Weekends at Bellevue

by Julie Holland

  The research project inched forward as I recruited new hallucinating patients into our study, running the interviews in a small room down the hall from the locked unit. In between, I attended the weekly staff meetings to discuss the patients. We gathered around a huge conference table: the doctors and nurses in charge of the two units, the chief resident, and me. I was the youngest in the room. The head of the acute ward was a short, playful doctor who moved the meetings along, peppering his descriptions of patients with words like “bonkers” and “bananas.” He obviously loved the patients and his job, but he called it like it was. He taught me that it was okay to marvel at the madness, to be titillated by the sheer lunacy that waited to envelop me on the wards. Also, he was clearly enamored with the chief resident, Lucy, a gal from Georgia with a strident Southern accent. She had light brown hair that wildly pointed this way and that, and she always seemed to be wearing a Hawaiian shirt, or something so bright and flowery that it should only be worn on an island. She was the most charismatic doctor I had come across in my training, and I wanted to be just like her when I grew up. In the staff meetings she was irreverent, flippant, and hilarious. The older doctors treated her as a prodigal genius-rebel. They put up with her sass, laughing in spite of themselves. In the hallways with her peers, or on the wards among the patients, she strutted with a swagger in her walk, captivating all in her path with her broad, knowing grin, her bravado, and her down-home charm.

  After several months on the wards, I asked my boss if I could hang out in the psych ER one night, knowing it was a night that Lucy was on-call. I spent the hours before the shift making homemade wontons in my cramped kitchen, mincing the garlic and water chestnuts, grating the carrots and ginger.

  It was cold and rainy as I drove my beat-up Honda Civic to Temple’s psych ER. When I finally tracked down the good doctor, she was in an office with her feet up, wearing her usual button-down Hawaiian shirt over her scrubs, her hair all akimbo. “Slow night tonight,” she apologized. “You may not get to see much.”

  “I brought you some wontons. Actually, they’re Korean. They’re called mondu,” I told her, fishing them out of my bag. “I thought you might be hungry.”

  “You’re kidding me. You made these?”

  I felt foolish, like a kindergartner who’d brought an apple for the teacher, except that this apple took two and a half hours to create.

  The ER was dead as promised. We saw no patients together, but we chatted about my plans for a future in psychiatry, and I gushed over how much it excited me—the patients, their symptoms and stories, the pharmacology. We bonded over our love of psychosis, how easily we found ourselves mesmerized by the potency of insanity. She told me war stories about her training, the kinds of patients who impressed her, and what she did to make an equal impression on them. Her boasting was engaging and endearing, and I was treated to an outpouring of tales about her rebellious adolescence and college years: how she worked construction and drove a backhoe one summer, how she called her father’s bosses “assholes” when unknowingly on speakerphone in his office, the time she got drunk in medical school and “beat up a car.” I noticed her boundaries were very loose, like mine, and she didn’t censor herself when regaling me with her greatest hits. Our styles were similar, and I had a feeling that she learned to act macho as a young girl to win the approval of her father, just as I had done.

  Although I was only a medical student, she treated me as an equal, taking me into her confidence, telling me about things I didn’t necessarily have a right to hear, like the leather fetish of one of the Temple psychiatrists. With this segue, she mentioned that she was a lesbian. I was speechless.

  For some reason, this had not occurred to me. I thought we were alike. I identified with her so strongly, wanting to be just like her. And she was gay? What did that say about me, with some sort of schoolgirl crush on her? I had to say something quickly, or there would be an uncomfortable silence and I would look like an idiot.

  “Do your parents know?” I stammered, transforming myself into a twelve-year-old girl from Kansas.

  “Of course!” she answered, irritated, dismissive, confirming my fears. Our conversation died. She clearly thought I was a boob. I left shortly afterwards, mortified at fumbling the most basic of exchanges. I wanted her to befriend me, to take me under her wing, but I was sure I’d ruined any chance of that.

