Authors: Robert Marion
Friday, September 13, 1985
We are going down to Philadelphia tonight. I wound up having to go. I'm just waiting for Karen to come home. I don't know how I'm going to get through this, but I found myself in a position where I couldn't say no.
All the patients I'm taking care of now are psychopaths. Every adolescent in the Bronx is trying to commit suicide. They're either trying to do it by an overdose, by shooting themselves, or by starving themselves to death. The floor is chock full of anorexics and bulimics. There are two types: the “walkers” and the “liers.” The “walkers” spend the entire day pacing up and down the halls. Whenever you need to find them, you just walk the corridors and there they are. They walk because they're trying to expend as many calories as possible, and this is about the only exercise they can get while they're in the hospital. They can't do their “jazzercise” four or five hours a day, so they just walk. The “liers” are worst off, though. They all look like concentration camp survivors; they're nothing but skin and bone. They're so debilitated, they can't do anything but lie in bed.
And there's nothing I can do to help them. I go and I try to talk to them, I try to reason with them about eating. They say they'll eat more but I know they're just doing it to get rid of me. They'll tell me anything they think I want to hear. Then they'll just go and do whatever they want.
I referred one of the psychopaths to my clinic today. A patient of mine, one of my suicide-attempt kids. He's nuts, but he's really a good kid. I think he just needs someone to look after him. I can't do a very good job of that as an intern, but I can at least be a little bit more of a support system. While I was making the appointment for him, I was thinking, Do I really want to do this? Do I really need this much of a problem coming to my clinic every week for the rest of the year? I hope I don't regret it.
My med student is turning out to be great. She told me I was great, too. She said I really cared about people. That's nice; I'm glad she said that. We pat each other on the back, and that's important because nobody else verbally applauds us. At first I didn't want her to do any of my scut, that's not what med students are for, but she was always willing to help and eventually I just got used to her being there when I needed her. I always tried to teach her things while we were scutting out, kind of on a one-to-one basis: I taught her how to do a gram stain
[a test to identify bacteria in a sample of body fluid]
and then when I needed one done, she'd run to the lab and do it for me. I taught her how to read an EKG
[electrocardiogram],
how to put in a Foley
[a catheter passed through the urethra into the bladder, to monitor the output of urine],
how to put in IVs. She liked that. She's going to be a great doctor.
Sunday, September 15, 1985, 1:00
A.M
.
I just got back from Philadelphia. I went down there with Karen and some friend. We went to a big party at Brad's house, but I couldn't stay for the bash; I had to come back home so I could be on call tomorrow . . . later this morning . . . Sunday.
Last nightâFriday, actuallyâI got home postcall and everybody came in after they'd gotten the car. They said they couldn't wake me up for ten or fifteen minutes; I wouldn't talk at all. I don't remember much, but I finally got out of bed and slept the whole way there. Soon's I got there, I went to sleep. I had a good time in Philadelphia; it was fun.
I talked to Ann while I was in Philly. She's a friend of mine from medical school. She's an intern doing pediatrics at St. Christopher's. Right now she says she just entered this phase of intense resentment and anger and depression and hatefulness. She hates her work, she hates her patients, and she especially hates anybody who's enjoying what they're doing. She says she doesn't think it's so bad because in three days she's going on vacation and she knows she can kind of get this way now. She says she didn't know what she'd do if she were in my shoes and had to wait another three months for vacation.
I'm starting to feel kind of apathetic, in a funny way. Does apathy follow depression? I don't have much more to talk about because I'm tired; tired and pissed. I'm also kind of sick of doing this diary, to be honest. I'm starting to feel kind of annoyed, I don't know why. I don't think I want to remember this fucking year.
Friday, September 20, 1985
I finally had a dream I remembered. I guess it's a good sign, but I think I'm better off when I forget them. The dream went like this: I was at work and the resident wanted me to check the potassium level on this patient who was taking a drug that depletes potassium. I kept making excuses, I don't know why, I kept putting off drawing the blood. Finally I was sitting in the library and a cardiac arrest was called. I went running in to find my patient dead and unresuscitatable. The rest of the house staff showed up and started yelling in unison that I had killed the patient. I woke up at that point in a cold sweat. I was terrified!
