The Intern Blues Read online

  And I’m entering with expectations that this’ll be an exciting and interesting time in my life, with memories I’ll always cherish. I know it’s not going to be easy, and it’s not going to be a lot of fun. I’m going to feel lousy a lot. But I hope when I’m all done, I’ll be able to look back at these years and be able to say that the time was better spent as an intern than in almost any other way I could have spent it. I’ve invested four years in this already; if I invest another three years and wind up realizing I hate being a doctor, well, that’s seven years of my life completely wasted. I’m twenty-seven, I’m still a young guy, but seven years of wasted time, that’s pretty sad.

  And finally, after all these emotions and worries, it started. I was on call on Saturday in the Mount Scopus emergency room. Once the day began, it really wasn’t so bad. There was just a resident and me. My first case was a little eight-month-old with a really bad case of cervical adenitis [swelling of the lymph nodes in the neck due to infection], and I thought, wow, here I am, a real doctor, with real pathology. I wound up having to admit the kid for IV antibiotics.

  I did pretty good during the day, I was really enjoying it. I wasn’t scared, I wasn’t freaked out and I don’t think I made any really horrible mistakes. I went at my own pace, which was about half the speed of the second-year residents but I felt good about it. I did an LP [a lumbar puncture, commonly called a spinal tap, a test in which a needle is inserted through the back and into the spinal canal, so that a sample of spinal fluid can be obtained for analysis] on an 18-month on whom we had a suspicion of meningitis, and it went perfectly. I got the spinal fluid and I started an IV without any problem at all. I did a CSF cell count [counting the number of white and red blood cells in the spinal fluid specimen in order to diagnose meningitis], and I learned a bunch of good bench lab stuff that I never knew how to do before. Hell, it was a good day and we even got a chance to eat dinner. I got out of there at 12:30 A.M., which isn’t bad. I have to say my first night on call was a positive experience, which gave me a good feeling about coming to this program in the first place.

  Sunday, July 7, 1985

  Karen went back to Boston today. Even though she’ll be back in three weeks to visit for a weekend, I know things are not going to be the same as they were for at least this whole year. I took her to the airport, she went through the gate, and I stood there waving and she waved back until all I could see was her arm. Then that disappeared and she was finally gone.

  I got back from the airport and putzed around the apartment for a while, feeling aimless. I dropped off Ellen O’Hara’s [one of the other interns] car keys—she had loaned me her car for the weekend—and Ellen and I talked for a while. She was a little spacey; she’d been on in the NICU [neonatal intensive-care unit] last night and didn’t get any sleep. Then I went out shopping.

  I was in the vegetable store and I had this really funny feeling, like I couldn’t think clearly for a minute. I couldn’t figure out what was wrong at first, but then I realized that I was shopping for myself. I started feeling really bad because I’d be the only person in the apartment eating this stuff. When I got back from the store, I called Karen right away. She was home already. I told her how much I missed her and how lonely I felt. She told me she felt the same way. We talked for a while and when we got off the phone, I felt real down, real down, and I didn’t know what to do. I just walked around the apartment, feeling very empty. I felt like I wanted to cry, so I sat down at my desk but the tears wouldn’t come. I had to talk to someone; the only person I knew was Ellen, so I called her and told her I’d like to come and talk for a while and she said sure. I went up to her apartment, she opened the door and asked what was wrong, and I told her I was feeling real low. We sat down on her couch and I started crying. I kind of fell onto her shoulder and cried for ten, fifteen minutes, really crying, soaking her blouse. She held me and I held on to her. I felt a lot better after that. We talked about getting together for dinner, and so I went back down to the store to get more food.

  That was amazing! That kind of thing, crying on a total stranger’s shoulder, is not something I’ve ever done before. I was feeling bad, really bad, and she was the only person I even knew here. All I can say is, I’m glad there are people like Ellen in this program.

  But all is not lost. When I went out for food the second time, I found a store that sold Häagen-Dazs ice cream! Häagen-Dazs in the Bronx! Amazing! [Häagen-Dazs ice cream has always been manufactured in the South Bronx.] There’s hope for this place after all!

  Work is good. I’ve finished my first week as an intern, and it’s shown me that I actually like being a doctor. I enjoy the people I’m working with, I like the kids . . . I’m rediscovering some of the things that made me go into pediatrics in the first place. This week, working in the ER [emergency room] and the clinics, I saw more kids than I had seen during the entire six-week rotation I spent in pediatrics in medical school. I love the kids, but I can see that the adolescents can drive you nuts!

  There are a lot of things I don’t understand about adolescents. Do you examine them with their parents in the room? Do you throw the parents out, and if so, when do you throw them out? And there are all these hidden agendas going on between the parents and the kids. The other day, I saw a fifteen-year-old girl with a vaginal discharge. Her mother insisted on staying in the room the whole time. I felt pretty uncomfortable asking the girl whether she was sexually active or not with her mother standing right there next to her, but the woman just wouldn’t leave. So I wound up doing a pelvic exam and getting all the cultures and stuff without even knowing what I was looking for. I guess when I get some of these issues sorted out, I’ll feel better about them, but as of now, give me those toddlers and little kids anytime!

