The Year of the Intern

by Robin Cook

  "That doesn't surprise me," I said, picking up a handful of new charts and heading for Room C.

  The afternoon babies were much like the morning babies, suffering mostly from colds and diarrhea. One had to be sponged for a temperature of 104.2, and another, about four years old, needed suturing for a laceration on his chin. Suturing children is very, very difficult. Their terror at being brought to a hospital, often bleeding and in pain, is only made worse by the papooselike contraption they are strapped into to keep them still. Not even the papoose could immobilize this boy's chin; it was like hitting a moving target. The worst part for him was being under the sheet with the hole in it. After the sting of the xylocaine, he didn't feel much of anything but pressure and slight pulling. Yet he screamed just the same, and hated it all the way. So did I.

  A thirty-two-year-old man in another room had a catalogue of complaints, beginning with a dry throat and proceeding down the body. His real aim was to be admitted as a hospital patient, and when he realized that the dry throat hadn't impressed me very much, his trouble shifted to a right-side chest pain. To test his reaction, I finally told him the hospital was already overcrowded, whereupon he stormed out in a rage, complaining that when you really needed a hospital it was always full.

  The afternoon drifted by in a carelessly busy way. By now I had seen about sixty patients, par for the course, with no more than the usual sweat. But Saturday night was approaching, and that always meant trouble. Two older men with asthma walked in together, and the nurses put them into separate rooms with the positive-pressure breathing machines. The gentleman in Room C was wheezing away, his bony chest held at almost full inspiration, his back straight, hands on his knees. I asked him if he smoked. No, he answered, he hadn't smoked in years. Reaching down, I slowly pulled the pack of Camels out of his shirt pocket, his eyes following my hand until he saw the cigarettes. When he looked up at me, the expression on his face, even in his suffering, was so comical yet warmly human that I couldn't help smiling. It was like catching a small boy in a piece of silly mischief. Much of the emergency room's appeal lay in its lavish display of the variety and folly of humankind.

  Old friends kept turning up. Another drunk, well known to us, stumbled in, complaining of a fall over a rocking chair that had left him with a chronic leg ulcer! I had seen the same ulcer a few weeks before when the drunk was a ward patient — an eventful time for all of us. Despite rigorous security measures, he had stayed drunk for days on end, and his discharge was probably hastened when the chief resident found him behind the blood bank with two bottles of Old Crow and a female patient. This time I bandaged his ulcer and told him to come back to the clinic on Monday.

  Between the drunks and the crying babies with colds, an ambulance pulled up unannounced, without siren or flashing red light. That meant it wasn't much of an emergency. When the stretcher was unloaded, it revealed a thin lady of about fifty dressed in dirty, ragged clothes. I followed one of the nurses, who was saying they couldn't get any response from this patient. And neither could I. The lady just stared at the ceiling, breathing heavily. She had a small laceration in the hairline of her forehead, but it wasn't even suturable. She seemed fully conscious, and yet she was totally immobile. I began a neurological exam, testing first her pupils and then her reflexes. No bad signs. But when I tried to do the Babinski test, by lightly scraping the bottom of her foot with a key, she practically hit the ceiling, screaming that there wasn't anything wrong with her feet, it was her head that hurt, and why was I fooling with her feet? She jumped off the examining table and disappeared down the hall, with a nurse in hot pursuit. Finally, we called the hospital administration and the police, who ended up dragging her away still screaming that she was all right.

  Down in Room F was an elderly gentleman who had run out of his diuretic, or water-eliminating, pills and whose legs were swollen with excessive fluid. He turned out to be one of those people with a remarkable talent for talking continuously and apparently sensibly without saying anything at all. A torrent of words rolled out as I tried to examine him. He spoke of his extrasensory perception and of the many times he had been able to use it, especially in communicating with his wife, who had died several years previously. Against my will I paused to listen while he described how he could take a bottle of water and distill it into his own model of the universe. In fact, he thought the earth was one small portion of one molecule of some gigantic object from another universe in another dimension. A little dazed, I gave him a supply of pills, told him to stay off his feet for a while, and took up the next chart.

  It was important to listen to these patients, despite the craziness and trivia. Every so often their ramblings were significant Once in the medical-school hospital a man had checked in to the ER complaining that he had eaten several shot glasses, without the usual complement of bread. The resident and intern began to escort him out the door, with the suggestion that he return in the morning, when the psychiatry department was staffed. Seeing their disbelief, the man grabbed at the intern's pocket, coming away with a test tube and a wooden throat swab, both of which he quickly chewed up and swallowed while the house staff watched in paralyzed disbelief. They turned him around, then, and led him back to the examining room, softly suggesting that he stay overnight. In the X ray, his abdomen had looked like a bag of crushed marbles.

  "Goddamn hospital. I'm never coming here again. Next time I'll go to St. Mary's." This was from the ubiquitous Morris, as he was rolled by on an examining table. Evidently he was to haunt me all day long, although I took some hope from the fact that now he appeared to be holding the X ray of his upper left arm. Perhaps I could get rid of him, after all.

  "Doctor, a call for you on 84," said one of the nurses.

  I already had the receiver to my ear, listening to a busy signal from my third effort to reach a Dr. Wilson, one of whose patients had come in suffering from a urinary-tract infection. Feeling frustrated, I pushed the burton for 84.

  "Dr. Peters."

