The Intern Blues (4 page)

Tuesday, July 9, 1985, 3:00
A.M
.

Must internship really be like this? Must it really have hours like this? Today was just one of those long, zooish days. I had clinic this morning, had about three seconds for lunch, went to the emergency room where there was already a big pile of charts in the triage box, and that's how it stayed until a little while ago. There wasn't even a minute to get some dinner; I was starving, but there just wasn't any time to stop. We kept working and working and the triage box of charts of patients waiting to be seen just kept getting bigger and bigger.

I've noticed I'm not nervous anymore. I did another spinal tap today, on a little one-year-old with a fever who had had a seizure. It went fine, the kid didn't have meningitis, it must have just been a febrile seizure
[a convulsion that occurs with fever and having no adverse long-term effects]
. I admitted a kid with anemia, the second kid I've admitted since starting. I used to sweat like a pig when I had to do procedures and stuff; I don't seem to be sweating much anymore. It happened very suddenly. So far, internship has been a period of exponential learning. I just hope all I'm picking up sticks.

I still can't believe I'm getting paid for this. But I'll tell you, I don't think it'll be long before I start thinking I'd damned well better be getting paid for this. I think that happens when you start to respect your skills. I'm not there yet; but I'm getting there, I think.

But I do get really pissed off about working in the West Bronx emergency room
[West Bronx, also referred to as WBH, is a municipal hospital adjacent to Mount Scopus]
. I was drawing blood today from a four-year-old and I had to stick him three times because he kept pulling his arm away and pulling out the needle. The reason he kept pulling his arm away was because the nurse wasn't holding him tightly enough. When I told her, she said, “I don't care, I don't give a damn!” Oh, really! She just didn't give a shit about the kid! Here's a woman who must really love her job.

I forgot to talk about something I can't believe I haven't mentioned yet. Something really significant happened tonight, something horrible, and I guess I blocked it out of my mind for a while. As the triage box was filling higher and higher with charts and we were getting farther and farther behind, we were called by a frantic clerk to come over to the critical care room. He said there was a pediatric cardiac arrest going on.

So we tore over there to see what was happening. I got there first. I found the place jammed with doctors and nurses working on what looked like a pretty big adolescent. They were pumping on his chest, they had him hooked up to the cardiac monitor, they were sticking him for blood and starting big IVs in his groin. I had no idea what to do. The resident showed up a few seconds after I got there and we stood around for a couple of minutes until they just told us that we could leave unless we wanted to run the code. “No,” we said (laugh), “it looks like you guys are doing just fine.” But no one had taken a history yet, or even talked to the mother, so the resident told me to go out there and get the story. I found the woman; she was perched outside the critical care room looking scared to death. I took her over to the social work office and started talking to her.

Briefly she told me the kid was a fifteen-year-old asthmatic who'd been in the middle of a bad asthma attack when it sounded like he had become obstructed
[the main breathing tube, the trachea or one of the mainstem bronchi, the tubes leading from the trachea to the lung, became blocked]
. He stopped breathing and they loaded him into a car and sped off to the hospital. They were headed for Jonas Bronck but on the way the kid was snatched up by a passing EMS team and brought to West Bronx. He had been pulseless, breathless, and unresponsive for God knows how long. When he got in the ambulance, he had vomited and aspirated
[leaked stomach contents into his lungs]
and gone into arrest.

So he was kind of dead when they brought him in, but I don't think I really believed it. His first pH was 6.9
[indicating severe buildup of acid in the blood, a condition resulting from lack of oxygen delivery to the tissue and not consistent with life for longer than a few minutes]
, which isn't great. His heart was beating only about eight times a minute, but he was a kid, and kids just don't die like this. Not the ones I'd known anyway.

When I was getting the history, the mother asked me, “How is he, Doctor?” and I was about to say . . . I don't know exactly what I was about to say, but then the clerk opened the door and took the mother away because he had to register the kid or something administrative like that, and I left, after telling her I'd come back to talk to her again when she was done.

Next thing I knew, that clerk came back to me, not as excited this time, and he said, “The kid died; he's dead.” I couldn't believe it. I knew he hadn't been doing well and that they were doing everything they could for him, but dead? I just couldn't believe it. I had to walk in and see him myself.

In the critical care room, the crowd was gone; there were just a couple of nurses, removing all the lines and stuff, cleaning him up, getting ready to bag him, and there he was with his glazed corneas—yeah, he looked dead, all right. The medical resident came in and we talked about it for a minute. No one had said anything to the family yet. I told him I'd gotten the history from the mother. “Well, I guess you're the only one who's established rapport . . .” he said. Rapport? I spoke with the woman for five lousy minutes; that's not exactly what I'd call establishing rapport.

But I was elected. Other than me, nobody had even laid eyes on the woman. The medical resident said he'd come along with me. On the way back to the social work office, I stopped myself and thought, What the hell am I going to say to this woman? I knew she was totally unprepared for this. When I had talked with her earlier, I got the impression she thought everything was going to be okay. I knew things weren't okay. I had seen him getting his chest pumped, being a full code. I should have said, “Your son is in critical condition. There's a chance he won't make it.” I wish I had said it when I'd had the chance, but then that damned clerk had come in and had taken her out to register her. I should have booted him out, told him I was talking and that it was important, but I didn't think to do that, so I didn't get to prepare her in any way. Ah, maybe she didn't want to know, maybe she would have been worse off had I tipped her off beforehand. Who knows?

