The Intern Blues (40 page)
Authors: Robert Marion
Thursday, June 5, 1986
So far, this has been the best day of my internship. Today's the day of the Pediatric Department picnic; the attendings all cover the wards so we can all go out to some park somewhere and have a good time. That's not exactly what I decided to do. When our attending showed up and told us we could leave, I came right home, picked up Sarah, and took her to the Bronx Zoo. Just the two of us; it was the first time all year I got to be alone with her during a workday. I'm so glad I decided to spend the day with her instead of going to the picnic. I'm really missing the best parts of her childhood.
The Infants' ward is pretty much what I expected. In some ways it's like being in the NICU except there aren't any really tiny preemies around. There are a lot of babies who graduated from the NICU. The ones with any real chance of a normal life go home; the disasters come to Infants'.
Of three babies on the ward who are DNR's, I'm taking care of two of them. One is Kara Smith, an eight-month-old who got meningitis about four months ago. She spent most of February in the ICU upstairs; she had everything wrong with her, there were problems with every single organ system, and all the doctors who had anything to do with her were sure she was going to die. But she didn't die, and eventually they transferred her down to Infants', to the DNR room, where she's been living ever since.
It's really sad; she's completely vegetative; she can't do anything. She has no head control, she can't smile, she can't suck. The nurses feed her through a G-tube
[gastrostomy tube: a tube inserted through the abdominal wall and into the stomach; G-tubes facilitate feeding of children who are neurologically impaired enough not to be able to suck or swallow]
. Five times a day they squirt blenderized baby food into her, and an hour or so later they change her diaper. She also has a trach so she can be suctioned
[babies with no gag reflex will not swallow the normal secretions that build up in the back of their throats; as a result, if these are not removed mechanically, the children will choke]
. And pretty much, that's the extent of her care. Since she's a total DNR, we don't draw bloods on her for anything, we don't culture her if she gets a fever, and we're not supposed to start her on any antibiotics. Eventually she'll probably develop pneumonia and die. But it's already been four months and she hasn't gotten pneumonia yet.
One of the nurses who's really attached to her told me that Kara's mother used to come every day when she was first moved down here. Eventually she only came every other day, then a couple of times a week. Now she comes maybe once a week. I haven't met her yet; usually she shows up late at night, so I suspect some night when I'm on call I'll run into her.
My other DNR baby is Lenny Oquendo. He's six months old. He's never been out of the hospital, and it looks like he never will be. He was one of the NICU disasters; he weighed a little less than six hundred grams
[one pound, five ounces]
at birth and spent three months on a ventilator. He has a grade IV IVH, severe hydrocephalus, and about a dozen other problems. He also has a G-tube and a trach. Lenny's mother hasn't come to see him in months. She seems to have completely lost interest in him.
There's a third DNR baby in the same room, but he's Ellen O'Hara's patient, and I don't know much about him. But that room is so depressing! The nurses and the rest of the staff buy these kids clothes and toys and things to try to liven up the atmosphere. But it doesn't help, it only makes everything that much sadder; the clothes and toys only make you realize how different these kids are from normal children. Just going in there and seeing those three hopeless and helpless babies lying in their cribs, it makes you want to cry! But at least they aren't much trouble. The only thing we have to do for them is rewrite their orders once a week and remember to sign them out to the intern on call.
The rest of the ward is filled with assorted disasters. There are three babies with spina bifida who have shunt infections
[infection of the ventriculoperitoneal shunt, the device that drains fluid from the brain into the abdominal cavity]
and are getting IV antibiotics, there are two babies with infantile spasms
[a severe form of seizures]
who are being treated with ACTH
[the medication used in this type of seizure disorder]
, there's a nine-month-old with AIDS who was in the ICU last week with PCP but who's getting better. There are even a few normal children who have bronchiolitis.
Working on this ward really takes a lot out of you. It's emotionally very taxing. So having today to spend with Sarah was especially good. It raised both our spirits.
I'm on call tomorrow night. I'm going to stop now and actually cook dinner.
