The Intern Blues (26 page)
Authors: Robert Marion
Friday, December 27, 1985
It snowed yesterday for the first time this winter. Sarah's amazed. We took her out in her stroller a little while ago and she kept looking down at the ground and looking up at Larry and me as if to say, “Where did all the grass go?” It's funny to watch.
I've been in the nursery at Jonas Bronck for a few days now. So far it's been a mixed experience. I'm assigned to the well-baby nursery, which is nice. I spend most of my time examining newborns and talking to their mothers. That's what I really liked about pediatrics in the first place, and it's nice to have the chance to do it without all the other nonsense that usually takes up our days. So that part of it is good. What I don't like, though, is that my night call is in the neonatal ICU. It's frightening in there! And it's harder for me than for the other interns because, since I'm only in the NICU at night, I don't know the sick ones very well. All I know about them is what the interns sign out to me, and it's impossible to get a really complete sign-out on a patient who has a hundred different problems. So that's frightening to me, but what can I do? It could be worse; I could have to spend all my time in the ICU.
Another bad part about working in the well-baby nursery is that we're always on call to the delivery room. If there's a premature baby being born or a baby who's in distress, the resident and I get called to come to the delivery. It's not really that bad, though, because during the day there's usually a fellow
[neonatal fellow, a physician who has completed a pediatric residency and is getting specialty training in neonatology]
or an attending around, and one of them usually comes in with us. If they weren't there, it would be terrifying!
I have to admit, I've been lucky with my schedule over the past couple of months. I've worked with very good residents and I haven't been on the hard wards or had a lot of bad patients. I guess I should say that I finished on Children's last week and Angela
[the young girl with neurofibromatosis]
was still alive. I heard she got worse the day after I left, though. She had another very long seizure and they had trouble stopping it, so they transferred her up to the ICU. They had to anesthetize her to get the seizure to stop
[general anesthesia is used as a last-ditch effort to stop intractable seizures only after every other treatment modality has failed]
. The intern who picked up my patients told me they don't expect her to survive much longer, only another few days at most. It's really sad; one month ago, she was a completely normal child. Now she's almost dead. That's not supposed to happen to children.
I was on call Wednesday, Christmas Day. It wasn't so bad, since we don't celebrate Christmas, but it was like working an extra weekend day. The hospital was completely dead, even deader than most Sundays. But babies don't know anything about holidays; they crump whenever they feel like it. I did get a couple of hours of sleep that night and I guess I should be thankful for that, but I can see that night call during this month is going to be terrible.
I had only one admission to the unit on Wednesday, a thirty-weeker
[thirty-weeker: a baby born ten weeks prematurely]
who did pretty well. We were in the DR when he was born. The obstetric residents thought he was only going to be about twenty-six or twenty-seven weeks; my knees were shaking while I stood in the delivery room waiting for him to come out. The resident and I were very relieved when we saw such a big baby come out. He weighed about thirteen hundred grams, which is gigantic for the NICU. And he didn't get too sick: He had a little bit of respiratory distress but nothing terrible. All he needed was a little extra oxygen, so we put him in a headbox
[a cylindrical Lucite box that covers the head of an infant and through which oxygen can be provided]
with 40 percent oxygen.
[Normal room air contains 21 percent oxygen; therefore 40 percent oxygen provides about twice the normal concentration of oxygen.]
He never retained CO2
[babies with respiratory distress syndrome, a major complication of prematurity caused by underdevelopment of the lungs, develop a buildup of carbon dioxide, or CO2, in the blood],
so we didn't have to intubate him. He should do fine. His mother is seventeen years old and already has a one-and-a-half-year-old at home. She lives with her mother, who essentially takes care of her and the baby as if they were siblings. It's a funny social system here in the Bronx. Most of our mothers are under twenty, and most live with their mothers, who wind up taking care of the children.
Well, the apartment is quiet. Sarah's asleep, Larry's watching TV in the living room. I'm going to go to sleep. I've got to be up early tomorrow morning so I can be on call.
