Intern

by Sandeep Jauhar

  Amanda and Nancy had come in early to receive sign-out from the departing intern. They had already divided up the fourteen patients, taking five each and giving me four. “So there’s an advantage to coming in late,” I quipped. Nancy forced a smile and handed me a stack of sheets. “You’ll need these for rounds,” she said curtly.

  The CCU was a rectangle, with most of the rooms arrayed along a long wall running parallel to the East River. There was a central bay with a nursing station and a medication room. At the front entrance were a clerk’s desk and a pneumatic tube system for ferrying specimens to the laboratory in the basement. At least once an hour one could hear the hut-hut-hut of a test tube containing a blood sample being whisked away for analysis. Sleek and modern, constantly buzzing, the CCU occupied a world apart from the rest of the hospital, which by comparison was relatively staid. Staff were constantly walking through, wheeling machines. Alarms rang incessantly. Consultants were always around, scribbling notes. That first morning, the nurses were in the middle of their change-of-shift routine. “Bed Two is still constipated,” a nurse announced. “She hasn’t had a bowel movement for me in three days. Bed Four got agitated again last night, requiring Xanax, which he’s still getting PRN. Seven is status-post a 250 cc bolus of normal saline because he was running tachycardic most of the night. Twelve was suctioned once: large, yellow . . .”

  I hurried to see my patients before attending rounds began at eight o’clock. The first of them, Paolo Fellini, was a well-to-do businessman who had been enjoying his retirement for years when he was felled by a massive heart attack. Over the ensuing weeks, he had suffered numerous complications, including respiratory failure requiring a ventilator, blood infections requiring broad-spectrum antibiotics, and a stroke, which incarcerated him in a sort of dementia that left him unable to recognize even his grandchildren, whose get-well cards were pasted all over the walls. On his bedside table was a picture of him standing on a boat, smiling broadly, looking every bit the Connecticut waterman he once was, a stark contrast to the man who lay before me. He was now wearing a diaper—judging by the fetid odor, it was filled with stool—and a hospital gown that was more off his body than on. His mouth was open: a thick crust coated his lips and tongue. His legs were twisted into an unnatural position, a result, no doubt, of his stroke. On his arms were large purplish bruises where attempts had been made to draw blood, and several tears in his paper-thin skin were still oozing. A plastic tracheotomy tube jutted out of his throat, connecting to a blue baffled hose that originated from a spigot in the wall. A bag was attached to his bed railing, filled with Coca Cola–colored urine. At the bedside were a teal blue IV monitor, several oxygen canisters, a ventilation bag, and a bundle of purple tubes which snaked across the floor and fed into inflatable cuffs on his legs. A bag of milky tube feeds and several bags of clear medicated fluids were hanging on a metal hook suspended from the ceiling. Above his head, connected to a flexible metal crane, was a small television, which was off.

  When I got near him, his eyes jiggled apprehensively in their sockets. “Good morning,” I said. “I’m Dr. Jauhar.” His breath faintly smelled of old rice. “What is your name?” He did not respond. “Do you know where you are?” I reached for my stethoscope. On the monitor, his heartbeat quickened and his breathing became more rapid and shallow. The ventilator started wailing. For all the talk of coma, he clearly sensed my presence.

  His ribs poked out of his bony chest like spokes on a wheel. So rippled was the topography of his chest that I could not find a flat place to put my stethoscope. I finally wedged it between two ribs. “I’m not going to hurt you,” I said as he grimaced horribly. I had read that patients who make it out of intensive care units often liken the experience to combat. Many suffer chronic anxiety and depression; others develop post-traumatic stress disorder. Drugs like morphine and fentanyl are used not just for pain relief but to keep patients from remembering their suffering.