  Another Girl

  The initial two years of med school are known as the “preclinical” years. We learned anatomy from dead bodies, and we pored over thick, heavy books filled with disgusting pictures. The tail end of the second year was spent getting the medical students more comfortable with the idea of patient contact. The faculty cautiously introduced us onto the wards to take histories from inpatients.

  When I finally got to practice interviewing a real live human, the woman I’d been assigned to had the chills and was coughing. It was unsettling to sit so close to her. All my life I’d been told to keep my distance from anyone who was ill and possibly contagious. “What the hell am I doing near this sick person?” the medical students joked with each other when we met up at the bar later.

  The first time I ever performed a gynecological exam, it was with a paid model. I was in a room with two other medical students, both men—big, hulking jocks actually—shaking with fear, stinking up the small exam room with their acrid sweat. (There are two types of sweat: the more watery kind, eccrine, that results from overheating, and the hormone-laden kind, apocrine, that comes from terror. Fear sweat smells a whole lot worse than exercise sweat.) When the teaching attending came in and asked who would go first, the two men looked at me wide-eyed, silently pleading. I volunteered to go first, and the model could not have been any nicer.

  “If you are commenting on appearances during the exam, use words like ‘normal’ and ‘healthy,’” advised the professor.

  “I guess ‘Nice rack’ doesn’t go over so well, huh?” I joked nervously. No one else thought this was funny, including me. My mouth was dry, my insides trembling, and I felt utterly alone. I performed the breast exam, feeling for lumps, and the vaginal exam, feeling for ovaries, as best I could, and then it was time to insert the speculum. I was supposed to slide it in closed, then open it up once it was inside the vagina. My big gaffe, which I’m sure was profoundly uncomfortable for the model, was that I removed the speculum without closing it first. I realized that I’d hurt her, and felt like a buffoon. As I apologized profusely, she was kind and sincere, understanding my mortification. (I still remember her to this day, and would again like to apologize and thank her for not yelling at me. I would’ve yelled.)

  Every July first is New Year’s Day for medical students—the first day of the new academic year. Recently graduated medical students become “doctors,” and second-year medical students become the much anticipated “third-years,” when the clinical rotations begin. No more lecture halls; it’s finally time to learn on patients.

  And so, in the summer of 1990, things finally got interesting. I left the classrooms, the endless labs, and the solitary studying. It was time for me to enter the hospital, and it was baptism by fire: I was assigned to surgery. I knew nothing—nothing practical, that is, nothing of any use to a surgeon. I didn’t know how to draw blood. I didn’t know how to order medications or labs, or how to check the lab results, or even where the lab was. I was worse than useless: I was a burden, plagued by the constant anxiety of “I’ve never done this before.”

  But the surgery residents had been where we were, and they knew the deal. They were used to teaching clueless kids in July. They knew the best patients for teaching were those who could not complain. At Albert Einstein hospital in the heart of Northern Philadelphia, that meant either a patient who was unconscious or was simply unaware that they could’ve asked for someone other than a medical student to provide their care.

  A tremendously obese woman was brought into the emergency room by her family because of some sort of a boil on her belly. The cyst was e
normous and angry red, with striations of scarlet spidering off its center. The patient was feverish and somnolent from the infection, which we would later diagnose as necrotizing fasciitis, requiring multiple surgeries to “debride” or remove the infected tissue. She was put on oxygen and given something for the pain, and then we swarmed in like ants on a melon rind. Her blood needed to be drawn, her cyst fluid to be cultured. She also required an arterial blood gas, an exquisitely painful procedure where a needle is inserted into an artery, as opposed to the standard venous draw adequate for most blood work. The surgery resident showed a group of us how to locate the artery by feeling the pulse prior to inserting the needle. Since this woman was nearly comatose, she wouldn’t mind if I didn’t get it on my first try. I was surprised to see that my hands had a fine tremor as I fished around for the artery. (When I attempted this on a conscious patient the next day, he winced stoically at first, then eventually tore his arm away, screaming and swearing at me, and I had to enter into complex negotiations with him for cooperation.)

