I came back from vacation relaxed and happy, and I was hoping my mellowness would carry me along for a couple of weeks, at least into February, when I’m scheduled to be in the ICU. The depressing thing is that the pace of being back in the ER, the aggravations of being an intern, the frustrations that come with taking care of patients all mounted very rapidly, and it took only a couple of days before I felt like I’d never left. And it’s kind of a drag. I mean, here I am, only back for a week and a half, and already I’m feeling aggravated.
Most of the patients I’ve been seeing have been really abnormal children, really abnormal! During OPD, I spend two out of five weekdays in clinic, and that’s what’s killing me! All the kids I follow now seem to be abnormal; I’ve picked up tons of patients who’ve been discarded by other doctors. I’ve got kids with MR-CP [mental retardation, cerebral palsy], kids with seizures, kids with weird syndromes, psychotic adolescents I picked up while on the ward; you name it, I’ve got one of them in my clinic. I seem to have no straightforward, healthy children at all.
And in the ER, well, we do see relatively normal kids there, but it’s such a bad situation. The parents are exhausted, they’re frustrated, they’ve had to wait no less than forty-five minutes before they’re seen; most of the time they have to wait a couple of hours. Half of your interactions with parents in the ER are not very good. I try so hard to make things go off well, but it’s so hard. By the time they get to see you, the parents are so aggravated that you get aggravated. It’s just a vicious cycle.
There were a couple of bad things in the ER today. I had one kid who came in and got worse right in front of my eyes. We wound up nearly coding him. And then we had a kid with 20 percent second-degree burns to the perineum [the diaper region] that didn’t look very nice. How do you think those got there? It was another abuse case, of course.
Then a thirteen-year-old stab victim came in. The stories are always the same with stab victims: They say they were just going to the store to get their grandmother some ice cream or something like that when somebody out of the clear blue came up to them and stuck a knife into their chest; they’re always innocent. This kid wasn’t really that bad. And he was about the worst we had today. I didn’t have to do any pelvics. So that made it a pretty good day.
I used to get upset about doing pelvics, but I really don’t care about them that much anymore. They really aren’t so bad as long as you’ve got a kid who isn’t going to be hysterical. That’s about one out of every five kids. I’m not wild about doing the other hysterical four, but one of those will be only semihysterical, and only one of the other three will be completely off the wall. But you really can’t blame them; most of them are twelve years old and they’ve never had a pelvic before, and then they find out they’re pregnant. Uhh, God forbid! Anyway, it happens all the time. And sexual abuse, you know—what can I say?
We had this attending on today who was driving me up a wall! She was so indecisive, I wish I’d never asked her anything! I think she made more trouble for me than anything else. But I kind of liked her, she was really very nice, and she actually gave me a little off-the-cuff talk on pharyngitis that was very good. But every other time I asked her for help, she just wound up making everything very confusing.
I’m getting to the point where I don’t want to bother with the attending, I just want to ask other residents for advice. The attendings usually wind up mucking you up, unless they’re really good, and that isn’t too often. I’m realizing that it’s best just to listen to their advice as a suggestion and then do whatever you want to do. Shit, it’s my name that goes on the bottom of the ER sheet, not theirs! [Although the attending is supposed to be supervising the care of all patients in the ER, the house officer is the one who signs the chart at the completion of the patient’s care.] I’m the one who’s really responsible!
I really can’t complain about anything tonight. First, I got home at a great hour. I mean, I left that emergency room at twelve-thirty. That’s almost unbelievable! And I have the next two days off because Monday is Martin Luther King’s birthday and all the clinics are closed. Hallelujah! What will I do with myself with all this spare time? Sleep, probably.
Sunday, January 19, 1986, 11:30 A.M.
