The Intern Blues (28 page)

And then attending rounds went on forever! We would have gotten done early because there had been only one admission last night, but then my moronic medical student asked Alan for a lecture on static and cidal levels of antibiotics
[cidal: the concentration of antibiotic needed to kill bacteria; static: the concentration needed to prevent the bacteria from reproducing]
, something I'd heard eight times already. And, of course, I couldn't get up and leave. No, I had to sit there or face the Wrath of Alan. It took a whole two hours before we were done.

Then I called the telephone company to tell them I was going to be late, and could they come later, and they told me “Oh, didn't you hear? The problem was on our side, not yours. Your phone works perfectly now!” So I built up all that serious aggravation for nothing!

So, to review the past week, I've had one episode of hyperventilation, which earned me a trip to the ER; one episode of phone failure, which nearly earned me a nervous breakdown; and one episode of battery failure, which I've taken care of by getting a new battery. And who's to say what lies ahead over the next couple of days; or months; or years, for that matter, in this exciting borough I hope to get out of sometime soon, or at least before I go completely crazy! I'm telling you, one day I'm just going to get this enormous ulcer and bleed right out on the floor! It's only a matter of time!

Wednesday, January 22, 1986

Fine. Now I've developed an allergy to something. My nose has been running and my eyes have been itching like hell all night long. I may not survive this month. If I were an insurance company, I certainly wouldn't allow me to take out a policy!

I guess you can say yesterday was just another typical day. I admitted this kid who was dehydrated. They thought he had mononucleosis in the ER, but when his CBC came back, it showed pancytopenia
[lack of all types of blood cells]
and lymphoblasts
[immature white blood cells]
. A diagnosis of leukemia was entertained (what an ironic expression). And unfortunately, this morning the diagnosis was confirmed. Of course, the family's really nice.

Sunday, January 26, 1986

So tomorrow I start my month in the NICU. I'm ready to jump out the window. It won't be too bad, though. I have clinic tomorrow afternoon, so hopefully I won't be around long enough to get
really
nauseated.
[Obviously, an afternoon in clinic exempts the intern from the hospital for the time he or she is scheduled to see outpatients in the clinic.]

I guess I'm going to miss Children's. It really is a good place to work. Alan Morris was an excellent attending. Even though he still scares me to death, I really learned a lot from him this month. When I went up to him on Saturday to thank him for the month, he told me I should have more confidence in myself because he thought I was a good intern. I think I've figured out what it is about him that makes me nervous: He reminds me of my father, whom I was always terrified of. I was always afraid he was going to yell at me for not eating my vegetables or something.

The main reason I liked Children's this month, though, was because of the resident. The resident was wonderful. She's just totally wonderful in all ways. She's smart and she's an excellent teacher. She's calm and she doesn't get upset no matter what happens or how many mistakes I make. And she's great-looking, too, which certainly helps. It's just too bad I won't get the chance to work with her again this year. And I swear to God, if she weren't married . . .

Bob

JANUARY 1986

 

We're getting into the seriously depressing part of the year now. New Year's Day marks the beginning of Intern Suicide season, the time when we really have to start worrying about the house staff's mental health. There are a number of reasons why January and February are so bad. First, exhaustion is cumulative, and the interns have now built up a six-month supply. They're chronically overtired and can't get themselves too enthusiastic about anything. This exhaustion affects all aspects of their lives: They don't have energy to socialize, so they completely lose contact with family and friends; they eat too much junk food and get little or no exercise, so they wind up gaining a ton of weight. This causes them to feel down about themselves and to lose confidence.

Second, although everybody around them is celebrating the end of one calendar year and the beginning of the next, the end of the internship year hasn't even yet appeared on the horizon. There's just about nothing for these guys to look forward to right now other than another half year of the same shit over and over again. So they develop a feeling of desperation, and that feeling is compounded by the fact that they know there's nothing they can do to make the time move any faster.

Finally, the environment seems to be conspiring against them. The weather this time of year is horrible. It's constantly freezing cold, and the city is frequently getting pelted with snowstorms. It gets dark so early that the house officers can go for weeks without ever actually seeing sunshine; they get to the hospital so early that it's still dark and they come home again at night, after the sun has set. So the house officers live in a constant world of cold and darkness, and there's nothing more depressing than that.

