The Intern Blues (13 page)

There are very few teaching conferences and much more free time at University than at the other hospitals. During the day, the interns work as glorified secretaries. Each patient's attending really makes all the important decisions affecting the patient's care, but attendings are not permitted to write in the nurses' order book. The nurses are instructed to pick up and carry out only those orders written by an authentic intern. So any time an attending wants to change a medication or order a test, he or she must get hold of an intern and ask that an order be written. The interns rarely have the opportunity to argue with an attending's request. They simply have to write down exactly what's been dictated.

Although there are very few emergency admissions, interns on call frequently spend a good part of their night fighting with the lab technicians. University's community hospital personality carries over to its laboratory. At night there are very few technicians covering the hematology lab, the chemistry lab, the bacteriology lab, and the blood bank. Because of the shortage of personnel, the technicians are never exceedingly happy about running any tests in the middle of the night, and if an exotic test needs to be done, they can turn downright ugly! Since a fair number of the patients on the ward can be very sick, it sometimes becomes critically important to get tests done after midnight. And this often results in massive arguments.

The patients at University Hospital are exceptional, to say the least. One reason people who train in pediatrics are attracted to the field is because children are basically healthy; their recovery usually is rapid, and it's a rewarding experience for the doctor. But at University Hospital, you have a ward full of children with uncorrectable chronic diseases. The pediatric renal service is housed at University Hospital, and all the kidney transplants are performed there. At any one time the ward will have five or so kids whose kidneys don't work and who are either waiting for, in the midst of recovering from, or actively rejecting a renal transplant. Except for the patients who have recently gotten a new kidney, few of these children are acutely sick. That's a mixed blessing: The chronically sick patients don't require a great deal of concentrated hard work, but they usually don't get remarkably better. And that can be discouraging.

Interns find different ways of coping with the aggravating parts of working at University Hospital. Some get into fights with the patients and staff; some spend their time hanging out in the cafeteria; and some try to get out of there as early as possible. The interns spend only one month out of their year there, so the rotation doesn't usually cause any serious or long-lasting damage.

Andy

SEPTEMBER 1985

Friday, August 30, 1985

I'm out of the NICU; I made it, although I had some question about whether I would that last night when I had to supervise at the death of a full-term kid who had aspirated meconium
[meconium is the first bowel movement; fetuses who are stressed intrauterinely frequently pass meconium before birth; they then breath it into their lungs during their first inspiration and develop a severe meconium pneumonia as a result]
and who wound up on maximum doses of tolazoline, dopamine, and the highest respirator settings possible. He finally died at four in the morning. The rest of the month is all a delirious blur. I think I actually learned something, but I just don't know whether it was worth the price I had to pay.

And now I'm on the Adolescent floor at Mount Scopus. I've been told it's easy street, but I don't totally agree. Life is certainly better, though. The veins of these kids look like pipelines. No more four hours wasted trying to start an IV. So far I haven't been beaten or abused, and if I can get a good night's sleep tonight, I'll be rejuvenated for call tomorrow. You know, I've been so burned out lately, I just hope that maybe in the next few days I'll get excited and interested again.

I almost thought I was getting excited and interested today. We had rounds with Marilyn Connors, our attending. She was pretty laid back. I've heard that all the adolescent attendings are hyper and picayune, so we'll see.

There's this intern I'm working with, Margaret Hasson. She was hysterical today, the way you get sometimes when you're postcall and can barely stay awake. She was presenting a patient she admitted last night and she got really out of line, making off-color jokes and stuff. When you get so tired you're falling asleep on your feet like that, you think things are hysterically funny when nobody else does. It was great. After rounds, she told me that after she spent July over on 8 West, she decided she totally hated her internship. She doesn't seem like she's in a bad mood now, though. She's not demoralized or grumpy and she doesn't hate everything.

I'm having my first experience with teaching medical students this month. I was assigned a good student who's very conscientious, humble, and a hard worker. I try to get her to spend as little time as possible in the hospital. She should be home, reading. That's what all medical students should be doing. They should spend only enough time on the wards to get an idea of what goes on there. I didn't do that; I think I spent too much time on the wards. Maybe that's why I'm so burned out already.

Having a student is interesting. I'm finding I do know a few things. I didn't think I had picked up anything since I got here, that I was a complete dum-dum. But I'm finding that I can actually talk about subjects intelligently. I don't know if they're sitting there thinking, Gee, this guy's really stupid, he's saying things that are completely wrong. But the important thing is I actually learned something over the past two months. I don't remember it happening; it must have been by osmosis.