Saturday, January 18, 1986, 10:00
P.M
.
I haven't recorded anything in a while. I've been very tired and very busy. I'm really enjoying working in the well-baby nursery; it's the first thing this whole year I could actually see myself doing for the rest of my life. The problem is, there's no way to do it without doing a fellowship in neonatology first, and that is something I definitely do not want to do. So once again, I'm kind of stuck.
I've gotten along very well with a lot of the mothers. They seem to trust me. They trust me even more when I tell them I've got a baby of my own who's almost nine months old. I guess they feel they can identify with me. Frankly, I'm not sure how you can be a pediatrician and give advice to mothers without having your own child. Anyway, it's been a very rewarding experience.
I've pretty much gotten my work down to a routine. When I arrive in the morning, I look at the list of babies who were born the night before. All of these kids need to have physsies
[physical exams; all babies get examined within twelve hours of delivery and then again right before discharge]
. I find the babies and do the exams. When I'm done with those, I find the list of babies who are supposed to be discharged that day. I find those babies, and one at a time take them out to their mother's bedside and examine them right in front of their mothers. I found that that gives the mothers the chance to ask about anything they don't understand or anything they're concerned about.
It's amazing how many strange things these women come out with. I had this one woman, a nineteen-year-old who had had her first baby, who asked me about the strawberry hemangioma on her baby's back.
[Strawberry hemangioma is a birthmark composed of a mass of blood vessels; they are very common and usually are of no medical significance; most disappear by the time the child is six years old.]
I told the mother it was just a birthmark and that it wasn't anything to worry about. She asked me three times if I was sure that that was all it was, and each time I told her I was positive. Finally, I asked her why she was so worried about it. She wouldn't say anything at first, but finally I got her to tell me the story. She said she had heard that some people with AIDS had a skin disease that might be the first thing that's noticed. I told her that was true, that the skin disease was called Kaposi's sarcoma. I also told her that babies almost never got Kaposi's and then I asked why she was so concerned. At first she said it was because the baby's father had been using drugs for years and she was worried that he might have AIDS, that he might have passed it along to her, and that she might have passed it along to the baby. I worked on her for a while, and I finally got her to admit that she had used drugs a few times about a year ago and that she and the baby's father had sometimes shared needles. Ever since, all through this pregnancy, she had been scared to death that she had AIDS.
I spent over an hour with her. I asked about all the signs and symptoms that might indicate AIDS. She didn't have any of them, and I told her that was a very good sign. But she said she had been having trouble sleeping at night for a few months because she was so worried and that it was starting to affect her schoolwork. She goes to Bronx Community College. She told me she wanted to be a lawyer but she honestly didn't think she was ever going to make it because she was going to die of AIDS. And then, when the baby was born with the strawberry hemangioma, she had become convinced that not only was she going to die of AIDS, so was her baby. She started crying and I held her hand and comforted her.
I waited until her crying stopped and then I told her that if she wanted, I could take some blood to see if she had antibodies to HIV. She told me she'd thought a lot about getting tested but she was afraid to. She said she didn't know what she'd do if she turned out to be positive. I told her that was a problem, but I pointed out that she was already suffering and it might all be for nothing; there was a good chance, after all, that she'd turn out to be negative. So I guess I talked her into letting me do the test. I had her sign the consent form, and then I drew her blood. I wore gloves when I was taking it. I felt funny putting on the gloves; it was as if I were saying, “I've been telling you I don't think you have it, but I'm not taking any chances.” She didn't say anything about the gloves. I don't know; maybe we make too much out of feeling guilty. So far, whenever I've worn gloves, none of the patients or their parents has said a word.
Anyway, I think I did some good for that woman. Here she had been coming to obstetricians for months, always with this dread fear, and nobody had found out anything about it. And just because I spent a little extra time with her, I was able to discover that her life was being completely disrupted by something that might be totally avoidable. I haven't gotten the results of the blood test yet. But I'm going to see her and the baby in clinic sometime next week, and hopefully by then I'll have the answer. I felt really good about that one.
