Year of the Intern

by Robin Cook

  But there is the problem of the bed. It is needed for others—people who perhaps are more alive, and yet will be just as dead if deprived of the resources of the ICU. It comes down to a decision based on subtle, undefined gradations of life versus death. It isn't a matter of black or white, but of varying shades of gray. What does it really mean to be alive? A perplexing question, the answer to which evades a mind numbed with fatigue.

  Where does the exhausted intern look for guidance in these moments? To college, where sterile concepts of truth, religion, and philosophy invariably lead to an automatic acceptance of life as the opposite of death? No help there. To medical school? Perhaps, but in the ivory tower the complexities of the Schwartzman reaction and the sequence of amino-acid cycles have pushed aside the fundamental questions. Nor will there be any help from an attending physician. He always remains silent, perhaps perplexed, but hardened by repetition. And the relative or friend standing by? What would he say if you meekly put forward the proposition that there may be halfway points between life and death? Alas, he cannot think beyond the poor soul that is, or was Uncle Charlie. Unassisted, then, the intern gropes in side himself and makes arbitrary decisions, depending on how tired he is, whether if s morning or night, whether he is in love or lonely. And then he tries to forget them, which is easy if he is tired; and, because he's always tired, he always forgets—except that later the memory may surface from his unconscious. Angry and uncertain, he has once more been tested and found unprepared…

  Paradoxically, even with six people around me I was alone, standing there next to the nonbreathing hulk of the bearded man. His extremities were cold, but his chest was quite warm; he had no pulse, no respiration, dilated fixed pupils. One of the ambulance attendants kept talking, telling me what he had heard from the neighbor who had been with the man. The man had called his doctor after an asthma attack that morning, but it had gotten worse—so bad, in fact, that he started toward the ER, driving with a neighbor. In mid trip he had experienced an attack of acute dyspnea, an inability to breathe. He had stopped the car, jumped out, staggered a few steps, and collapsed. The neighbor had run for help and the ambulance was called.

  "DOA," I said firmly trying not to show doubt. In fact, my mind was a jumble of loosely connected thoughts racing around in search of a pattern. Strangely, in the ER mornings are an intern's most vulnerable time. Despite the surface refreshment of a night's sleep, his decision-making abilities are undercut by the deep exhaustion of the twenty-four-hour cycle. His experience is insufficient for him to make critical decisions with the certainty not of rational thought, but of pure reflex. One takes for granted the old aphorism that familiarity breeds blind acceptance. And so it is. Very often, in the beginning of his career, the intern is faced with a situation in which his mind is clear enough to think, yet he can find no answers. As with the schizophrenic who cannot handle an overabundance of sensory input, information remains unassociated in his mind. So the intern absorbs these experiences that rush in upon him; they hang around his mind in a loose conglomerate until he is tired enough to relegate them to his unconscious, and eventually he does reach a point at which experience brings familiarity, and familiarity brings acceptance without thought. By then a large part of his humanity has dropped away....

  All this mental activity happened in milliseconds. I didn't stand pondering and uncertain while the bearded man lay there. From the time I opened the back of the ambulance to the time he was pronounced DOA, less than thirty seconds elapsed. But it seemed much longer, and it affected me for hours. I did have one thing to be thankful about. My training had advanced far enough so that I would not be popping back in to feel for a pulse.

  The central, cutting question remained: why should I be allowed to make such a decision? I felt somehow an accomplice of evil, an agent in this man's death. It's true that if I hadn't done so, someone else would have pronounced him dead; I was not necessary to the drama. That’s easy enough to say if you're not involved, but I couldn't dismiss the matter so quickly. I had made the decision without which the bearded man would not have been technically dead at this moment. We'd have had him all wired up by now, and we would have been pushing on his chest, breathing for him, keeping him legally alive. So I felt that, because I had cut off this possibility, I was the one responsible for his being dead.

