The Intern Blues (36 page)

Mark

APRIL 1986

Tuesday, April 15, 1986

Well, I'm back from another wonderful vacation. I don't know what it is about me and vacations, but no matter how hard we try or how much in advance we plan, things always seem to turn out as if we were characters in one of those low-budget disaster movies.

This time Carole and I went to this beautiful hotel right on the beach in Cancún. It was a gorgeous place: great rooms, delicious food, and an amazing view. Everything would have been perfect, absolutely perfect, if two weeks ago hadn't turned out to be Mexican monsoon season. I didn't even know they had monsoons in Mexico, but I could have sworn that's what it was. We got off the plane at the airport in the pouring rain, and the rain continued the entire time we were there! An entire week of looking out the window at rain falling on a beautiful beach. Very exciting! And of course this place didn't have any indoor activities. Why should they have indoor activities? It never rains in Cancún, the weather's always perfect, isn't it? Sure it is, it's always perfect, except, of course, when I go there on vacation!

Everyone I've met since I got back to the Bronx has mentioned what a nice tan I got. Nice tan? There's no way I could have gotten a tan! There wasn't enough sun to get tan, the sun never came out, not for the entire eight days we were there! The only way my skin could have turned color is if maybe I started to rust. That must be what it is, I went away on vacation and got a nice rust!

Well, at least I got some rest. And I did get to spend a lot of time alone with Carole. That was very nice; we had a good time together. And I even got to read a book while we were away. An actual novel, not a pediatric textbook. It's the first nonmedical book I've read all year. It was getting to the point where I was starting to think I wasn't allowed to read any sentence unless it had at least one six-syllable word that had a Latin root in it. Reading this novel was tough at first. I'm so conditioned by reading medical stuff that I kept falling asleep after reading one paragraph. But I finally managed to get through it. I guess there's still hope for me.

Well, so much for my fond memories of our trip. It's now the middle of April, and the big news is there's only a little more than two months of this misery left. Yes, winter's over, the snow's all melted, the leaves are starting to appear on the trees, the addicts are starting to hang out on the street corners again, and the cockroaches are mating. I guess the cockroaches are always mating, but I swear, I got back to my apartment after flying back from Cancún and there were at least four times the usual number of roaches hanging around. We had managed to cut down the number remarkably for a while but now they're back in full force. It was an awe-inspiring sight, opening the front door, happy to be home after narrowly escaping being killed in the floods, and looking inside to see that my apartment had turned into Cockroach Heaven! I've been fighting the war ever since, but it looks as if they've definitely established a foothold. It's time to start thinking about moving out of the Bronx! I think Carole may ultimately win this battle. She's wanted me to get out of here for months.

I'm spending the last two weeks of the month in the OPD at Jonas Bronck. I've been on call two nights so far and it really hasn't been bad. We've left the ER at the stroke of midnight both nights, which is kind of amazing. We seem to be between seasons right now. Respiratory infection season has ended, and diarrhea and dehydration season hasn't started yet. At least that's what all the attendings keep saying to explain why it's so quiet. They talk about it like these diseases are sports. You know, in a couple of weeks I expect the chairman of the department to come down to the ER and throw out the ceremonial first diarrhea and dehydration patient to open the season officially. Well, whatever's causing it to be quiet, I'm not complaining. I just hope it keeps up.

I'm assigned to neurology clinic on Friday mornings. What a lot of fun that is! The clinic is held on the fifth floor of Jonas Bronck, and you get there at about nine o'clock and the waiting area is already filled with what looks like hundreds and hundreds of kids seizing and shaking and yelling at the top of their lungs. Every kid has a chart that contains at least five thousand pages, and you have to read the entire chart to figure out what the hell is going on. And because there are so many patients scheduled, you have to move really fast or else you wind up staying all afternoon. This is the first time I've been assigned to neuro clinic this year, and I'm glad I have only a couple of sessions there before the month ends. If I had to imagine what hell might be like, I don't think I could come up with anything worse than being permanently assigned to neuro clinic. Get the feeling that I'm not going to be a neurologist when I grow up?

Over the past few weeks, I've started thinking about what I'm going to do when I'm finished with this internship and residency. The more I think about it, the worse the headache I wind up getting. I can see the advantage of specializing in something, but I also can see the advantage of not specializing in anything. I could go right into practice after I'm done, or I could do a fellowship. So far the only thing I've definitely decided is to put off making a decision about this for as long as I can. It's really very early. I don't even have to start panicking until about next year at this time. I've got all the time in the world.

