The Intern Blues

by Robert Marion

  In neonatology, there’s a tendency to lose sight of the end point. Sometimes a neonatologist who understands that he or she has the tools to keep any newborn alive for as long as he or she wants, may decide to flex his or her technological muscles and play God, keeping alive children who should be allowed to die. Neonatologists might argue that these exercises are good in the long run: By learning about keeping these children alive even for a brief period today, it might someday be possible for some to survive. And there might be some truth to this; after all, the argument that nothing should be done could have been made twenty years ago concerning babies who weighed twice what the babies who survive today weigh. But the question is, What price is being paid for this?

  During his month in the NICU, Mark was kept awake night after night caring for babies some of whom he considered brain dead, one of whom weighed only a little over seventeen ounces. Discouraged because of all the inevitable deaths, he asked, “What possible good am I doing here?” It didn’t seem as if many of the babies were benefiting from the intensive care. The parents, who were seeing everything done for their infants, were being given false hope; they reasoned, “If they’re doing so much, they must believe that my baby has a chance to survive.” This winds up making coping much more difficult for the parents when the baby ultimately does die.

  Taking care of patients who have no chance of surviving is extremely frustrating and anxiety-provoking. You’re asked to do things that don’t make sense to you; you’re called upon to counsel parents without having the picture clear in your own mind. But this state of mind is not limited to working in the NICU. These problems also occur in other intensive-care units.

  Physicians working in ICUs that care for older patients must deal with many of the same issues as the neonatologist, but the situations are often radically different. Patients in the pediatric or adult intensive-care units are not neonates; they come into the unit with a life history. They have relatives and friends who know them and love them, not just for what they might be in the future but also for what they’ve been in the past. They have personalities and desires, and often specific requests about what should and should not be done. The intensivist must often decide whether to honor these requests, or the requests made by the patient’s loved ones, or to do whatever he or she thinks is in the patient’s best interests. And that can be very difficult.

  During his month in the pediatric intensive-care unit, Andy became involved with three patients for whom “do not resuscitate” orders were ultimately written. Actual orders stating that a specific patient should not be resuscitated in the event of a cardiac or respiratory arrest are new at Mount Scopus Hospital. Prior to the time that the present interns began their year, plans for patients who had no chance of survival were formulated through conversations among the physicians, the family, and, if possible, the patient. If it was agreed by all parties that resuscitation should not be attempted, the word would be passed to all members of the care team. The concept of a patient being a “no code” developed; then the concept of a limited or “slow code” (the situation in which cardiac arrest leads to limited efforts at resuscitation) evolved. Verbal “no codes” were troublesome; to many members of the care team, it seemed like a sham. Notes and orders were being written in the patient’s chart that did not truly reflect the thoughts of the care providers or the wishes of the patient and his or her family. But DNR orders could not be written; they raised legal and ethical questions that had not yet been answered.

  The use of written, formalized DNR orders arose through the efforts of a committee composed of the hospital’s lawyers, ethicists, and physicians. Now the true plan for a specific patient can be spelled out in the chart without fear of legal or ethical retribution. The actual order must be written by the patient’s attending physician and must be reordered every week. Once a DNR order has been written, it leads to conflicts of another sort: Now that we’ve stated that the patient is expected to die, what should and what should not be done for that patient?

  Here’s an example that’ll help explain this conflict: A patient who is DNR develops a fever. Normally, hospitalized patients who develop fever are managed very aggressively; a “sepsis workup” consisting of blood and urine and sometimes spinal fluid cultures is done, and antibiotics are immediately begun. Failing to treat a patient with fever may lead to overwhelming infection and ultimately to death. But what should be done if the patient is DNR? Should antibiotics be started on such a patient, or should infection and its consequences be “encouraged”? If antibiotics are going to be withheld, should cultures be obtained? These questions must be considered in every case. Often, under the reasoning that to treat an infection would be to prolong life artificially, antibiotics will not be given and cultures will not be obtained.