Sunday, June 8, 1986
I've been in a good mood this weekend. The schedule for the next year finally came out on Friday. They actually came through with what they promised: I'm scheduled to have my CERC rotation
[a month spent learning developmental pediatrics at the Children's Evaluation and Rehabilitation Center on the east campus; CERC is a calm, nonstressful experience]
in October, my vacation in November, a month of elective without night call in December, and my neuro selective
[a rotation learning child neurology; like CERC, neuro is pretty laid-back]
in January. They gave me what I wanted. Finally, after everything that's happened this year, I wound up getting something without getting screwed!
It's hard for me to believe that I have only three more weeks of internship left. At this point in time, I'm fairly sure I'm going to be able to make it the rest of the way. I hadn't been able to say that before this week. I'd been dreading working on Infants' for months; I'd heard only bad things about it. But actually, although I can't say I'm really enjoying the patients I'm following, I am having a good experience here. We have a very good attending, Alan Morris. He's an excellent teacher and I've been learning a lot from him on attending rounds. And we have a strong team: Ellen O'Hara and Ron Furman are the other interns, and they're a lot of fun to work with. And our senior resident is my very favorite person in this whole program, Ben King. Ben's a little burned out at this point; this is his last month of residency, and I don't think he really wants to be in the hospital. Yesterday, on work rounds, he got into a wheelchair and made Ron push him around the ward. He's funny and he makes working easy because he's got excellent judgment. So, probably for the first time all year, I'm actually part of a team I like being on.
I was on call with Ben yesterday. It was a very quiet day. I had only two admissions, an eight-month-old sickler with dactylitis
[inflammation of the hands and feet, usually the first painful manifestation that occurs in children with sickle-cell disease]
who didn't require any work, and a nine-month-old with bronchiolitis who was admitted from the West Bronx emergency room but who Ben immediately sent home. It was really funny: I went down to the ER to get the baby at about three in the afternoon and he really didn't look that sick. But I didn't question it, I just brought him up to the ward. Then Ben came by to see him and he said, “Why did they admit this kid?” I told him I didn't know. He listened to the baby's chest and said, “This kid doesn't have bronchiolitis. He's healthier than I am! Send him home before something bad happens to him!” Just like that. His mother got him dressed and they left. I don't know any other resident who would have done that. But if you ask me, it was the right thing to do.
So all in all, I haven't been too overly stressed on Infants. Calls haven't been bad, and I've been getting out at a reasonable hour: not three or four in the afternoon, but usually no later than five. It's staying light out until seven o'clock now, so when I get home I can take Sarah out onto the lawn in front of the apartment building and just sit out there with her. It's nice. It's too bad the rest of the year hasn't been like this.
Sunday, June 15, 1986
Kara Smith died Friday night. She had developed a fever on Thursday; Ron was on, he examined her, and he thought she had pneumonia. He didn't do anything about it, just wrote a note documenting it in the chart. Then on Friday during the day her breathing became very labored. She must have been hypoxic. I felt very uncomfortable. I kept coming into the room to check on her. I knew she was DNR, but just sitting around doing nothing really bothered me. I wanted at least to get a blood gas and maybe start some oxygen, but the rules are no treatment.
Then finally on Friday night, one of the nurses called me around midnight to come to see her. She was blue and gasping for air. Her heart rate was down to about forty, so I figured the end was near. I called the resident on call to tell her what was happening, and she came down and checked Kara; she agreed with me that she was dying. We didn't do anything; we just sat by and watched.
She finally stopped breathing at about twelve-thirty. We covered her with her blanket and just walked out of the room.
I called the mother. I had met her last Saturday night. I had been on call and she came in at about eight o'clock. She didn't say much to me, only that she was pleased to meet me. It wasn't much, but at least I knew who she was and she knew who I was.
I got her on the phone and told her that Kara had died. She didn't cry at first. She seemed very composed. She asked if I thought Kara had felt any pain; I told her I didn't think so, that she had seemed comfortable the whole time. She asked if I knew what the cause of death was, and I told her about the fever and the breathing problems and the fact that she had probably developed pneumonia. Then the mother said, “I guess she's up with the angels now,” and that's when she started to cry. I couldn't think of anything to say; I just sat at the nurses' station with the receiver up to my ear.
