The Year of the Intern

by Robin Cook

  An even bigger scare concerning children had occurred with a seemingly routine case. It served to reinforce my fear that an ordinary situation would deteriorate before my eyes, leaving me helpless. The boy was about six years old, a cute little guy, brought to the scary ER by his overly solicitous parents. He wasn't feeling too well — that was apparent, because he had vomited three times and had other telltale symptoms adding up to the flu syndrome. For the parents' sake as much as the child's, I treated him with an antiemetic drug called Compazine, something I'd used successfully hundreds of time after operations. However, this time I got one of those adverse side reactions you read about at the bottom of the manufacturer's product information sheet — the type of episode the drug detail men don't like to talk about and doctors seldom see. Two minutes or so after the injection the child went into a convulsion, his eyes rolled back, he couldn't sit up unaided, and he developed an obvious rhythmical tremor. The parents were aghast, especially since I had been explaining to them the boy was not very sick. I frantically sedated the child with a little phenobarbital. While I was at it, I probably should have given some to the parents, too, and taken a little myself. I ended up having to admit the child to the hospital. Needless to say, the parents had not been very pleased by this performance, nor had I.

  So the early hours of Saturday passed, a combination of glorified pediatric clinic, suturing factory, and occasional true crisis. The few suturing jobs had been routine and rapid. My only disturbing problem had been that bearded fellow, but the hours and the tedium dulled it sufficiently so that the day became a typical one of generalized monotony punctuated by infrequent but memorable moments of terror and uncertainty.

  I was actually beginning to like the quick, uninvolved routine of the ER. No patient required such deep attention as to make a real claim on my emotions. I could remember when it had been different, six months ago, back at the beginning of my internship. Mrs. Takura, for instance, had gotten to me. We had become friends; her long operation, throughout which I held the retractors, unable even to see her wound, had been a physical and emotional trauma. When I finally got away from her operation, out to the beach with Jan, I had been secure in my intuition that Mrs. Takura would pull through. Returning to find her dead had been the final, backbreaking straw in my disenchantment with what was happening to me as an intern. I had blown up at the system — at petty day-to-day harassment, the retractors, the lack of teaching, and the constant, nagging fear of failure. It had taken me a long time to get over Mrs. Takura, and, finally, I hadn't so much accepted her fate as merely put it aside, vowing not to get emotionally involved again. It became easier, then, not to let patients get inside me. I began to think of them in hard, clinical terms, as so many hemorrhoids, appendixes, or gastric ulcers.

  Roso had also been a trial. Unlike the short time with Mrs. Takura, my rapport with him had developed over several months. I even gave him a haircut, after he had been with us so long that his hair was a shabby mane flowing halfway down his back. He didn't have any money, so I offered to cut it if he wanted me to. He was delighted; perched high on a stool in the sunlight of the alcove by the ward, he seemed proud to be alive. Everybody thought it was the worst haircut they had ever seen.

  Roso had always smiled, even when he felt terrible, which was most of the time. In fact, he had nearly every complication I had ever read about, and a few that were not even in the medical literature. His vomiting and hiccups had persisted until another operation became imperative. I was in my familiar position, both hands clenched around pieces of metal and looking at the back of the chief resident for six and a half hours while Roso's Billroth I was converted to a Billroth II; his stomach pouch was now attached to the small intestine at a point about ten inches farther down than usual. It was hoped that this procedure would end Roso's troubles, because the obstruction in his digestive system that was causing them was at the very connection between the stomach and the intestine that had been made in the first operation. But even after this second operation everything on his chart hovered near critical; his course was like a sine wave. Hiccups, vomiting, weight loss, and several horrendous episodes of upper gastrointestinal bleeding kept me busy— especially those bleeding episodes. A week after the Billroth II, Roso vomited up pure blood and rapidly sank into shock. I stayed with him several nights in a row, continuously irrigating his stomach with iced saline, and pulling out the nasogastric tube when it got clogged and pushing it back in. He hung on, somehow, through our mistakes and my miscalculations, and through his own relentless, troubled course.

