The Intern Blues

by Robert Marion

  I didn’t actually see the kid right away. I heard her first. The sound she made was very much like the sea lion tank at the Bronx Zoo around feeding time. And that was just her breathing! I walked over to see what was going on and the mother said, “Don’t intubate her, she’s got a problem with her trachea, she always sounds like this.” It was at that point that I started to get a little suspicious. It turned out, this was the orthopod’s patient. She was this five-year-old with some horrible disease called metachromatic leukodystrophy, a really rare metabolic disorder. She was followed by one of the neurologists. So I’m sure this is the only case in the history of recorded medicine of a kid with metachromatic leukodystrophy having been bitten by a horse. At least having been bitten by a horse in the South Bronx during the month of March.

  I have to admit, the story kind of piqued my interest, so I asked the mother how the kid got bitten. She told me the girl was involved in this therapeutic horseback riding program and she had been out for a ride that afternoon. At the end of the ride, the girl usually feeds the horse a carrot. She did it this time but she forgot to pull her hand away after the carrot was gone, and the horse, not understanding the difference between carrot and hand, continued to nibble. So she got bitten. Right; that made all the sense in the world. I’m glad she cleared that up for me!

  Luckily, the kid wasn’t too bad off. The horse had broken the skin on the back of her right hand a little, but it didn’t look like any bones were broken. The orthopod came in and we did some X rays, which were negative. He put a dressing on the hand and asked me what antibiotic I’d recommend to cover the bacteria from a horse bite. Since I’ve had so much experience with treating horse bites in the past, I decided maybe I should look it up. You know, in all the pediatric and infectious disease textbooks I could find, not one of them even listed horse bites in the index! Unbelievable! It’s such a common complaint, I thought there’d be long chapters on it wherever I looked. Anyway, we decided just to treat her with broad-spectrum coverage and see her back in a couple of days.

  I go to talk to this kid’s mother while we were waiting for the X rays to be developed and she told me the kid had been completely normal for the first year and a half of life and then started to deteriorate. She’s been going downhill ever since. It’s really a horrible story. There’s nothing anybody can do to help her. It’s only a matter of time now. It’s really sad.

  Anyway, so that was Fascinoma Night in the ER. And we didn’t even get out late, which is probably the biggest fascinoma. I like nights like that. Maybe “like” is too strong a word. I can tolerate nights like that. They don’t make me want to jump off the roof after I’m done with them.

  I had this weekend off but I’m on again tomorrow. I’ve got to get some beauty rest now. At this point, I’m at least six months behind.

  Friday, March 21, 1986

  Things have been pretty quiet, but I was on call last night and something did happen that I really want to get down on tape. At about eight last night this one-year-old came in with a fever. I called him in and started getting the history. He looked really familiar, but his name didn’t ring a bell. He was brought in by this woman who was his foster mother who said he’d spent the first five months of his life in the hospital. She said that she wasn’t sure what exactly had been wrong with him but that he had been really sick for the longest time and that all the doctors were sure that he was going to die. It was then that I realized that I was standing over Baby Hanson.

  Hanson! I only have to say the word and I get nauseated and want to run to the bathroom to throw up. But he looked great. That puny, disgusting, horrible bag of piss-poor protoplasm had grown into what looked like a fairly normal kid. He got taken away from his biological mother and placed with this foster mother in December, a couple of months after I had last seen him, when he was admitted to the ward at Jonas Bronck. The foster mother didn’t know anything about the biological mother, so I don’t know why he had finally been taken away from her. The foster mother had given him her last name, and that’s why he was now Rodney Johnson.

  It was amazing! He was sitting up, he could stand holding on, he wasn’t even that delayed. He could even say a few words, although he couldn’t say “crump,” which really should have been his first word. And he still didn’t have a vein in him. I looked all over, just out of curiosity. Amazing! If you would have told me back in August that Baby Hanson could have grown up into this kid, I would have called a psych consultant for you. But there he was!