When she finally stopped crying, she apologized to me. She told me she'd been prepared for Kara's death for months and that she didn't think she would cry when the time finally came, but that she just couldn't help it. She said, “They told me she was going to die and I came to accept it, but I never really believed it.” She started crying again at that point, but only for a minute or so. After we hung up, the rest of the evening was quiet; I didn't get any admissions, and the ward was calm. I went to the on-call room but I couldn't get to sleep. I kept thinking about Kara's mother.
Tuesday, June 24, 1986
Tomorrow's my last night on call as an intern. I've made it! It's hard to believe, but I actually survived. Believe me, it's not something I'd want to do again.
Looking back at the year, there have been a lot of things I've disliked; I didn't like the way I was treated by the chief residents, I didn't like the fact that I had to be on call every third night, I didn't like being tired and exhausted all the time, and I didn't like having to take care of sick, sick children. But definitely, the thing I disliked the most was being away from Sarah. I know I've said it before, but it's still true: I've missed some of the most important moments of my daughter's childhood.
I've asked myself a lot lately whether I'd have done this internship if I knew then what I know now. I'm not sure what the answer to that question is; over the past few weeks I've tended more toward, “Yes, I would do it.” But there are some days, when things are very stressful, when the answer is, “No way!” I guess it's silly to ask the question, though. I mean, it doesn't really matter. I've done my internship, I'm finished with it, and I never have to do it again. That's all that's really important.
Sunday, June 1, 1986, Noon
I just got back from my first night on call in the neonatal intensive-care unit at West Bronx, and I'm really starting to get the feeling that I'm not going to become a neonatologist when I grow up.
I got to the unit a little before eight yesterday morning. I got sign-out from Elizabeth, who was on the night before. I wouldn't say she was exactly sad to be leaving. Then she left and I started running around, and I continued through the night. I ran to the labs, I ran to the DR, I ran to the babies who were trying to die. The only time I sat down during the entire twenty-four-hour stretch was when I had to write those endless, pointless progress notes that go on for pages. It's a total waste, me writing notes. It's definitely gotten to the point where I can't even read my own handwriting anymore. Anyway, the whole day was horrible. Yesterday made my month in the nursery at Jonas Bronck seem almost pleasant!
Monday, June 2, 1986, 8:30
P.M
.
I just got home. It's eight-thirty and this is supposed to be my good night, and I just walked through the door. Oh, this is a nightmare. But do I care? No, I don't care at all. Why don't I care? Because I just stopped at the supermarket on the way home and found blueberries. When blueberries appear, the end of the year is nearly here. They can do whatever the hell they want to do to me, but I don't give a damn anymore. Because I've made it. I've made it to the blueberry season.
So what's life like in the NICU? It's wonderful, great, like a vacation in Cancún during the rainy season. The unit is really very small. You can walk from one side of it to the other in about ten or fifteen steps. But packed into those ten or fifteen steps are some of the sickest patients you could possibly imagine. It's one disaster after another. There's a roomful of preemies who don't do anything all day but seize and try to die; there's a roomful of cardiacs
[babies with congenital heart disease who are being evaluated for or are recovering from cardiac surgery]
who only rarely seize but who always are trying to die; there's a room of miscellaneous disasters; and a fourth room, filled with social holds.
And the unit continues to stay full, mainly because of the topnotch obstetric service. OB is run by a team of killer midwives who are really heavily into what they call “the psychosocial aspects of childbirth.” What that means is, they encourage the mothers to hold their babies right after birth to make sure they bond, no matter what's happening to the kid. On Saturday, Eric Keyes
[a senior resident who was cross-covering the unit]
and I were called to the DR stat for fetal distress. We got there and found this tiny midwife pushing on the belly of an enormous pregnant woman. The midwife told us she was applying external abdominal pressure. This pregnant woman must have weighed at least three hundred pounds, and the midwife weighed ninety at most. As she pushed down, it looked as if the midwife was going to be swallowed up by the pregnant woman. Anyway, we looked at the fetal tracing and saw there were late decels
[late decelerations: a heart pattern indicative of fetal distress]
, so Eric suggested maybe they should think about doing a C-section. The midwife gave him a look I was sure would instantly turn Eric to solid rock but apparently it didn't, because seconds later, when the membranes ruptured and meconium started splattering all over the room, Eric immediately said, “Holy shit, let's get ready to intubate!” A little while after that, this tiny baby came flying out. The midwife caught it, wrapped it in a towel, and immediately handed it over to the mother.