I can't exactly put my finger on what's wrong with me. I only have six patients now. Two of them are GORKs who don't make any extra work, and one is just a suicide attempt. But it doesn't matter. I still seem to get killed almost every night I'm on call. And then I come home postcall and fall asleep and Karen glares at me. I spend three hours with her every third night. Last Monday night, a friend from home came to visit. We went out for dinner. I fell asleep three times during the meal. When is it going to start getting a little better?
Monday, September 2, 1985, 11:00
P.M
.
I just got Sarah to sleep and I finally have some time to myself. Today's Labor Day and I had the day off. We had a great time: We went to a zoo, we went swimming, and we just generally relaxed. It was something we all really needed! It was freezing last night; I had to put Sarah to sleep in a sweater. Summer's ending; I usually get depressed at this time of year, but this year is different. I'm actually happy summer's ending. It means I'll never have to be an intern in the summer again!
I started on 8 West on Wednesday and so far it's been a mixed experience. It's not nearly as calm as University Hospital. There are some interesting things going on but it's not so taxing that I can't get out early. So those things are good. But our resident this month is an idiot! He's completely useless. He can't teach, and when he tries, he gets it all wrong! On Thursday he told us that the peak age for SIDS
[sudden infant death syndrome: the unexplainable death of an infant]
was six months to one and a half years. That's completely wrong! I know a lot about the subject, I've made myself crazy about it since Sarah was born, and I know the peak age is two to six months. I told Barry
[the senior resident]
what it really was and he stammered and argued for a while and finally said, “Let's just drop it, okay?” I looked it up in Rudolph
[a textbook of pediatrics]
after rounds and showed him I was right. He still hasn't admitted he was wrong.
He's also not very good technically. He couldn't start any of the IVs I've had trouble with and he can't get blood on kids after I've failed. So if he can't teach and he can't help, what good is he?
It's very upsetting having this guy in charge, but what can I do about it? So far what I've done is just ignore him. If I need help, I either ask Susannah, the other intern on our ward, or if she can't help, I go to the chief residents. The chiefs seem to understand our problem; they always come and help if we need it.
It's good to be working with Susannah. We were classmates at Schweitzer. She's got a ten-month-old daughter at home, so our motivation is pretty much the same: We both try to get out as early as possible. On days when I'm on call, I tell her to sign out to me as early as possible, and when she's on, I sign out to her as early as I can. Having this moron as our resident is mostly just a pain in the neck for Susannah and me. I feel bad for David, our subintern, and the medical students. They don't know how little they can trust Barry, and they might just believe some of the things he says. What this means is that Susannah and I are going to have to do some extra teaching this month to undo the damage caused by our resident.
I was on call Saturday, and it was quiet. I spent most of the day sitting in the residents' room watching TV. I got only one admission, in the afternoon, but we just about had to drag the patient up to the ward. It was a six-week-old who came to the ER with a history of a fever, a cough, and an eye discharge. The baby had been seen in some other ER the day before and was sent home, if you can believe that! Even I know that anyone under two months of age with a fever gets admitted to the hospital for IV antibiotics. But this bozo at the other hospital actually told the mother the baby was fine, he just had a little cold, and she should take him home. She brought him to Jonas Bronck the next day because he still had the fever. When the guys down in our ER heard it was a FIB
[fever in baby]
they pounced on him, did a complete workup, and got ready to admit him.
I wound up getting a few hours of sleep in the on-call room. The place is really disgusting; it's a tiny room at the end of 8 East with nothing in it except two sets of bunk beds and a telephone. Usually they don't provide pillows or blankets, so you have to steal linens from the clean-laundry cart, and you can do that only if the nurses like you or if they're not looking. They know me, so there wasn't any trouble. So life's not bad. At least so far.
