The Intern Blues

by Robert Marion

  But Sunday night was one of the worst possible nights I could imagine. I was on with Larry, the senior resident, and we were both working our butts off. I spent most of the afternoon and evening doing shitloads of scut. At about one in the morning, I finished most of my work and went up to the well-baby nursery [the well-baby nursery, maternity ward, and labor and delivery suites are on the seventh floor of WBH] to try to finish all the physsies [physical exams; all well newborns must be examined within twelve hours of birth]. There were a lot of new babies, and I was plowing through them all. At about 3:00 A.M. I realized that the chart of the baby I had just examined was still over in labor and delivery, so I went over there to get it. Just as I got through the door, a nurse came running out of one of the labor rooms, yelling, “Get peds! Get peds stat!” She saw me and asked if I was from peds. I told her I was and she said, “There’s a little preemie just delivered right in this room.”

  Great! This was just what I needed at three o’clock in the morning. I thought, Oh, my fucking God, what am I going to do? I had never been alone with a new preemie. So I turned to the unit secretary, yelled at her to call Larry stat, and then I ran into the labor room.

  Lying at the foot of the labor bed was this little fetus. The midwife said, “I measured him. He’s twelve inches long.” [A baby’s gestational age in weeks is roughly equal to two times its length in inches. Therefore, this baby was probably at about twenty-four weeks of gestation.] The baby was tiny but he was moving and I didn’t know what the hell to do.

  Last week I had gone to the delivery room with the neonatal fellow to see a micropreemie who had just been born. We knew about that baby in advance and we knew that it wasn’t going to be viable, but the fellow had taken me to teach me about what’s viable and what’s not. That baby had no breast buds, his skin was gelatinous, his eyelids were sealed shut, and he was only ten inches long [all signs of extreme prematurity]. And the fellow said, “This baby is clearly not even twenty-four weeks; he’s not viable. There’s nothing to do for this baby.” So we didn’t do anything, and he died. And that had been my one experience with extreme prematurity.

  Well, I checked all those things out in this kid. I measured him, and sure enough, he was twelve inches long. I looked at the eyes and they were sealed and there were no breast buds and the skin was gelatinous and I thought that this kid couldn’t possibly be viable. Then I listened to his chest; he had a strong heartbeat, so I rethought the situation and figured maybe I was wrong. I didn’t know what to think.

  I decided to take the baby over to the warming table in the DR [delivery room; all delivery rooms are outfitted with resuscitation equipment for preemies] to see what I could do. Everything I knew was telling me that this baby could not possibly survive, but I just hadn’t had enough experience and I was all alone. I ran into the delivery room with the baby and I laid him down on the warming table. I realized I didn’t have any idea what to do next. I figured I’d try some oxygen: I grabbed the oxygen mask, turned the oxygen on and started to try to bag the baby, but the face mask was too big; it went over his whole head. I wasn’t having any success.

  Just then the baby kicked a couple of times so I listened to the heart again with my stethoscope. It was still beating pretty strongly. I decided that weighing the kid might help decide whether he was viable or not, so I asked the nurse to get a scale. And just then, as my panic was reaching its peak, Larry came walking in. Thank fucking God! I think I had been out of the labor room for maybe a minute by that point, but it had definitely been the worst minute of my life.

  I told Larry everything that had happened. He took one look at the baby and said, “Forget it. This kid’s not viable. Don’t do anything.” I was pretty relieved. I still felt bad because I didn’t even have a clue about what I was supposed to do, but at least I realized I hadn’t done anything that was harmful.

  Then the nurse came back with this rickety old scale; it looked like something out of the nineteenth century. We put the baby on it and it read twelve hundred grams. No way that baby weighed twelve hundred grams! She said, “Well, this is the scale we use to weigh all the babies.” Larry said, “Well, it’s wrong.”

  We wrapped the baby up in a towel and brought him back into the labor room. Larry explained to the mother that the baby was too small to survive but since he still had a heart rate, we were going to have to take him down to the NICU. The midwife started throwing a shit fit. She said, “You can’t take the baby downstairs! This baby belongs with his mother! You have no right to take the baby out of this room!” Larry told her that he wished he could leave the baby, but it was hospital policy that any infant with a heartbeat had to be brought to the NICU.

