Year of the Intern

by Robin Cook

  But it had to be done. So I got up again, with the most complete lack of motivation, and dragged myself over to the OR. On with the scrub suit, the hat, and the mask. Once the mask was on, I pulled it down off my face, leaving the strings tied, and studied myself in the mirror. I hardly recognized the wasted man who stared back at me.

  Happily, when I got to the operating room proper I found that it was not to be an amputation, after all, but, rather, an attempt to save a leg whose knee had been crushed by a truck. Only the nerve and vein were intact, spanning the gap where the knee had been. The artery, bones—everything else was gone. To my surprise, I found two private surgeons there, both excellent vascular men. I asked if I was needed, since there were two of them, and they answered, "Perhaps." That left me no choice but to scrub and put on a sterile gown and gloves.

  My job was to stand at the end of the table facing the anesthesiologist and hold the foot rigid by cupping my hands together around it. Both surgeons, of course, had to be near my end of the table to work on the knee. But they had their backs to me, as usual—especially the surgeon on my left, who was leaning over the table. I couldn't see a damn thing. The clock to my right indicated that it was almost 5:00 a.m. by the time the operation really got under way. From their conversation, I gathered that they were putting in a graft for the main artery, which runs down behind the knee toward the foot. An hour passed as slowly as an hour can, the minute hand creeping around the face of the clock. They got the graft in, and a pulse appeared in the foot, only to fade and disappear after a few minutes. That meant the surgeons had to open the graft and take out a fresh blood clot. They got another pulse, which again faded. Another clot. Open again. Clot. This process went on and on and on. I was absolutely amazed by their cool persistence and patience.

  With nothing to do and nothing to see except the clock, and standing there motionless with my hands in one position, I began to get uncontrollably sleepy. The sound of the surgeons' voices wandered in and out of my head, along with the image of the room. Only half-conscious, I fought hard to stay awake, and lost; I fell asleep still holding the foot. I did not fall down. Rather, my head sank slowly until my forehead bumped gently against the shoulder of the surgeon on my left. That brought me awake, so close to the fabric of his gown I could make out the cross weave of individual threads. The surgeon looked around and pushed me back into an upright position with the point of his elbow. Over his mask, cold blue eyes cut at me in clear disapproval. I was beyond caring, but the incident did serve to keep me in the ball game, because it brought back all my pent-up fury.

  It was now eight in the morning and here I was, after a sleepless night, with a full schedule of surgery ahead of me, still standing and holding that foot like so much dead weight. A job for a bunch of sandbags. In fact, sandbags would have done a better job; they do not sag or get angry. This was not the first time I had fallen asleep in the OR. Helping once on a thyroid case after a night without sleep, I had drifted away while holding the retractors. For only an instant, I think, because I had suddenly given one of those falling-asleep jerks, which startled the surgeon. He had asked, only partly in jest, if I was about to have an epileptic fit. But I don't think that surgeon knew I had fallen asleep. This one did, and he was irritated, although he and his sidekick continued to ignore me. Finally, when everything was finished and I was preparing to leave, the surgeon let me have it.

  "Well, Peters, if falling asleep during a case indicates your interest in surgery, I think the fact should be brought to the attention of the board." Rather than tell him to go to hell, I backed all the way down and pleaded lack of sleep and not being able to see the operative field. He was not impressed. "I'd advise you not to let it happen again." "No, sir." I walked out, harboring ineffectual, murderous thoughts.

  The regular surgical schedule had begun more than an hour before. In fact, I had missed my first case, which didn't upset me much. It was a second assistant's spot on a cholecystectomy, totally routine. Besides, I was scheduled for two more of them that afternoon. Sneaking down to the surgeons' lounge, I scrounged a few slices of bread, my first food in about fifteen hours. As for sleep, I wasn't much better off—one hour during the last twenty-six. I felt a little weak. The thought of another full day in surgery was not cheering.

