The Year of the Intern

by Robin Cook

  Surprisingly, he was conscious, although dazed.

  "Do you have any pain?"

  "No, no pain. But I have something in my right eye."

  God, with all that injury he was worried about a cinder in his eye. I took it out. His blood pressure was all right, the pulse a little high at 120. I started an IV and sent up a sample for type and cross match, arbitrarily picking five units of blood to be available. He apparently didn't need blood right away, but he obviously was facing some bone surgery. With a hemostat I tried to stop a little of the blood oozing out of the leg muscles, which were in plain view. It amazed me how little he bled.

  I went back to the lady who had vomited up the blood and was relieved to find her blood pressure holding up well. Perhaps she had just swallowed the blood, I reasoned; after all, she was bleeding from both nostrils. Twenty minutes had passed since the ambulances pulled in, and some others from the house staff were there now, helping to stabilize the patients. I got X-ray to come down and shoot a group of heads and chests and other bones. No description could capture the uproar of that time. It was total chaos, as colds and diarrhea and babies and asthmatics mingled with broken bones and crushed heads. Nor did matters improve much when the attendings arrived and began ordering everyone about. The OR, alerted earlier, finally began to absorb the automobile-accident patients.

  Dr. Sung called again, threatening to file a complaint with the hospital if I didn't get right on that horse serum. At that point I didn't give a damn about his horse serum, so I hung up on him. This brought him storming in about twenty minutes later, ready to give me hell, just as we were moving the last of the critically injured up to surgery. I stood there, covered with a mixture of blood and vomitus, vaguely hearing him rant. This lunatic could get me into real trouble, so I didn't say anything except to mention the Hypertet again, and how much quicker it would have been. That made him even madder, and he stomped out taking his patient with him. Sure enough, a written reprimand showed up in my box a few days later. So much for priorities.

  By eleven the cyclone had passed, leaving the usual jumble of patients with lesser complaints, a much larger number than usual because of what had gone before. They were everywhere — inside, outside, sitting on the ambulance platform, on the floor, in chairs. I began to go from one room to another, half listening, performing like a tired machine. One man had fallen by his pool during a party, breaking his nose on the diving board as he went down and cutting his thumb on a gin-and-tonic glass. The nose was straight, so I left it alone. The laceration I sutured rapidly, after telling his private M. D. the sad story. Even he sounded drunk.

  It was, in fact, a big night for drunks; most of them were suffering from minor cuts and bruises or premature hangovers, with nausea and vomiting. And the kids were still coming in, long after bedtime, with their diarrhea and runny noses and fevers. Occasionally I had one with a temperature of around 104, yet I wouldn't be able to find anything wrong. This made me very uncomfortable. As a human being you have an almost irresistible desire to treat; you are expected to treat. The parents almost invariably clamored for penicillin, but I had enough sense not to give in most of the time. To treat a symptom like fever without a firm diagnosis is bad medicine; and yet I often got only a fleeting and rather limited look at the eardrums or the throats of those miniature screamers. Sometimes I treated, sometimes not; always I went on half-educated guesses.

  It went on being a typical Saturday night in the ER. The crowd thinned out about 1:00 a.m. From now on we would see less of the various things that drove people away from their TV sets during the evening to seek the sanctity of the ER — things like colds, diarrhea, and minor puncture wounds. In about an hour, the problems that were keeping them from falling asleep would begin to appear. The same ailments they had ignored all day and through the early evening would, of course, keep them awake, forcing them to the ER in the middle of the night to see the astute and understanding intern. Like itchy thighs. On another tour of duty, I had fallen asleep around 5:00 a.m. only to be awakened because some patient had itchy thighs.