  But using this reasoning, one could argue that feeding the patient would also lead to artificial prolongation of life. Therefore, should DNR patients receive the nutrition they require for life to continue, or should they be allowed to starve to death? Most physicians would agree that the withholding of nutrition should not occur. Implicit in DNR is that the patient should not be allowed to suffer. Starvation is a painful and drawn-out way to die. Therefore, most intensivists would make sure all patients were receiving an appropriate number of calories to sustain life.

  These are only some of the issues Andy and Mark agonized over during their month in the ICU. And they are not alone. The conflicts that arise for young physicians at the edge between life and death are universal. And they lead to a great deal of mental and emotional stress and anxiety.

  Andy

  MARCH 1986

  Tuesday, March 11, 1986

  For the past two weeks I’ve been in the OPD at Mount Scopus and West Bronx. It really hasn’t been too bad. I’ve come to realize that I’ve had to start acting more like a resident; I have to depend more on my own impressions and make my own decisions. The past few weeks have been the first time I haven’t felt that the residents and the attendings were giving me good answers or helping me solve problems very well. So it’s been a kind of stressful learning experience, but I think I’ve been doing okay at it so far. I guess this is how you learn to become a resident.

  The other night in the Mount Scopus ER was memorable. It was my last official night in the Mount Scopus ER. I was supposed to have another whole month of OPD on the west campus, but I switched to be at Jonas Bronck. Working in the Jonas Bronck ER is a better learning experience. So it was my last on call; I can’t say I’m not happy to get it over with.

  It was also one of the worst nights I can remember. There was a tremendous volume of patients; they kept just coming in. It was nuts! At one point we were fifteen charts behind, which is a lot for that place, but we couldn’t make any headway because we had about a half dozen acutely ill children. And the place has only four rooms; we were spilling over into the adult ER. Let’s see: We had two head traumas in various states of coma; we had a diabetic with sickle-cell disease who was in the middle of a painful crisis and in DKA [diabetic ketoacidosis, the buildup of acid in the blood of diabetics caused by high sugar in the blood and inability of the cells of the body to use the sugar for its normal processes]; we had a little baby sickler with fever; we had a couple of vaginal bleeders and a drug overdose. All of these were occurring pretty much simultaneously. And it was just me and a senior resident who was not the greatest doctor you ever saw. We couldn’t get help from anybody. The attending was over in the West Bronx emergency room. Every time we’d call with a problem, he’d say, “Well, it doesn’t sound too bad. Call the senior in the house [the resident in charge of the inpatient service at night] if you’re worried.” He wasn’t even concerned! What a shithead!

  I never ran as hard as I did that night. Finally at one point the nurse, who was fabulous, said to us, “Please call for some help!” So we did. And then slowly but surely we got some of the docs who were on call on the floors down there, and we cleared the place out. But it was still crazy the rest
of the night. Right before we were going to leave, this fourteen-year-old girl who’s an asthmatic and has been intubated twelve times came in tight as a drum. [She was not getting air into the lungs. Asthma is caused by narrowing of the air tubes. When these air tubes are slightly narrowed, wheezing will be heard in the chest; when they become very narrow, as they were in this patient, no breath sounds are heard and the patient is considered “tight.”] We had to intubate her in the ER. I didn’t get out of there until 3:00 A.M., which is late for Mount Scopus.

  Karen left a couple of weeks ago after nearly two months of that subinternship she was doing. It was sad taking her to the airport. Fucking LaGuardia Airport; I really hate that place! I’ve felt very blue since she left. I’ve been missing her a lot and it’s been a real drag being apart like this. She’s doing obstetrics/gynecology now; she has to be on call every third night, and our schedules are completely out of whack. We’ve been able to talk only a couple of times in two weeks. It’s weird. But we’ll be together soon. It won’t be too long before this insanity is over.

