The Intern Blues

by Robert Marion

  Realizing that I now was going to have the gargantuan job of informing this mother that her daughter, a child herself, was going to have a baby, I told Brenda to get dressed and sent her out to the waiting room. I started the conversation awkwardly, asking if Brenda had begun to get her period yet and whether she had a boyfriend. Finally, after beating around the bush long enough, I blurted out the news to the woman.

  She wasn’t surprised. She told me she had seen her daughter’s clothes get tight and had noticed that her breasts had become swollen. Then she told me an amazing piece of news: She knew who the father of the baby was. He was Brenda’s fifteen-year-old brother, the person who was entrusted with caring for the girl after school when the mother was at work. The brother, apparently fed up with having been saddled with the responsibility of looking after his sister when he’d rather have been out with his friends, had taken his frustrations out on the girl.

  I spent hours with that family. We talked about abortion, an option Brenda’s mother rejected for religious reasons. We talked about the effect the pregnancy would have on Brenda and on her brother. We talked about what measures should be taken to prevent anything like this from happening again. Brenda’s mother assured me that she would discipline the boy in her own way and begged me not to report the case to the Bureau of Child Welfare, the state-run agency charged with investigating possible cases of child abuse. After long discussions with the mother and the clinic attending, I decided to go along with her wishes. That might have been a mistake: I never saw Brenda or her mother again.

  I think I made that mistake for the same reason I can remember Brenda so distinctly: Hers was one of the few cases of child abuse I was called on to manage during my residency. Now, several years later, an intern can’t even make it through a single week in the OPD without getting involved with the BCW. Child abuse and neglect have definitely increased over the past few years. Rarely a day goes by now without a family of two or three or four kids who have been abandoned or beaten or sexually molested being escorted into the emergency room. I was working in the ER last week and the cops brought in a family of seven children ranging in age from ten months to eight years. The parents were both crack dealers; the mother had been arrested the previous Thursday, and the father had been taken into custody the day after that. These children had been left to fend for themselves for three full days. They were starving; dirty; and very, very scared. Medical care in their cases included food, baths, and hugs. The police had been called by a neighbor who had complained that the baby was crying too loudly. They were temporarily placed in a shelter.

  Although child abuse is clearly on the rise in New York, there’s another reason that so many more abuse patients are being identified. The house officers are far more sensitized to the signs and symptoms of child abuse than my fellow residents and I were in the early 1980s. Interns are asking questions I never would have even thought of asking, such as: Where does the child sleep? How many people sleep in the same room? Who watches the child during the day? And they’re performing more pelvic and rectal exams in younger kids than we performed. Through these means, they’re finding evidence that we simply would have missed.

  The net effect of all of this is that the Bureau of Child Welfare has become completely overwhelmed. The BCW always has had its problems. Calling their twenty-four-hour hot-line number to report a family has always been an exercise in frustration. They’ve been slow-moving in completing investigations. But this has all become worse since the current “epidemic” of child abuse hit. And new methods of guaranteeing the safety of at-risk children have had to be invented.

  The “joint response” for reporting serious abuse involving children was only recently developed. When the examining doctor believes that a child has been abused and that his or her life may be in danger, both the BCW and the New York City Police must be informed immediately. A member of the sex crimes unit of the police force is then immediately dispatched to investigate the situation. The child, who may have been beaten by the mother’s ex-boyfriend, may have been sexually molested by a relative who lives in the same apartment, or may have been removed from a home in which another child has been killed or seriously injured, cannot be released into the custody of the parents or other relatives until the results of the police investigation are known. Since most abused children appear in the emergency room during the evening or night, sleeping accommodations for the child must be arranged. This entails either admission to the hospital or, if possible, transfer to some shelter.

