What they’re doing is this: Usually the interns are divided, two working with a senior resident, the other two working with a junior resident. Because we were short, the chiefs decided that the other two interns would work with the junior resident and I would work alone with the senior resident. The senior this month is Ben King, who is one of the best people in the program. He was the person who let me leave the morning after my last night on Adolescents’ so I could catch the flight to Israel. So I’m very happy to be working with him. The junior resident is Dina Cohen, who’s one of the worst people we have.
Because there’s only one intern on our team and two on the other, we started off the month with only one third of all the patients. And not only that, but on that first morning, Ben was smart enough to realize that most of the patients who were assigned to us didn’t belong in the hospital in the first place. I started Thursday morning with seven patients. When we made rounds, Ben decided that three of them could be sent home right away, so I was down to four. I got only one admission Thursday night, and one of the other patients went home yesterday, so tomorrow I’ll start with only four patients. That’s not bad for 6A; that’s not bad for anywhere. And none of them is what you’d call sick. Two are preemie growers. [Six-A serves as an “overflow valve” for the neonatal intensive-care unit; when the unit gets crowded, preemies who have outgrown the problems of prematurity and only need to gain weight are transferred out to the ward. These babies frequently continue to have more problems than normal, healthy babies of the same age, however. Caring for a preemie who graduated from the unit is not just a baby-sitting service.] One is a kid with AIDS who’s here just because he’s got no place to go. And one is a six-month-old with meningitis who’s doing pretty well; he’s just in the hospital to finish his two-week course of antibiotics. So, so far I don’t have much to do. I’m not complaining about it. I know it won’t stay like this for long.
Thursday, March 6, 1986
I was on last night with Dina Cohen. Jesus, what an airhead that woman is! She’s completely incapable of making a single decision. She’s totally incompetent. Yesterday afternoon, Margaret was signing out and she told me she had this adolescent girl who had come in the night before with abdominal pain and a positive urine pregnancy test. An emergency sonogram had been done that showed something around the right ovary. Ben was sitting next to me, and when he heard Margaret say all this, he got very upset because he knew the girl had to have an ectopic pregnancy [a pregnancy in which the gestational sac implants someplace other than in the wall of the uterus; it is dangerous because it can cause a massive hemorrhage]. Ben asked if Gynecology had come to see her, and Margaret said, “No, they haven’t even been called yet.” Ben just about blew his top! He ran over to Dina and asked her about it and she said, “Well, the ultrasound attending said it wasn’t a conclusive study. He thought it could either be an abscess or a cyst or an ectopic—” Ben interrupted her and yelled, “It is an ectopic! You have to call Gynecology right now!” And Dina said, “Well, I’d rather be sure first. I think we should do a beta HCG [a blood test for pregnancy; more accurate than the usual urine pregnancy test], but you can’t get it done until tomorrow morning. Can you imagine? You can’t get a beta HCG done in this hospital after twelve o’clock—” Ben stopped her right there and said, “Dina, think a minute! You’ve got an adolescent with abdominal pain, a positive urine pregnancy test, and a finding consistent with an ectopic on ultrasound. You don’t need a beta HCG. What you need is a gynecologist. They have to take her to the OR right now or she may bleed out before tomorrow morning!” Then Dina said, “Well, I thought we should do more tests—” And Ben said again, “You have to call Gynecology right now. Don’t you understand?”
He finally convinced her to make the call. They came and saw her at about five o’clock and took her to the OR almost immediately. Of course, she had an ectopic. If Dina had waited and hemmed and hawed a while longer, that girl might have bled out right there on the ward!
Needless to say, I didn’t feel very comfortable being alone with Dina for the rest of the night. The girl with the ectopic did okay. She stayed in the recovery room for a few hours and then came down to the floor at about midnight. And luckily, it was a quiet night; I only got one admission, and that was an asthmatic who didn’t require any kind of expertise in his management. So I didn’t ask Dina for any help all night long. I didn’t even see her after midnight; she went off to sleep in her on-call room.
Sunday, March 9, 1986
It was seventy degrees today—really spring. We spent the day out on the grass in front of the apartment building. Sarah loved it. She got a chance to toddle around and see some of the other children. It was a really nice day.
Things on the ward are okay. I’m still getting along well with Ben. He’s just great, the best resident I’ve ever worked with. He’s got good judgment, he knows what’s important and what isn’t, and he’s got a good sense of humor.
But the other team is having a lot of trouble. Because Ben knows when to send patients home and Dina doesn’t, they now have almost all of the patients on the ward. And to make matters worse, the interns are finding it very stressful to work with Dina. Laura’s doing okay; she’s a very good intern and she doesn’t have to rely on anybody for much help. But Margaret isn’t as secure about herself and she’s having a very hard time with Dina. On morning rounds on Friday, Margaret completely fell apart. She started crying, saying she couldn’t go on. She refused to work up a patient. She wound up spending a few hours in the chief residents’ office. She just needs more help than Dina can give her. I think there’s also a lot of other things going on in her life now. But that’s true of all of us, isn’t it?
