The Intern Blues (22 page)
Authors: Robert Marion
Saturday, November 16, 1985
I'm not very happy about being back from vacation. We had a wonderful, relaxing time in Israel. I must have been in pretty bad shape before we went away. The frightening thing is I didn't even realize it until I had a chance to get away from it for a while.
Before we left, I was obsessed with being on call that last night of October. It became the most important thing in my life. As it turned out, it wasn't a problem. It was a very bad night; I admitted a new onset diabetic who was in DKA
[diabetic ketoacidosis, a buildup of acid in the blood caused by the inability of the body to use glucose as its energy source; insulin, the protein that allows the blood's glucose to enter the cells of the tissues, is either absent or abnormal in diabetics],
and I was up all night managing the boy's fluids and electrolytes, but Ben King, the senior who was on with me that night, threw me out of the hospital at seven in the morning. Just like that, he told me to leave and have a good time and not to worry about a thing, he'd take care of the patients and sign out to the new interns. So, after all that, I did manage to get home, take a shower, and change my clothes before we had to leave for the airport.
The flights were terrible both there and back. Sarah screamed the whole way. It didn't bother me that much on the way over; I was completely zonked and I slept most of the trip, so it was Larry's problem, not mine. But I couldn't believe it on the way back! I was sure the pilot was going to land and throw us off the plane. But outside of the flights, it was the best vacation of our lives. Larry's parents were great. They wanted to spend the whole time taking care of the baby; they left Larry and me alone, and they encouraged us to go out on our own and do whatever we wanted. I slept late every morning, and by the middle of the second week, I felt like I had finally caught up on my sleep. We traveled all over the country. I can't imagine a better vacation. The only problem was that the time just flew by. Before we knew it, it was time to pack up, get on the plane, and come back to work.
I've been working in the OPD at Mount Scopus. Things have been quiet. I've been getting out between twelve and one on the nights I've been on call. Things would be perfect if we weren't all so jet-lagged. When I'm not on call, I've been going to sleep at seven and waking up at three in the morning. And when I am on call, forget it; I have to use toothpicks to keep my eyelids open after nine. But I can see how much calmer I am now compared with before we left. I really needed that vacation, there's no doubt about it. It's just too bad I have to wait so long for my next one to come around.
Saturday, November 23, 1985, 2:00
P.M
.
I had a very bad night last night. The ER was busy and depressing. I didn't get home until after three this morning, and I just woke up about a half hour ago. It's a beautiful day and we're going to take Sarah out for a walk in a few minutes, but I wanted to record this while it was still fresh in my mind.
At about nine o'clock, I picked up the chart of a three-year-old whose mother said she had had a bloody bowel movement earlier that evening. I didn't think much of it at first; bloody bowel movements aren't that unusual. It's usually due to an anal fissure
[a tear in the anal mucosa caused by straining; very common in children around toilet-training age]
. I called the patient in and I saw she was a cute, well-dressed, healthy-looking little girl. I took the history from the mother, who seemed appropriately concerned. Then I examined the girl. I noticed right away that her rectum was very red and it looked kind of . . . well, boggy is the best way to describe it. I did a rectal exam and I noticed that the tone of the sphincter seemed a little decreased. I was suspicious, so I called the attending and did the rest of the rectal exam with him in the room. The girl didn't even cry while I was doing it. There wasn't a peep out of her, which, to say the least, is not normal for a three-year-old.
I got a sinking feeling in my stomach when I was doing the rectal because I've taken care of little kids who've been sexually abused and I knew what was going to happen from here. I was going to have to question the mother, she would probably deny everything and accuse me of making it all up, we'd get into a big fight, and she'd eventually start to cry. Then I would have to call the BCW and report the case to them and they'd wind up doing a full investigation, which might end with them taking the child away from her mother. I knew that none of this was fun or interesting and it was going to take up most of the rest of the night.
Anyway, I started asking all the questions I had to ask. Did they live alone, or were there other people living with them? Did she watch the girl all the time, or did she leave her with other people? Was the girl's father around, and did he have anything to do with her? The mother knew something was up because she answered every question honestly and without too much expression. It turned out that the mother and the girl lived in a two-bedroom apartment with ten other people. Some of the people who lived there were relatives, like the girl's grandmother; some were friends of their family; and some were just friends of the friends. The woman's father had been a junkie and had died of AIDS the year before. The family had all been tested for HIV and the girl's grandmother had been the only other person who tested positive. But some of the other people living in the apartment were junkies, and they hadn't been tested. And there were two teenage boys who were cousins of the mother and who had been taken into the apartment when they themselves had been abused by their own parents a few months before. It was a very confusing, chaotic story, but I believed it because it wasn't all that unusual. I've heard lots of stories like this one since I started medical school.
