The Year of the Intern

by Robin Cook

  Roso was Filipino, and his English vocabulary was limited to fifty or sixty trenchant words, which he used to convey emotional concepts. "Body no more strong," he would say, and it sufficed, like haiku poetry. I understood him and liked him very much. There was something tremendously noble and courageous about the man. Moreover, I think he liked me, which I realized later was an important part of my effort to keep him alive. When he saw me on morning rounds, Roso would smile broadly despite his hiccups, which made his whole body jump. Anyone could see that he was exhausted. I had tried every remedy I could find in surgical, medical, and pharmacological books, even folk medicine — breathing into a paper bag did not help him. In a more scientific vein, I had had him inhale a jug of 5-per-cent carbon dioxide, with no effect. Amyl nitrite and small doses of Thorazine hadn't worked, either, nor had calcium, which I tried in an attempt to correlate the hiccups with his general hypernervous state; his reflexes were so brisk that when I hit below his knee with my rubber hammer he'd flip his slipper off. My big mistake all along was in not considering the hiccups as symptoms of something deeper. I kept seeing them as an isolated problem, when in sad fact they were just a side effect of the smoldering catastrophe inside.

  The next symptomatic hint had occurred when the resident ordered Roso's stomach tube removed and fluids allowed by mouth. Within an hour his stomach blew up to twice its normal size, and he began to vomit. In no way could we have made him more miserable, what with the hiccups, the vomiting, and the lack of sleep; any one of them would have been enough to drive most people crazy, but valiant little Roso would still be there smiling every time I saw him. "Body no more strong," he'd say, always the same words, but carrying a slightly different meaning each time, depending on how he said them. "Body more strong soon"; I began to use his vocabulary in that curious way you do when talking to someone who doesn't speak very good English. You begin to think he'll understand better if you make mistakes, too. During medical school, with Spanish-speaking patients, I'd catch myself saying, "Operation you need inside abdomen." This made no sense, of course, because if the patient understood the words surely he'd understand them in the right order. Mainly we were trying to reach to these people, to connect.

  So poor old Roso had been put on intravenous fluid accompanied by constant gastric suction through the tube that disappeared into his nose en route to his stomach. Racked by constant hiccups, he vomited every time we took the tube out, whether we fed him or not. Just a few days earlier the tube had gotten completely clogged up, so that nothing but food stood between Roso and death. When I irrigated the nose tube to relieve the clogging, out had come a glob of material that looked like coffee grounds. It was old blood. It was lucky that I liked balancing fluid and electrolytes, because several times a day I had to figure out how much sodium and chloride were in those fluids that came out of him and replace them, plus the usual maintenance. I even gave him magnesium, on the chance it might help, after I came across an article in the hospital library on magnesium depletion.

  But Roso's big problem was inside, beyond my touch. Like Marsha Potts, he was leaking at the anastomosis site, the connection between the small intestine and the stomach pouch, except that in Roso's case the incision hadn't broken down. It was just leaking steadily all inside him, blocking his stomach and causing the hiccups, keeping him on IV fluids, driving his weight down every day so that now it was no more than eighty pounds. Fighting hard against the weight loss, which also meant loss of strength, I found articles about protein solutions and high percentage glucose solutions and tried everything they suggested; still he lost weight, going from merely skinny to the skeletal appearance of clear starvation. And through all this hell he smiled and talked his haiku. I liked him. Moreover, he was my patient, and I'd see him any time he needed me.

  "Roso, how you doing?" I asked, looking down at him now. What a sight he was lying there in the gloom, wearing nothing but pajama bottoms, with an IV sticking in his right groin and the tube hanging out his nose. Every eighteen seconds his body twitched with hiccups.

