The Intern Blues

by Robert Marion

  The mother told me the boy was running around the apartment and had fallen and hit the back of his head on the coffee table. He hadn’t blacked out but had become very sleepy. I examined him: He was sleepy, but then again, so was I. There were no focal findings. [A focal neurologic exam, one in which there is weakness, paralysis, or abnormal reflexes on one side of the body, indicates a neurologic deficit. A negative neurologic exam following head trauma is a fairly good indication that the brain hasn’t been harmed.] The senior resident told me it was okay to send the kid home, but when I went to give the mother a head trauma sheet, the kid suddenly couldn’t remember anything that had happened over the past few hours. So the senior told me to check the kid out with the neuro fellow [the pediatric neurology department trains a group of fellows, individuals who have completed two years of residency and have gone on to do another three years in neurology]. It took him twenty minutes to answer his page, and when he did and I told him the story, he told me he had to check with his attending [the senior doctor on call for neurology that night] before deciding what to do.

  It took him another forty minutes to get in touch with the attending! There I was in the ER in the middle of the night with nothing to do but wait. I could have been home sleeping! But I couldn’t sign this out to the night float. I had to stay.

  When he finally called back, he said the kid needed a CT [CT scan: a computerized X ray of the brain] and that he had to be admitted. I had to bring him up to the fourth floor and help the technician get him settled on the CT table. Finally, the intern from the ward showed up and I got out of there. I didn’t get home until four-thirty. If I hadn’t picked up that last chart, I would have gotten about two hours’ more sleep.

  Thursday was July 4 and I had the day off. It was great: just me and Larry and Sarah. We went swimming in the pool at our apartment complex; Sarah seems to love the water. It was like getting reacquainted.

  I had another run-in with Marie on Friday. I’m still having trouble with her. Even though we had a talk, she still carries Sarah around all the time and feeds her every two hours, as soon as she opens her mouth and lets out a peep. We got into a fight last Monday. I came home for lunch after clinic ended at about eleven-thirty. When I came into the apartment, Marie was holding the baby. I tried to take Sarah, but Marie wouldn’t let go of her. I just about had to pry them apart. I said a few things I probably shouldn’t have said. I don’t know what’s going to happen with her.

  I think having a baby at home is making me into a more efficient intern. I find myself trying to get my work done as quickly as possible and running home. Sarah gives me a lot of motivation to work fast.

  Friday, July 12, 1985

  I feel bad talking about this, but I think I should anyway. Maybe it’ll make me feel better to get it off my chest; I don’t know. I feel terrible and it isn’t my fault, it just isn’t my fault. I did what I was supposed to do, that’s all I know, and somehow I got into trouble.

  Last week, this adolescent girl came in complaining of rectal bleeding. I recognized her from my subinternship [a two-month rotation in the fourth year of a medical student in which the student works as an intern, taking night call and admitting and following patients]. She was on the ward for some psych problem, I don’t remember exactly what. I examined her and did a rectal exam; I didn’t find anything wrong, and the stuff I smeared from the glove onto the guaiac card was negative [the guaiac test is for hidden blood in the stool]. So I thought she was a crock [a patient who has nothing wrong and is faking symptoms; short for a “crock of shit”; sometimes referred to as a “turkey”]. I presented her case to Tom Kelly, who was the attending, and I told him . . . I told him . . . I’m sorry, I have to stop for a minute and pull myself together. Crying is not the answer.

  Sorry. Anyway, I told Tom I thought the girl was lying. He told me that very well might be the case, but that I should draw some blood for a CBC [complete blood count: a blood test that measures anemia] and a sed rate [erythrocyte sedimentation rate, a test for inflammation or infection, in this case used to rule out inflammatory bowel disease, which is a cause of rectal bleeding] anyway, to rule out any real problem. I agreed with him and I went back and got the blood. I sent the CBC to the lab and spun a hematocrit [a direct test for anemia] myself. It was fine—37 or something like that. I forgot to get the sed rate, though. I just . . . it slipped my mind. The girl . . . she was making me crazy while I was taking the blood and I just forgot about it. I did it, I don’t know why they don’t believe me. . . . I’m sorry, please forgive my outburst.