  Then Larry and the midwife started fighting about where the baby should be kept while we waited for him to die. I stayed out of it; I agreed with the midwife, but I wasn’t going to argue with the resident who had just rescued me. Finally Larry called the hospital administrator. She showed up, heard the story, and agreed with Larry. The midwife argued with her for a while but finally she backed down and we took the baby downstairs.

  When we got down to the NICU, we reweighed him; he really weighed only 460 grams. We put him in an isolette [also called an incubator—a Plexiglas box with a mattress and a heating element, used to house sick newborns] to keep him warm. I checked his heart rate about every ten minutes. Finally, after an hour, the heart stopped and I declared him dead. Then I went upstairs and told the mother that the baby had died. We brought him back up and gave him to her to hold for a while. She was exceedingly sad.

  Then I went downstairs and started doing more scut. At about seven o’clock all the new nurses came on, and they started yelling at me. They wanted to know why I hadn’t filled out the death certificate and gotten permission for an autopsy. They were being really hostile. I was exhausted and I’d had a horrible night; all I wanted to do was be left alone. I didn’t even know I was supposed to fill out the damned death certificate and get consent for the autopsy. Nobody told me I had to do those things.

  Finally, one of the nurses came up to me, and she was really nice. She knew I hadn’t done any of this stuff before so she showed me exactly what had to be done. She gave me the death certificate and the autopsy form and the form for burial. She told me that I should go up and talk to the mother and tell her that if she wanted a private funeral, it’d cost $600, and if she didn’t have the money, the city would bury the baby free.

  So I went back upstairs and talked to the mom, told her how sorry I was. I didn’t know what to say; I don’t have a lot of experience with this. I asked her if she wanted us to do an autopsy and she said no. She was really broken up.

  So I was up all night working pretty hard. Then today we rounded nonstop until one-thirty and then I had to go to my outpatient clinic. I signed out all my work. I saw five patients in clinic and that went pretty well. I got done by four o’clock or so and then I sat around and talked with my clinic preceptor, Ann Covington, for a while. I like Ann a lot. It’s nice to have someone calming like her to talk to.

  I went back to the NICU after clinic to finish my work. I got out at about eight and had to go to the bank and to the supermarket. The A&P closes at eight, so I missed it and now I can’t go shopping again for another three days. I’m totally out of food. I have to bring stuff home from the deli down the street if I want to eat dinner. It’s either that or going out every night. Fuck!

  Karen called last night; I guess it was after I had gone to sleep. I don’t even remember what we talked about. I don’t remember a word I said. We talked for quite a while, I think. It’s ridiculous. I hope she’s home tonight so I can find out what’s happening.

  So here it is, eight twenty-five on my good night, my one night out of three that I’m not either on call or postcall and I have nothing to do and I have to go to sleep in an hour, so I can get a good night’s rest before I’m on call tomorrow. I hate this! I think I’d really like the NICU if I weren’t so tired, but I’m tired all the t
ime. And you just don’t get any normal human contact in your free time unless you’re married or living with somebody. Even though I’ve made a couple of friends, they’re all interns and they’re either on call or tired. I really should be doing some reading about neonatology tonight, but screw it! I’ve got to get out of here!

  Friday, August 9, 1985

  I have a pretty nice white cloud right now [white cloud: good luck on call; black cloud: bad luck on call]. I still have only three patients. One’s just a grower [a preemie who has no medical problems except that he weighs less than two kilograms, the necessary weight for discharge from the NICU], and the others are pretty easy also. Poor Dina, the junior resident, she’s got five patients, three of whom are pretty sick, two of whom are really sick, both with NEC [necrotizing enterocolitis, a serious disorder of the intestinal tract]. I offered to take one of them but she didn’t want to give them up, I guess. I’m on tomorrow, so I know I’ll be picking up a sick kid who was born this afternoon, and I heard there’s another preemie on the way, so I’ll have at least two new ones to pick up. That’ll fill out my service to five. Not exactly a piece of cake, but still pretty easy.