  Slightly after one an ambulance pulled up without its siren, and the crew unloaded a peaceful-looking girl in her early twenties who was in a deep sleep approaching coma. Ingestion. The usual, as I found out: twelve aspirins, two Seconals, three Libriums, and a handful of vitamin tablets. All of these drugs, except maybe the vitamins, could be dangerous — especially Seconal, a sleeping pill — but you had to take quite a few of them if you were really serious. Otherwise it was only a gesture, a childish cry for attention within the social fabric of the individual's life; the usual ingestion case is a young woman lost in the unreal world of True Romance magazine. I could be interested and sympathetic, but not in my state; I was so tired that any sense of empathy had long since dissolved into irritation. How could this stupid girl pull such a stunt so late on a Saturday night? Why couldn't she throw her little show on Tuesday morning?

  As they always did, several members of the family and some friends arrived shortly after the ambulance. They stayed in the waiting room, nervously talking and smoking. I looked down at the girl sleeping on the table. Then, putting my hand on her chin, I forcibly shook her head and called her by her first name, Carol. The eyes opened slowly, so that only half the pupils were showing, and she whimpered, "Tommy."

  "Tommy, shit." Irritation became anger as my exhaustion and hostility sought expression and won. I ordered some ipecac from the nurse and decided to pump her out. The pumping-out procedure was no bargain for either of us, but I wanted to make her remember the ER. Besides, I knew that when I called her private doctor he would ask what I had gotten out of her stomach.

  An ingestion stomach tube is half an inch in diameter. After cranking her into a sitting position, I crammed one down her throat, through her left nostril. Her eyes suddenly shot open all the way as she retched and struggled to get free of the attendants holding her. She vomited a little around the tube as I pushed it farther down into her stomach, and then everything in her stomach came up, including an undissolved Seconal and a portion of one of the Librium capsules. When I pulled the tube out, what remained came with it. A few minutes later the ipecac took effect, causing her to vomit again and again, even though her stomach was empty. By now Tommy had joined the others in the waiting room. Perhaps he also wanted some ipecac, so as to play a full role in this melodramatic event.

  After sending up a blood sample to see if the aspirin had changed the acidity of the blood, and finding out that it hadn't, I called Carol's doctor. I told him what she had taken and that, aside from being sleepy, she was all right now, nicely tranquilized.

  "What did you get when you pumped her out?"

  "One Seconal, bits of Librium, not much else."

  "Fine, Peters, good work. Send her home, and tell her father to call me on Monday."

  Soon after that Carol was taken home, in all her glory, covered with vomitus. I never questioned my harsh attitude toward her, not after eighteen hours in the ER, and, while I'm not proud of it now, that’s the way it was.

  Back around midnight a new shift of nurses had come on. It was now two, and I was really sagging, but the new nurses were a clean and spirited bunch, displaying remarkable agility and garrulousness for that time of night. The contrast made me feel even lousier, like a silhouette. And the next patient didn't help. Her chart read, "Depressed, difficulty breathing."

  As I walked into the room, my dismay was instantly confirmed by the sight of a lady in her late forties who was wearing a light blue negligee. She lay on the table, one hand pressed dramatically against her ample upper chest. Two other ladies stood nearby hysterically telling me and the nurse that their friend was unable to breathe. I could see from a distance that the lady was breathing very easily.

  "Oh, Doctor," the lady whined, drawing out the word in a deep southern accent. "I cain't hardly breathe. You have to help me."

  She smelled like week-old martinis. One of the hysterical ladies produced a prescription bottl
e. I looked at it. Seconal.

  "Oh, those little red pills. I did take two. Was that all right?" The southern lady looked at me with fluttery eyelids; she was having a hell of a good time at two o'clock in the morning. I had a strong impulse to throw her neurotic ass out of the ER. That was a sure administrative bomb, however — perhaps even career suicide. Despite my disenchantment with the system, I hadn't come to that.

  "Do you hear anything strange, Doctor?" I was forcing myself to listen to her chest, which was totally clear. "Oh, you're going to take my temperature and blood pressure," she said gleefully. "I do feel rather faint. I just cain't understand what's happening to me." On her arm went the blood-pressure cuff and into her mouth the thermometer, silencing her at last. I was glad of the opportunity to get away from her for a few minutes by calling the doctor who covered the hotel where she was staying. He said to give her Librium.

