The Intern Blues (33 page)

Larry came home from Switzerland yesterday. I told him a little while ago. He thinks it's wonderful. We're both very excited. We'd talked about waiting until I was a junior resident before we tried again. I'm about six weeks now, which means I'm due sometime around next November. Sarah will be only about eighteen months then. That's closer than we had planned. And it means that for the last year and a half of my residency, I'll have two babies to worry about instead of one. But what the hell? One thing I've learned over the past few weeks is that we have to do what's best for us, and I think having this baby is the best thing for me, for Larry, and for Sarah.

I'm not going to tell anybody about this just yet. A lot of things can happen. I had a miscarriage in my first pregnancy, and that can certainly happen again. And anyway, the chiefs probably are not going to be exactly thrilled when they hear about this. But I don't care. That's their problem. I really don't care what they or anybody else thinks.

I just hope I can make it through next month in the neonatal intensive-care unit! If I continue to feel the way I do now, it isn't going to be easy.

Mark

MARCH 1986

Sunday, March 16, 1986

It's taken me a while to get back to normal, but here I am, having as much fun as I had during the first six months of this nightmare. Yes, even though I came that close to doing a triple gainer off the top of Jonas Bronck Hospital just two short weeks ago, life's now become a barrel of laughs again.

This last month has really been pretty disturbing. I mean, I always had this idea that I was immune to getting depressed or something. I really didn't think anything could get me down. I guess I just happened to stumble on the secret recipe for major depression: You take one garden-variety intern, deprive him of sleep for a couple of months, make him eat take-out pizza every meal during that time, and force him to take care of the sickest babies on the face of the earth. Mix well and let him marinate in his own juices for three weeks. Then you collect the pieces in a body bag and send them off to the morgue. I guess I managed to interrupt the process right before I made it to the final step.

I really can't take credit for saving myself. Carole really did it. She took care of me, and I'm really thankful to her. Our relationship had been going down the tubes over the past few months. And it's all been my fault; I mean, I've kind of had other things on my mind, like sleeping and eating, and I haven't been paying much attention to her. So things hadn't been great between us. I was starting to have some doubts that our relationship would make it through the year; of course, I was also having some doubts that
I
would make it through the year, so my concerns about the relationship were not exactly at the top of my list of things to worry about.

Anyway, over the past few weeks Carole has just about moved into my apartment. She's somehow figured out how to get rid of all the cockroaches. I have to admit, things are nicer without all the wildlife even though they had kind of become my pets. She's been here every night when I came home from work and she's been really understanding, listening to me complain about everything imaginable, from how much I hate my patients to the fact that the West Bronx coffee shop was closed down by the Health Department because of “unsanitary conditions.” (The amazing thing is, that was the best coffee shop in the system. I guess mouse droppings and rat hairs really do make everything taste better.) I know I wouldn't have gotten back to normal, if you can possibly call what I am now normal, if it hadn't been for her being here when I needed her. Well, enough of this; it's starting to sound like a sermon or something.

So for the past couple of weeks I've been working in OPD on the west campus. It certainly has been a welcome relief compared with the neonatal eternal-care unit. I like the emergency room because it gives you the chance over a very short period of time to torture a large number of children who, if you're lucky, you'll never have to see again. That's a unique opportunity. It almost makes being an intern seem like fun. Not quite, but almost.

I was on call on Friday and it turned out to be Fascinoma Night in the West Bronx ER. Every patient who came in between the hours of 5:00
P.M
. and 8:00
P.M
. had some bizarre diagnosis or some record-breaking laboratory result. The very first kid I saw was this one-month-old whose mother said he had vomited every feeding since he was discharged from the nursery. Every feeding! Now, I immediately recognized that there was some sort of problem here. I mean, I may not be Sir William Osler
[a famous physician of the nineteenth century who was known for his legendary clinical acumen]
, but I do know it's not normal to vomit every single feeding of your entire life. At first, I was a little skeptical about the story. It's a little hard to believe something like that, so I asked the mother why she had waited so long to bring the kid in. She said she hadn't waited long at all, that this was the fourth time she had been in an ER, and that no one seemed to want to do anything to find out what was wrong with the kid. Okay, so then I figured the woman had to be a fruitcake or something. I mean, any doctor seeing a baby who had vomited every single feeding of his entire life would get very concerned and do something definitive, wouldn't he?