  Had I been too hasty in calling him DOA, in taking the easy way out? As soon as I said it, all the medical doors clanged shut. Had the decision gone the other way, in favor of an attempted resuscitation, my first move would have been to insert an endotracheal tube so that we could breathe for him. I had always found this a very difficult task. Maybe I had pronounced him DOA partly to save myself the trouble. Or maybe it was because I knew all the beds up in ICU were full, and figured that even if we did manage to resuscitate him, he'd only be another vegetable anyway. I now think these are questions without answers, but at the time they were driving me crazy. In that state, I walked out into the hallway to face the wife and child. The wife was tall and thin, almost gaunt, with dark, deep-set eyes. She wore sandals and some sort of floor-length granny dress. Up against its ample folds, really wrapped in it, was a little girl of about seven.

  The situation was right out of a prime-time television program—"The Interns" or "The Young Doctors"— ingredients for either a dramatic or a terribly sentimental confrontation. The reality, again, was nothing Ben Casey would have recognized. Facing the dreadfully concerned and frightened wife and child was neither dramatic nor sentimental, only one more hurdle for me to jump. Perhaps an omniscient third party would have read more into it. I was hardly that. I knew what had happened in the room behind the curtains, but I had no idea what these people were thinking, what they needed to hear. Worst of all, I was hopelessly swamped in my own crazy thoughts about death and responsibility, about what might have been. I wanted to beg them to hear my lectures on the Krebs cycle or some other medical elegancy. How poorly medical school had prepared me for this. "Just get the concepts, Peters. The rest will come." The rest—death—you learned about by trial and error, and finally, gratefully, you did fall back on the comfortable stock phrases of television.

  "I'm very sorry. We did all we could, but your husband has passed away," I said softly. The banal words rolled out, seeming good enough, really quite satisfactory under the circumstances. Perhaps I had a future in television. The only bothersome part was that business about doing all we could; we hadn't done anything. What I said, however, was only a stupid self-serving hypocrisy. It would pass. Wife and child simply stood there, frozen, as I turned and walked away.

  Thank God no other patient was waiting to be seen. I signed the sheet of paper making it official that I was the reason the bearded fellow was dead, and then I went quickly into the doctors' room, slamming the door behind me. In the process I jarred off the wall a picture a drug firm had given us of a bunch of Incas opening up some poor devil's skull; but the Playboy calendar opposite only rustled a little in protest, and Miss December hardly seemed disturbed. I sank into an enormous old leather chair. It was a large room, with blank walls except for the Inca picture and Miss December. A low, crowded bookcase stood at one end, and a small bed and a lamp at the other. The chair I sat in faced the pale green wall that was supporting Miss December. I longed for my mind to become as empty as that room, and as placid.

  Miss December helped; in fact, she had me mesmerized. What did Playboy have against body hair? Aside from the required abundance on top of her head, Miss December was as smooth as a piece of marble—no hair around her breasts, under her arms, or on her legs, and apparently none between her legs, either, although that was difficult to tell for sure because of the artfully draped Christmas stocking. Maybe Playboy was misjudging a good part of its market. I didn't think pubic hair was so bad. In fact, remembering the night before, I decided that Joyce Kanishiro's pubic hair was one of her most appealing features. No offense meant—if s just that she had very pretty pubic hair, and a lot of it. When she was naked
, you saw it no matter what position she was in. I thought it would be hard to put Joyce on a Playboy calendar.

  Miss December, Joyce, and the esthetics of body hair couldn't drive the bearded man entirely out of my mind. It certainly wasn't the first time death had confronted me in the ER. In fact, on my very first day on ER service, when I trembled to see even a patient with mild asthma, an ambulance had pulled in, its siren trailing off, and disgorged a twenty-year-old boy on whom the ambulance crew had been performing artificial respiration and cardiac compression. I had stood on the landing virtually wringing my hands and hoping that someone would call a doctor. This was ludicrous. I was the person they had been racing to, running red lights, risking life and limb.

