The Intern Blues

by Robert Marion

  It turns out that Harrison Boyd, the other intern on our team this month, is completely insane. He’s got a very funny, terrible sense of humor. Very bad jokes, the worst! And Laura Santon, who is always happy, actually looked depressed today for the first time. Maybe she was just spacing out, but she looked kind of upset. I was surprised.

  Had pizza for the hundred and fifty thousandth time for dinner tonight. Seems that’s all I ever eat around here, pizza. Missed the shuttle [the bus that travels between Mount Scopus, Jonas Bronck, and University Hospital], had to take a cab home, and got a free, unguided tour of the Bronx, because they always take some strange route. Very interesting, the Bronx at night. Very exciting. I could have done without it.

  Sunday, October 13, 1985, Morning

  I’ve had so many nights of sleep in a row, I practically don’t know what to do with myself. Yesirree, I was on call Friday night and I got seven and a half hours of uninterrupted sleep, breaking all records heretofore known for all interns in this program. It sure is a record for me. And it was good timing because my parents are here this weekend, they came down on Saturday. So it was great.

  I just came back from medical records at Mount Scopus. I had a lot of charts to complete and I had to go over today because they were threatening to withhold my paycheck if I didn’t finish them. It’s impossible to get over to the record room during the week when you’re on the other campus. It’s so weird: I went back to these charts, two of them for babies who died. One was on a baby that was born premature in the bed. When the baby had been born, I was the first one to get to the labor room, and I didn’t know what to do. Here’s this little chart and I’m supposed to fill out the discharge summary. There was the autopsy report; it said the baby weighed 460 grams and had atelectasis [collapsed alveoli, the air sacs in the lungs], visceral congestion [accumulation of blood in the circulation going to the internal organs], PDA [patent ductus arteriousus, a persistence of the opening of the structure that, in fetal life, shunts blood from the underdeveloped lungs to the rest of the body], and patent foramen ovale [a communication between the left and right atria of the heart that allows oxygenated and deoxygenated blood to mix]; no big deal. It was just a really preemie baby. Four hundred sixty grams, it might just have been SGA [small for gestational age]. At any rate, I still feel kind of sad about it. Maybe we could have done something, we could have resuscitated it. Months later and I’m still wondering. Well, anyway, it’s sad. The chart was wafer thin. There wasn’t much to it; a baby who was born and then died. All it had was a heartbeat; it never had an Apgar of more than one. [Apgar: a scoring system used in the immediate newborn period designed to measure neonatal well-being. The baby is evaluated in five categories: heart rate, respiratory rate, color, muscle tone, and response to stimuli. Zero, one, or two points are awarded in each category, and the maximum score is ten. Babies are evaluated at one and five minutes after birth. Apgar scores above seven are considered normal. Less than five are definitely abnormal.] It’s very sad. The mother was a thirty-one-year-old woman, she has three living children, maybe she was happy this happened. Maybe eight months from now I’ll get named in a lawsuit. Who knows?

  You can’t focus on the negative all the time, you know? That’s what I’m trying to do now, that’s my new approach. I still haven’t found a way to focus on the positive. In fact, I’m still finding it hard to decide what is positive. I guess it’s positive when things turn out well, and when you have a good relationship with a family. That’s good. That’s the most positive thing I can think of right now.

  It’s pretty nice having my parents here this weekend. My father rented this total junker of a car. It sounded like the wheels were about to fall off at any moment. It’s tiny, you can park it anywhere. I took them down to Soho yesterday; that was fun, they had a good time. Then we went to the Upper East Side and had dinner at this really nice Italian restaurant; nothing fancy, just very nice.

  Then I went to sleep and Karen called at some point, I don’t know, I was half asleep, I don’t remember anything she said. I’ve had so many conversations with Karen over the phone where I don’t remember anything, or I remember hardly anything. It’s disgusting, it’s totally disgusting.