  A few hours later, Tom got it in his head that I hadn’t taken the blood. I don’t know why. He didn’t come to me directly and ask. He checked with the clerk and she told him she didn’t remember sending anything off to the lab. Then he called the lab and they denied ever getting a CBC on the patient. Then he called the girl at home and asked her if anyone had taken blood from her and she denied it. And then he came and confronted me with all this and accused me of having lied about the whole thing. I don’t know . . . I did it, that’s all I can say. I don’t know why the lab didn’t get it. The girl’s crazy, so I can understand her saying I didn’t take it. I don’t know. . . .

  The worst part of this is that now everyone knows. I didn’t do anything wrong, I swear it, but all the ER attendings are talking about it. Some of the residents know. Nobody’s going to trust me, I know it. I’ve been crying for the past three days. I’m on tomorrow and I can’t let this affect me. I have to go on and just ignore this. But how can I do that?

  Wednesday, July 17, 1985

  Things are a little better today. On Monday, Jon Golden [one of the pediatric chief residents; the chief residents are responsible for the house officers; they directly manage the patients, make up the on-call schedules, and look after house staff morale] came to talk to me. He told me he had heard about what had happened in the emergency room and he assured me he didn’t believe it and that I shouldn’t let it bother me or interfere with my work. It was nice to talk to him, it made me feel much better, but it’s sad to think it had reached the higher-ups that fast. Even though we’ve got so many interns and residents, this is a small department in terms of gossip. You have to be really careful what you tell people.

  Then yesterday, Tom Kelly talked to me in the ER. We cleared the air. He apologized for the story getting around. I understand it in a way; the ER attendings at Jonas Bronck are all close friends and they have to talk to each other about something! Anyway, it looks like this storm has passed. Now if I could only straighten things out with my baby-sitter.

  I’m still having trouble with Marie. I don’t know what to do about her; she’s very good but she’s got her own ideas about things and there isn’t anything I can do to change her. It comes down to two options: Either I try to live with the way things are, or I let her go and try to find someone else. I don’t think it would be very easy to find a replacement for her right now. I barely have enough time to eat; I don’t think I can afford to go through another round of interviewing. So, I guess I’ll have to keep her. It could be worse.

  I wonder what the other interns are doing with their free time. I mean, I spend all my time away from the hospital with Sarah. I never talk to anybody outside of work.

  Friday, July 26, 1985

  Yesterday was a terrible day. I was on call. I seem to be on call every night! But yesterday was worse than usual because it was Sarah’s birthday. She was three months old and I wasn’t there to see her. In the last couple of weeks, she changed into a real person. She doesn’t just lay in her crib anymore: She can lift up her head and look around and she smiles when she sees me. She’s got a beautiful smile. It’s great coming home to see her. I just wish I could spend more time with her!

  We were really busy all day and I couldn’t seem to do anything right. In the afternoon, I had this four-year-old who came in with a high fever and chest pain. She was coughing and congested and I was sure she had pneumonia. I listened, and sure enough, I
heard rales [a crackling sound in the lung fields, usually associated with pneumonia] in the area of the right lower lobe. I sent her for an X ray but it turned out normal, no evidence of pneumonia. I went to the attending, Harvey Abelson, for help. He examined her and said he didn’t hear any rales but he found that she had right CVA tenderness [tenderness over the costovertebral angle, the area of the back that overlies the kidneys] and told me to check the urine. Sure enough, the urine was loaded with bugs [bacteria] and white cells. I gram-stained it [a test to identify the type of bacteria causing the infection] and found E. coli [the most common bacterial cause of urinary tract infections]. She had pyelonephritis [an infection of the kidney], not pneumonia. She needed to be admitted, and I had almost sent her home! I’m just about finished with my first month of internship, and I think I know less now than I did when I started.