  I tried sitting him up so I could listen to his lungs, but he resisted. I tried pushing him gently onto his side but he would not budge. Tears streamed down his sunken cheeks. I looked around for a nurse to assist me but no one was available. His lungs made deep, guttural groans, like a foghorn, so clogged were they with fluid and muck. I placed my hand on his abdomen and pressed gently. He opened his mouth, as if to emit a blood-curdling howl, but because of the tube in his throat, there was no sound. “I’m sorry, sir,” I kept saying.

  Outside the room, I jotted down a few notes. It was already seven forty-five. The encounter had taken almost fifteen minutes. I was going to have to scramble to finish seeing the rest of my patients before eight o’clock.

  I hustled to the bedside of Camille Panizzo, an eighteen-year-old with a rare blood disorder requiring frequent blood transfusions. Over the years, the excess iron from the transfused blood had accumulated in her vital organs, including her heart, which had enlarged and thickened, leading to congestive heart failure. In the CCU she had had numerous runs of ventricular tachycardia, a potentially life-threatening heart arrhythmia. Electrophysiologists were considering implanting a defibrillator in her chest to shock her heart in case it stopped, but in the interim they had decided to treat her with intravenous lidocaine, an anesthetic that suppresses arrhythmias. The infusion had worked—the ventricular tachycardia had subsided—but now she was deeply somnolent, a side effect of the drug.

  When I arrived, she could barely open her eyes. She had delicate, appealing features—blond, curly hair, high cheekbones, and a narrow nose. Her jaundiced skin was the color of polenta, probably because of all the iron in her liver. Her eyelids only fluttered when I introduced myself, but I could still make out that she had green eyes, and that they were beautiful. Her mother, also blond and pretty, like a middle-aged flight attendant, was sitting by the window. She asked me if a decision had been made about a defibrillator. I told her that it was my first day but that I would check on it and get back to her. “They have to do something about this medication,” she said wearily. “I can’t stand to see her like this.”

  The mood next door could not have been more different. Ramón Ojeda, a middle-aged taxi driver, had had angioplasty, where a tiny balloon and a coil of wire called a stent was used to open a severely blocked coronary artery. Now, just a day later, he was sitting up in bed, admiring a magnificent view of the sun-soaked East River and the Queensboro Bridge. He was going to be transferred to a regular floor today. When I informed him of this, he feigned disappointment. “Look at me here,” he said, arms outstretched. “I’m king of the world!”

  Across the hall, my last patient, Irving Waldheim, was lying on a cardiac recliner, staring at a wall. Waldheim was a wizened man in his late sixties with a shock of wild, professorial hair and gray bushy eyebrows. His skin was pallid and shiny, with a residue of perspiration. Like Mr. Fellini, my first patient, he had suffered numerous complications during his monthlong stay in the CCU, the latest being unremitting fevers of unknown origin. The workup, including numerous blood cultures and CAT scans looking for occult infections, had been negative. Now his doctors were saying that, ironically, the antibiotics he was on might be causing the fevers.

  The room was dark, one of four in the CCU without windows. Next to the wall was a plastic bucket filled with foamy secretions. On the bed was a quilt knitted with a verse from the Twenty-third Psalm: “The Lord is my shepherd. I shall not want. He maketh me to lie down in green pastures.” I asked Mr. Waldheim some questions but he did not respond. Since I was running late, I didn’t press. I was about to leave when his son, who was just coming in, asked me if his father could be moved to a room with a view. “I think some light would do him good,” he said. I told him that I would check with the other doctors.

  When I finally made it back to the conference room, the team had already assembled at the long table, their white coats draped over the backs of the vinyl chairs. “Jauhar’s brother,” someone said as I took a seat. The attending physician, Jonathan Carmen, nodded to ackn
owledge me. Dr. Carmen was in his late thirties, muscular and square-jawed, with a balding pate and an almost menacing visage. My brother, who knew him well, had described him as smart, savvy, your basic tough kid from Brooklyn who’d made it up the hospital ranks through hustle and hard work. I didn’t know how much of his story was myth and how much fact, but it was appealing nevertheless, and I had been looking forward to meeting him. “I’ve heard a lot about you,” Carmen said, looking me over intensely. “Thank you,” I replied stupidly.

