Authors: Robert Marion
The Intern Blues (32 page)
Tuesday, March 11, 1986
For the past two weeks I've been in the OPD at Mount Scopus and West Bronx. It really hasn't been too bad. I've come to realize that I've had to start acting more like a resident; I have to depend more on my own impressions and make my own decisions. The past few weeks have been the first time I haven't felt that the residents and the attendings were giving me good answers or helping me solve problems very well. So it's been a kind of stressful learning experience, but I think I've been doing okay at it so far. I guess this is how you learn to become a resident.
The other night in the Mount Scopus ER was memorable. It was my last official night in the Mount Scopus ER. I was supposed to have another whole month of OPD on the west campus, but I switched to be at Jonas Bronck. Working in the Jonas Bronck ER is a better learning experience. So it was my last on call; I can't say I'm not happy to get it over with.
It was also one of the worst nights I can remember. There was a tremendous volume of patients; they kept just coming in. It was nuts! At one point we were fifteen charts behind, which is a lot for that place, but we couldn't make any headway because we had about a half dozen acutely ill children. And the place has only four rooms; we were spilling over into the adult ER. Let's see: We had two head traumas in various states of coma; we had a diabetic with sickle-cell disease who was in the middle of a painful crisis
and
in DKA
[diabetic ketoacidosis, the buildup of acid in the blood of diabetics caused by high sugar in the blood and inability of the cells of the body to use the sugar for its normal processes]
; we had a little baby sickler with fever; we had a couple of vaginal bleeders and a drug overdose. All of these were occurring pretty much simultaneously. And it was just me and a senior resident who was not the greatest doctor you ever saw. We couldn't get help from anybody. The attending was over in the West Bronx emergency room. Every time we'd call with a problem, he'd say, “Well, it doesn't sound
too
bad. Call the senior in the house
[the resident in charge of the inpatient service at night]
if you're worried.” He wasn't even concerned! What a shithead!
I never ran as hard as I did that night. Finally at one point the nurse, who was fabulous, said to us, “Please call for some help!” So we did. And then slowly but surely we got some of the docs who were on call on the floors down there, and we cleared the place out. But it was still crazy the rest of the night. Right before we were going to leave, this fourteen-year-old girl who's an asthmatic and has been intubated twelve times came in tight as a drum.
[She was not getting air into the lungs. Asthma is caused by narrowing of the air tubes. When these air tubes are slightly narrowed, wheezing will be heard in the chest; when they become very narrow, as they were in this patient, no breath sounds are heard and the patient is considered “tight.”]
We had to intubate her in the ER. I didn't get out of there until 3:00
A.M
., which is late for Mount Scopus.
Karen left a couple of weeks ago after nearly two months of that subinternship she was doing. It was sad taking her to the airport. Fucking LaGuardia Airport; I really hate that place! I've felt very blue since she left. I've been missing her a lot and it's been a real drag being apart like this. She's doing obstetrics/gynecology now; she has to be on call every third night, and our schedules are completely out of whack. We've been able to talk only a couple of times in two weeks. It's weird. But we'll be together soon. It won't be too long before this insanity is over.
Last Tuesday was my birthday. I was post-call and I felt terrible, and I didn't want to celebrate at all. I went to visit my friend Gary and his roommates out in Brooklyn. I had a good time. The next day I went out with my friend Ellen. We went into Manhattan and had a wonderful time. Anyway, the weekend was pretty good.
I've been kind of reflecting on what's happened over the past few months. I've been thinking about what's changed. One thing is, I really don't feel much like a medical student anymore. Occasionally I get into situations where I remember what being a student felt like, when I have no idea what I'm supposed to do. That's what being a medical student is all about, always with an undefined role. When that happens now, I remember how frustrating it was. I am more comfortable with making decisions now, but I don't think I'm ready to dictate those decisions to other people the way residents do. That's still frightening to me.
I'm staring to realize what I need to do to become a better doctor. I've got to become faster and more selective, be able to narrow things down quickly and home in on the diagnosis, because those are the things I'll need to be good at when I'm a resident.
So anyway, I guess I'm starting to become a master of internship, which is supposed to happen around now. I've become damn good at being a scut puppy, a data gatherer. I have a couple of tough months ahead: Infants' (pain and torture but with some good people); and a month in the Jonas Bronck OPD, which will be great but tough; and then my last month here, 6A. What a good-bye kiss!
Thursday, March 13, 1986, 1:30
A.M
.
