The Intern Blues (34 page)

Andy

APRIL 1986

Saturday, March 29, 1986, 11:30
P.M
.

I'm not going to talk for long because I've got to go to sleep; I'm on call again tomorrow. I'm on Infants'
[NW5—Infants' ward]
; I started a couple of days ago and of course I was on the first night. I got totally fucking killed. I was assigned six kids to start and then I got six admissions and a transfer that first night. It was like thirteen admissions, because I never had a chance to get to know anybody. In any case, it was terrible; I was up all night with a cross-covering resident who was really pretty mediocre; he didn't help organize things at all. Then the next morning was a nightmare; I couldn't present to save my life, it was like being a third-year student all over again. I was tired and they stole my scrubs and . . . it sucked. I felt disorganized, panicky, and I got chewed out by Alan Nathan for delaying giving an antibiotic to a patient. And there was so much scut I couldn't get anything done; I didn't have any progress notes written, nothing! I barely got my admission notes done. I finally got to sit down and write my progress notes at seven o'clock. I had two days' worth of notes to write! I was postcall and I had to try to make some sense out of what had happened over the past thirty-six hours! I didn't get out until after ten-thirty, and that was my post-call night! Ten-thirty at night! I was there for thirty-six hours without a wink of sleep, working my butt off the whole time. I'm still tired, and tomorrow I'm on call again. I think that was probably . . . that may have been the worst call I've had all year. What a fucking nightmare.

Anyway, I'm sure my senior resident, Eric Keyes, whom I like a lot, thinks I'm a complete idiot by now. He probably won't trust me for the rest of the month. First impressions are pretty important.

Tomorrow I'm on call with another idiotic cross-coverer. I won't mention names, but tomorrow I'm on with one of the worst, least-liked second-year residents in the program. What a pain in the butt! You know, they don't give a shit when they're cross-covering, because they're out of there the next morning. They don't have to face up to things; I do! I have to clean up the mess through the entire next day! And then my next call after that is on Wednesday, the day I have clinic. Then I'm on next Saturday. You know what that's like? It's like having four lousy calls in a row. It sucks! I hate it. I really hate this so much. If tomorrow's anything like yesterday and the day before, I don't know how I'm going to get through this month. It's absolutely torture.

Right after vacation to come back to this! I can't tell you! My vacation was pretty good. I'll talk about that some other time.

Monday, March 31, 1986, 8:30
P.M
.

I'm post-call again. Not so angry this time and not so unbelievably tired. I had a really easy night, actually; I got only one hit. It was easy, but still I was running scut until midnight. The guy I was on with turned out to be a completely obnoxious blowhard who at least is pretty smart. He's a total zero as a human, though. Two calls and two total-zero cross-coverers. But now that I got these two over with I'm scheduled to be on with really, really good people during my next two calls. It's just too bad it's worked out in this order.

The nurses are great on Infants'; I really like them. But the place is a zoo; the private patients drive me up a fucking wall. They make me wonder what I'm doing going back to a privately run system. This lady today told me she didn't want me to draw her baby's blood. Jesus Christ! These parents are so uptight and nervous, they always want to come in and see the procedures being done. They can't accept the fact that they shouldn't be in the room. What do they think we're going to do, break their kid's arms? I have to think of nice ways to say, “No, you should wait out here, we'll be back when we're done, it's best for the child, and it's best for you, too. So don't come in!” Usually I don't get nervous when I'm doing procedures, but this lady today was making me crazy! And I couldn't get the blood. It was the first time that's happened to me in months!

I got these new medical students today. Brand-spanking-new students, never been on a ward before, I have this big, hulking guy named Ronald; he seems very nice. God knows; maybe he'll turn out to be a tyrant surgeon a few years down the road. He looks like one. He looks like he's going to be an orthopod. Anyway, I did my best to teach him stuff today, to get him over the jitters of being on the floor with real patients for the first time.

I've been hanging around the hospital too much. I stay too late. I was there until seven tonight. It's ridiculous! Finally Keyes said, “Get the hell out of here, you're just making work for yourself.” He was right! What you're supposed to do is write your notes and get the hell out of there and let the person on call hassle with your patients. I think I'll do that tomorrow. I say I'll try, but I never can; I'm never able to get out before five.

I'm already in bed. It's eight-thirty and I'm already in bed, can you believe that? I'm going to sleep, I don't care. I'm always sleep-deprived; sleep's like going out of style for me. This job is so damn stupid! It's just stupid!

I spoke to Karen tonight for the first time in about a week, because of my stupid on-call schedule.

There I go; I fell asleep again. God! So, I spoke to Karen tonight. She's doing all right. We didn't talk for a long time. I miss her. I can't stay awake any longer.

Monday, April 7, 1986

For some reason, I've had all these revelations over the past week. At least they seemed like revelations at the time. Coming back to them now, they really seem like just a bunch of mundane thoughts. I seem to have them on the scut run between the chemistry elevator and the hematology elevator. I have no idea why, but over and over I get these things popping into my mind while I'm in the back corridor by the back entrance to the kitchen.

One of the things I realized was that, at this point in the year, I feel like I'm getting stupider, not smarter. I know it's not true, but I think maybe it has to do with the fact that the barn door has swung open to the world of knowledge. I guess I'm just realizing what you really need to know to be a decent resident. It's unbelievable; I just feel so stupid. And it doesn't matter whether I read or not; I don't remember anything an hour after I'm finished with it. But I've got to keep persevering. It's funny; I thought I was smart a couple of months ago. I'm not!