The woman said she and her daughter slept in the same bed at night but during the day the mother went to school and she had to leave the girl with anybody who happened to be around. She admitted it was possible for anyone, especially her teenage cousins, to have sexually abused the girl while she was out of the house.
At this point the mother started crying and I had to leave the room for a minute. I was ready to cry myself.
I went over to talk to the attending and told him the story and he asked me one question: Why was the mother being so honest? I hadn't even thought about it before that, but he was right; having your child sexually abused by one of your relatives is not something anyone would be especially proud of. The only thing I could think of was maybe the mother wanted to get something out of this. I mean, here she is living with all these people in this chaotic apartment. Maybe she figured the BCW would do their investigation and decide that the girl should stay with the mother but that they should be placed in their own apartment. It was a pretty disgusting thought but completely possible.
I had to go back and tell the mother what was going to happen, and I had to do the rape kit. The attending told me I should draw some blood for HIV testing, just as a baseline.
[People who are exposed to the human immunodeficiency virus will test positive for antibodies to the virus a few weeks after the exposure. As such, Amy's patient should have been negative but may later convert to positivity if she had been exposed to the virus.]
I hadn't even thought about that, but it certainly was a possibility. Not only did this little girl get raped, but also the rapist might have given her AIDS! I didn't even want to think about it.
After I finished the rape kit, I started to make all the phone calls. I first called the social worker, and she said that I'd have to make it a joint response.
[Joint response: When a child's life is considered to be in danger, a report must be made simultaneously to the Bureau of Child Welfare and the New York City Police Department. The BCW's investigation does not get started immediately. Therefore, an immediate investigation by the police must be done to determine whether the child can return home.]
So I called the BCW and the police. The whole thing, from start to finish, took about four hours. By the time I was done it was after one o'clock in the morning and there were still a bunch of charts in the box. What finally happened was the mother and the girl were placed in a shelter for the night. I think they'll ultimately get placed in their own apartment.
I've been thinking about that little girl constantly since I finished with her. All through the rest of the night, all during the cab ride home, while I was trying to fall asleep and since I woke up, that little girl didn't leave my mind. It's really terrible. I'm sure I'll see her face in front of me for years and years to come.
Friday, November 1, 1985
Yesterday was Halloween. I was on last night in the Jonas Bronck ER, and I learned an important lesson: If you want people to trust you, it's probably not a good idea to dress up like Bozo the Clown. I know that because I did dress up like Bozo the Clown yesterday and none of the parents of my patients wanted to have anything to do with me. I guess I can't really blame them; it's one thing to come to the ER and wait four hours to be seen by a competent, or at least a semicompetent, doctor. It's another thing to wait four hours and finally get called in to find out your kid's going to be treated by Bozo the Clown.
But, hey, it was Halloween, and we're supposed to be taking care of kids, aren't we? We all decided the day before to come in dressed in costumes. Peter Carson, who's about six feet three and weighs at least 250 pounds, came dressed as a ballerina, the chief residents were dressed as killer bees, Terry Tanner (a junior resident) was dressed as a witch, and I was Bozo the Clown. The kids seemed to like it even though their parents weren't ecstatic about it. And everything would have been fine if I hadn't had to tell a mother that her kid was dead.
It was about eight o'clock, right in the middle of the busiest time of the evening, of course. All bad things seem to happen when we're really busy. We got a call from the EMS
[Emergency Medical Service]
saying they were bringing in a traumatic arrest
[a patient who, as a result of some accident, was not breathing and whose heart was not beating]
. So Bozo the Clown; the six-foot, three-inch prima ballerina; the witch; and one of the killer bees stood around the trauma area waiting for the disaster to show up. It took maybe two minutes and they brought in this eight-year-old. He had run out into the street and had gotten flattened by a van. The van then stopped and the kid got pinned under the back wheels. They started CPR out on the street, but you could tell it wasn't doing him much good. He was pulseless and breathless, and when they hooked him up to a monitor, he was flatline
[he had no electrical activity in his heart]
.
We knew it was probably going to be pretty hopeless, but we started doing everything anyway. The chief intubated him, Peter started pumping his chest, and Terry and I tried to get lines
[IVs]
into him. I somehow got one in his right arm, which was a miracle in itself, and we started pushing bicarb
[sodium bicarbonate, to reverse the buildup of acid in the blood]
and epi
[epinephrine, in an attempt to get the heart to start beating again],
but nothing happened. Then the surgeons came by and offered to crack the kid's chest for us
[perform an emergency thoracotomy, an operation in which the chest is opened so that the heart can be directly massaged]
. Hey, when five surgeons walk up to you with scalpels in their hands and say they'd like to crack a patient's chest, it's hard to say no. So the kid got his chest cracked and they found that he had a bronchopleural fistula.