  Boy, was I dumb on rounds today! Laura asked me a simple question about how much glucose I was giving one of my kids. Shit! I couldn’t remember how to calculate it; everyone was standing there staring at me. I felt like an idiot. Later on I finally figured it out. Rounds are generally good, Laura’s a great teacher, and except for when I’m making a dope of myself, I really enjoy it. Well, I’ve got to stop now, Ron’s here, and we’re going out to dinner.

  Thursday, August 15, 1985

  Being cooped up inside the NICU, you miss things and you don’t even know it. I was riding down to Manhattan in the train this evening, you know, there’s always something to look at, there’s always guys coming through, telling you their life stories, begging for money, never fails. Walking around Manhattan on the way to the theater, I was just looking at all the people. They were all well-dressed, there were some very pretty women, something I almost never get to see in the Bronx. I realized that after only two weeks, I already missed the excitement that exists in Manhattan.

  Today I got a call from Nelly Kahn, one of the social workers who works in the outpatient clinic. She told me she thinks I should report one of my clinic patients to the BCW. It was a mother who told me that she beats her kids with a strap when they act up. Ann Covington was right there, so I talked it over with her and she thought I should, too. So I had to call the mother and tell her I was reporting them. It really surprised me, she took it pretty well. Maybe it was like Nelly said, maybe letting us know she hit the kids was like her cry for help. I’ll never figure these mothers out.

  Then I called up the BCW, and they put me on hold for about twenty-five minutes! Twenty-five minutes, and I finally only got to speak to someone for five minutes. I was kind of surprised, the worker seemed really nice and friendly. I thought they’d be boring bureaucrats. All they wanted to know about was whether there were marks on the child. I told them there were and that we’d taken Polaroids of them. They said that was enough, they were going to start an investigation.

  Sunday, August 18, 1985, 2:00 A.M.

  I’ve been in the NICU every day now for two weeks solid (having been on call last Saturday) and I finally have a whole day off. The sick thing is, I’m thinking I should go in today for about an hour because there’s a workup I didn’t quite finish. It wasn’t really clear that I was supposed to be taking this one patient. It was one of those situations, I thought the resident was picking the patient up, then it turned out she wasn’t . . . I don’t know. So I may actually go in for an hour, just to finish that up, then I’ll split before anybody catches me there and asks me to do something else.

  It looked like Friday night was going to be really easy. All my notes were written early, and I was ready. It looked like I was going to get to bed by two in the morning, then things got complicated and then, around four o’clock, the deliveries started. Shit! Then it was just one delivery after the next. What do they do, wait until four in the morning to have all the deliveries? It’s always like that! So the bottom line is I didn’t get any sleep.

  Truthfully, I’ve only actually gotten the chance to lie down in the bed in the on-call room once since the first night of the month, and that was only for about fifteen minutes or so. It was last week, at about five in the morning. The bed was unmade, the room was a mess, but it felt great! I fell asleep right away but I got woken up about fifteen minutes later: This weird guy who must have been high or something was in the room with me. He was opening and closing the door and doing all kinds of weird things. I lifted my head up and yelled, “Who the fuck is that?” and he ran away. I got up and locked the door, but my beeper went off and that was it for dreamland. Oh, well.

  There were a couple of exciting things that happened the other day. There was a twenty-nine-weeker [born eleven weeks prematurely] who was an extramural delivery [born outside the walls of the hospital]. We got stat paged to the ER, so we went running down the stairs, and there’s one of the pediatric residents holding this tiny, tiny baby. The guy looked uncertain about what to do. So we took the kid, who was doing fine at that moment, and we whipped him upstairs and wound up intubating him [placing an endotracheal tube into his trachea so that direct ventilation of the lungs could be accomplished] and so on and so forth. And it turns out the mom’s a drug abuser. She claims not to use them intravenously, but who knows? So I might have gotten my first AIDS patient, although it’s a little too early to tell, but who knows?