I also had this thought about nurses and how night nurses seem to be universally weak in all places except maybe the ICU, where they're still good. I don't know why this is. At night, there seems to be a certain stereotype: the middle-aged, fat, black nurse who's kind of disgusted and noncommunicative. And while she may not be all those things, the stereotype of being noncommunicative and disgusted seems to hold true. I don't know why, but from hospital to hospital, it seems to be the case. And it's kind of distressing because at night there's nobody else there, and sometimes you need to talk to somebody about a patient, and these nurses, they just don't want to talk about anything! Everything seems to be an effort when you ask them to do something.

Monday, April 14, 1986, 2:00
A.M
.

It's 2:00
A.M
. and I've woken up for some reason from my precall sleep. I really should be asleep. I have insomnia. I keep thinking terrible black thoughts because last night I wrote up the protocol for the M and M Conference
[Morbidity and Mortality Conference, a teaching conference run much like chief of service rounds in which a patient who has died is presented; the clinicians discuss the disease process, and the pathologists bring the autopsy report and describe what really happened]
on Emilio, my patient with AIDS who died when I was in the ICU in February. Yesterday I got Emilio's chart from the record room and I wrote up a summary of what happened to him over the weeks I took care of him. It really hurt to do it, to go through that chart again and to see that he was deathly ill the minute he arrived and never improved and that he finally, finally, by the grace of God, died. I remembered how he suffered and how his mother would come and sit by the bedside for hours. About a week before he died, she told me how at times when the Pavulon
[a paralyzing medication]
was wearing off, before he got his next dose, she would see tears forming in the corners of his eyes. She knew he was suffering terribly. But of course he couldn't cry out because he had a tube between his vocal cords and because he was more paralyzed than not. And we constantly would do horrible things to him in our effort to save him from certain death. So I wake tonight with these terrible black thoughts that I'm going to get AIDS, die the same death that poor Emilio died, having my lungs pumped with ventilator air every second, and my limbs poked with needles by young physicians in training, and my neck or groin poked by the fellow trying to put in a line, or my lungs needled and cut, while I hear the doctors saying crass and horrible things about my death and illness, making fun of my debilitated state, while I'm lying naked on a table and shitting on a blue chuck
[a pad made out of the same material as disposable diapers, which is placed under incontinent patients]
, the way poor Emilio did, with no dignity. Just pain. How he must have hurt.

And I think about the Infants' ward I have to go to tomorrow on call and all the sick children I have to take care of there, two of whom are trying to die on me all the time. I don't feel up to taking care of these fragile little things. I'm tired of being abused by the system, of having my sleep taken away every third night, of the stress I'm put under and the illness I'm exposed to, and the pain I have to see and cannot heal. I'm tired of dealing with parents whose pain I can never completely understand because there's never enough time. The only time I have to try to understand what's happening to them is the time I take away from my own sleep. It's a constant battle. The doctors who do the best with their own lives, who get the most sleep and get out the earliest, are the ones who don't talk to the families, who don't play with the children, who don't thoughtfully consider things. But I'm not that way; I'm not efficient. I spend time with the families, I talk with them, and so I get sleep-deprived.

Tuesday, April 15, 1986, 9:00
P.M
.

There's something I haven't talked about yet, something that's really hard about training that most people outside of medicine don't have to deal with, and that's the sense of loss of social skills that happens after you've been working all night. You then have to interact with people in a complex fashion. You have to go on rounds and talk to other members of the staff. I very often find that I have no idea how I'm coming off to anybody else. If people laugh, I can't tell if it's because I said something funny or if I've done something really dumb and embarrassing and that's the only reaction they can have. Am I offending anybody? Do I curse too much? Should I just fart and get it over with? A lot of times I just can't tell, I can't judge what people are saying to me: Are they being serious, are they making a joke?

It's not so bad with other residents. They understand, they can say, “Hey, he's been up all night, he's just post-call.” But what about the parents of my patients? What the fuck do they think is going on? I might be acting really weird. Do they understand it's because I haven't slept in two days? They must think I'm just batty or something. And that's not good, because here they are, trusting me with their most precious thing in life, and I'm acting really flaky. It's an ill-defined concern of mine, but it really bothers me.

Today my student had to give a presentation of a patient. It didn't go too well; it was very rough, to say the least. I like Ron, he's a good guy. He reminds me of how I was as a student. Real nervous, disorganized, can't think on his feet, that's just how I was when I started out as a third-year. Shit, I still get like that sometimes. Anyway, after rounds, Mike Miller, who's our attending, came up to me and said, “Andy, I think you guys have to work on your student's presentation. It really isn't very good.” And I told him I would, it was on the top of my list of priorities. So a little while later I sat down with Ron and we went over how to write up and H and P
[history and physical exam]
and how to present it on rounds. I can imagine what he was feeling: defensive, embarrassed, humiliated. It's one of those awful rites of passage. I don't know, I didn't get much sleep last night, I was really tired, and I wonder what he was thinking. I don't know if I was coming off as a hard-ass, if I was being condescending. I didn't mean to be; I kept saying to him over and over that you're not expected to know this, nobody ever teaches you this. I spent about twenty minutes talking to him about this, telling him the same stuff over and over again. He probably thought, You asshole, stop repeating yourself! I hope he learned something from it, and I'll tell you, the next time I'm on call, next Friday, he'll just have to take the admission and just go over it with me first. When I'm done with him, he'll sound like a master.

It's a beautiful, sunny spring day today. I came home and I really wanted to sit out on the porch with some friend and drink some beers, but I didn't feel like calling anybody; I guess I really wanted just to be by myself. I'm too fucking tired to talk anymore.