When I talk about it, I don’t think it’ll sound like last night was all that bad. I mean, I had six admissions, which is kind of bad, but all of them were electives and none of them was sick, so it should have been pretty easy, right? It would have been easy had they all come in at a reasonable hour. It would have been easy had at least of few of them come in at a reasonable hour. Did any of them come in at a reasonable hour? Of course not! Why would anyone expect a kid who’s scheduled to have surgery the next day, who needs to be seen by residents from at least three services [pediatrics, surgery, and anesthesiology], and who needs to have blood work and all kinds of other tests done, to come into the hospital before nine o’clock at night? What a silly idea that is!
Well, anyway, they started to arrive at about seven-thirty and they continued to show up until nearly midnight. I couldn’t believe it: A six-year-old who was scheduled to have a T and A [removal of tonsils and adenoids] this morning didn’t show up until midnight. A normal six-year-old shouldn’t even be awake at midnight, to say nothing of a six-year-old who’s scheduled to have an operation a few hours later! I was pissed, the anesthesiology resident who came to see the kid was pissed, the surgery resident was pissed, everyone was pissed except the kid and his mother, who couldn’t understand what we were all so upset about. To them a six-year-old coming in for an elective procedure at midnight was completely natural.
So it took me until after two-thirty to finish all my scut work on six lousy electives! And of course just when I was finished and I should have been able to get to sleep, Nelly, my AIDS kid with pneumocystis carinii pneumonia, decided to try to die on us. Boy, how happy I was to see that! It’s me and Diane Rogers [the cross-covering senior resident] in a hospital that doesn’t have a pediatric ICU, trying to keep alive a kid who’s trying her best to get to heaven. It was amazing: She was perfectly fine one minute, and the next minute she was dropping her pulse to sixty and her blood pressure to sixty-five over forty-five. It really looked like the end was near. We stood around scratching our heads for a couple of minutes, trying to figure out what the hell was going on and what we should be doing about it. Her blood gas was still okay, so we knew it wasn’t a ventilatory problem. Diane finally figured maybe we should try some Dopamine [a drug that increases blood pressure, among other things] to see what that did. I didn’t understand the reasoning (of course, there isn’t much reasoning I do understand), but the Dopamine seemed to do the trick. Nelly was good as new after that.
So there we were, with a kid with AIDS and PCP, who was going into shock, getting a Dopamine drip while on the regular ward. I had to stay with her for the rest of the night. I didn’t get any sleep, and then I had to start rounds so I could have my usual morning fight with the blood-drawing tech who was refusing to draw blood on everyone. This has become a regular part of my day, I’ve kind of become addicted to it. Fighting with the blood-drawing tech is like drinking coffee.
So much fighting goes on at this hospital, it’s unbelievable. Working at University Hospital is definitely like being drafted into the army during wartime. It’s us against them, with the “them” being everybody who’s not a house officer: the attendings, the nurses, the lab techs, and especially the patients and their mothers. Work rounds in the morning are more like a pre-battle strategy session. We plan out the tactics we’re going to use that day. But there are a lot of situations you can’t plan for; things like sneak attacks. They tend to keep you on your toes.
Friday, May 9, 1986
I really don’t know what to make of this place. This hospital definitely has some schizoid tendencies; sometimes it seems like the nicest place in the world. There are some afternoons when it’s so peaceful and quiet, you can relax, sit out on the sun porch, even take a nap. And then there are some days where the patients all get sick at once, there are millions of admissions, and all you do is fight with everybody you can find. Take yesterday afternoon. At about three o’clock, the whole team got stat-paged to the adult ICU. We had one patient in there, an eight-year-old who had been hit by a car a couple of days before and had been unconscious ever since, so we all were sure she had arrested. We went running into the ICU and found she was fine, but the neurosurgery attending and one of his residents were standing by her bedside. As soon as we pulled up, the attending started yelling about how poorly we were managing the patient and how embarrassed he was that a patient who had been referred to him was getting such lousy care. She wasn’t getting lousy care, she was getting great care. We all knew that. It’s just that this guy has this quota: He has to yell at at least one house officer a day.