I was just lying in bed here thinking about how no one tells you, really, how to be an intern. They tell you what to do, when to do it, how much to do it with, and how you’re not doing it fast enough, but no one tells you really how to be an intern. For instance, where do you draw the line between your own decisions and those of your superiors? Over the past few months I’ve come to feel comfortable with making decisions; I can deal with a lot of issues on my own now. But when the attending tells you to do something and you don’t think it’s exactly the right thing to do, what are you supposed to do? After all, it’s your name that’s on the paper, not the attending’s. A lot of times it seems like the attendings don’t really fully understand the case, and they make snap decisions with only a half or a three-quarter understanding, and you’re the one who’s supposed to carry out their orders. So what it all comes down to is, you have to decide for yourself. You’re not a medical student anymore, you’re really a doctor, even though you barely know how to function as one. That’s what no one can tell you. It’s something I can barely tell you myself.
The other night I examined a little three-year-old girl who came in with a vaginal discharge. The history wasn’t suspicious at all, and there were only a couple of very, very subtle things on the physical exam aside from the vaginal discharge, but the first thing you’re supposed to think of in a case like that is sexual abuse. And that’s exactly what went through my mind.
But I found myself getting talked out of reporting the case to the BCW because it wasn’t all that clear-cut. The attending argued that the discharge could have been caused by something other than sexual abuse. I had to agree. And I felt really pressured by the attending and the social worker, people who have had years and years more experience than I, just to let it pass, to sign it out as nonspecific vaginitis rather than sexual abuse. We talked about it for a long time, and they told me to think about what reporting it would do to the family; the child would be removed and placed in a foster home. The parents would be labeled as criminals, whether anything really happened or not. It might be years before these people’s lives would return to normal. And with all that pressure, I decided to go along with them.
Now I’m regretting it. I’ve been thinking about this kid ever since. The attending told me to be sure to follow the girl carefully. But let’s say this was a case of abuse: What if they don’t come back for their follow-up appointment? What can I do then? And, of course, I called the bacteriology lab at Jonas Bronck today and was told that they have no record of receiving the GC [GC: gonococcus, the bacteria that cause gonorrhea] cultures. Great! I’ll keep looking for them; I’m sure they’ll turn up sooner or later. I hope to God the messenger didn’t throw them down the elevator shaft or something like that. But if they don’t show up and we never find the cultures, what can I do? And what’ll happen if this girl comes back dead next week because whoever molested her decides to whack her over the head with a hammer? It’ll be my fault, because I listened to the attending and the social worker rather than doing what I thought was the right thing.
This feeling I have, that I have to start making up my own mind and not relying on other people, it’s really something that can’t be taught beforehand. I’m just realizing it myself, and I’ve been doing this for six months now.
I got on the elevator in the DTC building [the clinic building at Mount Scopus] the other day and the elevator stopped at one of the adult floors. This middle-aged man came on with these two middle-aged women, and he said something like, “All they see when they look at you is dollar signs.” Then he said, “Look at their mistakes. They fill the graveyard. They don’t give a damn. All they care about is money. I don’t trust doctors one damn bit anymore.” This guy was standing three inches from me! And I was
really biting my tongue. I felt like saying, “Look, there are some bad apples out there who suck, who are only in it for money, and who don’t give a shit about people. But most of us really do care about our patients.”
I don’t know, I find myself feeling defensive about organized medicine and at the same time being more disillusioned about it than ever. I do look at the mistakes that are made and the horrible outcomes that result, and yes, our mistakes do end up in the graveyard, but they dot them, they don’t fill them.
Well, I’ve gotten a little off the subject. Anyway, I don’t think there’s any way that people can be taught about what it’s like to be in the uncomfortable position of having to start to use their own mind but having very little to base decisions on. There’s just no way anybody could have prepared us for this transition from the little puppy dogs who do everything the attending tells us to independent doctors who wind up being very uncomfortable with some of the decisions we have to make. I’m constantly feeling as if I’ve got a green belt in karate, that I know enough to kick someone but I might break my own foot doing it.
