Робин Кук - The Year of the Intern

“What sutures will you be using, Doctor?”

I had no idea. “I’ll take the usual, Nurse.”

“The usual, Doctor?” Obviously, there was no usual.

“Uh, nylon,” I tried.

“What size?”

“Four-O,” I told her, wondering what I was ordering.

Needless to say, I quickly learned about sutures, and also about suturing, but always by trial and error. On the first case, I put in too many stitches, and on the second case, I came to the end of the laceration with too much skin on the top. Slowly but surely I learned the little tricks, like excising beveled edges, and even fancy stuff, like small Z-plasties to change the axis of a laceration in order to reduce scarring. I came to enjoy suturing quite a bit, because it was a clear problem with a neat, clean solution that I quickly enough learned to provide. It made me feel useful, a rare and cherished sensation.

All that learning was behind me now. The surfer was waiting, a sheet over his head. Through the little window at the site of the laceration, I began to clean and anesthetize the area with xylocaine. After trimming the edges slightly, I poised the needle with the attached nylon suture about midway from either end of the laceration and back a few millimeters from one edge. Guided by a rolling motion of my wrist, the needle pierced the skin, traversed the laceration, and emerged on the opposite side. I withdrew it with the needle holder. Then, barely catching the edges of the wound with the needle, I brought the suture back to the original side and tied it, not tight, but just a little loose so that the swelling of the wound would bring the edges together. Four more sutures finished the job.

The other patient was a somewhat mysterious twenty-year-old girl who appeared chronically ill. She admitted to having been diagnosed and treated for systemic lupus erythematosus. The name alone sounds forbidding, and, indeed, lupus is a serious disease. It was one of the diseases we had discussed ad nauseam in medical school because, being so rare and ill-understood, it was good for a lot of academic speculation. So I didn’t feel entirely unprepared — except that she was complaining of abdominal pain, which wasn’t a common symptom for someone with lupus. Trying to connect the two in my mind, I palpated her abdomen and asked questions about her condition, which either she or her mother answered. Then, needing to think, I went back to the desk-counter in the center of the ER and racked my brains for some association between her pain and her basic disease. While I was trying to come up with a suitably exotic lab test, mother and daughter walked by, said that the pain was gone, thanked me, and went out the door. So much for my challenging diagnostic mystery, and one of the few ER cases that four years in medical school had prepared me for.

At that point, Almost came rushing in and practically collapsed in front of me, putting his forehead on the counter, panting and wheezing. His real name was Fogarty, but we called him Almost because he invariably held off until the very last moment before coming into the ER to be treated for his asthma. It was like waiting until you ran out of gas so that you could coast into the filling station. The nurses led him, blue and heaving, into one of the rooms while I prepared some aminophylline. I had seen Almost several times, beginning with my second day on ER duty. From medical school I knew quite a lot about asthma in terms of pulmonic pressure gradients, pH changes, smooth muscle function, and allergic phenomena, and I even knew about the drugs that were useful — epinephrine, aminophylline, bicarbonate, THAM, and steroids. But I hadn’t known a thing about dosages. So, the first time, while Almost was in another room puffing on the positive-pressure breathing machine, I ran into the staff room and looked it up in a paperback. Anything to avoid asking the nurses. Actually, from ward cases I had an idea of what and how much to give a reclining patient. But this guy was walking around, not lying in bed, and that makes a big difference. You cannot use the same amounts. To ask the nurses something else would have demoralized me. Anyway, old Almost and I had gotten used to each other, and an aminophylline IV did the trick, as usual.

While the ER sometimes got so crowded that patients sat on the floor or stood against the walls, it was more usual to have a steady stream over the twenty-four-hour period, amounting, perhaps, to 120 or so on weekdays and twice that on Saturdays. It was now about 10:30 A.M. The stream had started to run, and I was on my feet, moving quickly from one room to the next, calling the private M.D.’s, not really thinking too much, almost unaware of the omnipresent fear of the next big case.

One chart read “Chief complaint, depressed.” Thirty-seven-year-old lady. As I walked into the room she lit a cigarette, cupping her hands around the match as if in a great wind. Throwing her head back with the cigarette precariously perched in the corner of her mouth, she looked at me blankly.

“I’m sorry, ma’am, you can’t smoke in here. Those green metal bottles are filled with oxygen.”

“All right, all right.” Obviously irritated, she ground the cigarette relentlessly in a small stainless-steel dish accidentally left on the examining table. She was silent now. When the cigarette was totally destroyed, she looked up and stared aggressively into my eyes, about ready to explode, I thought.

“Your name is Carol Narkin, is that correct?”

“That’s right. Are you the only doctor here?” She wanted to get at me.

“Yes, the only one here now. But we’ll call your doctor, too. His name is Laine, it says here on the chart.”

“That’s right, and a damn good doctor, too,” she said defensively.

“Have you seen him recently?” I was trying to calm her down with routine questions, working around to why she had come to the ER.

“Don’t get smart with me.”

“I’m sorry, Miss Narkin, I must ask a few questions.”

“Well, I’m not answering any more. Just call my doctor.” Angrily she looked away.

“Miss Narkin, what am I to say to your doctor?” She didn’t budge. “Miss Narkin?”

Clearly, I couldn’t help her, and so I walked out, thinking I’d go back after the next patient. Why had she come here? There was no point in calling her doctor without being able to give him some sort of report. When I returned to see her after a few minutes, she was gone. That was typical of ER work — brief, inconclusive encounters and a lot of wasted time.

Next the nurse pressed five charts into my hand and pointed a bit sheepishly into the next room, where I was confronted by an entire family — mother, father, and three kids — standing there waiting to be treated.

The mother spoke. “Doctor, we came because Johnny here has a temperature and a cough.”

I looked at the chart. “Temperature 99.”

“And as long as we were here, I thought you wouldn’t mind looking at these spots on Nancy’s tongue. Show the doctor your tongue, Nancy. Arid Billy fell at school last week. See his knee, see that scrape? Well, it’s been keeping him at home, and he needs a note. And George, he’s my husband, he has to have a doctor sign his welfare statement because of his back condition, since he doesn’t work and since we just came from California. And I’ve been having trouble with my bowels for the last three or four weeks.”

I stared at the faces. The husband didn’t meet my eyes, and the kids were busy climbing on the examining table, but the mother was loving it, looking at me excitedly. My first impulse was to throw them out. They should have been at the clinic, anyway, not the ER. We weren’t set up for routine outpatient care. But if I indulged my temper, I was sure the mother would complain to the hospital administrator that I had failed to see them in their hour of need. The administrator would report to the attendings in charge of the teaching service, and I would end up getting shit on. That was how much you could count on support.