Authors: Robert Marion
Monday, January 27, 1986
Today was my first day in the nursery. What fun I had! I love staying until ten-thirty, running around like a chicken with my head cut off, having no idea in the world what the hell I'm doing. It was a million laughs! I can't wait to go back there tomorrow!
Well, let's see: How can I describe what the day was like? I came in at about eight o'clock, and Ed Norris, the director of the neonatal ICU at Jonas Bronck, tried to give us an orientation lecture. He certainly made things very clear; it was like listening to a lecture in Swahili! I couldn't understand a good 50 percent of the things he was talking about. He kept referring to the inhabitants of the unit as “your patients.” You know, “your patients this” and “your patients that.” And then we walked around and he showed us these so-called patients. My God, those things weren't patients! They'd have to quadruple their weight to be classified as patients. Right now, they're mostly tiny portions of buzzard food with lots of ridiculous wires and tubes coming out of them. This is going to be a long month!
They gave me eight of these things to take care of. For most of them, the kid's chart weighs more than the kid does, which is a very bad prognostic sign. And, of course, I didn't have a clue about what the hell was going on with any of them, so I spent the whole day sitting in the nurses' station trying to read these ridiculous charts, which were filled with words I had never seen or heard before and numbers I couldn't even attempt to figure out. I was trying like hell to make sense of all of this before one of these things wound up dying. At least I didn't have to go to clinic this afternoon; it was canceled. Thank God, because there's no way I would have made it anyhow.
I really can't believe this! It's ten-thirty, I'm just getting home from work, and this is my good night! It's just amazing! I have eight patients, they're all stable, and none of them is really that complicated, but even uncomplicated preemies have this long, annoying history, most of which I don't give a damn about. I mean, truly, I just don't care! There was a point there, about five o'clock tonight, where I swear I was this close to just taking all the charts, throwing them out the window, and saying, “Forget it! I'm sorry I ever applied to medical school! I never really wanted to be a doctor anyway!” I just couldn't take it anymore: just all these little runts who shouldn't be alive in the first place! Damn! Really annoying! But hey, I stuck it out, because I have such great self-control, and here I am, celebrating by eating my favorite food, Sno-Caps. This is the first thing I've placed in my mouth since breakfast. That was over fifteen hours ago! Working in this damned ICU is like being on a self-imposed fast! I feel like Gandhi, for God's sake!
I better try to eat neatly. This looks like it's going to be one of those months where I'm not going to get to wash the dishes or do the laundry! Maybe I'd better just start using paper plates right now. It's too bad they haven't invented paper clothes. That'd be perfect: disposable clothes for the house officer. Maybe if they could be made edible, that would solve both problems at once. I'm not making any sense anymore. I've got to get some sleep!
This place really sucks. What am I going to do?
Wednesday, January 29, 1986
Well, I'm home again. It seems like only yesterday I was last here, but actually it was the day before yesterday. I'm exhausted. I was on last night and I didn't get any sleep. No one ever gets any sleep in the nursery, so saying you didn't get any sleep on a night you were on call is redundant. I spent the whole night running around from bed to bed, doing stuff I didn't understand on babies I didn't think were human, for reasons that are totally beyond me. What a rewarding experience.
Here are a few more of my thoughts about the neonatal intensive-torture chamber. What a fun place it is. Starting to work in the NITC
[neonatal intensive-torture chamber]
, or the NICU, as the neonatologists like to refer to it, is like being thrown into prison in a foreign country where you have no idea what the fuck's going on. I really don't know anything! I've never even taken care of well babies before. I can barely tell the difference between the respirators and the babies. Before Monday, I'd never seen a kid with jaundice.
[Neonatal jaundice is caused by immaturity of the liver, the organ that removes bilirubin from the bloodstream; it's a common problem in infants and is treated with phototherapy, placing the infant under banks of fluorescent lights.]
I don't know when to turn on the lights, when to turn off the lights. I don't even know what a normal bilirubin is for a baby!
And I don't know what you're supposed to feed these things. I don't know how much they're supposed to eat, how much they're supposed to pee, nothing! If it weren't for the nurses, who, thank God, seem to know what the hell's going on, I'd probably have managed to kill off every last kid by now!
And even if I did know all that simple, obvious stuff, there's all this other information I don't even have a clue about. There isn't one word that they use in there that even sounds like anything I've ever heard outside the unit. It's like they make up terms just to make our lives more miserable, if it's possible to be more miserable than I already am! Every one of those kids has biochemical rickets. What the hell is biochemical rickets? I have no idea! And besides that, who cares?
As you can tell, all these little annoyances aside, I'm really having a lot of fun. I'm really enjoying taking care of these bags of protoplasm. My favorite patient is this kid Moreno. He's a three-month-old with congenital hydrocephalus.
[Hydrocephalus is a condition in which an excessive amount of cerebrospinal fluid, the substance that normally bathes and protects the brain and spinal cord, accumulates in the skull. Usually it is due to obstruction of flow of the fluid from the brain, where it is produced, to the spinal cord, where it is absorbed. When hydrocephalus occurs at birth, it is usually caused by an abnormality in the formation of the brain.]
This kid is all head! He weighs twenty-five hundred grams, and about twenty-three hundred of those are housed above his neck. And of those twenty-three hundred grams, 99 percent of that is fluid. His cerebral cortex looks like a ribbon around a water balloon. And that's after he had a shunt put in that seems to be working.
[A shunt is a piece of plastic tubing, one end of which is placed in the brain, the other end of which is placed in either the abdominal cavity, the chest, or the heart, that drains the cerebrospinal fluid out of the brain in patients with hydrocephalus.]
His head circumference today was forty-nine centimeters.
