The Intern Blues

by Robert Marion

  Then I got out of the shower and as I sat around thinking, I realized that I wasn’t going to go to Princeton, it was all just a fantasy. My professors weren’t going to be around, they were going to be out of town on vacation. And I couldn’t just go and hang around there. I just wanted to escape from the difficult times I’m having right now into the past, when life was easier, when I didn’t have to worry about all the diseases and falling asleep on attending rounds, the jaded attitude of some of the residents, the oppressed lives my patients and their mothers lead, the crummy neighborhood I live in and the fact that I’m far away from my loved ones. I think this’ll blow over. When I finish this year and my residency and I’m just a practicing doctor when my hours are more regular and I’m more used to the responsibilities, it won’t be so bad. I don’t have any control over my life now, and that’s very difficult.

  I know I’m just saying this stuff over and over again, but it’s just so difficult! I knew internship was going to be hard, everybody tells you that, you see the interns work their butts off, you know it’s hard! But somehow you don’t believe it. I was trying to tell my friend Maura about being an intern tonight, she really wanted to know. I told her a little bit, I told her a story, and then I just shook my head and all I could say to her was, “It’s just really hard.” I was thinking, Why am I trying to explain? I don’t want to explain anymore, I don’t want to tell anybody about this, it’s just too crazed.

  Amy

  AUGUST 1985

  Tuesday, July 30, 1985

  University Hospital is a strange place. I’m not really sure what I’m supposed to be doing there. I’ve got about eight patients, but none of them is really mine. Everyone has a private pediatrician, and the attendings are the ones who run the show. So we make rounds in the morning and decide what we’d like to do on each patient and then the attendings come around and tell us what we’re really going to do. Having us there seems pointless. It doesn’t make any sense.

  We started yesterday and I got out at about three in the afternoon. Then today, I got home at three-thirty. All you do is eat lunch, write progress notes, and leave. My patients don’t keep me very busy. I’ve got this eight-year-old named Oscar who was in a car accident or something last year. He had a really bad head injury and was in a coma for months. They had to trach him [perform a tracheostomy: create an opening into the trachea, or windpipe] because he was on a ventilator for three months. He’s much better now, although he still needs a wheelchair, and ENT admitted him to take out his trach tube. He’s been in the hospital for two days so we can watch him breathe, and he’ll have to stay for another day or two. Very exciting!

  My only really sick patient is this six-year-old renal transplant kid. He was born with dysplastic kidneys [abnormally formed and nonfunctional kidneys], and he’s been in renal failure his whole life. They did the transplant yesterday morning using his mother as the donor. He was sick as a dog all last night and most of today but I couldn’t even get near him! The renal service is running the whole show. Occasionally one of them will talk to me, to tell me what scut they want me to run. I probably could be learning a lot, but I can barely squeeze myself into the room!

  This whole place is depressing! My patient is the newest of four transplant patients on the floor. The other three are all in some phase of rejection [rejecting the transplanted kidneys]. It’s a real pleasure to go into their rooms; they all want to die because they know that if they continue to reject, sooner or later they’re going to wind up back on dialysis.

  Of my eight patients, there’s only one who’s anything like a regular pediatric patient. It’s a three-week-old FIB [fever in baby; all infants under two months of age who are found to have a temperature of 100.6° or greater are admitted to the hospital, have blood work and a spinal tap, and are treated with antibiotics]. When she came in, I tried to do the workup but I had trouble getting the blood; I stuck her three times and I couldn’t get a drop. I know I’m not great at drawing blood so it didn’t bother me but then I called Diane Rogers [the senior resident assigned to the ward that month] and she tried five or six times and couldn’t get anything either. Diane got very angry, as if not getting the blood was a personal insult. Finally Dr. Windom, the baby’s private, came in and tried and he couldn’t get it either. We wound up just treating her as if she were septic [had an infection in her blood]. Windom told me to send off urine for viral cultures [a method of determining whether a viral infection is present]. What a waste of time and money! There’s nothing you can do if it’s viral, and besides, those cultures take at least two weeks. The baby will be completely better by the time we get the results back. But if that’s what he wants, then that’s what he’ll get. I had enough trouble last month with attendings. From now on I’m just going to do whatever anybody says and not protest at all.

