Authors: Robert Marion
Â
People who live outside of New York City carry a vivid image of what the Bronx is like. That image is based on a picture that appeared in newspapers around the country, a photograph of then-President Jimmy Carter standing amid the burned-out rubble of Charlotte Street. But the poverty and the dilapidation of the South Bronx is really only one view of the borough. At the opposite end of the spectrum, at the northernmost part of the Bronx, there's Riverdale, one of the wealthiest sections of New York City. And in between the North and the South there are numerous middle-class neighborhoods, each with its own special character and ethnic flavor. The people from all these communities share one thing in common: They receive their medical care at the hospitals in which our interns and residents work.
But the poor children of the South Bronx are by far the Pediatrics Department's biggest customers. They're the ones who crowd the waiting areas of our emergency rooms and fill past capacity the beds of our hospitals. Many of the problems from which these children suffer are directly related to the extreme poverty in which they live: They get anemia and growth failure because of inadequate diet, lead poisoning because they eat the paint chips that fall from the ancient walls and ceilings of their apartments, and asthma from inhaling the polluted air that hangs over the South Bronx like a deadly cloud. Other medical problems are indirectly related to the poverty: As young children they're physically and sexually abused and abandoned by their angry and frustrated parents and other adult caregivers; as adolescents, unable to find jobs or stimulation, seeing little to look forward to, they turn to drugs and sex, having babies when they themselves are still children and getting infected with venereal diseases and the human immunodeficiency virus in the bargain. And all these problems fall into the laps of our house officers, who have to work doubly hard to figure out how to relate to these abused children, sixteen-year-old mothers, and adolescent crackheads while very often functioning simultaneously as doctors, psychologists, and social workers.
The vast majority of the patients who come to the emergency rooms at Jonas Bronck and West Bronx hospitals are black or Hispanic. The vast majority of the house officers are white. Sometimes it's difficult for the patients to relate to these doctors who know very little about how poor people live or what makes them tick. When I was a resident, I saw a six-year-old boy who had come to the emergency room with a fever. I diagnosed an ear infection and prescribed an antibiotic in liquid form. I carefully instructed the boy's parents to give one teaspoonful of the medicine every six hours around the clock and to keep the container refrigerated. A week later, the child was back with the same symptoms. When I asked if they had given the medication as prescribed, the mother explained that she had tried, but since they didn't have electricity in their apartment, they couldn't keep the stuff refrigerated, nor was there enough light at night to measure it out. The therapy was bound to fail because I had no understanding of the social situation. It became necessary to treat the child with a capsule form of antibiotic to treat the infection effectively.
Dealing with these kinds of social situations is a huge problem for our house officers. As I've already mentioned, frequently social conditions are the direct cause of our patients' illnesses. The house officer can treat the asthma or the lead poisoning, but after the child is better, he or she will be sent back home and most likely will encounter the same environmental hazards that caused the illness in the first place. To provide really effective care, the home conditions would have to be altered, a monumental and frustrating task. Our overworked house officers wind up having to settle for treating the symptoms rather than the underlying disease, an unsatisfactory but necessary compromise.
Another big problem our interns and residents face is caused by their lack of understanding of their patients' cultural background. For example, people from certain areas of Puerto Rico have a very complex belief system based on hot and cold. Some illnesses are considered “hot,” some are thought to be “cold.” Similarly, remedies are believed to be effective for either hot or cold illnesses, but usually not for both. If a doctor prescribes what turns out to be a “cold” remedy for a “hot” illness, not only will the parent of the patient not use the medication, but also he or she will lose all confidence in that doctor.
Many of our patients speak no English and must rely on a doctor, nurse, or other patient to translate for them. In the emergency room, this slows down the doctors' progress through the pile of charts of patients waiting to be seen, lengthening the waiting time dramatically. The net effect of all these problems is that hostility builds between patient and caregiver.
Sometimes there's a great deal of hostility. Many of our patients use the emergency room as a kind of walk-in clinic, showing up at all hours of the day or night for problems the house officers consider trivial: belly aches that have been going on for three or four months, headaches for which no aspirin or Tylenol has been tried, mild gastroenteritis, complaints that the interns and residents know could be handled in a clinic setting, over the phone, or by the parents just using a little common sense. Since no one who shows up at the door of the ER can be turned away, the house staff winds up having to see these patients, getting backed up, and ultimately losing sleep because of what they consider this abuse of the system. And when one is chronically sleep-deprived, this can easily turn into resentment and anger, the ultimate effect of which is that the house officer will come to view the patient as an enemy.
