Mike Miller had me over to his house. He told me over and over that the baby’s death was not my fault. We talked for hours. I really think Mike cares. He told me that the whole thing had happened under the eyes of the attending and that I was not to feel responsible for the baby’s death. And yet I do feel responsible. I feel terribly guilty and terribly sad. And I need to find some place for this inside of me so that it won’t eat me up, so that I can live with it. This was definitely the worst death of all deaths this year.
Amy
APRIL 1986
Monday, March 31, 1986
I’m in the neonatal ICU at Jonas Bronck now. Most of my patients shouldn’t even be alive. They’re so small and sick, I can’t understand how any of these things are going to grow up to be anything like a normal child. Most of them don’t even seem human. It’s such a contrast for me. I spend the days running around doing all this worthless work on these premature babies and then I go home and see Sarah. Sarah’s a real person now, she’s walking around and talking. It’s great to watch her and to be part of the process, but then I go back to work the next morning and I realize that no matter what we do or how hard we work, it’ll never be possible for most of my patients to do any of the things my baby can do. I feel very sorry for them but I also feel sorry for myself, because I’m being forced to take care of them and I don’t want to have to take care of them. I stand back sometimes and realize that we’re not really doing anybody any good. But that’s not for me to say. I’m supposed to do what the attending tells me.
And things are even worse this month because I’m feeling so bad. I’m nauseous all the time now and I’m always completely exhausted. I get to a point around three o’clock every afternoon where I have to lie down for a few minutes. Trying to get a half hour or so off in the middle of the afternoon in the NICU is not the easiest thing to do when all your patients are in critical condition and dying and there’s still a ton of scut that has to get done. So far this pregnancy is a lot worse than my pregnancy with Sarah. I’m feeling a lot sicker. It’s probably because I started out this one so chronically exhausted.
I still haven’t told anyone in the program except Bob Marion that I’m pregnant, so I have to cover up how I’m feeling and make excuses about why I need to go off and be by myself for a while. I don’t think anyone’s caught on yet, but I’m sure it’s only a matter of time.
I’ve got a total of eight patients. Four of them started out weighing less than eight hundred grams [one pound, twelve ounces]. Two of these are relatively new preemies and are extremely sick. Both are on ventilators; one has NEC [necrotizing enterocolitis, a serious infection of the intestine] and sepsis and all sorts of other problems. I spend most of my time trying to keep these two from dying. My other two preemies have been around longer; one’s about a month and a half old and the other’s nearly four months old. I remember the four-month-old from the last time I worked in the unit; he was very sick back then. Now he and my one-and-a-half-month-old are stable but they’re both really damaged. They both have grade IV IVH [intraventricular hemorrhage, a hemorrhage into the ventrical of the brain; IVH is graded from I to IV, with IV being the most severe], and one has bad hydrocephalus. The four-month-old has been abandoned by his mother. The mother hasn’t been around in over a month. I don’t know if I can say I blame her. I’m not really sure what I would do if I were in a situation like that. God forbid! But the nurses are really attached to this kid. That seems to be something that happens a lot when babies spend so many months in the unit.
I’ve got another patient, a six-month-old, who was born with congenital hydrocephalus. He’s been in the nursery his whole life! His head is enormous; it looks like a basketball. He’s had five shunts placed, but none of them seems to have done any good. All he can do is suck, breathe, and keep his heart beating, so he won’t die for a long time, but he also isn’t going to be leaving this unit. It’s really sad. His mother visits him every day. She’s kind of a pain; she always asks about his head circumference and tries to find out what his last CT scan showed. I feel sorry for her. She’s really devoted to him. I don’t think she has much of a life outside of here.
Then I’ve got this whole assortment of crack babies who live in the ICU. We had some in the well-baby nursery when I was working out there but they were mostly just social problems. These babies in the unit are all very sick. They all started out addicted and SGA [small for gestational age]; a couple of them have had convulsions. And all of them have either been abandoned or have been taken away from their mothers by the BCW. They’re all very pathetic. They start out sick, and even when they get well, they have no place to go.