  Back in her presence, I coaxed myself to be civil. "Madam, the hotel physician has suggested Librium for you."

  "Librium, Doctor? Are those the little green and black pills? Well, I'm afraid I'm allergic to those. They make me so gassy, and sometimes," she said, sitting up now, moving into high gear, "sometimes if s so bad my hemorrhoids pop out." With this, we were fully launched into her extensive pill history and the dreadful details of her lower gastrointestinal tract. In the middle of her recital, a performance worthy of Blanche DuBois, I interrupted to say that perhaps orange Thorazine would do just as well.

  "Orange Thorazine!" She virtually squealed with delight. "I've never had that! I just cain't thank you enough, Doctor. You've been so sweet." And out she went, chattering gaily with her friends about the wonders of medicine.

  One of the nurses from a private ward appeared, limping slightly. She had fallen down a flight of stairs, with apparently no serious damage, but she had thought it best to have it checked. I agreed. Her name was Karen Christie, and nothing seemed wrong with her hip, but I suggested she have a pelvic X ray, anyway, to be perfectly sure. Hospitals are understandably sensitive to any threat of personal-injury claims on the part of the staff. When Miss Christie's X ray appeared fifteen minutes later, I snapped it up on the view box amid an assortment of skulls and broken bones. My eyes were a little blurry as I ran them over her femur, acetabulum, ilium, sacrum, and so on. All was normal. I almost missed the white coil toward the center, and when I did see it I couldn't figure out how the X-ray technician had managed to get such a strange artifact in his picture. Then it dawned on my sleepy mind that I was looking at an intrauterine contraceptive device, which served the double purpose of making Miss Christie a much more interesting case and lightening my mood for a moment.

  Unfortunately, my sour humor returned with the next patient. He sat quietly sobbing because he had hurt his nose when the car he was riding in hit a fire hydrant. With no encouragement from me, he loquaciously told the whole story. He had been minding his own business when he got picked up by a lesbian, who turned out to be so upset with her roommate that she ran the two of them into the fire hydrant. I didn't ask what had happened to the lesbian, being grateful not to have her, too. I thought wryly, and unkindly, that this fellow was the fag end of the night in more ways than one. Putting up with him was almost more than I could tolerate in my state of zero compassion. All I was prepared to handle were simple medical problems — diagnosis and cure. This guy needs more. He refused to do anything but sit and cry, and ask for Uncle Henry. When Uncle Henry arrived, not even he could persuade the man that an X ray was not lethal. Finally, when Uncle Henry agreed to stay constantly by his side, they disappeared to X-ray. The film showed a broken nose, and his private physician admitted him to the hospital by phone. Somewhat later, a policeman arrived with the real story. It had been a simple punch-out in one of the local "gay" bars; the lesbian was imaginary.

  Off in the distance, again I picked up the fateful sound of a siren, hoping it would pass us by. Instead, the ambulance screeched into the parking lot and backed quickly to the platform. I was in no shape for what I saw, the human wreckage of yet another automobile accident. The two girls on stretchers had obviously gone through the windshield. They were bloody from the waist up, with first-aid bandages covering their heads and faces. After the girls, two men stepped out of the ambulance under their own power, showing only minor bruises.

  As I removed the bandages from one girl's face, a geyser of blood spurted straight up onto my face and chest. A textbook case of arterial bleeding, I thought, replacing the bandages. I put on a pair of sterile gloves and a mask and then jerked the bandages off suddenly, immediately pressing a piece of gauze into the wound, working my hand along a gaping laceration that ran from her forehead down between her eyes almost to her mouth. Bleeders were spurting little jets of blood in various directions. With great difficulty, I managed to get mosquito hemostats on the bleeders, but before I could tie them the girl ripped them off. She was drunk. For a minute or so we went through a cruel, gory routine, she taking the hemostats off as fast as I put them on. I won by dogged persistence, finally tying off the bleeding vessels, but of necessity leaving enough work to enrich a plastic surgeon. Meanwhile, a resident had arrived to work on the other girl. Then we discovered that the two girls were military dependents, and since they were stable — meaning they weren't going to die in the next hour — off they went to a military hospital. That left me with the two fellows, who were in relatively good shape. I cleaned their abrasions and mechanically sutured a couple of scalp lacerations without uttering a word.