Although hostility might exist between patient and doctor, it's nothing compared with the hostility that exists between a doctor and some of the other members of the staff. The best example of this is the relationship between the interns and the people who work in the laboratories. The intern knows, almost instinctively, that fighting with the lab technicians will only bring him or her misery. No matter what happens, arguing with a technician is a fight the intern can only lose. The lab technicians, after all, hold the key to the completion of the scut list; without the results of lab tests, the intern can never go home. But sometimes it's impossible to hold back.
As a house officer, I managed to hold back every time but one. When I was a senior resident, I was taking care of a sick preemie who was scheduled to go to the operating room the following day. It was my job to make sure that the child was pre-op'd, which included sending a specimen of blood to the blood bank for typing. The intern on call that night tried six times to get blood from this poor baby, who seemed to possess no visible veins in his entire body. I tried and failed four more times. Finally, on my fifth attempt, I succeeded; I managed to get about two cc's of blood.
I put the precious specimen in the proper tube, gave it to the medical student who had volunteered to carry it down to the lab, and went on with the rest of my work. About two hours later, a nurse happened to mention to me that the technician in the blood bank had called and said that because the tube and lab slip had been signed by a medical student instead of a doctor, it had not been acceptable. He had tossed the specimen in the trash and now was demanding a second sample.
Needless to say, I got angry. Trying to hold myself back, I ran down to the lab. I explained to the technician how difficult it had been to get that blood; I described in vivid detail how small and sick the baby was. He told me he was sorry, but rules were rules; unless a person with M.D. after his or her name has signed in exactly the right places, he had been instructed to dump the tube.
I got angrier. I started searching the trash cans in and around the blood bank. The guy caught me and said, “It won't do you any good. I poured it down the sink.”
That's when I really lost it. Three years' worth of repressed anger at laboratory personnel was immediately released in a single, spectacular tirade. I cursed out this technician, I cursed out his mother, his father, the rest of his family and friends; I went on for at least ten minutes. He didn't say a word, he just continued doing what he had been doing when I had first appeared. When I finally ran out of steam, I went back up to the ward and tried to get another sample of blood from the baby. It took only three attempts this time, but I got it, carefully signed the tube and lab slip, and dropped it off myself.
This kind of explosion is not uncommon. Lab technicians have a great deal of work to do and have a lot of people on their backs trying to get results. It's impossible to make everyone happy, so frequently no one is made happy. Many house officers will tell you that dealing with lab technicians is the most aggravating of all their jobs.
Perhaps all of these little aggravations make working as an intern in the Bronx more difficult than working in some other area of the world. Battling the environment, the patients, and certain members of the hospital's ancillary staff while chronically overtired is no mean feat. Year after year our house staff does it, and they learn to do it well. But the question still remains: Is it all worth it?
Monday, September 30, 1985
I guess I'm starting to get sick of talking about internship. I don't talk about it to other people very much anymore; I used to think maybe I shouldn't talk about it, maybe people wouldn't be able to understand what I was saying, but now I just don't want to anymore. Nobody fucking understands.
I'm over at University Hospital now, into my fourth month. I'm going to lose my mind before I make it to my first vacation. I have three more months to go, so I'm now only slightly more than halfway there. I've finished a quarter of my internship year. If you include vacations, I've finished a third of it. Yeah, only eighty more nights on call, right?
My apartment has become disgusting. I have so many roaches, they're crawling all over the place. I turn on the faucet and the water goes in the sink and the roaches come cruising out. They all dive off the edge of the sink right onto you if you don't move fast enough, because they're trying to get away from the water. Too many roaches, no one to talk to about roaches; no one to talk to about roachy thoughts. I wish there were people on my team I felt buddy-buddy with, like last month. But there aren't any.
Thursday, October 3, 1985
I'm really tired. I don't have anything to say anymore. I've been feeling depressed and apathetic and ground down lately. Tomorrow I canceled plans to go out with a friend. You know what I want to do instead? I want to be by myself. Isn't that weird? Tomorrow's a precall night, the only time I ever feel even a little rested, my only chance to have a little fun. And all I want to do is be by myself.
There were a couple of times today when I thought I should never have become a doctor. I just don't have what it takes. I don't know, it must not be true, people say I'm really good sometimes. But that's how I was feeling.
Putting in too many IVs . . . yeah . . . yeah.
Friday, October 4, 1985, 1:00
A.M
.
Should I tell you about the baby who died the other night when I was on call? Should I tell you? Another one died, this one right in front of my eyes. A DNR baby
[DNR: “do not resuscitate”: DNR orders are written only after careful consultation with all parties involved in the patient's care, including the child's parents]
, very sick. She was born with multiple congenital anomalies and they couldn't figure out what caused them. She had terrible heart disease and it was only a matter of time.