  I was on in the ER for the last time Sunday night and it was pretty quiet. Larry took Sarah with him to his team’s last softball game. They made it into the league’s semifinals but they got beaten and Larry’s depressed about it. I can’t get over how good he is with Sarah. But Sarah is a good baby. She really has developed a personality. And she’s growing like a moose! I took her to see Alan Cozza [the chief of pediatrics at Jonas Bronck Hospital; he also is Sarah’s pediatrician] yesterday for her three-month checkup; she weighed twelve pounds, two ounces. She’s gained over five pounds in three months. Alan said everything was fine. He told me we were doing a good job with her, that she seemed like a happy, contented kid. I think she is, too. I’m happy that my internship doesn’t seem to be doing her too much harm.

  Monday, August 5, 1985

  I could take a whole year of University Hospital. It’s almost like being on vacation. I’ve been on call twice so far and I got about six hours of sleep both nights. That’s more than I usually get at home. And things have been quiet enough for Larry and Sarah to come visit me while I’m working. They spent most of Saturday afternoon at the hospital and they even had dinner with me in the cafeteria. There are almost never emergency admissions at night, and on days I’m not on call, I’ve been getting out by three in the afternoon.

  The other two interns have been having a pretty easy time, too, but they haven’t been leaving as early as I have. They stay until at least five. They don’t have more work than I do, they’ve just been hanging around, spending time teaching their medical students and basically just looking for things to do. When I’m on call, I tell them just to sign out and go home but they won’t do it. I think they feel guilty about leaving early, like it’s a sign that they’re goofing off. It’s not goofing off; it’s more like survival.

  I’ll tell you, even if I didn’t have a baby to get home to, I wouldn’t want to stay at that hospital any longer than I have to. The place is so depressing! My patient Ricky, the six-year-old boy who got his mother’s kidney, stabilized last week and the renal team finally let me into his room. He’s a nice kid; he’s very small [the effect of his chronic renal failure], maybe the size of a three-year-old, but he’s smart and he’s got a good sense of humor. I talked with his mother who was discharged from the hospital on Thursday [she had been hospitalized for removal of her kidney]. She and her husband have been through hell since Ricky was born. Now, because of the transplant, they were hoping their lives might finally get back to normal again. But then over the weekend, Ricky’s BUN [blood urea nitrogen] and creatinine started to rise. [BUN and creatinine are measures of renal function. Elevations imply that the transplanted kidney may not be functioning well.] Renal decided today that he was in acute rejection; they had me order a renal ultrasound and started him on ATG [Antithymocyte globulin, a drug designed to prevent the immune system from making antibodies against the foreign kidney]. The renal attending told Ricky’s mother this afternoon and she started to cry and of course then Ricky started to cry. The whole thing really upset me, so I was glad I was finished with my work. I just packed up and came home.

  One of my other renal patients is a twenty-year-old wi
th Down’s syndrome [a condition caused by an extra chromosome that leads to mental retardation and other abnormalities] who also happens to have chronic renal failure. He’s extremely high-functioning for a Down’s patient and he understands everything that’s happening. He came into the hospital last week because his BUN and creatinine were going up. He had had a cadaveric transplant [his transplanted kidney had come from a dead donor] a year ago, and they thought he was in rejection. They scheduled a biopsy [a procedure in which a needle is passed into the donor kidney and some tissue is removed; the biopsied material is analyzed under a microscope for signs of rejection] for Friday and told me to make him NPO [nothing by mouth] starting at midnight the night before. Well, of course they didn’t say a word to him about the biopsy, and when the breakfast trays showed up on Friday morning and he didn’t have one, he started to yell. I had to tell him they were going to do a biopsy. Nobody from the renal team had the decency even to talk to him about it!

