Year of the Intern

by Robin Cook

  The first day, Saturday, had been great. We stocked the car with beer, cold cuts, and cheese, and drove to the big Kauai canyon. On the way, the road rose and fell among the clouds, moving us in and out of quick rain squalls as the sugar-cane fields rolled by on either side. The canyon was even more expansive and spectacular than we had expected. I found a lookout for us, and Jan turned the groceries into sandwiches. I asked her not to talk—a necessary precaution, because as our relationship had developed so had her desire to communicate. The view was wonderful, what with rainfall, waterfalls, and rainbows sparkling in the corners of the steep valleys that branched off from the main canyon. I was totally at peace.

  By late afternoon we had driven to the end of the road on the northern shore, right at the beginning of the Napali coast. In a secluded grove of evergreen trees, I put up our borrowed pup tent, and as the sun prepared to set among the puffy little clouds along the horizon, we swam naked in the still waters within the protective reef. It didn't matter that there were campers in full view at the other end of the beach—although I wondered why they were so near the water, rather than where we were, on higher ground among the pines.

  Somewhat self-consciously we ran up to the car. I pulled on a pair of white jeans and Jan wriggled into a nylon windbreaker. Even another meal of cold cuts and beer couldn't destroy the atmosphere. Night descended rapidly, with the sound of breaking surf on the reef mingling with the soft whisper of the breeze through the evergreen trees above us. The night creatures began their eerie symphony, increasing in intensity until they dominated even the sound of the surf. The western sky was just a smudge of red. Jan looked beautiful in the half-light, and the idea of her in nothing but that nylon windbreaker seemed fantastically sexy. In fact, I was delirious with the sensuality of the moment.

  Naked once again, we returned to the beach. As we slid into the water the full Hawaiian moon floated over a ridge of trees; the scene was so perfect it seemed unreal. I couldn't stand it a second more. Holding hands, we ran back to the tent and fell together on the blankets. I wanted to devour her, to capture the moment in my mind.

  Slowly and reluctantly, from the depths of this wet embrace, I became aware of the whine of mosquitoes. In our desire to make love, we tried to ignore them at first, but they began to bite as well as whine. No passion could have resisted that onslaught. In dreadful seconds the whole sensual atmosphere disintegrated, ending with Jan's departure to the shelter of our Volkswagen. Still shaking with desire, I resolved to stick it out in the tent rather than sleep crammed into a car built for midgets. I rolled up in one of the blankets so that just my nose and mouth were vulnerable. Even so, the mosquitoes bit me so relentlessly that my face began to swell, and finally I surrendered, trudging back to the car accompanied by a swarm of mosquitoes who seemed as unfulfilled as I was.

  I knocked on the window, and Jan sat up, wide-eyed, opening the door with relief when she recognized me. I stumbled in wearily and told her to go back to sleep. After smashing the mosquitoes that had come in with me, I somehow fell asleep myself, under the steering wheel, in a contorted ball. In about two hours I awoke sweating. The temperature and humidity had risen to Turkish-bath levels; the moisture was so thick it had condensed on all the windows. Opening a side window, I felt a cool rush of air and about fifty mosquitoes come into the car. That was that. I started the engine, told Jan to relax, and drove out to the main road and back toward Lihue, until I found an elevated spot with a good wind, where I managed to doze until the sun came up. My breakfast was bread and cheese mixed with ants and sand and washed down with warm beer, all eaten off the hood of the car. Then I woke Jan up and we drove back to town.

  Somehow Jan and I had drifted apart after that. Not that I blamed her for the weekend. It was more because she began heckling me a lot, especially after we started sleeping together, wanting to know if I loved her, and why not, and what was I thinking about. I loved her sometimes, in a way that was hard to explain; as for what I was thinking, most of the time we were together my mind just drifted. Anyway, I couldn't cope with her questions. It had simply become convenient to let the whole thing slide back into casual friendship. But it was nice seeing her in the cafeteria. She was still a great-looking girl.