Although January is bad, it's nothing compared with February. In January, there's still some semblance of a “spark” left within the bodies of the interns, the last vestige of the excitement that accompanied the holiday season. The department's Christmas party did the whole staff a lot of good; there were a couple of weeks during which everyone seemed a little happier and a little calmer. But it was really short-lived. And usually by February 1, any spark of excitement has been snuffed out.

A fair number of pretty strange things happened during January. The strangest involved Andy Ames, one of the interns who's in Andy Baron's circle of friends. The story started like this: At the beginning of January, Andy Ames and one of the female senior residents were working together on the Jonas Bronck wards one night and admitted a six-week-old girl with fever. Because a significant percentage of these infants will be shown to have a serious bacterial infection in their blood or spinal fluid, it is policy that all babies under two months of age who come to the emergency rooms with fever routinely get admitted to the hospital. Blood, urine, and spinal fluid cultures are taken, and the infants are started on intravenous antibiotics.

Anyway, Andy Ames and the senior resident were trying to get a sterile specimen of urine from this little girl by doing a straight catheterization, a procedure in which a plastic tube is inserted into the urethra and passed up into the bladder. The cath went pretty well, and they managed to get an adequate sample of urine for culture and urinalysis. But the mother, who was standing in the treatment room the whole time, went nuts when she realized what Andy was doing. She accused him of sexually molesting her daughter and of “ruining” her for life. The mother yelled and screamed for most of that night, becoming more and more agitated as time passed. Early the next morning, she went to Alan Cozza and the hospital administrators to complain. When the situation was assessed, it was carefully explained to the woman that what Andy had done was completely aboveboard and standard treatment and did not in any way constitute sexual molestation. The mother continued to yell that Andy had “ruined” her daughter and that no man would ever want her after what he had done. The administrators continued throughout that day and the next to try to calm her and explain the anatomy of the procedure to her. When it finally became clear to the woman that she wasn't going to get any satisfaction from the hospital employees, she decided to take matters into her own hands: She began to threaten Andy Ames with bodily harm.

From then on, things became exceedingly weird. While the baby was in the hospital, the mother told Andy every time she saw him that she was going to sneak up behind him when he wasn't expecting it and stick a butcher's knife into his back. She also told this to everyone else who was hanging around the ward, the house staff, the medical students, the nurses, even some of the other parents. Since the baby was better and no sign of bacterial infection had been found, Alan Cozza decided to discharge the child a day earlier than usual. He hoped that with the baby and her mother out of the hospital, some of the pressure would be removed from Andy, who, needless to say, was feeling quite persecuted by all this. But discharging the baby didn't help; the woman managed to find other ways to drive Andy crazy.

After discharge, the baby's mother began to call the ward asking for Dr. Ames. When Andy got on, she'd repeat the threats. She somehow got the number of the residents' room and left cryptic messages for him with Lisa, the house staff secretary. She even managed to get Andy's home telephone number and left messages on his answering machine.

At about this time, Alan Cozza, concerned about what was happening to his intern, began investigating this woman's background. Not surprisingly, he found that she had a long psychiatric history and had been diagnosed as having paranoid schizophrenia. Then, about a week after the baby was discharged, a call came for Andy in the residents' room. The person identified himself as the woman's psychiatrist. He explained that the woman had told him exactly what had happened and had laid out in explicit detail exactly what she was going to do to get back at “that intern who ruined my daughter.” He told Andy that he was concerned about his well-being because she was angrier and more agitated than he'd ever before seen her.

This was all Andy needed. If he hadn't been worried about all this before, the psychiatrist's call certainly pushed him over the edge. And apparently there was very little at that point that anybody could have done. The woman wouldn't voluntarily consent to hospitalization in a psychiatric facility because she didn't think of herself as sick. Her psychiatrist, although truly concerned about Andy, was unwilling to proceed with forcing her into institutionalization against her will. He said he simply hadn't accumulated enough evidence yet to justify such a move. And so, during January, after work every day, one of the other members of the house staff had to walk Andy out to his car in the parking lot. The interns took turns staying over at his apartment. He had his phone number changed and made sure the new one wasn't listed. And all of this certainly took its toll on him. He began looking terrible: He was already exhausted from the usual intern routine, and he barely had enough strength to get through a typical day. But now he was no longer able to sleep even on the nights when he wasn't on call because he was so worried.

