We’re in the middle of packing. I’ve got to get everything done tonight because I’m on call tomorrow and there’s no other time to do it. I explained the situation to the chief residents and they told me they were sorry but there was no way they could force anybody to switch with me against their will. They at least said that if everything was under control, I could sign out to the senior who was covering at 7:00 A.M. and leave. I’ll still never have enough time to get home. So it looks like I’m going to be going on a twelve-hour plane trip after being on call. If it’s a busy night, I may not even get a chance to change my clothes or take a shower. I’m really pissed off.
The fact that nobody’d switch with me when I really needed it has made me incredibly angry. It may be a little thing, but I’ll tell you, I’m never going to help anybody around here. Except for Susannah, maybe.
Mark
OCTOBER 1985
Friday, October 4, 1985
They’re trying to kill me. I know they’re trying to kill me. I’m just surprised I’ve survived this long. I’ve been at Jonas Bronck since Monday, and so far everyone’s tried to kill me, the chief residents, the nurses, the elevator operators, the lab technicians, and especially the patients, but no one’s managed to finish me off yet. They’re all trying, so I know it’s only a matter of time.
See what a vacation will do for you? It clears your head, makes you see things in a new light.
Actually, my vacation wasn’t exactly what I’d call wonderful. No, wonderful is definitely not the word I’d use. How would I describe it? What word would I use? Lousy; lousy is definitely a word I’d use, lousy bordering on shitty.
It started off with my brother and me in my car driving south as fast as we could to escape from the Bronx. We didn’t have any real end point in mind; I was just trying to reach a place where cockroaches don’t exist. Actually, that’s not true. We were heading for Cincinnati. We both have friends there, and we decided to go visit them. Yes, there’s nothing more romantic than spending a week with your younger brother visiting friends in Cincinnati in late September. The whole experience almost made the Bronx seem nice.
Okay, so it wasn’t romantic, but Carole and I sure made up for that in the second week of my vacation. We went to the romance capital of the East, Pocono Castle, a resort hotel catering to the honeymoon crowd. What a place! I knew we had made a big mistake when the first thing the bellboy showed us was the heart-shaped bathtub in our room. Carole said she liked it; I thought I showed great restraint by keeping myself from puking right there on the spot. But that wasn’t the worst of it. We went down to the dining room for dinner that first night and discovered that everybody there, every last couple, was there on their honeymoon. It was Carole and me and four hundred newlyweds! The place was disgusting; the food was horrible, the decorating job was ostentatious, the rooms were dirty, and it rained all week. All for two hundred bucks a day! Just the kind of relaxing environment I needed.
In the dining room, they put us at a table with another couple. These two were great: They had just been remarried for the second time. They were reformed drug addicts. We spent every meal chatting about AIDS!
And then we got back to the Bronx last Sunday night. I started on the ward at Jonas Bronck Monday morning and it’s been hell, absolute hell! On Monday we started work rounds at eight o’clock and didn’t finish until three in the afternoon. Seven solid hours of rounds! I’m sure all our names are going to be listed in the Guinness Book of World Records under the category of “World’s Longest Work Rounds.” Every time we’d try to leave one patient and move on to the next, some disaster would occur and we’d have to stop and sort things out and then try to start again. I picked up five patients: a pair of twins with AIDS who, if you can believe it, are actually named “Winston” and “Salem” (as a result of taking care of them, I’ve decided to name my first two kids “Chesterfield” and “Lucky Strike”); a brain-dead kid who inhaled a little too much carbon monoxide when her apartment caught on fire; and the “specialties of the house,” a couple of asthmatics. That wouldn’t have been so bad, five new patients, but you’ve got to remember, this was my first day on the inpatient service at Jonas Bronck, and I never got a chance to get myself oriented. I didn’t know where the labs were, I didn’t know how to get results of anything, it took me a day and a half just to figure out where the damn bathroom was! I had to hold it in for thirty-six hours, which, if you’ve never done it, is not the most comfortable thing in the world. It got so bad, I started to feel like a water balloon. And to make matters worse, the intern who had been on the ward before me hadn’t written off-service notes on any of the patients. How considerate! So even if I had had a chance to read the charts, which I hadn’t, I still wouldn’t have been able to figure out what was going on with my patients.