I got back from the West Bronx ER a little while ago. It was a typical West Bronx night. As soon as I walked in, Andy Ames signed out a child-abuse case to me. It took the usual form of no one understanding where the second-degree burn on the child's right leg came from. The social worker who called in the case had naturally gone home, and Andy was also gone, so that left me in charge. When the father came in angry and hostile, he couldn't find anyone but me to threaten. Everything was getting out of hand, and then the police showed up to start their investigation and that led to more havoc. Christ! Anyway, the BCW finally decided that since there was no obvious perpetratorâthat is, no one had come forward and said, “Yes, I did it, I was the one who burned the baby,” they let the kid go back home with the parents. I said, “Fine! Let him go home. What the hell do I care?” That's typical of the BCW! And what usually winds up happening is the kid'll show up next week or next month or next year dead. But what can you do? You can't fight the parents
and
the BCW. That's a little too much to take on.
The rest of the night was the usual. We had a bronchiolitic
[a child with inflammation of the bronchioles, the small airways leading from the larger bronchi to the lungs; children with bronchiolitis are usually under one year of age, and have respiratory symptoms that are very similar to those of asthmatics]
who probably has pneumonia
[since bronchiolitis is caused by a viral infection, it's not unusual that pneumonia, or inflammation of the lung itself, is often an accompaniment]
who bought himself a bed on 6A. I also saw this girl, a skinny seventeen-year-old who had hematuria
[blood in her urine]
and stabbing pain in her right lower quadrant. When I told her I had to do a pelvic exam, she refused. She said she'd allow it only if someone from Gynecology did it. I paged Gynecology three times and they didn't answer. The next thing I knew, the patient's uncle was calling from a phone booth on Jerome Avenue. He said the girl had got fed up with the whole thing and just walked out of the ER and he followed her down to Jerome. So he was calling very apologetically to say that she wouldn't come back. Right under our noses, she just walked. She was actively bleeding from somewhere; whether it was her vagina or her uterus, God only knows. But she up and left. Unbelievable! So I got on the phone with her and said, “Look, you know you're leaving against medical advice. I advise you to come back to the emergency room right away.” She said, “No way! No fucking way!” So I said, “Promise me one thing: If you start to bleed profusely, you'll go see another doctor.” She said, “Well, maybe.” That was it. She just walked!
At about ten o'clock, the ER filled with exhaust fumes from the ambulances parked outside the emergency entrance. Exhaust fumes! That was great for the asthmatics. They thought they had come in to get treatment for their asthma; they wound up leaving in worse shape than they'd been in when they first got there! And the place was scorching hot for several hours; it must have been in the mid-eighties in there. God knows why! I felt very rundown and I had no appetite. I ate nearly nothing the whole night. I didn't want dinner. That whole child-abuse case was getting me down; it killed my appetite. But we finished at one, which isn't bad, and I came back home and listened to the messages on my machine. I ate some food and I'm listening to this music now and suddenly I'm on vacation. Tomorrow I'll be home! Strangely, I'm not that excited about it. I am excited about seeing Karen and my parents and everything, but I'm not excited about the idea of going home itself. It's funny, I think it's really starting to bother me that I'm going to be leaving the Bronx for good in a couple of months. I'm starting to feel that I've made some good friends here and I know I'll have to leave them and I'm already getting sad about it, three and a half months ahead of time. Isn't that terrible?
Wednesday, February 26, 1986
It's the last night of my last vacation of internship. Tomorrow I start on 6A
[at West Bronx]
. I haven't worked there before, but I've heard it's a real killer. And of course I'm on tomorrow night. So I've gotten myself really depressed.
These past two weeks have been very special to me, very relaxing and calming and restful. This was the first time I've been able to be a full-time mother, twenty-four hours a day, seven days a week, without interference. Since I started my internship, Larry and I have never been alone with Sarah for such a long stretch of time. There's always been someone else around. This was my first opportunity to get to know my daughter. I did everything for her: I changed her diapers and fed her her meals, I got to talk to her and to watch her go through her normal activities without any interruptions. And I actually managed to watch her take her first step! It happened about a week ago, while we were in Florida. She's been cruising for a while now
[cruising: walking while holding on to a surface, usually a bed or a table]
, but one morning last week she just let go and took three steps without holding on. It was great.
So I really got the chance to know what being a mother is about during this vacation. And I liked it. I liked it a lot. It sure is better than working in all these damned hospitals where nobody cares about anything except themselves. I really don't want to go back. I just don't want to go back to work tomorrow.
So what else can I say about the vacation? We stayed at a condominium in Fort Lauderdale. We went to the Miami Zoo, we went to the beach, we went out on day trips, we did a lot of things. I caught up on some sleep, and I had a lot of time to think about what's happened over the past few months and especially about what happened at the beginning of February. The more I think about it, the angrier I get. I really was taken advantage of! There was no need for the chiefs to do what they did to me. They definitely could have let me go home and found somebody else to cover the ER that night. It wouldn't have meant that much to them, but it sure meant a lot to me! I thought that going away, taking some time off, would make me ease up on this. But it didn't. I can't forgive them. And I can't forget it.