I guess not, because when I saw the baby, it became pretty clear the mother had to be right. I couldn't believe it. He looked like a baby concentration-camp survivor. He looked worse than Hanson did on Infants', which is pretty damn bad! This kid was a pound and a half below his birth weight, for God's sake! I did an exam and I didn't find anything. Then I sat and fed him for a few minutes. He seemed to do fine right away, but about ten minutes into the feeding he started to cry, and the next thing I knew there was baby vomit all over my sneakers. Great! So I ran over and got the attending and showed him my shoes and told him I thought the kid had pyloric stenosis.
[This is a condition caused by enlargement of the muscles at the junction between the stomach and the first part of the intestine. Because of the muscle enlargement, flow of partially digested food is obstructed, and once the stomach fills, the feeding is vomited. Pyloric stenosis is surgically repaired.]
He refused to help me clean off my sneakers, but he did come see the kid and we felt the abdomen, and sure enough, the kid had an olive
[a mass in the abdomen overlying the site of the stomach]
.

But the pyloric stenosis isn't what made the kid so interesting. What made this kid a fascinoma was the fact that because he was so sick, I sent off a blood gas to see how alkalotic he was.
[Because the infant with pyloric stenosis is vomiting stomach contents that contain hydrochloric acid, these children frequently manifest alkalosis, or lack of a proper amount of acid in their blood.]
It turned out he had a pH of 7.76, the highest recorded pH in the history of the pediatric chemistry lab at West Bronx. I think as a result of having my name on the lab slip as the doctor of record, I'm supposed to get a commemorative plaque or something. As a result of having the record-breaking pH, the kid is getting a no-expenses-paid trip to the ward at West Bronx for fluid and electrolyte therapy before the surgeons take him to the OR tomorrow to fix his stomach.

And that kid was just the beginning. A little later we got a call from one of the orthopedic attendings who told us that a patient of his was coming in. He told us, matter-of-factly, that the kid had been bitten by a horse. A horse! Where the hell is a kid from the Bronx going to find a horse to bite him in the middle of March? I mean, we're talking about the South Bronx here; this isn't the Kentucky Derby! So the story seemed a little peculiar to begin with. And then the kid showed up, and it got even stranger.

I didn't actually see the kid right away. I heard her first. The sound she made was very much like the sea lion tank at the Bronx Zoo around feeding time. And that was just her breathing! I walked over to see what was going on and the mother said, “Don't intubate her, she's got a problem with her trachea, she always sounds like this.” It was at that point that I started to get a little suspicious. It turned out, this was the orthopod's patient. She was this five-year-old with some horrible disease called metachromatic leukodystrophy, a really rare metabolic disorder. She was followed by one of the neurologists. So I'm sure this is the only case in the history of recorded medicine of a kid with metachromatic leukodystrophy having been bitten by a horse. At least having been bitten by a horse in the South Bronx during the month of March.

I have to admit, the story kind of piqued my interest, so I asked the mother how the kid got bitten. She told me the girl was involved in this therapeutic horseback riding program and she had been out for a ride that afternoon. At the end of the ride, the girl usually feeds the horse a carrot. She did it this time but she forgot to pull her hand away after the carrot was gone, and the horse, not understanding the difference between carrot and hand, continued to nibble. So she got bitten. Right; that made all the sense in the world. I'm glad she cleared that up for me!

Luckily, the kid wasn't too bad off. The horse had broken the skin on the back of her right hand a little, but it didn't look like any bones were broken. The orthopod came in and we did some X rays, which were negative. He put a dressing on the hand and asked me what antibiotic I'd recommend to cover the bacteria from a horse bite. Since I've had so much experience with treating horse bites in the past, I decided maybe I should look it up. You know, in all the pediatric and infectious disease textbooks I could find, not one of them even listed horse bites in the index! Unbelievable! It's such a common complaint, I thought there'd be long chapters on it wherever I looked. Anyway, we decided just to treat her with broad-spectrum coverage and see her back in a couple of days.

I go to talk to this kid's mother while we were waiting for the X rays to be developed and she told me the kid had been completely normal for the first year and a half of life and then started to deteriorate. She's been going downhill ever since. It's really a horrible story. There's nothing anybody can do to help her. It's only a matter of time now. It's really sad.

Anyway, so that was Fascinoma Night in the ER. And we didn't even get out late, which is probably the biggest fascinoma. I like nights like that. Maybe “like” is too strong a word. I can tolerate nights like that. They don't make me want to jump off the roof after I'm done with them.