  The ER had completely changed in the fifteen or twenty minutes I took for lunch. A new group of people stood waiting, and eight fresh charts were waiting in the basket. Obviously no real emergencies were at hand, or the nurses would have called me immediately. Just more routine stuff. One of the new people was a chronic visitor to the ER, in for his usual shot of xylocaine to ease an alleged back disorder. His arrivals were so frequent and predictable that the nurses always had a needle full of xylocaine ready and waiting for me on the tray next to the patient. Kid Xylocaine, as we called him, had developed a certain expertise about his condition, and this was his time to shine, as he directed me where to insert the needle, how to insert it, and how much to give. Feeling somewhat victimized by this ritual, I nevertheless did what he wanted; he sighed with apparent relief and left.

  Walking next into Room B, I was greeted once again by my drunk friend Morris, who had returned at last from the X-ray department. Flopped on an examining table and secured by a wide restraining belt, Morris held a large manila envelope filled with fresh X rays. He greeted me. "All I ever get is a goddamn intern. I don't know why I come here any more."

  Lunch had made me mellow and somehow able to ignore this prattle as I took the X rays out of the envelope and began to hold them up, one at a time, against the light of the window. I didn't expect to find anything of consequence, except perhaps in the upper left arm, which was badly discolored. Earlier, when I lifted and rotated the arm, Morris had rewarded me with a stream of obscenity. Something might be amiss there. I went through the whole stack of X rays—left knee, right knee, pelvis, right wrist, left elbow, left foot—on and on, without finding anything for the left arm and shoulder. Not there. Nothing to do but have the nurse return Morris to radiology. "They're going to love you up there, Doctor Peters," said the nurse. "He terrorized the X-ray department all morning and used up two boxes of film."

  "That doesn't surprise me," I said, picking up a handful of new charts and heading for Room C.

  The afternoon babies were much like the morning babies, suffering mostly from colds and diarrhea. One had to be sponged for a temperature of 104.2, and another, about four years old, needed suturing for a laceration on his chin. Suturing children is very, very difficult. Their terror at being brought to a hospital, often bleeding and in pain, is only made worse by the papooselike contraption they are strapped into to keep them still. Not even the papoose could immobilize this boy's chin; it was like hitting a moving target. The worst part for him was being under the sheet with the hole in it. After the sting of the xylocaine, he didn't feel much of anything but pressure and slight pulling. Yet he screamed just the same, and hated it all the way. So did I.

  A thirty-two-year-old man in another room had a catalogue of complaints, beginning with a dry throat and proceeding down the body. His real aim was to be admitted as a hospital patient, and when he realized that the dry throat hadn't impressed me very much, his trouble shifted to a right-side chest pain. To test his reaction, I finally told him the hospital was already overcrowded, whereupon he stormed out in a rage, complaining that when you really needed a hospital it was always full.

  The afternoon drifted by in a carelessly busy way. By now I had seen about sixty patients, par for the course, with no more than the usual sweat. But Saturday night was approaching, and that always meant trouble. Two older men with asthma walked in together, and the nurses put them into separate rooms with the positive-pressure breathing machines. The gentleman in Room C was wheezing away, his bony chest held at almost full inspiration, his back straight, hands on his knees. I asked him if he smoked. No, he answered, he hadn't smoked in years. Reaching down, I slowly pulled the pack of Camels out of his shirt pocket, his eyes following my hand until he saw the cigarettes. Whe
n he looked up at me, the expression on his face, even in his suffering, was so comical yet warmly human that I couldn't help smiling. It was like catching a small boy in a piece of silly mischief. Much of the emergency room's appeal lay in its lavish display of the variety and folly of humankind.

  Old friends kept turning up. Another drunk, well known to us, stumbled in, complaining of a fall over a rocking chair that had left him with a chronic leg ulcer! I had seen the same ulcer a few weeks before when the drunk was a ward patient—an eventful time for all of us. Despite rigorous security measures, he had stayed drunk for days on end, and his discharge was probably hastened when the chief resident found him behind the blood bank with two bottles of Old Crow and a female patient. This time I bandaged his ulcer and told him to come back to the clinic on Monday.