The story finally came to a head in early February. The baby's mother showed up in the residents' room at Jonas Bronck one day, demanding to see Andy and wanting to know why he wasn't on the ward where he belonged. Lisa, the secretary, told her that at the end of January he had rotated onto another service and was no longer at the hospital. The woman demanded to know where he was, and when Lisa, who was well aware of the situation, refused to tell her, the woman pulled a big knife out of her pocketbook. One of the residents who had been sitting in the outer office ran to get the security guard who was stationed on the pediatric floor. The guard ran into the room, surprising the woman. In the confusion, he was able to overpower her and force her to release the knife. No one was hurt, thank God, and the woman was taken to the psych emergency room in handcuffs. She was ultimately admitted to Bronx State Psychiatric Hospital. Andy, who was working on the Infants' ward at Mount Scopus, was relieved to hear this news, to say the least. He went home that night and had his first good night's sleep in weeks. And within a week or two, the whole incident was forgotten.

This melodrama is certainly not an everyday occurrence. But when something like this does happen, you can be sure it'll occur in January or February.

Andy

FEBRUARY 1986

Sunday, February 23, 1986

All in all, the two weeks I spent in the Jonas Bronck OPD were pretty good, even though it was so frustrating. My prior ER experience at Jonas Bronck had been horrendous, and I had expected the same. But it was much quieter this time; the asthma room wasn't constantly packed, it wasn't constantly filled with screaming, wheezing children who were vomiting all over the floor, making the place smelly and sticky and making the whole emergency room so noisy because of the sound of the oxygen coming out of the wall tanks. Instead, it was much quieter, and on call nights we'd get out of there at twelve or one o'clock, instead of at four or five in the morning. And the chiefs, thankfully, were really nice to me for some reason. They gave me no Friday nights
[the night without a night float]
and the only even slightly hard thing I had was neurology clinic, which is bad only because there always are so many patients.

Even dealing with the ER staff was easier in January. I really felt like I was getting along well with the nurses for a change. When I had worked in the ER last there was this one nurse named Eve whom I didn't like at all. One day during my first month there I just said to her, “I've had it with you! I'm not going to ask you for any help anymore. All you ever do is give me a hard time! As far as I'm concerned, you're not even here! I'm not talking to you anymore!” And she said, “Fine.” So we left on horrendous terms. She was in a really bad mood because she was going to be quitting at the end of November and at that point she hated being in the Jonas Bronck ER. And then one day I was seeing a patient in my clinic at Mount Scopus and I walked out of the examining room and there she was, there was Eve, whom everybody else loved and I hated. We were standing there, staring at each other eye to eye, and she kind of looked afraid. It was a strange thing; I had never seen Eve like that, she'd always been so nasty and aggressive. She had an almost scared look on her face. And I kind of just laughed and walked past her and said, “Oh,
you're
here!” And she said, “Yeah, I'm working here now, I'm one of the nurses here.” And we both laughed, and she said, “Don't worry, I'm not going to be such a bitch because I don't know what I'm doing yet.”

Things still weren't exactly great. But then, the next time I saw her, we talked for a little while and then we went out to lunch and now we've become friends. She's really a good nurse, she's fast and efficient, and she's funny. Now I even like her.

I should mention one patient I had in neurology clinic. He was a seventeen-year-old autistic, severely mentally retarded, violent guy who had been sent over from Bronx Developmental Center
[a residential facility for moderately and severely developmentally disabled children and adults]
for evaluation because he was becoming increasingly depressed and had been losing weight. He was on all kinds of phenothiazines
[a class of tranquilizers],
but nothing was helping. I brought him into the examining room with the health care worker who had come with him. While I was looking through his old chart, he suddenly started to become extremely agitated. He got up and began stomping his feet on the ground and then he started slamming his head into the green tile wall over and over again. I looked over and realized there was blood on the wall, and there was blood coming out of his mouth. He had actually knocked a couple of teeth loose!