I thought Eric was going to blow out his cerebral artery right then. He looked at the midwife for a second, then he looked at the baby, who was blue and not breathing, and he yelled, “What the hell is going on here?” The midwife turned to him and said, “Bonding. Shut up and go away!” Eric immediately grabbed the baby away from the mother, brought it over to the warming table, and we started working on it. The kid wasn't breathing. Eric intubated and sucked out a huge glob of meconium and then we started to bag the kid
[blow oxygen through an endotracheal tube directly into the baby's lungs]
. The baby picked up at that point and cried for the first time since birth. His heart rate came up, he started breathing on his own, and he turned pink, which looked much nicer on him than his original blue. It looked like a save.
But that wasn't the end. Just as we were finishing, the midwife came over and started yelling at Eric, telling him his grabbing the baby away like that severely disturbed the mother-child relationship. Eric said something like, “Oh yeah, sure, anoxic brain damage would have markedly improved the mother-child relationship, right? Bonding to a blue baby is much better than bonding to a pink baby. How stupid of me to interfere.” They then got into a real big shouting match, right there in the DR. Eric told me later the midwives are always like that. He said you can expect to get into at least one argument with them a night. He said he thought there must be a required course in blue-baby bonding in midwife school.
Thursday, June 5, 1986
Today was the Pediatric Department picnic. The people in charge actually gave us the whole day off just to go and have a good time. It's so out of character, it's almost frightening!
This morning at about eight-thirty, our attending, Laura Kenyon, showed up and told us just to sign out to her and get the hell out of the hospital. Elizabeth and I were out of there instantaneously! If an attending's offering, we aren't about to give her a chance to reconsider. So we drove up to this camp in Chappaqua where the party was going to be. When we got there, we couldn't believe it. It was acres and acres of green grass and trees. It was great!
The picnic was actually a lot of fun. Just about all of us were able to go. We played softball, ate hamburgers and hot dogs, and drank much too much beer; in other words, we did all the things normal people might do if they were on a company picnic. We did a good job of pretending we were normal, at least for a few hours. It gave us hope that someday we might be able to shed this schizophrenic outer coat we've grown and return to the Land of Normalcy.
Anyway, on the way to the camp, we passed Peter Anderson's house, the place where we had orientation almost one year ago. Boy, that's amazing! It's hard to believe that orientation happened a year ago. It seems more like something out of a different century. There were the Middle Ages, the Renaissance, and orientation at Peter Anderson's house, not necessarily in that order. Well, what difference does it make? In another couple of weeks a whole new group of interns will be deposited on Peter Anderson's doorstep, sweating bullets. I bet they're all sweating bullets right now. I remember last year at this time, I was scared to death. By the way, if you haven't guessed by now, sweating bullets was the completely correct reaction. I wouldn't trade places with those guys for all the money in the world!
I left the picnic at about three-thirty because I had to get Elizabeth back to the hospital. She's on call tonight. Elizabeth wasn't exactly in the best mood today. It's kind of hard to enjoy yourself when you know that in a couple of hours you're going to be face to face with your worst nightmare.
I'm going to watch some TV now. Yes, it's been the kind of day normal people have, and I'm going to end it the way normal people end their day. I'm going to watch
The Tonight Show
!
Twenty-three days to go. But who's counting?
Sunday, June 8, 1986
Carole and I are getting along really well. It's kind of frightening. Either I'm over my internship depression, or she's slipped into a serious state of depravity. Anyway, it looks like our relationship has weathered the year. I'm glad it did, I guess. I like Carole a lot.
I just got off the phone with Elizabeth. She's on call tonight. She said her foot is feeling better, but it's still not great. I don't know if I mentioned what happened to Elizabeth last week. She was on on Friday night and there was a code about 3:00
A.M
. She told me she was in another part of the unit, trying to teach one of the cardiac kids how to breathe like a human, when the alarm went off in the preemie room. She went running in there but tripped on an electrical wire on the way and flew about ten feet into the air. This is a new Olympic event, the Preemie Resuscitation Slalom Course. She must have made a perfect landing, because she said the judges gave her scores of 9.5 and above, but she came down on her ankle, which got all twisted up. A couple of hours later, after she had made sure the preemie who had coded would live to face another sunrise, she was drawing the morning blood and noticed her ankle was hurting. I got there about that point and we rolled down her sock and both noted that her ankle had become the size and color of a ripe eggplant. At about that moment she said she was feeling a little queasy. I noted that her face had turned a sickly shade of green. That was right before she passed out.