Well, I'm going to put Sarah to sleep now and then I'm going to try to relax a little. I'm really very tense about tomorrow.
Saturday, March 1, 1986
So far, 6A hasn't been as bad as I thought it would be. The census is low and it's a good thing because the chief residents are trying to screw me again. It may actually work out in my favor this time. I'm sure they won't be too happy about that!
What's happening is, there are usually four interns working on 6A. It's a big ward, there's the capacity to house fifty patients, so when it's busy, you really need to have four interns. But this month, we're one person short. That's because the fourth intern is supposed to be a psych rotator
[psychiatry residents have to work for four months on either internal medicine wards or, if they're interested in child psychiatry, on general pediatric wards during their internship year]
, and he's not going to be showing up. The reason he's not going to be showing up is that the people who run the psych program felt he was too “psychiatrically unstable” to do a rotation on a ward as stressful as 6A. So rather than having four people covering, we have only three people. It's too stressful for the psych rotator when there would have been four, but nobody's concerned about how stressful it's going to be for us now that there are only three. That's typical, typical! But I just might luck out because of the solution the chiefs have come up with.
What they're doing is this: Usually the interns are divided, two working with a senior resident, the other two working with a junior resident. Because we were short, the chiefs decided that the other two interns would work with the junior resident and I would work alone with the senior resident. The senior this month is Ben King, who is one of the best people in the program. He was the person who let me leave the morning after my last night on Adolescents' so I could catch the flight to Israel. So I'm very happy to be working with him. The junior resident is Dina Cohen, who's one of the worst people we have.
Because there's only one intern on our team and two on the other, we started off the month with only one third of all the patients. And not only that, but on that first morning, Ben was smart enough to realize that most of the patients who were assigned to us didn't belong in the hospital in the first place. I started Thursday morning with seven patients. When we made rounds, Ben decided that three of them could be sent home right away, so I was down to four. I got only one admission Thursday night, and one of the other patients went home yesterday, so tomorrow I'll start with only four patients. That's not bad for 6A; that's not bad for anywhere. And none of them is what you'd call sick. Two are preemie growers.
[Six-A serves as an “overflow valve” for the neonatal intensive-care unit; when the unit gets crowded, preemies who have outgrown the problems of prematurity and only need to gain weight are transferred out to the ward. These babies frequently continue to have more problems than normal, healthy babies of the same age, however. Caring for a preemie who graduated from the unit is not just a baby-sitting service.]
One is a kid with AIDS who's here just because he's got no place to go. And one is a six-month-old with meningitis who's doing pretty well; he's just in the hospital to finish his two-week course of antibiotics. So, so far I don't have much to do. I'm not complaining about it. I know it won't stay like this for long.
Thursday, March 6, 1986
I was on last night with Dina Cohen. Jesus, what an airhead that woman is! She's completely incapable of making a single decision. She's totally incompetent. Yesterday afternoon, Margaret was signing out and she told me she had this adolescent girl who had come in the night before with abdominal pain and a positive urine pregnancy test. An emergency sonogram had been done that showed something around the right ovary. Ben was sitting next to me, and when he heard Margaret say all this, he got very upset because he knew the girl had to have an ectopic pregnancy
[a pregnancy in which the gestational sac implants someplace other than in the wall of the uterus; it is dangerous because it can cause a massive hemorrhage]
. Ben asked if Gynecology had come to see her, and Margaret said, “No, they haven't even been called yet.” Ben just about blew his top! He ran over to Dina and asked her about it and she said, “Well, the ultrasound attending said it wasn't a conclusive study. He thought it could either be an abscess or a cyst or an ectopicâ” Ben interrupted her and yelled, “It is an ectopic! You have to call Gynecology right now!” And Dina said, “Well, I'd rather be sure first. I think we should do a beta HCG
[a blood test for pregnancy; more accurate than the usual urine pregnancy test]
, but you can't get it done until tomorrow morning. Can you imagine? You can't get a beta HCG done in this hospital after twelve o'clockâ” Ben stopped her right there and said, “Dina, think a minute! You've got an adolescent with abdominal pain, a positive urine pregnancy test, and a finding consistent with an ectopic on ultrasound. You don't need a beta HCG. What you need is a gynecologist. They have to take her to the OR right now or she may bleed out before tomorrow morning!” Then Dina said, “Well, I thought we should do more testsâ” And Ben said again, “You have to call Gynecology right now. Don't you understand?”
He finally convinced her to make the call. They came and saw her at about five o'clock and took her to the OR almost immediately. Of course, she had an ectopic. If Dina had waited and hemmed and hawed a while longer, that girl might have bled out right there on the ward!