I had this weekend off but I'm on again tomorrow. I've got to get some beauty rest now. At this point, I'm at least six months behind.

Friday, March 21, 1986

Things have been pretty quiet, but I was on call last night and something did happen that I really want to get down on tape. At about eight last night this one-year-old came in with a fever. I called him in and started getting the history. He looked really familiar, but his name didn't ring a bell. He was brought in by this woman who was his foster mother who said he'd spent the first five months of his life in the hospital. She said that she wasn't sure what exactly had been wrong with him but that he had been really sick for the longest time and that all the doctors were sure that he was going to die. It was then that I realized that I was standing over Baby Hanson.

Hanson! I only have to say the word and I get nauseated and want to run to the bathroom to throw up. But he looked great. That puny, disgusting, horrible bag of piss-poor protoplasm had grown into what looked like a fairly normal kid. He got taken away from his biological mother and placed with this foster mother in December, a couple of months after I had last seen him, when he was admitted to the ward at Jonas Bronck. The foster mother didn't know anything about the biological mother, so I don't know why he had finally been taken away from her. The foster mother had given him her last name, and that's why he was now Rodney Johnson.

It was amazing! He was sitting up, he could stand holding on, he wasn't even that delayed. He could even say a few words, although he couldn't say “crump,” which really should have been his first word. And he still didn't have a vein in him. I looked all over, just out of curiosity. Amazing! If you would have told me back in August that Baby Hanson could have grown up into this kid, I would have called a psych consultant for you. But there he was!

He only had an otitis
[ear infection]
, and I sent him out of there with some amoxicillin. But I learned something from seeing him. I learned that no matter how horribly disgusting and wretched a baby is, there's always a chance he could grow up into a seminormal child. I never would have believed it.

I finish in the OPD next week and then I go on vacation. Carole and I have decided to go to Cancún. We were thinking about going back to that hotel in the Poconos we went to during my last vacation, but Carole decided against it. She thought I had been tortured enough for one lifetime over the past few months. I still think that maybe we should go. I mean, if I go someplace nice and actually have a good time, how am I going to be able to come back to the Bronx to finish the last couple of months of this wonderful experience? But who knows? Maybe Cancún will be hit by an earthquake or some other natural disaster, just to keep me in shape!

Bob

MARCH 1986

 

In 1981, three reports of an apparently new disease appeared in a single issue of the
New England Journal of Medicine
. The articles described a series of patients who had become sick over the previous few years with some serious and unique symptoms. The patients shared a great deal in common: Each had been in excellent health before the appearance of the illness; each had developed pneumonia caused by
Pneumocystis carinii
, a parasite that only rarely caused problems in otherwise healthy individuals; many had also developed unusual malignancies, such as lymphomas and Kaposi's sarcoma; and, in retrospect, all were gay men. These articles, which at the time appeared to be the result of chance coincidence, would have incredible implications. They signaled the beginning of the age of AIDS.

The story of acquired immunodeficiency syndrome in children began at our hospitals. In 1979, two unrelated children were referred to the pediatric immunology clinic at University Hospital with serious, recurrent bacterial infections, including pneumonia. These children presented a puzzling picture of immune deficiency not previously seen in the pediatric age group. By the time those first articles on AIDS appeared in the
New England Journal of Medicine
, five children had been identified with symptoms that were identical to those reported in the gay men. In addition to their recurrent infections and immunological abnormalities, these five kids shared one common factor: All had been born to women who were drug addicts. And these women were also becoming sick, developing symptoms very similar to those of their offspring.

The widespread acceptance of the fact that AIDS could occur in children did not occur until 1983. But whether accepted as fact or not, by 1983 it had become clear to everyone working in the Bronx that something terrible was happening.

Although pediatric AIDS started with a handful of cases, by the mid-1980s a full-fledged explosion had begun. The Centers for Disease Control in Atlanta estimate that by 1990 a total of three thousand children in the United States will become sick with AIDS. Scientists who have watched the epidemic develop believe this figure is an underestimate.

What this means to those of us working in the Bronx is that there are many infants and children who are or soon will become sick with AIDS and who will ultimately die because of it. At this moment, there are currently ten to twenty children with AIDS and the AIDS-related complex hospitalized in Jonas Bronck, Mount Scopus, University, and West Bronx hospitals. These children are in the hospital for one of two reasons. Some are critically ill; these patients have serious infections, cancer, and chronic lung disease. They fill beds in the ICUs for extended periods, draining resources and causing the staff who care for them severe emotional distress.