  "Doktoor, no more strong, too weak already." He managed that much without hiccuping. We had to do something. I had been plaguing the attending physician, the chief resident, everybody, but to no avail. Wait, they said. I knew we couldn't wait. Roso still trusted me, but his will was wearing out. "Doktoor, I no wanna live no more—" hiccup " — too much." No one had ever said that to me, and it stopped me cold. Although I could understand how he felt, I wouldn't admit to myself that he'd reached this point, because I had seen what happened to patients when they gave up fighting. They died, just drifted away. Something in the human spirit could hold everything together, even in the face of utter physiological collapse, until the spirit gave way and carried the body down with it. Sometimes the despair was so obvious you didn't ask a patient for normal responses, but Roso had spoken it, and that made his case different. I told myself that he just wanted to let me know he was near to giving up but actually hadn't yet.

  He desperately needed sleep. Although I could give him that, it was a two-edged sword. Sparine, a potent tranquilizer, would knock him out, anesthetize even the hiccups. But with that tube down his throat he was in constant danger of pneumonia, especially if he was unconscious; without the tube he might vomit, and if he vomited while he was knocked out, he might aspirate.

  The Demerol and the skinny old man upstairs still nagged me, too. His relatives had been splendid about everything, never sensing the doubt in me, taking my words at face value, not cringing at the autopsy request. What if I had told them that I only thought their father was dead? How could they know that the difference between life and death was sometimes not black and white, but gray and indistinct? Marsha Potts, for instance: was she alive or someplace in between? I guessed I could call her alive, because if she got better she'd be fine, maybe; on the other hand, she probably wouldn't get better, and at least part of her brain might already be dead. Some of her liver must surely be gone, in order for her to have jaundice and liver flap; her kidneys, too. Again, it wasn't black and white, any more than my decision about Roso and the Sparine. But Roso was in need of a rest, and I had an irresistible urge to do something. That must be a strong human drive, to do something — just as when somebody in a crowd faints, one bystander is sure to run for a glass of water and another always makes a pillow for the head. Both actions are ridiculous in medical terms, but people feel more comfortable to be doing something, even in a situation that calls for a type of action they are not equipped to give.

  I had had the same sensation several times. Once, during a high-school football scrimmage, I had been hurled onto a pile-up just as a guy broke his leg with an audible crunch, the leg bending off at an angle below his knee. Although he wasn't in much pain, the rest of us were panic-stricken, and, true to stereotype, I tried to get him to drink some water. I think that at that moment I set out unconsciously on the road to med school. The idea of knowing what to do, of satisfying an urge to act, was overpowering.

  So, all right, Peters, now you're a doctor — do something for Roso. Right, the Sparine it would be, and the second I made that decision, the happiness of positive, directed action flooded over me.

  "Roso, I make you sleep you feel more strong."

  As I sat down at the nurses' station, the almond-eyed nurse slid Roso's chart across to me. She looked even prettier than she had before. "Are you Chinese?" I asked, not looking at her.

  "Chinese and Hawaiian. My grandfather on my mother's side was Hawaiian."

  I thought it would be fun to get to know her. "How come you live at home?"

  No answer to that. Well, the hell with it. I opened the chart to write the Sparine order. Too bad, though. She looked like all the girls I had expected to see under Hawaiian waterfalls. Only I hadn't been outside the hospital long enough at that point to see any waterfalls, and my sex life, if you could call it that, was restricted to Jan. Would she still be there, even at midnight?

  I'd better get the hell out of here
, I thought, as I wrote "Sparine 100 mg. IM stat," put a marker in the chart to indicate a new order, and tossed it on the counter. Roso would sleep. The last time I gave him 100 mg. he was out for eighteen hours.

  "Doctor, as long as you are here" — the fateful, familiar question—'would you mind seeing a man with a cast, and also the quadriplegic?" I knew the quadriplegic, but not the man with the cast.

  "What's wrong with the cast?" I asked with some hesitation, fearing a request for a new cast at that hour.

  "He says it cuts into his back when he moves."

  "And the quadriplegic?"

  "He refuses to take his antibiotic."