  I’m starting to feel more confident and more willing and able to see patients without supervision. [In the beginning of the year, interns working in the emergency room are supposed to check with the attending on duty before discharging any patient.] It was so busy the other day, I didn’t have time to check everything out. We were about four hours backed up most of the time and I was just running from one thing to another without any time even to think, let alone consult an attending. Occasionally I asked for advice just to check myself, and the attending who was on call in the ER always agreed with what I wanted to do. That felt good; it was a real boost to my ego.

  There is one thing about work that’s starting to bother me, though. When I was in medical school, one of the things I liked best about pediatrics was dealing with the parents. Over the past few days, though, I’ve found myself getting really annoyed with some of the parents who bring their kids to the emergency room. For instance, this mother brought her two-year-old in the other night. When I asked her why she was there, she said, “My kid hasn’t gone to the bathroom for two days.” All she had was minor constipation, for God’s sake! And the woman hadn’t even tried anything. Here it is, twelve-thirty in the morning, and there’s an eight-year-old boy in the other room who just got his eye blown out by a firecracker. And there’s a five-year-old sickler with a fever in painful crisis [a child with sickle-cell anemia, a common inherited disorder mainly occurring in blacks and Hispanics, in which the red blood cells collapse when the blood oxygen is low; the collapsed, or sickled red blood cells clog up the smaller blood vessels, leading to obstruction and further lack of oxygen, which results in pain in the hands and feet; in a patient with sickle-cell disease, fever can be a sign of serious, possibly overwhelming infection], it’s time for me to get home, and this woman brings her child in for minor constipation. I wanted to strangle her, just put my hands around her neck and strangle her! And this kind of thing isn’t unusual. It happens all the time, every night, that’s why there’s always a three- or four-hour wait to be seen. I tried to be nice to her, but I can’t help getting really pissed.

  Occasionally there’ll be parents who seem really weird. The other day, this woman came in with her two kids who had colds. She was like a street
person, she was carrying around all her possessions in shopping bags and she was dirty and her hair was all matted. The kids seemed perfectly okay though. There wasn’t much I could do; just examine them, tell her to give them Tylenol, and send them on their way. But it bothers me; there has to be something wrong there. I’ve tried to figure out a way to get kids like that away from the parents, to protect them, but it seems to be impossible to do unless the parent actually harms the kid. You can’t call the BCW [the Bureau of Child Welfare, the state-run agency that investigates physical and sexual abuse of children] just because a mother looks and acts a little funny. Even when the parent actually does harm the kid, like when they beat the kid with a strap because he or she misbehaves or acts up, it’s sometimes difficult to do anything to prevent it from happening again.

  Tuesday, July 9, 1985, 3:00 A.M.

  Must internship really be like this? Must it really have hours like this? Today was just one of those long, zooish days. I had clinic this morning, had about three seconds for lunch, went to the emergency room where there was already a big pile of charts in the triage box, and that’s how it stayed until a little while ago. There wasn’t even a minute to get some dinner; I was starving, but there just wasn’t any time to stop. We kept working and working and the triage box of charts of patients waiting to be seen just kept getting bigger and bigger.

  I’ve noticed I’m not nervous anymore. I did another spinal tap today, on a little one-year-old with a fever who had had a seizure. It went fine, the kid didn’t have meningitis, it must have just been a febrile seizure [a convulsion that occurs with fever and having no adverse long-term effects]. I admitted a kid with anemia, the second kid I’ve admitted since starting. I used to sweat like a pig when I had to do procedures and stuff; I don’t seem to be sweating much anymore. It happened very suddenly. So far, internship has been a period of exponential learning. I just hope all I’m picking up sticks.

  I still can’t believe I’m getting paid for this. But I’ll tell you, I don’t think it’ll be long before I start thinking I’d damned well better be getting paid for this. I think that happens when you start to respect your skills. I’m not there yet; but I’m getting there, I think.

  But I do get really pissed off about working in the West Bronx emergency room [West Bronx, also referred to as WBH, is a municipal hospital adjacent to Mount Scopus]. I was drawing blood today from a four-year-old and I had to stick him three times because he kept pulling his arm away and pulling out the needle. The reason he kept pulling his arm away was because the nurse wasn’t holding him tightly enough. When I told her, she said, “I don’t care, I don’t give a damn!” Oh, really! She just didn’t give a shit about the kid! Here’s a woman who must really love her job.

  I forgot to talk about something I can’t believe I haven’t mentioned yet. Something really significant happened tonight, something horrible, and I guess I blocked it out of my mind for a while. As the triage box was filling higher and higher with charts and we were getting farther and farther behind, we were called by a frantic clerk to come over to the critical care room. He said there was a pediatric cardiac arrest going on.