Other children with AIDS who are hospitalized are not sick, at least not initially. These kids live in our hospitals because they have no place to go. Their parents are drug addicts, many of whom have become sick themselves, and some have died. Grandparents and other family members have abandoned them; they've become pariahs because of their disease. Although some manage to escape from the hospital for some short period of time, most members of this group wind up living out their short lives knowing no home other than a steel crib in a three-bedded room at the back of 8 East or 8 West at Jonas Bronck Hospital, knowing no family other than the nurses, house officers, and medical students who provide their care.

But these hospitalized patients are only the tip of the iceberg. There are over a hundred sick children in our system currently being followed by the immunologists. Another hundred have already died. And these numbers are growing daily. Unless a cure is miraculously found, all these children will presumably die.

There's no question that AIDS has altered every aspect of modern medicine. It has radically changed residency training in virtually every specialty, including pediatrics. When I was an intern, there were few deaths on the pediatric wards. In fact, one of the reasons I chose to specialize in pediatrics was because children tended to recover from illnesses. But thanks to AIDS, all that's changed.

Amy, Mark, and Andy, as well as every other intern and resident in our program, have each been involved with at least one sick and dying AIDS patient. Over the past couple of years, about one child with AIDS has died every month. Occasionally the death seems almost like a blessing; these children are alone, with no loved ones; they are comatose, lingering on day after day in a vegetative state, with no hope of survival. But most of the time the death of a child, any child, is a tragic, deeply disturbing, and anxiety-provoking event for the house officers, nurses, and other staff members who care for the child and who stand by helplessly watching, unable to do anything to alter the course, as the child grows sicker and weaker until he or she ultimately dies.

But the inevitability of the death of the patient is only one factor that's changing the way house officers approach their charges with AIDS. The second and perhaps dominant force is tied to our current knowledge of the way in which the human immunodeficiency virus, the agent that causes AIDS, is transmitted. House officers know very well that if they stick themselves with a needle that has been in the vein of an HIV-infected individual, they can become infected. And becoming infected is equivalent to a death sentence.

When I was an intern, we drew blood, started IVs, even did mouth-to-mouth resuscitation without giving it a second thought. We knew of few risks and little harm that could come to us from stabbing ourselves with a needle or breathing in secretions from a patient who had had a respiratory arrest. Now it's mandatory that all house officers wear gloves whenever sticking a needle through the skin of any patient, regardless of whether the patient is thought to have AIDS or not. This increased use of gloves has caused a worldwide shortage of rubber. New types of gloves advertised as being resistant to HIV are being marketed. In the emergency rooms, nurses have been issued goggles to be worn over their eyes when around a patient who is bleeding profusely. Some residents don surgical gowns and masks just to enter a patient's room. And forget mouth-to-mouth resuscitation! What was once knee-jerk reflex is now something that house officers, with good reason, try to avoid at all costs.

Even though these precautions are being taken and everyone is being very careful, there is still a great deal of fear about AIDS within the ranks of our house staff. I went out for a couple of beers with Andy Baron one night early this month. He looked terrible: He has lost at least ten pounds since the start of internship, and he was barely able to keep his eyes open. It was pretty clear he was depressed. During our third beer, he let me in on why: He's convinced that he's infected with HIV. “I've stuck myself with so many needles, there's no way I don't have it,” he explained.

I told him he shouldn't worry so much, that every intern and resident has stuck himself or herself multiple times over the past five years and so far nobody's tested positive for HIV. Andy replied that the key phrase there was “so far.” He's sure that it may not be today and it may not be next month, but within ten years he and most of the rest of the interns in his group are going to wind up coming down with AIDS.

“How do people get AIDS?” he asked. “Drug addicts get it from contaminated needles that have been used by people who are infected with the virus, right? If we stick ourselves with needles that have been stuck into the veins of children who are infected, why shouldn't we get it? We're no different from drug addicts. We don't have any magical protection.”

There's really no way to argue with his reasoning. I think it's pretty safe to say that at this point in the year, most of the interns would agree with Andy. This fear of AIDS has definitely changed the way the members of the staff approach patients. And it's not something that will go away or change in the near future. AIDS is here, apparently to stay.