by Robin Cook
"Don't you like being an intern?" she interjected.
"No, not really."
She was again surprised. "Why not?"
"Basically I feel so tired, really exhausted, all the time. And yet I lack any sense of real usefulness. I realize most of the things I do could be done by someone without the training I've had. Plus I'm constantly scared, thinking I'll screw something up and look like a fool. You see, medical school didn't seem to prepare me very well at all." By now, the resolution of that afternoon to keep my mouth shut had dissolved in the intensity of the moment.
"Well, I think that's understandable. Medical school can't do everything," she said.
"It might be understandable from a distance, but when you're right in the middle of it, you don't understand what’s happening to you. And when I do stop to think, and realize that the four years at medical school were mostly wasted as far as taking care of the patients is concerned, and that I'm being exploited under the guise of learning, the psychological burden is too heavy. I just get furious at the system— the way medical school and internship and medical practice are interconnected — and at the society that supports it."
"Being furious is hardly the best attitude for a doctor to have," she added with coolness.
"I couldn't agree with you more, and I wish the establishment realized that, too. Eventually, you reach a point where you don't give a damn. Sometimes, after getting called on a cardiac arrest in the middle of the night, I suddenly realize that I wish the guy would die so I could go back to bed. I mean that’s how tired and pissed off I get. In a sense, I've stopped thinking about patients as people, and of course that only adds to the guilt."
Looking over at her, I could see her ethics creaking under the strain of my words. But I went on blindly.
"I suppose this business of not thinking about patients as people is the hardest to explain. Maybe a few doctors can empathize indefinitely. But not me. I can't take it. To survive now, I want to know my patients only as gall bladders or hernias or ulcers. Of course, I include in that anything about them that directly affects their basic disease process, and I believe I am becoming a good doctor technically, but beyond that I don't want to get involved. My system is not geared for it. I had this one patient named Roso, and I got so tied up with him that when he was discharged I was more relieved he was gone than I was happy he was alive."
The silence was icy. I stared into the sky, purposely looking away from her. Then I went on.
"Another thing. Very important. As an intern, I'm exploited the same as an underdeveloped country operating under mercantilistic relations with a colonial power. For instance, all I do in the operating room ninety-nine per cent of the time is hold retractors, often for the sloppiest G.P., who shouldn't be doing surgery, anyway. I'm there to be used. Anything I learn is in spite of the system, not because of it. And if I don't do what I'm told, or make too many complaints about the medieval system — pouf! — out goes my chance to specialize in a good hospital. So when I say I'm scared about making a mistake, I'm worried not so much for the patient — although that's partly it — but because I might get the boot and end up in some hick town giving typhoid shots. That's medicine's equivalent of the living death.
"And besides, a lot of very real and serious problems come up, which no one tells us about or even offers any advice. Like the emergency-room question of when you should try to revive a patient and when you should just let him alone. As interns with no experience, we're totally vulnerable about such things. And this is not entirely a medical problem. What about the ethics involved? If the person is revived and becomes a brain-stem preparation — and that means he is taking up a sorely needed bed in the ICU — then you've deprived somebody else of the ICU bed, someone else who might have a better chance. That's a godlike decision. Medical school never taught me to play God. And then all—"
I had been rambling on, looking out through the dark trees, putting these thoughts together for the first time. In some ways I was talking only to myself, and when I turned and looked at Nancy she exploded, stopping me in the middle of a sentence.
"You're an unbelievable egotist!" she said.
"I don't think so. I just live in the real world."
'To me you're an egotist — cold, inhuman, unethical, immoral, and without empathy. And those are not traits I look for in a doctor." She could really lay it on when she wanted to.
"Look here, Nancy, what I've told you is the truth, and it's not just my truth. I'm a composite of most of the interns I know."
"Then the whole bunch of you ought to be thrown out."
"Right on, baby! If you feel so strongly about it, why don't you organize a sit-in at the ER? Compassion's a cheap commodity when you get eight hours of sleep a night. Most nights I get less than half that much. The rest of the time I spend checking Mrs. Pushbotton's itchy hemorrhoids. Don't you moralize at me from your easy chair."
And so it went, ending with both of us steaming with anger. I left after a halfhearted promise to call her sometime.
Back in my geometric, all-white room, I lay fuming, all keyed up, with less than nine hours before the ER holocaust was to begin again. Sleep was clearly out of the question. I called the lab, and Joyce answered. Could she come by at eleven? She said she would, and I felt better.
Day 307
General Surgery:
Private Teaching Service
To an intern in medical practice during the latter half of the twentieth century, Alexander Graham Bell is the arch villain of all time. The blame, of course, must be spread a bit wider, to include not only the man who invented the telephone, but also the sadist who designed the ring. And then all those fellows working for Ma Bell who perpetuate the jangle— they're in it, too. How did hospitals function before the invention of the telephone? I often thought of myself, nowadays, as a mere extension of that little piece of black plastic. It was every bit as terrifying as the ambulance, and a good bit more sudden — always somehow expected in the back of my mind, and yet at the same time coming on me unawares. In all the world, there is no sound like it for disturbing the peace.