It was really hard to keep a straight face while this guy was yelling at us because he was sucking on a lollypop the whole time. It’s hard to take this neurosurgeon seriously in the first place, but when he’s got a lollypop in his mouth, it’s damn near impossible!
And that wasn’t even the end of it. Today, when we were on work rounds, we ran into the neurosurgery team. In spite of how poorly we had managed the kid, she had awakened out of her coma last night and seemed just fine today. Now her prognosis is excellent, and the neurosurgery chief resident told us we had done a great job with the patient. The attending immediately yelled at him, saying, “How can you tell them they did a great job less than twenty-four hours after I yelled at them for doing a lousy job?” The chief resident apologized and told him that since he hadn’t been on rounds yesterday afternoon, he didn’t know the attending had yelled at us. Then the attending got real pissed and said, “Next time I yell at somebody, I want the whole team there. I don’t want to have to yell at people twice for the same thing!”
So last night I had a really quiet night. No admissions, just some coverage, and almost everyone remained stable. This was mainly due to the fact that Nelly, the AIDS kid, got transferred over to the ICU at Jonas Bronck. When Al Warburg, the daytime senior resident, found out that we had a patient on the ward on a Dopamine drip, he picked up the hot line to the chief residents’ office and told them they had to transfer Nelly. So after I had been up all night with the kid, she got whisked away to Jonas Bronck. Don’t get me wrong, I’m not complaining.
I guess the sickest kid on the ward right now is José, a one-year-old with this weird metabolic disease called argininosuccinicademia. The name of this thing is longer than the kid is! Anyway, having José on the ward is like taking care of an unremitting Hanson. He’s constantly crumping and then stabilizing and then crumping again. He’s lived in the hospital for the past couple of months, and all the nurses have come to love him. That’s always a bad prognostic sign.
This disease has something to do with the urea cycle, and the kid is being treated with all these weird chemicals that make him smell really strange. I spent a few minutes standing at his doorway yesterday, sniffing his bouquet, trying to figure out what in hell it was he smelled like. It took a while, but it finally came to me: He smells just like the bottom of a birdcage. The kid smells like parakeet droppings! It’s the strangest thing, but that’s exactly what it is. Since I figured that out, I’ve become fixated on thinking of him as a parakeet. I’m waiting for him to start singing. And I’m sure it won’t be long before he sprouts wings and just sort of flies away.
When you start sniffing the patients, I think it’s safe to say you’ve been an intern too long. I think it’s time to get out of here!
Sunday, May 18, 1986
Well, I haven’t recorded anything for over a week, and nothing much has happened. Working at University really isn’t so bad if you like taking care of kids with diseases whose names you can’t pronounce. It’s not like the other hospitals; they actually hire people here to do some of the scut work we’re normally expected to do. So workwise there just isn’t that much to do. But you more than make up for it in aggravation.
This is definitely the weirdest place I’ve ever worked in! At all the other hospitals, you really know what the score is. The rules are simple: They try to pile as much shit on your head as they can until you collap
se, at which point a chief resident comes along, pats you on the shoulder, and gives you the weekend off to recover. Here the work isn’t that hard, but you always have the feeling that you’re missing something. You don’t have control over anything. There are always attendings around who are trying to do things without telling you, and the parents always know more about what’s happening with their kids than we do. It’s very frustrating.
Nobody wants their kids touched by an intern. The parents all want the private attending to come in and draw the blood or start the IV. That’s pretty funny because most of these private attendings haven’t started an IV on a kid in years. People always naturally expect the more senior people to be able to do everything better than the interns. I’ll tell you, at this point in the year there are very few people who are better than the interns at starting IVs, doing spinal taps, drawing blood, doing any kind of scut. But the parents still want to know why the private attending isn’t coming in to do the stuff. So even though there’s lots of time to sit out in the sun, I think I’d rather be in the wasteland of Jonas Bronck.
