Sunday, June 29, 2014
Back in the day, that is the distant past of 1985 the word “Internship” could fill a medical student with anxiety and stress. The internship was a rite of passage, a necessary stop on the road to becoming a full fledged, finished doctor, rather than a person with a couple of initials after his or her name.
And, the surgical internship was supposed to be the worst: thirty six hour shifts, every other night call, holding retractors for hours without a break, this was the plight of those of us who chose to pursue the surgical arts. It was a period of initiation which led to joining an exclusive fraternity called “Surgeon.”
I have to report that, at least for me, my internship was nothing like this. I was in a large private hospital where there was no “scut” work, the name given such mundane tasks like drawing blood, starting IV’s, doing EKG’s and such. These duties are important to patient care, but do little to advance the knowledge of the medical trainee. I do think there is some value in learning to draw blood and start IV’s, but doing my own CBC’s or urinalysis would have been a waste of my time.
All this being said there were days when the work was never ending and there was one day in particular which stands out as a shining example of what an internship can be.
It was during my final month, a month I spent away from the safe confines of my mother hospital and its friendly IV, EKG and phlebotomy teams; thus the aforementioned “scut” work still plagued the lowly intern. I finished out my intern year rotating through the Pediatric Surgical Service at Children’s Medical Center (CMC) in Dallas. This included responsibility not only for CMC, but also Parkland Hospital, the county hospital for Dallas. I was paired with a fourth year resident as well as interns and residents from the program at UT Southwestern. We were responsible for all the pediatric surgery which included elective surgeries, trauma, the Parkland Emergency room, surgical consultation for pediatric patients in both hospitals and, finally, the nascent Pediatric Liver Transplant program.
The intern’s duties included: history and physical on all admissions, morning rounds which commenced around 6:00 am, drawing blood on all the liver transplant patients which needed to be done before morning rounds, assisting in surgery, afternoon rounds, making sure all tests that had been ordered were done and being the first to respond to any emergency that should arise throughout the day. In between all this we all hoped to find the time to actually do some surgery, the occasional appendectomy or a hernia, remove some lumps and bumps and so on.
There was a day, an unforgettable day which snuck up on me about two thirds of the way through the month. It was a Saturday which started like every other day. I arrived early enough to help the intern coming off call draw blood on the liver transplant patients and to check on my other patients before the fourth year resident arrived and formal rounds began. So far, so good.
Round and round we went, from Children’s Medical Center, to Parkland, which included a brief stop in the newly minted, but as yet untested, Pediatric Trauma Unit. There was a post op appendectomy, the previously mentioned post liver transplant patients, including little Terry. Terry had received her new liver four days ago, but was still looking green. We were all concerned that something wasn’t right. Diagnosing and treating her was priority number one for this Saturday.
“See if Radiology can do an ultrasound of Terry’s abdomen with Doppler to check her hepatic artery,” the Transplant surgeon attending commanded.
“Yes sir,” the fourth year resident agreed.
Rounds ending, this fourth year resident, who aspired to be a Pediatric Transplant surgeon, which meant an unusual amount of groveling and brown nosing of the Attending staff, turned to me and gave me the job of tending to all of Terry’s needs.
It was seven a.m. and the proverbial shit was poised to hit the fan. I started at the top of the scut list and ran down to Radiology to request the stat ultrasound on Terry. I checked the requisition up and down and front to back, made sure all the t’s were crossed and I’s dotted and ventured in to find the senior radiology resident. I finally found him hidden away in the dark, which is the usual place to find Radiologists, the vampires of the medical world who shun all light and live in shadow. I begged and pleaded and convinced him of the urgent need. I have to admit I almost brought tears to his eyes as I related the “Plight of Baby Terry.” The ultrasound was scheduled stat.
One task settled I moved on to the daily, mundane chores an intern battled. In those days, before computers, I gathered lab results and X-Ray reports and started writing my progress notes on each patient. It wasn't too long when I received the first of many "rude" interruptions.
"Dr. Gelber," the sweet voice called, "we've got a premie down here in NICU with a distended abdomen and the KUB shows pneumotosis."
A bothersome, but ocassionally disastrous NEC watch. One more thing to complicate what was turning out to be a far from peaceful Saturday.
What, pray tell, is "NEC" watch?
NEC stands for Necrotizing Enterocolitis. This is a condition which most commonly arises in premature babies. Whether from ischemia, or infection, or some other unknown agent, the neonate becomes very sick. The child cannot be fed, they demonstrate signs of sepsis and their condition can deteriorate before your eyes.
I made my way to the NICU and took a look at baby girl Nicole born at 28 weeks and now sporting all the findings one would expect in early NEC, distended abdomen, mild tachycardia and an abdominal X-ray which revealed an area of “pneumotosis intestinale” which means air in the wall of the bowel. I communicated my findings and assessment to my fourth year resident, specifically that baby Nicole could be watched, tube feedings were put on hold and she was to start on IV fluids and antibiotics.
