The Intern Blues

by Robert Marion

  Today’s an important day because after long and tedious deliberation, Karen and I have definitely decided to go back to Boston for the remainder of my residency. Karen’s been getting internship offers from everybody. Every single place she’s applied to is offering her a position. It’s hard to turn opportunities like that down, but we’ve decided to go back. Karen feels she’ll be happy at Boston University, the program where she’ll wind up going, even though it’s not in the same league as Cornell and Columbia.

  The important thing that we’ve decided is that we want to be around family and friends. This year has been so hard for me because of the separation. I don’t think internship can ever be easy, but I know I would have been better off had I stayed in Boston instead of coming to the Bronx. Plus, we both think Boston is a nicer and easier city to live in than New York, which is very exciting but also crazy and congested and stressful. So this morning I’m going to call up Scott Thomas, the director at Boston Children’s, and tell him I’d like that spot if he’s still got it. If he hasn’t got it, I’m going to wring his little neck. Then I’ll have to call Mike Miller and let him know that I’ve made my decision. Hopefully I’ll get the contract and the whole thing will be signed, sealed, and delivered within the next week or so.

  A couple of days ago, I thought for the first time that I’d ultimately like to subspecialize. It’s not because I have some burning interest in any one field; I don’t really. A lot of things interest me, but there’s not any one field I’m that attached to or interested in. I want to subspecialize because I’m tired of being so inexpert at so many things. I don’t think I could spend the rest of my life knowing a little about a lot of things, like many of the OPD attendings do. I need to feel like there’s one area in which I have a great depth of knowledge. Someone just walked in; I’m going to have to stop now.

  Sunday, November 10, 1985

  Karen’s still here. I’m finding myself getting all depressed again, and I’m not really sure why. I just can’t put my finger on it. There’s just nothing that’s obviously wrong: I’m in OPD, and that’s pretty easy, I’m not lonely. Something’s just wrong.

  I guess one of the reasons I’m depressed is that I made this massive decision about going back to Boston, and now there’s a kind of letdown. It’s official now: I called Dr. Thomas the other day and accepted the job. And Karen officially turned down Cornell and accepted the place at Boston University. On Monday, Thomas is going to call Mike Miller and discuss it with him, then he’s going to call me back and let me know it’s all sealed, and that’s it! That’s it; we’re going back.

  Last Friday was a horrendous day. I started working at my clinic at Mount Scopus at nine o’clock, and I began the day with a child-abuse case. A patient who requested me because they had seen me in the emergency room once, came in. I saw signs of abuse and reported them. That was a very unpleasant situation; they were very angry, and I can understand why. And then at noon, I went to the Jonas Bronck ER, and I was there until seven the next morning. I was so tired, I fell asleep taking a history! While I was talking to the mother, I just zonked out! Soon as I woke up, I picked it up with the next question I had in my mind, but I knew I had been asleep. The mother was sitting there staring at me with a strange look in her eyes that hadn’t been there a second before (because it probably had been several seconds). Then I fell asleep listening to some asthmatic’s chest several times. I kept wondering, Why is it taking me so long to get a respiratory rate? Because I kept falling asleep every time I put the ’scope on the kid’s chest, that’s why! So that was an abysmal night.

  I guess all the shit I’ve been seeing at Jonas Bronck’s depressing me a little, too. All the child abuse and the codes and all that, that stuff gets me down. And it’s been really cloudy and nasty and rainy, and that doesn’t help. And living in the Bronx is just a bore.

  And there’s something else: I’ve started to become obsessed that I’ve got AIDS. I’ve started waking up in the morning feeling anxious, thinking I’m going to die. That’s one of the main criteria for major depression. I’ve been trying to go and get the test [blood test for antibodies to HIV] but I haven’t done it yet, initially because if I think rationally about it, there’s no reason I should have it, and then because I realize I don’t want to find out if I’m positive.

  I’m getting a little bit of the feeling I used to have in medical school, that I’m trapped in a prison, and the rest of the world out there is beautiful and happening and I’m not in it. I saw The New York Times today; I read the headline saying that the Democrats had taken over the Senate, controlling fifty-five of the seats. I didn’t even know there was an election. I didn’t know until after it was over. So I feel very much isolated from the mainstream of humanity. And at times I feel like I’m not taking this seriously enough. I mean, each mother brings her kid in and the kid means all the world to her, but to me, it’s just another set of wheezing lungs. I try to do my best with each one, I try to think of each one individually and I do, I know I do, but, I don’t know, in some ways it all becomes a blurred mass of humanity flowing through the doors of the emergency room.

  There are these two kids, I see them all the time, the mother calls me every week, she comes into clinic every week. She’s a really good mom, maybe a little neurotic. She has a Down’s baby; the other kid’s normal. And she’s really great. Seems like there are so few other patients and families I’m happy to see, though. That can’t be right; you can’t just like one family out of the hundreds who come through.

  The streetlights are still on. It’s the middle of the day but it’s so dark that the lights are still on. I’m supposed to go shopping to get my brother and his wife a wedding present. I don’t know what the fuck to get them.