[Normal head circumference for a newborn is thirty-five centimeters. At three months, the head circumference should be about forty centimeters.]
This kid's got a great prognosis!
So anyway, Moreno's mother called me today. I wasn't in a very good mood, having been up all night and not having understood anything anybody has said to me in nearly three days, so I wasn't really in much of a mood to put up with her. She calls every few days to ask what the kid's head circumference is. She's fixated on his head circumference. I told her it was forty-nine centimeters this morning and she got all panicky, saying it was only forty-eight centimeters on Sunday and now it was a centimeter larger, and wasn't I worried about it, and what was I going to do about it? I calmly explained to her that no, I wasn't worried about it because it had been forty-nine centimeters when I got there on Monday and it was still forty-nine centimeters now and he wasn't irritable or vomiting and he didn't have any of the other signs of increased intracranial pressure, and since the neurosurgeons and the neurologists had been by to see him and neither of them had been upset by his head circumference, I wasn't going to do anything about it. I think I also told her that I was happy that his head circumference was forty-nine centimeters, I was pleased as Punch, and if she wanted to find someone who wasn't happy, I suggested she call the neurosurgeons or Ed Norris to see what they think. I think I said that, but I'm not sure because, like I say, I was kind of tired and I haven't been making much sense over the past few days. But I'm pretty sure of one thing: I don't think Mrs. Moreno is going to be calling me much during the rest of the month!
Well, there is one saving grace about working in this torture chamber. Some of the night nurses are extremely cute. One in particular: dark, brown hair, really beautiful. Damn! She almost makes it worth staying up all night. But not quite. Nothing could really make it worth staying up all night.
I must say, my progress notes have deteriorated significantly. I never really wrote very good notes in the first place; in fact, my progress notes have been voted among the worst ever seen at Mount Scopus Hospital. Recently, no one's been able to read any of them. But at least they used to be short. Now, because of all the problems these kids have, instead of my usual three or four lines of unreadable scribble, I now write whole pages of unreadable scribble.
What a stupid thing to do to us, throw us in the middle of this unit when we don't know what the hell we're doing. And Norris screams at us that they're our patients! Bullshit! He should be thrown in jail if he really thinks they're our patients! None of us knows what the hell we're doing with them. All right, show us around, give us a week or two to figure out what's going on, then you can think of them as if they were our patients. At this point we can have virtually nothing to do with their care, because we know virtually nothing about how to care for them.
Hey, but the jury's not in yet. I'll give it a little more time to see what it's like before I make up my mind. I'm on call Friday night with a senior resident who sort of drives me crazy. She's reasonably intelligent and she seems to know what's going on, but she really lacks self-confidence. It wouldn't be so annoying if she didn't keep turning to me for reassurance. Me, can you believe that? I mean, I have absolutely no idea what the hell is going on! The other night she did something that I think was probably wrong. She wanted to intubate this kid for having one bad blood gas. And she asked me if I thought it was the right thing to do. I said, “No, it doesn't sound right. I think you should just turn up the oxygen and repeat the gas before you do anything.” That was just common sense; this kid was perfectly pink at the time. I hope I'm not that unsure of myself next year, when I'm in a position of authority. Hah! Boy, we're all going to be in trouble when that happens!
Thursday, January 30, 1986
It's nine o'clock and I just got home. Things are looking up: I cut an hour and a half off the time I finished on Monday night. Why, if this keeps up, I'll have so much free time this month, I may actually get to cook my own dinner one night! I think washing the dishes'll still be out of the question, though. That'd be just too much to shoot for.
Here's some news on the Moreno front: Today's head circumference was forty-nine and a half centimeters, up one-half centimeter from yesterday's closing. And you know what? I don't give a shit! I just don't care!
I don't like the neonatal ICU. I'm not positive, but I just don't think I'm going to grow up to be a neonatologist!
I've got this nervous feeling in my stomach all the time. I stopped at a drugstore on the way home and bought this great big bottle of Maalox. Either I'm coming down with gastroenteritis or I'm beginning to burn a big hole in my gastric muscosa.
Monday, February 10, 1986
I'm post-call. There's nothing like being post-call when you're in the NICU. It's at least a hundred times worse than being post-call anywhere else in the world, including Infants', which until this month had won the prize hands down as the Most Horrible Post-call Experience in the Bronx. I should be asleep now, but I haven't recorded anything in over a week. I've wanted to; I just haven't had enough strength to push down the “record” button on this silly machine. I don't want to let this fabulous experience escape immortalization on cassette tape, so, at great expense (at least ten minutes of precious sleep), here goes.
Working in this nightmare has now settled into a nice, regular, predictable routine of devastation and misery. Take yesterday, for instance. It was Sunday and I was on call. I walked through the doors of 7 South with a smile on my face at seven-thirty and was completely and overwhelmingly depressed by eight o'clock. Iris Davis, who'd been on call Saturday, signed out to me. She was in a great mood. When she gets real tired, she starts to cry, so it took her about an hour and a half and at least three boxes of tissues to get through sign-out. All I got out of it was a scut list about a mile long and a terrible headache.
Most of what Iris signed out to me was checking bloods that had been drawn earlier in the morning. So I started calling the labs to get the results, a very rewarding experience. Each lab had a different and very novel explanation for why the results weren't available. The chem lab claimed they had never received any samples, even though Iris assured me that she hand-delivered them. The hematology lab said that all the specimens, every one of them, was QNS
[quantity not sufficient]
. That's a polite way of saying, “We poured the blood down the sink, so you're going to have to draw them all over again.” And the blood gas lab said the machine was broken and they wouldn't be able to run any samples for at least another hour. What this all meant was that I was going to have to spend the next two hours redrawing all these bloods and then spend another half hour delivering the samples to all the different labs.