The Year of the Intern

by Robin Cook

  I injected the bicarbonate into the same IV site— and pricked my finger in the process by putting the needle all the way through the little rubber section. Sucking my index finger, I watched the EKG. Slowly it began to show stronger fibrillation.

  "How about defibrillating now?" the ER intern suggested. The defibrillator was all charged up. A nurse held the paddles, with a smear of conductant on each one. Stopping his pumping, the ER intern took the paddles, placing one over the heart and one to the side of the chest. "Away from the bed!" The nurse-anesthetist let go of the Ambu. Wham! The patient jumped, his arms fluttered, and the EKG blip was gone. When it came back, it was just about the same. A medical resident arrived breathlessly and quickly got oriented.

  "Hang up a 5-per-cent bicarbonate on the IV and give me some xylocaine." The nurse gave the medical resident 50 mg. of xylocaine. He handed it to me, and I injected it. We defibrillated him again. In fact, we tried about four times before the fibrillation disappeared. But instead of a normal cardiac rhythm taking over, all evidence of activity in the heart disappeared, as the electronic blip on the EKG screen became perfectly flat.

  "Damn! Asystole," said the resident, watching the blip.

  Epinephrine, isuprel, atropine, pacemaker: we tried all the stuff we had. Meanwhile, the man's pupils came down to about normal size from the widely dilated state they'd been in when we first started. At least that meant that oxygen was getting to his brain, that our cardiac massage was effective.

  Another intern arrived, taking over the massage part so the ER intern could go back to his primary duty, poor fellow. Then I took a turn at the massage. "How about calcium?" the other intern suggested. The resident injected some calcium. I asked for another nasogastric tube, but didn't get to put it down until the intern could relieve me at the massage. There wasn't much in his stomach except some gas, and that was probably just what I had pushed in there earlier by mistake, through the misplaced endotracheal tube. I told the resident that this patient was the one whose EKG I had called him about earlier. I also told him that the portable X ray of the chest was generally clear.

  Looking behind me, I was surprised to see the Supercharger standing there quietly watching our feverish activity. I guess the nurses had called him. He didn't say a word. The resident injected the heart several times with intracardiac epinephrine. Still we couldn't break the asystole, and we were running out of options. Pumping and breathing, pumping and breathing, for fifteen minutes more we watched the machine trace a straight line across the oscilloscope.

  "All right, that’s enough. Stop now." It was the Supercharger finally speaking, after standing by in silence for almost thirty minutes. His words surprised us and failed to penetrate our routine, so that we didn't stop right away, but kept on pumping and breathing as if he hadn't said anything.

  "That’s enough," he repeated. The nurse-anesthetist compressing the Ambu was the first to stop. Then the intern, who happened to be massaging at the time. All of us were tired by then, thinking about getting back to bed, and conscious of the fact that we might have stopped earlier if the man's pupils hadn't reduced so well. Constriction of the pupils is one of the signs of revival; that had kept us going. But clearly this time it had been a false sign. So we stopped, and the man was dead. The Supercharger walked out and disappeared down the corridor toward the nurses' station, where he did the paper-work chores and called the relatives. The nurses unhooked the EKG machine, while I got out a large intracardiac needle.

  "How are you at hitting the heart?" I asked the other intern.

  "I've hit it one hundred per cent, but only on two tries," he answered.

  "I'm only doing about fifty per cent," I confessed. After attaching a 10-cc. syringe to the needle, I walked over to the patient and felt for the transverse ridge called the angle of Louis, about midway down the breastbone. This oriented me with respect to the rib cage. It was then a simple matter to find the fourth interspace on the left. The needle went in quite easily, and when I drew back on the plunger the needle filled with blood. Bull's eye.

  "I think my problem has been that I've been using the third interspace," I ventured. I tried it again, this time in the third interspace, and when I withdrew no blood appeared. "That's it. Okay, you have a go." I handed him the syringe, and he got the heart right away.

  I pulled the endotracheal tube out of the dead man, wiping the rather thick mucus on the tip off onto the sheet, where it left a gray trail. "This guy was really hard to get an endotracheal tube into. Want to try?" Gingerly holding the tube between my thumb and index finger, I advanced it toward the other intern. I was pretty good at entubating now, because I had made it a point over the last few months to practice whenever we had an unsuccessful resuscitation like this one, which happened pretty often. He took the laryngoscope and slipped it in. He said he couldn't see anything. I looked over his shoulder and could tell he wasn't lifting enough with the point of the blade. "Lift until you think you're going to dislocate his jaw." His arm quivered as he strained. Still something wrong. "Let me try." I pulled up, and then with my right hand I pushed down on his larynx. The cords came into view. "He has a pretty oblique angle there. Try it again, but push a little on the larynx." The nurse stuck her head in, saying she needed the 'scope so she could return the crash car to the ER. With a wave of my hand, I staved her off for a few seconds, while I looked over the other intern's shoulder. A sound of satisfaction came out of him as he finally saw the vocal cords. Then, walking out, he handed the 'scope to the nurse, who clucked in disapproval.

  Suddenly I was alone as the activity moved on, like some grim parade, to the living in other parts of the hospital. I wondered again whether to go to Karen's place or mine. It was a lonely time, especially because the man had died. I had been one of the last people to see him alive. But I had done everything I could — we all had — I guessed we had given it a good try. Besides, it was the Supercharger who had made me take the NG tube out and who had given him some sort of drug. So it wasn't my fault, though he probably thought it was. No doubt he would blame it on all those expensive tests. That was one of the troubles with the setup for private patients. I was available to see the patient but had no real responsibility, whereas the attending had the ultimate responsibility but was not on the scene. That made my position ambiguous, to say the least. It was too complicated for 4:00 a.m. Still, I was curious about Supercharger's last injection. The nurse had said it was a sedative. If I went back to look at the chart, I'd have to see the bastard again, and he'd probably have some timely comments about expensive blood counts. But, going up the hall, I decided it was worth the risk.

  The Supercharger was gone already. That was a relief; it was also an indication of his interest in teaching. Seconal, the order sheet said. It added nothing to what I knew. Reading through the work-up again, I noted that the man did not have a history of heart trouble. The stomach and kidneys were normal, too. Then I read that the hernia had been a huge, basketball type of problem; yet that didn't seem to explain his course. Something had made him go into respiratory failure ultimately leading to heart failure. The gastric distention I had relieved must have added to the problem, but it had not caused it. What about the anesthesia? I wondered. Turning to the anesthesia record, I read that it had been pentothal induction, maintenance nitrous oxide, no complications. I vainly struggled to pull in all the loose pieces, but I couldn't work through the maze. I was too exhausted. Better hurry back to bed, I thought cynically, so as to be there when the operator calls to wake me up for the day. Very funny.

  But it was a bad, bad Tuesday night. Tuesday nights were generally active, Like Monday nights, since both Monday and Tuesday always had full operating schedules, and that meant a lot of nighttime dressing, pain, and drain problems; still, I usually got some sleep. Not this time; hardly had I put my head against the pillow when the phone rang again. It was the OR; a case was coming up for amputation, and I was needed to assist.

  There was something particularly upsetting to me
about an amputation, especially of the leg. An appendectomy or a cholecystectomy or any of the other interior operations left the surface of the person intact. But lifting a foot and a lower leg from the table and carrying them away from the person they belonged to was an irreversible act of alteration. No matter how jaded I became, I was never able to look upon the removal of a human limb as just another medical procedure.

  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.