Year of the Intern

by Robin Cook

  "Orange Thorazine!" She virtually squealed with delight. "I've never had that! I just cain't thank you enough, Doctor. You've been so sweet." And out she went, chattering gaily with her friends about the wonders of medicine.

  One of the nurses from a private ward appeared, limping slightly. She had fallen down a flight of stairs, with apparently no serious damage, but she had thought it best to have it checked. I agreed. Her name was Karen Christie, and nothing seemed wrong with her hip, but I suggested she have a pelvic X ray, anyway, to be perfectly sure. Hospitals are understandably sensitive to any threat of personal-injury claims on the part of the staff. When Miss Christie's X ray appeared fifteen minutes later, I snapped it up on the view box amid an assortment of skulls and broken bones. My eyes were a little blurry as I ran them over her femur, acetabulum, ilium, sacrum, and so on. All was normal. I almost missed the white coil toward the center, and when I did see it I couldn't figure out how the X-ray technician had managed to get such a strange artifact in his picture. Then it dawned on my sleepy mind that I was looking at an intrauterine contraceptive device, which served the double purpose of making Miss Christie a much more interesting case and lightening my mood for a moment.

  Unfortunately, my sour humor returned with the next patient. He sat quietly sobbing because he had hurt his nose when the car he was riding in hit a fire hydrant. With no encouragement from me, he loquaciously told the whole story. He had been minding his own business when he got picked up by a lesbian, who turned out to be so upset with her roommate that she ran the two of them into the fire hydrant. I didn't ask what had happened to the lesbian, being grateful not to have her, too. I thought wryly, and unkindly, that this fellow was the fag end of the night in more ways than one. Putting up with him was almost more than I could tolerate in my state of zero compassion. All I was prepared to handle were simple medical problems—diagnosis and cure. This guy needs more. He refused to do anything but sit and cry, and ask for Uncle Henry. When Uncle Henry arrived, not even he could persuade the man that an X ray was not lethal. Finally, when Uncle Henry agreed to stay constantly by his side, they disappeared to X-ray. The film showed a broken nose, and his private physician admitted him to the hospital by phone. Somewhat later, a policeman arrived with the real story. It had been a simple punch-out in one of the local "gay" bars; the lesbian was imaginary.

  Off in the distance, again I picked up the fateful sound of a siren, hoping it would pass us by. Instead, the ambulance screeched into the parking lot and backed quickly to the platform. I was in no shape for what I saw, the human wreckage of yet another automobile accident. The two girls on stretchers had obviously gone through the windshield. They were bloody from the waist up, with first-aid bandages covering their heads and faces. After the girls, two men stepped out of the ambulance under their own power, showing only minor bruises.

  As I removed the bandages from one girl's face, a geyser of blood spurted straight up onto my face and chest. A textbook case of arterial bleeding, I thought, replacing the bandages. I put on a pair of sterile gloves and a mask and then jerked the bandages off suddenly, immediately pressing a piece of gauze into the wound, working my hand along a gaping laceration that ran from her forehead down between her eyes almost to her mouth. Bleeders were spurting little jets of blood in various directions. With great difficulty, I managed to get mosquito hemostats on the bleeders, but before I could tie them the girl ripped them off. She was drunk. For a minute or so we went through a cruel, gory routine, she taking the hemostats off as fast as I put them on. I won by dogged persistence, finally tying off the bleeding vessels, but of necessity leaving enough work to enrich a plastic surgeon. Meanwhile, a resident had arrived to work on the other girl. Then we discovered that the two girls were military dependents, and since they were stable—meaning they weren't going to die in the next hour—off they went to a military hospital. That left me with the two fellows, who were in relatively good shape. I cleaned their abrasions and mechanically sutured a couple of scalp lacerations without uttering a word.