She had been admitted the day before I was on call because she was severely hyponatremic
[had a marked deficiency of sodium, an essential electrolyte, in her blood]
. As soon as she hit the floor, all these consulting services came to see her: genetics, renal, neurology, and endocrinology, you name it, they came by. Harrison, the intern who had admitted her, signed her out to me, saying that nobody knew what the hell was going on with her but that it didn't really matter because she was DNR, and if she crumped, I wasn't supposed to do anything but stand by and watch. The only scut he told me to do was that if she died, I was supposed to call the neurologist so they could do a brain biopsy
[take a specimen of brain in hopes that studying it would suggest a diagnosis]
.
It hadn't been a bad night; things were pretty quiet. Then at about eight o'clock, a nurse came and told me and the resident that the baby's breathing had stopped for a few seconds but then started again. The resident and I went in to look, and sure enough, she was having these long pauses in breathing. I did a quick physical exam and couldn't find anything specific that was different except the breathing pattern. We asked the nurse just to watch her, and we went back to the nurses' station.
About five minutes later, the nurse came running out again, saying, “Now she's not breathing at all!” We went back into the room and found that the nurse was right; the baby wasn't breathing; she was also bradycardic
[had a slow heart rate]
. The resident grabbed an ambubag and started bagging her and the heart rate started coming up again. Then all of a sudden it hit me: We were resuscitating a DNR baby. By that point it was too late: The heart rate had come back to normal.
I felt bad; I mean, this might have been the baby's one chance to die, and by resuscitating her, we kind of screwed that up. No telling how much longer the baby was going to hang on now. I went back in to talk to the father, who had been sitting in the room this whole time, to tell him we weren't going to do any more resuscitation. The father agreed.
About an hour later, the nurse came to tell us the baby wasn't breathing. We went back into the room, but this time we just quietly walked over to the bedside and listened to her chest. She still had a heart rate, but there wasn't much respiratory effort left in her. She was white as a sheet; I've never seen a baby that white before.
We stood over her like that for a while, occasionally listening to her heart, and finally, after about fifteen minutes, it stopped. The baby was dead. I looked up to the resident, expecting him to say something, and he just stood there with a goofy look on his face. I was thinking, You're in charge, you've got to say something. But he didn't say a word. It was very uncomfortable for a while, and finally I had to say it. I had to tell the father that the baby had died. There I am again, having to tell a parent that his kid was dead. I still have no formal training in it, but once again, the job fell to me. Why am I always the one? At least this time, everyone was expecting it, so it didn't come as a shock. But it still made my skin crawl.
I took the father outside the room and let him sit by himself for a while. Then I had the nurses come back and together we cleaned the baby up, took out all the tubes and stuff that had been in her. We swaddled her in a blanket and cleaned up the room. I had learned to do this in the NICU; after babies had died in there, the attending always tried to put everything in order before letting the parents spend time with their child. It made a lot of sense to me. So when we were all ready, the father came back in, I handed him the baby and sat him down on a chair. He held the baby, and we all left the room so he'd have some privacy. Standing outside, I could hear him cry. I started crying a little myself.
After a few minutes, I went to call the neurology attending. She was a total bitch; she yelled at me for not calling when the baby had stopped breathing the first time. I told her I had been told to call her after the baby had died, not when the baby was dying. I thought I was doing them all a favor, and all I got for it was a bunch of abuse. She told me I might have ruined any chance of making a diagnosis because of the delay. Shit!
Well, that was my last night on call. I've been feeling a little better, though. I wasn't completely depressed at work today. I actually enjoyed myself a little bit. I realized there are two things that make me enjoy work: sleep and not being on call. Being on call is the worst because when you're on call, even if you get very tired and you have tons of work to do, you still have to do it, there's no one around to help you out. It's very stressful. Being postcall is next worst because you're really tired and you always have a fair amount of work still to do, but you feel some relief because you're finally off the hook. Of course, the best time is when you're not on call and you're not tired, like today. I really liked that, it was really nice. Internship could almost be good if there were more times like today.
Sunday, October 6, 1985
I just got home. I'm postcall, I got no sleep, it was a busy night. I admitted four patients, which isn't bad, but there was an AIDS patient who was exsanguinating
[hemorrhaging; losing all his blood]
on the floor, a renal transplant kid who was in the midst of an acute rejection crisis, and some other patients who were basically causing trouble. My admissions were hideously staggered throughout the day and night, and I didn't know what the fuck was happening.