  Between the drunks and the crying babies with colds, an ambulance pulled up unannounced, without siren or flashing red light. That meant it wasn't much of an emergency. When the stretcher was unloaded, it revealed a thin lady of about fifty dressed in dirty, ragged clothes. I followed one of the nurses, who was saying they couldn't get any response from this patient. And neither could I. The lady just stared at the ceiling, breathing heavily. She had a small laceration in the hairline of her forehead, but it wasn't even suturable. She seemed fully conscious, and yet she was totally immobile. I began a neurological exam, testing first her pupils and then her reflexes. No bad signs. But when I tried to do the Babinski test, by lightly scraping the bottom of her foot with a key, she practically hit the ceiling, screaming that there wasn't anything wrong with her feet, it was her head that hurt, and why was I fooling with her feet? She jumped off the examining table and disappeared down the hall, with a nurse in hot pursuit. Finally, we called the hospital administration and the police, who ended up dragging her away still screaming that she was all right.

  Down in Room F was an elderly gentleman who had run out of his diuretic, or water-eliminating, pills and whose legs were swollen with excessive fluid. He turned out to be one of those people with a remarkable talent for talking continuously and apparently sensibly without saying anything at all. A torrent of words rolled out as I tried to examine him. He spoke of his extrasensory perception and of the many times he had been able to use it, especially in communicating with his wife, who had died several years previously. Against my will I paused to listen while he described how he could take a bottle of water and distill it into his own model of the universe. In fact, he thought the earth was one small portion of one molecule of some gigantic object from another universe in another dimension. A little dazed, I gave him a supply of pills, told him to stay off his feet for a while, and took up the next chart.

  It was important to listen to these patients, despite the craziness and trivia. Every so often their ramblings were significant Once in the medical-school hospital a man had checked in to the ER complaining that he had eaten several shot glasses, without the usual complement of bread. The resident and intern began to escort him out the door, with the suggestion that he return in the morning, when the psychiatry department was staffed. Seeing their disbelief, the man grabbed at the intern's pocket, coming away with a test tube and a wooden throat swab, both of which he quickly chewed up and swallowed while the house staff watched in paralyzed disbelief. They turned him around, then, and led him back to the examining room, softly suggesting that he stay overnight. In the X ray, his abdomen had looked like a bag of crushed marbles.

  "Goddamn hospital. I'm never coming here again. Next time I'll go to St. Mary's." This was from the ubiquitous Morris, as he was rolled by on an examining table. Evidently he was to haunt me all day long, although I took some hope from the fact that now he appeared to be holding the X ray of his upper left arm. Perhaps I could get rid of him, after all.

  "Doctor, a call for you on 84," said one of the nurses.

  I already had the receiver to my ear, listening to a busy signal from my third effort to reach a Dr. Wilson, one of whose patients had come in suffering from a urinary-tract infection. Feeling frustrated, I pushed the burton for 84.

  "Dr. Peters."

  "Doctor, my boy has a terrible headache, and I can't find my doctor. I don't know what to do." Her story hung in my head, blending with the din of crying babies in the background. We didn't need another aspirin case, but there was no way for me to tell her not to come. Reluctantly I answered, "If you are convinced that the boy is ill, then by all means bring him to the emergency room."

  "Doctor, a call on 83." I told the nurse to put it on hold while I redialed Dr. Wilson, steeling myself for another busy signal. Instead, there was a ring and Dr. Wilson answered. "Dr. Wilson, I have a patient of yours here, a Mrs. Kimora."

  "Mrs. Kimora? I don't think I know her. Are you sure she's one of my patients?"

  "Well, she says so, Dr. Wilson." It frequently happened that doctors couldn't remember their patients' names. Perhaps a description of her problem would jog his memory, and it seemed to as I went on. "She has a urinary-tract infection, with heavy burning on urination, and her temperature—"

  "Give her some gantrisin and send her to my office on Monday," he said, interrupting me.

  I paused, fighting an urge to hang up. Why didn't he want to hear about the case—her temperature, urinalysis, blood count? "How about a culture?" I asked.

  "Sure, get a culture."

  "Okay," I pushed 83 to take the call on hold.

  "Doctor," a voice wailed on the other end, "I just had a bowel movement and there's blood in it?"

  "Was it bright red on the toilet paper?"