I'm also getting a little worried about July. In July I'm going to be magically transformed into a junior resident. I like the idea of not being an intern anymore, but I'm not so sure I like the idea of being a resident. I mean, residents are people the interns turn to when they have questions and concerns. Residents are figures of authority. For some reason, I can't seem to imagine myself as an authority figure. I can't imagine giving interns advice. I wouldn't trust advice I gave to myself. Of course, that sounds kind of ridiculous.

Bob

APRIL 1986

 

During the course of training, each doctor develops his or her own individual style of dealing with the family of a patient who has died. The evolution of this style occurs mostly through trial and error; with enough experience and having made enough mistakes, you gradually develop a method that makes both you and the family comfortable. There's no way this can be taught in a classroom or through reading books or articles.

Some doctors find that they feel most comfortable sitting down and having an open and frank discussion with the family, explaining to them in an honest and supportive way the events that led up to the death of the patient. This method is used most often by physicians who have had a lot of experience and who have a great deal of confidence in their skills. Young house officers have difficulty being very frank when discussing the death of a child with parents. Often there are many questions in the minds of the intern and resident about what actually led to the patient's death; they worry that they might have missed something important that could have saved the child's life, or that some task for which they were responsible was overlooked and contributed in some way to the patient's death. So interns usually don't feel comfortable having long discussions with the parents of a child who has died.

Some doctors overstep the traditional role of the physician and cry along with the parents of a child who has just died. This isn't necessarily a bad thing; the parents often appreciate the fact that their grief is shared by others who knew and cared a great deal for their child.

This style certainly described me as a house officer. While on the oncology ward in May of my internship, I cared for a twelve-year-old boy with leukemia. Tom's disease had been diagnosed the previous September, and coincidentally I had cared for him during that admission as well. Now we were both back on the ward, and on the first morning of the month, Tom was once again assigned to me.

It was a shock to see him after all that time. Back in September, he had been a strapping, healthy-looking young adolescent; by May he had been reduced to a wasted, comatose vegetable, unable to speak or eat or react to any outside stimulus. His mother, with whom I had become friendly during his first admission, stayed with the boy constantly during the time he spent in the hospital, guarding over him for what proved to be the remainder of his life.

I was on call the night Tom finally died. His vital signs had become very irregular during the evening; his nurse had called to tell me this news, and I had left what I was doing to come. We stood silently over him, his mother at the foot of the bed, the nurse to the left, and me on Tom's right, and we waited for his breathing to stop. That finally happened about an hour and a half after I had first entered the room. I was the one to declare him dead.

I had spent all that time in Tom's room not because I was his doctor; there was nothing I had learned in medical school or during my internship that could in any way have altered the course of events. I knew that, and Tom's mother knew that. I had stayed in his room because I was a friend; I had known him and his mother for nine of the most difficult months of their lives, and I was with them at the end out of respect for that friendship. I think my being there meant something to Tom's mother; I know it meant an awful lot to me.

But some doctors find that they can't deal with death at all. They equate death with failure, and they have trouble dealing with and accepting their own failures, and they have trouble dealing with and accepting their own failures. Once the patient dies, these physicians simply wash their hands of the whole affair. They leave the counseling of the family, the “mopping up after,” to others.

In the case of Andy Baron's little patient, it seems as if the child's attending fell into the latter of these three groups. Unfortunately, the job of talking to the parents fell to Andy and the other house officers who happened to be around. At this stage in his training, Andy is looking to people such as that attending to guide him through this process. I'm almost positive Andy did a good job with these parents; I know him well enough at this stage to understand how sensitive and sympathetic he can be. But still, the attending's absence at this critical time must have been very difficult for the house staff as well as for the parents, who were looking for answers that couldn't possibly have been given by anyone other than the attending.

I know it must have been difficult for the parents, because I've been on their side of the fence. Last year, my wife delivered a stillborn baby. Beth had started having what she thought were labor pains one evening about two weeks before her due date. We had gone to the hospital with all our stuff, figuring our baby was about to be born. When we got to the labor floor at University Hospital, a nurse listened to Beth's abdomen with a fetoscope, a special stethoscope designed to amplify the fetal heartbeat. She couldn't hear a thing. Without a word to either of us, she left the room, and about five minutes later, a resident appeared at the door, pushing an ultrasound machine in front of her. She introduced herself and told us that she was going to do a sonogram. And without saying anything else, she went about her work.