I've had a couple of cases that didn't turn out that well, though. And one of those made me feel as bad as that last case made me feel good. During rounds our attending, Joan Cameron, always tells us we should try to push breast feeding whenever we get the chance. I have mixed feelings about breast feeding. I mean, I know it's the best thing for the baby; it's supposed to be helpful in preventing infections and things like that, and it's also supposed to help the bonding process between mother and infant. But it's not the easiest thing to do. A woman really has to be committed to breast feeding, and she has to have a lot of support from the people around her. If she's kind of wishy-washy about it, it's just not going to work out.
Anyway, last week I was talking to this woman who asked me about breast feeding. I gave her the party line: I said yes, it's the most important thing you could do for your baby. Then she asked if I had breast-fed my baby (I had already mentioned to her about Sarah). And I had to say that I did it for a few weeks only and then stopped because I had to start my internship. And she said something like, “You doctors are all alike! You tell us to do things you wouldn't be caught dead doing yourself!” And she said some other things that weren't very nice. Basically she called me a hypocrite and she immediately asked for a bottle of formula.
I knew she was right, and she hit a nerve. I mean, I would have liked to have breast-fed Sarah for longer if I'd had the chance. It makes me pretty angry. Here we are, being told by our attendings that we should advocate breast feeding, but there's no way I would have been able to do it with my own baby. How can you breast-feed if you're on call every third night and there's no place in the hospital to keep your baby while you're working? That woman was right, it
was
hypocritical for me to suggest she do something I couldn't do, and it's very hypocritical for our faculty to try to get patients to do something that's best for their babies and not give the house staff the same opportunity. So that situation didn't work out so well. And I'm still angry about the whole thing.
My night call is just about what I expected. I've only gotten sleep a couple of times on nights I've been on call. I'm finding something out: I really need only about two hours of sleep to function well the next day. But those two hours have to be between four and six in the morning. If I'm up between four and six, I'm just about worthless the next day. If I sleep those two hours, even if I haven't seen the bed the rest of the night, I'm fine.
And doing night call in the NICU hasn't made me feel any more comfortable about working with these tiny babies. If anything, I've become more terrified. The unit is brand new; it just opened a couple of months ago, so everything is state of the art. And these babies are so sick! We've had three deaths so far this monthâtwo preemies and one full-term kid. I was on call the night the full-term kid was born. That's something I won't forget for a long time!
We were called to the DR because of thick mec and late decels
[late decelerations: a pattern on fetal heart tracing indicating fetal distress]
. The obstetricians decided to do a stat C section and they pulled out the baby, who was covered with mec. I tried to suction her mouth while she was still on the table, but I guess I didn't get all of it out because she was in respiratory distress almost immediately.
[Actually, the baby had probably already aspirated meconium prior to delivery; in this case, suctioning of the oropharynx probably didn't provide any help in preventing what subsequently happened.]
Eric Keyes was the senior on call with me, and he was on the baby as soon as she hit the warming table
[the table in the DR on which the baby is placed following delivery]
. He intubated her and started suctioning out her airway through the ET tube. He was getting tons of thick mec out. In the meantime, I was listening to her heart. She was really bradycardic
[had a low heart rate],
so Eric told me to start a line and get ready to push meds. I hadn't ever started a UV
[umbilical vein]
line myself, so he talked me through it as he was suctioning out the trachea. When I finally managed to get something in, we changed places so Eric could push the first round of meds. The airway was pretty clear by that point, so I started bagging the baby
[pushing oxygen through the endotracheal tube, using an ambubag to generate pressure]
. The heart rate came up a little, to about 80
[the normal heart rate for a newborn is 120 to 140 beats per minute],
and Eric decided that we'd better get the baby out of the DR and into the ICU right away, so we put the baby in the transport incubator and ran with her down the hall to the unit.