  To the house officer, dealing with child abuse translates into pure aggravation. There’s endless scut that must be done. In cases in which sexual abuse is suspected, a “rape kit” must be completed and followed to the letter so that the collected specimens can be used later in court as evidence; reams of medical and legal forms must be completed according to strict guidelines; telephone calls to agents who are themselves overworked and who aren’t always the most caring or sympathetic individuals must be made; and careful explanations to hostile, suspicious, and often guilt-ridden parents must be given. All this must be carried out by doctors to whom child abuse is a particular anathema; these people, who become adjusted to death and disease, frequently become physically ill themselves while working with a child who has been abused.

  The net effect of all this is that progress through the pile of ER charts is dramatically slowed. A house officer can be tied up for an entire night reporting a single child abuse case. In an emergency room in which three or four residents are seeing all patients, the loss of one or sometimes two doctors can add endless hours to the waiting time. Parents sitting with sick children become angry and hostile as the clock ticks on. Often the whole situation ends with hospital guards being called to protect everyone from injury.

  Andy

  DECEMBER 1985

  Wednesday, November 27, 1985

  So I survived my first night on call at Jonas Bronck. It was busy, another night of sleep deprivation. Harvey Abelson announced in front of about six people that I was going back to Boston. Not in a real obvious way; no, he was very subtle. He said something like, “So I hear you’re going to Boston next year!” He said it really loud, in kind of a nasty tone. So now I feel a little bit like a persona non grata around some people. What do people think when you leave a program? Do they think you’re turning your nose up at it and, in a sense, at them? Can’t they accept that you’re leaving because there’s something else, something more important than being in this program for you? Why can’t they just accept that?

  Friday, November 29, 1985

  I’m on a flight to Boston, to spent the weekend at home. This is the first year I was away from my family on Thanksgiving. It was a real bummer. I was on call yesterday, and there was nothing to eat. Stupidly, I forgot to bring anything to the hospital from home. I should have known that there would have been nothing available to eat at Jonas Bronck, but I just didn’t think about it. I mean, there was nothing. I starved during Thanksgiving. What an image! Well, it’ll make going home even better. I don’t know . . . I just hope I’m never on call for another Thanksgiving.

  It’s been an amazing few days. I started working on 8 East this week. It took only a few days for word to get around that I’m leaving the program next year, and I’ve already noticed a big change in the way people are reacting to me. It’s a funny thing; some people want everybody to know that I’m leaving. For example, Alan Cozza, the director of the pediatric service at Jonas Bronck, has referred to my leaving in front of a lot of people on a couple of occasions over the past week. He’s not doing it with any kind of malice. I’m not really sure why he’s doing it, whether there’s a certain sense of pride he feels, like he’s proud of this program and thinks that when I go to Boston I should reflect how good it is, or if he really wants to mark me as different from everybody else. It’s a strange thing.

  Thursday, December 12, 1985, 11:00 P.M.

  I don’t think I’ve put much of an entry into this thing for a l
ong time. I think I’ve made it out of my month or two of depression, and I haven’t felt the need to vent about things as badly. Even though I’ll still wind up cursing about life, and I still hate being on call more than anything else I can ever remember hating, and I’m still chronically tired, I’m definitely not depressed anymore. I don’t know why; maybe it’s because I know vacation’s coming up very soon. Maybe it’s because I’m so goddamned used to working all the time now. Maybe it’s because I like working on 8 East because of the social feel of the place; it’s as if the whole staff is part of one big family. I just don’t know.

  I find myself looking back on the past six months and realizing that so far this is the month I’ve enjoyed the most out of all of them. Jonas Bronck and my month at University Hospital are definitely my two favorites. Isn’t that strange? University Hospital was like a torture chamber half the time. But there were some really nice things about it, too. Cute nurses, that helped, but I think it was also because the patients were complicated and interesting. Or maybe it was just because it seemed like it was just us residents against everybody else. I think I like the idea of working in a tertiary-care hospital. Everything is right there, there aren’t any interruptions from the emergency room or the clinics or anyplace else; it gives you a sense of self-containment. But I also like Jonas Bronck, which is just the opposite. It’s hard to justify that, it’s hard to figure how I can like two such different systems.