  I found myself reassuring my parents last night that this neighborhood was really okay. Isn’t that funny? Because just a few months ago I was telling them how much I hated it. I don’t like it, really, but I don’t feel threatened so much anymore. I don’t think it’s a really bad neighborhood; it’s not beautiful, but . . .

  I’m feeling better now, I’m not feeling depressed, I’m starting to feel like there’s an end in sight. I know it’s too early to be saying that, but if you look at it, there’s twelve months in this year. A hundred divided by 12: That’s 81⁄3 percent of the internship per month. At the end of this month, I’ll have completed four months; that’s 331⁄3 percent. If you add in vacation time, well, then you’re at 412⁄3 percent. So at the end of this month, if you include vacation time, which is really free time, I’ll have completed over 40 percent of my internship. Not bad! Not bad at all! Forty percent: That has a definite, hefty ring to it. Forty percent! That means I have survived the beginning. I really have, I’ve gotten through the hell of being an early intern. Whatever hell lies ahead, and I’m sure there’s more, at least this has been survived.

  Sunday, October 13, 1985, Late at Night

  My parents have gone. I felt kind of lonely after they left. I sat down and did a little paperwork, paid a bill, wrote a letter to somebody, and I feel a little better now. It bummed me out because I have to go into work tomorrow and be on call. And I know I need a vacation, I know I need it, but I’ll just have to wait. I know I’ll make it.

  I’ll just have to wait.

  It’ll be so great.

  To be on vacation

  And to sleep late.

  Friday, October 18, 1985

  Postcall. Cleared my bed for roaches. In bed here, getting ready to make the big snooze after a rough night on call at University Hospital. Tomorrow I’ve got to decide what to do with my life. I’ve been talking with the director of the program I originally wanted to go to up in Boston. He says there’s a place for me back there for next year if I want it. I have to decide if I should stay or if I should go. I don’t know what the fuck to do, and I’m too tired to think about it now.

  Yesterday I got my first kid with AIDS; actually it’s ARC [AIDS-related complex], but still, it’s the first kid I ever admitted with the big “A.” I don’t know, it’s no big deal; it’s just another horrible, fatal disease. Our team got a talk from the immunologist about the disease. Part of it was about health workers with AIDS, and every one of us started wondering if we had it. We were wondering whether we, the people who suck meconium out of the mouths of newborns have gotten AIDS yet. Who knows? Sometimes I think maybe I should go and get myself tested or something. Then at other times I think, what difference does it make?

  I had dinner tonight with Ellen. Bought a little Indian food and came back here and ate it. She conked out and went home. That’s life when your only friends are interns.

  Monday, October 21, 1985

  I didn’t get much sleep last night, less than an hour. It was a pretty hard night at University. Goddamn renal transplant patient came in! Nice kid for a whining three-year-old. Got his mom’s kidney. Jesus Christ, I think the nephrology attendings sit around just thinking of more tests they can order. Anyway, they transplanted the kidney and the kid looked like a million bucks afterward. I hadn’t slept all day, and I looked like about thirty cents! I spent two fucking hours in the recovery room; it seemed like I was in there forever. Before the kid came in, there were like a thousand people, a big commotion, everybody wanted to get involved. Then when they saw nothing too exciting was happening, they all split and all of a sudden it was me sitting there alone. All the nurses, all the nephrologists, all the surgeons, they were gone! There’s just this kid and I’m in charge. It turned out to be no big deal; nothing h
appened. I had to make a couple of decisions, but hey, I think I know how to do that. But I didn’t get much sleep.

  And so what do I do? I get out of work, come home, and stay awake for like three hours! I could have gone to sleep at like seven or eight o’clock. I’m totally overtired. I slept through half of attending rounds today. I didn’t even make any bones about it, I just leaned on my elbow and went to sleep. I must be crazy!

  I don’t know, I guess I just like to come home and pretend I have a life or something. So you know what I wound up doing tonight? I watched TV. I haven’t sat and watched TV since well before my internship. Isn’t that interesting? Very interesting. Interesting as a pond of mud.

