts. We spent every meal chatting about AIDS!

And then we got back to the Bronx last Sunday night. I started on the ward at Jonas Bronck Monday morning and it's been hell, absolute hell! On Monday we started work rounds at eight o'clock and didn't finish until three in the afternoon. Seven solid hours of rounds! I'm sure all our names are going to be listed in the
Guinness Book of World Records
under the category of “World's Longest Work Rounds.” Every time we'd try to leave one patient and move on to the next, some disaster would occur and we'd have to stop and sort things out and then try to start again. I picked up five patients: a pair of twins with AIDS who, if you can believe it, are actually named “Winston” and “Salem” (as a result of taking care of them, I've decided to name my first two kids “Chesterfield” and “Lucky Strike”); a brain-dead kid who inhaled a little too much carbon monoxide when her apartment caught on fire; and the “specialties of the house,” a couple of asthmatics. That wouldn't have been so bad, five new patients, but you've got to remember, this was my first day on the inpatient service at Jonas Bronck, and I never got a chance to get myself oriented. I didn't know where the labs were, I didn't know how to get results of anything, it took me a day and a half just to figure out where the damn bathroom was! I had to hold it in for thirty-six hours, which, if you've never done it, is not the most comfortable thing in the world. It got so bad, I started to feel like a water balloon. And to make matters worse, the intern who had been on the ward before me hadn't written off-service notes on any of the patients. How considerate! So even if I had had a chance to read the charts, which I hadn't, I still wouldn't have been able to figure out what was going on with my patients.

Then I was on call that first night. I picked up five additional patients and I didn't get any sleep. And the way the schedule worked out, I was on Monday and again on Wednesday and I was postcall on Tuesday and Thursday, so my brain's been in hyperspace for an entire week. I wasn't sure I could find my way back home today, let alone try to figure out what was going on with my patients.

I've been completely helpless. Mike Miller is my attending this month, and he and the senior resident have asked me a lot of questions on rounds and I haven't even been close on any of them. I feel like a real idiot, which I probably am. And since Miller's a friend of my family's, I've felt even worse about it. I mean, I'm sure I've gone a long way to convince him I got into medical school on the one scholarship given every year to the most deserving mentally retarded individual in the United States. I've also had this fantasy that he's been calling my mother at home every night and telling her what a moron I turned out to be.

But hey, it hasn't all been my fault. I've gotten some really sick patients over the past few days, and working in Jonas Bronck isn't exactly my idea of living in paradise! What a place! The elevators don't work; people have died waiting for them, and those weren't patients, those were interns! The people who work in the labs have a combined IQ of about 3. If you're nice to them, they'll screw you; if you're not nice to them, they'll screw you. I'm convinced they sit around up there trying to come up with the most difficult ways to give out results. If you call them on the phone they'll put you on hold for ten minutes and then hang up on you. If you call back and say you were cut off, they'll yell at you and say it's not their job to give results over the phone. I walked into the bacteriology lab Wednesday night at ten o'clock and a woman pushed me out of the door and said they were closed. They were closed! What does that mean? You're allowed to diagnose infectious diseases between the hours of nine and five only?

And the food stinks! That hellhole downstairs is the worst excuse for a coffee shop I've ever seen! I was wondering how they could get away charging only a dollar and a half for a turkey sandwich, so I tried one and I figured it out: They don't put any turkey on the bread; they don't sell turkey sandwiches, they sell mock-turkey sandwiches, for God's sake! And the place keeps the same hours as the bacteriology lab, which is pretty telling. So when you're up all night, when you really get hungry, you can't even get a mock-turkey sandwich.

And how can Miller and all those other guys who run this department and who say they're really concerned about our well-being not provide us with a shower? If I don't get to take a shower after a night on call, I'm worthless. I feel like shit! Just working in this hospital, you wind up covered with about an inch and a half of municipal hospital crud, and if you don't get a chance to wash that off, you just can't work effectively.

Well, now I've really depressed myself. I was in a pretty good mood when I started recording this, but listening to what I had to say, I have to admit, I must have been pretty crazy to have come back from vacation. I mean, a week at Pocono Castle was a picnic compared to an afternoon at Jonas Bronck.

Monday, October 7, 1985

I think I've finally recovered and gotten myself a little better oriented to Jonas Bronck. It was pretty rough there for a while. That's a real problem with this program: You work at so many places, by the time you feel comfortable at one hospital, they move you to another and you have to start from scratch again. It's the concept of perpetual confusion, an ancient form of torture developed, I believe, during the Ming dynasty.