  In the lounge I was bearded by an irritated chief resident who demanded to know where I had been during rounds. Early on, an intern learns the impossibility of pleasing everybody. Lately, however, I was striking out every time up and pleasing nobody, least of all myself. I reported to the chief resident on the few staff patients I had. Since I was on the private teaching service, I didn't have many staff patients—only those whose surgery I'd helped with. Both hernias were doing fine; the gastrectomy was already eating; the veins were okay and walking; and neither hemorrhoid had managed a BM. The disease paraded verbally out of me, unattached to personal names or thoughts.

  I almost forgot to mention the aneurysm patient whom we had scheduled for aortography that day.

  He had been sent to us from one of the outer islands because his X ray showed a suspicious shadow in the left lung field. It was probably an aneurysm, a bulge in his major artery. Without surgery, such an aneurysm generally bursts in six months or so, and the patient quickly bleeds to death. So it was important to act quickly, and to be sure of the diagnosis, which we could do best by making an aortogram. This fairly simple procedure took place in X-ray, where radiopaque dye would be injected into the man's artery just above the heart. For a few moments, before the blood swept it away, the dye would outline the shape of the artery, and X rays taken in rapid sequence would pick up an imperfection. Only then would we know whether surgery was necessary. Since I had done the history and physical on the man, I wanted to be there, and I asked the chief resident about it. "Sure," he said. "If the surgical schedule permits."

  That part of the system had not changed during the past nine months. We interns were still bounced back and forth between cases at the whim of the surgical schedule; too often, we had to miss seeing our own patients. If you work a patient up, you should stay with him and follow him through all his diagnostic procedures and his surgery. No one would care to argue against that, either from an academic point of view or from the standpoint of the patient's good. Nevertheless, whenever someone needed an extra pair of hands on a gall-bladder attempt (our minds, it seemed, were never in demand), we were sacrificed, without regard to the educational aspect or to the psychological effect on our own patients. It was another way to impress upon us how very dispensable we were.

  The chief resident disappeared, and a few minutes later I got a call from the surgical desk telling me that he had assigned me to help on a gastrectomy that was already under way. Apparently those extra hands were needed. I finished my stale bread and plodded once more into the OR area, mentally mapping out the rest of my day in surgery. After the present gastrectomy, I was scheduled for a nephrectomy—a kidney removal—in Room 10, and then the two cholecystectomies. As I passed Room 10 I realized the nephrectomy was already under way and that I would miss it. Nakano, another intern, was scrubbing on the case. Lucky bastard. That nephrectomy was more interesting to me than all the other cases put together. The patient had a tumor on his kidney, and the tumor had to be removed, even though it was not malignant. Until very recently, the surgeon on such a case would have been forced to take out the whole kidney; now, with advanced radiology, such tumors could be "mapped" very accurately, so that only the involved portion need be cut away. Ah, well, another time. I continued down the corridor toward my gastrectomy assignment. Normally I would also have been dismayed at the prospect of back-to-back cholecystectomies. But today I was in for a bit of luck, because both were scheduled with a good teaching surgeon. This man was like an oasis in a desert of conservatism. Of course, there was always a chance that the gastrectomy I was joining now would run over into the first cholecystectomy with the teaching surgeon. I hoped not.

  Hardly noticing the activity around
me, I strolled slowly down toward Room 4, in no hurry, forcing myself all the way. A glance at the operating schedule posted on the bulletin board increased my dismay.

  Like the Supercharger, this G.P. was a man of advanced age, small skill, and no modesty. He was also given to interminable and egotistical stories about his travail in the early days. Apparently, he had for years carried most of the burden of American medical service on his shoulders, performing feats of skill and endurance that blew the mind. At least, they blew his mind. A puckish resident had once dubbed him Hercules, and the name stuck. Hercules was another who always admitted his patients on the teaching service, so that the house staff would do histories and physicals for him. If you ever ordered an X ray, or even an extra blood count, he'd hit the ceiling, bawling you out for extravagant utilization of costly laboratory tests. Apparently 99 per cent of the lab tests had been developed since he graduated from medical school about the time the Curies were beginning to play around with pitchblende. Moreover, he had a favorite habit of prescribing penicillin or tetracycline for every cold that appeared in the ER—a practice that virtually all medical authorities now agree is worse than doing nothing at all. That he was supposed to be one of our teachers was simply a bad joke.