  Wednesday, November 13, 1985

  It’s cold outside, it’s turning into winter. You can see your breath in the air. I’m still in the OPD. And I’m feeling better.

  My depression has gone, for the most part. At least the acute exacerbation. I’m still left with the chronic, smoldering depression I’ve had since August. It turns out I was also getting sick. Got this goddamn viral syndrome from some kid and now I’ve got this residual cough.

  Monday, November 25, 1985

  I haven’t talked into this for a while. Karen left yesterday, and when she’s here, I usually talk less. I’d rather spend time with her than this machine.

  Today’s the end of the fifth month. I finished outpatient this afternoon. Tomorrow I start on 8 East at Jonas Bronck. And while part of me is relieved to get the hell out of that ER, which has just been a madhouse, I’m kind of dreading tomorrow because I’m on call and I have my clinic, so it’s going to be a dreadful night. I’ll be up all night. I’m already sure of that.

  But I’m also looking forward to being back to the somewhat protected environment of a floor where I know what my work is. The work’s cut out for you, and even if what most of the other interns have said about Jonas Bronck wards is true, that there are too few nurses up there and the nurses who are there don’t want to work, in a lot of ways it’s better than being out in the unprotected emergency room.

  I’ve been paying more attention to some of the other interns lately. Some of them are a lot worse off than I am. Take Peter Carson, for instance. I’ve been working with him in the ER. My God, is he an angry man! He makes the rest of us seem like laughing hyenas. I’ll give you an example. Saturday we were both on call. It was a horrendous day in the emergency room. The third year resident was Larry Brooks, and he said it was the worst day he’d ever seen in that ER. It wasn’t because we had so many terrible things happening. We did have a few kids in the back [the back: the trauma area of the Jonas Bronck emergency room], but there weren’t any real tragedies that took up a lot of time. It was because of the volume; it just never let up, and there were only three of us working until four in the afternoon when the evening float resident showed up four hours late (ooops). I literally had only ten minutes to eat during the entire nine
teen hours I was there. It was exhausting. By 4:00 A.M. I was just going cross-eyed. I couldn’t concentrate for shit.

  Anyway, at 4:00 A.M. we were ready to get out of there, but the triage box wouldn’t empty. Finally it got down to two charts. The night float was there, he was all alive and peppy, and we were getting ready to leave, but Larry came in and told us there were a couple more to see and I heard the night float say, “Just give them to the interns and go home yourself.” Well, when Peter heard that, he went completely berserk. He started screaming, “That fucker! Let the interns do it? Let me at him! I’ll rip his testicles off, one by one!” He was screaming so loud that everybody in the emergency room could hear him. A nurse came knocking on the door in a second saying, “You know, not everybody out here wants to hear about testicles being torn off!” But Peter was beyond help; he was so incensed, he just kept screaming. We were saying, “Peter, Peter, shut up or we’re going to have to call security on you,” and then he kind of calmed down, but only a little. He was wild. And then what ended up happening was that Larry told us to go home and he wound up seeing the last patient himself.

  Peter and I split a cab back to our apartment building, and all the way there he was just cursing, saying how much he hates being an intern and how much he hates the ER. He was just absolutely infuriated. But he’s back there every day, somehow or other. I guess I’m not the worst off, but I think I’m getting a reputation as being one of the depressed interns.

  Amy

  NOVEMBER 1985

  Saturday, November 16, 1985

  I’m not very happy about being back from vacation. We had a wonderful, relaxing time in Israel. I must have been in pretty bad shape before we went away. The frightening thing is I didn’t even realize it until I had a chance to get away from it for a while.

  Before we left, I was obsessed with being on call that last night of October. It became the most important thing in my life. As it turned out, it wasn’t a problem. It was a very bad night; I admitted a new onset diabetic who was in DKA [diabetic ketoacidosis, a buildup of acid in the blood caused by the inability of the body to use glucose as its energy source; insulin, the protein that allows the blood’s glucose to enter the cells of the tissues, is either absent or abnormal in diabetics], and I was up all night managing the boy’s fluids and electrolytes, but Ben King, the senior who was on with me that night, threw me out of the hospital at seven in the morning. Just like that, he told me to leave and have a good time and not to worry about a thing, he’d take care of the patients and sign out to the new interns. So, after all that, I did manage to get home, take a shower, and change my clothes before we had to leave for the airport.

  The flights were terrible both there and back. Sarah screamed the whole way. It didn’t bother me that much on the way over; I was completely zonked and I slept most of the trip, so it was Larry’s problem, not mine. But I couldn’t believe it on the way back! I was sure the pilot was going to land and throw us off the plane. But outside of the flights, it was the best vacation of our lives. Larry’s parents were great. They wanted to spend the whole time taking care of the baby; they left Larry and me alone, and they encouraged us to go out on our own and do whatever we wanted. I slept late every morning, and by the middle of the second week, I felt like I had finally caught up on my sleep. We traveled all over the country. I can’t imagine a better vacation. The only problem was that the time just flew by. Before we knew it, it was time to pack up, get on the plane, and come back to work.