  I have to present chief of service rounds again tomorrow. [These rounds are held every Friday at noon at Jonas Bronck Hospital. An interesting case is selected, a summary is prepared and presented by the responsible intern, and the patient is discussed in depth by the faculty’s expert in that particular field. It’s a well-liked teaching conference, but it’s a pain in the ass for the overworked intern who has to prepare the presentation.] I wish they’d ask somebody else. It takes a long time to get that stuff together. I did it once already this month and I had to do a grand rounds, too. [Grand rounds, held on Wednesday at noon, are occasionally constructed around an in-house patient. As in the case of chief of service rounds, the intern caring for the patient is responsible for preparing the case presentation.]

  We’ve got a pretty good team this month. Our senior, Pat Cummings, has turned out to be okay. I actually like him; he’s a good resident. He’s kind of got a gruff, hard edge to him, but other than that he’s a funny guy.

  And I like my medical student. We spent a fair amount of time together today, doing scut. Makes all the difference in the world to do scut with another person. We had to stick some kid five times to get his IV in. I finally got it in, and it ran like a dream. I hope the damned kid doesn’t kick it out tonight. It looked good enough to stay in a couple of days.

  Last night wasn’t too bad. I got four admissions and I managed to get a couple of hours of sleep. And I got everything done. For me that’s good. I couldn’t do that at the beginning of the year. If I got four admissions back in August, I’d be up all night, writing and writing and writing. Now I write less and go to sleep. By the end of the year, I should be able to do ten or twelve a night. Ten or twelve admissions a night—boy, is that a horrible thought.

  I’ve got the FIB service [FIB: fever in baby]. I have six patients and they have a combined age of about nine months. And they all look and act alike; it’s hard to tell one apart from all the others. It’s not very interesting.

  I ran into Mike Miller the other day. When he saw me, he kind of frowned. And I sort of frowned when I saw him frown. I said, “What’s the face?” He said, “Well, I’m just sad you’re going to be leaving and you’re not going to be around here next year.” I don’t know if that’s what he was really frowning about. At any rate, it was a nice thing to say.

  This tape recorder’s kind of annoying me; it’s making weird noises. It’s hypnotizing me . . . Well, you get the idea. Those sleeping noises go on for the remainder of this tape, which I’ll be recording over now, because ten minutes of sleeping noises aren’t very exciting. I fell asleep again, fell asleep while recording on this fucking tape recorder.

  Sunday, December 22, 1985

  I’ve actually wanted to talk into this machine for a few days but I ran out of tapes and haven’t had a chance to get any until now. It wasn’t that I was saving up anything much to say, just the sense of having something to say.

  I’ve had this whole weekend off and in some ways it felt like my vacation actually started yesterday. I’ll be on call tomorrow and then I leave on Tuesday morning. I’m tempted to wear a big button to work tomorrow that says, “THEY CAN’T HURT ME NOW!” I’ve told several people that no one’s died on me yet this month, and everyone’s said the same thing: “Don’t be so smug. You still have one more night!” But I feel somewhat confident that I’ll make it unscathed off this ward and that I’ll always have fond memories of general pediatrics when it’s provided in a place like Jonas Bronck, surrounded by lots of smart, nice people in a great environment without disasters.

  Well, that’s not exactly true; I did have one near disaster, a kid with asthma who I was supposed to admit to the ward but who wound up going to the ICU on an Isuprel drip [Isuprel drip: a continuous IV infusion of isoproterenol, a drug used in cases of asthma when there is danger of respiratory failure]. I was the one who started that Isuprel drip. I didn’t know how to do that before. Hey! I now know how to do an Isuprel drip! Now I pretty much know everything.

