Year of the Intern

by Robin Cook

  As the clock slid around to six, our traffic unaccountably fell off, giving me a short respite. I even began to get a little ahead, and after I dug a large fishhook out of a middle-aged man, no one else was waiting. The ER was suddenly peaceful; outside, the golden afternoon sun cast a long shadow of violet across the parking lot. This was the calm before the storm, a temporary armistice between battles. Feeling tired and lonely—surprisingly lonely, with so many people around—I ambled over to dinner. On the way I passed a few people waiting for rides home. Those who had come from the ER nodded pleasantly and smiled; I smiled back, glad to have the unusual second contact and hoping I had done right by them. Interacting with the patients outside the hospital made all of us seem more real and took away some of the fear that dogged us as we came to expect disaster in every movement of the clock.

  Sitting down was a luxurious experience. I stretched my feet out under the table onto a chair opposite. Joyce came along and sat by me, which was pleasant, although we didn't have much to say to each other. She was full of laboratory gossip and blood counts, which threatened to give me indigestion; nor did I want to discuss the ER. I ate rapidly, knowing that each bite might be my last for the night. At least that part of television's view of medicine is dead right. We ended up talking about surfing with another intern, named Joe Burnett, from Idaho.

  Every intern needs an outlet, a safety valve; surfing was mine. It provided the perfect detachment and escape. Not only was the environment different in sound, sight, and feeling; on top of a decent wave, struggling and concentrating to make the shore, no other thought was possible. As the months passed and my addiction to surfing grew, I began to understand why people follow the sun in search of the perfect wave. I suppose it's healthier than drugs and alcohol, but its grip is just as strong, and a bad move can kill you. Hawaii does not publicize that last fact very widely.

  But never mind that. Even if the waves weren't good, beauty was all around. And who could tell?— any minute a big one might rise up to challenge you. Surfing is its own thing, basically unlike any other sport, although it superficially resembles snow skiing. The difference is that in skiing the mountain stays still; on a wave everything moves—you, the mountain, the board, the air around you—and when you fall off your board in a big wave you have no say about where you go. All you know is you weren't meant to be there. So Joe and I talked about surfing, excitedly describing little episodes, our hands and feet motioning and moving, telling how the waves curled, how we got locked in or wiped out, everything. And I forgot about the ER.

  Curiously, surfing is not a sociable sport except when you are away from the water talking about it. Out there on your board you hardly speak. You're part of a group of detached people held together by a bond of water, but you are unmindful of the others except to curse if someone drops in on your wave. Every wave you catch is somehow your wave, even though you don't go surfing alone. You always go with someone, but you don't talk.

  The phone rang for me, and I had to break off with Joe; the ER was getting some business. It wasn't peaceful any more when I arrived. During my thirty minutes away, more babies had come in, crying with the usual complaints. A teen-aged girl complained of cramps. I asked her how much relief she had obtained with aspirin. She hadn't tried any aspirin yet. I gave her two. Another miracle cure worthy of four years of medical school. And the colds. There were several people with plain old garden-variety colds— runny nose, irritated throat, cough, the usual. Why they had to come to the ER was beyond my comprehension. Even though I had reached my third wind after dinner, any humor in the situation was going right by me unnoticed. People were waiting to be sutured, and I had to see those with runny noses.

  One of the suturing jobs was a little out of the ordinary. A lady had cleanly sliced off the tip of her index finger with a carving knife. She had been swift enough to rescue the little piece, and after I soaked it for a while, I sewed it back in place with very thin silk. All this was done while the private M.D. gave explicit instructions over the telephone. Had I seriously expected him to come down and do it himself?

  One of the back rooms held an elderly man who was troubled by back pain and inability to hold his urine. The latter symptom was clear enough from the smell in the room, which nearly overpowered me as I examined the man by degrees, ducking into the hall from time to time for fresh air. Bad smells were still my bete noire. I thought maybe he should be admitted to the hospital, since he had a urinary-tract infection and obviously couldn't take care of himself.

  However, the first attending I called knew him and didn't want him as a patient. He told me to find another doctor. Seems that the old man was a notoriously bad patient, famous for disappearing from the hospital without being discharged, and always turning up again on weekends or in the middle of the night. The next doctor refused, too, and suggested yet another. Finally, after calling five M.D.'s, I got one to agree to take him as a patient, but as the nurses were preparing the man for admission they discovered he was a veteran. All my efforts on the phone flew out the window; now we had to ship him to a military hospital.

