So far, the weirdest story of the month has to do with Fenton, that GE reflux kid I admitted on Monday. I sat down and talked to his grandmother on Wednesday. She’s the kid’s caretaker; his mother’s about fourteen and is treated more like an older sister. Anyway, the grandmother told me this real bizarre story. She said he vomited everything they fed him when he was a little baby and she brought him to some hospital in Westchester, which we all finally figured out had to be Westchester County Medical Center [a teaching hospital affiliated with New York Medical College, in Valhalla, New York]. They worked him up, diagnosed the reflux, and did a fundoplication and a feeding gastrostomy [placing of a tube directly through the abdominal wall and into the stomach, to facilitate feeding while the esophagus is healing]. But he never seemed to get any better after the operation. The grandmother took him home but he kept vomiting whenever they fed him anything by mouth and got diarrhea when they gave him anything through the g-tube [gastrostomy tube]. She kept bringing him back to the hospital and they finally started him on continuous gastrostomy drip feedings [sort of like an IV, delivering small amounts of fluid throughout the day and night, into the stomach]. She told me that that was the only thing that seemed to work.
Well, none of this made any sense to any of us, including Dr. Gordon [the pediatric gastroenterologist]. There’s no way this kid could have so many problems and look so healthy. And the grandmother is a pretty suspicious character; she knows all the medical terms and the names of all the procedures. So yesterday we called the gastroenterologist at Westchester County Medical Center and he told us what really was going on. He said that the grandmother kept bringing him to the ER there with a history of diarrhea and vomiting but the kid never looked dehydrated. They admitted him a few times and he did have loose stools but for a long time they couldn’t figure out what was happening. Finally, during an admission about a month ago, one of the nurses found a bottle of laxative in the grandmother’s possession. They couldn’t prove it, but they’re convinced she was giving the kid the laxative in his bottle to make him have diarrhea. Amazing!
So today, while the grandmother was off the ward, we started the kid on regular feeds and he took it like a normal child. When the grandmother showed up, she got really angry and tried to sign him out of the hospital AMA [against medical advice], but we stopped her and slapped a BCW hold on the kid [the Bureau of Child Welfare can order a child retained in the hospital if the child’s well-being is endangered]. The grandmother went crazy but the social worker talked her down; the social worker handled the whole situation pretty damned well.
Well, there’s only about another week of this insanity left. I can’t wait. I’ve had about enough of this Infants’ nonsense!
Friday, August 23, 1985
I meant to record this yesterday, but I fell asleep as soon as I got home and I couldn’t do it. Wednesday was another classic night on Infants’. I’m beginning to lose my sense of humor about all this, which is a pretty serious problem. It’s definitely time to get off this ward. I’m going to OPD [Outpatient Department—the ER and Clinics] for two weeks and then I’ve got vacation.
Well, Hanson crumped again yesterday morning. He started stooling out again and got acidotic, and while we were trying to start an IV his heart rate dropped and we had to call a CAC [resuscitation for cardiac arrest]. We got him back but the chiefs decided he was sick enough to be transferred to the ICU, so we shipped him up to the sixth floor. Just like that! I don’t know, he’s fine as long as he doesn’t do anything to bother you. But the kid crumps at least once a week! He’s got to learn a lesson if he expects anyone ever to like him.
And Fenton is fine, absolutely fine. His grandmother has become a basket case, though; she simply can’t cope with the fact that he has no medical problem. It’s really weird. The grandmother told one of the nurses that she herself has had over twenty operations; she even had a CAT scan last week while the baby was in the hospital because she’s afraid she’s got a brain tumor. The nurse pointed out to us that she wears one of those plastic hospital bracelets as jewelry! The social worker has been trying to get her into some sort of therapy but the woman is resistant. I’m not sure, but I think it’s going to come down to either the woman gets some form of help or the baby is going to be placed in a foster home.
I’m on tomorrow for the last time on Infants’. I can’t wait to get it over with. Carole and I are going to go out for dinner Sunday night to celebrate. I’m really afraid I won’t find anything funny anymore. I really think I’ve lost my sense of humor on Infants’.
Bob
AUGUST 1985
Although I was a medical student at Schweitzer and did my residency at Jonas Bronck and the Schweitzer University Hospital, I was an intern at a medical center in Boston. I left the Bronx because it was suggested that I should see how medicine was handled at places other than those associated with the Albert Schweitzer School of Medicine. So I spent a year in Boston; I’m still recovering from it.
I did my first month of internship in the neonatal intensive-care unit of a maternity hospital that was affiliated with the program’s main teaching hospital. I arrived at work on the first day, a Saturday, and took sign-out from the old intern who had been on call the night before. After he left for home that morning, I was pretty much left on my own with thirty-five of the sickest premature babies you could possibly imagine. That first day of internship was definitely in the top ten of the most frightening days of my life.