The chiefs decided that they had to get Margaret out of the hospital for a few days. How nice of them! She’s stressed, so they give her the weekend off. My daughter gets the measles and is sicker than most of the patients who come to the emergency room but I still have to work! That’s typical! Oh, what’s the use? What’s the use of talking about it and thinking about it over and over again?
Anyway, Margaret got to go home Friday afternoon and didn’t have to come in for her call on Saturday. She’s got a great medical student, Susan, who’s running the service for her. Susan took Margaret’s call on Saturday and did a good job. She did as well as a lot of the interns. I wish I had a student like that. I haven’t had a good student all year. All my students have ever done is complain. They don’t want to do scut, they don’t want to run to the labs, all they want to do is stand around and be spoon-fed information twenty-four hours a day. Susan isn’t like that; she’s willing to work. A student like Susan can make internship a whole lot easier.
Actually, having a good student doesn’t matter for me right now. I’ve still been having great luck on call. I’ve gotten only one or two admissions per night. I left yesterday with only three patients, and one of those is probably going to go home tomorrow. That’ll leave me with only my AIDS patient, who’s really just a social hold, and one of the preemie growers I picked up when I started. Neither of them requires any real work. I should be able to leave tomorrow right after work rounds. I’m planning to go home at ten o’clock in the morning! It’s amazing!
Saturday, March 15, 1986
I just finished putting Sarah to sleep. This is my weekend off. It’s been a strange week. Work’s fine, there’s no problem there. But Larry got called away on business on Monday. He’s in Switzerland and he’ll probably be gone all next week. It’s been hard for me. I’ve had no relief in taking care of Sarah at night. Usually, when I’m post-call, Larry handles her 3:00 A.M. wake-up; usually I don’t even hear her cry. But on Wednesday it was all me, and I was tired. I don’t know how I got through it.
We got Marie to stay over on the nights I don’t come home. She wasn’t very happy about doing it and it’s costing us an arm and a leg, but what else could I do? Someone has to be with Sarah; I can’t take her to the hospital with me. I’ll be happy when Larry
gets back. His being away like this makes me realize how much I depend on him!
I haven’t been feeling very well, either. I’ve been very tired. And I’ve lost my appetite. I think I’ve just made it to the point in the year where I’m simply exhausted all the time. I know a lot of the other interns have gotten to this point already; I’m surprised it’s taken me this long to get here. And being tired sure isn’t making it easier to take care of Sarah by myself!
My luck has been holding: I got two admissions last night; and when I was on this past Tuesday, I didn’t get any. But that doesn’t mean I’ve been getting a lot of sleep. The other team’s been getting killed on their on-call nights. They’ve got a lot of patients, and some of them are really sick. So I still wind up staying up, doing scut on their patients all night long. More IVs fall out on 6A than anyplace else I’ve ever worked. I don’t know what it is about that ward! Some of the other interns say the nurses actually pull the IVs out, but I don’t believe it; to pull out an IV would mean the nurses were actually touching the patients. So far I haven’t seen one come that close.
Friday, March 21, 1986
I know this is going to sound crazy. It doesn’t make much sense, but it’s true. I’m pregnant! I found out today. I think it’s great, but I know everybody else is going to think I’m crazy.
I’ve been feeling lousy for a couple of weeks now. I’ve been run-down and a little nauseous all the time, but I just figured it was internship finally getting to me. And my period didn’t come last week, but that’s not so strange; it happens to me a lot. I saw Susannah in clinic last week and I was telling her how bad I was feeling and she said, “It sounds like you’re pregnant. Is that possible?” I hadn’t really even thought about it until then. I told her it was certainly possible, and she told me to send off a urine sample. I found out this afternoon that it was positive. Unbelievable!
Larry came home from Switzerland yesterday. I told him a little while ago. He thinks it’s wonderful. We’re both very excited. We’d talked about waiting until I was a junior resident before we tried again. I’m about six weeks now, which means I’m due sometime around next November. Sarah will be only about eighteen months then. That’s closer than we had planned. And it means that for the last year and a half of my residency, I’ll have two babies to worry about instead of one. But what the hell? One thing I’ve learned over the past few weeks is that we have to do what’s best for us, and I think having this baby is the best thing for me, for Larry, and for Sarah.
I’m not going to tell anybody about this just yet. A lot of things can happen. I had a miscarriage in my first pregnancy, and that can certainly happen again. And anyway, the chiefs probably are not going to be exactly thrilled when they hear about this. But I don’t care. That’s their problem. I really don’t care what they or anybody else thinks.
I just hope I can make it through next month in the neonatal intensive-care unit! If I continue to feel the way I do now, it isn’t going to be easy.
Mark
MARCH 1986
Sunday, March 16, 1986
It’s taken me a while to get back to normal, but here I am, having as much fun as I had during the first six months of this nightmare. Yes, even though I came that close to doing a triple gainer off the top of Jonas Bronck Hospital just two short weeks ago, life’s now become a barrel of laughs again.