  I’ve been working in the OPD at Mount Scopus. Things have been quiet. I’ve been getting out between twelve and one on the nights I’ve been on call. Things would be perfect if we weren’t all so jet-lagged. When I’m not on call, I’ve been going to sleep at seven and waking up at three in the morning. And when I am on call, forget it; I have to use toothpicks to keep my eyelids open after nine. But I can see how much calmer I am now compared with before we left. I really needed that vacation, there’s no doubt about it. It’s just too bad I have to wait so long for my next one to come around.

  Saturday, November 23, 1985, 2:00 P.M.

  I had a very bad night last night. The ER was busy and depressing. I didn’t get home until after three this morning, and I just woke up about a half hour ago. It’s a beautiful day and we’re going to take Sarah out for a walk in a few minutes, but I wanted to record this while it was still fresh in my mind.

  At about nine o’clock, I picked up the chart of a three-year-old whose mother said she had had a bloody bowel movement earlier that evening. I didn’t think much of it at first; bloody bowel movements aren’t that unusual. It’s usually due to an anal fissure [a tear in the anal mucosa caused by straining; very common in children around toilet-training age]. I called the patient in and I saw she was a cute, well-dressed, healthy-looking little girl. I took the history from the mother, who seemed appropriately concerned. Then I examined the girl. I noticed right away that her rectum was very red and it looked kind of . . . well, boggy is the best way to describe it. I did a rectal exam and I noticed that the tone of the sphincter seemed a little decreased. I was suspicious, so I called the attending and did the rest of the rectal exam with him in the room. The girl didn’t even cry while I was doing it. There wasn’t a peep out of her, which, to say the least, is not normal for a three-year-old.

  I got a sinking feeling in my stomach when I was doing the rectal because I’ve taken care of little kids who’ve been sexually abused and I knew what was going to happen from here. I was going to have to question the mother, she would probably deny everything and accuse me of making it all up, we’d get into a big fight, and she’d eventually start to cry. Then I would have to call the BCW and report the case to them and they’d wind up doing a full investigation, which might end with them taking the child away from her mother. I knew that none of this was fun or interesting and it was going to take up most of the rest of the night.

  Anyway, I started asking all the questions I had to ask. Did they live alone, or were there other people living with them? Did she watch the girl all the time, or did she leave her with other people? Was the girl’s father around, and did he have anything to do with her? The mother knew something was up because she answered every question honestly and without too much expression. It turned out that the mother and the girl lived in a two-bedroom apartment with ten other people. Some of the people who lived there were relatives, like the girl’s grandmother; some were friends of their family; and some were just friends of the friends. The woman’s father had been a junkie and had died of AIDS the year before. The family had all been tested for HIV and the girl’s grandmother had been the only other person who tested positive. But some of the other people living in the apartment were junkies, and they hadn’t been tested. And there were two teenage boys who were cousins of the mother and who had been taken into the apartment when they themselves had been abused by their own parents a few months before. It was a very confusing, chaotic story, but I believed it because it wasn’t all that unusual. I’ve heard lots of stories like this one since I started medical school.

  The woman said she and her daughter slept in the same bed at night but during the day the mother went to school and she had to leave the girl with anybody who happened to be around. She admitted it was possible for anyone, especially her teenage cousins, to have sexually abused the girl while she was out of the house.

  At this point the mother started crying and I had to leave the room for a minute. I was ready to cry myself.

  I went over to talk to the attending and told him the story and he asked me one question: Why was the mother being so honest? I hadn’t even thought about it before that, but he was right; having your child sexually abused by one of your relatives is not something anyone would be especially proud of. The only thing I could think of was maybe the mother wanted to get something out of this. I mean, here she is living with all these people in this chaotic apartment. Maybe she figured the BCW would do their investigation and decide that the girl shou
ld stay with the mother but that they should be placed in their own apartment. It was a pretty disgusting thought but completely possible.

  I had to go back and tell the mother what was going to happen, and I had to do the rape kit. The attending told me I should draw some blood for HIV testing, just as a baseline. [People who are exposed to the human immunodeficiency virus will test positive for antibodies to the virus a few weeks after the exposure. As such, Amy’s patient should have been negative but may later convert to positivity if she had been exposed to the virus.] I hadn’t even thought about that, but it certainly was a possibility. Not only did this little girl get raped, but also the rapist might have given her AIDS! I didn’t even want to think about it.

  After I finished the rape kit, I started to make all the phone calls. I first called the social worker, and she said that I’d have to make it a joint response. [Joint response: When a child’s life is considered to be in danger, a report must be made simultaneously to the Bureau of Child Welfare and the New York City Police Department. The BCW’s investigation does not get started immediately. Therefore, an immediate investigation by the police must be done to determine whether the child can return home.] So I called the BCW and the police. The whole thing, from start to finish, took about four hours. By the time I was done it was after one o’clock in the morning and there were still a bunch of charts in the box. What finally happened was the mother and the girl were placed in a shelter for the night. I think they’ll ultimately get placed in their own apartment.

  I’ve been thinking about that little girl constantly since I finished with her. All through the rest of the night, all during the cab ride home, while I was trying to fall asleep and since I woke up, that little girl didn’t leave my mind. It’s really terrible. I’m sure I’ll see her face in front of me for years and years to come.