The Intern Blues

by Robert Marion

  Things still weren’t exactly great. But then, the next time I saw her, we talked for a little while and then we went out to lunch and now we’ve become friends. She’s really a good nurse, she’s fast and efficient, and she’s funny. Now I even like her.

  I should mention one patient I had in neurology clinic. He was a seventeen-year-old autistic, severely mentally retarded, violent guy who had been sent over from Bronx Developmental Center [a residential facility for moderately and severely developmentally disabled children and adults] for evaluation because he was becoming increasingly depressed and had been losing weight. He was on all kinds of phenothiazines [a class of tranquilizers], but nothing was helping. I brought him into the examining room with the health care worker who had come with him. While I was looking through his old chart, he suddenly started to become extremely agitated. He got up and began stomping his feet on the ground and then he started slamming his head into the green tile wall over and over again. I looked over and realized there was blood on the wall, and there was blood coming out of his mouth. He had actually knocked a couple of teeth loose!

  Then he started going completely wild; he attacked the health care worker and turned around and slugged me in the ribs a couple of times. Then he went and smashed his face against the wall again. The health care worker, a large, matronly black woman, grabbed him and tried to hold him still. All this time, he was screaming and making unintelligible grunting noises. Pretty soon he began flailing around, and the health care worker, who was getting kind of panicked, looked over and said, “He doesn’t like to be in tight spaces. We need to get him out of here!”

  I thought I had been very calm up until that moment. I opened the door, walked out, and everybody was looking toward the door because there had been a lot of ruckus in my room. I said, “I have a problem here.” We got the kid out of the room and into the hallway, where apparently he didn’t feel so enclosed, and we called security and I sat down with the neurology attending to whom this guy had been referred and said, “Why did you put me in that room with him? You knew exactly what was going to happen.” And she made some comment like, “Well, you have to learn to take care of these kinds of patients,” and I thought, No, I don’t. As a resident, I don’t have to take care of severely disturbed, autistic, retarded, violent patients who’ve been referred to a specific doctor for evaluation. In fact, the neurologist didn’t want anything to do with him either. She finally said, “You know, we just can’t evaluate him.” So we sent him back with a letter saying sorry, there’s nothing we can do. It was too bad, but we had nothing to offer.

  I’ve thought about that patient a few times since this happened. I’m wondering how I would have reacted to the whole thing if this had happened back in July instead of in January. I think in July I would have tried a little harder, maybe looked farther through the chart or pushed the attending a little more. I don’t know, the kid was crazy, he was dangerous, but when I was in OPD last July, I did some things for patients I don’t think I’d do now: I stayed late to finish the workups on patients, things like that. I don’t know if that’s bad; it’s just that it’s a real change in me.

  Anyway, those last weeks in January were very nice and I began regretting my decision to leave the Bronx. And on my last day in the ER, I said to the nurses on the afternoon shift, “This is the last time I’ll ever be in Jonas Bronck.” (My schedule at that time had been set so that I spend the rest of the year at Mount Scopus.) And they said, “What are you talking about? You’ll be back next year.” I said, “No, I won’t.” And they all said how much they’ll miss me and stuff. It was very nice. Very nice and very sad.

  I just finished my month in the ICU at Mount Scopus. It was a terrific month. We had a great team: Alex George was the attending, Diane Rogers was the senior resident, Terry Tanner was the junior resident, and we had a couple of good cross-coverers at night. The ICU was tremendously exhausting but somehow I didn’t feel as overwhelmed as I had in the NICU, where I never got any sleep. There were a few nights this past month when I didn’t get to bed either, but I got at least some sleep most nights I was on call. And I slept for seven whole hours my last night.

  I seemed to have the same luck in the ICU that I’ve had all through the rest of the year. I seemed to get the sickest patients with the most dismal prognoses, and Terry got a lot more of the acutely ill, rapidly recovering patients with relatively good prognoses. It became kind of a standing joke that if I were there to admit a patient, the patient would either wind up dead or with some kind of severe permanent deficit. I guess I’ve got a lot of bad luck.