Anyway, there I was, sitting in front of her in the social work office, and the medical resident was standing behind me and there she was, looking at me, not having a clue what was going on. All I could think to say was, “I'm sorry, but I have to tell you, your son is dead.”

She looked at me, her eyes bugged out, and she became completely hysterical. And the woman who was there with her also became completely hysterical. They began screaming in Spanish and wailing and throwing themselves around. I didn't understand a fucking word they were saying, I didn't know what was going on, they were making a tremendous ruckus and I just . . . I just didn't know what to do. It was a terrible moment. I felt completely powerless. I couldn't think of anything to make her feel better. It was probably the most horrible moment in her life.

As we were walking to that room and I knew I was going to be the one to tell her about her son, I remembered hearing about situations like this, when you have to tell a mother that her child has died, and you don't even know her; you're just on call and it's not your patient and you just kind of get signed out to take care of the dying person. I expected it to happen sooner or later; I'm just kind of surprised it happened so soon in my internship, in virtually the first week.

Wednesday, July 10, 1985

I spent the afternoon in the West Bronx ER, where I had a great case. We had this kid I saw a couple days ago, the one-year-old who came in with a febrile seizure. I tapped him and found he didn't have meningitis, but today the blood cultures I'd sent came back positive, with gram negative rods
[meaning that there was a bacterial infection in the blood with a bacteria called
E. coli,
a potentially serious infection]
. We called the kid back in and he still had fever on the antibiotics I had prescribed, so we admitted him for treatment of sepsis
[infection of the blood]
.

Then later in the day, a little five-month-old came in with a high fever. I did another spinal tap and did the cell count and this time, yes, lots of white cells; this kid did have meningitis and was admitted. That's routine pediatrics, very routine, I know, but for me it was a very exciting thing. I was able to do everything from start to finish, and that was all stuff I learned here, stuff I didn't know how to do in med school, and that's very exciting. I'm now able to do some things that doctors are supposed to do.

I told the mother we'd have to admit the baby and take more blood and she said “No way.” She was frightened to death. I knew there was no way that I, with my vast two-week experience as an intern, was going to be able to convince her to let us do what we needed to do, so I called the attending and he came over and sat and explained the whole thing to her, telling her how important it was that we start an IV and begin antibiotics as soon as possible so that the baby would have the best chance possible of surviving and she listened carefully but it was clear she was so frightened she couldn't think straight. She finally said, “I don't know what to do anymore. Call my husband and ask him.” We called the father and he said, “Do whatever you have to,” and he came in. It was very sad: Here's this beautiful, normal baby with this terrible infection and the real possibility that he'll wind up retarded, and I was excited because I had been able to do the workup from start to finish. It's like I'm less interested in the patients and more interested in what I can and cannot do.

I've been here a week and a half and I've done more spinal taps than I'd done in all of med school. You see a lot in this place, it's a great program, but I can see how I could get burned out. It's a real danger in a place like this, with call relentlessly every third night and the ancillary staff somewhat less than helpful. I can see I'm going to have to watch out; down the road when it's the winter and my vacation is a month or two away, I can see how I could possibly come to hate this, how what seems like fun and is exciting now could turn into a real drag later.

Monday, July 15, 1985

Time seems both to drag and to race onward. It seems like forever since I last saw Karen; it's only been a week and a half. I really miss her.

Last night I was on call in the West Bronx ER again, and from the word go, it was crazy, packed from the start until about two o'clock. I didn't have even a second to catch my breath. This is getting to be a very disturbing routine.

I spent Friday and Saturday down in Manhattan with some of my friends from college, Gary and Maura. They live in the city; it was nice to get out of here and see some people outside of medicine. I tried to explain to them about some of the stuff I've been doing and seeing. They say they understand, but I get the feeling they only believe about half the things I tell them.

Today I acted as the supervising physician for IV sedation in a kid who was getting a radioulnar fracture
[a fracture of the two bones of the forearm]
reduced by the orthopods
[internese for orthopedic surgeon]
. Although the attending popped his head in a few times to make sure everything was all right, I basically just did it on my own. Even though nothing really happened, it's still kind of a nerve-racking experience.

Thursday, July 18, 1985, 2:00
A.M
.

Just finished another call in the West Bronx ER. The past few days have been mixed. Today was pretty good, but the two days before pretty much sucked. I had a couple of aggravating days in clinic
[all pediatric house officers are assigned to a “well-child clinic” in one of the hospitals; interns and residents have office hours once or twice a week in clinic during which they usually see six or seven of their own patients]
, where I just felt overwhelmed and disorganized; it was driving me crazy. The problems were pretty boring, but I'm picking up lots of new patients, slowly but surely drumming up my clinic. I have the feeling it's going to be a booming clinic pretty soon. It seems like every walk-in
[a patient who comes to the emergency room]
needs a regular doctor. They ask me if I'd be their doctor, I say sure and give them the clinic's number. I have a feeling this is going to be a mixed blessing in the long run, but anyway . . .

I was really tired most of today. I just don't seem to have any pep. It's this every-third-night-on-call business, the inevitability of it, it's just dreadful. Even though this is the easiest rotation I'll have and I get to go home every night (even though it might be at three or four in the morning), these hours just get very tiring. Is it possible that I'm really starting to get tired this early into the year? I'm worrying about everything; I've even started to have trouble sleeping on the nights I'm not on call. I didn't sleep well last night—I woke up three times before my alarm went off.