Sunday, September 8, 1985
This is the end of another terrific weekend. We spent yesterday and today with my father in New Jersey. Because of the way the schedule worked out, I had Sunday and Labor Day off last week and this whole weekend off. I feel like a banker, not an intern. And I've actually had a chance to spend quality time with Sarah without the sitter being around.
Marie and I are getting along fairly well. We're not exactly best friends, but I think we at least understand each other. I guess I've come to accept some of her mishegoss
[Yiddish for craziness]
, and she's come to accept some of mine. I was concerned for a while that Sarah would come to think of Marie as her mother and me as someone else who happened to spend a lot of time around the house, but it's clear she knows who I am and who Marie is. Sarah's doing a lot of things now, rolling over front to back and back to front. She doesn't lie still for a second; we can't leave her alone on the bed anymore or she might roll off onto the floor. Then I'd have to take her to the ER for head trauma and they'd probably report me to the BCW.
I did bring Sarah to work with me last Wednesday. She had an appointment with Alan Cozza, and since his office is right off the ward, I figured we could get it in before work rounds. Alan told me Sarah's doing fine. She weighed over fourteen pounds. She's nearly doubled her birth weight in four months! And she got her second DPT
[diphtheria, pertussis, and tetanus immunization]
and OPV
[oral polio vaccine]
. I had to leave the room when Alan stuck her. It definitely hurt me more than it hurt her. Now I can understand how the parents feel when we stick their kids. Sarah cried for about twenty minutes after he finished. And that's after pretreatment with Tylenol!
Anyway, before rounds started, I sat in the residents' room with Sarah on my lap, and all the other interns and residents came over and oohed and aahed over her. A lot of them didn't even know I had a baby. It's so strange! Here are people I work with every day, I even sleep in the same room with them every third night, and they don't even know I have a baby! Of course, I don't know what's happening in their lives either. But this job tends to do that to you, it brings you into intimate contact with people who remain total strangers.
The work on the ward still is pretty easy. I've been getting out between three and four on the days I'm not on call; so has Susannah. The subintern's been staying until six or seven every night, but of course he's not really sure what he's doing yet, so naturally everything takes him longer. He also thinks he has to stay late to get something out of the rotation.
Everything would be perfect if it wasn't for that idiot Barry Bresnan! He really is dangerous. I hate work rounds in the morning. We do nothing but argue for an hour. He's got some very strange ideas about medicine, and most of the time they're wrong. One day last week, Susannah admitted a five-year-old with a hyphema
[bleeding into the anterior chamber of the eye; dangerous because it can lead to blindness]
. The boy had been hit in the eye with a baseball. Susannah did what the ophthalmology consultant told her to do: She put him in a private room, patched his eye, and kept him sedated so the eye would not get reinjured and bleed again. But on the rounds, Barry said there was no reason to sedate these kids; in fact, it was dangerous for some reason he never explained. He told us to stop medicating the boy and just let him run around and do what he wanted. Susannah told him he was crazy, that if the kid were to rebleed into his eye, it could cost him his vision, and that she was going to continue the medication because that was what ophthalmology wanted done. Barry yelled at her that ophthalmology wasn't running the ward, he was, and this is what he wanted to do. At that point Susannah figured it was useless to argue with him. She said “All right” and left it at that. She kept the patient sedated though.
Later in the day, when the chiefs made rounds with Barry, they told him the boy had to be kept sedated or else he might rebleed. So Barry came back to Susannah and said he'd changed his mind and she should start sedating the boy again. She told him she'd never changed the order in the first place, and that really pissed him off. But what could he do? He had been wrong and we had been right. He couldn't very well go to the chiefs and complain that the interns weren't following his orders, because his orders were wrong! He's so stubborn and so stupid. And he's dangerous. He could cause a lot of trouble for our patients. It's frightening!