So that’s my service so far. I don’t understand how I’m going to have enough motivation to get up every morning and go to work. I’d rather just stay home and lie in bed all day than go to that horrible ICU.
Saturday, April 5, 1986
One of my patients died last night. Dying was definitely the best thing that could have happened to this baby; he had almost no chance of survival. But dealing with the mother was very hard.
It was a baby who had been born two days ago with severe malformations. At first we weren’t sure what the baby had, but we knew it was something really bad. She was very abnormal-looking; she had a loud heart murmur; and she didn’t respond to anything, including pain. Bob Marion came to see her and said the baby had trisomy 13. [This is a disorder caused by an extra copy of chromosome thirteen. Children with trisomy 13 have so many malformations, both internally and externally, that almost all die within the first few months of life.] He told us we shouldn’t do anything heroic to try to prolong life, so we didn’t, we just let the baby be and kept her comfortable. It took her over twenty-four hours to die; she waited until everybody else had gone home, so it was only me and a senior resident who was cross-covering.
The baby’s heart just stopped beating. One of the nurses called me over and told me she was dead. I listened and didn’t hear any heart sounds. At least she chose a reasonable time to die; it was about eight-thirty. At least the nurses didn’t have to wake me up at four in the morning to declare her.
The mother was out on the postpartum ward and I went out to her room to tell her. She was really upset. Bob Marion and Ed Norris, our attending, had talked to her a few times since the baby had been born, so she knew what was wrong and that it was only a matter of time, but still she got very upset when I told her. It was really sad. She’s thirty-nine years old and this was her first pregnancy. I sat with her for about a half hour, trying to calm her down. She told me she really wanted this baby, that she had had a lot of trouble getting pregnant and had gotten to the point where she didn’t think she’d ever be able to conceive. And then, just when she had just about given up hope, she became pregnant with this baby, who turned out to have trisomy 13. I had absolutely no idea what to say to her. What can you say at a time like that? I don’t even want to think about it, especially not now. So that wasn’t the easiest thing in the world to deal with.
The rest of the night wasn’t bad, though. I even got a few hours of sleep. Most of the preemies behaved themselves and didn’t do anything stupid while I was on. Still, all night, I kept thinking about that mother. And so even though it should have been an easy night, it wasn’t.
Friday, April 11, 1986
Yesterday was the official opening of the neonatal intensive-care unit on 7 South. The unit’s actually been open for months now, but that’s beside the point. They had this big celebration, and Mayor Koch, a group of other officials from the city, and all these reporters were here. Ed, our attending, who’s the director of the nursery, took the mayor on a tour and showed him some of the six-hundred-grammers. The mayor was, to say the least, a little put off by the appearance of some of our patients. He didn’t volunteer to kiss any of them, the way most politicians kiss babies.
I was on last night, and I had a terrible night. At about 1:00 A.M., we got a call from the DR that they had this woman who had just
walked in off the street who was ready to deliver and had had no prenatal care. They weren’t even sure when her LMP [last menstrual period] was, but they thought the baby might be about twenty-six weeks. Luckily, I was on with Enid Bolger, who’s the senior in the unit this month. Enid also happens to be very good. We went running down to the delivery room just as the baby was coming out. It was tiny! I was positive it was too small to survive. Enid thought so, too, so we just gave it some oxygen and didn’t do much else. It was only about eleven and a half inches long, so it was probably about twenty-three weeks [about three weeks too early for the baby to live independently outside the uterus]. But the baby came out with a heart rate, so we had to take it back to the ICU and wait for it to die.