I've watched over five hundred fetal sonograms. I have a pretty good idea of what's occurring on the ultrasound machine's screen. And while watching the scan that the resident did, I could make out our daughter's head and her chest, her abdomen and her limbs, but I could not see her heart beating. After a few minutes of searching, the resident picked up the ultrasound machine's transducer, turned off the power, and said she'd be back in a few minutes.

“I didn't see the fetal heartbeat,” I said.

“I didn't either,” she said quietly, startled at my statement. “I'm going to call your attending.”

Beth and I sat in the room crying; no one came to explain what was going on or what would happen next. Finally, after about a half hour, Beth's doctor appeared at the door. He told us that it seemed as if the baby had died. He talked with us, answered our questions, and told us what the most appropriate management plan was. Since the labor pains that had begun this whole episode a few hours before had completely ceased, Beth agreed to wait until natural labor resumed, an occurrence her doctor assured her would take place within the next week or so. And so, devastated, we prepared to go home.

After leaving the labor room, we approached the nurses' station. The nurses and the resident who had done the ultrasound were having an animated conversation, laughing and apparently enjoying themselves, but as we approached, they became silent. I was used to this; I had been part of this kind of behavior, especially during my time in the neonatal ICU. But now I was experiencing it in a different way; Beth and I were the opposition now, and this behavior made our grief just a little bit worse.

I've learned something from this experience, and accordingly I've altered the method I use when talking with the families of children who have died. This isn't an experience I would recommend, but it did help me understand a little more about what goes through the mind of a parent whose child has died.

Andy

MAY 1986

Wednesday, May 7, 1986, 7:00
P.M
.

I finally finished Infants'. It was a horrible, depressing month. About a week after the baby with heart disease died, I had another patient who got very sick and had to go up to ICU. I intubated him myself. He deteriorated so fast, he almost died on the ward before we could get him up to the unit.

Now I'm in the OPD, and all the details are starting to blur. I suppose if I spoke into this thing religiously every day, I could tell you endless story after story about all the kids and their various problems. But what does it matter? It's all just a horrible blur, one after the next, made up of all these poor, sick kids.

Thursday, May 8, 1986, 10:00
P.M
.

It's become really hard to continue keeping this diary. Over the past few months I've lost touch with my inner self; I'm not sure completely why that's happening, but I think it's because I'm defending myself against all the bad feelings I've had about being an intern. It relates to a lot of different issues having to do with the general feeling of being abused and mistreated, and the fatigue and the sleep deprivation, and the death and the morbidity of my patients. So certainly that's one reason I haven't been talking. I'm out of touch with myself, and it's hard to know what exactly to talk about. The other thing is, the thrill and excitement and novelty are gone, and they've been replaced by a more realistic perception of what I think medicine is. And for some reason, there's something in me that doesn't want to relate all those stories about all the various patients. Talking about it makes me feel like I'm back at work, and I hate even to think about being at work.

Saturday, May 10, 1986, 4:10
A.M
.

I just spent the last six hours in the Jonas Bronck ER working on a fucking child-abuse case. I really hate them; I hate them more than anything else in this job. I think I've seen enough child abuse for an entire lifetime. I don't want to see any more, thank you. They never go well, they're always difficult.

This one, I just pulled the chart from the box, I didn't even read the triage note, and I called the kid in. She had a bandage on her forehead. Oh, great, I thought. A laceration. I asked what happened and the mother gave me this story that the girl was lying on the floor and playing and she bumped her head and cut herself on the hinge of her glasses or something weird like that and cut her forehead. I asked her to go over that again and the mother gave me basically the same story. So I took the glasses off the kid's face and I tried to find a way to make the hinge hit up against the forehead. I couldn't do it. The frames were plastic and they were totally intact. I thought, No way! No way the kid could have done this!

So I decided I'd better do a complete examination. I got her undressed, and lo and behold, she had big contusions across her back and across her upper right thigh. I just thought, Oh, fuck! You get a feeling down in the pit of your stomach when you finally figure out what you're dealing with, and I got it at that moment.

Then I examined her vagina, and it looked kind of red and smelled bad, and I thought, Oh fuck! again. To make a long story short, I reported the kid to the BCW and the cops as a suspected physical and sexual abuse case. And I had to fill out only about a thousand forms among the chart, documenting the living shit out of it, the BCW 2221 form, and the rape evidence kit
[documents and materials that will be needed when the case goes to court]
.