  I had scrubbed with Hercules several months earlier, on a kidney-stone removal. At the time, he'd just finished reading, so he said, an article in a recent surgical journal recommending a new way to remove kidney stones. I doubted that Hercules read deeply or often, but this article had intrigued him—although he could not seem to remember the name of either the author or the journal, or even where the experiment had been conducted. As he worked down to the kidney, fondling the notion of this new procedure, he had indulged his habit of slicing through arteries indiscriminately and then stepping back to say, "Get that bleeder, boy," hardly interrupting what he was talking about. The resident would scramble around in the wound, dabbing with gauze sponge and hemostats, while the surgeon pontificated.

  This new kidney method of Hercules's involved putting a 2-0 chromic suture—a very large thread— through the kidney and then, by holding the suture at both ends and manipulating it somewhat like a blunt knife, sawing back up through the kidney. This was supposed to reduce bleeding. The procedure sounded a bit strange and oversimplified to me. As it turned out, mine was a healthy skepticism. Hercules had forgotten one vital point that the article repeatedly emphasized: before "sawing" with the suture, the surgeon must first gain control of the kidney pedicle—the source of blood to the kidney—so that the blood flow through the organ is essentially stopped. Well, our fearless innovator plunged ahead, making no provision to control the blood flow, but sawing nonchalantly up through the kidney "to minimize bleeding." The result was the worst uncontrolled hemorrhage I have ever seen in an operating room—except for the time the right atrial catheter of a heart-lung machine fell out of the patient. But that was a legitimate mistake. The kidney disaster was not. Blood from the kidney vessels filled the wound instantaneously, overflowing it and soaking the table and all the operating team. We began to pour blood into the man through the IV, as down a deep well. Eight pints later, we had finally clamped down on the kidney, sucked out the wound enough so that the stone could be removed, and put enormous sutures through the kidney cortex. Since the human body holds only about twelve pints of blood, we had practically drained the poor man and filled him up again. It scared hell out of everybody. Even the anesthesiologist—normally in another world up behind the ether screen, with one eye on the automatic breather and both hands on his newspaper—was upset.

  Naturally, then, I wasn't looking forward to this gastrectomy with Hercules, whom I could see inside working away as I scrubbed. I hoped he hadn't read any more current literature. A resident named O'Toole was there, too, but no intern was in evidence. As I backed in, surrendering, I could tell the atmosphere was anything but congenial.

  "I want a decent clamp," yelled Hercules to the scrub nurse as he threw one over his shoulder against the white tile wall. "Peters, get the hell in here. How is a man supposed to do surgery without any help?" Some of these surgeons took a bit of getting used to. Much of the time they behaved like petulant children, especially when it came to the instruments, which they tended to throw around rather indiscriminately and to use in unexpected ways—such as cutting wire with dissecting scissors. Yet the next time they were handed one of these instruments that they might have damaged themselves, they'd stomp and rage, blaming all their recent bungles on a lack of proper equipment. No one ever said anything about these outbursts. You got used to them after a while.

  As I moved in next to Hercules, he clamped my hands around a couple of retractors and said to lift up, not pull back. A familiar line. Actually, I was able to fake it, because there was nothing to retract at the moment. The stomach, which Hercules was working on, sat right on top of the incision in full view. He would need retraction later, while making the connection between the stomach pouch and the beginning of the intestine called the duodenum. I fervently hoped he had already cut the nerves to the stomach that are partially responsible for the secretion of acid. Those vagus nerves wind around the esophagus, and in order for the surgeon to cut them the intern has to hold up the rib cage; I hated that retraction.

  Here I was again at my post in the OR watching a minute hand that appeared to be glued in place. As I fought to stay awake, my eyes blurred after each yawn, and my nose itched uncontrollably on the left side, a little below my eye, as if I were being attacked by a subtle, sadistic insect.