That was pretty bad, but it could have been worse. Enid was very good about it; she didn’t go crazy, like some of the other residents do. Some people would have done everything: intubated it, put it on a respirator, started IVs. But it wouldn’t have accomplished anything. That baby never had a chance. It weighed only 520 grams [about one pound, two ounces]. So it was good to have someone like Enid in charge; I agreed with her completely in how this baby was managed. When the heart finally stopped beating, Enid and I went down and talked to the mother. She didn’t seem too upset. I don’t think she had really thought of it as a baby yet. I’m not even sure if she had realized she was pregnant before that day. She has three children at home. I don’t know, I’m fairly sure it was for the best.
But I didn’t get much sleep, and I’ve now had two deaths in one week. That’s a lot, even if you’re expecting the baby to die. I hope my luck changes.
I got into a fight with a mother last night. It was the mother of my patient Moreno, the six-month-old with hydrocephalus. I was in the middle of doing my evening scut and one of the nurses told me that Mrs. Moreno wanted to talk to me. I told the nurse I was busy just then and I’d try to stop by later. It was a very busy night and I completely forgot to go back to find the mother, and about an hour and a half later the woman came up to me and said, “Didn’t the nurse tell you I wanted to talk to you?” I very nicely explained to her that I had a lot of work to do and I couldn’t talk just then. She then got nasty, accused me of neglecting her child because I didn’t think he was as important as the other babies, and said she was going to go right down to the patient advocate’s office to make a formal complaint against me. I felt so lousy and I was so fed up with everything that I just told her, “Go ahead! Go and complain! What can they do, fire me? Let them fire me! I’d be glad if they fired me!” And I went on like that for a while. The woman didn’t say another word, she just walked off the unit. I guess she went and complained. I haven’t heard anything about it, but I’m sure I will. The nurses told me not to worry, though, because since the baby’s been in the unit, she’s complained about four other doctors. Still, I don’t think I should have been so nasty to her. But what can I do?
Thursday, April 17, 1986
I don’t think I want to work in that unit anymore. Too many bad things have happened in that nursery. I don’t like taking care of those things. I just want to stay home with Sarah.
I had another death last night. That makes three on my time in three weeks. This last one was the worst of all of them because it was my four-month-old preemie, the one the nurses were really attached to. He had been doing poorly all along, and last night at about two o’clock, one of the nurses went in to check him and found him dead. Just like that. He was cold already. There wasn’t anything we could do for him at that point. The nurses were really upset about it; some of them cried. I’ve never seen a nurse cry before for a patient who had died. At least I didn’t have to go through the stress of talking to the mother, but spending the rest of the night with the nurses who were in a rotten mood might have been even worse.
Mrs. Moreno did complain about me to the patient advocate. I got called down there on Monday, and one of the administrators asked me to explain what happened. I told him the whole story and he told me that this woman was very angry about what had happened and what was happening to her baby, and she was blaming the entire staff for everything. He said it was a bad situation but they were trying to keep her calm and that for the rest of my time in the ICU I should try to be nice to her and put up with all her craziness. He didn’t fire me. I was hoping I was going to get fired or at least suspended for a week or two. No such luck.
There’s only one more week to go, so it looks like I’m going to make it through the month. I go to the OPD next, and that should be easier. And I think I’m starting to feel a little better. I didn’t feel like I had to vomit once all yesterday and today. So maybe this part of the pregnancy is coming to an end. I know that’ll make things easier.
Mark
APRIL 1986
Tuesday, April 15, 1986
Well, I’m back from another wonderful vacation. I don’t know what it is about me and vacations, but no matter how hard we try or how much in advance we plan, things always seem to turn out as if we were characters in one of those low-budget disaster movies.
This time Carole and I went to this beautiful hotel right on the beach in Cancún. It was a gorgeous place: great rooms, delicious food, and an amazing view. Everything would have been perfect, absolutely perfect, if two weeks ago hadn’t turned out to be Mexican monsoon season. I didn’t even know they had monsoons in Mexico, but I could have sworn that’s what it was. We got off the plane at the airport in the pouring rain, and the rain continued the entire time we were there! An entire week of looking out the window at rain falling on a beautiful beach. Very exciting! And of course this place didn’t have any indoor activities. Why should they have indoor activities? It never rains in Cancún, the weather’s always perfect, isn’t it? Sure it is, it’s always perfect, except, of course, when I go there on vacation!
