The View from the Vue (33 page)

My expression must have revealed my emotions, because Ellen took me by the arm and led me back across the room to the desk. “Sit down here a minute, Larry,” she said. “Just wait here for me. I’ll be right back, and we’ll straighten this all out.” She stared hard into my eyes.

I nodded.

“Promise you won’t get up till I come back.”

“I’ll wait,” I said. I no longer wanted to run. The panic was still there, but it had become paralyzing. I felt afraid to do or say anything.

Ellen flew out of the ward and came back, almost immediately, it seemed, with the chief resident. “Tell Bob what’s bothering you,” she said.

I hesitated, and then, suddenly, the words came out in a stream. “Well, on rounds Ellen told me to give Mrs. Greenspan a dose of Dexedrine to wake her up but the more I think about it the sillier it sounds because Dexedrine won’t wake up an old lady out of a stroke and for all I know it might even kill her but somehow it got to be one-thirty right after rounds were over and I don’t understand it.”

Bob and Ellen looked at each other, and I got even more scared. “What the hell is going on?” I asked, not at all certain I wanted an answer.

“I’m not sure,” Bob said, very gently. “Let’s go down the hall and talk to Dr. Kalb.”

Dr. Kalb was the associate chairman of the department of medicine, and was in charge of the training program. If I had been frightened before, I was terrified now.

“Don’t worry,” Bob said. “No sweat. We’ll have this all straightened out in no time. Come on, let’s go.”

Dr. Kalb listened patiently to the three-part recitative, tapping the eraser end of a pencil against his desk and smiling faintly in the manner of a man who knows exactly what’s coming. I envied him intensely. When we had finished talking, he leaned back in his chair and folded his hands across his belly. “Tell me something,” he said, looking at me. “Have you been up a lot at night during the past few weeks?”

I started to laugh. I knew it wasn’t appropriate, but I couldn’t help it. I fought to get myself under control, and finally managed to choke out the information that I hadn’t seen my bed during the last three weeks of call.

Dr. Kalb nodded. Suddenly he barked out, “What did you have for lunch today?”

I began to stammer, and as I did, the true state of affairs popped into my head. I quickly explained my recently acquired habit of midday nap-taking. “So I must have dreamed that Ellen told me to give that old lady the Dexedrine,” I said. But then, the doubts regrouped. “Problem is,” I muttered, “it still seems real to me, not a dream. And I still don’t remember getting up and going down to the ward.”

“You’re suffering from the sleep-deprivation syndrome,” Dr. Kalb said. “Go on home and go right to bed. You’ll be as good as ever in a couple of days.”

I was horrified. Go home? If I were to do that, another intern would have to cover for me. The ultimate crime! Two years before, an intern had nearly died because he had insisted upon carrying out his duties in spite of a severe stomachache. The next day they took him directly from his ward to the operating room and removed his burst appendix.

“I’ll be okay now,” I said quickly. “I’ll just stay awake until tomorrow morning, so I won’t be able to have any more dreams; then I’ll go to bed for the weekend.” It seemed very logical to me.

Dr. Kalb tried as delicately as he could to lead me to understand that my judgment was sufficiently impaired that I could not be trusted with the care of patients. However, he was in a situation right out of
Catch-22
. My judgment was indeed in a bad way, and as a result, I didn’t believe him. Had I been of sound judgment, of course, I’d have understood at once. But then, there would have been no need for him to be talking to me in the first place.

In any event, Dr. Kalb really went out of his way not to upset me. He could have told me to simply get my ass out of his office and into my bed, that I was summarily relieved of duties till further notice. But instead he asked, almost casually, “You believe that Dr. Cohen knows his business, don’t you?”

My judgment was not so far gone that I could say no. Dr. Henry Cohen had been trained in both neurology and psychiatry, and was universally acclaimed at The Vue as the most competent and rational of all possible shrinks. I said yes.

“Good,” said Dr. Kalb. “I’m going to call him now. Then, you go and talk to him. If he says you can work, then it’s fine with me. But if he says you should go home, then you’ll go. Fair enough?”