My peace just then consisted of falling gently asleep beside Karen Christie in her apartment after, I trust, a mutually satisfying encounter. When the telephone rang at 2:00 A.M., we both reached. I let her have it — not because it was probably for her. Since I was on call, it would more likely be the hospital night operator extending me an invitation to return to those corridors. But it might have been Karen's so-called boyfriend.
Indeed it was the hospital operator, who put me through to a nurse. "Doctor, would you come immediately? One of Dr. Jarvis's private patients is having trouble breathing, and Dr. Jarvis wants you to handle it."
Rolling over on my back, I stared at the ceiling and cursed inwardly, holding the telephone away from my ear. Dr. Jarvis I knew all too well. He was none other than our old friend the Supercharger, famous for his OR butchery, especially on breast biopsies. "Are you still there, Doctor?" the nurse intoned.
"Yes, Nurse, I'm still here. Does Dr. Jarvis plan to come in?"
"I don't know, Doctor."
Typical. Not only of the Supercharger, but of most private doctors affiliated with the hospital. The intern would go to see the patient, work up a recommendation, and phone the private doctor, who, of course, would tell the intern to do what he thought best. On most such occasions these guys didn't even bother with the amenities. One time I had spent about an hour going over one of the Supercharger's cases. When I called in my report. Supercharger had stepped out of his office and I had to leave a message with his secretary for him to ring me back. He rang back, all right, but to the floor nurse, not me. When she told him I wanted urgently to speak with him, he said he didn't have time to talk to every intern in the hospital. Rush, rush, for a few more bucks — that was the Supercharger's game.
Supercharger had another endearing habit. He admitted almost all his patients on the so-called teaching program. One might naturally think that
a teaching program would in fact teach, at least a little. God knows, we interns were in need of it. In practice, the teaching program was a grim joke. It meant only that I or one of the other interns did the patient's whole admission history and physical — the "scut" work. As a reward, we might be allowed to do the discharge note as well. But in between we weren't allowed to fool with the orders, and in the operating room our contribution consisted of holding retractors, removing warts, and perhaps tying a few knots, if the doctor was in a condescending mood.
The ultimate in Supercharger's gall had occurred earlier, on that breast biopsy, the one he mauled so badly. On the admitting chart, giving the particulars of the case, he had written a little note saying that when the house staff — meaning the intern — worked the case up, he was not to examine the breasts. Now, how was I supposed to do an adequate history and physical on a breast-biopsy case without examining the breasts? Farcical. And now he wanted me to pop over at two in the morning to straighten out another of his messes.
The nurse was still waiting on the line.
"Has the patient had surgery?" I asked.
"Yes, this morning. A hernia repair," she replied. "And he's not in good shape. The breathing difficulty has been going on for several hours."
"All right, I'll be over to see him in a few minutes. Meanwhile, have a portable X-ray machine brought to the room and get a chest film. And get me some blood for a complete blood count, and be sure there's a positive-pressure breathing machine and an EKG machine on the floor."
I didn't want to wait the rest of the night for that stuff. Maybe I wouldn't need it, but all the better if it was there anyway. When I got out of bed, Karen didn't budge. Not that it mattered. As I put on my clothes, I thought again what a convenience she was. Her apartment was just across the street from the hospital, even closer than my room in the quarters. It held all the creature comforts — television set, record player, a refrigerator well supplied with beer and cold cuts.
Karen and I had started seeing one another four months earlier, just after I had looked at her unusual pelvic X-ray the night she fell down the hospital stairs. Right after that she had been moved to a day shift, where we met again and started having coffee breaks together. One thing led to another, and going to her apartment became a habit — just about the time Joyce stopped being one.
Joyce, who'd been switched to the day shift, too, began wanting to play the tourist, make all the night spots. With that came some pressure to meet her parents and an increasing distaste for those surreptitious leave-takings in the early-morning hours. I tried to go along with her, but her roommate, the TV addict, was still there, and our relationship, which hadn't been very healthy to begin with, finally went completely sour. In any case, Joyce and I decided to cool it a while, to give ourselves a chance to think.
Karen did have another boyfriend, who continued to puzzle me. She saw him every now and again, perhaps two or three times a week, when they would go to a movie or even to a night club. She said that this fellow wanted to marry her, but she couldn't make up her mind. I didn't know him, or much about him, although we had talked once, briefly and quite by accident, when he phoned Karen's place. On the whole, I was not inclined to imperil a good thing by further investigation.
On my way over to see Supercharger's patient, I noticed that the night was unusually quiet, with almost no wind, although a low bank of clouds hung over the island, obscuring the sky. It had been raining hard all week. As I walked around to the west end of the hospital I glanced over into the ER, and the memory of my blind, exhausted bustle there came rushing back. I could see the usual clumps of activity, with people waiting and nurses appearing for fleeting moments in a seemingly disorganized jumble. It looked a little busier than usual for a Tuesday night, and I hoped that it would stay quiet enough not to require my presence. Whenever I got a night call from the ER, it usually meant an admission — probably surgery, and that could be bad.