When I started in that NICU, I knew absolutely nothing; the intern who signed out to me communicated in what seemed to be a foreign language. He spoke a hodgepodge of medical terms, slang, and numbers all mixed together. I just wasn’t ready for: “That’s a forty-five-hundred-gram IDM who aspirated mec and got PFC. We tubed him and put him on the vent with settings of twenty-five over five, 100 percent, and forty, and his last gas was seven point thirty, forty-four, and forty-five. He blew two pneumos so we put in tubes. He’s on DIOW at eighty per kilo per day.” I had absolutely no idea what any of this meant; I just wrote as much of it as I could on my clipboard, nodded my head to make him think I understood what he was saying, and hoped to God that the nurses knew what the hell was going on.
I eventually figured it all out. It didn’t take long before I could translate even the most complex of these monologues into English. (By the way, the intern was talking about a nearly ten-pound newborn whose mother was a diabetic. The baby had passed a bowel movement while still in the womb and had breathed in the contents of the bowel movement, causing severe respiratory and cardiac problems. He was being breathed for by machine, had too much acid and not enough oxygen in his blood, had had two episodes of collapsed lung, and was being given intravenous sugar water. That baby, one of my first patients, survived and did fairly well in spite of me.) And eventually I even became comfortable with the preemies. But that Saturday was terrifying for both me and my patients.
I spent August back at the medical center, working in their NICU. Although I was feeling more comfortable with preemies after my month at the maternity hospital, I encountered many other problems. First, two months in a row in a NICU is cruel and unusual punishment. Preemies, unlike older children and adults, don’t seem to understand the difference between day and night. They didn’t discriminate: they’d crump at any moment, morning, afternoon, evening, and in the middle of the night. As a result, when working in a NICU, it’s almost impossible to get any sleep during nights on call; you usually don’t even get a chance to see the inside of the interns’ on-call room.
Second, although the neonatologists will tell you that saving preemies is an exciting and exhilarating experience, to me the unit was an unbelievably depressing place to work. There were a lot of deaths, and although dealing with the parents of the babies who died was sad and difficult, it was even harder to care for some of the very tiny and extremely sick infants who didn’t die. These survivors often didn’t have a snowball’s chance in hell of leading anything resembling a normal
life. Yet we were ordered to do everything possible to keep them going, and their parents were often given unrealistic expectations about how their infant would turn out. That conflict between what was medically demanded and what seemed ethically correct took a toll on me and on a number of my fellow interns.
The third problem that struck me when I made it back to the medical center was that I felt alone. There were two reasons for this. First, all the other interns had met and become friends during July. By being farmed out to the maternity hospital, I had become “odd man out.” It took me months to make inroads into the cliques that had formed.
The other reason I felt alone was because my wife and the rest of my family were back in New York. In a situation almost parallel to Andy Baron’s, while I was off in Boston, my wife was a graduate student in New York. We would see each other only on those weekends when I had at least a full day off. Since that happened only two of every three weeks, there were long stretches of time when I was completely alone. Without friends and family, my life was miserable.
And miserable was the tone set for the entire year. I felt overworked, dead tired, conflicted by what I was being called on to do, and uncared for by the senior people in the program. And even though I had originally planned to stay in Boston for the three years of my training, I decided to leave the medical center after my internship. I made my first call to Alan Cozza, the chief of service at Jonas Bronck Hospital, asking for a job as a junior resident toward the end of August. By September I informed my chief resident in Boston that come the following July 1, I’d be moving back to the Bronx.
In retrospect, my experiences in Boston were not unique. All interns suffer during their internships. Although there might be some variations, the issues are pretty much the same for everyone. The main issue is the hours: Being on call every third night all year long makes it impossible to lead anything like a normal life. Regardless of how caring the people who run the program are, or how nice the city in which it’s placed is, or how much support is available from family and friends, interns usually spend a hundred hours or more per week in the hospital. And anytime someone spends that much time at their place of work, there are going to be problems.
But why do house officers have to spend so much time in the hospital? What do interns do all day long? To explain this, I should outline what a typical intern’s day is like.
On a typical day, most of the interns show up for work at about 7:30 A.M. They briefly walk around the ward, making sure that all their patients have literally survived the night. They check the vital-sign records kept by the nurses to see if the patients have had fevers or any other complications. Then, at about eight, work rounds begin. The ward team, made up of three interns, a resident, the head nurse, and the third-year medical students who are assigned to pediatrics that month; walks past each patient, reviews his or her progress and decides on a plan of action for the day. The interns must carefully note the plans for each of their patients; it is their job to make sure the plans are carried out, to order the tests, schedule the appointments, send off the lab specimens, and check on their results. It is at work rounds, which last until approximately nine o’clock, that the interns generate the “scut lists” that will occupy them for most of the rest of the day.
At nine, an intake conference occurs. At intake, all patients admitted the night before are reviewed with the chief of the service. This is a teaching conference, and a large portion of the house staff usually is present. The interns are expected to present their own patients briefly and, if recommendations regarding management are made, to add these to their usually already burgeoning scut lists.
Intake lasts until about nine-thirty, at which time an X-ray conference begins. At this conference, all X rays taken the day before are reviewed with the radiologists. This X-ray conference usually lasts until ten o’clock.