We've got these two residents, Nancy Rodriguez and Terry Tanner, working on Adolescent this month. Nancy and Terry seem real nice, but they're only second years; they were just interns a couple of months ago. They're only a few months ahead of me and they're supervising on a busy ward! It's scary. I couldn't do it.

Saturday, September 7, 1985

This is supposed to be an easy ward, but God, there's just so many goddamned frustrations! Like there was this patient admitted the other day, this cute little fourteen-year-old girl from Barbados with severe mitral stenosis
[a tight closure of the mitral valve, the valve between the left atrium and the left ventricle of the heart; stenosis results in the atrium having to work harder to push an adequate amount of blood into the left ventricle and to the rest of the body]
as well as pulmonary hypertension
[an irreversible increase in the pressure in the blood vessels that carry blood from the heart to the lungs; frequently the cause of death in children with congenital heart disease]
and hemoptysis
[coughing up of blood]
. She's really sick, but all anyone cared about was fucking politics. Even though she could be dying, the administrators have to decide whether she can stay in the hospital because she's not a U.S. citizen and not eligible for any kind of insurance. I was told that it would probably be okay if we said that she was here visiting relatives and got sick, rather than that she came here for medical treatment, which was the truth. I was told not to write anything in the chart until administration had cleared it and that I shouldn't exactly lie, but I should tell the truth in a certain way, you know, make it sound like she's really more acute than she is. I can't stand buffing the chart
[buff: polish to improve an appearance];
it really bothers me. But fortunately, I had blown the cover the first day when I wrote in my admission note that she had come to the United States specifically for medical care. A lot of other people said the same thing in the chart, so it wasn't all my fault. Anyway, Loomis, the head of Adolescent Medicine, spoke to some big cheese and got the hospital to foot the bill. It was really nice of him, actually, and it was nice of the hospital, too. This's going to be a fucking thirty-thousand- or forty-thousand-dollar bill. But all this time, at least a half hour of attending rounds a day was being wasted on this bullshit.

Yesterday was just one of those bad days; I wasted the morning with the attending and the administrators trying to figure out what we were going to do with this kid. Then later on, I was told I was getting a patient with sickle-cell disease who was in painful crisis. Nobody bothered to mention to me that the patient was on the ward until the kid had been there for two and a half hours, lying in his bed down the hall and writhing in pain! I was so pissed I ran over to the head nurse and yelled, “Why didn't someone tell me this guy's been here so long? How come I haven't heard about this?” And she said, “Well, it's not our fault,” and she looked at me as if it were my fault, that I should have somehow instinctively known the kid was there. I was so furious, it took me two hours to cool down because the main thing was, here's this poor kid, he's in agony, and he didn't have to be! What can I say? It was just one of those days.

I think I probably get flustered too easily. I shouldn't allow myself to get angry about these things. Okay, so the patient's lying there, writhing in pain. Complaining to the head nurse didn't do him any good, and it sure as hell didn't do me any good. I could have just very quietly, very calmly filled out an incident report that I wasn't informed of the patient's presence. I could have sent that down to administration and then, whoever's ass had to be cooked, let his or her ass be cooked! I shouldn't allow myself to get aggravated about stuff like that; there's more than enough other stuff to get aggravated about. That's easy to say, but I still get all fumy and angry whenever something like this happens because, really, deep down inside, I want to do a good job, and I don't want people to be suffering. It really pisses me off.

I also got into a fight with a lab technician last night. I admitted a teenager with leukemia at about 6:00
P.M
. He came in because he had fever and the hematologists were sure he was septic
[had a bacterial infection in his blood; especially dangerous in patients with malignancies because their white blood cells, an important line of defense against invading organisms, are usually markedly deficient]
. He got sent up to the floor very fast; they had seen him in clinic but they hadn't even done any of the lab work. They were really worried about him, so they sent him up directly from clinic.

