I’m already in bed. It’s eight-thirty and I’m already in bed, can you believe that? I’m going to sleep, I don’t care. I’m always sleep-deprived; sleep’s like going out of style for me. This job is so damn stupid! It’s just stupid!
I spoke to Karen tonight for the first time in about a week, because of my stupid on-call schedule.
There I go; I fell asleep again. God! So, I spoke to Karen tonight. She’s doing all right. We didn’t talk for a long time. I miss her. I can’t stay awake any longer.
Monday, April 7, 1986
For some reason, I’ve had all these revelations over the past week. At least they seemed like revelations at the time. Coming back to them now, they really seem like just a bunch of mundane thoughts. I seem to have them on the scut run between the chemistry elevator and the hematology elevator. I have no idea why, but over and over I get these things popping into my mind while I’m in the back corridor by the back entrance to the kitchen.
One of the things I realized was that, at this point in the year, I feel like I’m getting stupider, not smarter. I know it’s not true, but I think maybe it has to do with the fact that the barn door has swung open to the world of knowledge. I guess I’m just realizing what you really need to know to be a decent resident. It’s unbelievable; I just feel so stupid. And it doesn’t matter whether I read or not; I don’t remember anything an hour after I’m finished with it. But I’ve got to keep persevering. It’s funny; I thought I was smart a couple of months ago. I’m not!
I also had this thought about nurses and how night nurses seem to be universally weak in all places except maybe the ICU, where they’re still good. I don’t know why this is. At night, there seems to be a certain stereotype: the middle-aged, fat, black nurse who’s kind of disgusted and noncommunicative. And while she may not be all those things, the stereotype of being noncommunicative and disgusted seems to hold true. I don’t know why, but from hospital to hospital, it seems to be the case. And it’s kind of distressing because at night there’s nobody else there, and sometimes you need to talk to somebody about a patient, and these nurses, they just don’t want to talk about anything! Everything seems to be an effort when you ask them to do something.
Monday, April 14, 1986, 2:00 A.M.
It’s 2:00 A.M. and I’ve woken up for some reason from my precall sleep. I really should be asleep. I have insomnia. I keep thinking terrible black thoughts because last night I wrote up the protocol for the M and M Conference [Morbidity and Mortality Conference, a teaching conference run much like chief of service rounds in which a patient who has died is presented; the clinicians discuss the disease process, and the pathologists bring the autopsy report and describe what really happened] on Emilio, my patient with AIDS who died when I was in the ICU in February. Yesterday I got Emilio’s chart from the record room and I wrote up a summary of what happened to him over the weeks I took care of him. It really hurt to do it, to go through that chart again and to see that he was deathly ill the minute he arrived and never improved and that he finally, finally, by the grace of God, died. I remembered how he suffered and how his mother would come and sit by the bedside for hours. About a week before he died, she told me how at times when the Pavulon [a paralyzing medication] was wearing off, before he got his next dose, she would see tears forming in the corners of his eyes. She knew he was suffering terribly. But of course he couldn’t cry out because he had a tube between his vocal cords and because he was more paralyzed than not. And we constantly would do horrible things to him in our effort to save him from certain death. So I wake tonight with these terrible black thoughts that I’m going to get AIDS, die the same death that poor Emilio died, having my lungs pumped with ventilator air every second, and my limbs poked with needles by young physicians in training, and my neck or groin poked by the fellow trying to put in a line, or my lungs needled and cut, while I hear the doctors saying crass and horrible things about my death and illness, making fun of my debilitated state, while I’m lying naked on a table and shitting on a blue chuck [a pad made out of the same material as disposable diapers, which is placed under incontinent patients], the way poor Emilio did, with no dignity. Just pain. How he must have hurt.