  By about three-thirty there was only one more patient to be seen, a baby sixteen months old. I was really dragging by then, and I don't remember much about the case except that the parents had brought the child in because he really hadn't been eating too well for the last week or so. Thinking I must have missed something, I had them repeat that several times. All the while the child was sitting there smiling and alert. With a touch of sarcasm, I asked if they didn't think their behavior was a little strange. Why strange, they wanted to know; they were worried. A slow burn came over me as I silently examined the perfectly normal baby, and then fled to the telephone to call their private doctor, who was equally irritated because I'd waked him up. That was absurd, too. The doctor was angry because his patient was bothering me at 3:30 a.m. I ended up turning everything over to the nurses, who sent them all home. I couldn't talk to them again.

  After the child left I wandered out on the platform, peering blankly into the silent blackness. I felt nauseous and drained, but I knew from sore experience how much worse I would feel to be waked up for the inevitable next patient after sleeping for only fifteen or twenty minutes. All the nurses were busy with small jobs except one, who was having coffee. I felt strangely detached, as though my feet were not firmly on the ground, and thoroughly lonely. Even fear was gone, banished by exhaustion. If anything serious came in now, all I could do would be to try to keep it alive until a doctor arrived. Well, that was a useful function, of sorts. Of course, I would continue to do miracles with the drunks and the depressed and the kids who weren't eating too well—my true constituency.

  Somewhere near and coming nearer, a Volkswagen's horn was beeping, disturbing the deceptive tranquility of the ER. As the beeping got louder, it began to remind me of the cartoon character called the Road Runner—an absurd association, but somehow appropriate to my mental state. Beep-beep. Maybe it was the Road Runner. Thirty seconds later fantasy was replaced by a VW that pulled up, still beeping, next to the platform. A man jumped out yelling that his wife was having a baby in the back seat. After calling for a nurse to bring a delivery kit, I ran down to the VW and opened the door on the right side. There in the back, sure enough, was a woman lying on her side, obviously in the last stages of labor. The light was very poor, obscuring the birth area; everything would have to be done by feel. As she started into another contraction, I felt the baby's head right on the perineum. The woman's panties were in the way, so I cut them off with some bandage scissors, and while she grunted through the contraction, I kept my hand on the baby's head to prevent it from popping out. After convincing her to roll over on her back, I pushed the front seats forward, and got one of her legs braced on the rear window and the other one draped over the driver's seat. My hands were moving by reflex now, leaving my mind to do absurd things, such as remember an old joke— what’s harder than getting a pregnant elephant into a Volkswagen? Getting the elephant pregnant in a Volkswagen. With the contraction over, I got the baby's head out slowly, rotated it, pulling it down to get one shoulder out and then up for the other shoulder, and suddenly I was holding a slippery mass. I almost dropped it trying to back out of the car. Thank God, just then the baby choked and started to cry. Not knowing what to do through all this, the father had been behaving oddly; he interrupted his audible anguish about the upholstery, which was pretty messy by now, to ask whether it was a boy or a girl. In the dark I couldn't tell. Must not be this guy's first child, I thought. I wanted to suck the newborn's mouth out with the bulb syringe, but the baby was too slippery to hold in one hand. Instead, I gave the infant to one of the nurses, with explicit instructions to keep it level with the mother, and, after putting on some clamps, I cut the cord. Then everyone— attendants, nurses, and father—helped lift the mother out of the car. The afterbirth came away without effort in the ER. I was amazed that there were no lacerations. The whole crew disappeared up to the obstetrics area.

  That baby redeemed the night. Maybe they would na
me it after me. More likely they'd call it V.W.

  I almost didn't even mind seeing the dirty drunk who had come in during the excitement of the birth. He had a scalp laceration, which I sewed up without anesthetizing it while he swore at me. Actually, he started to swear and swing at me as soon as I appeared. He was so drunk he was beyond feeling. After the last stitch, I went into the doctor's room and plopped down on the bed, instantly asleep.

  That was 4:45; at 5:10 a nurse knocked and came in to say a patient was waiting to be seen. At first I was disoriented, literally unable to recall where I was and aware only of the hammering of my heart. In the twenty-five minutes between then and now, sleep, the great healer, had incapacitated me, leaving me dizzy and weak, with scintillations in the periphery of my visual field. These passed as I began to move around. Even so, my left eye refused to focus, and when I opened the door the light in the hall was like a thousand flash bulbs. I felt just about as shitty as I could feel and still function.

