Anyway, I think I did some good for that woman. Here she had been coming to obstetricians for months, always with this dread fear, and nobody had found out anything about it. And just because I spent a little extra time with her, I was able to discover that her life was being completely disrupted by something that might be totally avoidable. I haven’t gotten the results of the blood test yet. But I’m going to see her and the baby in clinic sometime next week, and hopefully by then I’ll have the answer. I felt really good about that one.
I’ve had a couple of cases that didn’t turn out that well, though. And one of those made me feel as bad as that last case made me feel good. During rounds our attending, Joan Cameron, always tells us we should try to push breast feeding whenever we get the chance. I have mixed feelings about breast feeding. I mean, I know it’s the best thing for the baby; it’s supposed to be helpful in preventing infections and things like that, and it’s also supposed to help the bonding process between mother and infant. But it’s not the easiest thing to do. A woman really has to be committed to breast feeding, and she has to have a lot of support from the people around her. If she’s kind of wishy-washy about it, it’s just not going to work out.
Anyway, last week I was talking to this woman who asked me about breast feeding. I gave her the party line: I said yes, it’s the most important thing you could do for your baby. Then she asked if I had breast-fed my baby (I had already mentioned to her about Sarah). And I had to say that I did it for a few weeks only and then stopped because I had to start my internship. And she said something like, “You doctors are all alike! You tell us to do things you wouldn’t be caught dead doing yourself!” And she said some other things that weren’t very nice. Basically she called me a hypocrite and she immediately asked for a bottle of formula.
I knew she was right, and she hit a nerve. I mean, I would have liked to have breast-fed Sarah for longer if I’d had the chance. It makes me pretty angry. Here we are, being told by our attendings that we should advocate breast feeding, but there’s no way I would have been able to do it with my own baby. How can you breast-feed if you’re on call every third night and there’s no place in the hospital to keep your baby while you’re working? That woman was right, it was hypocritical for me to suggest she do something I couldn’t do, and it’s very hypocritical for our faculty to try to get patients to do something that’s best for their babies and not give the house staff the same opportunity. So that situation didn’t work out so well. And I’m still angry about the whole thing.
My night call is just about what I expected. I’ve only gotten sleep a couple of times on nights I’ve been on call. I’m finding something out: I really need only about two hours of sleep to function well the next day. But those two hours have to be between four and six in the morning. If I’m up between four and six, I’m just about worthless the next day. If I sleep those two hours, even if I haven’t seen the bed the rest of the night, I’m fine.
And doing night call in the NICU hasn’t made me feel any more comfortable about working with these tiny babies. If anything, I’ve become more terrified. The unit is brand new; it just opened a couple of months ago, so everything is state of the art. And these babies are so sick! We’ve had three deaths so far this month—two preemies and one full-term kid. I was on call the night the full-term kid was born. That’s something I won’t forget for a long time!
We were called to the DR because of thick mec and late decels [late decelerations: a pattern on fetal heart tracing indicating fetal distress]. The obstetricians decided to do a stat C section and they pulled out the baby, who was covered with mec. I tried to suction her mouth while she was still on the table, but I guess I didn’t get all of it out because she was in respiratory distress almost immediately. [Actually, the baby had probably already aspirated meconium prior to delivery; in this case, suctioning of the oropharynx probably didn’t provide any help in preventing what subsequently happened.] Eric Keyes was the senior on call with me, and he was on the baby as soon as she hit the warming table [the table in the DR on which the baby is placed following delivery]. He intubated her and started suctioning out her airway through the ET tube. He was getting tons of thick mec out. In the meantime, I was listening to her heart. She was really bradycardic [had a low heart rate], so Eric told me to start a line and get ready to push meds. I hadn’t ever started a UV [umbilical vein] line myself, so he talked me through it as he was suctioning out the trachea. When I finally managed to get something in, we changed places so Eric could push the first round of meds. The airway was pretty clear by that point, so I started bagging the baby [pushing oxygen through the endotracheal tube, using an ambubag to generate pressure]. The heart rate came up a little, to about 80 [the normal heart rate for a newborn is 120 to 140 beats per minute], and Eric decided that we’d better get the baby out of the DR and into the ICU right away, so we put the baby in the transport incubator and ran with her down the hall to the unit.