The hall of the ward was deathly quiet and dark except for the little night lights that peeked out of the rooms as I walked briskly past them toward the nurses' station. The nurses' station was at the far end of the ward, and as I approached the light gradually grew brighter. It was a familiar sensation to me by now, walking down those dark corridors, the silence broken only by an undercurrent of hospital sounds— the light tinkle of an IV pole, an occasional sleepy moan — sounds that always made me feel I was alone in the world. Other doctors have told me of similar feelings. Actually, I had stopped analyzing the hospital and its effects on me as much as I used to, having become, in a sense, blind to my surroundings. Like a blind man, I took for granted the landmarks, the various doors and turns, and often reached my destination without noting my route or my thoughts along the way.
Some months ago the operator had called me in the early-morning hours for a cardiac arrest. I had gotten up, dressed, and run all the way over to the hospital before I realized that she had forgotten to tell me where the patient was, in which ward. Fortunately, I had guessed right about the location— through some sixth sense, you reached the point of being so routinized that when you were awakened you automatically plugged in the right information without being told.
This had its occasional disadvantages — as, for instance, on one of the frequent night calls to see a patient who had fallen out of bed. I made the automatic, insensate run to the ward and found him there, in good shape, of course. After calling his doctor, I left an order for an injection of Seconal, to be sure he'd sleep, and then plodded back to bed. All without ever coming fully awake. The same nurse called just a little later to say that the patient had fallen again, this time down a flight of stairs. So I got up again, plugged in the ward, and started off. In the middle of the journey, while climbing a flight of stairs, I stumbled across an inert mass lying on the landing. Standing there, dazed, I took fully ten seconds to reprogram myself to the fact that lying before me was the patient I had come to see. He should have been on the floor above! But, of course, he was where he was because he had fallen downstairs. Being totally limp during the fall, he hadn't hurt himself a bit. It turned out that all his shots — the painkiller, his antihistamine, his muscle relaxant, and my Seconal order — had been given simultaneously by the nurse and had taken effect at the same time, just as he took the first downward step.
I didn't always walk around in a fog. I simply developed an uncanny ability to continue sleeping while on the way to do some stupid job in the middle of the night. It was different when I got called for something serious, or when I was angry. But since our hospital suffered from an epidemic of patients who habitually fell out of bed, I learned to carry out that mission only half-awake.
The nurses' station seemed as bright as a television studio after that long walk in the dark. The nurse was effusively glad to see me and ticked off what she had done. The blood had been sent up and the X ray taken, and the EKG and positive-pressure breathing machines were both standing ready in the patient's room. I took the chart from her hand and scanned the work-up, which, of course, had been done by a fellow intern. A box of chocolates beckoned from the nearby desk, and I popped a couple in my mouth. Temperature was normal. Blood pressure was up and pulse very high. The rum-cherry centers were particularly good. I could find nothing to explain the breathing trouble. All seemed more or less normal for a recent hernia operation.
I turned back down the hall and retraced my steps almost to the end. Entering the room, I snapped on the light, illuminating a pale-looking man propped up in bed and forcibly inhaling with each breath. As I got closer I could see that he was quite diaphoretic, with beads of perspiration glistening on his forehead. He glanced at me for a second and then looked off, as if he had to concentrate on his breathing. Squinting, I realized I could see the apartment building next door, and Karen's window, the second from the right on the third floor. I wondered if she knew I was gone.
With my stethoscope in my ears, I pushed the patient forward and listened to his lung fields. The breath so
unds were clear — no popping, no crackles, no rhonchi, no wheezing. Nothing there. Perhaps his lung fields sounded a little high; that seemed to go along with the fact that his abdomen was swollen and rather firm. It was not tender, however. Listening to his abdomen, I heard the familiar, reassuring gurgles. The heart sounds were normal; he had no signs of cardiac failure. About all that remained was to see if his stomach was full of air. Gastric dilatation was a frequent problem after general anesthesia. I told the nurse to get a nasogastric tube, and meanwhile I hooked up the EKG machine. These EKG contraptions were a source of irritation to me whenever I tried to use one at night, with no technicians around to help. Since I could never seem to get a good electrical ground, the tracing would wander all over the page. But I got this one going okay by hooking the ground wire to the drainpipe of the sink, and I took a tracing while the patient lay there still puffing hard. The nurse had returned with the nasogastric tube before I finished with the EKG. As I greased the tube, I couldn't help thinking of that doctor sleeping away at home while I was putting in his NG tube.
One thing had stayed with me, even grown stronger, over the past ten months — the satisfaction in achieving a quick, desired result — and I felt relieved when I evacuated a large quantity of fluid and air from the patient's stomach. My relief was minimal, however, compared to his. He was still having some troubles, but his breathing was much easier. When he thanked me very much, it took him two breaths to get the phrase out. I listened to his lungs again, just to make sure that there wasn't any fluid in them. They were clear. His legs were normal, too, showing neither edema nor any suggestion of thrombophlebitis. Peeking under the dressing, I thought his incision looked fine, without excessive drainage. I told the nurse to get a suction machine for the NG tube and hook it up, while I went back to the nurses' station with the EKG.