The Intern Blues (2 page)

Preface

A
ll of the events described within this book actually occurred. Not all of them, however, involved the intern to whom they have been assigned here. In order to provide the doctors, patients, and staff with anonymity, some of the occurrences, patient contacts, and reactions have been altered or switched. As a result, some of the characterizations that emerge represent composites rather than actual portraits.

Additionally, the names of the hospitals, physicians, staff members, and patients have been changed. To render the interns even less identifiable, their physical characteristics have been appreciably altered. In spite of these changes, however, this is a work of nonfiction; the events and experiences described are all true.

This book would not have been possible without the cooperation of a large number of people. I'd like to take this opportunity to thank the faculty and administration of our pediatric program, the administrations of both the hospitals through which our interns and residents rotate and the medical school affiliated with those hospitals, the house staff who make up our program, and especially the interns who allowed me to just about live inside their heads during that very difficult year.

Finally, I'd especially like to thank the following people: my wife, Beth, and my children, Isadora, Davida, and Jonah, for putting up with the long hours I spent playing with my computer rather than playing with them; Pamela Altschul, editorial assistant at William Morrow, for her help and sharp insights; Diana Finch, my literary agent, for her encouragement; and Adrian Zackheim, senior editor at William Morrow and self-proclaimed “medical junkie,” who has been there to guide me through every step in the writing of this book.

Introduction

T
he stretchers arrived at the emergency room about fifteen minutes after I started my shift. I had barely had enough time to say hello to the residents and nurses on call when suddenly, out of the clear blue, three critically ill brothers were being wheeled into the trauma area.

We all immediately went running to the back to meet them. One of the Emergency Medical Service workers yelled out an abbreviated version of their story: “It's an apartment fire. The FD
[Fire Department]
pulled them out of the bedroom. We loaded them onto the stretchers and transported.” He further explained that the boys' mother was at that moment being wheeled into the adult emergency room. She was near death.

Apartment fires were unusual in May; they're usually winter events, when everyone's using space heaters to try to keep warm. But unusual or not, we swung into action. With very little discussion, we triaged them: The senior resident took the eight-year-old, who was semiconscious. The junior resident began to work on the six-year-old, who was the best off of the three: His vital signs were stable and he was awake enough to answer questions. And the two interns and I moved straight toward the ten-year-old, who was comatose; he wasn't breathing on his own, and his fingers and lips were beginning to turn purple. We knew we had to act fast.

By reflex, Amy, one of the interns, grabbed the black rubber ambubag and began to force oxygen into the boy's lungs while I went about gathering the supplies needed for intubation. I got a pediatric laryngoscope
[a light source with a metal blade at its end, designed to push away the tongue and illuminate the back of the throat]
and an endotracheal tube from the code cart. Meanwhile, Andy, the other intern, after listening with his stethoscope, had determined that the boy's heart wasn't beating. Without a word, he immediately began pumping the chest about a hundred times a minute. At that point I heard the announcement over the loudspeaker: “Attention, attention: CAC in the pediatric emergency room. Attention attention: CAC in the pediatric emergency room.” I was relieved to hear it: It meant that help was on the way.

After Amy had bagged the kid for maybe a minute, I nudged her away and got ready to do the intubation. I concentrated all my efforts on the back of that boy's throat. Holding the laryngoscope in my left hand, I placed the instrument into the patient's mouth and shifted it around until I could clearly see the vocal cords. Then I began to push the endotracheal tube through those cords. At first the tube slipped backward, falling down into the esophagus. I repositioned it and tried again. This time the tube slipped right through the cords and slid down into the trachea.

I was sure it was in, so I began to call for a piece of tape, but before I could get the words out, a healthy piece of the stuff was being dangled before my eyes. Anticipating my need, Amy had torn a supply and now all that needed to be done was to apply one end to the skin of the boy's upper lip and wrap the other end around the tube so it would remain steadily in place. It took me about a minute to secure the tube, and when I finished, I hooked up the ambubag and began to force oxygen directly into the boy's lungs.

As I compressed the ambubag, I began to take stock of the situation. The trauma area was now packed with medical personnel who, thanks to the loudspeaker announcement, had come running from all corners of the hospital. It was then that I realized that for the first time all year, Amy Horowitz, Andy Baron, and Mark Greenberg, who had answered the call for help, were all working together on a single patient.