Amy
JANUARY 1986
Friday, December 27, 1985
It snowed yesterday for the first time this winter. Sarah’s amazed. We took her out in her stroller a little while ago and she kept looking down at the ground and looking up at Larry and me as if to say, “Where did all the grass go?” It’s funny to watch.
I’ve been in the nursery at Jonas Bronck for a few days now. So far it’s been a mixed experience. I’m assigned to the well-baby nursery, which is nice. I spend most of my time examining newborns and talking to their mothers. That’s what I really liked about pediatrics in the first place, and it’s nice to have the chance to do it without all the other nonsense that usually takes up our days. So that part of it is good. What I don’t like, though, is that my night call is in the neonatal ICU. It’s frightening in there! And it’s harder for me than for the other interns because, since I’m only in the NICU at night, I don’t know the sick ones very well. All I know about them is what the interns sign out to me, and it’s impossible to get a really complete sign-out on a patient who has a hundred different problems. So that’s frightening to me, but what can I do? It could be worse; I could have to spend all my time in the ICU.
Another bad part about working in the well-baby nursery is that we’re always on call to the delivery room. If there’s a premature baby being born or a baby who’s in distress, the resident and I get called to come to the delivery. It’s not really that bad, though, because during the day there’s usually a fellow [neonatal fellow, a physician who has completed a pediatric residency and is getting specialty training in neonatology] or an attending around, and one of them usually comes in with us. If they weren’t there, it would be terrifying!
I have to admit, I’ve been lucky with my schedule over the past couple of months. I’ve worked with very good residents and I haven’t been on the hard wards or had a lot of bad patients. I guess I should say that I finished on Children’s last week and Angela [the young girl with neurofibromatosis] was still alive. I heard she got worse the day after I left, though. She had another very long seizure and they had trouble stopping it, so they transferred her up to the ICU. They had to anesthetize her to get the seizure to stop [general anesthesia is used as a last-ditch effort to stop intractable seizures only after every other treatment modality has failed]. The intern who picked up my patients told me they don’t expect her to survive much longer, only another few days at most. It’s really sad; one month ago, she was a completely normal child. Now she’s almost dead. That’s not supposed to happen to children.
I was on call Wednesday, Christmas Day. It wasn’t so bad, since we don’t celebrate Christmas, but it was like working an extra weekend day. The hospital was completely dead, even deader than most Sundays. But babies don’t know anything about holidays; they crump whenever they feel like it. I did get a couple of hours of sleep that night and I guess I should be thankful for that, but I can see that night call during this month is going to be terrible.
I had only one admission to the unit on Wednesday, a thirty-weeker [thirty-weeker: a baby born ten weeks prematurely] who did pretty well. We were in the DR when he was born. The obstetric residents thought he was only going to be about twenty-six or twenty-seven weeks; my knees were shaking while I stood in the delivery room waiting for him to come out. The resident and I were very relieved when we saw such a big baby come out. He weighed about thirteen hundred grams, which is gigantic for the NICU. And he didn’t get too sick: He had a little bit of respiratory distress but nothing terrible. All he needed was a little extra oxygen, so we put him in a headbox [a cylindrical Lucite box that covers the head of an infant and through which oxygen can be provided] with 40 percent oxygen. [Normal room air contains 21 percent oxygen; therefore 40 percent oxygen provides about twice the normal concentration of oxygen.] He never retained CO2 [babies with respiratory distress syndrome, a major complication of prematurity caused by underdevelopment of the lungs, develop a buildup of carbon dioxide, or CO2, in the blood], so we didn’t have to intubate him. He should do fine. His mother is seventeen years old and already has a one-and-a-half-year-old at home. She lives with her mother, who essentially takes care of her and the baby as if they were siblings. It’s a funny social system here in the Bronx. Most of our mothers are under twenty, and most live with their mothers, who wind up taking care of the children.