  Passing by the entrance on my way to see another patient, I nearly bumped into a young woman of about twenty, clutching a poodle as she was propelled by a man not much older than she. She was screaming that she didn't want to talk to any goddamn doctor. That was fine with me; I proceeded into the room where I was going. But I had to see her anyway, eventually, and when I did she wouldn't say a word; it would have been easier to communicate with the poodle, still tightly clutched. I decided to let her sit a while, but that was a mistake, because a few minutes later she dashed down the hall and disappeared. I was too busy to take much notice—until the family psychiatrist arrived shortly thereafter with the girl's parents. It seems that the hospital had called the police when the girl was found outside pulling up flowers. I was a little surprised to see the psychiatrist—I always had so much trouble getting any of them to come in on weekends or after 4:00 p.m. I could count on having two or three psych patients on Saturday night, a bad time for them. Since I never got a psychiatrist to come around, I just did what I could to make the patients quiet and comfortable; but a light sedative and kind words don't do much for them.

  "Doctor, 84," a nurse called to me from the main counter. I picked up the phone outside Room B and poked the 84 button.

  "Peters, this is Sterling." Sterling was the orthopedic resident. "I finally got hold of Dr. Andrews, who's covering staff orthopedics this month, and he thinks that a hanging cast would do for Morris."

  There was a pause. I began drawing interconnected circles on the scratch-pad by the phone. This bastard Sterling didn't intend to come down and put on a hanging cast, whatever the hell that was.

  "Why don't you have a go, Peters? And if you have any trouble let me know, okay?"

  "I've got about eight patients here I haven't even seen yet."

  "Well, if he has to wait too long, call me back."

  "For Christ's sake, Sterling, he's been here since ten o'clock this morning. Don't you call that long? I mean nine hours?"

  "Aw, that's all right. Give him a chance to sober up."

  Arguing with Sterling involved more effort and thought than I wanted to put into it, and, furthermore, it went against my new determination to keep my distance, not to get pissed off. "Okay, okay, I'll get to it as soon as I can." I hung up the phone, mentally mapping out the next half hour.

  "Nurse, have the attendant draw up some warm water and get a supply of plaster ready down in the ortho room."

  "What size plaster, Doctor?"

  "Two- and three-inch, four rolls of each."

  Putting on my most nonchalant air, I wandered into the doctors' room and quickly scanned the shelves for a book on orthopedics. Mercifully, I found one and turned rapidly to the index. There it was— cast, hanging, see page 138, which turned out to be a discussion of breaks and fractures of the proximal humerus, just what I was looking for. Despite my apprehension at being shoved into stil
l another strange task, I was impressed by the ingenuity of the hanging cast, which did, in fact, work by a kind of traction. Rather than encasing the patient's whole arm and shoulder, the cast was placed only around the area just above and below the elbow, where its weight would pull downward on the fractured bone and ease it back into alignment. The whole arm was then pulled into the body by swathing the cast to the chest; this held the arm immobile but allowed movement in the shoulder. Amazing.

  A nurse stuck her head in. "Doctor, there are nine patients waiting."

  I knew that I would hear from the nurses if a real emergency arose; now was the time to get rid of Morris once and for all. After replacing the book, I headed toward the ortho room, somewhat better prepared to make a hanging cast than I had been five minutes before. As I entered the room, it became obvious why Morris had been easy to forget for the past hour or so. He lay on the examining table fast asleep, snoring lightly, cinched in place by a broad leather strap. Nor did he awake when I cranked him into a sitting position, holding his head to keep it from flopping over. Damn that Sterling; this was his job. I had heard the television blaring in the background while he was talking on the phone with me. After cutting Morris's left shirt sleeve off at the shoulder, I fashioned a piece of stockinet for the underside of the cast and slipped it on his arm, trying not to disturb the fracture.

  "Doctor, there's a call on 83."

  I didn't even answer the nurse, hoping that whatever it was would solve itself.

  "Ohhhhh." Morris came to when I positioned his arm for the cast. "What are you doing to me?"

  "Mr. Morris, you broke your arm falling down the stairs, and I'm putting a cast on it."

  "But I don't—"

  "Yes, you do! Now don't say another word." I hoped Sterling would ask me for a favor some day. After soaking the plaster rolls in water long enough for the bubbles to stop, I wrapped them around and around Morris's arm, building the cast up layer on layer. I made it big, almost an inch thick. Since it functioned by its weight, mine was going to work very well.

  "Now just stay where you are, Mr. Morris. Don't move. Let it dry."

  Reaching the main portion of the ER, I picked up 83, but no one was there. Good strategy. It was only seven-thirty; I was already eleven patients behind, and I knew it would get worse. Grabbing a handful of charts, I started off, glancing at the top one: "Skin rash."

  Skin problems drew a blank in my mind no matter how many times I read and reread the descriptions of papulosquamous erythematous pruritic vesicular eruptions. The words lost all sense, twisting and turning in my memory so that if I saw a patient with anything other than acne or poison ivy I was lost. And there in front of me stood a man with a violent pruritic eczematous erythematous rash. I knew what it was, because a dermatologist had used those words to describe my sunburn after an Easter week in Miami during medical school. It meant itchy, wet, and red, but dermatologists preferred complicated scientific jargon. In fact, dermatology is the only branch of medicine still using Latin to any great extent—appropriate, in a way, since I couldn't see that the science had advanced very far since the days of alchemy. Although the terminology and the diagnosis of skin disorders were difficult, the treatment was simplicity itself. If the lesion was wet, you used a drying agent; if the lesion was dry, you kept it wet. If the patient got better, you continued what you were doing; otherwise you tried something else, ad infinitum.