And I think about the Infants’ ward I have to go to tomorrow on call and all the sick children I have to take care of there, two of whom are trying to die on me all the time. I don’t feel up to taking care of these fragile little things. I’m tired of being abused by the system, of having my sleep taken away every third night, of the stress I’m put under and the illness I’m exposed to, and the pain I have to see and cannot heal. I’m tired of dealing with parents whose pain I can never completely understand because there’s never enough time. The only time I have to try to understand what’s happening to them is the time I take away from my own sleep. It’s a constant battle. The doctors who do the best with their own lives, who get the most sleep and get out the earliest, are the ones who don’t talk to the families, who don’t play with the children, who don’t thoughtfully consider things. But I’m not that way; I’m not efficient. I spend time with the families, I talk with them, and so I get sleep-deprived.
Tuesday, April 15, 1986, 9:00 P.M.
There’s something I haven’t talked about yet, something that’s really hard about training that most people outside of medicine don’t have to deal with, and that’s the sense of loss of social skills that happens after you’ve been working all night. You then have to interact with people in a complex fashion. You have to go on rounds and talk to other members of the staff. I very often find that I have no idea how I’m coming off to anybody else. If people laugh, I can’t tell if it’s because I said something funny or if I’ve done something really dumb and embarrassing and that’s the only reaction they can have. Am I offending anybody? Do I curse too much? Should I just fart and get it over with? A lot of times I just can’t tell, I can’t judge what people are saying to me: Are they being serious, are they making a joke?
It’s not so bad with other residents. They understand, they can say, “Hey, he’s been up all night, he’s just post-call.” But what about the parents of my patients? What the fuck do they think is going on? I might be acting really weird. Do they understand it’s because I haven’t slept in two days? They must think I’m just batty or something. And that’s not good, because here they are, trusting me with their most precious thing in life, and I’m acting really flaky. It’s an ill-defined concern of mine, but it really bothers me.
Today my student had to give a presentation of a patient. It didn’t go too well; it was very rough, to say the least. I like Ron, he’s a good guy. He reminds me of how I was as a student. Real nervous, disorganized, can’t think on his feet, that’s just how I was when I started out as a third-year. Shit, I still get like that sometimes. Anyway, after rounds, Mike Miller, who’s our attending, came up to me and said, “Andy, I think you guys have to work on your student’s presentation. It really isn’t very good.” And I told him I would, it was on the top of my list of priorities. So a little while later I sat down with Ron and we went over how to write up and H and P [history and physical exam] and how to present it on rounds. I can imagine what he was feeling: defensive, embarrassed, humiliated. It’s one of those awful rites of passage. I don’t know, I didn’t get much sleep last night, I was really tired, and I wonder what he was thinking. I don’t know if I was coming off as a hard-ass, if I was being condescending. I didn’t mean to be; I kept saying to him over and over that you’re not expected to know this, nobody ever teaches you this. I spent about twenty minutes talking to him about this, telling him the same stuff over and over again. He probably thought, You asshole, stop repeating yourself! I hope he learned something from it, and I’ll tell you, the next time I’m on call, next Friday, he’ll just have to take the admission and just go over it with me first. When I’m done with him, he’ll sound like a master.
It’s a beautiful, sunny spring day today. I came home and I really wanted to sit out on the porch wit
h some friend and drink some beers, but I didn’t feel like calling anybody; I guess I really wanted just to be by myself. I’m too fucking tired to talk anymore.
Saturday, April 19, 1986, 11:30 P.M.
Last night one of my patients coded and died. It really hurts to go through the story again, but I suppose I’ll try.
It was a little five-month-old with bad heart disease, doesn’t matter what type, who had been admitted several times before for congestive heart failure. This time she was coming in to get a cardiac cath done so they could plan her surgery. When I first saw her, she was in some failure: She was puffing away and a little cyanotic [blue], but her mother said she always looked that way. And so I got her plugged in and talked to her attending and he also told me not to worry because this really was her baseline, so it wasn’t necessary to start oxygen. The cath was scheduled for the next morning. In the evening, she spiked a temp; there was no obvious source, and it was only a low-grade fever. I figured maybe it was the start of a URI [upper respiratory infection; cold]. The resident who was covering looked at the kid and said she had an otitis [otitis media, an ear infection]. She didn’t have an otitis, no more than I did. But the resident insisted, so we gave her some amoxicillin and some Tylenol and she defervesced. But she had spiked and it was the day before her cath.