  There were three patients who were the saddest patients I’ll remember for a long, long time. The worst was Ronnie Morgan, this wonderful, beautiful, redheaded boy. When I met Ronnie Morgan for the first time, he was intubated, with a shaved head, a swollen face, and a dozen lines running in and out of his comatose body. Ronnie Morgan was a little two-and-a-half-year-old who had been doing really well until three months before I met him, when he became ill with some minor symptoms and was found on a routine blood test to have an outrageously high white blood cell count. He was admitted, a bone marrow biopsy was done, and a diagnosis of ALL [acute lymphocytic leukemia] was made. Soon thereafter, he had a bout of ARDS [adult respiratory distress syndrome, a condition in which the lungs fill with fluid and respiration becomes extremely difficult] and a systemic fungal infection. He was admitted to the ICU at death’s door, recovered, went through some chemotherapy, and finally was thought to be going into remission. Although his disease and his chemotherapy turned him into a cranky and irritable little kid, his mother always remembered him as being a beautiful, wonderful, happy boy. And then a few days before I first saw him, he was leaving his hematologist’s office after a routine visit and fell and hit his head. That’s not so unusual; he was a toddler, and toddlers fall a dozen times a day; that’s why they’re called toddlers. But when he fell, he happened to have a very low platelet count because of the chemotherapy, and he got an occipital hematoma [a large, blood-filled bruise in the back of his head]. So he was admitted to the hospital for a transfusion of FFP [fresh frozen plasma, a blood product containing the elements of the blood essential for blood to clot] and platelets because it was feared he could bleed out into the hematoma.

  Over the course of the next thirty-six hours, he became progressively more lethargic, his mental status deteriorated, and with that concern he was brought down for an EEG [electro-encephalogram, a test to examine brain waves]. While he was in EEG, he began to seize. He was then rushed to a CT scan, where a massive intracranial bleed was found [intracranial bleed: a hemorrhage in the skull]. At that point, he was immediately brought to the operating room for emergency neurosurgery. There, a huge intraparenchymal [within the body of the brain] and subarachnoid [below the inside layer of the meninges, the tissue that surrounds and protects the brain] hemorrhage was evacuated, along with a good part of Ronnie’s brain, something that happens when you do that kind of surgery. He was then brought up to the ICU on a ventilator and became my patient.

  I knew Ronnie was a goner from the moment I saw him. He had a horrible problem, a subarachnoid and intraparenchymal bleed, and that diagnosis on its own was horrendous. And then you add to it his age and his fragility with his leukemia and the low platelets and all the rest and he really had no chance at all. And everyone in the ICU identified so much with him and his parents, who were young, white, middle-class, articulate people.

  He was with us for about ten days. After maybe the fourth or fifth day, he had a sudden, uncontrollable rise in the pressure inside his skull. We had been able to keep the intracranial pressure down prior to that time with various maneuvers and drugs, but that day it just became uncontrollable. And with that it was felt that he was essentially brain dead, and yet his body wouldn’t die. It was all so horrendous, continuing to take care of this boy who had no prognosis at all. His father understood the situation; he knew how bad things were, and he was trying to mourn his son’s
death before it actually occurred. But his mother was too defensive and wouldn’t accept it, and in a sense was preventing the father from doing his mourning. I never really got to know these people very well; when I first picked up Ronnie as a patient, I saw all the people who were gathered around the parents and I felt that my availability as a support person would not be needed. I didn’t see the need of intruding myself into these people’s lives when they had already made acquaintance with Alex George, a hematologist, and some other members of the staff. And while it was true that there was nothing extra I could have offered them, I think I missed out on something and I wish I’d had the opportunity to learn how to help these people grieve.