[The impact of the van had caused the left main stem bronchus, the main windpipe to the left lung, to tear in half. Oxygen that was being forced into the boy's windpipe was ending up in the pleural space outside the lung, causing an ever-worsening tension pneumothorax.]
It was about then that we realized that this code was pretty much over.
I walked out of the trauma area, and the boy's mother was standing there less than ten feet away. She was literally being held up by one of the nurses. She said, “Doctor, how is he? Is he going to be okay?” I didn't see any way out; I was too upset to come up with a lie. So that's when I, wearing my Bozo wig; my Bozo makeup; my Bozo shoes; and my Bozo suit, which was now covered with blood, told the woman that her son had died.
She went crazy. She started crying and she fell down on the floor. I felt like a total idiot standing there dressed like that, and there was nothing I could do to change anything. One of the hospital administrators, the guy we call the administrator-in-charge-of-patients-dying because he always seems to show up when this kind of thing happens, came, and he, the nurse, and I lifted the mother up off the floor. The administrator led the woman out of the ER. I don't know where they went, but before seeing the next patient, I changed my clothes and took off the stupid makeup. I don't think I'll wear that costume again. The bloodstains kind of take all the fun out of it. And next year, if I'm on call on Halloween again, I don't think I'm going to dress up.
Tuesday, November 5, 1985, 10:00
P.M
.
I'm feeling much better today. Sure, a weekend off, that's just what I needed. It gave Carole and me two whole days to fight about whether we should get married. It was a whole lot of fun. At least she didn't make me wear my Bozo costume while we argued.
I really don't know what to do about this. I don't want to get married during my internship. Can you imagine that? Falling asleep standing up right in the middle of the ceremony. And then the wedding night! Yes, the wedding night must be a memorable event for the intern's spouse. Eight continuous hours of snoring. Seriously, being married is hard enough when you lead a relatively normal life. I don't think it'd be possible for us to survive if we got married while I was doing this. But Carole thinks we should do it. She says if we got married, she'd be able to take better care of me for the rest of the year. I think I'll eventually wind up marrying Carole. We get along very well and we basically want the same things out of life. I just can't do it yet. I think I'll be able to think a little more clearly after this is over, but that's not for seven months yet. Well, what can I do? I'll just try to hold her off as long as possible.
And then, after that fabulous weekend, I got to be on call again last night in the Jonas Bronck emergency room. And what a night it was! We were five hours behind the whole time. We had two security guards stationed at the doors to protect us. Every five minutes, another angry customer would appear and want to know why his or her precious little child who had been sneezing for three days hadn't been seen yet. And what interesting patients I had to take care of! I got this four-day-old who, through some sort of screwup in our world-renowned Social Service Department, wound up getting discharged from the nursery with his psychotic mother who also happened to be a crackhead. Usually when a baby's born to a crackhead mother, Social Services picks up their hot line and gets a BCW hold slapped on the kid so that the baby can be kept in the hospital while the BCW figures out what to do with him. We usually have to keep them longer than three days anyway because the kids usually have withdrawal symptoms and need to be treated. But somehow Social Services missed the boat and sent him home early.
When the nursery's social worker realized the kid had been discharged, she called the cops and had them find the kid and bring him back. The cops did a great job: They went out and scooped up the baby, the mother, and, lucky for us, the father and brought them all in. Of course, they didn't mention to them what was going on. So not only did we have two psychotic crackheads roaming around the ER, we also had two psychotic crackheads who were paranoid and had no idea what was going on, which is a wonderful combination.
Well, it didn't take long for them to figure it all out. Once they woke up to the fact that we were planning to admit the kid and slap a BCW hold on him and that their chance of ever getting him back again was about the same as my chance of being elected president of the United States, they let their best qualities come to the surface. The father picked up the baby like he was a football and started to move toward the exit. The city cops, who were still hanging around, knew the mistake had been the hospital's and not the parents'. They also knew that the parents hadn't done anything wrong, at least not at that exact moment, and so they didn't try to stop them. The cops left, and that's when the hospital security guards stepped in. They caught the guy, brought him back, put them all in a room, and watched them for the rest of the night, but they weren't exactly happy to do it. They acted as if they had better things to do than baby-sit for a couple of ranting junkies.