I actually got a really interesting case last night: a little kid with argininosuccinicacidemia
[an extremely rare inborn error of metabolism caused by a deficiency of an essential enzyme that results in liver disease, neurologic dysfunction, frequent infections, and, often, death in early childhood]
. The kid is really sick, but he looks just like the Michelin Man. He's got layers of fat around his belly and arms and legs, and it looks like tires. It's hard to feel sympathy for him because I laugh every time I look at him.
Harvey Abelson, the director of pediatric home care, the service that manages all the chronically sick patients, is the Michelin Man's doctor. He's really nice and he's smart and he's a good teacher from what I can tell. Very intense, totally intense guy.
The transplant kid sounds like the beginning of a sad story. He got this new kidney in August. His mother donated it to him. There were some problems around the time of the transplant, but he pulled through. Now he comes in with rejection crisis. His blood pressure's about 180/140
[normal for this patient would have been about 100/60]
. They're talking about having to take out the good kidney to bring down the blood pressure. The mother's beside herself.
Monday, October 7, 1985, 11:00
P.M
.
I think I want to be Harvey Abelson when I grow up. He's hyper but he's a pretty impressive guy. He's right on top of everything all the time. You should see him working out what needs to be done with the Michelin Man. He knows everything! Yes, Harvey Abelson, that's who I want to be.
My brother got married today. He didn't want anybody else to be there, so he invited only a couple of people. My parents weren't invited, I wasn't invited, we were “uninvited.” I wished I could have been there, but I respect their wishes. My parents, however, are major-league pissed off. My brother and his wife, they were going to do it in December but then at the last minute they decided to do it today. I heard about it, of course, from Karen. I don't know . . . there has to be a better way.
I had to stay late tonight to get my work done. My transplant patient seems to be better; his renal function's coming back and his mother's calmed down a little, too. But there was a lot of scut work to do so I had to stay until nearly eight. Now I'm going to bed. A solitary life, that's what I'm leading.
Let me check if there're any roaches in my bed. I've had roaches in my bed recently, roaches crawling in my bed. I woke up the other day and there was a dead roach underneath me. I must have rolled over and squished it.
I don't know how I'm going to make it until Christmas, when I have my vacation. I just don't know how I'm going to make it. It's just too long.
Some kid asked me what I was doing, who I was today. He asked me if I was a doctor and what kind of doctor I was. I told him I was a hospital doctor. Just a hospital doctor. Someday I'll look back on all this and cry. Has it always been this hard?
Tuesday, October 8, 1985
I've got to do something about this. I've been wallowing in this low- to moderate-grade depression for about the past month now, and that's all I'm doing is wallowing. I can't stand this feeling anymore. I've got to do something about changing my attitude. It's the only way, because if you can't go over and you can't bow out, you gotta go through it. And that's what I've got to do.
Thursday, October 10, 1985
I spent a long time teaching my medical student today, telling him about fluids and electrolytes. Very exciting! I feel like I don't know anything. I guess that's not exactly true, though. I do know how to teach about fluids and electrolytes. But that's about it.
And I got myself reorganized again. Started using my daily flow sheets again on all my patients, something I hadn't done for the past week because I was too depressed. I didn't give a shit, and I never really knew what was going on, and that made me more depressed and so I gave less of a shit. Getting organized should help. Getting organized will make things better.
I'm feeling kind of horny these days. Doesn't help having Karen two hundred and fifty miles away. Kind of get to eyeing the nurses, you know? But I don't think I'm going to follow up on any of that. Nope! Think I'll just stay true blue and all that stuff. It's just a couple more weeks; I think I can make it.
It turns out that Harrison Boyd, the other intern on our team this month, is completely insane. He's got a very funny, terrible sense of humor. Very bad jokes, the worst! And Laura Santon, who is always happy, actually looked depressed today for the first time. Maybe she was just spacing out, but she looked kind of upset. I was surprised.
Had pizza for the hundred and fifty thousandth time for dinner tonight. Seems that's all I ever eat around here, pizza. Missed the shuttle
[the bus that travels between Mount Scopus, Jonas Bronck, and University Hospital]
, had to take a cab home, and got a free, unguided tour of the Bronx, because they always take some strange route. Very interesting, the Bronx at night. Very exciting. I could have done without it.
Sunday, October 13, 1985, Morning
I've had so many nights of sleep in a row, I practically don't know what to do with myself. Yesirree, I was on call Friday night and I got seven and a half hours of uninterrupted sleep, breaking all records heretofore known for all interns in this program. It sure is a record for me. And it was good timing because my parents are here this weekend, they came down on Saturday. So it was great.