Then he started going completely wild; he attacked the health care worker and turned around and slugged me in the ribs a couple of times. Then he went and smashed his face against the wall again. The health care worker, a large, matronly black woman, grabbed him and tried to hold him still. All this time, he was screaming and making unintelligible grunting noises. Pretty soon he began flailing around, and the health care worker, who was getting kind of panicked, looked over and said, “He doesn't like to be in tight spaces. We need to get him out of here!”

I thought I had been very calm up until that moment. I opened the door, walked out, and everybody was looking toward the door because there had been a lot of ruckus in my room. I said, “I have a problem here.” We got the kid out of the room and into the hallway, where apparently he didn't feel so enclosed, and we called security and I sat down with the neurology attending to whom this guy had been referred and said, “Why did you put me in that room with him? You knew exactly what was going to happen.” And she made some comment like, “Well, you have to learn to take care of these kinds of patients,” and I thought, No, I don't. As a resident, I don't have to take care of severely disturbed, autistic, retarded, violent patients who've been referred to a specific doctor for evaluation. In fact, the neurologist didn't want anything to do with him either. She finally said, “You know, we just can't evaluate him.” So we sent him back with a letter saying sorry, there's nothing we can do. It was too bad, but we had nothing to offer.

I've thought about that patient a few times since this happened. I'm wondering how I would have reacted to the whole thing if this had happened back in July instead of in January. I think in July I would have tried a little harder, maybe looked farther through the chart or pushed the attending a little more. I don't know, the kid was crazy, he was dangerous, but when I was in OPD last July, I did some things for patients I don't think I'd do now: I stayed late to finish the workups on patients, things like that. I don't know if that's bad; it's just that it's a real change in me.

Anyway, those last weeks in January were very nice and I began regretting my decision to leave the Bronx. And on my last day in the ER, I said to the nurses on the afternoon shift, “This is the last time I'll ever be in Jonas Bronck.” (My schedule at that time had been set so that I spend the rest of the year at Mount Scopus.) And they said, “What are you talking about? You'll be back next year.” I said, “No, I won't.” And they all said how much they'll miss me and stuff. It was very nice. Very nice and very sad.

I just finished my month in the ICU at Mount Scopus. It was a terrific month. We had a great team: Alex George was the attending, Diane Rogers was the senior resident, Terry Tanner was the junior resident, and we had a couple of good cross-coverers at night. The ICU was tremendously exhausting but somehow I didn't feel as overwhelmed as I had in the NICU, where I never got any sleep. There were a few nights this past month when I didn't get to bed either, but I got at least some sleep most nights I was on call. And I slept for seven whole hours my last night.

I seemed to have the same luck in the ICU that I've had all through the rest of the year. I seemed to get the sickest patients with the most dismal prognoses, and Terry got a lot more of the acutely ill, rapidly recovering patients with relatively good prognoses. It became kind of a standing joke that if I were there to admit a patient, the patient would either wind up dead or with some kind of severe permanent deficit. I guess I've got a lot of bad luck.

There were three patients who were the saddest patients I'll remember for a long, long time. The worst was Ronnie Morgan, this wonderful, beautiful, redheaded boy. When I met Ronnie Morgan for the first time, he was intubated, with a shaved head, a swollen face, and a dozen lines running in and out of his comatose body. Ronnie Morgan was a little two-and-a-half-year-old who had been doing really well until three months before I met him, when he became ill with some minor symptoms and was found on a routine blood test to have an outrageously high white blood cell count. He was admitted, a bone marrow biopsy was done, and a diagnosis of ALL
[acute lymphocytic leukemia]
was made. Soon thereafter, he had a bout of ARDS
[adult respiratory distress syndrome, a condition in which the lungs fill with fluid and respiration becomes extremely difficult]
and a systemic fungal infection. He was admitted to the ICU at death's door, recovered, went through some chemotherapy, and finally was thought to be going into remission. Although his disease and his chemotherapy turned him into a cranky and irritable little kid, his mother always remembered him as being a beautiful, wonderful, happy boy. And then a few days before I first saw him, he was leaving his hematologist's office after a routine visit and fell and hit his head. That's not so unusual; he was a toddler, and toddlers fall a dozen times a day; that's why they're called toddlers. But when he fell, he happened to have a very low platelet count because of the chemotherapy, and he got an occipital hematoma
[a large, blood-filled bruise in the back of his head]
. So he was admitted to the hospital for a transfusion of FFP
[fresh frozen plasma, a blood product containing the elements of the blood essential for blood to clot]
and platelets because it was feared he could bleed out into the hematoma.