  Actually, I hadn't really wanted an answer to that question. Paralyzed people caused me about as much psychic distress as those with tuberculosis. My mind went back to the most attractive building and the most depressing service in medical school, neurosurgery and neurology. I remembered examining one patient who answered my questions as I stuck him with a pin. He had seemed so normal I almost wondered why he was in the hospital until, when I pricked him again, his eyes suddenly disappeared into his head and the right side of his body stiffened, pushing him onto his left side and nearly, rolling him off the bed. All I could see were the whites of his eyes, and I was as paralyzed as he was, not knowing what the hell to do. There wasn't even the satisfaction of running for a glass of water. The patient was only having a convulsion, but I didn't know that then. He could have been dying, and I would have stood there with my mouth hanging open. No one outside the medical world can know what a crisis like that means to a medical student. You get so gun shy that you try not to be around when something goes wrong.

  Neurology students were expected to stand with hands in pockets enjoying the professor's elegant diagnosis: "Some of the spinal pathways cross over before running to the brain. Others don't. If you have a lesion effectively cutting off one side of the spinal cord, the tracts that cross will still work. Here, notice how this patient is able to feel this temperature change but cannot have any proprioceptive sense, because I can move the toe in any direction without his being conscious of it." And so it went.

  Everybody had a ball discussing those tricky little temperature fibers crossing over in the ventral white commissure and running up the lateral spinothalamic tract to the posterolateral ventral nucleus of the thalamus. Great arguments erupted over whether fibers were unmyelinated or myelinated. No field of medicine can match neurology for high-flown jargon. Meanwhile, nobody thought much about the patient. Well, you hardly had time, trying to remember all those tracts and nuclei, and besides, you couldn't do anything, anyway.

  Perhaps it was this lack of possibility that made paralysis cases so hard for me to handle emotionally. I particularly remembered one neurology case in medical school, although it was not unusual; in fact, it was a fairly typical case. The patient had lain before us in a respirator, his facial muscles moving constantly. Nothing else about him moved: he could control nothing else because the rest of him was a pile of immobile, unfeeling tissue and bone, completely helpless and totally dependent on the respirator for life. The professor had been saying, "You will find this an extremely interesting case, gentlemen, a fracture of the odontoid process, which caused the spinal cord to be severed just at the point where it comes out of the head." The professor was loving it. His diagnostic triumph had been accomplished, he proudly told us, only after a delicate X-ray procedure through the mouth. Then he was off, puffed like a pigeon and virtually cooing, into a long discussion of how the atlas had been dislocated from the axis.

  I had not been able to take my eyes off the patient, who was staring fixedly into the mirror just over his head. About my age and a hopeless case. To know that his body and mine were essentially the same, that the only difference was a tiny disconnection deep in his neck and that this fractional difference was total, had made me conscious of my body at that moment as never before, and ashamed of it. Just then I had felt hunger, my fingertips, a backache, sensations he would never have again. I was filled with helpless rage and a kind of heartsickness. Movement is so much a part of living, almost life itself, that from day to day normal people deny this kind of death. Yet here in front of me was death in life, and my mind was screaming at me that my own body hung on the same fragile string that lay broken there under the respirator. Many times since, in the dark moments, I had thought that the morbidity in medicine made it the wrong road for me, but I kept at it. Do other doctors have such doubts?