  The position of my mask was another subtle torture. Each time I yawned it moved a little down my nose, perhaps half an inch. After five yawns it fell completely off my nose and was just covering my mouth. This called into play the circulating nurse. She hopped around to my side and lifted the mask up, touching it ever so carefully to avoid my skin, almost as if my whole face were infectious. Wishing to relieve the itch, I tried several times to push my nose against her hand as she adjusted the mask. But she was too quick for me, and pulled away each time before hand and nose could meet.

  Hercules was even more nervous and erratic than usual. None of us around the table could anticipate what his next move might be. Fortunately I was immobilized by the retractors and not expected to contribute otherwise, but poor O’Toole was like a rat in an uncharted maze being called upon to perform impossible feats of anticipation.

  "O’Toole, are you with me or against me? Hold that still!” While delivering this rhetorical question, Hercules gave O’Toole's left hand a sharp swat with the Mayo scissors. O’Toole gritted his teeth and adjusted his grip on the stomach.

  “For Christ's sake, Peters, haven't you learned how to retract?" He grabbed my wrist for about the sixth time to readjust the retractors, even though retracting had nothing to do with what was going on at the moment. In fact, I wasn't needed; yet he wanted me there. He was like a lot of surgeons, who felt slighted if they weren't assisted by both a resident and an intern, regardless of need. I was a status symbol.

  Hercules had rotated in front of me so that I was staring at his back as he began putting in the second layer of sutures on the stomach pouch. I could see neither the operative field nor my own hands.

  The anesthesiologist spoke up rather suddenly. "Peters, please don't lean on the patient's chest. You're compromising his ventilation." He pushed my lower back through the ether screen to keep me from crowding the intravenous line. But I had no place to go, being already mashed up against Hercules.

  Just then O’Toole stepped abruptly back with a startled expression on his face, holding up his right hand. I could see a few drops of blood dripping out of a neat slice through the rubber glove into the side of his index finger.

  "If you had your finger where it was supposed to be it wouldn't have happened, O’Toole. Let’s wake up," boomed Hercules.

  O’Toole said nothing as he turned to the scrub nurse, who slipped on another glove. I guess he was thankful to be still in possession of the finger.


  Despite all, the surgeon somehow finished, and we began to close. One of my jobs was to irrigate with the bulb syringe after the strong, fibrous fascial layer of the abdominal wall had been closed with silk sutures about a quarter of an inch apart. O’Toole and I were feeling frisky by then, and as Hercules was rinsing his hand I raised the syringe up over the wound, over the patient, and shot a stream of warm saline across the table, hitting O'Toole in the gut. Our eyes met in understanding; we were partners in an unhappy situation.

  Rejoining us at the table, Hercules turned suddenly jovial. Obviously, he thought he had accomplished the impossible once again. "If s too bad that my art gets covered up under the skin instead of being visible to the patient. All he has to show is this little incision." O'Toole's eyes rolled up into his head in mock dismay.

  Since both O'Toole and Hercules were on hand to finish up, I marshaled my courage for the exit. "I have several other operations coming up, Doctor. Will you excuse me, please?" That irritated the old boy a little, but he waved me free with a gesture of noblesse oblige.

  First I scratched my nose, long and hard, a sensual experience. Then I urinated, which was equally satisfying. It was eleven-twenty-five, and since the nephrectomy patient was just coming out of Room 10, I had a few minutes while it was being made ready for the first of my cholecystectomies. Nearby, at the door of the recovery room, I saw Karen, my angel of mercy and sex, pristine in her white uniform. She had come to take a patient down to the ward, and when she saw me she smiled broadly, asking with a trace of sarcasm if I had slept well last night. I told her to be pleasant or one of these nights I would roll her out of bed. Glancing around, she shushed me, adding that she had told her boyfriend she didn't want to go out that evening; she would be in, probably from eleven on, in case I was free. I filed the fact away, but I didn't think I'd be up to doing anything about it.