Then I was on call that first night. I picked up five additional patients and I didn’t get any sleep. And the way the schedule worked out, I was on Monday and again on Wednesday and I was postcall on Tuesday and Thursday, so my brain’s been in hyperspace for an entire week. I wasn’t sure I could find my way back home today, let alone try to figure out what was going on with my patients.
I’ve been completely helpless. Mike Miller is my attending this month, and he and the senior resident have asked me a lot of questions on rounds and I haven’t even been close on any of them. I feel like a real idiot, which I probably am. And since Miller’s a friend of my family’s, I’ve felt even worse about it. I mean, I’m sure I’ve gone a long way to convince him I got into medical school on the one scholarship given every year to the most deserving mentally retarded individual in the United States. I’ve also had this fantasy that he’s been calling my mother at home every night and telling her what a moron I turned out to be.
But hey, it hasn’t all been my fault. I’ve gotten some really sick patients over the past few days, and working in Jonas Bronck isn’t exactly my idea of living in paradise! What a place! The elevators don’t work; people have died waiting for them, and those weren’t patients, those were interns! The people who work in the labs have a combined IQ of about 3. If you’re nice to them, they’ll screw you; if you’re not nice to them, they’ll screw you. I’m convinced they sit around up there trying to come up with the most difficult ways to give out results. If you call them on the phone they’ll put you on hold for ten minutes and then hang up on you. If you call back and say you were cut off, they’ll yell at you and say it’s not their job to give results over the phone. I walked into the bacteriology lab Wednesday night at ten o’clock and a woman pushed me out of the door and said they were closed. They were closed! What does that mean? You’re allowed to diagnose infectious diseases between the hours of nine and five only?
And the food stinks! That hellhole downstairs is the worst excuse for a coffee shop I’ve ever seen! I was wondering how they could get away charging only a dollar and a half for a turkey sandwich, so I tried one and I figured it out: They don’t put any turkey on the bread; they don’t sell turkey sandwiches, they sell mock-turkey sandwiches, for God’s sake! And the place keeps the same hours as the bacteriology lab, which is pretty telling. So when you’re up all night, when you really get hungry, you can’t even get a mock-turkey sandwich.
And how can Miller and all those other guys who run this department and who say they’re really concerned about our well-being not provide us with a shower? If I don’t get to take a shower after a night on call, I’m worthless. I feel like shit! Just working in this hospital, you wind up covered with about an inch and a half of municipal hospital crud, and if you don’t get a chance to wash that off, you just can’t work effectively.
Well, now I’ve really depressed myself. I was in a pretty good mood when I started recording this, but listening to what I had to say, I have to admit, I must have been pretty crazy to have come back from vacation. I mean, a week at Pocono Castle was a picnic compared to an afternoon at Jonas Bronck.
Monday, October 7, 1985
I t
hink I’ve finally recovered and gotten myself a little better oriented to Jonas Bronck. It was pretty rough there for a while. That’s a real problem with this program: You work at so many places, by the time you feel comfortable at one hospital, they move you to another and you have to start from scratch again. It’s the concept of perpetual confusion, an ancient form of torture developed, I believe, during the Ming dynasty.
Things have calmed down a little on the ward. I was on last Monday and Wednesday and then again on Saturday, but from here on it’s every third for the rest of the month. (Oh, what joy, only every third night! How lucky can I get?) All last week was a blur. I admitted about ten patients, some of them really sick. It was interesting. They kind of came in groups: Monday was Leukemia Day. First I admitted this fourteen-year-old boy whose gums had started to bleed a lot when he brushed his teeth. He also had a slight fever, he was feeling kind of sick, and he had bone pain. He turned out to have ALL [acute lymphocytic leukemia, the most common form of cancer in the pediatric age group], and he’s in the poor-prognosis group for everything—age, sex, race, you name it. He only stayed at Jonas Bronck overnight. On Tuesday we shipped him over to Mount Scopus, where he’ll get started on a chemotherapy protocol.