  For now, however, the man with the cast came first; I'd see the quadriplegic later. I got a cutter out of the closet and walked down the hall with the nurse. Turning into the room, we came upon a man in a gigantic spica cast extending from his navel all the way down his right leg to the toes. The left leg was free. That morning, he had fractured his femur about midway between groin and knee, and the cast had been put on right away. As usual on the first day in such a constricting mold, the man was excruciatingly uncomfortable. I found the edge that was bothering him and began to cut pieces away. It would have been quicker with the power cutter from the emergency room, but midnight is the wrong time for a tool that sounds like a chain saw. Besides, the vibration always scared the patient half to death, despite all your assurances that the power cutter vibrated very rapidly and therefore would cut only something stiff, not soft like skin. He would seem to understand until the cutter whined into action, knifing easily through the rock-hard plaster. I finished my cutting, and the fractured-femur case lay back with a sigh of relief, gratefully moving from side to side. "Much better, Doctor. Thank you very much." Simple things like that make you feel good. Of course, anybody off the street could have cut away the offending piece, but no matter. To know that the man would rest easily now somehow justified me and made my being there worth while. I was learning that an intern is not often allowed to make patients more comfortable. He is usually hurting them, sticking needles into them, putting tubes up their noses, coaxing a cough after an operation to force them to fully expand their lungs. That cough is especially hard and painful for chest cases. In chest surgery, it is a common procedure for the surgeon to split the breastbone down the middle, and wire it together again at the end of the operation. Four or five hours later, it was my job to cram a small tube down the patient's windpipe, irritating the membrane to force a full cough. The method was foolproof. Like anyone with something in his trachea, the patient invariably coughed, thinking halfway through that the convulsion would tear him apart, trying to stop but not being able to, and finally subsiding, sweat-soaked and exhausted, as I pulled the tube out. In the long run I had perhaps helped the patient avoid pneumonia or worse, but in the short run I had put him through hell. So making the man with the cast more comfortable was not to be lightly regarded.

  My euphoria didn't last long, however, for now I had to face the quadriplegic. Completely paralyzed from the neck down, he lay in a Striker frame on his stomach. A stream of anguished profanity poured out of him. A tube twisting out from underneath his body was connected to a dear plastic bag half full of urine. Urine was always a big problem in these cases. Since a paralyzed patient loses control of his bladder, he requires a catheter; with the catheter comes infection. Most cases of Gram-negative sepsis that I had seen came from urinary-tract infections. Criminal abortions were the not-so-rare exceptions. At the end of my gynecology service in third-year med school, we had so many septic criminal abortions that an epidemic seemed to be sweeping New York. Young girls, mostly, who generally waited until the infection was roaring before they came in, and even then they gave us no help with the diagnosis. Never. Some of them died denying the abortion right up to the end. With the legalization of abortion, I suppose the picture has changed, but many times back then I saw Gram-negative sepsis set in, with the irreversible combination of zero blood pressure, failing kidneys, and dying liver. Those Gram-negative bacteria like the urine, especially after a patient has been taking the usual antibiotics.

  Looking at this fellow as he lay there cr
ying and cursing, I knew all those things. Figuratively, I had my hands in my pockets, not knowing what to say or do. What would I want if I were twenty and lying in that contraption with everybody saying take it easy, you'll be all right, and knowing it was a lie? I thought maybe I'd like someone strong, who wasn't trying to fool me, who acknowledged the bald truth. So in an effort to be firm, I told him he had to take the antibiotic, that we knew it was tough, but still he had to take it. He had to take the responsibility of being human.

  Sometimes we surprise ourselves, talking out of unknown places inside us. I didn't know whether I believed what I was saying or not, but out it came. While I stood there the boy stopped crying long enough for the nurse to give him the injection. It suddenly became important for me to know whether he was relieved or only furious, but I couldn't see his face, and he didn't say anything. Neither did I. The nurse broke the silence and told him to try to get some sleep. Since I couldn't think of anything to say, I put my hand softly on his shoulder, wondering if he could feel my touch and my sorrow.

  I knew I had to get away from the ward now or collapse. At any time, in any hospital, a thousand small chores are there to be done, like looking at someone's drain, checking an incision, responding to a complaint about a stiff neck, restarting an intravenous. Actually, the nurses in Hawaii were pretty good about starting IV's; back in medical school it had been a primary job for the student. Neither rain nor snow could spare us from being called at three-thirty in the morning to trudge off across the deserted New York streets to restart an IV. One winter night I had braved the elements only to be confronted by a veinless man. I had poked and cursed, and finally started an infant scalp-vein needle on the back of his hand. Then back through the rain, eventually sliding into my bed after being up for more than an hour, whereupon the phone rang again. It was the same nurse, half apologetic and half aggressively defensive. While putting on some more tape to reinforce the IV, she had accidentally cut the tubing.