  Tomorrow’s Tuesday, and Mike Miller is probably going to ask me what I’m planning to do next year. I don’t know what the fuck I’m going to tell him. I don’t know if I’m going to tell him the truth about this job offer in Boston or what. I’m still trying to make up my mind about it. It depends a lot on Karen, too. She has to decide whether she wants to do her internship in Boston or come down here to one of the real hot shit New York programs. I tried to call her tonight to talk to her about it, but she wasn’t home.

  My eyes are burning. Someone told me at work that they’re really red. What do you expect? Christ, I lie down, trying to get an hour of sleep, and the nurses wake me up. Fucking transplant kid had a headache. I had a headache, too, for God’s sake, and I didn’t see why the hell they had to wake me up about the transplant kid. But no, they said he had a headache and they took his pressure and it had decided to hop up from 120 to 180.

  So I called the renal fellow and told him the kid’s pressure was up and he told me to give him a dose of captopril [an antihypertensive medication]. I gave it, the pressure immediately came down, and I went back to bed. About a half hour later, just as I was getting into some deep sleep, a nurse knocks on the door and tells me this other renal kid had a headache. It’s an epidemic, for Christ’s sake.

  I went to see this second patient, and she said that not only did she have a headache but she also had fucking blurry vision. And her blood pressure was 200. So I gave her some captopril, too, and her pressure came down, but she was still complaining of the headache and the blurry vision. I thought about it for a while and I figured, screw it; if her pressure’s down, there’s nothing wrong. There wasn’t anything else I could do.

  I went in to talk to her and tried to calm her down. She said she’d try going to sleep. I went back to the on-call room but now I couldn’t fall asleep. I was too worried about her. So I got back up and went to her room and sure enough, she was sound asleep.

  I kept getting woken up all night long for little things. It was a quiet night and I still couldn’t get any sleep.

  Another week to go at University Hospital. It’ll be a great feeling to be a third of the way through the year, knowing I’ve completed four tedious months of internship.

  Friday, October 25, 1985

  I just woke up. I was on call the night before last and I’m on again tonight. I’m doing an every-other, which is okay, I guess, because I get the weekend off. Thank God.

  Karen called last night, I think. I think she called and said she’d been offered a place in Boston at the program she wanted to go to. But I’m not sure. I was so tired! I’ve managed to hold them off here. Mike Miller asked me whether I’m planning to be a resident here next year. He offered me the job. I told him I wasn’t sure yet, that I had to do some thinking. We’ve got to make a decision about this pretty soon.

  Tomorrow is my last day at University Hospital. So what have I learned this month? I don’t know. Maybe I’ve learned how to handle many patients all at once. I don’t think I learned too much about kidneys, even though that’s about all we see.

  I better get up before I fall back to sleep.

  Saturday, October 26, 1985

  My last night at University turned out to be pretty shitty. Everybody on the ward was sick. They all had fever spikes and high blood pressure and headaches, and everything necessary to ruin my day.

  And then in the evening, Henry got sick. I guess I haven’t mentioned Henry yet. He’s an eighteen-year-old with Down’s syndrome who’s had end-stage renal failure for a long time. He’s pretty high-functioning: He’s no genius or anything, but he’s a really sweet kid with a good personality, and everybody loves him.

  Henry has a cadaveric transplant [transplanted kidney obtained from a cadaver] and hasn’t been doing very well. He came in at the beginning of the month with rejection crisis. We gave him steroids and he got better and went home. Then earlier this week he got admitted because he was rejecting the kidney again; he’s been hypertensive and peeing tea-colored urine for days. We’ve been giving him these massive doses of antirejection medication but he seems to be getting sicker and sicker.

  He got really sick last night. He’d been feverish in the afternoon, but we weren’t told about it. The nurse who took his temperature called the renal fellow directly and didn’t bother informing us. At about six o’clock last night, the fellow called to find out what the results of the sepsis workup were. “What sepsis workup?” I asked. That’s how I found out that Henry had spiked a fever.

