The Intern Blues

by Robert Marion

  Well, there is one saving grace about working in this torture chamber. Some of the night nurses are extremely cute. One in particular: dark, brown hair, really beautiful. Damn! She almost makes it worth staying up all night. But not quite. Nothing could really make it worth staying up all night.

  I must say, my progress notes have deteriorated significantly. I never really wrote very good notes in the first place; in fact, my progress notes have been voted among the worst ever seen at Mount Scopus Hospital. Recently, no one’s been able to read any of them. But at least they used to be short. Now, because of all the problems these kids have, instead of my usual three or four lines of unreadable scribble, I now write whole pages of unreadable scribble.

  What a stupid thing to do to us, throw us in the middle of this unit when we don’t know what the hell we’re doing. And Norris screams at us that they’re our patients! Bullshit! He should be thrown in jail if he really thinks they’re our patients! None of us knows what the hell we’re doing with them. All right, show us around, give us a week or two to figure out what’s going on, then you can think of them as if they were our patients. At this point we can have virtually nothing to do with their care, because we know virtually nothing about how to care for them.

  Hey, but the jury’s not in yet. I’ll give it a little more time to see what it’s like before I make up my mind. I’m on call Friday night with a senior resident who sort of drives me crazy. She’s reasonably intelligent and she seems to know what’s going on, but she really lacks self-confidence. It wouldn’t be so annoying if she didn’t keep turning to me for reassurance. Me, can you believe that? I mean, I have absolutely no idea what the hell is going on! The other night she did something that I think was probably wrong. She wanted to intubate this kid for having one bad blood gas. And she asked me if I thought it was the right thing to do. I said, “No, it doesn’t sound right. I think you should just turn up the oxygen and repeat the gas before you do anything.” That was just common sense; this kid was perfectly pink at the time. I hope I’m not that unsure of myself next year, when I’m in a position of authority. Hah! Boy, we’re all going to be in trouble when that happens!

  Thursday, January 30, 1986

  It’s nine o’clock and I just got home. Things are looking up: I cut an hour and a half off the time I finished on Monday night. Why, if this keeps up, I’ll have so much free time this month, I may actually get to cook my own dinner one night! I think washing the dishes’ll still be out of the question, though. That’d be just too much to shoot for.

  Here’s some news on the Moreno front: Today’s head circumference was forty-nine and a half centimeters, up one-half centimeter from yesterday’s closing. And you know what? I don’t give a shit! I just don’t care!

  I don’t like the neonatal ICU. I’m not positive, but I just don’t think I’m going to grow up to be a neonatologist!

  I’ve got this nervous feeling in my stomach all the time. I stopped at a drugstore on the way home and bought this great big bottle of Maalox. Either I’m coming down with gastroenteritis or I’m beginning to burn a big hole in my gastric muscosa.

  Monday, February 10, 1986

  I’m post-call. There’s nothing like being post-call when you’re in the NICU. It’s at least a hundred times worse than being post-call anywhere else in the world, including Infants’, which until this month had won the prize hands down as the Most Horrible Post-call Experience in the Bronx. I should be asleep now, but I haven’t recorded anything in over a week. I’ve wanted to; I just haven’t had enough strength to push down the “record” button on this silly machine. I don’t want to let this fabulous experience escape immortalization on cassette tape, so, at great expense (at least ten minutes of precious sleep), here goes.

  Working in this nightmare has now settled into a nice, regular, predictable routine of devastation and misery. Take yesterday, for instance. It was Sunday and I was on call. I walked through the doors of 7 South with a smile on my face at seven-thirty and was completely and overwhelmingly depressed by eight o’clock. Iris Davis, who’d been on call Saturday, signed out to me. She was in a great mood. When she gets real tired, she starts to cry, so it took her about an hour and a half and at least three boxes of tissues to get through sign-out. All I got out of it was a scut list about a mile long and a terrible headache.

  Most of what Iris signed out to me was checking bloods that had been drawn earlier in the morning. So I started calling the labs to get the results, a very rewarding experience. Each lab had a different and very novel explanation for why the results weren’t available. The chem lab claimed they had never received any samples, even though Iris assured me that she hand-delivered them. The hematology lab said that all the specimens, every one of them, was QNS [quantity not sufficient]. That’s a polite way of saying, “We poured the blood down the sink, so you’re going to have to draw them all over again.” And the blood gas lab said the machine was broken and they wouldn’t be able to run any samples for at least another hour. What this all meant was that I was going to have to spend the next two hours redrawing all these bloods and then spend another half hour delivering the samples to all the different labs.

  Okay, so I did all that, and then I got to spend the next six hours writing progress notes. I love writing progress notes! You have to write a note on every patient every day or else the administrator on duty swoops down at about midnight and puts an evil spell on you. And these notes aren’t just “Patient still alive. Plan: Make sure he stays alive until tomorrow morning.” These notes go on and on, listing problem after problem. Each one can take an hour.