One crisis stopped before it started, I hoped.
I had just hung up the phone with the my senior resident when my beeper went off.
Parkland ER. Just great, what now?
“You are the surgery intern on call today?” asked the voice form the ER.
“This is Dr. Gelber, I am on call today.”
“This is Dr. Barry. We’ve got a seven year old who we think has appendicitis. Do you think you can come check him out?”
“OK, I’ll be there in a little bit.”
I took the time to write a couple of progress notes on the patients I’d seen earlier in the day and then made my way through the tunnel which connected Children’s Medical Center and Parkland. It was like moving from one world to another.
CMC always looked new and clean. It was a place I would want to bring my kids if they were ill. Parkland, although not dirty, looked older and worn, a spot which looked beaten down by years of caring for the sickest, most severely injured patients Dallas could offer.
I found Mikey in the pediatric ER accompanied by his worried mother. He had been sick for three days. From the door way it was obvious he was ill. He lay still on the exam table, his face was flushed. The bedside chart listed Vital signs: heartrate 130, Temp 103.1, blood pressure 86/40, Respirations: 20.
A typical history for appendicitis was obtained and a gentle tap on his abdomen elicited a grimace and wincing that screamed “PERITONITIS.”
I called my senior resident again and schedule Mikey for surgery. My beeper went off again: call the transplant floor.
“Terry needs to go for abdominal ultrasound now. The Radiologist is here and you need to bring her,” the unit secretary informed me.
Four years of college, four years of medical school and almost a year of internship and I’m still just a glorified orderly.
“OK, I’ll be right up.”
I left orders for Mikey and called the OR and told them I would call when we were ready for surgery. One good thing about Mikey and most patients with appendicitis was that an appendectomy was an intern case, so I would get to do the operation. I hustled my way back to CMC to wheel little Casey to ultrasound. On my way my beeper went off again and again and again.
“Michelle has a temp of 102.”
“Michelle who?” I inquire.
“Michelle S. in 204, She had a liver transplant ten days ago.”
“Oh, that Michelle. Get a UA, draw two sets of blood cultures and a CBC. I’ll be over to check her shortly.”
“Are you going to come draw the blood?”
“Yeah, OK, I’ll get to it as soon as I can.”
“IV is out on Darren in 331.”
“He had an appendectomy two days ago.”
“Is he eating?”
“Clear liquid diet.”
“Is he on any meds?”
“Ampicillin, Gentamicin and Clindamycin.”
“No fever for twenty four hours.”
“Was the appendix ruptured?”
“How should I know?”
I looked at my sign out sheet. No mention of how bad the appendix was.
“OK,” I finally answered. “Could you please put everything at the bedside and I’ll be there when I can.”
And the third call:
“Dr. Gelber, Scott in 320 has a headache…”
Finally, something simple.
Now, onto the Transplant floor and little Terry. She was very small for her age and her skin was green because of her liver failure. Even after her transplant she stayed green and now she had fever. Everything said her new liver wasn’t right. But, the question remained: Was it a technical problem? Or rejection? Or infection? Thus the ultrasound and Doppler of her hepatic artery which would start to provide some answers, we hoped.
The nurses already had her loaded up on the stretcher. We began wheeling her down the hall to the elevator. She gave me a weak smile. Father and Mother trailed behind us talking in whispers. Terry was four days post transplant. I knew her fairly well and was very well acquainted with the veins of her right arm where I drew her blood every morning. Her mother was only worried, while her father seemed to mix his worry with distrust, as if the Transplant team was somehow conspiring to harm his little girl.
The Radiologist and the Transplant Attending were waiting for us. The ultrasound clearly demonstrated a patent hepatic artery and we brought Terry back to her room. On the way my beeper went off again. It was my Chief resident. It was a good time to do the appendectomy on Mikey. I called the OR and met the team in the ER and we wheeled our patient up to surgery.
With my Chief across the table from me I started the surgery. This was the final month of my internship and I was pretty adept at appendectomies. I delivered the offending organ, which was ruptured, and completed the surgery like a pro. No sooner had I tucked Mikey into the Recovery Room when my beeper went off again. Terry was crashing.
I raced through the tunnel and up the stairs to her bedside. My Chief was right behind. Her nurse wasted no time informing me that an ICU bed was ready. Terry was barely responsive, her BP was fifty over zero and she looked even greener. I scooped her up in my arms while her father stood behind me, screaming.
“If she doesn’t get better, you’ll never work in this city again,” he shouted. I think he would have punched me if he had the chance.
Meanwhile I laid her in the ICU bed. The Pediatric Anesthesiologist was standing by and deftly intubated her while the nurses opened up her IV and gave her a bolus of fluid.