Next, I admitted this eight-year-old who had had ALL diagnosed six years ago. He had been treated with chemotherapy for four years and had been considered cured. He woke up one day last week with a terrible headache. He was seen at every emergency room in the Bronx, and all the doctors told his mother the same thing: There was nothing wrong with him, and she should try giving him some Tylenol. He finally showed up to see his hematologist here at Jonas Bronck, and she noticed that he had a sixth-nerve palsy. [The sixth cranial nerve, the abducens, runs the longest course in its path from its origin in the brain to its point of action in the eye. Because of its long path, the sixth nerve is sensitive to increased pressure within the skull. If pressure is increased, the sixth nerve will not work properly and is said to be “palsied.”] She arranged a stat CT scan that showed a golf-ball-sized mass in his frontal lobe, most probably a lymphoma but possibly some other terrible horrenderoma. [I don’t think the term “horrenderoma” requires defining.]
So Monday was a really comforting night. I’m starting on a new service in a new hospital, and I picked up five patients who didn’t have adequate off-service notes, so I didn’t know what the hell was going on with any of them, and I admitted two kids with terrible prognoses. And I barely had time to recover from that night when I was on again on Wednesday, and that turned out to be Chromosome Abnormality Night. My first hit was this three-month-old who looked like she’d been dead for a few weeks already except for the fact that she’d just had fresh casts put on her legs to correct her clubfeet. Her mother brought her into the ER with a complaint that she was breathing too fast. The intern who saw her in the ER asked if she had any problems with her health, and the mother said, “No, there’s nothing wrong with her.” Turns out she’s got trisomy 18 [a congenital malformation syndrome caused by an extra chromosome No. 18 in every cell of the body] and severe congenital heart disease, which had caused her to go into congestive heart failure and led to the breathing problem. [Almost every child born with trisomy 18 has congenital heart disease. The heart disease is one of the factors that leads to early death in these patients. Eighty percent of trisomy 18 children will die before their first birthday.] The kid’s got trisomy 18, and the mother says there’s nothing wrong with her! When the intern got the old chart and found out the diagnosis, the mother still denied it. Sounds like she got some top-notch genetic counseling! Anyway, the kid was in congestive failure, so I started her on some Lasix [a diuretic that rids the body of excess fluid; since fluid buildup is a major problem in congestive heart failure, treatment with Lasix often relieves symptoms such as rapid breathing] and suddenly she started looking like a million bucks.
I don’t really understand why this kid’s got those casts on her legs. I mean, if she’s got such a bad prognosis, what’s the use of fixing her clubfeet? It doesn’t make much sense. Of course, that doesn’t mean anything; there aren’t many things around here that seem to make much sense.
Anyway, later on Wednesday night (actually it was about five o’clock on Thursday morning) I admitted a fourteen-year-old with Down’s syndrome who was having an asthma attack. Now, asthma’s pretty straightforward. At this point, I can manage asthma in my sleep. In fact, that’s when I usually do the best job. But this kid was just a touch more complicated because, in addition to his Down’s syndrome and his asthma, he also had chronic renal failure. The problem with that is that aminophylline [a medication used in the treatment of asthma] is removed from the bloodstream by the kidneys. I could give the stuff to him and it’d probably help his asthma but he wouldn’t ever be able to get rid of it. He’d probably wind up with toxic side effects; he’d stop wheezing and start seizing, and that wasn’t going to be very helpful. We thought about it for a while and decided to turf him [turf: internese for “transfer to another service”; also referred to as “a dump”] immediately to University Hospital, where the renal dialysis unit is located. So I had to ride over to University Hospital in the ambulance with him and drop him off at the ward.
Well, I got over to University, brought the kid up, and introduced him to Andy Baron, who was the intern on call over there. He wasn’t exactly happy to see me. What the hell happened to him? I mean, I haven’t seen him in a couple of months. He used to be a kind of easygoing, friendly guy. He yelled at me when we got there. He accused me of dumping this kid on him, which of course I was. But, hey, that’s not my fault. We weren’t doing it to make Andy’s life more miserable, we were doing it because it seemed to be the best thing for the patient.