  So we tore over there to see what was happening. I got there first. I found the place jammed with doctors and nurses working on what looked like a pretty big adolescent. They were pumping on his chest, they had him hooked up to the cardiac monitor, they were sticking him for blood and starting big IVs in his groin. I had no idea what to do. The resident showed up a few seconds after I got there and we stood around for a couple of minutes until they just told us that we could leave unless we wanted to run the code. “No,” we said (laugh), “it looks like you guys are doing just fine.” But no one had taken a history yet, or even talked to the mother, so the resident told me to go out there and get the story. I found the woman; she was perched outside the critical care room looking scared to death. I took her over to the social work office and started talking to her.

  Briefly she told me the kid was a fifteen-year-old asthmatic who’d been in the middle of a bad asthma attack when it sounded like he had become obstructed [the main breathing tube, the trachea or one of the mainstem bronchi, the tubes leading from the trachea to the lung, became blocked]. He stopped breathing and they loaded him into a car and sped off to the hospital. They were headed for Jonas Bronck but on the way the kid was snatched up by a passing EMS team and brought to West Bronx. He had been pulseless, breathless, and unresponsive for God knows how long. When he got in the ambulance, he had vomited and aspirated [leaked stomach contents into his lungs] and gone into arrest.

  So he was kind of dead when they brought him in, but I don’t think I really believed it. His first pH was 6.9 [indicating severe buildup of acid in the blood, a condition resulting from lack of oxygen delivery to the tissue and not consistent with life for longer than a few minutes], which isn’t great. His heart was beating only about eight times a minute, but he was a kid, and kids just don’t die like this. Not the ones I’d known anyway.

  When I was getting the history, the mother asked me, “How is he, Doctor?” and I was about to say . . . I don’t know exactly what I was about to say, but then the clerk opened the door and took the mother away because he had to register the kid or something administrative like that, and I left, after telling her I’d come back to talk to her again when she was done.

  Next thing I knew, that clerk came back to me, not as excited this time, and he said, “The kid died; he’s dead.” I couldn’t believe it. I knew he hadn’t been doing well and that they were doing everything they could for him, but dead? I just couldn’t believe it. I had to walk in and see him myself.

  In the critical care room, the crowd was gone; there were just a couple of nurses, removing all the lines and stuff, cleaning him up, getting ready to bag him, and there he was with his glazed corneas—yeah, he looked dead, all right. The medical resident came in and we talked about it for a minute. No one had said anything to the family yet. I told him I’d gotten the history from the mother. “Well, I guess you’re the only one who’s established rapport . . .” he said. Rapport? I spoke with the woman for five lousy minutes; that’s not exactly what I’d call establishing rapport.

  But I was elected. Other than me, nobody had even laid eyes on the woman. The medical resident said he’d come along with me. On the way back to the social work office, I stopped myself and thought, What the hell am I going to say to this woman? I knew she was totally unprepared for this. When I had talked with her earlier, I got the impression she thought everything was going to be okay. I knew things weren’t okay. I had seen him getting his chest pumped, being a full code. I should have said, “Your son is in critical condition. There’s a chance he won’t make it.” I wish I had said it when I’d had the chance, but then that damned clerk had come in and had taken her out to register her. I should have booted him out, told him I was talking and that it was important, but I didn’t think to do that, so I didn’t get to prepare her in any way. Ah, maybe she didn’t want to know, maybe she would have been worse off had I tipped her off beforehand. Who knows?

  Anyway, there I was, sitting in front of her in the social work office, and the medical resident was standing behind me and there she was, looking at me, not having a clue what was going on. All I could think to say was, “I’m sorry, but I have to tell you, your son is dead.”

  She looked at me, her eyes bugged out, and she became completely hysterical. And the woman who was there with her also became completely hysterical. They began screaming in Spanish and wailing and throwing themselves around. I didn’t understand a fucking word they were saying, I didn’t know what was going on, they were making a tremendous ruckus and I just . . . I just didn’t know what to do. It was a terrible moment. I felt completely powerless. I couldn’t think of anything to make her feel better. It was probably the most horrible moment in her life.

  As we were walking to that room and I knew I was going to be the one to tell her about her son, I remembered hearing about sit
uations like this, when you have to tell a mother that her child has died, and you don’t even know her; you’re just on call and it’s not your patient and you just kind of get signed out to take care of the dying person. I expected it to happen sooner or later; I’m just kind of surprised it happened so soon in my internship, in virtually the first week.

  Wednesday, July 10, 1985

  I spent the afternoon in the West Bronx ER, where I had a great case. We had this kid I saw a couple days ago, the one-year-old who came in with a febrile seizure. I tapped him and found he didn’t have meningitis, but today the blood cultures I’d sent came back positive, with gram negative rods [meaning that there was a bacterial infection in the blood with a bacteria called E. coli, a potentially serious infection]. We called the kid back in and he still had fever on the antibiotics I had prescribed, so we admitted him for treatment of sepsis [infection of the blood].