That’s why Mark Greenberg came to the Bronx. He told me he wanted to get as much experience with as many types of patients as possible during his training. After meeting him for the first time at orientation, I got to know Mark a little better this month. He told me he had chosen pediatrics because it was the third-year clerkship he had enjoyed the most. He had liked it for the same reason most people are attracted to the specialty: He said it seemed to make more sense to watch sick children get well than it did to watch sick adults get sicker and die.
Mark told me his biggest problem with being an intern is that his brain is always tending toward entropy. Unless he tries very hard to keep his life controlled, he becomes exceedingly disorganized. Disorganized is not a great way to be during internship. All interns share a common short-term goal in life: to get out of the hospital as soon as possible. One must be very organized to accomplish that. If Mark continues to be disorganized, he might have to consider permanently moving into an on-call room.
There’s something about Mark I noticed very early in the month. It’s a funny thing: There are some people who look great after a night on call. No matter how many admissions come in and how little sleep they get, these people look unbelievably good the next day. Mark is definitely not one of these people. He had a couple of bad nights during July, and this was readily apparent in his appearance the next morning: His eyes were very droopy; his reddish-blond hair was uncombed and shot straight up in the air in all directions; and his clothes looked as if they’d been slept in, which obviously was not the case because Mark always claimed that he hadn’t gotten any sleep at all.
Amy Horowitz didn’t really decide to come to Schweitzer; she decided to stay here. She had been a medical student in the Bronx and had stayed on because she liked the program and felt comfortable with the people. She’s always lived in the New York metropolitan area. Born in Morristown, New Jersey, she was her parents’ only child. Her father owns an office supply business.
I’ve known Amy for a little over a year. In March, when she was in the ninth month of pregnancy, she told me that she’d thought a lot about being an intern and having a young baby but was somewhat concerned that she wouldn’t have time to be both a good intern and a good mother. But she’s convinced she can do it. It’s because of this conflict that Amy’s the one intern in the entire incoming group about whom I’m truly worried.
Early in the month, a crisis developed involving Amy. While working in the emergency room at Jonas Bronck, she was told by one of the attendings to get some blood tests on a patient. Amy swears that she drew the blood and sent it off to the lab. The attending, in checking on the situation a little later, could find no evidence that the lab had received the specimen or even that the blood had been drawn. He confronted Amy and, when she affirmed that she had done what was requested, he accused her of lying.
Whether this is true or not, lying about lab results is about the worst sin a house officer can commit. The implications are far-reaching. First, although our department is immense, word of mouth travels like wildfire, and within three days of this incident, rumors about Amy had already reached every member of the outpatient faculty. Second, and more importantly, whether she was guilty or not, Amy has lost a great deal of credibility. Interns have to be trusted. Although life-and-death decisions are always made by more senior physicians, such as attendings or chief residents, interns must be expected to function fairly independently with only occasional supervision when it comes to performing the more mundane, everyday types of activities, such as drawing blood, checking lab results, ordering tests, or making appointments for their patients. Amy’s ability to function independently has been called into question. Whether she drew that blood or not, Amy probably will have an attending or senior resident perched over her shoulder at all times to make sure she does what she’s supposed to do, at least for the immediate future. Amy is smart and a reasonably good worker, and within a month or so she’ll probably make everyone forget that this happened. But if she screws up just one time, she’s going to get nailed. And that could be it for her for the rest of this year.
I’m pretty sure Andy Baron doesn’t want to be in the Bronx. I think he was one of those people who had a major anxiety attack when he opened his Match envelope last March and found out he was coming here. I don’t think he objected because of our program. It’s just that he never thought he would actually have to leave Boston.
Except for college at Princeton, Andy’s spent his whole life around the Boston area. He returned to that city after college, attended medical school at Tufts University, and vowed that he’d never leave again. He told me he ranked Boston Children’s Hospital first on his list, and he’d been led to believe that getting in there wouldn’t be a problem. So you might say he was more than a little surprised when he found out he hadn’t matched there.
I think leaving Boston will have a major impact on Andy. Back home he had a very structured and broad-based support network. His family and friends are there, and, most importantly, so is Karen.
Karen Knight is the woman Andy’s lived with for the past year. Karen is a fourth-year medical student at Tufts; she’s going to have to spend a good portion of the year there. Andy has told me repeatedly that their relationship is strong, that it had lasted through a lot of adversity in the past, and that he feels it will easily be able to weather this year of separation. It sounds almost as if he were willing it to be that way.
And what was waiting for Andy here in New York? Almost nothing; there are a few friends who attended college with him, but nobody close who would understand or be there when things start getting rough. Internship is hard enough when you have a lot of love and support to help you through; it’s nearly impossible when you have to go it alone.
Andy
AUGUST 1985
Thursday, August 1, 1985, 12:40 A.M.