She went for her cath bright and early yesterday morning and she came back at about ten. We were on attending rounds. I saw her for a moment, at about noon. She had fallen asleep in her mother’s arms, and her mom asked me not to disturb her. I told her I’d come back and see her later, after she’d slept for a while. When I came back, she looked a little uncomfortable, but not bad. I got called away to do something else before I had a chance to finish my exam.
At two o’clock we were called to see her because the nurse had noticed she was looking worse. We went in: There she was, pale, tachypneic, with cold extremities. She looked clamped down and shocky. We had a devil of a time getting a line in. Before we did, we got a blood gas: It showed she was quite acidotic, with a pH of 7.21. But after we got the line in, we gave her a small amount of fluid and she seemed to become more comfortable. Her repeat blood gas was improved; she was less acidotic.
A little later we decided we should give her a little Lasix [a diuretic] so she wouldn’t go into congestive failure or pulmonary edema. When I went to give it she looked comfortable, breathing at sixty instead of eighty. I spent the afternoon darting in and out of the room; basically she looked okay. We put her in 60 percent oxygen by headbox to help her out. Her attending also kept coming in and going out all afternoon. He was concerned that she had suffered some sort of ischemic event [damage to the heart muscle due to lack of oxygen], but he didn’t know when. He told me I might have caused it by drawing blood and introducing an air embolus, something I’d never heard of before. That sounded like a really ridiculous idea. He said it might have been that or it might have been the cath, but he sort of kept stressing that I had done something.
Anyway, at about five o’clock he was there, and he chastised Eric. He told him how foolish and unobservant he had been. He told him that the child was in respiratory distress, grunting and flaring, and that he’d noticed it an hour and a half before, but that he didn’t seem concerned. During the afternoon, the baby had spiked to 40.5°C [almost 105°F]. We were very worried, so we got a chest X ray, drew some blood, and started the baby on antibiotics. Her attending told us the fever was just a “dehydration fever.” I saw him put his hand on Eric’s shoulder and say condescendingly, “I’ve been in this business for a long time. I can tell you that’s all it is.” He didn’t want us to start the antibiotics. But we did nonetheless.
At about six-thirty I was writing my sign-out, trying to get home; Eric was with Kelly Jacobs, the other intern, almost at the end of evening rounds. Eric remarked to Kelly that the baby had a “preterminal look.” She had a heart rate of ninety, which is slow. Suddenly her heart stopped, right in front of their eyes, a witnessed cardiac arrest!
When I first heard the scream “Call a code!” I jumped up; I knew it was my baby. I ran into the room; they were starting to position her to start CPR. I turned around and helped the nurses haul the crash cart in. Eric intubated the baby and I took over managing the endotracheal tube while he ran the code. I started ventilating the baby while Kelly started sternal compressions. He was counting “One one-thousand, two one-thousand,” up to five, and I forced a breath in every time he got to five. Meanwhile, the nurses had ripped open the crash cart and people began to fill the room from everywhere. And we began to code the baby.
We did everything we could. We pushed four rounds of meds. Jon, the chief resident, came and stuck a line in the baby’s external jugular vein. We poured in fluid and kept pushing meds. But every time we stopped the CPR and looked up at the monitor, there was nothing. Flat-line. Finally we put her on an Isuprel drip. Even that didn’t work. Then Eric tried intracardiac epi. And when that didn’t work, after twenty-five minutes, they called the code and declared her dead.
At one point, well into the code, I remember looking up and seeing the mother, horror-stricken, with her hands to her mouth, bent at her hip like she had been punched in the stomach, screaming with horror. And then Jon had pulled the curtain so she couldn’t see in. When we stopped the code, Eric pushed me out of the room and told me to tell the parents. He said, “You go first, go tell them.” Just for a moment I stood in the baby’s room terrified that I’d have to go through this experience again; I’ve already had to tell three sets of parents that their child had died. But this would have been the worst of them, because this was my patient, I had admitted her, and because this was a baby who wasn’t supposed to die.