  After the bleeding, nothing would go through his stomach until I was lucky enough to pass a nasogastric tube down through the anastomosis and into his small intestine. Using that as a start, I fed him directly into the intestine with special stuff. Some stayed down — but he got diarrhea. Then one day he sneezed out the nasogastric tube. I had him on intravenous feedings off and on for four months, balancing sodium and potassium and magnesium ions. He developed a wound infection, inflammation of his leg veins, a touch of pneumonia, and a urine infection. Then we became aware of an abscess under his diaphragm, which was causing the hiccups; back to surgery again. Somehow he managed not only to live through all this, but actually to recover. It took me four hours to do his discharge summary; his chart weighed five pounds — five pounds of my own writing, frequently stained with blood, mucus, and vomitus. When he left the hospital, I was happy to see him alive and vastly relieved to have him gone. His case and my attachment to it had been almost too much to bear on top of everything else. At times during his bleeds, administering the iced saline and seeing to his tube, I had begun to wonder if I had set him up as a challenge just because everybody said he wouldn't make it. Maybe I didn't give a damn about him, was just using him to prove to myself that I could handle a tough case. Eventually, though, I stopped examining my motivations and began to treat my patients as hernias, or whatever they had; it was infinitely less wearing. The ER was easy on a brooder. You were always too busy or too tired or too scared to think….

  Eleven forty-five in the morning. I was about to go to lunch when a rather pale young woman in her early twenties walked in with two girl friends. After a hushed consultation with the nurse, the pale one followed her into one of the examining rooms. The other two sat down and nervously lit cigarettes. The sound of a New York accent drifted out of the examining room as I wrote the last sentence on a baby's chart and put it in the "Finished" basket. Eager to get away for lunch, I pushed into the room where the nurse had taken the girl. The chart indicated vaginal bleeding for two days, clots that morning. The girl took out a cigarette.

  "Please, no smoking here, Miss."

  "I'm sorry." She carefully put the cigarette back and looked at me, then away. She was of average build, and dressed in a short-sleeved blouse and a miniskirt. With some color in her face, she would have been pretty. Her conversation suggested no more than a high-school education.

  "How many days have you been bleeding?"

  "Three," she said. "Ever since I had the D and C." We were both nervous. Wondering if my uncertainty showed, I tried to stand motionless and appear knowledgeable.

  "Why did you have a D and C?"

  "I don't know. The doctor said I had to have it, so I had it, okay?" She feigned irritation.

  "Where was it, here or in New York?"

  "New York."

  "Then you came here right away?"

  "Yeah," she said. She really had an accent. The fact that she had come to Hawaii so soon was off center. A six-thousand-mile trip directly after a D and C was not standard medical procedure.

  "Was it done by a professional person?" I asked.

  "Of course. Whaddaya mean, by a professional person? Who else?"

  What to do? If she had had an abortion — and I was pretty sure of it — I knew I would have some difficulty getting a private M.D. Also, I remembered all too well from medical school a string of girls in endotoxin shock from infections caused by bad D and C's. It
can happen so fast; the kidneys give up and blood pressure disappears. However, this girl's blood pressure was obviously all right for the moment. In fact, she was functioning well in all respects, except that she was quite jumpy and a little pale. I wondered if she was trying to follow my thoughts. She need not have worried. I didn't care how she had gotten into her condition, only how to get her out of it. My chances of discovering the exact cause of her bleeding were pretty small. She'd probably have to have another D and C. In that case, I would try to locate a private gynecologist, but few of them cared to get mixed up in such an affair — picking up someone else's pieces, so to speak. One way or another, a pelvic examination was in my future, and that was the last thing I wanted right before lunch.

  The memory of my first pelvic floated across my consciousness. It had been during a second-year medical-school course in physical diagnosis. I had had no preconceptions, which was fortunate, because my patient was quite a hefty lady. She was a clinic patient in for a regular checkup. At first I didn't think my arm was long enough to reach the uterus, and the guy after me claimed he lost his watch— although he found it later in the bag where we threw the gloves. At the time, we had not yet been through obstetrics or gynecology, and reaching into the lady was strangely unsettling. But after a hundred or so, a pelvic examination is a routine like any other. The only problem is finding the cervix — which might seem absurd, because it's always there. But when there's a lot of blood and dots, the job can be hard, particularly if the patient is uncooperative. Moreover, you don't want to hurt the patient by fumbling around. So it pays to take a few minutes extra and do a good job. But not before lunch.