  I went and talked to the mom later in the day. She doesn’t want the baby at all. It’s really sad. The father is nowhere to be found; when she was telling me this she got really teary-eyed.

  So I didn’t get out of there until six last night and I was just delirious. I’m not as good a doctor postcall as I am precall; I don’t think anybody is. You just can’t make as good decisions when you’re that tired. I think postcall, I function at about 80 percent, which is not bad, but that extra 20 percent, that’s got to be important sometimes. I think it’s really stupid, I just think this whole unbelievable call system is stupid because it really makes you . . . you’re just not as good! Don’t misunderstand me, I’m not so much complaining that I’m unhappy about having to take the abuse of being up all night every third night, I don’t like that, I don’t like the way it makes me feel, but the thing that really bothers me is I don’t think I can give as good care. If you’re trying to give the best care in the world, you should be able to work out a system where doctors can function at their best. Anyway, I’m sure this won’t be the last time I tirade about the evils of call.

  Monday, August 19, 1985, 6:45 A.M.

  I can talk only for a minute or two because I have to go back to work. I’m glad that I have only another nine days to go in the NICU and that I have only three more calls (one of which is tonight), because I don’t think I’m wild about neonatology. I can’t say it’s been a horrible experience, but I wouldn’t want to spend my life with tiny babies. There’re much more interesting things in pediatrics than little tiny critters.

  This morning I’ve been feeling kind of low; I’ve been missing Karen a lot. I talked to her yesterday morning, but she could talk for only a minute. I tried to call her last night, but she wasn’t home. I really feel cut off. I fell asleep thinking about her and missing her and I woke up this morning feeling kind of low and lonely. I never want to do this again, be apart from her for so long, never, never. I never want to feel this homesick for Boston again either. It’s eleven more days until Karen will be here, and she’s coming for a month. It’s going to be great, really great.

  In the meantime, nine of those days I’ve got to go bust my butt. So that’s what I’ve got to do. I’m on call tonight with Larry, the third-year resident in the NICU; I’m kind of glad about that. There’s a definite difference between the second-year resident and the third year; the third years let you do thing
s on your own; the second years hog all the procedures. So with the second year, all you do is scut, but when you’re on with the third year at least you get to feel a little bit like you’re doing something. And Larry’s a good guy; he’s a really fun guy, I’m sure we’ll have a good time.

  Well, I guess I gotta go. I’d rather go back to bed. But I gotta go . . . I know I’ll feel better about it when I get there; it’s always hard just getting there, though.

  Friday, August 23, 1985, 7:20 P.M.

  I’m in bed, and I’m going to go to sleep because I was on call last night and I didn’t get any sleep, and I’m really tired because I worked my butt off. It’s really ridiculous, this every fourth is crazy . . . I mean every third. I suppose I should have a lot to talk about . . . it’s all so much of the same shit . . . you know . . . creatinine, BUN, all that shit . . . it’s all gobbledygook. I’m going to sleep. . . .

  Saturday, August 24, 1985, 8:00 P.M.

  In another couple of days I’ll have finished my second rotation. Two down out of twelve and already, so early on, I feel tired. I’m not worn out, I’m not whipped yet, but I feel tired. I feel the effects of this every third night, it’s already wearing on me. And I already hate the system; I think it’s a stupid and foolish system that rules your life and hurts your patients. And already I’m losing some sensitivity toward people—you know, as hurting, suffering human beings.

  This morning when I woke up, I thought, What will I do with myself today? I got this fantasy; I thought about going back to my college, Princeton in New Jersey, and just spending the day down there. I figured I’d look up a couple of my professors and try to go see them. And then I got into the shower and the more I thought about it, the more appealing it got. I had it all planned: I’d go into the city and catch the train down to Princeton. I thought of all the beautiful green lawns and the tall trees reaching way up over the buildings, and about the flowers that would be in bloom, and the serenity and peacefulness of the place since there wouldn’t be any students there yet. I became entranced with the whole idea, how quiet and pretty and pastoral it would be.