Everyone I’ve met since I got back to the Bronx has mentioned what a nice tan I got. Nice tan? There’s no way I could have gotten a tan! There wasn’t enough sun to get tan, the sun never came out, not for the entire eight days we were there! The only way my skin could have turned color is if maybe I started to rust. That must be what it is, I went away on vacation and got a nice rust!
Well, at least I got some rest. And I did get to spend a lot of time alone with Carole. That was very nice; we had a good time together. And I even got to read a book while we were away. An actual novel, not a pediatric textbook. It’s the first nonmedical book I’ve read all year. It was getting to the point where I was starting to think I wasn’t allowed to read any sentence unless it had at least one six-syllable word that had a Latin root in it. Reading this novel was tough at first. I’m so conditioned by reading medical stuff that I kept falling asleep after reading one paragraph. But I finally managed to get through it. I guess there’s still hope for me.
Well, so much for my fond memories of our trip. It’s now the middle of April, and the big news is there’s only a little more than two months of this misery left. Yes, winter’s over, the snow’s all melted, the leaves are starting to appear on the trees, the addicts are starting to hang out on the street corners again, and the cockroaches are mating. I guess the cockroaches are always mating, but I swear, I got back to my apartment after flying back from Cancún and there were at least four times the usual number of roaches hanging around. We had managed to cut down the number remarkably for a while but now they’re back in full force. It was an awe-inspiring sight, opening the front door, happy to be home after narrowly escaping being killed in the floods, and looking inside to see that my apartment had turned into Cockroach Heaven! I’ve been fighting the war ever since, but it looks as if they’ve definitely established a foothold. It’s time to start thinking about moving out of the Bronx! I think Carole may ultimately win this battle. She’s wanted me to get out of here for months.
I’m spending the last two weeks of the month in the OPD at Jonas Bronck. I’ve been on call two nights so far and it really hasn’t been bad. We’ve left the ER at the stroke of midnight
both nights, which is kind of amazing. We seem to be between seasons right now. Respiratory infection season has ended, and diarrhea and dehydration season hasn’t started yet. At least that’s what all the attendings keep saying to explain why it’s so quiet. They talk about it like these diseases are sports. You know, in a couple of weeks I expect the chairman of the department to come down to the ER and throw out the ceremonial first diarrhea and dehydration patient to open the season officially. Well, whatever’s causing it to be quiet, I’m not complaining. I just hope it keeps up.
I’m assigned to neurology clinic on Friday mornings. What a lot of fun that is! The clinic is held on the fifth floor of Jonas Bronck, and you get there at about nine o’clock and the waiting area is already filled with what looks like hundreds and hundreds of kids seizing and shaking and yelling at the top of their lungs. Every kid has a chart that contains at least five thousand pages, and you have to read the entire chart to figure out what the hell is going on. And because there are so many patients scheduled, you have to move really fast or else you wind up staying all afternoon. This is the first time I’ve been assigned to neuro clinic this year, and I’m glad I have only a couple of sessions there before the month ends. If I had to imagine what hell might be like, I don’t think I could come up with anything worse than being permanently assigned to neuro clinic. Get the feeling that I’m not going to be a neurologist when I grow up?
Over the past few weeks, I’ve started thinking about what I’m going to do when I’m finished with this internship and residency. The more I think about it, the worse the headache I wind up getting. I can see the advantage of specializing in something, but I also can see the advantage of not specializing in anything. I could go right into practice after I’m done, or I could do a fellowship. So far the only thing I’ve definitely decided is to put off making a decision about this for as long as I can. It’s really very early. I don’t even have to start panicking until about next year at this time. I’ve got all the time in the world.
The Intern Blues Page 35