  The patient standing before me was a skinny, sallow-faced fellow with dark hair, bushy and unkempt. Looking at his hands and his arms, I couldn't think of a thing except how little I knew about dermatology. He didn't have a private doctor, which meant I would have to call one, and I wondered what I could say without sounding like an idiot.

  I noticed that the rash was on the palms of his hands, too, and some distant bells began ringing in my mind. Only a few dermatological disorders occur on the palms of the hands. Syphilis is one. Hmmm. I was so involved with my own thoughts, I hardly heard the patient when he said that he had neurodermatitis and needed more tranquilizers. I was still trying to remember the exact list of those diseases that occur on the palms when his words suddenly scored in my consciousness. Neurodermatitis. With practice, I had developed an ability not to show surprise or gratitude when such sudden gifts of diagnosis were presented, and I continued to look at his arms knowingly until sufficient time had elapsed. It made me feel that my knowledge of dermatology at least equaled his when I guessed correctly, that he was on Librium. He was thankful to get some more.

  As evening spread into night, my steps became labored and slow, and my fear mounted, giving rise in my imagination to a series of hopeless cases waiting to descend upon me. There was no pause in a continual stream of patients that kept me always five or six people behind. My suturing became more rapid, out of a combination of necessity and diminishing interest. Whenever I sutured, the people waiting stacked up, so I had to be fast, dispensing with trimming the edges and other fancy stuff. I was not haphazard, just less careful, and perhaps more easily satisfied. As, for instance, with the man who had a flap laceration on his arm. During the daytime I probably would have excised the flap and closed it as a linear cut. Now I just sewed it up, flap and all, hoping for the best.

  In the eye-and-ear room a four-year-old boy sat forlornly on the examining table. His grandfather stood nearby. As I entered, the boy started to whimper, putting his arms to his grandfather, who held him while I read the chart. It said, "Foreign body, right ear." After talking quietly with the little guy for a few minutes, I convinced him to let me look in his ear. Far up in the canal I could see something black; it looked like a raisin or a small pebble.

  Since the grandfather didn't know an ear, nose, and throat man, I picked one out of the M.D. roster, a Dr. Cushing, and gave him a call.

  "Dr. Cushing, this is Dr. Peters at the ER. I have a four-year-old boy here with a foreign body in his ear.

  "What's the family name, Peters?"

  "Williams. The father's name is Harold Williams."

  "Do they have health insurance?"

  "What?"

  "Do they have health insurance?"

  "I haven't the slightest idea."

  "Well, find out, my boy."

  What a scene, I thought, retracing my steps into the eye-and-ear room. With a dozen people waiting, I've got to find out about the health insurance. No, the grandfather said, they were not insured.

  "No, no insurance, Dr. Cushing."

  'Then see if any of the adults are employed."

  Once again I returned to the eye-and-ear room to quiz the concerned grandfather. Actually, I knew that this information gathering was easier than calling a dozen or so physicians until I found one who wasn't so concerned about getting paid; but it seemed gross and inhumane, just the same.

  "Both the parents are employed, Dr. Cushing."

  'Tine. Now, what is the problem?"

  "Little David Williams has a foreign body in the ear, something black."

  "Can you take it out, Peters?"

  "I suppose so. I can try."

  "Good. Send them to my office on Monday, and call me back if you have any trouble."

  "Oh, Dr. Cushing."

  "Yes?"

  "I had a little girl in here this morning with infections in both middle ears." The Pablum child suddenly came back into my consciousness. "One drum was ruptured, and the other was bulging out. Should I have drained it?"

  "Yes, probably."

  "How do you do that?"

  "Use a special instrument called a myringotomy knife. You merely make a tiny incision in the lower, posterior part of the eardrum. It's very simple, and the patient gets immediate relief."

  "Thanks, Dr. Gushing."

  "Not at all, Peters."

  Thanks for nothing, Dr. Gushing. After all that nonsense, I had to go fumble for the foreign body myself. As for incising the eardrum, I decided that I should consider myself instructed on the procedure.

  Back in the eye-and-ear room, I immobilized the
boy and reached into his ear, trying to grab the black object. It came apart as I pulled the forceps back, and when I looked at what came out I didn't want to believe my eyes. It was the back leg of a cockroach. The little fellow was sobbing now as I dug out the cockroach piece by piece, feeling sorry for the boy and wanting to have it over and done with, nearly vomiting with revulsion. The last few pieces came out with a great gush of irrigation. The boy's crying gradually subsided, and I swabbed out the ear with disinfectant. He seemed all right, but I felt pretty faint.