Amy grabbed the ambubag and relieved me. Andy was continuing the chest compressions, while Mark was working on getting an IV into the boy's arm. He succeeded on the first try and was simultaneously hooking up the IV drip and asking one of the nurses for a shot of epinephrine, a drug that hopefully would help start the boy's heart beating again. Meanwhile, I began to attach the leads from an electrocardiograph machine to the boy's wrists and ankles, in an attempt to monitor the activity of his heart better. All this was being carried out without a word of direction from me. Each of us knew what had to be done and were doing it without any prompting.

It took nearly fifteen minutes to get that kid's heart started again, but after Mark had pushed in the second round of medications, electrical activity began to appear on the cardiograph paper. “We've got complexes,” I said when I saw them. “It looks like a normal rhythm.” The interns breathed a sigh of relief when they heard my words. Now comes Miller Time!

In another minute, the boy began breathing on his own. He was reasonably stable now, so we pulled back and took stock of what needed to be done. Amy volunteered to take charge of the boy until the intern from the ICU
[intensive-care unit]
upstairs came down to get him. His brothers, now also stable, and our patient went up to Jonas Bronck's pediatric ICU about a half hour later. After prolonged hospital stays, they each recovered and were discharged home. Their mother, however, wasn't as fortunate. She never regained consciousness and died later that night in the adult ICU.

Watching those three interns working together on that boy in such perfect harmony, with such confidence in their judgment and their technical ability, it was hard for me to believe that only eleven months earlier they had begun this internship. It seemed incredible that they were the same people who, when I had talked with them out on the lawn of Peter Anderson's house in Westchester County at orientation, had seemed so tense and uncertain and downright scared to death.

I had met Amy, Mark, and Andy at that orientation retreat at the house of the chairman of the Department of Pediatrics on June 26, 1985. All around us on the lawn, the exact same scene was being played out: Stretched out on the grass were groups of three or four new interns, each looking well rested and tanned from their month of vacation and each as tense as a turkey around Thanksgiving because of the year of torture that loomed ahead. Sitting with each group of interns was an attending physician, one of the senior doctors affiliated with the pediatric program, who would serve as teacher, mentor, and at times taskmaster to the new interns. We attendings were trying our best to convince these guys that the next twelve months weren't going to be as bad as they had been led to believe. In other words, we were lying through our teeth.

Over the past seven years, it had become traditional in the Albert Schweitzer School of Medicine's pediatric residency training program that the internship year begin with this orientation retreat. Regardless of what the day accomplishes, it's a nice idea, an opportunity for the thirty-five new interns to get to know each other in a relaxed atmosphere, to make friends with the people with whom they'll be spending every day and every third night over the next twelve months. The retreat also gives the interns a chance to meet the chief residents, the four physicians who are directly in charge of them, the people they'd have to turn to in times of crisis.

My first meeting with Amy, Mark, and Andy started out pretty disappointingly. I'd led small groups at these retreats for the past three years, and this one was definitely the hardest to get off the ground. The idea was to get the interns talking about their concerns so that they'd discover these concerns weren't unique, that the same fears were shared by each of their classmates. But for that to happen the interns had to talk, and so far they were keeping their mouths tightly shut.

I decided to cut through the small talk and take a more direct approach. “Look,” I began, “I know you guys must be scared to death. You're so nervous, I'm getting jumpy just sitting here. What are you so worried about?”

There was silence again for what seemed like hours, but it was probably no more than a minute. I was thinking I'd have to come up with some other tactic when Andy Baron suddenly spoke up. “I'll tell you what I'm worried about,” he said just loud enough to be heard. “I'm worried I don't know enough.”

“Don't know enough about what?” I immediately asked, overjoyed that somebody had actually said something.

Andy thought for a few seconds. “I'm worried that I'm going to get out there on the wards and be expected to know certain things that I just don't know. I don't know the kinds of things doctors are supposed to know.”

“What are doctors supposed to know?” I asked.

“They're supposed to know everything,” Andy replied without hesitation. “They're supposed to know what to do in an emergency; they're supposed to know what's going wrong when it goes wrong and what to do to make it better. I don't know any of those things. I never had to know anything that important when I was a medical student.”