  I had looked down at the boy and seen that his left eye was evulsed. Its distorted pupil looked off into nowhere. What on earth could I do with that eye? Actually, I didn't have long to think about it, because the boy wasn't breathing and his heart had stopped. The crew rapidly informed me that he had not made the slightest movement since they picked him up, in response to a call from a neighbor. As they rolled him onto the examining table, I glimpsed a wound in the back of his head. I tried to get a better look at it, but my view was blocked by little pieces of brain oozing out of a hole about an inch in diameter, and I suddenly realized that he had been shot, that a bullet had gone through the left eye and out the back of the head. The nurses and ambulance crew stood by, panting from their efforts, while I went through my routine. It was sheer nonsense to fuss with my stethoscope—nothing would make any difference—but for lack of another strategy I put it on his chest. All I heard were my own thoughts, wondering what to do next. The intern is always expected to do several things, yet this boy was so dead he was practically cold.

  "He's dead," I had said finally, after feeling for pulses.

  "You mean DOA, Doctor? No arrest, is that right?" That was right, dead on arrival, The medical jargon was reassuring; it made me feel secure. That boy with the hole in his head had been very different from the bearded man. Sure, the hole had scared me half to death, and I had been greatly relieved to be rid of the responsibility of figuring out what to do with that eye. The main point, however, was that he had had a big hole right through his head that preempted any action by me; hence, I had felt little responsibility. On the other hand, even now, without the sheet that covered him, the bearded man would look quite normal, as if in a deep sleep. That's the thing about death from asthma. You don't find much even at an autopsy, unless the victim has had a massive heart attack.

  Sitting in the doctors' room, I tried to picture Joyce Kanishiro in the center fold of Playboy. That would be something. She even had a few black hairs around her nipples. They'd have to touch up the photo a bit.

  Joyce was a laboratory technician with a strange schedule like mine. That was no problem, but she did have one gigantic drawback: her roommate was always at home. Every time I took Joyce back to her apartment, the first few times we went out, her roommate was there eating apples and watching television. There was a bedroom, but it was never opportune for us to go into it. Anyhow, the roommate, a confirmed night person, would probably have still been there staring at the test pattern when we came out at 5:00 a.m. After a few nights of situation comedies followed by the late news and the late movie, I knew Joyce and I would have to change the locale.

  My reverie about Joyce was interrupted by another memory, an episode that had taken place in the late afternoon some two weeks after I started ER duty. The same routine—siren/ red flashing lights—and this fellow had looked normal, too. As the attendants unloaded him and rushed him inside, they told me he had fallen fifteen stories onto a parked car. Had he moved? No. Tried to breathe? No. But he looked normal, quite peaceful, somewhat like the bearded man only a lot younger. How long did it take to get him here? About fifteen minutes. They always exaggerated on the low side, to forestall criticism. With an ophthalmoscope, I looked into the fellow's eyes, focusing until I saw the blood vessels. Concentrating on the veins, I made out clumps that could only represent blood clots. "DOA," I said. "No arrest." I had been pretty upset about that case, too, although falling fifteen stories onto a parked car was generally conclusive.

  Then the family had started arriving, in spurts— not the immediate family, at first, but cousins and uncles, even neighbors. It seemed that the man—his name was Romero—had lost his footing while painting the outside of a building. After the nurses called his wife to tell her that Romero was in critical condition, word of the accident had spread quickly, and by the time Mrs. Romero arrived the place was jammed with people demanding to know how he was and waiting to see him. As I informed Mrs. Romero of the death in my best quiet and confidential tones, she raised her hands to heaven and began to wail. Taking their cue from her, the rest of the crowd began wailing, too. For an hour or so from that moment I witnessed the most incredible and frightening performance by the Romeros and their friends as they, continued to drift in and engulf the ER. They beat the walls, tore their hair, screamed, cried, fought with each other, and finally began to break up the waiting-room furniture. I had no time to brood over the metaphysical implications of the case, being much too busy protecting myself and the rest of the staff. Interns have been killed in the ER That’s no joke.