This last month has really been pretty disturbing. I mean, I always had this idea that I was immune to getting depressed or something. I really didn’t think anything could get me down. I guess I just happened to stumble on the secret recipe for major depression: You take one garden-variety intern, deprive him of sleep for a couple of months, make him eat take-out pizza every meal during that time, and force him to take care of the sickest babies on the face of the earth. Mix well and let him marinate in his own juices for three weeks. Then you collect the pieces in a body bag and send them off to the morgue. I guess I managed to interrupt the process right before I made it to the final step.
I really can’t take credit for saving myself. Carole really did it. She took care of me, and I’m really thankful to her. Our relationship had been going down the tubes over the past few months. And it’s all been my fault; I mean, I’ve kind of had other things on my mind, like sleeping and eating, and I haven’t been paying much attention to her. So things hadn’t been great between us. I was starting to have some doubts that our relationship would make it through the year; of course, I was also having some doubts that I would make it through the year, so my concerns about the relationship were not exactly at the top of my list of things to worry about.
Anyway, over the past few weeks Carole has just about moved into my apartment. She’s somehow figured out how to get rid of all the cockroaches. I have to admit, things are nicer without all the wildlife even though they had kind of become my pets. She’s been here every night when I came home from work and she’s been really understanding, listening to me complain about everything imaginable, from how much I hate my patients to the fact that the West Bronx coffee shop was closed down by the Health Department because of “unsanitary conditions.” (The amazing thing is, that was the best coffee shop in the system. I guess mouse droppings and rat hairs really do make everything taste better.) I know I wouldn’t have gotten back to normal, if you can possibly call what I am now normal, if it hadn’t been for her being here when I needed her. Well, enough of this; it’s starting to sound like a sermon or something.
So for the past couple of weeks I’ve been working in OPD on the west campus. It certainly has been a welcome relief compared with the neonatal eternal-care unit. I like the emergency room because it gives you the chance over a very short period of time to torture a large number of children who, if you’re lucky, you’ll never have to see again. That’s a unique opportunity. It almost makes being an intern seem like fun. Not quite, but almost.
I was on call on Friday and it turned out to be Fascinoma Night in the West Bronx ER. Every patient who came in between the hours of 5:00 P.M. and 8:00 P.M. had some bizarre diagnosis or some record-breaking laboratory result. The very first kid I saw was this one-month-old whose mother said he had vomited every feeding since he was discharged from the nursery. Every feeding! Now, I immediately recognized that there was some sort of problem here. I mean, I may not be Sir William Osler [a famous physician of the nineteenth century who was known for his legendary clinical acumen], but I do know it’s not normal to vomit every single feeding of your entire life. At first, I was a little skeptical about the story. It’s a little hard to believe something like that, so I asked the mother why she had waited so long to bring the kid in. She said she hadn’t waited long at all, that this was the fourth time she had been in an ER, and that no one seemed to want to do anything to find out what was wrong with the kid. Okay, so then I figured the woman had to be a fruitcake or something. I mean, any doctor seeing a baby who had vomited every single feeding of his entire life would get very concerned and do something definitive, wouldn’t he?
I guess not, because when I saw the baby, it became pretty clear the mother had to be right. I couldn’t believe it. He looked like a baby concentration-camp survivor. He looked worse than Hanson did on Infants’, which is pretty damn bad! This kid was a pound and a half below his birth weight, for God’s sake! I did an exam and I didn’t find anything. Then I sat and fed him for a few minutes. He seemed to do fine right away, but about ten minutes into the feeding he started to cry, and the next thing I knew there was baby vomit all over my sneakers. Great! So I ran over and got the attending and showed him my shoes and told him I thought the kid had pyloric stenosis. [This is a condition caused by enlargement of the muscles at the junction between the stomach and the first part of the intestine. Because of the muscle enlargement, flow of partially digested food is obstructed, and once the stomach fills, the feeding is vomited. Pyloric stenosis is surgically repaired.] He refused to help me clean off my sneakers, but he did come see the kid and we felt the abdomen, and sur
e enough, the kid had an olive [a mass in the abdomen overlying the site of the stomach].
But the pyloric stenosis isn’t what made the kid so interesting. What made this kid a fascinoma was the fact that because he was so sick, I sent off a blood gas to see how alkalotic he was. [Because the infant with pyloric stenosis is vomiting stomach contents that contain hydrochloric acid, these children frequently manifest alkalosis, or lack of a proper amount of acid in their blood.] It turned out he had a pH of 7.76, the highest recorded pH in the history of the pediatric chemistry lab at West Bronx. I think as a result of having my name on the lab slip as the doctor of record, I’m supposed to get a commemorative plaque or something. As a result of having the record-breaking pH, the kid is getting a no-expenses-paid trip to the ward at West Bronx for fluid and electrolyte therapy before the surgeons take him to the OR tomorrow to fix his stomach.
And that kid was just the beginning. A little later we got a call from one of the orthopedic attendings who told us that a patient of his was coming in. He told us, matter-of-factly, that the kid had been bitten by a horse. A horse! Where the hell is a kid from the Bronx going to find a horse to bite him in the middle of March? I mean, we’re talking about the South Bronx here; this isn’t the Kentucky Derby! So the story seemed a little peculiar to begin with. And then the kid showed up, and it got even stranger.
The Intern Blues Page 32