“Yes, I'll tell you, they just don't make these interns like they used to! At the first sign of adversity, they all find it necessary to fall over. They're just not as durable as they used to be in the Days of the Giants!”
Anyway, we got her a wheelchair and I took her down to X ray. There weren't any fractures. Laura Kenyon got hold of an orthopedic surgeon who examined her, said it was just a flesh wound, and wrapped her ankle in an enormous Jones dressing
[a bulky dressing made of three layers of Ace bandages]
. She was up and caring for the clients in less than two hours. What a trooper!
I'm finding it very difficult to concentrate on my patients. They've all become a blur to me at this point. I get one preemie mixed up with another; all the cardiacs seem the same; I just can't keep them straight anymore. I think I've got spring fever. I'm going to stop now.
Saturday, June 14, 1986
It hasn't been such a bad week. There are these bugs
[bacteria]
flying around the NICU that seem to be resistant to every antibiotic known to man. I don't know how they got into the unit, but I'm glad they did, because it means we're contaminated and closed to all admissions.
If I had known closing the unit would have been that easy, I would have brought the bugs in myself. I must have some type of bacteria resistant to every antibiotic known to man living in my apartment. I seem to have everything else living here. I can see a great future in the bacteria-resistant-to-every-antibiotic-known-to-man mail-order business. Interns all over the world would beat down my doors trying to get enough bacteria to close down their particular ICU. What a great concept!
Anyway, the infection hasn't done my old patients any harm. Of course, these kids are so sick, it's kind of hard to tell whether something does them harm or not. But it has caused us to have a nice, leisurely week.
Saturday, June 28, 1986
Well, it's over. It's all over. I am no longer an intern. As of nine o'clock this morning, I officially became a junior resident. No more internship! Ever! No more daily progress notes! No more blood-drawing! No more IVs! No more fighting with lab technicians! No more fighting with elevator operators! No more mock-turkey sandwiches! No more patients who are as sick as Hanson! No more Hanson!!
I think you can see here that I'm exaggerating a little. I think you can also see that I'm completely out of control! And I don't care! Because I'll never have to be an intern anymore, never again. Hooray!
This morning at about eight o'clock, I was drawing the morning blood and whistling. Yes, I've been whistling on blood-drawing rounds over the past few weeks because it's such fun! Anyway, I'm walking around the unit whistling and jabbing great big needles into my wonderful patients because I love them all so much and this guy who looked lost and scared to death came in and asked, “Is this the nursery?” Guess who he was? He was . . . an intern. He was the intern who was on call in the NICU today! And I didn't know who the fuck he was! Because he's brand-new!
I told him he was in the right place and I showed him where to get a set of scrubs and then I showed him the patients. While I was doing this, I stayed between him and the door at all times because I was sure that at some point or other he was going to bolt, leave the hospital, and never come back, and I'd have to stay and be on call again. But he didn't leave. He was really nervous, but he seemed very enthusiastic. It was like I was talking to a member of a completely different species on the evolutionary tree. He took notes on this clean pad on this brand-new clipboard. He didn't ask any questions, and I'm convinced he didn't understand a single word I said to him.
Anyway, I finished rounding with him at about ten and then we all gathered in the West Bronx library and the party started. A bunch of us were sitting in there, drinking champagne and getting soused. At ten in the morning. We stayed until about eleven, when the bar across the street opened, and then we all went over there for brunch. It might seem strange that ten or eleven interns would be sitting around a bar drinking at eleven o'clock in the morning, but hell, we weren't alone. The place was packed! It wasn't only pediatrics that changed over today; medicine and surgery changed also, and everyone was getting loaded. Anyway, we stayed there until about two. I just came home to take a nap and get ready for the real partying, which will start tonight.