Well, the apartment is quiet. Sarah’s asleep, Larry’s watching TV in the living room. I’m going to go to sleep. I’ve got to be up early tomorrow morning so I can be on call.
Saturday, January 18, 1986, 10:00 P.M.
I haven’t recorded anything in a while. I’ve been very tired and very busy. I’m really enjoying working in the well-baby nursery; it’s the first thing this whole year I could actually see myself doing for the rest of my life. The problem is, there’s no way to do it without doing a fellowship in neonatology first, and that is something I definitely do not want to do. So once again, I’m kind of stuck.
I’ve gotten along very well with a lot of the mothers. They seem to trust me. They trust me even more when I tell them I’ve got a baby of my own who’s almost nine months old. I guess they feel they can identify with me. Frankly, I’m not sure how you can be a pediatrician and give advice to mothers without having your own child. Anyway, it’s been a very rewarding experience.
I’ve pretty much gotten my work down to a routine. When I arrive in the morning, I look at the list of babies who were born the night before. All of these kids need to have physsies [physical exams; all babies get examined within twelve hours of delivery and then again right before discharge]. I find the babies and do the exams. When I’m done with those, I find the list of babies who are supposed to be discharged that day. I find those babies, and one at a time take them out to their mother’s bedside and examine them right in front of their mothers. I found that that gives the mothers the chance to ask about anything they don’t understand or anything they’re concerned about.
It’s amazing how many strange things these women come out with. I had this one woman, a nineteen-year-old who had had her first baby, who asked me about the strawberry hemangioma on her baby’s back. [Strawberry hemangioma is a birthmark composed of a mass of blood vessels; they are very common and usually are of no medical significance; most disappear by the time the child is six years old.] I told the mother it was just a birthmark and that it wasn’t anything to worry about. She asked me three times if I was sure that that was all it was, and each time I told her I was positive. Finally, I asked her why she was so worried about it. She wouldn’t say anything at first, but finally I got her to tell me the story. She said she had heard that some people with AIDS had a skin disease that might be the first thing that’s noticed. I told her that was true, that the skin disease was called Kaposi’s sarcoma. I also told her that babies almost never got Kaposi’s and then I asked why she was so concerned. At firs
t she said it was because the baby’s father had been using drugs for years and she was worried that he might have AIDS, that he might have passed it along to her, and that she might have passed it along to the baby. I worked on her for a while, and I finally got her to admit that she had used drugs a few times about a year ago and that she and the baby’s father had sometimes shared needles. Ever since, all through this pregnancy, she had been scared to death that she had AIDS.
I spent over an hour with her. I asked about all the signs and symptoms that might indicate AIDS. She didn’t have any of them, and I told her that was a very good sign. But she said she had been having trouble sleeping at night for a few months because she was so worried and that it was starting to affect her schoolwork. She goes to Bronx Community College. She told me she wanted to be a lawyer but she honestly didn’t think she was ever going to make it because she was going to die of AIDS. And then, when the baby was born with the strawberry hemangioma, she had become convinced that not only was she going to die of AIDS, so was her baby. She started crying and I held her hand and comforted her.
I waited until her crying stopped and then I told her that if she wanted, I could take some blood to see if she had antibodies to HIV. She told me she’d thought a lot about getting tested but she was afraid to. She said she didn’t know what she’d do if she turned out to be positive. I told her that was a problem, but I pointed out that she was already suffering and it might all be for nothing; there was a good chance, after all, that she’d turn out to be negative. So I guess I talked her into letting me do the test. I had her sign the consent form, and then I drew her blood. I wore gloves when I was taking it. I felt funny putting on the gloves; it was as if I were saying, “I’ve been telling you I don’t think you have it, but I’m not taking any chances.” She didn’t say anything about the gloves. I don’t know; maybe we make too much out of feeling guilty. So far, whenever I’ve worn gloves, none of the patients or their parents has said a word.
The Intern Blues Page 25