  Last Tuesday was my birthday. I was post-call and I felt terrible, and I didn’t want to celebrate at all. I went to visit my friend Gary and his roommates out in Brooklyn. I had a good time. The next day I went out with my friend Ellen. We went into Manhattan and had a wonderful time. Anyway, the weekend was pretty good.

  I’ve been kind of reflecting on what’s happened over the past few months. I’ve been thinking about what’s changed. One thing is, I really don’t feel much like a medical student anymore. Occasionally I get into situations where I remember what being a student felt like, when I have no idea what I’m supposed to do. That’s what being a medical student is all about, always with an undefined role. When that happens now, I remember how frustrating it was. I am more comfortable with making decisions now, but I don’t think I’m ready to dictate those decisions to other people the way residents do. That’s still frightening to me.

  I’m staring to realize what I need to do to become a better doctor. I’ve got to become faster and more selective, be able to narrow things down quickly and home in on the diagnosis, because those are the things I’ll need to be good at when I’m a resident.

  So anyway, I guess I’m starting to become a master of internship, which is supposed to happen around now. I’ve become damn good at being a scut puppy, a data gatherer. I have a couple of tough months ahead: Infants’ (pain and torture but with some good people); and a month in the Jonas Bronck OPD, which will be great but tough; and then my last month here, 6A. What a good-bye kiss!

  Thursday, March 13, 1986, 1:30 A.M.

  I got back from the West Bronx ER a little while ago. It was a typical West Bronx night. As soon as I walked in, Andy Ames signed out a child-abuse case to me. It took the usual form of no one understanding where the second-degree burn on the child’s right leg came from. The social worker who called in the case had naturally gone home, and Andy was also gone, so that left me in charge. When the father came in angry and hostile, he couldn’t find anyone but me to threaten. Everything was getting out of hand, and then the police showed up to start their investigation and that led to more havoc. Christ! Anyway, the BCW finally decided that since there was no obvious perpetrator—that is, no one had come forward and said, “Yes, I did it, I was the one who burned the baby,” they let the kid go back home with the parents. I said, “Fine! Let him go home. What the hell do I care?” That’s typical of the BCW! And what usually winds up happening is the kid’ll show up next week or next month or next year dead. But what can you do? You can’t fight the parents and the BCW. That’s a little too much to take on.

  The rest of the night was the usual. We had a bronchiolitic [a child with inflammation of the bronchioles, the small airways leading from the larger bronchi to the lungs; children with bronchiolitis are usually under one year of age, and have respiratory symptoms that are very similar to those of asthmatics] who probably has pneumonia [since bronchiolitis is caused by a viral infection, it’s not unusual that pneumonia, or inflammation of the lung itself, is often an accompaniment] who bought himself a bed on 6A. I also saw this girl, a skinny seventeen-year-old who had hematuria [blood in her urine] and stabbing pain in her right lower quadrant. When I told her I had to do a pelvic exam, she refused. She said she’d allow it only if someone from Gynecology did it. I paged Gynecology three times and they didn’t answer. The next thing I knew, the patient’s uncle was calling from a phone booth on Jerome Avenue. He said the girl had got fed up with the whole thing and just walked out of the ER and he followed her down to Jerome. So he was calling very apologetically to say that she wouldn’t come back. Right under our noses, she just walked. She was actively bleeding from somewhere; whether it was her vagina or her uterus, God only knows. But she up and left. Unbelievable! So I got on the phone with her and said, “Look, you know you’re leaving against medical advice. I advise you to come back to the emergency room right away.” She said, “No way! No fucking way!” So I said, “Promise me one thing: If you start to bleed profusely, you’ll go see another doctor.” She said, “Well, maybe.” That was it. She just walked!