  It wouldn’t even be so bad if all I had to do was the scut and the notes, but that’s all broken up by the endless rounding. First the attending showed up at about eleven so that he could view the patients close up for about an hour. He also has to fill his daily quota of yelling at the house officers. Then in the evening, there were rounds with the senior resident, who managed to come up with a whole new list of scut for me to take care of during the night. So I got to draw some more blood, have more fights with the lab technicians who have perfected the art of denying having received blood samples you handed them not an hour before, and write more long notes in the charts documenting what the results of those fights with the lab technicians have been.

  And even all that would have been okay if it hadn’t have been for the fact that the DR [delivery room] kept calling us to come down to deliveries. That’s the real ulcerogenic part of this job. The rest is just irritating, but the DR is downright frightening. At any moment, without so much as a minute’s warning, you could be called down there and find yourself face to face with a brand-new four-hundred-gram wonder whose only goal in life is to make your next two or three weeks completely unbearable. Also, there are all these little emergencies that come up in the unit, like kids deteriorating or spiking fevers, stuff like that. It’s all such fun!

  Last night, I actually got myself in a position to go to sleep at about three o’clock. I was in the on-call room, in my winter coat, getting ready to lie down on the cot. The on-call room is an interesting place. They recently rebuilt the entire ICU and they made us this very nice place to sleep. The only problem is, they forgot to put any heat in there. The average temperature is about forty to forty-five degrees. Sleeping in there is like camping out in Alaska.

  Anyway, I was on the cot, getting ready to lay down. I was lowering my head toward the pillow and just as my hair made contact with the pillowcase, my beeper went off, calling me to the DR stat. I went running down there to find it was an uncomplicated problem, a little meconium-stained amniotic fluid. The baby was out by the time we got there and he was fine, just fine. There was nothing we needed to do. So I went back to the unit, got back into the on-call room, put my coat back on, and actually got about an hour of sleep. At five o’clock, I got another stat page. We went running down to the DR, and what did we find? An obstetric resident with her arm, up to the elbow, thrust inside a woman’s vagina
. What a romantic sight!

  It turned out, this woman had wandered in off the street with a prolapsed cord. [The umbilical cord had come through the cervix and was lying in the vagina. The danger of this is that if the cervix should close up again, blood would stop flowing through the umbilical cord and the fetus would suffer from lack of oxygen, causing either death or severe brain damage.] The resident was trying to push it back up into the uterus while two other people were preparing to do an emergency C-section. The whole thing took about an hour, and when the baby came out, he was just fine! By that point it was eight o’clock in the morning and time for the day crew to show up. I finished with the work on that patient, started drawing the morning bloods, and then started rounds with the rest of the team.

  We went on work rounds and then we had attending rounds. I tried to write my notes during all this because I had clinic this afternoon and I didn’t want to have to come back to the unit again after clinic was over. So I got to clinic at Mount Scopus at about two and I got home a little while ago, at about six. A typical thirty-four-hour day; at least I got one whole hour of sleep!

  I’ve had some really terrific experiences in the unit over the past week. Really terrific! I’ve got these two kids who are essentially brain stem preparations. One weighed 525 grams at birth and from the very beginning had virtually no chance of surviving. So what do we do? We use everything we have to keep him alive. And all that comes out of it is a great deal of work for me and the other interns. The other kid was good-sized at birth, a thirty-three- or thirty-four-weeker, but the mother had an abruption [abruptio placentae: a condition in which the placenta tears itself off the wall of the uterus, leading to a great deal of bleeding and a severe deficiency of blood in the fetus] and the kid was severely asphyxiated, with Apgars of 0, 0, 3, and 3. Not what you’d call very good. Where I come from, we have a name for children like this: stillborn. So this kid is basically brain dead but we’re keeping the body alive to have something to keep us busy. As if I already didn’t have enough to keep me busy!

  This rotation continues to have only one redeeming feature, that being the nurses. These nurses are fantastic. They’re young, real attractive, and real good at their job. Last week one of the night nurses handed me a prescription form. It looked like this:

  I’ve been carrying it around ever since. I had lunch with her last week. She seems nice. I don’t want to jeopardize my relationship with Carole; Lord knows it’s already suffered enough! So I don’t think I’ll actually take this any farther. But it sure was nice to get that note. It made me feel . . . it made me feel almost as if I were a human.

  Tuesday, February 25, 1986

  I haven’t recorded anything in a couple of weeks. I look upon these tape recordings as kind of a funny running monologue, but I haven’t felt very funny over the past two weeks. Working in this unit has been terrible, just terrible, much worse than I ever imagined. We’ve had a lot of deaths and, even worse, we’ve had a lot of survivors, babies who should never have been allowed to live. I don’t want to think back on what’s happened, I just want to look ahead. In just a couple of days I’ll be done with the NICU, and then I’ve got a month in OPD at Mount Scopus, two weeks of vacation, and two more weeks of OPD after that.

  Every month so far there have been a lot of bad memories, but there have also been some good ones, funny stories. I’ll carry with me probably forever. This month there have only been bad memories and worse memories. Moreno and his steadily increasing head circumference; the wasted, dying preemies hanging on much longer than they should be allowed to because of all the machines we have to use on them; the bigger kids with PFC [persistence of the fetal circulation]; the brain-dead baby with the abruption; these were terrible, terrible things. I’ve been finding that I just can’t defend myself against them. It’s been just brutal.

