Intern (11 page)

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 humiliated, 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.”

“Did you know that you were in the hospital?” I asked.

“No.”

“What did you think when you saw the nurses?”

He looked away, straining to remember. “Well, then I gradually came to know it. But it had never happened to me before like this. This sense of not knowing the place.”

“Were you short of breath?”

“No,” he replied. “Just confused. But it never happened before.”

I nodded, having already seen a few cases of ICU psychosis. “That happens here sometimes,” I said.

“Oh, okay.” He looked relieved. “Was your wife here with you?”

“No, she came later.”

“Tell her to visit more frequently.” He said he would do that.

At six-thirty Amanda and Nancy arrived. Amanda brought breakfast for me—a toasted bagel with cream cheese and coffee (it was customary at New York Hospital for the on-call intern to bring in breakfast for the post-call intern). We sat at the conference table while I reviewed overnight events. I told Nancy about Mrs. Piniella; she thanked me for filling out all the death forms. Then the three of us went out to preround. Nurses kept asking me to do things, seemingly oblivious to the fact that I was post-call, so I tried my best to avoid them. On rounds, Dr. Carmen mostly left me alone. Periodically I'd nod off and yank myself awake, momentarily disoriented. Trying to stave off sleep was like trying to pull open a screen door in a hurricane. It took every last ounce of energy.

We rounded quickly, and I was essentially done with my work
by late morning. Before leaving, I stopped by to say goodbye to Mr. Waldheim. Per his son's request, he had been moved to a room with windows. I walked in to find him sitting in a chair, admiring the Queensboro Bridge. He gave me a thumbs-up, and his message was clear: all he wanted was a room with a view.

At noon, when rounds were finished and progress notes were done and orders had been written and consultants had been called, Steve and I walked out together. I could hardly believe it: my first call night was finally over. Only 140 more to go during residency. The thought might have depressed me, but I was giddy at the prospect of going home after thirty hours on and having a free day. I had heard about the brutally utilitarian post-call routine of one of the senior residents. When she would get home, she'd pop a couple of pills of Valium and go straight to her bedroom, locking the door, often sleeping for sixteen hours until the next morning. It didn't matter if the baby wanted to play, or if her husband wanted to talk, or there were errands to be done. She was totally focused on getting her sleep. But not me; I was going to stay up; leisure time was too precious to squander on sleep. I was going to check stocks or maybe go for a run. I was going to watch the talking heads on CNBC. I was going to order lunch from Chicken-fest. I was going to call my mother. I was going to write in my journal. I was going to read the newspaper. I was going to read magazines. I was going to read . . . well, anything but medicine.

We walked by the information desk in the lobby. An administrator had called me during rounds to tell me that I had forgotten to sign the death certificate. She had been waiting for me, and scolded me for taking my time to come down. I just smiled and apologized and signed my name. The night was over and I wasn't going to let anything bother me.

Steve led me out an emergency exit and into a courtyard. The day was bright and sunny. In a daze, I walked to the main thoroughfare. “Thank you,” I said to Steve when we got to my corner. “I couldn't have gotten through the night without you.” He smiled and patted me
on the back and told me to get some sleep. I walked the two blocks back to my apartment, my shadow cutting the sidewalk ahead of me. The summer sun reflected off the smudges on my glasses, breaking into tiny speckles, like puddles on a crater-filled road. In the living room, I sat down on the couch, turned on the television, and collapsed. When I woke up, it was after dark.

The doctor has paid for the power with suffering.

—MELVIN KONNER,
BECOMING A DOCTOR
, 1987

 

M
orning was the busiest time in the CCU, when patients were wheeled off for catheterization and other procedures. One of the most common reasons for admission was to rule out myocardial infarction. Residents called it a ROMI (pronounced “roamie”), and this was the bread and butter of the CCU, often requiring a trip to the catheterization lab. There was always a long line of gurneys by the front desk, like airplanes on a runway waiting to take off.

After rounds I usually hovered around Steve, my resident, like a groupie. He was a lanky man, over six feet tall, with long arms that dropped down below his knees. He told me that he was planning on getting a job in a small town after he graduated. In small towns, he said, internists were doing a lot more than their counterparts in big cities: stress tests, flexible sigmoidoscopies, even implanting pacemakers. “Once you get out of the city, it's a whole new world.” He had briefly considered becoming a “hospitalist,” a new breed of internist that exclusively took care of hospitalized patients, but he had decided against it. He said he believed that primary care medicine would provide ample intellectual rewards. Like Steve, at one time I too had worried
about being challenged in medicine. Now my fears were very different.

One morning, Steve taught me a mnemonic for organizing the problems in my daily progress notes: RICHMAN (respiratory, infectious, cardiovascular, hematological, metabolic, alimentary [or gastrointestinal], and neurological). Another time, he taught me how to insert an arterial line. I put on a sterile gown while he threw a sterile sheet over the patient. Then he tore open a procedure kit and spilled its contents onto the drape. His long fingers started moving rapidly, opening packages of needles, drawing up saline flushes, arranging the instruments we were going to use with the meticulousness of a sushi chef. After he was done, he taped the patient's right arm to a bedside table so it wouldn't move. Then I cleaned it with antiseptic soap. With a needle I stabbed a small vial of lidocaine he held up in the air, drawing some of the medicine into a syringe. I injected a tiny bleb into the patient's arm to numb it up. “Go deeper,” Steve advised, and I did. Then I took a longer “finder” needle and poked it through the skin, trying to locate the artery. The patient winced.

“Go in at more of an angle,” Steve suggested. “Okay, pull back a little bit, I think you went through the artery. A bit more. Pull back. Pull back.” A burst of maroon filled the barrel. “Okay, perfect. Now take off the syringe. No, leave the needle where it is—” but I had already pulled it out of the artery. “That's okay, just put the syringe back on and try again.”

I tried again, but this time with no luck. “Go in at the same angle,” Steve said, making a jabbing motion with his hand, but I was unable to draw back any blood. “Okay, sharpen the angle . . . sharpen . . . sharpen . . .” With each attempt, the patient groaned, and I started to sweat. I was reminded of a patient I had tortured as a third-year medical student trying to get an arterial blood gas. Dean Dowton had told us to come up with a code of ethics in his commencement address; my first rule was that I was only going to allow myself three attempts at a procedure before asking someone more experienced to take over. But now I found myself wanting to try again and again.