Then comes attending rounds, when the ward team meets with a member of the faculty. During attending rounds, admissions from the night before are focused upon, the presenting symptoms dissected, and the patients’ diagnoses discussed at length. The ward attending is the person who is ultimately responsible for the care that’s delivered, and so in addition to teaching about the conditions that afflict the patients, the attending must make sure that the proper things are being done in a timely fashion. Depending on how many patients were admitted the day before and how long-winded the attending is, rounds can go on until between eleven o’clock and noon. Every day at noon there is a didactic lecture on a pertinent topic in pediatric medicine. So, the average intern may not get down to attacking the scut list until after one o’clock in the afternoon.
Most interns will tell you that scut is the sole reason for their existence. Scut includes blood drawing, IV starting, the tracking down of lab results, the ordering of diagnostic tests, the calling of consulting services, and finally the writing of progress notes. Most of this stuff is sheer frustration and takes hours and hours to complete. While “running the scut” the intern also is responsible for teaching his medical student about pediatrics. Depending on how many patients he’s following, how efficient he is, and how many questions his medical student asks, the intern who’s not on call may get out of the hospital anywhere between three in the afternoon and nine o’clock at night, with the average being around six.
When they’re on call, of course, they don’t go anywhere. They stay all night, managing any complication that may arise in any of the patients on the ward and admitting all new patients who are sent up from the emergency room. Sometimes, when the emergency room is quiet and the patients on the ward are stable, the intern might be able to retire to the on-call room to get some sleep; at other times, when things are hectic, he or she might not even have enough free time to go to the bathroom. And the daily routine begins again at seven-thirty the next morning; even if the intern has gotten no sleep during a night on call, he or she is expected to participate in all the activities that occur during the entire postcall day.
This cycle is repeated every third night. Interns spend the first night in the hospital. The next night, when they’re postcall, they usually are unable to do anything other than go home and hit the sack. The final night in the cycle, the precall night, is the only one in which most interns feel alive enough to go out and have a little fun. But very often, the precall night is ruined by anxiety; lurking in the back of the intern’s mind when they’re precall is the fact that the following night may be a complete and utter disaster. And so, in a sense, even when they’re out of the hospital, there’s no escape.
The interns are also expected to carry out certain tasks that are not all that difficult when well rested but may prove to be impossible after a night spent on call without any sleep. Without sleep, an intern can lose track of the subtle social skills that are necessary for communication; as a result, talking to patients and their families can become torture. The intern also is expected to present orally, during attending rounds the next day, all the patients who were admitted during his or her shift. Keeping track of names, symptoms, physical findings, lab results, and treatments can become an insurmountable task when you’re having trouble just keeping awake. And screwing up a presentation can bring on the wrath of the attending, who is relying on the intern’s information, and a lowering of the intern’s own self-esteem.
This system of night call has come under a great deal of scrutiny in recent years. Public awareness, however, has not been focused on the toll that these long shifts are taking on the interns and residents, but rather on the toll that they’re taking on the patients. It’s been argued that a house officer who’s been up all night can’t possibly provide adequate care for critically ill patients. So, over the past few months, some alternatives to the current system have been proposed. The most popular of these would limit both the number of hours an intern or resident could work during a single stretch to twenty-four, and the number of hours worked within a single week to eighty.
On the surface, this seems as if it would
be a good situation, but some house staff members have expressed fear that new regulations such as these would actually make their lives more miserable. These house officers recognize the fact that to provide staffing of the wards and emergency rooms on a twenty-four-hour basis, hospitals would have two choices: Either hire 25 percent more interns, or have the existing interns work twelve-hour shifts seven days a week. Because of the lack of availability of funds to pay for a whole crop of new house officers, as well as the problem of finding qualified medical school graduates to fill these positions, people are worried that the second choice is the one that would be instituted. And almost everyone agrees that they’d much rather work thirty-six hours at a stretch and have a day off every week than work shorter periods every day of the week.
The only hospital in which the intern’s day deviates significantly from what I’ve outlined above is University Hospital. University is a hospital with a split personality. On the one hand, it seems like a laid-back, friendly community hospital nestled in a neighborhood of two-family houses; all the patients have private attendings (in sharp contrast to the two municipal hospitals, where the opposite is true), the nurses and the rest of the staff are like the boy and girl next door, and the pace is slow and relaxed. This makes University Hospital seem like a place you might actually like to visit during your summer vacation. However, the hospital is a major teaching affiliate of the Schweitzer Medical School and therefore is in reality a high-powered academic center. It’s the place where many of the full-time clinical faculty of Schweitzer admit their “interesting cases” for special studies. As such, the hospital contains patients with rare and often deadly diseases who need vigorous, round-the-clock management. Trying to fit these two personalities into the same building is not the easiest job in the world. And who suffers because of this? The interns and residents, as usual.
There are very few teaching conferences and much more free time at University than at the other hospitals. During the day, the interns work as glorified secretaries. Each patient’s attending really makes all the important decisions affecting the patient’s care, but attendings are not permitted to write in the nurses’ order book. The nurses are instructed to pick up and carry out only those orders written by an authentic intern. So any time an attending wants to change a medication or order a test, he or she must get hold of an intern and ask that an order be written. The interns rarely have the opportunity to argue with an attending’s request. They simply have to write down exactly what’s been dictated.
The Intern Blues Page 11