  "How long had you been pregnant?" I suddenly asked the girl from New York.

  "What?" She was sputtering again, in obvious surprise. Since it was important for me to know, I let the question hang in silence. "Six weeks," she said finally.

  "And was it a doctor or someone else?"

  "A doctor in New York," came the resigned answer.

  "Well, we'll do what we can for you," I said, and she nodded in relief.

  Leaving the room, I told the nurse to get her ready for a pelvic. In a matter of minutes the nurse reappeared to say that everything was ready, and when I walked back in the patient was draped and waiting nervously in the stirrups, with her skirt rumpled around her waist. As I prepared to insert the speculum, I couldn't help recalling a night six weeks before when I had been waked up by a nurse saying that she couldn't catheterize an elderly patient with a full bladder because she couldn't find the right hole. I had gotten up and been halfway over to the hospital before the ridiculousness of the situation hit me. If the nurse couldn't find it, how could I? But I did, after a while; it was just a matter of persistence.

  It was the same with finding this cervix. Persistence. Surrounded by blood and clots, which I cleared away as best I could, the cervix suddenly popped into view. The orifice was closed, and no new blood appeared when I dabbed it with a sponge stick. I pushed down on the abdomen, to the girl's great discomfort, and got nothing. Then I noticed a small tear, bleeding very slowly, on the posterior aspect of the cervix. Almost surely that was the problem. I cauterized it with silver nitrate, called a gynecologist, explained things, and walked over to lunch with a unique feeling of accomplishment. Miraculously, I was still hungry.

  Lunch was a rapid affair; fifteen minutes of stuffing down two sandwiches and a pint of milk amid careless banter of surfing, surgery, and sex. Nothing serious — there wasn't time for it. I made some tentative plans with Hastings to go surfing late the following afternoon about four-thirty. Carno was eating at a distant table; except for seeing each other at the hospital, we rarely got together any more. I also talked with Jan Stevens for a few minutes. I hadn't seen much of her lately, although during July and August, early in my internship, we had had quite a spree, culminating in an unusual weekend trip to Kauai.

  The first day, Saturday, had been great. We stocked the car with beer, cold cuts, and cheese, and drove to the big Kauai canyon. On the way, the road rose and fell among the clouds, moving us in and out of quick rain squalls as the sugar-cane fields rolled by on either side. The canyon was even more expansive and spectacular than we had expected. I found a lookout for us, and Jan turned the groceries into sandwiches. I asked her not to talk — a necessary precaution, because as our relationship had developed so had her desire to communicate. The view was wonderful, what with rainfall, waterfalls, and rainbows sparkling in the corners of the steep valleys that branched off from the main canyon. I was totally at peace.

  By late afternoon we had driven to the end of the road on the northern shore, right at the beginning of the Napali coast. In a secluded grove of evergreen trees, I put up our borrowed pup tent, and as the sun prepared to set among the puffy little clouds along the horizon, we swam naked in the still waters within the protective reef. It didn't matter that there were campers in full view at the other end of the beach — although I wondered why they were so near the water, rather than where we were, on higher ground among the pines.

  Somewhat self-consciously we ran up to the car. I pulled on a pair of white jeans and Jan wriggled into a nylon windbreaker. Even another meal of cold cuts and beer couldn't destroy the atmosphere. Night descended rapidly, with the sound of breaking surf on the reef mingling with the soft whisper of the breeze through the evergreen trees above us. The night creatures began their eerie symphony, increasing in intensity until they dominated even the sound of the surf. The western sky was just a smudge of red. Jan looked beautiful in the half-light, and the idea of her in nothing but that nylon windbreaker seemed fantastically sexy. In fact, I was delirious with the sensuality of the moment.