I tried my hand at talking the parents down. I told them that putting the baby in the hospital was the best thing for him, that if he was hooked we could give him medication to make him better and slowly wean him off. It sounded great to me, but of course the parents, who were pretty crazed, didn't buy it. Then the social worker showed up and she talked to them for about a half hour. Obviously she made just as great an impact on them as I did, because when they came out, the mother was still holding on to the baby. We didn't know what to do next, so we had a priest come down and talk to them, we had some friend of the family's who had shown up talk to them, but nothing seemed to do any good. Finally, after about five hours of this nonsense, the mother said she had to get home right away because she needed something to steady her nerves. She handed the baby over to the social worker and she and the father kind of ran for the door. So we got the baby back. Her fix was more important than the baby in the long run.
We got out this morning at four-thirty. I didn't get home until after five, and I fell right to sleep. I didn't even get out of my clothes. I had two and a half hours of sleep. But it was quality sleep, so that makes a big difference. Yeah, right! And when I woke up, I was still wearing my smelly, dirty clothes. What a wonderful experience this internship is!
At least I got to go to my grandmother's for dinner tonight. My grandmother's good, she's doing fine. I'm sure she thinks I've lost my mind or something because I can't keep up even boring conversations with her and I keep falling asleep every five minutes. But she doesn't say anything. She just keeps the food coming.
I'm going to sleep now. Maybe when I wake up, I'll realize this has all been a dream.
Monday, November 11, 1985
I'm suddenly not feeling very well. I think I'm coming down with something. I've had this stomach ache and a sore throat since this morning. I have the chills, too, so I probably have a fever. I can't understand why I'm getting sick. After all, all I do is hang around an emergency room, working twenty-hour shifts, seeing sick children who sneeze on me, cough on me, pee on me, shit on me, and vomit on me. What possible means would I have of getting sick?
My mother came to visit on Saturday. She walked into my apartment, took one look, and said something like, “Oh, dear, I hadn't heard anything about a nuclear attack in this part of the Bronx.” (I get my sense of humor from my mother's side of the family.) I have to admit, I have kind of neglected the housework over the past few months. So my mother rolled up her sleeves, got to work, and spent the next six hours cleaning up my apartment. I had all sorts of great things planned; I was going to take her to lunch at the Jonas Bronck coffee shop. I figured she'd love those mock-turkey sandwiches. Oh, what the hell! We did go out for dinner at a nice Italian restaurant. It was nice to see her. And now I can be sick in a nice, clean apartment.
I took some Tylenol, but it hasn't done any good. I think I'm really sick.
Wednesday, November 13, 1985, 9:00
P.M
.
I'm dying. I didn't expect it to be one of the patients who would finally get me, and I never thought they'd use germ warfare. But there it was, the most virulent GI
[gastrointestinal]
bug ever to exist, and now I'm sure it's only a matter of time.
I fell asleep Monday night at about seven. I wasn't feeling well Tuesday, but I made it to work and somehow I made it through the day. I took my temperature in the ER at about one in the afternoon. It was over a hundred. But hey, I'm an intern, and interns can do anything, including working a full fourteen-hour day when they're sick. I came home yesterday and fell asleep right away. I slept until 11
P.M
., and when I woke up, I had the worst cramps in the history of the human race. I ran to the bathroom and stayed there for the next four hours. I got back into bed sometime after three and I fell asleep for a while. Then I woke up with worse cramps than before and tried to get up to run to the bathroom. My brain was strongly in favor of the idea but my body just wouldn't budge. I managed to crawl out of bed and make it to the bathroom just in time and I fell asleep in there until my alarm went off at seven-thirty. I still could barely move. At that point, something told me that I probably wasn't going to be able to make it to work.
I called Jon Golden
[one of the chief residents]
and told him what was going on. I told him I was on call and that I probably wouldn't be able to make it in. Calling in sick on the day you're on call is the biggest sin an intern can commit. But what could I do? I couldn't even walk! Jon told me not to worry, just to try to get well and make it back tomorrow.
I got into bed and fell asleep, but Elizabeth woke me up at about ten. She's on the Jonas Bronck wards this month. She'd heard I was sick and wanted to know if I was making it up just to cash in on some sympathy. I guess when she heard my voice, she realized I was serious. She asked if there was anything I needed; I asked for cyanide. She said she'd see what she could do. She asked if I thought I was dehydrated and I said I was easily about 10 percent dry.
[The main complication of gastroenteritis is dehydration. Five percent dehydration is enough to require hospitalization; 10 percent is serious, and 15 percent may lead to shock.]
She said I should come in and let her start an IV. I told her I hated pain, and knowing her technical skills, I would never allow her anywhere near me with a needle in her hand. She thanked me for the vote of confidence and said I must be feeling better to be making jokes. I said, “Who's making jokes?”