  At about ten o’clock, the ER filled with exhaust fumes from the ambulances parked outside the emergency entrance. Exhaust fumes! That was great for the asthmatics. They thought they had come in to get treatment for their asthma; they wound up leaving in worse shape than they’d been in when they first got there! And the place was scorching hot for several hours; it must have been in the mid-eighties in there. God knows why! I felt very rundown and I had no appetite. I ate nearly nothing the whole night. I didn’t want dinner. That whole child-abuse case was getting me down; it killed my appetite. But we finished at one, which isn’t bad, and I came back home and listened to the messages on my machine. I ate some food and I’m listening to this music now and suddenly I’m on vacation. Tomorrow I’ll be home! Strangely, I’m not that excited about it. I am excited about seeing Karen and my parents and everything, but I’m not excited about the idea of going home itself. It’s funny, I think it’s really starting to bother me that I’m going to be leaving the Bronx for good in a couple of months. I’m starting to feel that I’ve made some good friends here and I know I’ll have to leave them and I’m already getting sad about it, three and a half months ahead of time. Isn’t that terrible?

  Amy

  MARCH 1986

  Wednesday, February 26, 1986

  It’s the last night of my last vacation of internship. Tomorrow I start on 6A [at West Bronx]. I haven’t worked there before, but I’ve heard it’s a real killer. And of course I’m on tomorrow night. So I’ve gotten myself really depressed.

  These past two weeks have been very special to me, very relaxing and calming and restful. This was the first time I’ve been able to be a full-time mother, twenty-four hours a day, seven days a week, without interference. Since I started my internship, Larry and I have never been alone with Sarah for such a long stretch of time. There’s always been someone else around. This was my first opportunity to get to know my daughter. I did everything for her: I changed her diapers and fed her her meals, I got to talk to her and to watch her go through her normal activities without any interruptions. And I actually managed to watch her take her first step! It happened about a week ago, while we were in Florida. She’s been cruising for a while now [cruising: walking while holding on to a surface, usually a bed or a table], but one morning last week she just let go and took three steps without holding on. It was great.

  So I really got the chance to know what being a mother is about during this vacation. And I liked it. I liked it a lot. It sure is better than working in all these damned hospitals where nobody cares about anything except themselves. I really don’t want to go back. I just don’t want to go back to work tomorrow.

  So what else can I say about the vacation? We stayed at a condominium in Fort Lauderdale. We went to the Miami Zoo, we went to the beach, we went out on day trips, we did a lot of things. I caught up on s
ome sleep, and I had a lot of time to think about what’s happened over the past few months and especially about what happened at the beginning of February. The more I think about it, the angrier I get. I really was taken advantage of! There was no need for the chiefs to do what they did to me. They definitely could have let me go home and found somebody else to cover the ER that night. It wouldn’t have meant that much to them, but it sure meant a lot to me! I thought that going away, taking some time off, would make me ease up on this. But it didn’t. I can’t forgive them. And I can’t forget it.

  Well, I’m going to put Sarah to sleep now and then I’m going to try to relax a little. I’m really very tense about tomorrow.

  Saturday, March 1, 1986

  So far, 6A hasn’t been as bad as I thought it would be. The census is low and it’s a good thing because the chief residents are trying to screw me again. It may actually work out in my favor this time. I’m sure they won’t be too happy about that!

  What’s happening is, there are usually four interns working on 6A. It’s a big ward, there’s the capacity to house fifty patients, so when it’s busy, you really need to have four interns. But this month, we’re one person short. That’s because the fourth intern is supposed to be a psych rotator [psychiatry residents have to work for four months on either internal medicine wards or, if they’re interested in child psychiatry, on general pediatric wards during their internship year], and he’s not going to be showing up. The reason he’s not going to be showing up is that the people who run the psych program felt he was too “psychiatrically unstable” to do a rotation on a ward as stressful as 6A. So rather than having four people covering, we have only three people. It’s too stressful for the psych rotator when there would have been four, but nobody’s concerned about how stressful it’s going to be for us now that there are only three. That’s typical, typical! But I just might luck out because of the solution the chiefs have come up with.