The Year of the Intern

by Robin Cook

  That baby redeemed the night. Maybe they would name 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 it 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.

  The waves added to the atmosphere with their impetuosity and rhythm; one minute an organized vibration of harmonic motion, the next a swirling mass of senseless confusion. I caught one of the waves. I felt its power, the wind and the sound. Twisting as the board responded, I made my body work against the force to fall; speed and crucial milliseconds. Down the wave and then a twist of my torso, running my hand along the sheer wall of water and the crash and swirl, yet still standing, my feet on the board lost beneath a swirl of white foam. Finally the sudden kickout, with a violent but controlled backward twist, made me want to shout with the joy of being alive.

  Darkness erased the scene slowly and drove us back to shore. Hastings went his way and I mine, to the hospital for a shower. Back in the geometric, sanitized world of clean floors, utilitarian showers, and fluorescent lights, I dressed and left the grounds again. Driving up Mount Tantalus, I pleasantly anticipated the night to come.

  Her name was Nancy Shepard, and I had met her — how else? — through the hospital. Her father had been a gall-bladder patient whose progress I followed closely after assisting a private M.D. in the operation. Every time I changed his dressing, he had mentioned that he wanted me to meet his daughter, retelling how she had gone to Smith and spent a year at Boston University working on a master's degree in African history. In truth, I grew a little tired of hearing the stories, although I remained interested in meeting her. Finally, the day before her father left the hospital, she had appeared, and she was nice — very. In fact, she looked a little like another girl from Smith I had dated while I was in college. Anyway, we went to the beach a few times, which we both enjoyed. She could talk about almost anything; it was fun to be with someone educated and intelligent. A political-science major, she was fond of arguing heatedly over small points of government, especially about Africa. Despite a number of successful dates and my admiration for her, I stopped asking her out very often, mostly because of lethargy and lack of time. In fact, that night’s invitation to dinner had come out of the blue. Not that I didn't want to see Nancy. I just never got around to it — and by then Joyce had become pretty convenient.

  The dinner was fine. Nancy's parents and two brothers were also there, all of them lively talkers. After coffee, Nancy and I wandered out into the large, verdant yard and began an argument about Jomo Kenyatta and Tanzania. Why had Africa failed to produce more Kenyattas? She was emotional on the subject; it was good to see her color rise as she warmed to the argument, making her even prettier.

  But then she started asking me questions about medicine. Because she was really interested, not just passing the time, like so many, I worked hard to make her understand, answering as well as I could. Inevitably, she asked why I had gone into medicine. To this question an intern develops many answers. Most of them are evasive half-truths. But with her I decided to try for the whole truth.

  "Well, Nancy, I don't think I'll ever know exactly. In the beginning I suppose I had some vague notion about helping people by entering a noble profession. But now that I have a lot of medicine behind me, I think I was attracted just as much by the idea that being a doctor would give me a sort of power that other people don't have — a power over people as well as disease. Few things mean more to Americans than good health, and those who have that to give, or claim to have it, are automatically authority figures in our society."

  "What do you mean by power and authority?"

  "Just that, I suppose. It's something like the power a medicine man holds in a primitive tribal society. He holds a high position only so far as he's able to play on the fears of his fellow tribesmen and make them think he can control nature. If s a kind of legitimate hoax — legitimate because he performs a more or less useful function, and a hoax because he doesn't really control anything but the tribal psychology. I think modern medicine is the lucky heir to that kind of psychological misconception. My patients don't fall prostrate before lightning and thunder, but they're sure as hell terrified by cancer and lots of other diseases they don't understand. When they come to the hospital, they are looking for a medicine man in more ways than one. Before I went into medical training, I was like any guy in the street. I mean I believed in the power of medicine to do almost anything, and I wanted that power, wanted to be looked up to as the agent of that power."

  "But surely you mean the power to help people?" She still didn't understand.

  "Sure, I can help people. Not as much as I'd like, and nowhere near what they hope for, but some. But that kind of power is severely limited. Medicine is still fairly primitive. We just don't know enough. It's the other kind of power, the more abstract kind, that I'm talking about. That's nearly unlimited. For example — I played a little football in high school, and one time a fellow broke his leg in practice. I was right next to him in the pileup, and I found myself there looking straight at him, wanting to do something, but totally helpless. When I thought about it later, what I remembered was the envy I felt toward the doctor. I know now that he didn't do much except say a few soothing words, administer a painkiller, and haul the guy away. But to me, to all of us, he was a kind of god. The more I thought about it, the more I wanted a piece of that power."

  "But what about the idea you started with, of medicine as a noble profession, of just helping the boy with the broken leg. What happened to that?"

  "It got all mixed up with the god idea. Anyway, I went on to college planning to become a doctor. Although a lot of new avenues opened up after that, no pressing alternative appeared. So I finally just drifted into medical school, not really having anything else in mind, wanting both kinds of power, and realizing I could have them in the medical profession, plus the social status and a reasonable income. Now mat I've more or less made it, all those abstract notions have fallen apart on me. I don't have much social status, no money at all, the god-power thing seems utterly empty, and as for the power over disease itself — I hope to heaven I n
ever have to undergo any surgery. I know too much about the limitations of medicine."

  I should have been sharp enough to notice the slight chill Nancy was giving off, but I didn't. She had been waiting for the "ever since I was a little boy" story so dear to television and other fictionalized accounts of medicine. But she had made me reach down into myself, searching for answers, and the little boy wasn't there.

  "Then you don't feel you have any special quality that made you go into medicine? No vocation, so to speak?" She was still looking for Ben Casey.

  "No, this is definitely not like the priesthood for me. The closest I can come to medicine being a vocation is that I did well in both science and the humanities in college, and medicine is a logical combination of the two."

  "Well, you don't sound like you have the same motivations as the doctors I know." She was flaring up. And so was I.

  "Just how many doctors do you know, Nancy? My whole world is made up of them. I live with them— interns, residents, attendings, the medical-school crowd — and I can tell you that, in general, what happened to me happened to them, and what I feel is pretty much what they feel, if you can get them to admit it."

  "Well, I think it stinks."

  "What stinks?"

  "That our society has let you get this far. You're the wrong person to train as a doctor, because you don't care enough about helping other people."

  "I just told you that I want to help people, and I do, but the whole thing is more complicated than that. Hell, I'm just like everybody else. I don't have one consuming goal that shuts everything else out. I want to live, too. Besides, a lot of the idealism I had was smothered in medical school. It's just not oriented that way."