  I didn’t get home this morning until after four and I didn’t get much sleep. I’m exhausted. But what can I do? This is the way internship is, and I’ve just got to survive it. At least I’ve got tomorrow off. Then I’m on again on Sunday for the last time this month. Larry’s team has a softball game on Sunday, so he’s going to take Sarah with him. Thank God he’s so good with her! He takes her everywhere he goes when I’m on. I don’t know what I’d do if he weren’t so understanding or helpful. If I do make it through this year, it’s because of Larry.

  I start at University Hospital on Monday. I don’t know what that’s going to be like. I’ve heard bad things about it. I don’t care if it’s hard or boring or whatever. All I care about is getting out at a reasonable hour.

  Mark

  JULY 1985

  Friday, June 28, 1985

  My internship officially starts tomorrow. I’ve waited for this day a long time, years, the way people wait for their arteries to clog up enough for them to have a heart attack. I’m starting on 6A, the ward at West Bronx. I talked to some of the old interns and they told me that 6A was a pretty horrible place to work, that the nursing stinks, the lab technicians were impossible, and, on a good day, the clerical staff mostly just ignored you. Sounds like my kind of place! I like a challenge like that. It’s just what I need, a little more aggravation. And of course I’m on tomorrow night, the first day of the year. Just my luck; I’ll probably also be on call every holiday and the last day of the year as well.

  At least orientation’s over. It was a lot of fun, if your idea of fun is hanging around a bunch of terrified lunatics who are just figuring out that they’ve made a terrible mistake in their career choice and have ruined their entire lives. It really wasn’t that bad; at least the food was good.

  It’s funny, my coming here to Schweitzer. I worked with AIDS patients in New Jersey during med school and I became pretty convinced it was a disease I didn’t want to experience personally. So I was looking for a program that didn’t have a lot of AIDS patients, and Schweitzer didn’t exactly top the list of places meeting that criterion. I went on some other interviews and got a look at some of the other programs and suddenly the Bronx didn’t look all that bad to me. So whatever happens during this internship, I can’t blame anybody but myself; it’s all my fault.

  Carole wasn’t all that happy about my coming here. I guess I should mention Carole. We’ve been going out off and on since we were seniors in college. She’s an accountant in Manhattan and she lives in New Jersey, so my being in the Bronx is probably the worst thing that could happen to our relationship. We’ll probably never get to see each other over the next year. Not that it would be much better if I were working in Manhattan. It’s pretty hard to keep up a reputation as Mr. Romance when you’re working a hundred hours a week. Oh, well; being an intern is probably going to be like becoming a monk; except monks have a stronger union, I think.

  Well, I’m going to try to get some sleep now. I’m sure I’ll wind up walking around the apartment half the night. I’ve got all these butterflies in my stomach, and it feels like they’ve just organized a softball game.

  Monday, July 1, 1985

  What a great idea it is to start new interns on Saturday! What better way to greet someone who’s not only completely new to the hospital and doesn’t even know where the bathrooms are, but also who has never worked as an intern before, than to have him cover a ward filled with twenty-five sick patients, none of whom he’s ever seen. I wonder who came up with that brilliant stroke of genius?

  Needless to say, Saturday was a complete disaster. I started off the day just nervous, but by the time we finished work rounds at about ten, I was completely petrified. I mean, they had kids with meningitis who could die without batting an eyelash, kids with asthma who were on oxygen, and they were telling me to do things like “Get a blood gas on that kid” [blood gas: an analysis of the acid, oxygen, and carbon dioxide levels in the blood; usually performed on patients in respiratory distress]. “Check the X ray on that kid,” “That other kid needs a new IV,” etc., etc. I had to sit down for an hour after rounds, just to talk myself out of quitting right then!

  I have to admit, the technical stuff is about the only thing I can do. So I started off by drawing all the bloods and starting the IVs that were needed. Then I was heading for the lab, wherever the hell that was, when I got called down to the emergency room to pick up a patient. And that was the first time I got lost. I couldn’t believe it, I wound up wandering around in the basement of the hospital for twenty minutes, having no idea where I was. I found the morgue, I found the Engineering Department, but the ER seemed to be missing. I had this medical student with me, but he wasn’t much help; this was the second week of his first rotation and he was more confused than I was, if such a thing was possible. We finally found a guy down there who spoke English and I asked him where the ER was. He laughed at me for a few minutes and then told me I was on the wrong floor, it was one flight up.