  He only had an otitis [ear infection], and I sent him out of there with some amoxicillin. But I learned something from seeing him. I learned that no matter how horribly disgusting and wretched a baby is, there’s always a chance he could grow up into a seminormal child. I never would have believed it.

  I finish in the OPD next week and then I go on vacation. Carole and I have decided to go to Cancún. We were thinking about going back to that hotel in the Poconos we went to during my last vacation, but Carole decided against it. She thought I had been tortured enough for one lifetime over the past few months. I still think that maybe we should go. I mean, if I go someplace nice and actually have a good time, how am I going to be able to come back to the Bronx to finish the last couple of months of this wonderful experience? But who knows? Maybe Cancún will be hit by an earthquake or some other natural disaster, just to keep me in shape!

  Bob

  MARCH 1986

  In 1981, three reports of an apparently new disease appeared in a single issue of the New England Journal of Medicine. The articles described a series of patients who had become sick over the previous few years with some serious and unique symptoms. The patients shared a great deal in common: Each had been in excellent health before the appearance of the illness; each had developed pneumonia caused by Pneumocystis carinii, a parasite that only rarely caused problems in otherwise healthy individuals; many had also developed unusual malignancies, such as lymphomas and Kaposi’s sarcoma; and, in retrospect, all were gay men. These articles, which at the time appeared to be the result of chance coincidence, would have incredible implications. They signaled the beginning of the age of AIDS.

  The story of acquired immunodeficiency syndrome in children began at our hospitals. In 1979, two unrelated children were referred to the pediatric immunology clinic at University Hospital with serious, recurrent bacterial infections, including pneumonia. These children presented a puzzling picture of immune deficiency not previously seen in the pediatric age group. By the time those first articles on AIDS appeared in the New England Journal of Medicine, five children had been identified with symptoms that were identical to those reported in the gay men. In addition to their recurrent infections and immunological abnormalities, these five kids shared one common factor: All had been born to women who were drug addicts. And these women were also becoming sick, developing symptoms very similar to those of their offspring.

  The widespread acceptance of the fact that AIDS could occur in children did not occur until 1983. But whether accepted as fact or not, by 1983 it had become clear to everyone working in the Bronx that something terrible was happening.

  Although pediatric AIDS started with a handful of cases, by the mid-1980s a full-fledged explosion had begun. The Centers for Disease Control in Atlanta estimate that by 1990 a total of three thousand children in the United States will become sick with AIDS. Scientists who have watched the epidemic develop believe this figure is an underestimate.

  What this means to those of us working in the Bronx is that there are many infants and children who are or soon will become sick with AIDS and who will ultimately die because of it. At this moment, there are currently ten to twenty children with AIDS and the AIDS-related complex hospitalized in Jonas Bronck, Mount Scopus, University, and West Bronx hospitals. These children are in the hospital for one of two reasons. Some are critically ill; these patients have serious infections, cancer, and chronic lung disease. They fill beds in the ICUs for extended periods, draining resources an
d causing the staff who care for them severe emotional distress.

  Other children with AIDS who are hospitalized are not sick, at least not initially. These kids live in our hospitals because they have no place to go. Their parents are drug addicts, many of whom have become sick themselves, and some have died. Grandparents and other family members have abandoned them; they’ve become pariahs because of their disease. Although some manage to escape from the hospital for some short period of time, most members of this group wind up living out their short lives knowing no home other than a steel crib in a three-bedded room at the back of 8 East or 8 West at Jonas Bronck Hospital, knowing no family other than the nurses, house officers, and medical students who provide their care.

  But these hospitalized patients are only the tip of the iceberg. There are over a hundred sick children in our system currently being followed by the immunologists. Another hundred have already died. And these numbers are growing daily. Unless a cure is miraculously found, all these children will presumably die.