  By about three-thirty there was only one more patient to be seen, a baby sixteen months old. I was really dragging by then, and I don't remember much about the case except that the parents had brought the child in because he really hadn't been eating too well for the last week or so. Thinking I must have missed something, I had them repeat that several times. All the while the child was sitting there smiling and alert. With a touch of sarcasm, I asked if they didn't think their behavior was a little strange. Why strange, they wanted to know; they were worried. A slow burn came over me as I silently examined the perfectly normal baby, and then fled to the telephone to call their private doctor, who was equally irritated because I'd waked him up. That was absurd, too. The doctor was angry because his patient was bothering me at 3:30 a.m. I ended up turning everything over to the nurses, who sent them all home. I couldn't talk to them again.

  After the child left I wandered out on the platform, peering blankly into the silent blackness. I felt nauseous and drained, but I knew from sore experience how much worse I would feel to be waked up for the inevitable next patient after sleeping for only fifteen or twenty minutes. All the nurses were busy with small jobs except one, who was having coffee. I felt strangely detached, as though my feet were not firmly on the ground, and thoroughly lonely. Even fear was gone, banished by exhaustion. If anything serious came in now, all I could do would be to try to keep it alive until a doctor arrived. Well, that was a useful function, of sorts. Of course, I would continue to do miracles with the drunks and the depressed and the kids who weren't eating too well — my true constituency.

  Somewhere near and coming nearer, a Volkswagen's horn was beeping, disturbing the deceptive tranquility of the ER. As the beeping got louder, it began to remind me of the cartoon character called the Road Runner — an absurd association, but somehow appropriate to my mental state. Beep-beep. Maybe it was the Road Runner. Thirty seconds later fantasy was replaced by a VW that pulled up, still beeping, next to the platform. A man jumped out yelling that his wife was having a baby in the back seat. After calling for a nurse to bring a delivery kit, I ran down to the VW and opened the door on the right side. There in the back, sure enough, was a woman lying on her side, obviously in the last stages of labor. The light was very poor, obscuring the birth area; everything would have to be done by feel. As she started into another contraction, I felt the baby's head right on the perineum. The woman's panties were in the way, so I cut them off with some bandage scissors, and while she gr
unted through the contraction, I kept my hand on the baby's head to prevent it from popping out. After convincing her to roll over on her back, I pushed the front seats forward, and got one of her legs braced on the rear window and the other one draped over the driver's seat. My hands were moving by reflex now, leaving my mind to do absurd things, such as remember an old joke— what’s harder than getting a pregnant elephant into a Volkswagen? Getting the elephant pregnant in a Volkswagen. With the contraction over, I got the baby's head out slowly, rotated it, pulling it down to get one shoulder out and then up for the other shoulder, and suddenly I was holding a slippery mass. I almost dropped it trying to back out of the car. Thank God, just then the baby choked and started to cry. Not knowing what to do through all this, the father had been behaving oddly; he interrupted his audible anguish about the upholstery, which was pretty messy by now, to ask whether it was a boy or a girl. In the dark I couldn't tell. Must not be this guy's first child, I thought. I wanted to suck the newborn's mouth out with the bulb syringe, but the baby was too slippery to hold in one hand. Instead, I gave the infant to one of the nurses, with explicit instructions to keep it level with the mother, and, after putting on some clamps, I cut the cord. Then everyone— attendants, nurses, and father — helped lift the mother out of the car. The afterbirth came away without effort in the ER. I was amazed that there were no lacerations. The whole crew disappeared up to the obstetrics area.