Over the course of the next thirty-six hours, he became progressively more lethargic, his mental status deteriorated, and with that concern he was brought down for an EEG
[electro-encephalogram, a test to examine brain waves]
. While he was in EEG, he began to seize. He was then rushed to a CT scan, where a massive intracranial bleed was found
[intracranial bleed: a hemorrhage in the skull]
. At that point, he was immediately brought to the operating room for emergency neurosurgery. There, a huge intraparenchymal
[within the body of the brain]
and subarachnoid
[below the inside layer of the meninges, the tissue that surrounds and protects the brain]
hemorrhage was evacuated, along with a good part of Ronnie's brain, something that happens when you do that kind of surgery. He was then brought up to the ICU on a ventilator and became my patient.

I knew Ronnie was a goner from the moment I saw him. He had a horrible problem, a subarachnoid and intraparenchymal bleed, and that diagnosis on its own was horrendous. And then you add to it his age and his fragility with his leukemia and the low platelets and all the rest and he really had no chance at all. And everyone in the ICU identified so much with him and his parents, who were young, white, middle-class, articulate people.

He was with us for about ten days. After maybe the fourth or fifth day, he had a sudden, uncontrollable rise in the pressure inside his skull. We had been able to keep the intracranial pressure down prior to that time with various maneuvers and drugs, but that day it just became uncontrollable. And with that it was felt that he was essentially brain dead, and yet his body wouldn't die. It was all so horrendous, continuing to take care of this boy who had no prognosis at all. His father understood the situation; he knew how bad things were, and he was trying to mourn his son's death before it actually occurred. But his mother was too defensive and wouldn't accept it, and in a sense was preventing the father from doing his mourning. I never really got to know these people very well; when I first picked up Ronnie as a patient, I saw all the people who were gathered around the parents and I felt that my availability as a support person would not be needed. I didn't see the need of intruding myself into these people's lives when they had already made acquaintance with Alex George, a hematologist, and some other members of the staff. And while it was true that there was nothing extra I could have offered them, I think I missed out on something and I wish I'd had the opportunity to learn how to help these people grieve.

The day his ICP
[intracranial pressure]
skyrocketed, we were standing by his bedside, and Alex said that Ronnie had died, that the bleed inside his head and the pressure had completely destroyed his brain. In the bed right next to him, separated only by a flimsy curtain, was a fourteen-year-old girl who had been diagnosed with a horrible brain tumor and who was going to die of that tumor within the next year or so. She had just undergone some surgery and she was a little off the wall and her mother, who had been sitting here, suddenly said, “I can't take this, this is too much for me!” and left the room. It was just a little too close to home for her.

Finally Ronnie did die. He died a couple of hours before I came in one morning. I had been post-call the day before and he'd been doing very badly; I left knowing it was only a matter of time. I didn't go to his funeral, but I wish I had. I think I've been mourning his death ever since he died; not often or always, but whenever I think about him, I get very sad. But it's strange: I never did know him as a person; I only knew him through the eyes of the people who loved him. Still, I know I'll remember him and be sad for him through maybe the rest of my professional career.

I had another patient, Kara Smith, a little four-month-old who broke my heart. Her first three months of life were normal, and then she came down with pneumococcal meningitis
[meningitis caused by the bacteria
Streptococcus pneumoniae;
this type of meningitis causes particularly devastating effects]
. When I picked her up at the beginning of the month, she was just this little seizing baby who was in renal failure, on peritoneal dialysis
[a procedure performed on patients in renal failure; dialysis rids the body of the waste products of metabolism that normally are removed by the kidneys],
getting multiple antibiotics, and who had a very abnormal neurologic exam. To make a long story short, Kara was the patient who should have died but didn't. Her mother agreed to a DNR order. I actually first brought up the idea of DNR with Ms. Smith. I told her it was something she should consider, and she decided that it would be best if Kara just died. It sounds cold-blooded saying it like that, but it really would have been the best thing that could have happened. We decided we'd just do supportive care and nothing heroic, but even that division became increasingly unclear.