  The day his ICP [intracranial pressure] skyrocketed, we were standing by his bedside, and Alex said that Ronnie had died, that the bleed inside his head and the pressure had completely destroyed his brain. In the bed right next to him, separated only by a flimsy curtain, was a fourteen-year-old girl who had been diagnosed with a horrible brain tumor and who was going to die of that tumor within the next year or so. She had just undergone some surgery and she was a little off the wall and her mother, who had been sitting here, suddenly said, “I can’t take this, this is too much for me!” and left the room. It was just a little too close to home for her.

  Finally Ronnie did die. He died a couple of hours before I came in one morning. I had been post-call the day before and he’d been doing very badly; I left knowing it was only a matter of time. I didn’t go to his funeral, but I wish I had. I think I’ve been mourning his death ever since he died; not often or always, but whenever I think about him, I get very sad. But it’s strange: I never did know him as a person; I only knew him through the eyes of the people who loved him. Still, I know I’ll remember him and be sad for him through maybe the rest of my professional career.

  I had another patient, Kara Smith, a little four-month-old who broke my heart. Her first three months of life were normal, and then she came down with pneumococcal meningitis [meningitis caused by the bacteria Streptococcus pneumoniae; this type of meningitis causes particularly devastating effects]. When I picked her up at the beginning of the month, she was just this little seizing baby who was in renal failure, on peritoneal dialysis [a procedure performed on patients in renal failure; dialysis rids the body of the waste products of metabolism that normally are removed by the kidneys], getting multiple antibiotics, and who had a very abnormal neurologic exam. To make a long story short, Kara was the patient who should have died but didn’t. Her mother agreed to a DNR order. I actually first brought up the idea of DNR with Ms. Smith. I told her it was something she should consider, and she decided that it would be best if Kara just died. It sounds cold-blooded saying it like that, but it really would have been the best thing that could have happened. We decided we’d just do supportive care and nothing heroic, but even that division became increasingly unclear.

  One afternoon she had an acute respiratory attack; it was probably just mechanical, just her [endotracheal] tube slipping down her right mainstem [bronchus, the breathing tube going to the right lung], and she began deteriorating. She became cyanotic [blue], and her heart rate dropped. We readjusted her tube and she recovered a little but she still looked shitty. I felt really uncomfortable doing nothing, and yet, to bag her back was kind of a resuscitation. It was very unclear. And there was a senior, Eric Keyes, sitting there, and he said, “Forget it, just leave it, don’t do anything.” It was so easy for him to say that, it was nothing for him, he was just looking at her and thinking, This kid’s just a GORK, forget her. But I felt bad doing nothing. She was my patient. I’d made a pact, in a sense, to support her. So when she continued to deteriorate, I in fact did bag her a little. And then, after a while, she was fine again. I’m still haunted by that issue. It’s one of those very gray areas of medicine.

  I talked to Karen so many times about this baby. One night after a really long discussion, she said, “Listen, you have no medical basis for what you’re doing with this kid. Why don’t you just put down the side rails on the bed and let the baby fall to the ground and die? Is that any different from letting her electrolytes get out of whack because you’re not doing blood tests on her? Why not just put down the rails?” In fact, putting down the rails wouldn’t make a difference; the baby never moved anyway. But she was right; there was no medical basis for so many of the decisions that were made. Everything seemed so arbitrary and based on emotions rather than facts. I think we were very much guided by the fact that the mother just didn’t want that baby anymore, she didn’t want a baby who was so severely damaged. We consulted the mother at many points along the road, we involved this poor woman who had no support system and who had other kids at home to worry about, and these decisions were difficult for her to make. One day I asked her to come in because we needed to talk about something; she showed up late at night, hours after the time I had asked her to come. She came with this young guy, about seventeen, who looked scared and a little intoxicated, and it turned out to be the baby’s father. I had never seen him before; he had been nowhere near the hospital for at least two and a half weeks. We sat in the family room for a long time and talked; we talked about DNR and the new thing we were going to withdraw and she said, “Go ahead.” It was as if she were saying, “Please don’t let this baby live!”