Well, there’s only a little over a week to go and I’ll be out of here. And then there’s only one more month of internship left. That’s pretty unbelievable, but I’m finding the idea of me being a resident even more unbelievable. In a little over a month there is going to be a group of poor, innocent interns who are actually going to look up to me with respect. They’re even going to think they can trust me! My God, what a frightening thought!
Wednesday, May 28, 1986, 8:30 P.M.
Well, it looks like I made it. I just came home, which means I’m done with University Hospital. The rest of my internship consists of one measly month in the NICU at West Bronx. It’ll be a cinch compared with last night.
I had the feeling last night that what was going on wasn’t real. I figured this had to be a setup for Candid Camera. But nobody told me to smile, and no short, fat, bald guy came out and shook my hand. So I think it must have been real.
I was supposed to be on with Diane Rogers, but she called in sick and there was nobody to cover for her. So the chiefs asked if I would mind working on the ward by myself. Me mind covering a ward filled with twenty-five sick kids by myself? No, no way I’d mind it. I told them I looked forward to challenges just like this, that I welcomed just this type of adversity. In fact, I even told them I’d be happy to work every night next month by myself because that’s the kind of guy I am. I don’t think they realized I was being cynical, because somehow at around ten o’clock last evening I found myself rounding on the ward by myself. I even yelled at myself a couple of times for not following up on some scut I was supposed to do.
Anyway, everything was going fine, mostly because there hadn’t been any admissions in a couple of days and the place was really quiet, but then at about four o’clock this morning I got a call from one of the neurology attendings, who told me he was sending in a kid with a brain tumor who had been in status epilepticus for about four hours. Status for four hours! I told him fine, I welcomed these kinds of patients, that I looked forward to challenges just like this, and that I’d be waiting for him. Then I calmly hung up the phone, ran for the staircase, and started moving in a downward direction. I was getting out of there; I might be crazy, but I’m no fool.
When I hit the third-floor landing, something weird happened. I got this sudden rush of guilt and I realized I’d have to go back. So I slowly climbed back up, told the nurse what was happening, and got ready.
The kid got there at about four-thirty. He was seizing, all right, there wasn’t any doubt about it. I had no trouble figuring out he was seizing; what I had trouble figuring out was what I was going to do about it. So I called the neuro attending at home, and the first thing he did was yell at me for waking him up. I was expecting that; the first thing everybody does when you call them from University Hospital is yell at you. But then I asked him what I should do, and he said, “You’ve got a kid who’s seizing. What the hell do you think you should do?”
My neurons turned on and I waited a couple of seconds for an answer to come out of my mouth. When it finally did, it was, “Give him an anticonvulsant?” The neurologist said, “Brilliant,” so I knew I was on the right track. I said, “Should I start a line, give him some Valium, and then load him with Dilantin?” He told me that that sounded like a wonderful idea, so that’s what I did. I got the line in, I pushed the Valium, and the kid suddenly stopped seizing. It was great. By six-thirty I had him stabilized, lying in bed, sleeping, which was a lot more than I can say about myself.
This was pretty amazing. I have a lot of trouble believing I was capable of working by myself for a whole night and even admitting a seriously ill patient and not making any major screw-ups. I guess now that I’ve got pediatrics perfected, it’s time to try another field. Maybe I’ll become a heavyweight boxer.
Bob
MAY 1986
At the beginning of the month, Amy Horowitz told the chief residents that she was pregnant and needed to arrange maternity leave. Her announcement was met with the release of an explosion of venom aimed at her by the chief residents, who weren’t about to give any special treatment to Amy just because she happened to be pregnant. This reaction of the chiefs produced the release of an equal explosion of venom from Amy, who, fed up with what she viewed as the chronically poor treatment she’d received all year long, decided to call the Committee of Interns and Residents to find out exactly what she was entitled to. The situation, which was escalating, was finally defused by Mike Miller, who managed to put Amy’s ire to rest, at least for the time being.