  There’s no question that AIDS has altered every aspect of modern medicine. It has radically changed residency training in virtually every specialty, including pediatrics. When I was an intern, there were few deaths on the pediatric wards. In fact, one of the reasons I chose to specialize in pediatrics was because children tended to recover from illnesses. But thanks to AIDS, all that’s changed.

  Amy, Mark, and Andy, as well as every other intern and resident in our program, have each been involved with at least one sick and dying AIDS patient. Over the past couple of years, about one child with AIDS has died every month. Occasionally the death seems almost like a blessing; these children are alone, with no loved ones; they are comatose, lingering on day after day in a vegetative state, with no hope of survival. But most of the time the death of a child, any child, is a tragic, deeply disturbing, and anxiety-provoking event for the house officers, nurses, and other staff members who care for the child and who stand by helplessly watching, unable to do anything to alter the course, as the child grows sicker and weaker until he or she ultimately dies.

  But the inevitability of the death of the patient is only one factor that’s changing the way house officers approach their charges with AIDS. The second and perhaps dominant force is tied to our current knowledge of the way in which the human immunodeficiency virus, the agent that causes AIDS, is transmitted. House officers know very well that if they stick themselves with a needle that has been in the vein of an HIV-infected individual, they can become infected. And becoming infected is equivalent to a death sentence.

  When I was an intern, we drew blood, started IVs, even did mouth-to-mouth resuscitation without giving it a second thought. We knew of few risks and little harm that could come to us from stabbing ourselves with a needle or breathing in secretions from a patient who had had a respiratory arrest. Now it’s mandatory that all house officers wear gloves whenever sticking a needle through the skin of any patient, regardless of whether the patient is thought to have AIDS or not. This increased use of gloves has caused a worldwide shortage of rubber. New types of gloves advertised as being resistant to HIV are being marketed. In the emergency rooms, nurses have been issued goggles to be worn over their eyes when around a patient who is bleeding profusely. Some residents don surgical gowns and masks just to enter a patient’s room. And forget mouth-to-mouth resuscitation! What was once knee-jerk reflex is now something that house officers, with good reason, try to avoid at all costs.

  Even though these precautions are being taken and everyone is being very careful, there is still a great deal of fear about AIDS within the ranks of our house staff. I went out for a couple of beers with Andy Baron one night early this month. He looked terrible: He has lost at least ten pounds since the start of internship, and he was barely able to keep his eyes open. It was pretty clear he was depressed. During our third beer, he let me in on why: He’s convinced that he’s infected with HIV. “I’ve stuck myself with so many needles, there’s no way I don’t have it,” he explained.

  I told him he shouldn’t worry so much, that every intern and resident has stuck himself or herself multiple times over the past five years and so far nobody’s tested positive for HIV. Andy replied that the key phrase there was “so far.” He’s sure that it may not be today and it may not be next month, but within ten years he and most of the rest of the interns in his group are going to wind up coming down with AIDS.

  “How do people get AIDS?” he asked. “Drug addicts get it from contaminated needles that have been used by people who are infected with the virus, right? If we stick ourselves with needles that have been stuck into the veins of children who are infected, why shouldn’t we get it? We’re no different from drug addicts. We don’t have any magical protection.”

  There’s really no way to argue with his reasoning. I think it’s pretty safe to say that at this point in the year, most of the interns would agree with Andy. This fear of AIDS has definitely changed the way the members of the staff approach patients. And it’s not something that will go away or change in the near future. AIDS is here, apparently to stay.

  Andy

  APRIL 1986

  Saturday, March 29, 1986, 11:30 P.M.