  I don’t want to make this sound too sappy, but I knew I was in trouble when I cried in the hospital last week. Iris, the other intern, has been crying just about every day, but last Thursday I had been up the whole night before with this PFC’er who had done really poorly, and when he finally died, I just couldn’t take it anymore. I went into the bathroom, locked the door, and just cried my eyes out. I’m really starting to fall apart. That was the first time I’d cried all year. I know most of the other interns have cried, but I kind of prided myself on the fact that I could control myself. Not this month.

  Maybe sometime in the future I’ll be able to come back to this and fill in some of the blank spaces I’ve left, but I can’t do that right now. I need a nice vacation. I think I’ll take my vacation in the West Bronx emergency room over the next four weeks.

  I’m going to sleep. Maybe when I wake up, things’ll start being funny again.

  Bob

  FEBRUARY 1986

  Mark Greenberg and Andy Baron worked in ICUs during February, and both had experiences caring for patients who were being kept alive thanks to technological advances that had been developed over the past few years. It’s always been true that technology has run way ahead of ethics in medicine. With every advance that’s been made, be it the development of antibiotics, the iron lung, present-day respirators, chemotherapy and radiotherapy for cancers, or the ability to transplant organs, physicians have been able to take discoveries made in the laboratory and apply them to humans. The immediate result of these advances has been that patients who the week before would surely have died have been given the opportunity to survive, at least for some period of time. But we’ve often learned that survival may not always be the best outcome for the patient or for society. The question of whether these fruits of medical technology should be utilized has to be addressed. In many cases, answering this question can be more difficult than developing the technology in the first place.

  In no place is this truer than the neonatal intensive-care unit. Although there has always been interest in the very premature baby, until the 1960s these infants were considered little more than curiosities. Rather than being cared for in specially designed intensive-care units where all their life functions were meticulously monitored, these babies used to be warehoused in circuses and freak shows, and exhibited to the public for a price. If they lived for very long, it created more interest. If they died, usually because of respiratory failure, it meant only that they needed to be replaced.

  Unlike most other medical specialties, which gradually evolved into existence, neonatology had a sharply demarcated beginning, largely the result of a specific event. In August 1963, Patrick Bouvier Kennedy, the premature son of President John and Jacqueline Kennedy, died of respiratory distress syndrome at Boston Children’s Hospital. For a few days, an intense media spotlight was shone on the special problem of babies who were born too soon. Although, sadly, this event ended with the death of the infant, it resulted in millions of dollars of national grant funding being devoted to research into the special problems of the premature. And therefore the death of Patrick Bouvier Kennedy led to neonatology as we know it today.

  The major advances in the field occurred early. By the mid-1970s, using respirators, intravenous medications and fluids, specially developed dietary formulas, and very aggressive care, it became technically possible to keep alive infants who were born as much as fourteen weeks prematurely and who weighed as little as twenty-eight ounces. Some of these infants did well; they’ve gone on to lead relatively normal lives. Most of the other survivers, though, have been left with significant physical and developmental problems: Some developed cerebral palsy and required orthopedic intervention and braces to help them walk but were otherwise spared; others were found to have suffered extensive brain damage and, in addition to cerebral palsy, were left with mental retardation and seizures; still others were so extensively damaged by the consequences of their prematurity that they wound up leading a vegetative existence, many residing in institutional settings. And so the question was raised, “Although technically possible, is any of this justified?” Neonatologists and medical ethicists have bee
n struggling to answer this question ever since.

  Neonates with problems can be divided into three groups. A first group includes those who have an excellent prognosis right from the beginning. This group includes the “garden variety” preemie who weighs two pounds or more and who is born without any problem other than prematurity. Most everyone in the field of neonatology would agree that everything possible should be done to support these infants.

  A second group is made up of those infants who are born with such severe defects that survival is not possible no matter what is done for them. Included in this group are babies with anencephaly, a condition in which the skull and brain fail to develop; all of these infants are either stillborn or die within the first days of life. Also included in this group are babies born before twenty-four weeks of pregnancy. Most but not all neonatologists feel that these infants should be made as comfortable as possible and be allowed to die without intervention.

  The third group of infants with problems is the most difficult ethically. It is made up of those children who fit between these two extremes: babies born weighing less than two pounds but above the twenty-fourth-week-of-pregnancy cutoff; and infants with major birth defects that are not necessarily lethal. The medical community is divided about what to do with these babies. Many neonatologists would do everything possible to offer these infants the opportunity to survive, knowing that possibly for every surviver who turns out to be normal, there’ll be an infant or two who will wind up significantly damaged. Others would provide limited care, reasoning that the “strong” will survive and the “weak” will die off (the problem with this reasoning is that some in the former group who would have led a normal existence had aggressive care been provided will wind up damaged as a result of this method). Finally, some would argue that nothing should be done for this middle group and that nature should be allowed to take its course; physicians who think this way are clearly in the minority.