  The patient, where was the patient? The chart in my hand said, "Abdominal pain, twelve hours." Jesus! That meant I had to record a complete history and probably wait for lab reports. I walked into the room and looked at the patient. About fourteen, soft silky hair of shoulder length, skinny, large nose. Mother sat over in a corner. The check list of questions for possible appendicitis is a long one, and I started in on it. When did the pain start? When did you first feel it? Did it move? Was it like indigestion cramps? Did it come and go or remain steady? Meanwhile, I casually felt the abdomen for sensitivity, through Bermuda shorts, reasonable apparel in Hawaii's climate—but underneath them was something odd, the distinct outline of a girdle? Crazy. Did you eat today? Tonight? Did you feel like vomiting? The stomach seemed soft. It could not have been very tender, for moving my hand over it evoked no sign of discomfort. Did you move your bowels? Was it normal? I took out my stethoscope. Has your urine been normal? I put the stethoscope in my ears and rested the bell of it on the abdomen, the patient's words filtering through the earplugs. Have you had trouble with abdominal pain before? Have you ever had an ulcer? For some reason I always left the questions about the menstrual cycle until last. It was just a small propriety. When was your last period? The answer came rather apologetically: "I'm a boy."

  I looked at her—him—for a minute, my dull mind reeling. Long silky hair, loose purple velvet shirt. No, it was a blouse. Girdle! Putting my hand under the girdle, I lifted the whole works up, practically raising him off the table. No doubt about it, that was a penis. The mother just looked away. I was unprepared for such sudden reverses. It all seemed a huge, cruel joke. Here I was struggling to make some sophisticated intra-abdominal diagnosis, and I was wrong even on the sex. Anyway, he didn't have appendicitis or anything else terribly serious. Probably a simple case of abdominal cramps. I thought to myself, if I told him they were menstrual cramps he'd be pleased.

  Being a slow learner, I immediately fell asleep again. Crash! The door came open and a delighted nurse informed me that I had a patient. The same process occurred, the same agonizing gauntlet of getting up and blinking and gradually clearing as I emerged into the light. This one was a dandy, a Sa-moan lady towing along her ailing mother, who couldn't speak a word of English. With so many languages in use around the islands, we were accustomed to working through translators, but in this case the daughter's English was not even a serviceable pidgin. Besides, the complaints were so numerous that every organ system seemed to be involved. She had pains here, pains there, headache, weakness, couldn't sleep, and generally felt crappy. Sounded like me.

  Very carefully I asked the daughter if her mother had any burning sensation when she passed her urine, and was rewarded with a blank look. Rephrasing it, I asked if her mother had any pain when she made pee-pee, wee-wee, shishi, umm ... my mind had run out of synonyms ... when she makes water. I thought this brought a glimmer of understanding, so I put it together again. Does your mother have pain when she makes water? The answer was great, made me want to give up medicine entirely. She said she didn't know. The lexicon of English does not hold a word to describe my frustration. I said, for Christ's sake, ask her, then. So she asked her. Yes. That was how it went with every question. Slowly, and every answer was yes. She had burning on urination, frequency of urination, nausea, vomiting, vaginal discharge, diarrhea, constipation, chest pain, cough, headache.... Since the mother was quite emphatic about her chest pain, I tried to take an electrocardiogram, but the machine broke. When the birds started singing outside, it was as if they meant to attack me with their song; but of course they were only heralding the light. I was so tired I just didn't care about the old lady, about anything. In the firm conviction that she would not die within the next few hours, I gave her some Gelusil, which she liked enormously, and set up an appointment in the clinic. It was glorious morning by the time she left.

  Before I could disappear into the doctors' room again, a baby and an old man came in simultaneously. The mother had dropped the baby on its arm, which was a little swollen, and the man had strained his back several days before. With the baby and the man up in X-ray, I fell asleep in a chair by the counter, smack in the center of the ER. When my relief came to take over, he let me sleep on. Forty-five minutes later I woke up feeling as bad as before, but knowing that this time I could go back to my own bed. Where are the television cameras now? I mused, trudging along home looking like a Jackson Pollock action painting made of dried mucus, vomit, and blood. It was a strange and wonderful feeling to take off my clothes and slide between the cool, slightly coarse sheets.