  I’m not going to talk for long because I’ve got to go to sleep; I’m on call again tomorrow. I’m on Infants’ [NW5—Infants’ ward]; I started a couple of days ago and of course I was on the first night. I got totally fucking killed. I was assigned six kids to start and then I got six admissions and a transfer that first night. It was like thirteen admissions, because I never had a chance to get to know anybody. In any case, it was terrible; I was up all night with a cross-covering resident who was really pretty mediocre; he didn’t help organize things at all. Then the next morning was a nightmare; I couldn’t present to save my life, it was like being a third-year student all over again. I was tired and they stole my scrubs and . . . it sucked. I felt disorganized, panicky, and I got chewed out by Alan Nathan for delaying giving an antibiotic to a patient. And there was so much scut I couldn’t get anything done; I didn’t have any progress notes written, nothing! I barely got my admission notes done. I finally got to sit down and write my progress notes at seven o’clock. I had two days’ worth of notes to write! I was postcall and I had to try to make some sense out of what had happened over the past thirty-six hours! I didn’t get out until after ten-thirty, and that was my post-call night! Ten-thirty at night! I was there for thirty-six hours without a wink of sleep, working my butt off the whole time. I’m still tired, and tomorrow I’m on call again. I think that was probably . . . that may have been the worst call I’ve had all year. What a fucking nightmare.

  Anyway, I’m sure my senior resident, Eric Keyes, whom I like a lot, thinks I’m a complete idiot by now. He probably won’t trust me for the rest of the month. First impressions are pretty important.

  Tomorrow I’m on call with another idiotic cross-coverer. I won’t mention names, but tomorrow I’m on with one of the worst, least-liked second-year residents in the program. What a pain in the butt! You know, they don’t give a shit when they’re cross-covering, because they’re out of there the next morning. They don’t have to face up to things; I do! I have to clean up the mess through the entire next day! And then my next call after that is on Wednesday, the day I have clinic. Then I’m on next Saturday. You know what that’s like? It’s like having four lousy calls in a row. It sucks! I hate it. I really hate this so much. If tomorrow’s anything like yesterday and the day before, I don’t know how I’m going to get through this month. It’s absolutely torture.

  Right after vacation to come back to this! I can’t tell you! My vacation was pretty good. I’ll talk about that some other time.

  Monday, March 31, 1986, 8:30 P.M.

  I’m post-call again. Not so angry this time and not so unbelievably tired. I had a really easy night, actually; I got only one hit. It was easy, but still I was running scut until midnight. The guy I was on with turned out to be a completely obnoxious b
lowhard who at least is pretty smart. He’s a total zero as a human, though. Two calls and two total-zero cross-coverers. But now that I got these two over with I’m scheduled to be on with really, really good people during my next two calls. It’s just too bad it’s worked out in this order.

  The nurses are great on Infants’; I really like them. But the place is a zoo; the private patients drive me up a fucking wall. They make me wonder what I’m doing going back to a privately run system. This lady today told me she didn’t want me to draw her baby’s blood. Jesus Christ! These parents are so uptight and nervous, they always want to come in and see the procedures being done. They can’t accept the fact that they shouldn’t be in the room. What do they think we’re going to do, break their kid’s arms? I have to think of nice ways to say, “No, you should wait out here, we’ll be back when we’re done, it’s best for the child, and it’s best for you, too. So don’t come in!” Usually I don’t get nervous when I’m doing procedures, but this lady today was making me crazy! And I couldn’t get the blood. It was the first time that’s happened to me in months!

  I got these new medical students today. Brand-spanking-new students, never been on a ward before, I have this big, hulking guy named Ronald; he seems very nice. God knows; maybe he’ll turn out to be a tyrant surgeon a few years down the road. He looks like one. He looks like he’s going to be an orthopod. Anyway, I did my best to teach him stuff today, to get him over the jitters of being on the floor with real patients for the first time.

  I’ve been hanging around the hospital too much. I stay too late. I was there until seven tonight. It’s ridiculous! Finally Keyes said, “Get the hell out of here, you’re just making work for yourself.” He was right! What you’re supposed to do is write your notes and get the hell out of there and let the person on call hassle with your patients. I think I’ll do that tomorrow. I say I’ll try, but I never can; I’m never able to get out before five.