  Naked once again, we returned to the beach. As we slid into the water the full Hawaiian moon floated over a ridge of trees; the scene was so perfect it seemed unreal. I couldn't stand it a second more. Holding hands, we ran back to the tent and fell together on the blankets. I wanted to devour her, to capture the moment in my mind.

  Slowly and reluctantly, from the depths of this wet embrace, I became aware of the whine of mosquitoes. In our desire to make love, we tried to ignore them at first, but they began to bite as well as whine. No passion could have resisted that onslaught. In dreadful seconds the whole sensual atmosphere disintegrated, ending with Jan's departure to the shelter of our Volkswagen. Still shaking with desire, I resolved to stick it out in the tent rather than sleep crammed into a car built for midgets. I rolled up in one of the blankets so that just my nose and mouth were vulnerable. Even so, the mosquitoes bit me so relentlessly that my face began to swell, and finally I surrendered, trudging back to the car accompanied by a swarm of mosquitoes who seemed as unfulfilled as I was.

  I knocked on the window, and Jan sat up, wide-eyed, opening the door with relief when she recognized me. I stumbled in wearily and told her to go back to sleep. After smashing the mosquitoes that had come in with me, I somehow fell asleep myself, under the steering wheel, in a contorted ball. In about two hours I awoke sweating. The temperature and humidity had risen to Turkish-bath levels; the moisture was so thick it had condensed on all the windows. Opening a side window, I felt a cool rush of air and about fifty mosquitoes come into the car. That was that. I started the engine, told Jan to relax, and drove out to the main road and back toward Lihue, until I found an elevated spot with a good wind, where I managed to doze until the sun came up. My breakfast was bread and cheese mixed with ants and sand and washed down with warm beer, all eaten off the hood of the car. Then I woke Jan up and we drove back to town.

  Somehow Jan and I had drifted apart after that. Not that I blamed her for the weekend. It was more because she began heckling me a lot, especially after we started sleeping together, wanting to know if I loved her, and why not, and what was I thinking about. I loved her sometimes, in a way that was hard to explain; as for what I was thinking, most of the time we were together my mind just drifted. Anyway, I couldn't cope with her questions. It had simply become
convenient to let the whole thing slide back into casual friendship. But it was nice seeing her in the cafeteria. She was still a great-looking girl.

  The ER had completely changed in the fifteen or twenty minutes I took for lunch. A new group of people stood waiting, and eight fresh charts were waiting in the basket. Obviously no real emergencies were at hand, or the nurses would have called me immediately. Just more routine stuff. One of the new people was a chronic visitor to the ER, in for his usual shot of xylocaine to ease an alleged back disorder. His arrivals were so frequent and predictable that the nurses always had a needle full of xylocaine ready and waiting for me on the tray next to the patient. Kid Xylocaine, as we called him, had developed a certain expertise about his condition, and this was his time to shine, as he directed me where to insert the needle, how to insert it, and how much to give. Feeling somewhat victimized by this ritual, I nevertheless did what he wanted; he sighed with apparent relief and left.

  Walking next into Room B, I was greeted once again by my drunk friend Morris, who had returned at last from the X-ray department. Flopped on an examining table and secured by a wide restraining belt, Morris held a large manila envelope filled with fresh X rays. He greeted me. "All I ever get is a goddamn intern. I don't know why I come here any more."

  Lunch had made me mellow and somehow able to ignore this prattle as I took the X rays out of the envelope and began to hold them up, one at a time, against the light of the window. I didn't expect to find anything of consequence, except perhaps in the upper left arm, which was badly discolored. Earlier, when I lifted and rotated the arm, Morris had rewarded me with a stream of obscenity. Something might be amiss there. I went through the whole stack of X rays — left knee, right knee, pelvis, right wrist, left elbow, left foot — on and on, without finding anything for the left arm and shoulder. Not there. Nothing to do but have the nurse return Morris to radiology. "They're going to love you up there, Doctor Peters," said the nurse. "He terrorized the X-ray department all morning and used up two boxes of film."