  Thus my twenty-four hours off began. After more than a month of the ER routine, I was a mental and physical shamble. I became lucid around lunchtime, when I was waked by a combination of the birds, the sun, and hunger. A shave and shower made me feel somewhat human, and by the time I had walked over for lunch in the warm noonday sun, I was back in the real world again.

  Following lunch, I succumbed to an imperative somewhere in me to get away from the hospital. More sleep would have been the prudent course, but I had discovered through experience that, no matter how tired I was, the general afternoon din around my quarters would keep me awake. So I put on my bathing trunks, loaded the surfboard on to my car, threw some medical books into the back seat, and took off for the beach.

  It was a relief to drive out there and let the clutter of colors and movement capture my mind. People seemed to be everywhere, all of them strangely whole and healthy. In the hospital, one often feels that everybody in the world has diarrhea or a chest pain. But there they were, busily and happily walking around, laughter mixing with the physical activity, suntans, and brightly flashing bikinis. These people looked so normal. With my morose thoughts, I was somehow an outsider, not belonging. Too tired to swim or play volleyball, I propped myself up against the surfboard, facing the sun, and let the scene roll by.

  I didn't try to talk to anybody and no one approached me, which was just as well. I was so full of the ER that I would quickly have turned off anybody in his right mind with my yammer about blood and broken bones. But that wouldn't be my real subject; my real subject would be me—my anger, exhaustion, and fear. Come on, now, I thought, too many dire and dramatic nouns; stop wallowing in self-pity. That's about all you've been doing lately, feeling sorry for yourself. So what if it's a crappy deal being an intern? Change it if you can, but stop feeling sorry for yourself. That doesn't help anybody, least of all you. I still wished, however, that our culture would take some of the pressure off by realizing that a white coat and a stethoscope do not confer wisdom. Much less instant nobility.

  Well, screw it. I'd take a nap instead.

  I fell asleep there in the sun by myself, in the middle of all that gaiety and laughter. Actually, this happened every afternoon I was off during the period of ER duty. Sleep in the morning, eat, sleep in the afternoon, eat. Do nothing for a while, then sleep, only to wake and find the twenty-four-hours-on cycle beginning again, wondering where the time had gone. When I awoke i
t was late afternoon; the people had thinned out and the sun was much weaker. No one bothered me as I continued to sit and look at the sun on the water. It was like watching a bonfire. Its activity seemed an excuse for my stillness and undirected thought. Not that I was unconscious; everything around me came into my mind—all movement, sound, and color. I just wasn't connecting.

  Hastings had to wave his hand in front of my face a few times before I got him into perspective. Surf? Sure, why not, if I could get myself and my board down to the water. I felt immobile, as if the sun had sapped all my remaining strength. This was another part of the afternoon-off routine. Hastings would meet me down at the beach, quite late, and we'd surf, not talking to each other except to say a few words like "outside" if a large wave was coming. I didn't understand why we made such elaborate plans to meet and then ignored each other. But both of us liked it that way.

  Paddling out was the high point of the day, a kind of catharsis. I felt my body and mind join again. I used my arms and feet to paddle, feeling the strength that was there and the touch of water under me, cool and gently moving. The expanse of the ocean, spreading to apparent infinity around me, made me feel small yet real, the true center. People vanished; their voices changed, became muted and distant as they were swept off by the waves. The setting sun turned the whole western sky into warm, soft oranges and reds reflecting millions of times from the surface of the water, like a Claude Monet painting. To the east, silver blues and violets began to appear among the pinks and faraway greens. Sailboats were dotted around haphazardly, little dabs of color against water and sky. The island rose up sharply from the water's edge, and sunlight cast contrasting shadows among the canyons, creating a texture as soft as velvet, making the soaring ridges fly like buttresses off a Gothic cathedral. Deep violet clouds hovered over the island, concealing the peaks, forming the prismatic reflections of rainbows in the shadows of the valleys. Whatever effect it may have on others, this beauty cradled me, drained all other thoughts and made me whole again.