  "Yes." We established that her hemorrhoids were the probable cause of the bleeding and that she wouldn't have to come in to the emergency room, just see her physician on Monday. With a sigh of relief and profuse thanks she hung up. The nurse was holding another call, on 84, but this sort of thing could go on indefinitely, and I ignored it. Instead, I went back to Mrs. Kimora and explained very carefully about the gantrisin, that she would have to take two of the pills four times a day. A nurse took the urine for culture.

  Now for Morris. Immobile on the table and apparently somewhat less drunk than before, he greeted me with his usual cheer. "I wanna get outa here." At least we agreed on that. Taking up the next X rays I held them against the light and saw immediately, with great disappointment, that he had a sharp fracture halfway between his elbow and his shoulder, as if he had taken a good karate chop. He would be with us a while longer.

  "Mr. Morris, you have a broken arm." I looked at him sternly.

  "I do not," he countered. "You don't know what you're doing."

  Wanting to avoid another yes-you-do-no-I-don't series, I retreated and rapidly wrote an order commending Morris into the hands of the orthopedic resident. The nurse called the switchboard operator and put the resident on page.

  By midafternoon I was barely keeping abreast of he crowds. About 4:00 p.m. we were briefly overwhelmed by a bunch of surfers with lacerated scalps, cut fingers, and deep coral cuts. The surf was up! The babies seemed unending, crying in every corner, with their temperatures, diarrhea, and vomiting. I was suturing madly, sending people to X-ray, and desperately trying to look into the ears of totally uncooperative children. One mother came in quite frantic, saying her baby had fallen down a third-floor rubbish chute with the garbage. I was tempted to inquire exactly how that had happened. But instead of asking any questions, I examined the child, and removed onion rings from his ear lobes and coffee grounds from his hair. Amazingly, he was quite intact. But I sent him to X-ray because his right arm appeared to be a little tender, and it did turn out that he had a greenstick fracture of the right humerus— about the least you could expect after falling three stories into a pile of garbage.

  Meanwhile, the X rays were piling up, all different kinds, from skulls to feet. I was the first to admit I wasn't much good at reading these things. But that was the system—the intern read the X rays at night and on weekends. It didn't make any difference that we were badly trained for the
job; we had to do it as best we could. Knowing my lack of qualifications, I was always fearful of missing something important— especially after the humbling experience with the toe. That incident had occurred one other Saturday night, when a girl came hobbling in on the arm of her boyfriend. She had stubbed her toe. When I sent her up for an X ray, her friend went along. About an hour later, in the middle of pandemonium, I looked at the X rays, mostly at the metatarsals, and told them that they were apparently negative and— The friend interrupted quietly to say that when he saw the film he thought there was a fracture. I paused and gulped. "You did?" Back at the X-ray view box, he pointed out a line in the middle phalanx of the third toe that was definitely suspicious and could have been— indeed, was—a fracture. So it goes in on-the-job training!

  Morris was now conveniently stashed away in the orthopedic room, out of earshot. The orthopedic resident had responded to his page, examined Morris and his reams of X rays, and disappeared, after trying unsuccessfully to reach the on-call staff orthopedic attending. Morris would stay in the orthopedic room until the attending was contacted. So Morris was an albatross still to be carried, but he wasn't around my neck any more. I forgot about him.

  Around five-thirty the whiplash injuries started trickling in. That was standard whenever traffic got heavy and cars began piling into one another out on the freeways. Anyone claiming a whiplash injury needed a careful palpation of the neck, a thorough neurological exam, and a cervical spine X ray before his doctor could be called. All these X rays looked frightfully the same, and when I slipped one of them on the gigantic view box in the middle of the ER I felt as transparently vulnerable as the negative of itself. Moreover, the patients were always there, peering anxiously over my shoulder while I read their films. I only hoped they were impressed with my wizardry at making so much out of those smudgy black, white, and gray pictures of bones and tissue. It was mostly for their sake that I generally faked a thorough analysis, lingering a little longer than necessary over some part of the negative. Actually, anything I could diagnose had to be pretty far out of line or clearly broken in two, which took about ten seconds to determine. Anything else was a lucky hit. But you couldn't let the home team down, so I would gaze knowingly at the negatives, mumbling to myself and making notes, while the patient fidgeted, expecting the worst.