I nodded smugly. How could Dr. Cohen say I was unfit to work just because I was a little tired?

“Dr. Kalb is as right as he can be,” said Dr. Cohen, after he had listened to me tell my story for the fourth time. “You absolutely have got to get some sleep, and right away.”

I was crushed. Before I knew what was happening, tears started to run down my cheeks.

“What’s wrong?” asked Dr. Cohen. “Why should an intern cry when someone tells him to go to bed?”

I wiped at my eyes, but to my annoyance and embarrassment, the waterworks flowed on. I explained how sad it was making me to think that because of my dereliction, another intern was going to have to do double work.

For a few minutes Dr. Cohen remained quiet. He seemed to be thinking. “Try to understand,” he finally said. “Look how unstable your emotions are. You know that’s not normal. But it fits right in with the sleep-deprivation syndrome. You know, people are funny. If you happened to have caught pneumonia, and were running a temperature of 103°, you’d get right into bed and stay there until you were better. Well, let me tell you: you’re no less sick at this moment than a patient with pneumonia, and you’re no less in need of treatment. If it makes you feel any better, you’re not in the least unique. Once a year we go through this business. That’s right: every year, one intern manages to get so little sleep that he collapses. Or has delusions. Or hallucinates. And do you think we can ever manage to convince him what’s wrong? Every time, Kalb has to call me up to act as the arbiter. So don’t feel guilty. There’s nothing fundamentally wrong with you. You just happen to have pulled the short straw for this year.”

I took a deep breath. “What do you want me to do?” I asked.

“Get all the sleep you can between now and Monday morning,” said Dr. Cohen. “Then come back and see me.”

“Then can I go back to work?”

“Then we’ll talk about it. Go home.”

Myra was a little alarmed when she came home from work and found me curled up like a fetus on one of the living room chairs. She was not reassured when I gave her the fifth recitation of my lengthening story of sleeplessness.

“Why aren’t you asleep, then?” asked my wife.

“I’m too hungry to sleep,” I said. Actually, I hadn’t wanted her to come home and find me inexplicably sacked out. I don’t know why I didn’t just say that.

“So why didn’t you get something to eat?”

“I never thought of it,” I said lamely.

Myra looked at me in a peculiar tone of voice. “I’ll get you a sandwich,” she said. She did, and I ate it ravenously. I realized I actually was very hungry. Then, I went to bed. It was 4:30 in the afternoon.

When I opened my eyes, the room was still light. At least I thought it was still light. But when I looked at the clock radio and saw that it was 2:30, I realized that it actually was
again
light, and I had slept for twenty-two hours. Furthermore, I’m quite certain that the only reason I woke up even then was because my bladder was threatening to rupture. Bent over double, I made my way to the bathroom and urinated for what seemed like five minutes.

Myra appeared at the door in midstream. “You’re alive,” she said.

“Very funny.” My head was both pounding and swimming, and I was not amused.

“No kidding,” she insisted. “A couple of times I went in to feel your pulse. You didn’t move for hours at a stretch, and there were times when I wasn’t sure you were breathing.”

I ate some cereal and toast, and then we sat and talked for a while. Before long, I began to yawn uncontrollably, and this symptom, together with the headache and dizziness, impressed upon me the undeniable fact that I ought to go back to sleep. So I did. This time I slept only till noon on Sunday, a stretch of a mere nineteen hours. Out of a total of forty-four consecutive hours, I had been awake three. I managed to remain conscious until nine Sunday evening, and then conked out again until the alarm roused me at eight Monday morning.

By nine I was in Dr. Cohen’s office. He asked me how I felt, and I could truthfully tell him much better, even though I hadn’t felt bad the past Friday. As I looked back, though, I realized how foggy and confused I had been. I asked whether I might return to work.

Dr. Cohen held up his hand. “Let’s do an EEG first,” he said.

The electroencephalogram was a scary thing. They stuck little needles under my scalp; the needles were attached to wires which led to a recording apparatus which, in turn, traced out the patterns of the electrical activity in different parts of my brain. I couldn’t help conjuring up an image of myself, with wires coming out of a machine and disappearing into my scalp. I knew that the flow of information was from me to the machine, but how could I be sure they weren’t going to reverse polarities and give me electroshock, or maybe even reprogram my cerebrum?