  I went in to see him at that point. He was feverish to about 102 and was tachypneic [breathing rapidly]. He didn’t look very comfortable. I ordered some Tylenol for him and told the nurses to sponge him down. As the night wore on, he became more and more tachypneic and his fever just wouldn’t stay down.

  At about ten o’clock, he was looking really uncomfortable. I ordered a chest X ray and drew a blood gas. I brought the blood gas down to the lab myself but I couldn’t find the technician for about ten minutes. He was hiding in a back room somewhere. I finally found him and he ran the test grudgingly. The gas just showed a little hypoxia [the oxygen was a little low], so I went back upstairs, put Henry in 35 percent oxygen, and then went down to radiology to look at the chest X ray. It didn’t look too bad, but when I got back to Henry’s room, he was looking more uncomfortable. We turned up his oxygen to 50 percent and, after about another half hour, I did another blood gas. I ran it down to the lab, and again I couldn’t fucking find the technician anywhere. I looked all over the damned place; the guy was nowhere to be seen. I spent at least fifteen minutes looking for him. And when I finally found him and told him that I had a really sick patient and needed the gas stat, he said, “I have something else to do stat. I’ll get around to yours when I have a chance.”

  I was ready to strangle the guy! I had already wasted fifteen minutes looking for him and now he was telling me I was going to have to wait longer. And for all I knew, while I was down fucking around with this technician, Henry could have been arresting up on the ward. I was tempted to run the blood gas myself, but I knew that if I touched the machine the guy would have my head on a platter. And yelling at him was completely pointless because I knew that the more you yelled, the more hostile he’d become, and the longer he would take to run the sample. So I just sat on the stool feeling my blood pressure go through the roof.

  Finally, the guy picked up the sample, strolled over to the machine, and did it. The gas was pretty lousy. I ran upstairs and showed the resident. Henry was going into respiratory failure in front of our eyes. He was just going down the tubes. And he was scared shitless.

  We called the nephrologist and told him we were going to intubate Henry and bring him over to the ICU, and he told us to go ahead. We called the anesthesiology resident, and he did a great job of intubating him. We put him on a respirator and brought him down the hall [University Hospital’s ICU, located down the hall from the Pediatrics ward, admits patients of all ages].

  I spent the whole night in there with him. He was all squared away by about three in the morning, but we had to stay and monitor him constantly. At least he was stable on the respirator. He wasn’t getting any sicker and he seemed more comfortable. And I didn’t have to deal with that lab technician again because the unit has its own blood gas machine.
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  Then, this morning, we spent until about noon rounding. I felt like warmed-over shit. After rounds, I went back to the ICU to write a note in Henry’s chart, detailing what had happened the night before, and as I was sitting there, one of the nurses called a code. There was this obese, middle-aged guy whose heart had completely stopped beating. He was in fucking asystole [without a heartbeat]! And there was no doctor around other than me.

  I jumped up onto his chest and started doing compressions. After about ten minutes, the critical-care fellow showed up with a bunch of medical residents trailing behind. But all those guys did was stand around for a while and discuss what to do. They didn’t even offer to help. Finally, they decided to shock him [apply an electrical charge to the chest in hopes that this will start the heart beating again], so I jumped off his chest. They got his heart beating again and they figured he was stable, so everybody disappeared. I sat back down and tried to finish my note, but fifteen minutes later the same nurse yelled out that the guy had arrested again. And again, nobody was around. So I jumped back on his chest and started CPR again. This time the critical-care fellow showed up with the code team really fast, but again, they all stood around talking while I was doing the resuscitation. Finally I said, “Does somebody else want to do this? I’m from Pediatrics, for God’s sake!” I couldn’t believe it.

  Finally, one of them took over for me and I went to finish my note. They got the guy’s heart beating again, but what would have happened if I hadn’t been there? The guy would have fucking died because there wasn’t a doctor around to do CPR. And I wasn’t even supposed to be there. What kind of care are these patients getting?

  Amy

  OCTOBER 1985

  Saturday, October 5, 1985