Needless to say, I didn't feel very comfortable being alone with Dina for the rest of the night. The girl with the ectopic did okay. She stayed in the recovery room for a few hours and then came down to the floor at about midnight. And luckily, it was a quiet night; I only got one admission, and that was an asthmatic who didn't require any kind of expertise in his management. So I didn't ask Dina for any help all night long. I didn't even see her after midnight; she went off to sleep in her on-call room.
Sunday, March 9, 1986
It was seventy degrees todayâreally spring. We spent the day out on the grass in front of the apartment building. Sarah loved it. She got a chance to toddle around and see some of the other children. It was a really nice day.
Things on the ward are okay. I'm still getting along well with Ben. He's just great, the best resident I've ever worked with. He's got good judgment, he knows what's important and what isn't, and he's got a good sense of humor.
But the other team is having a lot of trouble. Because Ben knows when to send patients home and Dina doesn't, they now have almost all of the patients on the ward. And to make matters worse, the interns are finding it very stressful to work with Dina. Laura's doing okay; she's a very good intern and she doesn't have to rely on anybody for much help. But Margaret isn't as secure about herself and she's having a very hard time with Dina. On morning rounds on Friday, Margaret completely fell apart. She started crying, saying she couldn't go on. She refused to work up a patient. She wound up spending a few hours in the chief residents' office. She just needs more help than Dina can give her. I think there's also a lot of other things going on in her life now. But that's true of all of us, isn't it?
The chiefs decided that they had to get Margaret out of the hospital for a few days. How nice of them! She's stressed, so they give her the weekend off. My daughter gets the measles and is sicker than most of the patients who come to the emergency room but I still have to work! That's typical! Oh, what's the use? What's the use of talking about it and thinking about it over and over again?
Anyway, Margaret got to go home Friday afternoon and didn't have to come in for her call on Saturday. She's got a great medical student, Susan, who's running the service for her. Susan took Margaret's call on Saturday and did a good job. She did as well as a lot of the interns. I wish I had a student like that. I haven't had a good student all year. All my students have ever done is complain. They don't want to do scut, they don't want to run to the labs, all they want to do is stand around and be spoon-fed information twenty-four hours a day. Susan isn't like that; she's willing to work. A student like Susan can make internship a whole lot easier.
Actually, having a good student doesn't matter for me right now. I've still been having great luck on call. I've gotten only one or two admissions per night. I left yesterday with only three patients, and one of those is probably going to go home tomorrow. That'll leave me with only my AIDS patient, who's really just a social hold, and one of the preemie growers I picked up when I started. Neither of them requires any real work. I should be able to leave tomorrow right after work rounds. I'm planning to go home at ten o'clock in the morning! It's amazing!
Saturday, March 15, 1986
I just finished putting Sarah to sleep. This is my weekend off. It's been a strange week. Work's fine, there's no problem there. But Larry got called away on business on Monday. He's in Switzerland and he'll probably be gone all next week. It's been hard for me. I've had no relief in taking care of Sarah at night. Usually, when I'm post-call, Larry handles her 3:00
A.M
. wake-up; usually I don't even hear her cry. But on Wednesday it was all me, and I was tired. I don't know how I got through it.
We got Marie to stay over on the nights I don't come home. She wasn't very happy about doing it and it's costing us an arm and a leg, but what else could I do? Someone has to be with Sarah; I can't take her to the hospital with me. I'll be happy when Larry gets back. His being away like this makes me realize how much I depend on him!
I haven't been feeling very well, either. I've been very tired. And I've lost my appetite. I think I've just made it to the point in the year where I'm simply exhausted all the time. I know a lot of the other interns have gotten to this point already; I'm surprised it's taken me this long to get here. And being tired sure isn't making it easier to take care of Sarah by myself!
My luck has been holding: I got two admissions last night; and when I was on this past Tuesday, I didn't get any. But that doesn't mean I've been getting a lot of sleep. The other team's been getting killed on their on-call nights. They've got a lot of patients, and some of them are really sick. So I still wind up staying up, doing scut on their patients all night long. More IVs fall out on 6A than anyplace else I've ever worked. I don't know what it is about that ward! Some of the other interns say the nurses actually pull the IVs out, but I don't believe it; to pull out an IV would mean the nurses were actually touching the patients. So far I haven't seen one come that close.
Friday, March 21, 1986
I know this is going to sound crazy. It doesn't make much sense, but it's true. I'm pregnant! I found out today. I think it's great, but I know everybody else is going to think I'm crazy.
I've been feeling lousy for a couple of weeks now. I've been run-down and a little nauseous all the time, but I just figured it was internship finally getting to me. And my period didn't come last week, but that's not so strange; it happens to me a lot. I saw Susannah in clinic last week and I was telling her how bad I was feeling and she said, “It sounds like you're pregnant. Is that possible?” I hadn't really even thought about it until then. I told her it was certainly possible, and she told me to send off a urine sample. I found out this afternoon that it was positive. Unbelievable!