The whole thing was horrible. The parents were crazed; at one point they tried to take the kid out. They started to dress her and said they were going to take her to Washington Hospital
[a municipal hospital in the South Bronx]
. Give me a break! I called security at that point. Once I called security, that was it, they knew the jig was up. They knew they had been caught. Oh, man! It was horrible. I hate it. After I called security, I was shaking and nervous for a while because it's such a bad thing to have to deal with. I don't want to help take kids away from their parents! Kids don't want to be taken away from their parents; they love them even if they are horrible! So even though the parents have done something terribly wrong, I'm the one who feels like he's committing the crime.

Anyway, it takes so long to do everything, God knows what the kid's disposition will be. I don't know what to say. I hate it, I hate child abuse so much, I wish it never existed.

Wednesday, May 21, 1986, 9:30
P.M
.

It's been a typical wild month in the Jonas Bronck ER. I'm getting out of this month exactly what I wanted: I'm learning how to manage trauma, and I'm learning how to see multiple patients in a short period of time. I'm a lot better at it than I was; I'm still not able to be as accurate as I'd like to be, but I can see some improvement every day. I can be fast when things aren't too complicated; I still haven't gotten good at seeing a complicated patient and a couple of uncomplicated patients at the same time. But I have another week in the ER and maybe I can get a handle on that.

I can't remember anymore what I've talked about and what I haven't talked about. I don't know, there are so many stories, so many stories of frightened mothers and frightened children, sick children, and I don't know why, I just don't want to talk about any of it anymore. I've had some bad nights, I've had some good nights. I'm sorry . . . I'm sorry this is deteriorating. But the year's almost over, it's just another five weeks or so and I'll be moving back to Boston. I really need to start making arrangements. I haven't done that yet. I'll have to take a day off from work to get that squared away.

Everybody seems to be calling in sick all the time now. Except me. There's one intern in particular who's always calling in sick, or coming late to clinic. I'm thinking that maybe I'll fucking call in sick one morning and get everything arranged for the move. But I think maybe this is another fantasy of mine. I haven't missed a day of work yet this year and I probably won't start changing and calling in sick with so little time left. It pisses me off a lot when other people call in sick. It's totally irresponsible and everybody always winds up having to work a little harder to make up for the person who calls in sick, and that's not fair.

My clinic's going fine, and I have a couple of specialty clinics including renal, which I think I like a lot. I think I could actually do renal. I'm not sure yet, I'll have to try it again when I'm in Boston, but there are a lot of good things about it: It's interesting, it isn't a lot of hard work, and the people seem nice. I don't know, it's something I might be able to be content with for the rest of my life.

People have been saying a lot of nice things about me over the past few weeks. They tell me how much they're going to miss me and that I've added a lot to the program. A couple of the attendings have said that I'd make a good chief resident. That's all very nice and very flattering; part of me likes that fantasy of staying here and being asked to be chief, even though I know it's just a fantasy, and part of me now is very slowly, very slowly recognizing that I'm actually going to be leaving soon. I haven't started thinking of myself as being a resident in Boston next year; I don't have an emotional attachment to that program yet. I can see myself as a junior resident here much better than I can see myself as a junior resident there. I really wonder if I'll be ready for the demands of that place.

Next week I start my last month on 6A. My last month! My God! You know, this is going to sound tacky and very clichéd, but the year really has gone by fast. Two hundred ripped-off nights!

The chief residents' beeper party was today, and I missed it. I'd been looking forward to it for months. I even went out this morning and bought a blueberry pie to bring. Then I got stuck in the ER with a fifteen-year-old who got hit by a car and was dragged twenty yards. He was a mess; he had a basilar skull fracture, a hemotympanum
[blood behind his tympanic membrane, a sign of skull fracture],
blood in his urine, a laceration over the eye. I was fuckin' stuck with him and I missed the party but I learned a little about handling multiple trauma. I wanted to go so badly, I really was pissed off. One of the highlights of the year, and I missed it. Too bad. There'll be new chiefs the day after tomorrow. New chiefs: No more calling Jon, no more calling Claire, no more calling Arlene, no more calling Eric. I wanted to thank them, I wanted to thank them all, and now I don't know if I'll get the chance. I'll miss them, and I'll remember them. They were really great.

The tape's running out. So I'll stop now. One more month to go. One more month.