  We’re going to New Orleans this vacation, I just found out yesterday. I got home post-call, turned on my answering machine, and there was a message from my brother saying he and his wife and Karen all decided it would be great fun to go to New Orleans and they asked if I wanted to do it and I said sure. I’d go anywhere. Just to get the hell out of the damn Bronx!

  I know this sounds weird, but a lot of people I talk to say I’m the most enthusiastic person about the program. Isn’t that ironic? Here I am, I’ve been depressed for months, and now I’ve even decided to leave at the end of the year, and I’m the most enthusiastic of the interns! But it’s true, I have been in a good mood for the past month, and I’ve started to wonder why. I think it had a lot to do with two things: first, being on 8 East, which was really great; and second, knowing I’ve finally got this vacation coming up. I survived, I’ve made it through six long months! I’ve reached the halfway point.

  I feel like I’ve gotten a lot out of this first half of the year. I think I’ve learned a lot. I don’t know how I’ll compare with those second years at Children’s when I start out there next year. Will they be way ahead of me? Will they know a lot more, having been in that highly academic environment for their internships? Will my vast ability to do scut really pay off at all? Will it matter? I don’t know.

  Will my learned ability to manipulate the ancillary personnel to get patient care done quickly and efficiently make any difference in a place where the ancillary services are actually good? I mean, I’ve gotten good at working through this system, I’ve finally learned how to get things done fast. I’ve just watched how the third years do it and I’ve figured out you either stretch the truth or you simply lie outright. You have to make everything seem like an incredible emergency or people will ignore you. You tell the elevator operator that you need an elevator right away or else the patient’s going to die. And they’ll do it! That elevator will be there in a second. It’s too bad, but it’s just the way it is here, it’s just a game you have to play if you want to get things done or you want to take proper care of your patients. You have to lie; they just don’t give a shit any way else.

  I’m learning to be efficient and how to be smart. Friday night on call was pretty quiet, I didn’t have a bad night, I only got two admissions; one was a FIB, the other a UTI [urinary tract infection]. I even got a couple of hours of sleep. So on Saturday morning when I was postcall, instead of going right home, I sat down and wrote four of my off-service notes on my chronic patients. I put them in my clipboard, I’ll bring them back tomorrow, date the
m, then I’ll stick them in the chart, and I’ll be done with them. The fact of the matter is, I’ve got to get out of there Tuesday morning and catch a plane, and I want to be able to bolt at early as I can.

  The UTI I admitted was kind of interesting. It was a one-month-old who came up as a FIB. Of course, no one in the ER had done a sed rate [erythrocyte sedimentation rate—the rate at which red blood cells settle when left to stand in a capillary tube; an elevated sed rate is a sign of inflammation and therefore an indication of infection] or a UA [urinalysis]; thanks a lot. It’s always the second and the third years who send them in unworked up. So I basically did the whole admission by myself. Pat kind of danced in for a minute, copied down the history I took, poked and prodded the kid, then went back to sleep, and I finished the rest of the workup. I actually got one of the night-shift nurses to hold the kid while I drew the blood and did the suprapubic [bladder tap], and there they were on the unspun urine, sheets of polys [polys: polymorphonuclear leukocytes, white blood cells that flock to the site of a bacterial infection] and gram-negative rods [the microscopic appearance of E. coli]. So I decided what to do: I wrote the orders to start the antibiotics, went in, woke up Pat, and said, “Pat, this kid’s got a UTI and I’m starting her on ampicillin and Cephotaxime [two types of antibiotics], a hundred per kilo of both. How’s that sound?” He mumbled something like, “Huh? Fine,” and went back to sleep. In the morning he said he was very impressed with the gram stain. I had done the right things. So how do you like that? I can now manage unbelievably simple problems all by myself!

  You know, I might have been able to do all this a few months ago, but I sure wouldn’t have felt right about it. Now I feel like I know what I’m doing. Watch, I’ll come back and something horrible will have happened by Monday.