  One of the senior residents turned to me. He was tall, with glasses, short brown hair, and handsome features. “I’m Steve,” he said, extending his hand. “We’ll be taking call together.”

  Carmen quickly went through the logistics of the rotation. There were three intern-resident teams, so call was every third night. Rounds were long, he warned, “so keep your presentations on point. Start with the chief complaint. And don’t just tell me what the patient said. Sometimes I’ll hear the chief complaint is, ‘It’s cold in here.’ ” He drew out each syllable in a high-pitched nasal sneer, like Jackie Gleason on The Honeymooners, and we all laughed. “That may be the chief complaint, but that’s not the reason the patient is in the hospital.”

  On rounds, we huddled around a metal rack bulging with charts, Carmen and the fellow in the center, then the interns, then the residents, who hovered on the periphery, periodically breaking away to answer pages. Outside each room, arms folded in postures of serious purposefulness, everyone listened intently as Amanda, Nancy, or I read off vital signs, medications, ventilator settings, fluid intake, urine output, nutritional data, and lab results from the flow sheets. Carmen and the cardiology fellow interrupted frequently to fill us in on details or to ask questions or to make clarifying comments. One of our patients was a nephrologist with kidney failure who wept inconsolably when we went to see him. It wasn’t clear what was wrong, except everything. There was a music school teacher who woke up with chest tightness and went to work, only to go to the ER in the evening and be told that he was having a heart attack. A young man with an artificial heart valve had continued to use heroin and now was hospitalized with another valve infection. “When’s the surgery?” he asked defiantly, and Carmen brusquely told him that it was up to the surgeons. When a resident brought up the issue of drug withdrawal, Carmen said, “Just give him what he needs. Let’s not worry about detoxing him here.”

  There was a pecking order to examining the patients. Carmen got first dibs, then the fellow, then the resident on call (today it was Steve), then the intern on call (me), then the remaining residents, and, finally, Amanda and Nancy. Carmen usually placed his stethoscope on a patient’s chest, but rarely did he perform a complete physical exam. He acted more like a facilitator who knew what was there but was trying to direct us to discover it for ourselves.

  I quickly discovered that Carmen loved to teach, and he favored the Socratic method. In true form, interns were first in line to get “pimped” (or interrogated), residents second, the fellow third. Knowing a question was eventually coming my way left me feeling anxious, like sitting on an electrified grid and waiting to be shocked.

  The first question came about halfway through rounds, when Carmen handed me an EKG. “Can you read this for us, Dr. Jauhar?” he said. My heart started thumping; a giddy sensation coursed through my belly and lower body. Then I stared at the EKG and couldn’t believe my luck. It was something I had reviewed in Central Park the previous week.

  “I see P waves that are not followed by a QRS complex, which tells me that there is some kind of block,” I started off. This (as I would soon discover) was classic roundsmanship, pretending to figure out in real time what you already knew. “The PR interval is getting prolonged before each dropped complex.”

  “So what’s the diagnosis?”

  “Type I, second-degree block.”

  “Right: Wenckebach,” Carmen said, referring to the cardiologist who had discovered it. “Good.” The team walked on in silence. When no one was looking, Amanda smiled at me and gave me a thumbs-up.

  At the bedside, Carmen showed us how to interpret the pressure tracings on a telemetry monitor, explaining how certain cardiac conditions give rise to certain waveforms. The terms were familiar from medical school, but I understood only a small fraction of what he was saying. By the time he was finished, I had scribbled down five things I needed to read about: transvenous pacemakers, dilated cardiomyopathy, systemic vascular resistance, thermodilution, and the Fick equation. I reproached myself for not reading more during the outpatient month.

  Outside the closed door of Mr. Waldheim’s room, I asked if he could be moved to a room with windows. “He’s circling the drain!” one of the residents blurted out.