Things have calmed down a little on the ward. I was on last Monday and Wednesday and then again on Saturday, but from here on it's every third for the rest of the month. (Oh, what joy, only every third night! How lucky can I get?) All last week was a blur. I admitted about ten patients, some of them really sick. It was interesting. They kind of came in groups: Monday was Leukemia Day. First I admitted this fourteen-year-old boy whose gums had started to bleed a lot when he brushed his teeth. He also had a slight fever, he was feeling kind of sick, and he had bone pain. He turned out to have ALL
[acute lymphocytic leukemia, the most common form of cancer in the pediatric age group]
, and he's in the poor-prognosis group for everything—age, sex, race, you name it. He only stayed at Jonas Bronck overnight. On Tuesday we shipped him over to Mount Scopus, where he'll get started on a chemotherapy protocol.

Next, I admitted this eight-year-old who had had ALL diagnosed six years ago. He had been treated with chemotherapy for four years and had been considered cured. He woke up one day last week with a terrible headache. He was seen at every emergency room in the Bronx, and all the doctors told his mother the same thing: There was nothing wrong with him, and she should try giving him some Tylenol. He finally showed up to see his hematologist here at Jonas Bronck, and she noticed that he had a sixth-nerve palsy.
[The sixth cranial nerve, the abducens, runs the longest course in its path from its origin in the brain to its point of action in the eye. Because of its long path, the sixth nerve is sensitive to increased pressure within the skull. If pressure is increased, the sixth nerve will not work properly and is said to be “palsied.”]
She arranged a stat CT scan that showed a golf-ball-sized mass in his frontal lobe, most probably a lymphoma but possibly some other terrible horrenderoma.
[I don't think the term “horrenderoma” requires defining.]

So Monday was a really comforting night. I'm starting on a new service in a new hospital, and I picked up five patients who didn't have adequate off-service notes, so I didn't know what the hell was going on with any of them, and I admitted two kids with terrible prognoses. And I barely had time to recover from that night when I was on again on Wednesday, and that turned out to be Chromosome Abnormality Night. My first hit was this three-month-old who looked like she'd been dead for a few weeks already except for the fact that she'd just had fresh casts put on her legs to correct her clubfeet. Her mother brought her into the ER with a complaint that she was breathing too fast. The intern who saw her in the ER asked if she had any problems with her health, and the mother said, “No, there's nothing wrong with her.” Turns out she's got trisomy 18
[a congenital malformation syndrome caused by an extra chromosome No. 18 in every cell of the body]
and severe congenital heart disease, which had caused her to go into congestive heart failure and led to the breathing problem.
[Almost every child born with trisomy 18 has congenital heart disease. The heart disease is one of the factors that leads to early death in these patients. Eighty percent of trisomy 18 children will die before their first birthday.]
The kid's got trisomy 18, and the mother says there's nothing wrong with her! When the intern got the old chart and found out the diagnosis, the mother still denied it. Sounds like she got some top-notch genetic counseling! Anyway, the kid was in congestive failure, so I started her on some Lasix
[a diuretic that rids the body of excess fluid; since fluid buildup is a major problem in congestive heart failure, treatment with Lasix often relieves symptoms such as rapid breathing]
and suddenly she started looking like a million bucks.

I don't really understand why this kid's got those casts on her legs. I mean, if she's got such a bad prognosis, what's the use of fixing her clubfeet? It doesn't make much sense. Of course, that doesn't mean anything; there aren't many things around here that seem to make much sense.

Anyway, later on Wednesday night (actually it was about five o'clock on Thursday morning) I admitted a fourteen-year-old with Down's syndrome who was having an asthma attack. Now, asthma's pretty straightforward. At this point, I can manage asthma in my sleep. In fact, that's when I usually do the best job. But this kid was just a touch more complicated because, in addition to his Down's syndrome and his asthma, he also had chronic renal failure. The problem with that is that aminophylline
[a medication used in the treatment of asthma]
is removed from the bloodstream by the kidneys. I could give the stuff to him and it'd probably help his asthma but he wouldn't ever be able to get rid of it. He'd probably wind up with toxic side effects; he'd stop wheezing and start seizing, and that wasn't going to be very helpful. We thought about it for a while and decided to turf him
[turf: internese for “transfer to another service”; also referred to as “a dump”]
immediately to University Hospital, where the renal dialysis unit is located. So I had to ride over to University Hospital in the ambulance with him and drop him off at the ward.

Well, I got over to University, brought the kid up, and introduced him to Andy Baron, who was the intern on call over there. He wasn't exactly happy to see me. What the hell happened to him? I mean, I haven't seen him in a couple of months. He used to be a kind of easygoing, friendly guy. He yelled at me when we got there. He accused me of dumping this kid on him, which of course I was. But, hey, that's not my fault. We weren't doing it to make Andy's life more miserable, we were doing it because it seemed to be the best thing for the patient.

It's kind of scary, running into people you haven't seen for a while. It's like going to see a horror movie and realizing that you and your friends are the main characters. You look at Andy and you see what kind of a monster he got turned into and you start to wonder if maybe the same thing hasn't happened to you, but you haven't noticed it because you live with yourself every day and it's hard to notice any changes. I don't know, it's pretty scary.