  The biopsy was done and it did show signs of rejection, so they rolled him back to the ward and started him on ATG, too. I’ve got five patients on ATG now. The drug doesn’t seem to cause any harm, so having all those patients on it isn’t making my work any harder, but since it’s only given to patients who are in the process of rejecting their transplant, there’s a lot of misery attached to giving it. This ward is filled with gloom and doom.

  Things with Marie have calmed down. She and I have been on good terms since I changed services last week. I think she’s relieved I’m not coming home for lunch anymore. And I don’t think she minds very much that I’ve been sending her home early two out of every three days. So, all in all, if things keep up like this, I don’t think I’ll mind the rest of my internship. Of course, I doubt that it’ll keep up like this!

  Tuesday, August 13, 1985

  I was on call last night and I’m tired. It was my hardest night so far this month and I got only an hour and a half of sleep. Ricky’s been really sick. He had to go back to the operating room yesterday because of complications. I really thought he was going to die.

  I guess he started to go bad last Thursday night. He started complaining of belly pain. His mother told me about it when we were on rounds on Friday morning and I told her I’d check with renal but I forgot to mention it to them. I was on Friday night and he seemed to be in pretty good spirits even though his BUN and creatinine had gone up a little. He did complain that his belly was hurting a few times but whenever I examined him, I couldn’t find anything wrong. He slept well and didn’t get a fever or anything, so I just forgot about it. But I guess the pain got worse on Saturday afternoon and his mother told Margaret Hasson, the intern who was on call, about it and she examined him and found that he was tender all over the place and that his belly was distended. She called the renal fellow and he told Margaret to get a CBC and a sed rate and another BUN and creatinine and that he’d call ultrasound and try to arrange an emergency renal scan. Margaret said he seemed to be a little better when she went back to draw his blood, so the renal fellow wasn’t as concerned when it turned out he couldn’t get the scan done because there wasn’t a technician available during the weekend.

  Things got worse again on Sunday afternoon when the third intern, Janet, was on call. Ricky’s belly became very distended again, he was complaining of more pain; now he had pain shooting down his leg. The renal fellow came in and got all the information together. He found out that Ricky’s urine output had steadily dropped over the past couple of days, so he called Dr. White [the renal attending] at home and discussed the whole thing with him. Dr. White must have called the radiology attending at home because within an hour there was somebody there to do an ultrasound exam. They found that the kidney looked fine but that there was some problem with the ureter [the tube connecting the kidney with the bladder]. Dr. White thought that Ricky’s ureter had detached itself from his mother’s kidney and that the kidney was making urine that was slowly leaking into the abdominal cavity and causing the pain.

  This was an emergency, so Janet called the urology resident and he came to see Ricky and agreed with what Dr. White had said. The resident called the urology attending at home and the urologist refused to come in! He just refused to come in; he said it wasn’t such an emergency that it needed to be fixed on a Sunday night and that he’d be in the next morning to assess the situation and, by the way, that it probably would be a good idea to keep Ricky NPO and pre-op him [do everything necessary for surgery]. By this point Ricky was in intense pain and his temperature went up to 102, so Dr. White was called and he went nuts! He called the urologist at home and they yelled at each other for a while, but the result was still the same, the guy wasn’t going to come in until the next day. Since there was nothing he could do about it, Dr. White called Janet, told her to start Ricky on broad-spectrum coverage [antibiotics to cover a wide range of possible bacteria] and pain medication. It was terrible; his mother and Janet and Ricky’s nurse were up all night with him.