We worked on her all night. We called the neonatal fellow at home, and he came in to help. She had severe respiratory distress and PFC [persistence of the fetal circulation]. We were having trouble ventilating her and getting her blood circulating. We put her on a ventilator and had it turned up to very high settings. [To ventilate a child with mec aspiration, it’s often necessary to use a great deal of pressure with which to push oxygen into the lungs. Meconium causes the lungs to become very stiff, and the pressure is necessary to get them to expand.]
At about four in the morning, she crumped. Eric decided she had a pneumothorax [a collapsed lung, caused, most likely, by the high ventilator pressure that was being used to force air into the baby’s lungs], so he put a chest tube in and she immediately looked better. But she was still hypoxic all night, and at about five in the morning Eric and the neonatal fellow decided to start her on tolazoline, which is supposed to help PFC. It didn’t do her much good. She crumped again at about eight, just when the day crew started showing up. It was another pneumothorax. I didn’t stay any longer than that. I had to get out to the well-baby nursery and start doing my physsies. The baby died a little later that morning.
It was terrible. She had been completely normal. If she hadn’t gotten all fouled up with meconium, she probably would have been a normal child.
That baby’s mother was put on the gyn ward, so I didn’t get a chance to talk to her. They did that so it would be easier for her; it would have been very hard if they’d put her on the regular postpartum ward and she had to be surrounded by all the new mothers with their healthy babies. I don’t know what I would have said to her if I had gone to talk with her. Nothing seems right.
I heard that Angela died a little over a week ago. She spent her last couple of weeks in the ICU at Mount Scopus, comatose. I never thought there’d be so many deaths in a pediatric internship!
Anyway, I’ve got to go to sleep. I’m getting tired and I’m on call again tomorrow, so I’ve got to get a good night’s sleep. I’ve got another week to go in the nursery, then I have two weeks in the OPD and then vacation. I hope I make it until then.
Sunday, January 26, 1986
There are so many crack users around. There are six babies who’ve stayed in the nursery the entire month. The mother of each of these babies is a crackhead and the babies have been taken out of their custody by the BCW. They’re all waiting for foster placements, but it’s hard to find homes for these kids because there’s a good chance they’re infected with HIV. All of them spent their first few weeks of life withdrawing from drugs. It’s sad. For a lot of these children, their lives are already over before they even had a chance to start.
The ICU has been pretty quiet over the past week. There was an outbreak of naf-resistant staph [a type of bacteria that is insensitive to nafcillin, the antibiotic that is most effective in treating staph], so they had to close two whole rooms [closing the rooms and cleaning them is the only effective way to prevent sick newborns from getting infected with the bacteria]. That cut the census by
about half, so taking call in there wasn’t so bad. I even got a few hours’ sleep the last two nights I’ve been on. So all in all, it’s been a pretty good month.
We’re going out to New Jersey to visit my father this afternoon. Sarah was nine months old yesterday, so my father’s going to have a little party for her. We haven’t seen him in over a month; he’s starting to feel like we’re trying to avoid him. He still doesn’t understand what it’s like to be an intern. He thinks I’ve got a lot of free time and that we’re just doing other things rather than coming out to see him.
Well, I’m going to stop now. Tomorrow I’ll be back in the Jonas Bronck ICU. Seven months down, five more to go.
Oh, one more thing. That woman who thought her baby’s strawberry hemangioma was a sign of AIDS showed up at clinic this week. I called the lab to get the results of her HIV testing, and guess what? She tested negative! When I told her, she hugged me and kissed me. That’s the first time this whole year when I really thought I had done somebody some good. And it happened only because I took the time to sit and listen to what she had to say. It had nothing to do with medicine.