The issue of maternity leave for house officers is a relatively new one. In the 1950s, residency training programs didn’t have to worry about developing specific policies regarding leaves of absence for new mothers for two reasons: First, at that time, there were very few women in medicine; and second, many programs strictly prohibited house officers of either sex from being married. Over the past thirty-five years, however, this situation has changed dramatically: Today over 50 percent of the 105 house officers who make up our program are women, and the majority of these women are married. In recent years we’ve averaged about five new babies born to female house officers annually. As a result, a definite plan regarding maternity leave has been developed, with the intern or resident receiving about three months away from the hospital around the time of delivery.
The development of this plan has been met with mixed reactions from the house officers, both male and female. After all, if one person is given three months off, someone else is going to have to fill in for her. An attempt is always made to spread the coverage evenly, but often a few people wind up doing what they consider more than their fair share. This leads to resentment directed toward the person on maternity leave, resentment that may stay with her through the rest of her training.
But the problems that female doctors face are certainly not limited to these issues surrounding maternity leave. Discrimination against all women in medicine is rampant. Although the foundation of this discrimination is rooted in the past, when medicine was exclusively a male profession and when house officers were referred to as “the boys in white” and specialists such as ear, nose, and throat surgeons were called “ENT men,” the image lives on in the public’s mind. It lives on mainly because the medical establishment, which at this time is composed of those “boys in white” of the 1940s and 1950s who have grown up and taken charge, perpetuates the myth. And so the acceptance of women as medical equals of men is a difficult goal to attain.
It’s easy to see examples of discrimination. In our emergency rooms, any male who has contact with a patient is immediately referred to as “Doctor” by the patient’s parents, regardless of whether he is a doctor, a nurse, a medical student, or a clerk. Any female, no matter how senior or expert, is automatically assumed to be a nurse. At the beginning of the year, the female interns take great effort to correct the parents; they explain that they’ve gone to medical school, h
ave graduated, and are just as much doctors as any man; but as time passes and it becomes clear that these explanations are doing little to change the public’s conception and actually are creating hostility between doctor and patient, the women try to ignore what they consider this slight, managing just to cringe a little and swallow hard a few times when it happens.
And patients often believe that women can’t do as good a job as men when it comes to the technical aspects of medicine. I’ve seen it a hundred times: parents refusing to let the senior resident, who happens to be a woman, draw blood, do a spinal tap, or start an IV on their child, demanding that the male doctor in the next examining room, who happens to be an intern, try the procedure first.
But the patients clearly are not the only ones who discriminate against female doctors; it’s also firmly entrenched in academic bureaucracy. Thus far, few women have achieved positions of authority at medical schools in the United States. As an example, only a handful of the chairmanships of pediatric departments, the specialty with the largest percentage of practitioners who are female, are held by women. Part of this is due to the fact that until recently there weren’t many senior physicians who were female, but part is definitely because qualified women are frequently not offered a job when an equally qualified male candidate is available.
Also, it becomes difficult for female doctors to deal with nurses, the majority of whom also are women. A good intern has to be aggressive, but aggressiveness is not a trait that is viewed as acceptable in women. When a male doctor orders a nurse to perform a task for his patient, it is viewed positively; he is just carrying out his responsibility. When a woman is the one who requests that a nurse do something, she is regarded as “uppity” and a troublemaker. It’s a bind that is difficult for the female house officer to resolve satisfactorily.
These issues present an enormous identity problem for the female intern. On the one hand, she’s not getting equal treatment from her patients or from the nurses; on the other hand, she has few or sometimes no role models to guide her in her training. Very often this second problem is more serious than the first.
The Intern Blues Page 38