  Later I had seen in the pathologist's autopsy report that Romero's aorta was severed. That made me feel a little better. But I knew that the pathologist would probably find nothing so plainly wrong with the bearded man.

  Dozing and musing in the old leather chair, I played with such thoughts and memories while Miss December's gigantic, almost hilarious breasts seemed to grow even larger. Joyce didn't have breasts like that. We had moved to my room to avoid the TV addict, and I vaguely remembered waking up at four-thirty that very morning as she left via the back door before anybody else was up in the quarters. It was her idea; I couldn't have cared less. But that was how we got away from Miss Apples and TV. It was a great schedule. During my twenty-four hours off, I surfed in the afternoon, read in the evenings, and then about eleven, after her work, Joyce would arrive and we'd go to bed. She was an athletic girl, who liked to bounce all over the place. She had great endurance, really insatiable. When she was around I didn't think about anything else.

  But the hospital bed in my room made a hell of a lot of noise, and it was pretty small. When Joyce got up to leave at four-thirty or so, it always felt delicious to expand all over it, luxuriating in the spaciousness. For a while I had gotten up with her—it seemed the courteous thing—and waved as she went down the stairs and drove away. But lately I had just propped up on one elbow, watching her dress. She didn't seem to mind. This morning she had come over to the bed, all starchy white, and kissed me lightly. I said we'd get together soon. She was an okay playmate.

  When the phone rang to wake me up three hours later, such a short time had elapsed that I half expected to see Joyce still standing there. I must have fallen asleep before she got out the door.

  Saturday, busiest day of the week in the ER, 7:30 a.m. Even though I had been in bed for eight hours, I felt physically bankrupt and out of phase. It was that twenty-four-hour baloney. I had followed my usual routine, which started when I balanced against the sink and studied my bloodshot eyes and ended with my arrival at the ER at one minute after eight, as always. Strangely, despite a general tendency toward tardiness, I always managed to arrive promptly at the ER to relieve my colleague, who would slink off gratefully with blood-spattered clothing and drooping eyelids.

  Until the arrival of the bearded man this had been a relatively quiet Saturday morning, with no big problems, only the usual procession of people who had dropped a steam iron on their toes or fallen through a plate-glass window. Everything had been handled quickly.

  A half hour had come between me and the bearded man, and obviously nothing untoward had happened outside the doctors' room, else I would not have been allowed to sit there musing. My watch showed 10:00 a.m. I knew it was only a matter of time!

>   After a perfunctory knock, a nurse entered to say that a few patients were waiting. Feeling almost relieved at being tugged from my reverie, I went back into the daylight and took the "boards" the nurse had prepared. My hat is off to these nurses. They routinely escorted each patient into the examining room, took all the administrative detail, the blood pressure, and even the temperature if they thought it was necessary. In other words, they screened the patients very well. Not that they decided whom I should see, because I had to see everyone, but they did try to establish priorities if the place was busy, or to give me a little peace occasionally if it wasn't. Whenever a new intern arrived, I guess the nurses were tempted to handle everything alone, because most of the stuff that came in really didn't rate as an emergency.

  But I was the intern and in charge, dressed in white coat, white pants, and white shoes, stethoscope tucked and folded into my left pocket in a very particular way, equipped with several colored pens, a penlight, a reflex hammer, a combined ophthalmo-otoscope, and four years of medical school— apparently ready for anything. In fact, really, only for the ailments I had already seen and dealt with. Considering that the variety of bodily ills approaches infinity, I wasn't ready at all. My inadequacy was like a shadow that fell away only when the place was jammed with crying babies and suturing to be done. After about ten hours, I usually got so tired that even if there were no patients I couldn't think. So the morning was toughest, just getting through to the afternoon; the rest seemed to take care of itself.