  "Doctor, my boy has a terrible headache, and I can't find my doctor. I don't know what to do." Her story hung in my head, blending with the din of crying babies in the background. We didn't need another aspirin case, but there was no way for me to tell her not to come. Reluctantly I answered, "If you are convinced that the boy is ill, then by all means bring him to the emergency room."

  "Doctor, a call on 83." I told the nurse to put it on hold while I redialed Dr. Wilson, steeling myself for another busy signal. Instead, there was a ring and Dr. Wilson answered. "Dr. Wilson, I have a patient of yours here, a Mrs. Kimora."

  "Mrs. Kimora? I don't think I know her. Are you sure she's one of my patients?"

  "Well, she says so, Dr. Wilson." It frequently happened that doctors couldn't remember their patients' names. Perhaps a description of her problem would jog his memory, and it seemed to as I went on. "She has a urinary-tract infection, with heavy burning on urination, and her temperature—"

  "Give her some gantrisin and send her to my office on Monday," he said, interrupting me.

  I paused, fighting an urge to hang up. Why didn't he want to hear about the case — her temperature, urinalysis, blood count? "How about a culture?" I asked.

  "Sure, get a culture."

  "Okay," I pushed 83 to take the call on hold.

  "Doctor," a voice wailed on the other end, "I just had a bowel movement and there's blood in it?"

  "Was it bright red on the toilet paper?"

  "Yes." We established that her hemorrhoids were the probable cause of the bleeding and that she wouldn't have to come in to the emergency room, just see her physician on Monday. With a sigh of relief and profuse thanks she hung up. The nurse was holding another call, on 84, but this sort of thing could go on indefinitely, and I ignored it. Instead, I went back to Mrs. Kimora and explained very carefully about the gantrisin, that she would have to take two of the pills four times a day. A nurse took the urine for culture.

  Now for Morris. Immobile on the table and apparentl
y somewhat less drunk than before, he greeted me with his usual cheer. "I wanna get outa here." At least we agreed on that. Taking up the next X rays I held them against the light and saw immediately, with great disappointment, that he had a sharp fracture halfway between his elbow and his shoulder, as if he had taken a good karate chop. He would be with us a while longer.

  "Mr. Morris, you have a broken arm." I looked at him sternly.

  "I do not," he countered. "You don't know what you're doing."

  Wanting to avoid another yes-you-do-no-I-don't series, I retreated and rapidly wrote an order commending Morris into the hands of the orthopedic resident. The nurse called the switchboard operator and put the resident on page.

  By midafternoon I was barely keeping abreast of he crowds. About 4:00 p.m. we were briefly overwhelmed by a bunch of surfers with lacerated scalps, cut fingers, and deep coral cuts. The surf was up! The babies seemed unending, crying in every corner, with their temperatures, diarrhea, and vomiting. I was suturing madly, sending people to X-ray, and desperately trying to look into the ears of totally uncooperative children. One mother came in quite frantic, saying her baby had fallen down a third-floor rubbish chute with the garbage. I was tempted to inquire exactly how that had happened. But instead of asking any questions, I examined the child, and removed onion rings from his ear lobes and coffee grounds from his hair. Amazingly, he was quite intact. But I sent him to X-ray because his right arm appeared to be a little tender, and it did turn out that he had a greenstick fracture of the right humerus— about the least you could expect after falling three stories into a pile of garbage.

  Meanwhile, the X rays were piling up, all different kinds, from skulls to feet. I was the first to admit I wasn't much good at reading these things. But that was the system — the intern read the X rays at night and on weekends. It didn't make any difference that we were badly trained for the job; we had to do it as best we could. Knowing my lack of qualifications, I was always fearful of missing something important— especially after the humbling experience with the toe. That incident had occurred one other Saturday night, when a girl came hobbling in on the arm of her boyfriend. She had stubbed her toe. When I sent her up for an X ray, her friend went along. About an hour later, in the middle of pandemonium, I looked at the X rays, mostly at the metatarsals, and told them that they were apparently negative and— The friend interrupted quietly to say that when he saw the film he thought there was a fracture. I paused and gulped. "You did?" Back at the X-ray view box, he pointed out a line in the middle phalanx of the third toe that was definitely suspicious and could have been— indeed, was — a fracture. So it goes in on-the-job training!

  Morris was now conveniently stashed away in the orthopedic room, out of earshot. The orthopedic resident had responded to his page, examined Morris and his reams of X rays, and disappeared, after trying unsuccessfully to reach the on-call staff orthopedic attending. Morris would stay in the orthopedic room until the attending was contacted. So Morris was an albatross still to be carried, but he wasn't around my neck any more. I forgot about him.

  Around five-thirty the whiplash injuries started trickling in. That was standard whenever traffic got heavy and cars began piling into one another out on the freeways. Anyone claiming a whiplash injury needed a careful palpation of the neck, a thorough neurological exam, and a cervical spine X ray before his doctor could be called. All these X rays looked frightfully the same, and when I slipped one of them on the gigantic view box in the middle of the ER I felt as transparently vulnerable as the negative of itself. Moreover, the patients were always there, peering anxiously over my shoulder while I read their films. I only hoped they were impressed with my wizardry at making so much out of those smudgy black, white, and gray pictures of bones and tissue. It was mostly for their sake that I generally faked a thorough analysis, lingering a little longer than necessary over some part of the negative. Actually, anything I could diagnose had to be pretty far out of line or clearly broken in two, which took about ten seconds to determine. Anything else was a lucky hit. But you couldn't let the home team down, so I would gaze knowingly at the negatives, mumbling to myself and making notes, while the patient fidgeted, expecting the worst.

  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.