  It didn’t really hit me how dismal Kara’s prognosis was until I saw her CT scan. Her brain looked like a minefield; there was more space and fluid than there was brain tissue. This little baby had so little substrate to build her life on. But by then it was too late, all the miracles had been done on her; she just wouldn’t die. I eventually got her off the ventilator and off the dialysis. I got her electrolytes corrected, I got her to feed, we stopped the antibiotics, and she became just a baby in a basinette. And one day we needed a bed in the unit and she was the most stable patient, so she was shuffled off to the Infants’ ward.

  The third patient was Emilio Diaz, a really adorable three-year-old with AIDS who had done so well for so much of his life. Emilio spent his first year in the hospital because there was no place for him to go. He was finally adopted by one of the nurses who had taken care of him when he was a baby. This woman really loved him. She married Emilio’s father, an IV drug user who had AIDS so that she could legally adopt him and take care of him. She had done a lot to try to give Emilio as full a life as possible. He’d gone to Puerto Rico to visit relatives, he’d gone for trips all over the place, he’d done a lot more than your average Bronx three-year-old. And then he became sick and was admitted to the ICU and rapidly deteriorated. He had terrible pneumonia; he became ventilator-dependent and reached ventilator settings that nobody had ever seen before in the ICU. And he just kept getting worse until finally I had to have that horrible discussion with the parents about DNR on him, too. In Emilio’s case, though, it was his parents who first asked about DNR. I suppose it’s not surprising, since his mother is a nurse and very medically sophisticated. But one day she came to me and said, “He’s suffered enough; we want to make him DNR.”

  Emilio died one evening just after I left for home. He was there the longest of all three of these patients; he was my patient for a good three and a half weeks. It was so sad taking care of him. There finally came a point, around the time that he officially was made DNR, when I felt very, very depressed. Every time I had to go over to his bedside, every time I had to write a note in his chart or I had to look at his bedside clipboard or call for his lab results, I became severely depressed. It was really sad. Really sad.

  Well, anyway, I learned a lot of medicine from those three patients and from the other patients I took care of in the ICU. I learned how to put in A lines [arterial lines; like IVs, except going into arteries instead of veins], I got good at intubating, and I learned about Dopamine and Dobutamine drips [a class of drugs known as pressors, which raise blood pressure; they’re used in critically ill patients who cannot maintain their own blood pressure]. And I did a lot of thinking about ethics an
d the fact that, basically, we can keep just about anybody alive for an indefinite period of time but that keeping people alive may not be such a good thing. That’s a hell of a lot to pick up in one month! And I think one of the reasons I was able to do all that was because of the people I worked with.

  Diane was a great resident. She’s very, very bright; extremely capable; and very talented. She has a very wry sense of humor. We were on call together five of my nine nights, and we had a lot of fun. I thought she was kind of attractive, too, but of course that was something I couldn’t really tell her. Her body is very similar to Karen’s, and I found that very erotic. I told her that the morning after the last night of the month we were on call together. I was kind of delirious and I don’t know how it came up but I said something like, “You know, you’re very erotic,” and she said, “What’s wrong with you? You must be completely out of it!” And I said, “Yeah, I guess I am,” but in fact I had been thinking about it for a while. But I couldn’t say it until then because we’d been on call and slept in that little on-call room so many nights together. Not that it would have mattered, for God’s sake. Anyway, it would have been an inappropriate thing to have done.

  Alex is a great attending, and he really was very supportive. He’d come up, give me these big bear hugs during the day, and ask me how I was doing. He said he was worried about my psyche all the time because I was taking care of all these very sick patients. He was a good teacher, too. And he has a really big heart, he really cared about so many of the patients. He was somehow able to be a very devoted and involved ICU director, there all the time, always available and really involved, and yet he could keep some distance and let the residents try to run the place.