I just got off the phone with Karen, the only nice thing in the entire day. Three days of the NICU done, three and a half more weeks to go. What can I say? It’s another planet.
Saturday, August 3, 1985, 7:00 A.M.
I just woke up. I’m thinking about going back to sleep again, but I’ve got to get to work. Internship is turning out to be so much harder than I thought it would. The NICU is amazing; it’s only about twenty-five yards from one end to the other, and there are four little rooms off the central nursing station. In each of the rooms, which are about ten feet by ten feet, they have five or six tiny babies arranged with all this massive equipment around them. It’s claustrophobic and frightening because each of the kids is so sick. Being in the NICU so far has been a total shock.
I was on call the first day (Monday) and I actually got a couple of hours of sleep. I was on call again on Thursday and it was a horrible, horrible night. We didn’t get any sleep at all. And there were these three kids who kept trying to crump [deteriorating; trying to die] on us. We seemed to be doing a good job of stopping them, but then at about five in the morning, little baby Cortes decided to really crump. Cortes was one of the “ageless” preemies who live in the ICU. She was born fourteen weeks prematurely, weighing about a pound and a half, and she’d lived for four months right on the edge between life and death. We called a CAC [West Bronx’s and Mount Scopus’s term for cardiac arrest; literally, “clear all corridors”; also called a “code”]. I pumped on her little chest for about half an hour while everybody tried to put in IVs and get access. We called for epinephrine [a drug that stimulates the heart to beat], and we called for more epinephrine and we called for bicarbonate [a drug that reverses the buildup of acid that occurs any time blood stops circulating], and we tried to give bicarb intraosseously [through a needle directly into a bone, usually in the lower leg; intraosseous meds are given only in dire emergencies, when an intravenous line cannot be established] and we got a blood gas and the pH was 6.6 [indicating that there’s so much acidity in the blood that life is not possible], and then the heart rate kept slowing down and we gave intracardiac bicarb [through a
needle passed through the chest directly into the heart; used as a last-ditch attempt]. And the heart rate came up again. Unbelievable! It looked like she was going to make it, but her color still was really bad. We bagged her [blew oxygen through an ambubag through an endotracheal tube and directly into the lungs] and we pumped her heart, but then she went into V-tach [ventricular tachycardia, a preterminal heart rhythm] and we gave her some lidocaine [an anti-arrhythmic drug, used to reverse an abnormal heart rhythm], and then the surgeons came and did a cut-down [a surgical procedure in which a vein is found and a catheter is placed into it, ensuring direct intravenous access], and we pumped some albumin into the femoral artery. We got another blood gas; it was still 6.6 and the kid had deteriorated into an agonal rhythm [a heart rhythm signifying impending death].
So we stopped the resuscitation. We had been working on her for about an hour, I guess. There was nothing more to do. I left the room and went back to try to finish up the evening scut before the morning shift came on. The baby died. And I felt really, really shocked. I felt stunned, like somebody had hit me over the head with a two-by-four. I had gotten so close to that little baby. She was so sick and so tiny. She was the first patient I ever did CPR [cardiopulmonary resuscitation] on. It’s a strange thing doing CPR on a baby that small. It’s kind of an intimate act. You’ve got your hands all the way around the chest and you’re trying to pump her life back into her. You’re trying to prevent her life from ebbing out of her. It doesn’t matter that the kid’s got snot running out of her nose onto your hands, it doesn’t matter that she looks like shit, you just want her to live so badly! It was terrible when she died.
Laura Kenyon, our attending, came in at about eight. She took a look at me and asked if I was okay. I told her I was fine, and she took me into the on-call room and kicked everybody else out. “Are you really okay?” she asked. At first I told her yeah, but then I said I was really upset and I started crying. I was crying for that little baby whose life we couldn’t save. I told her how much I liked that little baby even though I hardly knew her. I told her how I thought we were going to bring her back to life and keep her from dying. I told her I’d seen other people die when I was in medical school, but this was completely different. It’s different when it’s a baby. She told me it was okay to cry, it was okay to feel bad because it meant you really care about people, about your patients. She said that eventually you’re able not to feel so bad, you can internalize it, but that you always feel something, because each death reminds us of all the others that preceded it.
She was really good. She let me get that baby’s death out of my system. She told me I could go take a shower and have some breakfast. That was nice of her, but I didn’t do it because I knew if I left the NICU, I’d get horribly behind in my work, and I knew that once that happened, I’d never get out of there.
After she talked with me, Laura had to go deal with the parents. She told the mother what had happened, and the woman started wailing. I turned around and saw Laura walk out of the unit. She had this expression on her face; I could tell she was really upset. She put her hand over her mouth; she was fighting off tears. For a second or two she looked really different, she almost looked like a little girl. And then she began to regain her composure and her face returned to normal. I listened to the mother’s wailing for a while, but then I had to get back to work.