  Taking a history to establish what was wrong with a patient was much trickier than cramming for exams. They didn’t know the names or dosages of their medications. They pronounced their diagnoses in a way that confounded me as to what they actually had. A patient told me she was just getting over her “flea bites” which, after some detective work, turned out to be phlebitis. Another man reported he was taking “peanut butter balls” for his seizures. The ER docs had a good laugh over this, translating “phenobarbital” for me. When I asked a patient, “Where were you shot?” I got aggravated when he answered, “Right down on Broad Street,” which is the information his friends might’ve appreciated. I, on the other hand, needed to know where on his body. Misunderstandings like these abounded. (The classic medical school joke is to ask a patient if she’s sexually active, to which she will reply, “No, I usually just lie there.”)

  My surgery rotation was part ER, part surgical wards, and part operating room. I developed a love-hate relationship with the adrenaline and the hours. I would repeatedly envision Hawkeye Pierce (this was before Grey’s Anatomy) each time I scrubbed-in at the sink with the other surgeons and then pushed my back through the OR door, my arms at ninety-degree angles. I spent most of my time feeling like I was in either a gory movie or a well-written medical drama. I am playing the part of a doctor, I told myself, and hopefully, eventually, I will feel like one.

  Philadelphia in July was a festival of mortality: car accidents, gunshot wounds, stabbings, muggings. A man with his initials in gold on his top two teeth stumbled into the ER literally holding his guts. He had been shot in the belly and his intestines had “avulsed” outside of his skin. I was invited to join in his surgery. Instead of using a scalpel to open his abdomen, they used the bovie, the device typically used to cauterize bleeders, something like a hot poker. As the surgery commenced, there was a small explosion as the escaped intestinal gas ignited the bovie. “Okay, that means he’s perfed his intestines somewhere,” the resident explained to me calmly, in contrast to my jumpiness. We examined what seemed like miles of his intestines, passing them through our hands trying to find the perforation. He had been shot with a shotgun, and the chief resident made the same joke repeatedly as he dropped endless pieces of buckshot into a silver bowl held by the nurse. “Send this to ballistics,” he quipped as one clinked. “This one too.” “Ballistics.” He thought it would never get old, and for some reason, he was right. It’s all in the delivery.

  It was during these first few months of my third year that I learned something crucial about myself: I couldn’t stand to see people writhing in pain. I felt horrible that they were suffering and I wasn’t yet in any position to stop it. Broken bones sticking out of skin or fractures grinding against themselves when the limb was moved (a sound called crepitus) creeped me out more than anything. But give me someone in psychic pain, whose soul was aching, and I felt fully equipped to involve myself.

  The surgical residents sensed this in me, and I was frequently pulled along when one of them had to deliver bad news to a patient or family member.

  On the Fourth of July weekend I was helping to cover the ER. I was very excited, and a bit nervous, because a trauma call had come in. EMS was five minutes out, bringing us someone from a car accident. The members of the trauma team converged on the ER from various parts of the hospital—the surgeon’s lounge, the wards, the call-room. We “gowned up” in yellow plastic robes, gloves, and goggles. We were gathered around a gurney waiting for the ambulance when I heard the chief surgeon of the trauma team say, “Remember, it’s not a trauma call, it’s a trauma code.” I had no idea what the difference was but I stayed mum as she explained to the third-year resident, “She’s already coded. All we can do is try to revive her.”

  I realized then that we were all dressed up and waiting for a dead girl.

  When EMS wheeled the patient in, they gave their report. “Sixteen-year-old girl, unknown medical history, unrestrained, driving a Suzuki Samurai which flipped multiple times. She was thrown from the car. CPR started in the field.” As she was transferred from the ambulance stretcher to our gurney, I noticed her small, light-blue running shoes, the razor stubble on her legs, her turquoise terry-cloth shorts, and her chipped fingernail polish.