“Rejection,” the Transplant Attending decided.
Terry was now functioning without a liver, more or less; her transplanted liver was causing more harm than help. She was placed at the top of the list so that the first ABO compatible liver that came available would be hers. Her father came in and stood at her bedside, glaring at me while I stood at the foot of the bed staring at the monitors. Her BP was better at 70/40 and her oxygen saturation was 100%. Still, she wouldn’t last long without a new liver.
It was early evening now and I finally had a few moments to catch up. I finished my charting for the day, drew some overdue blood tests and started a few IV’s which had been waiting for me. I was about to have “breakfast” when my Chief called me.
“A two year old girl is on her way by helicopter to the Trauma ICU. She was accidentally run over by her father.”
A minute later the call came. I was already on my way.
A crowd of nurses and paramedics surrounded the stretched as Christina was wheeled inside.
“BP 60/30, heart rate 125, O2 sat 100%,” a nurse screamed.
Two clear but terrified eyes stared up at me as my Chief arrived just behind me. Christina was awake and alert and breathing comfortably. A quick survey revealed bruising across her lower abdomen and pelvis and blood staining her diaper. There was obvious deformity of both legs.
Two distraught parents waited outside as the trauma team went to work. New IV lines were established and fluids administered. Blood was drawn for the blood bank and baseline lab tests. Antibiotics were given, oxygen administered. We did a quick peritoneal tap which was negative. Her vital signs were holding steady.
X-rays revealed a fractured pelvis and bilateral femur fractures. Her chest X-Ray was normal.
The OR was standing by and at 8:57 pm surgery commenced. My job, as intern, was holding retractors as the Attending and Chief Resident began the task of putting her lacerated perineum back together. Her vagina was torn down the middle and there was a small laceration of her rectum. Her fractures were to be treated without surgery, at least at this time.
The surgery dragged on, past nine o’clock, past ten o’clock, past eleven o’clock. All the while messages came, baby A needs a new IV, Mikey has a fever, Terry’s urine output is low and on and on. As midnight approached I began to feel a little dizzy. I sensed my heart was racing and I remembered I had not eaten anything all day. I concluded my blood sugar was probably around forty. I asked the OR circulating nurse to get me some orange juice.
The nurse found some apple juice and fixed it up with a straw and managed to get it into me. A few minutes later I was back among the living as the sugar filled my bloodstream. I was able to continue my relationship with the end of a Richardson retractor without passing out. Finally, shortly after one in the morning the vaginal and perineal repairs were finished. All that was left was to do a colostomy. I begged to be allowed to leave and finish all my undone work and to check on my other sick patients.
My superiors took pity on me and I was dismissed. I scrounged up a couple of Oreo cookies and went about the business of catching up. I checked on Terry first, gave her some more fluid and was informed that there was a potential liver in Houston. I started IV’s, answered calls for patients with fever or drainage from their wounds, drew the morning labs and thought I could see a glimmer of light at the end of the tunnel.
Christina was now back in the Trauma ICU and she looked stable, if not a little forlorn as she lay in bed with both legs up in traction, IV’s in each arm and tubes going every which way. However, she was OK and she still had those beautiful clear eyes, only now I didn’t see the terror.
Then my beeper went off. It was the ICU where Terry was clinging to life.
My Chief answered, “There’s a compatible liver in Houston. We’re leaving in ten minutes. Make rounds with the next crew and then you can go. We won’t be starting the surgery until about ten.
And there it was. My twenty four hour shift was now growing to twenty six. I did take a few minutes to get a real breakfast before starting morning rounds with the next team of residents.
Rounds were uneventful. We finished around eight thirty, but instead of leaving to get a little rest I stayed around to help with Terry. Dedication or stupidity? Both, I guess, but I assume it was mostly dedication and a sense of responsibility.
We started Terry’s surgery at around ten thirty and I took my position on the patient’s left where I would become reacquainted with my old friend, Richardson. The case went fairly quickly, at least for a liver transplant and after about two hours the new liver was in place. Every one left to take a break, that is everyone but me. Someone had to stay with the patient, who was still under anesthesia while the new liver “breathed.” I sat and watched the liver take on new life as Terry’s blood percolated through its sinusoids and it started to sweat bile. After about thirty minutes the rest of the team returned to do the final step, which was the biliary anastamosis.
I was happy to see the intern on call for that day return with them, which meant I was to be set free. It was almost two in the afternoon. My twenty four hour shift had lasted thirty two; a typical day for a surgery intern in 1985.
Christina, by the way made a complete recovery. Mikey spent about a week in the hospital but also recovered, while Nicole recovered from her NEC. Terry’s new liver worked for a few days, but she suffered through another rejection and this time it was too much and she passed away.
Modern medicine does indeed have its limitations.