  “It wasn’t my idea,” I replied defensively. “His son was asking.”

  “I have no objections,” Carmen said, cutting off the conversation. “Just check with the nurse manager.”

  When we got back to the conference room, someone flipped off the lights and we assembled in front of a digital workstation. Carmen pulled up the first X-ray. “Dr. Jauhar,” he barked. I jumped. “Can you read this for us?”

  I stared at the image, trying to make out the serpentine shadows running across the screen. Chest X-rays were not my forte. In medical school we had been taught a systematic way of reading them but I had forgotten it.

  “The bones look normal,” I said, trying to buy time.

  “What else?” Carmen said sharply.

  “It looks like he has fluid in the lungs.”

  “What are these?”

  Two pendulous shadows draped the screen. “Breasts?” I replied. There were snickers.

  “Correct. This is Camille, your patient. But don’t look at the lungs yet; just read the X-ray systematically.”

  This was precisely what I had forgotten how to do.

  “What’s the first thing you do when you read an X-ray?” Carmen asked rhetorically.

  I sat quietly, staring helplessly at the screen.

  “You ask yourself, ‘Is it a good-quality film?’ Assess the radiographic penetration. Look at the spine. You should just barely see the intervertebral spaces. See them too well and it’s overpenetrated. Not at all and it’s underpenetrated.” He paused. “Okay, what else?”

  I did not reply, inviting in the sharks. “You count the ribs,” Nancy volunteered. A bolt of anger shot through me. How dare she show me up!

  “Right, you want to assess the quality of inspiration. You should be able to count at least ten ribs. So, Dr. Jauhar, count the ribs.”

  I pointed to the first rib. “That’s the second rib,” Carmen said. “See how it comes straight out? The first rib is C-shaped.” I pointed uncertainly to another line. “That’s the clavicle,” Carmen said impatiently. He took my finger and placed it on a white marking on the screen. “That’s the first rib.”

  I counted them from top to bottom; there were ten.

  “What else?” By now he was answering his own questions. “You said it already. Look at the lung fields.”

  “They look wet,” I stammered.

  “You should get into a habit of calling things by their correct name. She has diffuse interstitial edema. As you alluded to before, there is pulmonary vascular congestion. See how the costophrenic angles are blunted; these are bilateral pleural effusions. These tiny markings are Kerley B lines. The cardiac silhouette is big. Of course, this is a portable film so you can’t really say if the heart is enlarged, but we know it is.”

  An acorn was pressing into the center of my brain. My throat was tight and my mind had ground to a halt. If not for my seat back, I felt that I would fall backward.

  “You have to read these things systematically or you’ll miss something,” Carmen said, his tone softening a bit. “But you know this already.”

  The cardiology fellow pulled up the next film and someone else took the hot seat. In the dark room, my face burned with embarrassment. I couldn’t recall ever feeling so publicly hum
iliated, and on my first day in the CCU, too.

  Later that morning, I was inputting orders into a computer when Rajiv stopped by the conference room. Even in his cotton scrubs and day-old beard, he looked debonair. He asked me how rounds went. I told him about the X-ray debacle. “Don’t take things so seriously,” he said. “That’s why it’s a three-year program.” I nodded indifferently and got back to my work.

  IT WAS NOW five-thirty in the morning, and I was done pronouncing Mrs. Piniella dead. Amanda and Nancy would be coming in soon to preround, so I printed the flow sheets for the day and started writing skeletons of my daily progress notes, to be filled in later as the blood tests and other data came in. An Indian man had been admitted by Steve during the night to rule out myocardial infarction, so I went to see him. A nurse was sitting quietly at the computer in his room, inputting data. The patient, an elderly man with the quiet dignity of those who had endured and fought the British occupation, was sitting up in a chair. “It was the strangest thing, Doctor,” he said, breathing a bit fast but otherwise looking comfortable. “Last night I did not know where I was.”