Mark
JANUARY 1986
Thursday, December 26, 1985
I was on call Tuesday for the first time this month, and it wasn’t too bad. It should have been great: It was Christmas Eve, the ward was quiet, and I had only one admission. I should have gotten six hours of sleep at least, right? Wrong! It was one of those cases where if anything can go wrong, it will go wrong. It was a two-and-a-half-year-old sickler with pneumonia. She was called up from the ER at about eleven-thirty, so I figured great, I’ll go down, bring her up to the floor, do the workup, start her on some antibiotics, and be in bed by one. Of course, that’s not even close to what happened. First, I got down there and found that no one had been able to get an IV into her. Everyone had tried and everyone had failed. So they figured what the hell, let old Mark take the kid up to the ward and have a crack at it. How nice of them! But it turned out okay, because you know what? I got it in on the first stick. That’s right, the very first stick! I’ll tell you, I’m becoming the King of Scut. It just shows you that if you take a plain, ordinary, moronic intern and make him do the same things over and over again until he loses his mind, you can teach him to do almost anything. I think that now that I’ve mastered IVs, I might take up neurosurgery in my spare time.
I’m getting off the track here because I’m a little tired. Anyway, so I brought her up to the floor and got the IV in and did the whole workup, and by two o’clock everything was done except a urinalysis. I spent most of the rest of the night chasing after her with a urine cup, trying to get some of her precious body fluid. Yes, my mother sure would have been proud of me!
They hadn’t been able to get any urine from her in the ER. I didn’t want to start her on antibiotics until we had a sample of urine because she had had a UTI [urinary tract infection] in the past, and if she had one again, we needed to know about it. I wasn’t having trouble getting the urine because she wasn’t peeing; it was that she wasn’t real happy about peeing into any kind of container. Right after we got her up to the floor, she was standing on the scale in the treatment room and she let loose a stream, so I ran over with a cup just in time for her to pee all over my hands. No urine ended up in the cup, of course. Then we decided to straight-cath her [place a sterile catheter through her urethra and into her bladder in hopes of obtaining clean urine], but just as soon as I got close to her with the catheter, she started to pee straight up into the air. I managed to catch some of that in a cup, and I ran off to the lab to analyze it. It turned out that her urine was clean as a whistle. By that point it was about five in the morning. I got a total of two hours of sleep.
I found out later she was a patient I had taken care of in August on Infants’. Now she’s graduated to Children’s. These kids keep following me all over the place. Next thing you know, Hanson’ll show up again. Hanson! Now, there’s someone I haven’t thought about in a while! You know, no one’s heard anything about him since I discharged him from Jonas Bronck in October. But I know he’ll turn up again, you can be sure of it. It’ll be the busiest night of the year; there’ll be hundreds of admissions to take care of, and he’ll come toddling in and take one look at me and crump right there and then!
I’ve been totally and completely terrified of Alan Morris [the attending in charge]. Monday, on the first attending rounds of the month, he asked me to tell him about my patients. I went to present my first kid and I started off by saying, “This is a six-month-year-old-month old . . .” I just couldn’t get the words to come out right. I got so tongue-tied I finally said, “Forget it! I can’t present anybody to you! You make me too damn nervous!” That was good because it loosened everybody up. Alan seems to make a lot of people uptight. I’m not sure what it is about him that does it. Maybe it’s the whip he brings to rounds with him. Or the buzzards who are always circling over his head. I don’t know why, but he definitely makes me uptight. He’s a great teacher, though; so far, rounds have been excellent. I had to present my sickler to him this morning and I managed to get the words out, but I was still nervous. Then we wound up talking about sickle-cell disease and he happened to hit on the one area I actually knew something about. He grilled me for about a half hour and I think I did a pretty good job. In fact, he must know I need some positive reinforcement, because for the first time since I’ve been here, I actually heard him give someone—in this case, me—a compliment. He said something like, “I don’t care what everybody else is saying about you, I think you’re doing a reasonably good job.” Talk about a vote of confidence! I guess it’s better than having him say he thought I was a complete idiot!