  Then finally, yesterday morning, the urology attending showed up. By the time we started work rounds on the floor at eight o’clock, Ricky was on his way to the operating room. I saw him before he left; he looked terrible. His belly and his right leg were tense and swollen. It turned out he had so much urine in his abdomen that some of it had worked its way down into his leg. It was a real mess. He was in the OR four or five hours. First they had to clean out all that urine. Then they had to reattach the ureter to the kidney and make sure it was working okay. He spent another three hours in the recovery room and he didn’t get back to the ward until after four in the afternoon. The renal fellow and I were with him all night. Plus I had four new admissions to work up, nothing serious, just more pre-ops for tomorrow. It was far and away the worst night for me at University Hospital, and now I’m exhausted. I couldn’t even eat dinner. Larry fed the baby and took her out for a walk and I’ve just been lying here, not able to get out of bed.

  I don’t think I’ve ever seen anybody as angry as Ricky’s mother. Most of the parents at University Hospital are weird. They’re very private, and they protect their privacy and that of their children. I guess it’s understandable, since so many of them are chronically sick and wind up spending so much time in the hospital with all these doctors and nurses and medical students and other people constantly going in and out of their rooms. So they give you a really hard time when you have to do something and it makes you feel as if you’re intruding into their space. Ricky’s mother is different. She’s friendly and she likes to have company in the room. But she’s been seething since she found out the urologist refused to come in Sunday night. She’s sure the delay in getting Ricky to the operating room is going to cause permanent damage to the kidney, her kidney, the only kidney she can give to her son. Dr. White told her he didn’t know what effect this would have, that only after everything’s back to normal will we be able to figure out what’s what. She was still livid when I left the hospital this afternoon. I hope everything works out all right. But in the meantime, Ricky’s on about a hundred medications, he’s still NPO, and he’s still really sick. There is at least one good sign: His BUN and creatinine from this afternoon were down.

  I can’t stay awake any longer. I’m going to sleep.

  Monday, August 19, 1985

  It’s been a good week. I’ve been getting sleep, I’ve been coming home early, I’ve been spending time with Sarah and Larry. I can’t complain.

  The other interns on the team seem depressed, and I can understand why. There just aren’t any normal children on this ward. Very few of these patients wind up being normal at any time during their lives. There’s almost no hope here. On rounds yesterday, Janet said there were two kinds of patients at University Hospital: the ones who cry when you stick them for blood and the ones who don’t. She said the ones who cry are bad because they make you feel guilty when you stick them. But the ones who don’t cry are much worse because they’re the ones who know that crying isn’t going to do them any good.r />
  I know what she meant and I know that if I were to hang around the hospital as much as she and Margaret do, I’d be depressed, too. But I can escape; I’ve got Sarah to run home to. And that makes everything a lot better.

  Here’s an example of what we have coming into this place: When I was on last Thursday, I got a five-year-old girl with intractable seizures who was coming in to have her anticonvulsant medication manipulated. She had metachromatic leukodystrophy [a rare inborn error of metabolism caused by deficiency of the enzyme arylsulfatase; the disease leads to severe neurological abnormalities]. Metachromatic leukodystrophy: You know how many of those there are in the world? Maybe a dozen. And one of them comes waltzing into University Hospital to have her seizure medication changed. She’s still on the ward. She’s on five separate anticonvulsants and we’re raising one and lowering another. So far I haven’t seen any real change in her. She could wind up staying in the hospital for months.

  Her story’s frightening. She was completely normal for the first year and a half of her life, and then her mother noticed she was getting clumsy. She started falling down a lot and losing her balance. She took her from doctor to doctor until she saw Dr. Rustin [a pediatric neurology attending] who made the diagnosis immediately. And now she’s a GORK [an acronym for “God only really knows”] with an intractable seizure disorder.

  The first thing I thought about when the mother told me the story was, Can something like that happen to Sarah? I mean, she seems completely normal now, but who knows what might happen next year or next month or next week? Who knows? Thinking about things like this can drive me crazy! I find myself doing it a lot. Every time I admit someone with something strange I think, Can Sarah get this? It usually doesn’t stay with me for long, I can shake it pretty fast, but when it happens, it’s like a wave of terror passing through me. I don’t even want to think about it.