A little while later, I had to go back into the room where the baby died to draw blood from another patient, and there was Laura with the parents looking at the poor little dead baby, all swaddled and wrapped up. All day, I felt really down. Any time I’d think about it, I felt bad . . . really bad.
During the day, I was completely drained. The night had been such an emotionally exhausting experience for me, I was completely wiped out. It was so bad, any time I sat down, I’d start to fall asleep. Laura gave a really good lecture on physiology that I wanted to hear, but I just kept falling asleep. It was embarrassing; at one point, in front of everybody, she said to me, “You can go to sleep if you want, Andy.” I wanted to pay attention, but I just couldn’t.
Laura’s the most amazing attending I’ve met here. She’s tough, but I think she really cares. I think she loves her work and she wants everything to work well, so she’s willing to put in the effort to make everything work on all levels. It’s really exceptional, having someone around like that. I’m lucky to have her as my attending.
I got out of there around seven. I was too tired to do anything. I went out and got some food and ate dinner. By seven-thirty, I was ready to go to sleep. Karen called at about ten. We spoke for over an hour. I kept telling her how much I missed her. We didn’t want to get off the phone; we kept thinking of something else to talk about. It’s really hard being away from her this long. It’s another four weeks until we get to spend any real time together again.
So anyway, the NICU is a very strange place. It’s very exciting, physiology in medicine brought to its highest application. But when you think about it, it’s also a very sad place because there’s life and death involved; you take these little babies, most of whom would have been dead ten years ago, and there they are, just sort of cruising along. I think the best workers for a place like the NICU would be robots, or people who can blot out all their emotions and just do the work that has to be done.
The technical work you do in the NICU is pretty straightforward; once you’ve had some experience, you get very good at it. But the technical stuff is really the easiest part of the job. It’s the decision-making that’s the hard part. Almost every day in there, we’re called on to decide whether to keep a baby alive or to let him or her die. I don’t have any of the tools necessary to make those kinds of decisions. I don’t have any experience with preemies, I don’t know which babies might have a reasonable chance of surviving and which babies don’t. All I can do is what somebody else tells me.
A lot of these babies don’t even look human. They’re really fetuses. Take poor baby Cortes, for instance; she weighed about a pound and a half at birth. I don’t know, it doesn’t seem to me like we’re doing anyone any favors by working so hard to keep a baby like that going. We’re just delaying the time when the parents’ll have to mourn their baby’s death.
Saturday, August 3, 1985, 8:00 P.M.
I thought I’d make a little list here, not necessarily in order of importance:
What’s Right with My Life
1. I’m in an excellent training program and basically enjoying my work, despite the fact that I complain a lot.
2. When I’m at work, where I spend most of my waking hours, I’m with people who, for the most part, I like, some of whom I’m becoming friendly with, people like Ellen O’Hara and Ron Furman.
3. In my nonwaking hours, I’m in an apartment that I basically like. It’s not great, but it’s sufficient, and I tend to sleep pretty well because I’m not overly anxious, even though I have lots of reason to be.
4. When I’m not working, I have some old friends around whom I get to see.
5. New York City is a great place to live with tons to do, and I’m taking a lot of advantage of being here. I went down to Manhattan today, my only day off for the next two weeks. Oh, well.
6. I’m not depressed, something about which I worried when I came out here.
What’s Wrong with My Life
1. I’m not with Karen, and I miss her a lot.
2. Even though I’ve made a few friends, I don’t have any really good friends here. I miss having good friends around whom I can call and talk to about the things that are troubling me.
3. I’m not wild about this neighborhood. As time goes by I find more and more that I do like, but basically it’s a kind of boring neighborhood that tends to roll up its sidewalks at about eight o’clock.
4. I miss my family—my parents, my brother, his girlfriend, they’re all back in Boston. I used to see all of them very often; they were a source of great support, of great enjoyment.
5. I miss Boston. I really li
ke it. It’s much more hassle-free than New York, a more sane and easy place to live, and far less crazy and bizarre.
6. Sometimes I wonder if I’m in a program that has just too goddamned much scut and is too goddamned big. Sometimes I wonder if the great downfall of this program is the fact that we rotate through too many fucking hospitals and we have to spend so much time and energy on just learning the mechanics of survival on all the different wards that there’s almost no time and energy left for stuff like relaxing, socializing, reading, sleeping, and just thinking constructively and thoughtfully about the patients.
So, those are my lists. Now that I think about it, they are basically arranged in order of importance.
Tuesday, August 6, 1985
Things are going all right, I guess. I got rid of a couple of patients. I have only three right now, and they’re pretty stable. And I got a decent night’s sleep last night. I really needed it; I basically collapsed at nine-thirty after I got home totally wiped out from another all-nighter without any sleep. So right now, things are looking up.
The Intern Blues Page 7