Friday, September 13, 1985
I am really angry! That jerk is continuing to find ways to torment me. Every time Susannah or I make a decision, every time we try to do something to help one of our kids, he comes and tells us we're wrong and we have to change things, and we argue and get into a big fight. And it always turns out that we're right and he's wrong! It never fails! I don't know how he can be a resident and know so little! It's actually scary!
Today was the worst so far. We started off the morning fighting about a kid with asthma I had admitted last night. Nothing earthshaking or exotic, just a simple, straightforward eight-year-old asthmatic, something we see every day on the wards, and he found a way to screw up the kid's care!
This was a kid who gets admitted to the hospital four or five times a year. They gave him a minibolus of aminophylline in the ER.
[Aminophylline, a drug that dilates the breathing tubes, was, at the time of
The Intern Blues,
the mainstay of asthma therapy. In severe asthma attacks it was given by vein either in boluses, when a large dose is given once every six hours, or by constant infusion or drip; more recently, newer, inhaled medications have supplanted aminophylline in the treatment of asthma]
. I started him on a one-per-kilo drip
[a drip containing one milligram of aminophylline per kilogram of body weight per hour, the dose needed to maintain the blood aminophylline level]
after checking the old chart and finding that that's what it took to maintain his level. I drew levels
[blood samples to determine the amount of aminophylline in the blood]
after the bolus and four hours after starting the drip, and they showed he was in the therapeutic range. By this morning he was much better, but still he was wheezing a little. On work rounds Barry asked me what we had done. I told him and he said, “No, you did it all wrong, that's not the way to figure out what dose of aminophylline to give an asthmatic.” He then recalculated everything using this strange formula I'd never seen before and told me that we should have started him on a 1.5-per-kilo drip. I told him he was crazy, that if we put the kid on a 1.5 drip he'd get toxic
[develop blood levels of aminophylline in the toxic range; signs of aminophylline toxicity include nausea and vomiting and convulsions]
in a matter of hours and I certainly wasn't going to do that to my patient. He told me I was wrong, that he'd always used this formula and he'd never had any trouble with toxicity. That's when Susannah told him he probably just had been lucky in the past because she was positive that if we changed the dose to 1.5 per kilo, the kid would be vomiting by noon. She also happened to mention to Barry that she thought he was both full of shit and dangerous and that we'd all be better off without him. Although she and I had been thinking all of this since the very first day of the month, neither of us had said it to him before. He yelled back at us that we were the ones who were full of shit and that we could say whatever we wanted about him, but he was sure he had never seen two interns who cared less about their patients. I got really angry at that point and asked how he could say that. He said something to the effect that he had never heard of interns who left the hospital at three o'clock every afternoon.
Well, we were yelling loud enough at that point to get the chief residents out of the ICU, where they were rounding. Susannah said something about the fact that she and I were able to get out early because we had learned to be very organized and that maybe Barry's problem was that when he'd been an intern he hadn't learned anything and that was why he'd turned into such a bad resident.
That was when the chiefs separated us. Jon Golden pulled Susannah and me down the hall, and Eric Weinstein took Barry into the residents' room. Jon asked us what had happened, and I related the incident from start to finish. Jon said that Barry, as usual, was definitely wrong and that we were definitely right. He told us they were having a lot of problems with Barry, that he really did have some problem with his knowledge base and that, on top of it, he had no confidence in himself. “Of course he has no confidence in himself!” I told Jon. “He doesn't know anything! There's no reason for him to have any confidence!” Jon told us that may be true, but they were stuck with him, and we would have to try to make the best of the situation. He also told us we should try to be nice to him because it might help him with this confidence problem. That's not exactly what I wanted to hear and it wasn't what Susannah wanted to hear, either. She said there was something really wrong with all of this, that this guy was dangerous and he shouldn't be in a position where he had the chance to harm the patients. I said I thought he should be thrown out of the program. Jon kind of groaned and said that he really wasn't that bad and that we just should give him a chance. We just walked away at that point. There was nothing else we could say. We weren't getting through.