“That’s typical of the sleep-deprivation syndrome, too,” said Dr. Cohen, when I told him my reaction to the EEG. He smiled. “That’s really a pretty paranoid thought, when you come right down to it. Prolonged sleeplessness often brings on some very impressive reactions.”

Disappointment began to build up in my throat. “You mean I’m not better yet?”

“No, I do think you’re better,” said Dr. Cohen. “But you’re certainly not ready to go back to work. Look. You slept twenty-two hours, nineteen hours, and eleven hours, and the only reason you stopped at eleven was that you set an alarm so you’d be able to come and see me.” He held up the EEG tracing, a long, thin line of what to me were indecipherable jumps and squiggles. “Your tracing still shows some of the changes we see with sleep deprivation—but they’re non-specific sorts of things. There’s certainly nothing to worry about: no sign of organic disease, no tumor or anything like that. Just go on back home and sleep until you can’t sleep anymore. Come see me again Friday.”

“Friday?” I screeched.

“Friday,” Dr. Cohen calmly echoed. “It’ll take that long to get you back into condition.”

“That’s ridiculous,” I snapped, without thinking.

Dr. Cohen smiled wanly. “Dr. Karp,” he said laconically. “Let me appeal to the sense of logic you’ve undoubtedly regained since last week. Since when has Bellevue Hospital ever in any way coddled an intern?”

I turned around and went home. By the time Myra returned from work, I had already put in six and a half blissful hours and was still going strong.

That night I slept only fourteen hours, and twelve each of the next two. The feeling of drawing achiness vanished from my thighs and calves, and the inside of my head felt almost painfully clear. Thursday night, I needed just nine and a half hours, and Friday morning Dr. Cohen gave me the go-ahead to come back to work the following Monday. I did, and managed to finish out the remainder of my internship year without trouble.

In 1956, eight years before I fell victim to the sleep-deprivation syndrome, Dr. Salvatore Cutolo, the deputy administrator of The Vue wrote:

It’s utterly incomprehensible to me how Dr. Cutolo could never have heard an intern complain about being overworked. We bitched about it endlessly. We bitched on the wards; we bitched in the halls. We bitched in the dining room, in the elevators, and in the bathrooms. One of my roommates even bitched in his sleep. We bitched about it to anyone who would give half an ear. But then, Dr. Cohen had put it very well: The Vue was never known to coddle an intern in any imaginable way.

However, the question still remains:
Should
interns work those hours? It used to be that whenever the issue arose, the elders would shut off discussion with a simple, “It’s the only way to learn medicine. We survived, and you’ll survive, too.”

Well, it may not be the only way to learn medicine; in fact, it may not even be the best. And the interns may survive, but the patients may not. A couple of years ago, an article in the
New England Journal of Medicine
reported that after a full day and night on call, interns could be shown to be suffering from serious defects in both judgment and cognitive abilities. Studies of this sort can’t be ignored forever, and therefore I think it’s likely that eventually doctors-in-training will find themselves working on a shift basis, which will provide them the opportunity to get necessary amounts of sleep on a regular basis. It won’t be like the good old days, but maybe that’s not the most important consideration.

The members of the Bellevue house staff employed only the most modern of medical practices. Nothing but current theories and principles were utilized. The local version of the game of one-up consisted of trying to outdo your competitors in quoting facts and figures from recent issues of medical journals.

Like all young people, we suffered from a disease called Severe History Deficiency. We shuddered at the barbaric practices of our ancestors, but naturally we never gave much thought to the mental discomfort we would ourselves one day cause our descendants.

A mere hundred years before my time at The Vue, the famous British obstetrician John Braxton Hicks introduced a new, less-traumatic method for turning a fetus around inside the uterus. By the use of his technique, he was able to reduce the maternal mortality associated with placenta previa (a placenta implanted very low in the uterus, so as to block the birth canal) from 30 to 5 percent, surely a remarkable achievement. Hicks became justly famous in his day.