“Doctors are also supposed to be able to do things like start IVs and do spinal taps,” Mark Greenberg said next. “I don't know about you guys, but if I were to go into a hospital today and do a spinal tap on a baby, I could be charged with assault with a deadly weapon. I'm not sure, but I don't think a criminal record is exactly what we're trying to accomplish here.”

“So you're worried that you don't know enough and that even if you did know enough, you couldn't do anything to help the patients because you don't have the technical skills,” I said. “Is that about right?” The three of them nodded yes. I wrote this down on a piece of paper. As group leader, I was supposed to act as a kind of anxiety scorekeeper.

“Look,” I began to explain, “if you think we'd expect you to come into this knowing how to start IV's and do spinal taps, and knowing what to do in a cardiac arrest, you're out of your minds.” Meeting blank stares, I went on: “All of us were interns once and we know how completely hopeless you are at this point. We know that all four years of medical school gives you is a basic foundation on which to build. Every medical school graduate knows a bunch of facts but very little practical information. You know all the complex physiologic mechanisms that are necessary for the digestion of food by the intestine, but you've never actually taken care of a patient with a malabsorption syndrome; you know how the glomeruli of the kidneys filter impurities out of the blood, but you've never had to manage fluids and electrolytes in a patient whose kidneys have failed. That's what you're going to do in this internship: learn how to put all these principles into practice. And while you're learning this stuff, we're not going to let you do anything that might even come close to hurting the patients. The only thing we'll ask of you over the next few days is that you somehow figure out how to get yourselves onto the wards without getting too lost. Anything more than that is extra credit. Now I'm sure that made you all feel a lot better, right?”

It obviously didn't, and they all fell silent again. “So what else are you worried about?” I finally asked. “Or is that it?”

“Well, okay, so maybe you don't expect us to be able to make decisions on our own, but there are a lot of other things we're going to be responsible for,” Andy responded after a bit more silence. I liked Andy right away. “I mean, starting Saturday, parents are going to be trusting us with their sick kids. They're going to expect us to take care of them and make them well. I'm worried I'm going to wind up betraying that trust.”

The other two considered this. “That's certainly a frightening thought for society,” Mark added. “People trusting me with anything.”

I added “Anxiety about responsibility” to my list.

“I don't know about you guys, but I'm worried about my home life,” Amy Horowitz said next. “I can understand worrying about doing a good job, but I've got a two-month-old baby at home. If I'm on call every third night and I'm exhausted the next night, that means I'm only going to have one night out of every three to spend with her and just about no days.”

I knew Amy from her days as a medical student, and of all the interns in the incoming group, she was the one about whom I was most concerned. “Who's going to be taking care of the baby while you're at work?” I asked.

“We have a baby-sitter during the day and my husband will be home every night,” she replied. “I've been on vacation since I delivered, and I've spent a lot of time with her. It's really going to be hard.”

The others considered this and were silent for a few moments. “Yeah, outside life, that's a problem for me, too,” Andy finally added. “I've seen what happens to interns. They don't have time for anything. They turn into boring, out-of-shape slobs, and I don't want that to happen to me.”

And I added “Anxieties about home life: No time for families, hobbies, or exercise” to my list.

We spent about an hour talking. Even though it started out slowly, our discussion rapidly picked up steam. The interns had some kind of chemistry that made them work well together. By the time Mike Miller, the department's director of education, finally called us to lunch, our list of anxieties covered nearly two pages.

Things had gone so well during the second half of that hour that at the end of our session I told Amy, Andy, and Mark about a project I'd been thinking about for some time. “I've thought about trying to write a book about internship,” I told them, “and I'd like you guys to help me with it. All you'd have to do is keep a diary and meet with me for dinner every once in a while. After some discussion, the interns agreed that they'd like to give it a try. Since one of their anxieties was that they'd lose touch with their nonphysician friends who had no understanding of what it was like to work a hundred hours a week and who therefore could not possibly sympathize with this lifestyle, they thought that a book about what an intern's life was like might be helpful to future interns. They decided that tape-recording their experiences would be the best method of keeping a diary.