As soon as he got to the floor, I drew all the admission blood work out of his central line and sent it off to the lab stat. Of course, I included a CBC
[complete blood count]
with diff
[differential cell count: percentage of various types of white blood cells within the sample],
and I wrote the diagnosis on the lab slip so they couldn't blow off doing the diff
[the differential count requires some tedious microscope work; therefore it is done only in cases where there's an abnormal number of white cells or in cases of malignancy]
. When I called the lab about an hour later to get the results, they told me nothing was ready yet. I called back a half hour after that and they gave me the CBC, but the tech said they hadn't done the diff. I said, “What do you mean, you haven't done the diff? I checked off ‘diff' on the lab slip and wrote the patient's diagnosis.” He said, “We don't do diffs at night.” And I said, “What do you mean, you don't do diffs at night? I need a diff on this patient; he's got leukemia, for God's sake, and he might be septic. I have to have a diff! This kid could die.” And the guy said, “Lots of people die every day,” and then he hung up. He fucking hung up on me!

I was ready to go down there and kill. But the senior I was on with said it wouldn't do anybody any good and that all I had to do was take another sample over to West Bronx's lab and they'd run it for me. I did that, and sure enough, the kid was neutropenic
[had a deficiency of the particular type of white blood cells most important in fighting off infections]
and septic. He's pretty sick. He may die. But the people in the lab don't care about stuff like that. They only know what the rules are.

The aggravations of being an intern are just endless. I would say nine out of ten interns say these same two words over and over again: “Internship sucks.” I've heard that particular phrase so many times in the past week or two.

I mean, think about it: To the nurses and most of the rest of the staff, we're nothing but another piece of shit. To the nurses, anything that goes wrong is the intern's fault. Somehow they're always innocent and the intern always is wrong. And nobody around here seems to give a shit! There are really only three good nurses on this ward. The rest are worthless, lazy, uncaring shitheads who spend most of their time sitting around on their fat asses in the back room, watching TV and eating junk food. They don't want to do anything. They certainly don't want to take care of patients. They're so fucking, incredibly lazy! Anytime you ask them to do anything, even take a patient's temperature, they either take it as a racial slur or as a personal insult. Oh, my God, it's a federal case to get a temp done! I'm used to being in a hospital where the nurses were superefficient; they'd fall all over each other to get an order filled. I'm not used to this attitude.

And there's another problem: There's a major cultural difference. Here I am, this white, upper-middle-class Jewish kid, and most of the nurses are black, working-class women. We're from completely different worlds. God knows what they're thinking when they look at me and the rest of us, but I definitely get the feeling that they think we're a kind of annoyance they have to put up with. There's so few of them who really want to make the effort to work together. Oh, well, what can you do?

We got a really fascinating patient last night. She's this poor little thirteen-year-old Hispanic girl, very cute and extremely suicidal. She was brought in by ambulance because she told someone she had taken a full bottle of asthma medication. She didn't have any symptoms and her theophylline level was zero, so she really hadn't taken anything. But she told the people in the emergency room that voices in her head were telling her to kill herself, so they admitted her. Poor kid, she comes from the original scrambled family. She's under the care of her grandparents, each of whom has attempted suicide multiple times. She's with the grandparents because her mother is a drug abuser who severely beat the girl when she was younger. She lives in a complete fantasy world; she told me about it in vivid detail. But other than listen to her talk, there wasn't anything I could do for her. What she really needs is a psychiatrist. It's sad, it's really sad.

Karen's been here almost a week now. She's doing an elective in Manhattan. I've spent maybe six or seven hours with her, total. Next weekend she's dying to go to Philadelphia and she wants me to come along for this party a friend of hers is throwing. But that would mean I'd have to do every other night on call and I'd have to trade with Margaret, who would have to work an extra weekend day. I don't want to ask her to do that; it's not fair to her and it's also not fair to me. It would mean having to sleep on somebody's floor or something, and I'd come back and have to do the every-other. I'd be completely fatigued and I wouldn't even get to see Karen for five whole days. And that's just to try to go to a little party in Philadelphia. In other jobs, you'd expect to have every weekend off, and it wouldn't be such a big deal to go somewhere and have some fun. As an intern, you can forget it.

This past week Karen has had a very difficult time adjusting to my life. She's been really upset at my absence, at the fact that the first night she was here I fell asleep four times over dinner. She had just had this interview at a program for a psych residency and it hadn't gone well. The place seemed extremely disorganized, the people were disinterested, and they didn't know a thing about her. She was upset and she wanted to talk about it and all I could do was fall asleep; I'm worthless to her! So she was very frustrated. And since that night she's been getting angrier and angrier about the fact that two out of three nights I'm either away or asleep. Fortunately we have this weekend to be together. It's only Saturday afternoon now. I'm going to go to sleep for a while and then we'll have tonight and tomorrow together.