  We began our efforts at resuscitation. Her eyes were open and staring at the ceiling as her clothes were cut from her body. A male nurse noticed she was wearing contact lenses and removed them, telling me how her eyes would dry out if we left them in. The girl did not blink.

  “You see that? Not good,” the nurse explained to me. “She’s got no corneal reflexes.” I stood by the gurney, trying to make myself small and not get in anyone’s way as the doctors and nurses buzzed around the young girl. They put intravenous lines in her arms, a catheter into her bladder, and they checked her for internal bleeding. This is done by peritoneal lavage, which is basically a way to rinse out the inside of the torso. It’s not exactly rocket science: If the liquid comes back red, there is internal bleeding. The liquid came back clear. Her heart started beating somehow, but she did not breathe on her own, and so she was intubated and connected to a respirator.

  I had been working with a second-year surgical resident up on the wards, and he startled me out of my glassy stare, which mirrored the young girl’s.

  “Julie. We gotta go talk to the family.” As we walked out of the trauma room, I glanced at the small blue sneaker lying on its side in the corner.

  These past couple of days, the second-year had seemed like such a softie, apologizing to patients if he needed to draw a blood gas, feeling sorry for a little boy who needed his IV site “cut down,” but he hardened up when confronted with this girl’s family. As he explained her current condition, I saw him become emotionally removed and overly technical with them—the mother, father, and older sister of a girl who was celebrating her new license to drive. He hid behind the medical jargon, stiffening visibly as he explained our attempts at resuscitation, the condition of the heart, the lungs, the brain, which ones were working now and which weren’t. The sister looked at me with such hate in her eyes. Why was she blaming me? I wasn’t the doctor delivering the horrible news. But I knew why she was angry. There was something callous and hurtful about his attitude—and therefore mine, by association, although I remained silent, careful not to show any expression—as he catalogued the damage and explained the unlikelihood of her awakening from this coma.

  The family insisted that she remain on life support. They had heard of people waking up from comas, they’d seen it on television, and so we were unable to convince them of its improbability. She was admitted to the surgical ICU, a girl with a beating heart and nothing more, taking up an intensive-care bed in the hospital for thousands of dollars a day, so the family could have some time to say good-bye. They were angry and confused, and they wouldn’t be rushed into accepting what even I could clearly see: She was gone already.

  For reasons I did not yet understand, I ended
up displaying the same condescending, remote attitude as my surgical resident when I was asked to go explain her condition again, this time to her high school friends who had gathered in the waiting room: “Right now, your friend is on a machine to keep her alive, and we’re not sure she’s going to pull through.” Short and sweet, and the young girls shrieked and sobbed. They barely stayed to hear my explanation of the shutdown of her various organ systems, turning away to hug each other and cry instead. It was my first time telling anyone their friend was dead, or as good as dead, and my delivery needed work, but doing a surgery rotation in an inner-city hospital would give me plenty of opportunities.

  Back at the hospital a few days later, a patient I’d been working with that holiday weekend had tested negative for the AIDS virus. Since I had stuck myself with a needle filled with her blood, I had been anxious, waiting for the results. Unfortunately for the patient, however, the good news about her test results meant very little in the scheme of things. Before the long weekend, she had been hit by a car and had broken her leg. When she left the hospital, with a cast from toes to thigh, she went home to hang out with friends, who, like herself, smoked crack. She must have gone on some sort of a binge; when she eventually started paying attention to her surroundings and her body, she realized that her leg was bothering her. She felt a tingling, an aching, and returned to the ER to have it examined, where she was told she had gangrene in her toes and foot. The cast was too tight and had cut off her circulation.

  I was with her, avoiding her eyes and instead staring at her swollen, black toes, when the surgeons gave her the devastating news: She needed an amputation. I spent time with her, helping her to adjust, and was present in the operating room when the lower part of her leg was removed, the electric saw sparing her knee. (For years after this surgery rotation, it was hard for me to eat chicken, turkey, and especially leg of lamb without thinking about amputations.)