It’s kind of scary, running into people you haven’t seen for a while. It’s like going to see a horror movie and realizing that you and your friends are the main characters. You look at Andy and you see what kind of a monster he got turned into and you start to wonder if maybe the same thing hasn’t happened to you, but you haven’t noticed it because you live with yourself every day and it’s hard to notice any changes. I don’t know, it’s pretty scary.
Anyway, Saturday was pretty quiet. I got only two admissions the whole day, so I had a chance to spend the day sitting in the residents’ room watching TV and eating mock-turkey sandwiches. It was good; I needed a chance to relax a little and figure out who all my patients actually were. And today was pretty quiet, too. So right now I’ve got most of this straightened out.
I spent yesterday in the city with Carole. We went to a matinee. We saw Cats. I fell asleep four times and Carole had to wake me up because my snoring was disturbing all the people around us. I don’t think I missed much; from what I saw during the short period when I was conscious, it looked pretty lame. I can’t figure out how they get people to wear those silly costumes eight times a week. I guess if they can get me to do the ridiculous stuff I do, they can get anybody to do anything!
Thursday, October 10, 1985
As if my life weren’t bad enough, Hanson’s back. I couldn’t believe it! I got called down to the ER to pick up an admission last night and all I knew was it was supposed to be a six-month-old with diarrhea and dehydration. I got down there and there he was. There was no doubt about it. No other six-month-old I’ve ever seen has that characteristic putrid look about him. His mother had brought him to the ER, and of course she didn’t recognize me. During the entire month he had made my life miserable on Infants’, she had never once come to see him. All I knew about her was that she was a drug addict. When I realized she was his mother, I almost said, “Oh, I’m sorry, I didn’t recognize you without the needle in your arm,” but I showed excellent restraint and tact and kept quiet. I’m getting really good at this patient-relations stuff. Anyway, poor little Hanson had been home maybe two weeks and had developed diarrhea again. I asked his mother why she didn’t bring him back to Mount Scopus since, after all, all his records are there, and she said, “I
don’t like those doctors at Mount Scopus. They don’t know nothing. They’re all a pain in the ass.” I guess she came to Jonas Bronck because she wanted a second opinion. Very smart!
Anyway, I figured I should try to get some history on his last days at Mount Scopus, so today I got in touch with Jennifer Urzo, the intern who discharged him from Infants’. I said, “I just admitted Hanson,” and I could hear her groan. It’s amazing how one tiny baby can cause such a uniform reaction from everybody who’s come in contact with him. Jennifer told me this weird story about how she spent the entire month of September working really hard to get him straightened out. Not only did she work on getting him relatively healthy, she also arranged for a bunch of outpatient follow-up appointments, home visits by the VNS [Visiting Nurse Service], social work involvement, the works. It sounded as if she genuinely liked the kid (there’s no accounting for taste). When everything was arranged, Jennifer somehow got in touch with the mother and actually convinced her to come in and learn how to take care of the baby, which must have been a major miracle. The mother came a few times. Jennifer said she never felt really comfortable around her but that the nurses felt the mother knew what she was doing. So Jennifer told her she could take the baby home. She started going over all the appointments she had made and the mother said something about the fact that she was going to take the baby home and she’d keep most of the appointments but she sure as hell wasn’t going to come back to see Jennifer because she didn’t like her, she didn’t think she was doing a good job with the baby. She said she didn’t think she was a very good doctor. This obviously really hurt Jennifer. She even got tearful on the phone just talking to me about it.
Anyway, he seems to be doing okay now. I kept standing around his bed all night waiting for him to crump but he never did. He hasn’t had any diarrhea since early this morning but we’re still keeping him NPO. I started an IV last night. What thrilling memories that brought back! I’ll tell you one thing: He may be a little bigger and two months older, but he still has shit for veins! I stuck him about a dozen times to get the line to stay in place. It felt so comfortable. Just me and him and a box of twenty-two-gauge plastic IV catheters.
The Intern Blues Page 18