  Anyway, my first admission was a six-year-old with asthma. My first admission. What a moment! I wanted to have the kid bronzed so I could hang him from my car’s rearview mirror, but his parents wouldn’t give their consent. I managed to find my way back to the ward with the kid, who didn’t seem all that sick, and then I got yelled at by the head nurse: “You have an admission? Nobody told me about any admission! We’re not ready for an admission!” So I made a mistake, but she stood there, blocking the door to the treatment room like she wasn’t going to let us in. What’d she expect me to do, bring the kid back down to the ER and call and tell her I was coming up with him? The way things were going, I probably would have screwed up, gotten off on the wrong floor again, and wound up bringing the kid straight to the morgue (at least I knew where that was).

  Well, I finally apologized, told her I wouldn’t let it happen again, and she let us into the treatment room. There really wasn’t much to do for the kid except take a history, do a physical, and write an order for aminophylline [an asthma medication]. Even I could do that! So it only took me about an hour to finish, and then I tried to get up to the lab but I got called back to the emergency room for another admission.

  This went on all day. I got one admission after the other from about noon until after seven at night—six admissions in all. By that point I had a lot more lab tests to check and finally made it up to the thirteenth floor [the laboratory floor at West Bronx] at about eight. It took me an hour to check all those labs. Then I came down and had to show them to the senior resident and he told me what to do next. So it was about nine o’clock, I had gotten six new patients, I had done most of the scut that had been signed out to me, but I had missed three complete meals, I hadn’t even had a chance to pee (it was about then that I felt the top of my bladder hitting my rib cage). And that’s when all the IVs started falling out.

  I don’t know what it was, but all of a sudden three nurses came up to me at once and told me that an IV had come out on one of her patients. Three IVs at once! It seemed to be too much of a coincidence. I went to find the senior resident to ask him if it was possible that the nurses were pulling them out to torture me.
He said it definitely was a possibility but there was nothing I could really do about it and, no matter what happened or what I was thinking, I’d better not get into a fight with any of the nurses or my life would be ruined. I told him about what had happened when I had brought up my first patient and he just sighed and shook his head.

  I got two more admissions in the middle of the night and more IV’s fell out and there was more scut to do and I didn’t get a chance even to lie down but somehow I made it through and nobody died. So I guess, all in all, I’d have to say it was a successful night. My only problem is, I don’t ever want to be on call again!

  Well, after a night like that, at least today was pretty good. I met our team’s senior resident, and he seems great. His name is Eric Keyes and he’s got a weird sense of humor. Then I met our attending, Alan Morris, who’s director of pediatrics at West Bronx. He’s very serious and kind of stiff, but he also knows a lot and I’ve heard he’s great.

  I didn’t get out tonight until after nine. I was trying to get my work done, but I kept getting lost around the hospital. I’m really hopeless. I’m going to have to get better organized.

  Saturday, July 6, 1985

  I am definitely on the chief residents’ hit list. I’ve been on 6A for a week now, and everything seems to have settled down. I’ve finally figured out where everything is; I know where the admission forms are kept and where the lab slips are stored. I’ve found the ER three straight times without getting lost. I liked the people I was working with. I even made up with the nurses; I brought them a box of cookies on Tuesday, and amazingly, no IVs fell out when I was on call Tuesday night. Everything was going fine and then, yesterday, just when I was really beginning to feel comfortable, one of the chief residents came up to me and said they’d decided to transfer me to the Children’s ward at Mount Scopus. I told her I didn’t want to go, that I was having a really good time on 6A. She said she was sorry but they were a body short on Children’s and there was an extra person on 6A that month (because we had a subintern) and there was nobody else who could be pulled. I argued a little more, but I could see there was no way I was going to change her mind. Finally I just gave up. So after figuring out 6A, I had to move over to a completely different ward in a completely different hospital, pick up a whole new group of patients, learn where the Mount Scopus labs are and where the forms are kept, and I have to meet a whole new group of nurses and probably go through another night of IVs falling out. Terrific!