The floor was a real disaster today; poor Ron was getting creamed! There were four admissions, and each one had a bizarre story. One of them was an eight-year-old with subaortic stenosis [an obstruction to the flow of blood below the aortic valve; this obstruction prevents blood from getting from the left ventricle of the heart out to the rest of the body] who was only mildly symptomatic but who was admitted for surgery anyway. Ron and Amy, our resident, did a complete workup, history, physical, labs, the works. When they had drawn his type and hold [a specimen of blood to be sent to the blood bank so that blood for transfusion could be prepared], the mother said, “What are you doing that for?” Martha told her it was for the blood bank and the mother said, “Well, you don’t have to send it. Don’t you know we’re Jehovah’s Witnesses? There’s no way you’re going to give my child any blood, and that’s final!”
They went crazy. Ron was ready to reach into the cardiologist’s mouth and tear out his vocal cords. And then this whole big thing started with the cardiothoracic surgeon, two or three anesthesiology attendings, the cardiologist, and us. The Anesthesia Department refused to do the surgery without the option of using blood if it was needed. They had to call the hospital lawyers and wait for a ruling. The whole thing took hours, and the end result was that the kid wound up going home. Amy and Ron were pissed off, the cardiologist was pissed off, the CT surgeon was pissed off, and the anesthesiology people weren’t exactly happy.
I sat through all this in kind of a daze because I was so tired. I’ve got to try to get more rest. Well . . . maybe next year.
Tuesday, December 31, 1985, 11:30 P.M.
I know it seems pretty strange, but here it is, eleven-thirty on New Year’s Eve, and I’m lying in bed, talking into this stupid machine. I’m too tired to go out, so I’m here all alone. Carole went to a party by herself. I was supposed to go with her, but I called her a couple of hours ago and told her I was just too tired to make it. I’m pretty pathetic!
I had a long night last night. It took forever to finish my work today, and just as I was about to leave, a nurse came running out of a room yelling, “Hurry up, she’s not breathing right!” So I calmly got my stethoscope and walked into Cassandra’s room, and there she was, sure enough, breathing at a rate of eighty to ninety. Now even I know tha
t eight-year-old girls aren’t supposed to breathe at a rate of eighty to ninety. I wasn’t sure what was happening. She’s got osteogenic sarcoma [a malignant tumor of the bone] and she isn’t expected to live very much longer, but I at least expected her to make it into 1986. When I came in and found her breathing that fast, I figured maybe she was having a pulmonary embolus [a clot in one of the lung’s major arteries]. But she had equal breath sounds. We did a whole workup and didn’t find anything. She’s not my patient, but we’ve all gotten to know her. I just called and found out that she’s still alive and she seems to be reasonably comfortable, which is reassuring.
I don’t know about these terminal patients; it’s really draining taking care of them. You don’t even want to go near the room because you know there isn’t anything you can do to help, and whenever you do go in the room, it’s to do something terrible, like draw blood. It’s very frustrating. The only thing we can do is try to make the last few months as comfortable as possible for her. If we can do that effectively, then we’ve really done our job. Dealing with these kinds of issues is really the hard part of this year.
There, now I’ve really cheered myself up! I’ll tell you, I’m not sorry to be seeing 1985 end. In 1986 I’ll be an intern for only half the year. That’s not so bad. I’m going to sleep. Good night. And Happy New Year, tape recorder! Now, that’s really pathetic!
Tuesday, January 7, 1986, 9:00 P.M.
This has been an interesting couple of days here. On Friday morning I had to get some blood from a patient before attending rounds started. I was late, and I was worried that Alan was going to yell at me. He still scares me to death. I was postcall and really crazed and I guess I hadn’t eaten in maybe sixteen hours. So I went into the patient’s room and started drawing the blood, and pretty soon I started realizing that I was feeling kind of light-headed. Really light-headed! So light-headed, in fact, that I grabbed on to the patient’s mother, who was helping me hold the kid down. She, of course, thought I was coming on to her, but I reassured her that I wasn’t trying to do anything nasty, I was merely trying to prevent myself from collapsing in a heap on the floor. I told her I’d be fine just as soon as I finished drawing the blood. I’m sure that reaffirmed her faith in me as her child’s physician!
The Intern Blues Page 26