But I was spared giving the news this time. By the time we left the room, the mother already knew. Word got out very fast; one of the nurses had told the baby’s grandmother, and the grandmother had told the mother.
We went out of the room as the nurses came in to clean up the mess. As we passed through the hall, there were shocked, terror-stricken looks on all the other parents’ faces. Then we saw the mother. She was panicky and crazed. She wanted to run in and see the baby. We had to hold her back; we kept telling her that she shouldn’t go yet, that she should wait until everything had been cleaned up. She was screaming that she had to see the baby and we couldn’t keep her from her baby! But we told her again that she shouldn’t see her baby now, with all the needles and the mess.
Someone found a wheelchair and we got her into it; with a lot of effort, we pushed her into the house staff lounge. We got the father in and we got everyone else to leave, and we told the parents exactly what had happened. That’s when they began to cry. We told them we had done everything, everything possible, and that nothing had worked; there was never a response. They just couldn’t understand.
Then finally one of the medical students came in and said it was okay for them to come and see the baby. The mother darted out of the room and we followed behind her. We stood in the hallway and we called for the attending and we called for the priest and we called for the social worker. There were a lot of crying, hysterical relatives filling the hallway, filling the ward, and panic-stricken parents of the other children stood uncomfortably at the edge of the doorways, not knowing what to say or how to act. It seemed to go on forever.
The father didn’t stay in the room long; he couldn’t bring himself to look at the baby. The mother stayed. When she finally came out, we took her, and the father, back to the house-staff lounge and we sat and talked for a long time.
After a while I left the room. I had to try to finish my work so I could go home. It was hard to concentrate on my other patients, but somehow I did it. At some point, Jon came in and asked me if I would go back and sit with the parents while he and Eric went to attend to some other business. I went in. It was just the parents and me. They sat there, upset but now calm. They asked me, “What will happen to our baby now? Where will you put her?” I told them the baby would stay in t
he hospital until they had decided what they wanted to do. They asked me if I thought an autopsy should be done, and I said yes, I thought one should, so that we could find out exactly what had happened. But they shook their heads no.
A little later, Jon and Eric came back with the autopsy permission form. They urged the parents to consent to an autopsy; the parents said they would think it over.
Before I left for the day, I pulled Jon aside and began to cry. I couldn’t stop; I cried for the baby and for all the other children I’d seen die. I told him that I’d had other patients who had died and that I was beginning to feel like a death cloud. We went and talked and he reassured me it wasn’t my fault.
Then the family met with the priest and the social worker. Phone numbers were exchanged; I didn’t give them mine, but I thought that someone else had given them my number. Now I worry that I’ve lost touch with the parents forever. I wish I could be available to them.
When the family left, Jon, Eric and I were standing in the house-staff lounge. Eric cursed about how terrible this all was and then, in a very serious and angry tone, he said, “This job sucks!” We sat there silently, morose and upset. But then Eric began to imitate and make fun of some of the attendings in the most merciless way. And pretty soon, we were all laughing, and it felt so good to laugh because it had seemed like forever since I’d last done it. But as I was sitting there laughing, this terrible sadness came over me; I started feeling guilty for laughing at such a serious time. Then I began to sense a horrible, black feeling coming over me.
I left after that. The baby’s attending had never shown up. I was exhausted, so exhausted. It was a very bad night, a night during which I thought about quitting. And so I got up, and walked home.
I tried to call someone, just to talk about what had happened. All I kept getting was answering machines. So I tried to get drunk, but I could barely finish two beers because I was so tired. It’s been over twenty-four hours since it happened, but all day today I’ve been feeling depressed and upset. And I feel guilty as hell about it, even though I’ve been told over and over again that it wasn’t my fault.
The Intern Blues Page 34