Робин Кук - The Year of the Intern

A nurse stuck her head in. “Doctor, there are nine patients waiting.”

I knew that I would hear from the nurses if a real emergency arose; now was the time to get rid of Morris once and for all. After replacing the book, I headed toward the ortho room, somewhat better prepared to make a hanging cast than I had been five minutes before. As I entered the room, it became obvious why Morris had been easy to forget for the past hour or so. He lay on the examining table fast asleep, snoring lightly, cinched in place by a broad leather strap. Nor did he awake when I cranked him into a sitting position, holding his head to keep it from flopping over. Damn that Sterling; this was his job. I had heard the television blaring in the background while he was talking on the phone with me. After cutting Morris’s left shirt sleeve off at the shoulder, I fashioned a piece of stockinet for the underside of the cast and slipped it on his arm, trying not to disturb the fracture.

“Doctor, there’s a call on 83.”

I didn’t even answer the nurse, hoping that whatever it was would solve itself.

“Ohhhhh.” Morris came to when I positioned his arm for the cast. “What are you doing to me?”

“Mr. Morris, you broke your arm falling down the stairs, and I’m putting a cast on it.”

“But I don’t—”

“Yes, you do! Now don’t say another word.” I hoped Sterling would ask me for a favor some day. After soaking the plaster rolls in water long enough for the bubbles to stop, I wrapped them around and around Morris’s arm, building the cast up layer on layer. I made it big, almost an inch thick. Since it functioned by its weight, mine was going to work very well.

“Now just stay where you are, Mr. Morris. Don’t move. Let it dry.”

Reaching the main portion of the ER, I picked up 83, but no one was there. Good strategy. It was only seven-thirty; I was already eleven patients behind, and I knew it would get worse. Grabbing a handful of charts, I started off, glancing at the top one: “Skin rash.”

Skin problems drew a blank in my mind no matter how many times I read and reread the descriptions of papulosquamous erythematous pruritic vesicular eruptions. The words lost all sense, twisting and turning in my memory so that if I saw a patient with anything other than acne or poison ivy I was lost. And there in front of me stood a man with a violent pruritic eczematous erythematous rash. I knew what it was, because a dermatologist had used those words to describe my sunburn after an Easter week in Miami during medical school. It meant itchy, wet, and red, but dermatologists preferred complicated scientific jargon. In fact, dermatology is the only branch of medicine still using Latin to any great extent — appropriate, in a way, since I couldn’t see that the science had advanced very far since the days of alchemy. Although the terminology and the diagnosis of skin disorders were difficult, the treatment was simplicity itself. If the lesion was wet, you used a drying agent; if the lesion was dry, you kept it wet. If the patient got better, you continued what you were doing; otherwise you tried something else, ad infinitum.

The patient standing before me was a skinny, sallow-faced fellow with dark hair, bushy and unkempt. Looking at his hands and his arms, I couldn’t think of a thing except how little I knew about dermatology. He didn’t have a private doctor, which meant I would have to call one, and I wondered what I could say without sounding like an idiot.

I noticed that the rash was on the palms of his hands, too, and some distant bells began ringing in my mind. Only a few dermatological disorders occur on the palms of the hands. Syphilis is one. Hmmm. I was so involved with my own thoughts, I hardly heard the patient when he said that he had neurodermatitis and needed more tranquilizers. I was still trying to remember the exact list of those diseases that occur on the palms when his words suddenly scored in my consciousness. Neurodermatitis. With practice, I had developed an ability not to show surprise or gratitude when such sudden gifts of diagnosis were presented, and I continued to look at his arms knowingly until sufficient time had elapsed. It made me feel that my knowledge of dermatology at least equaled his when I guessed correctly, that he was on Librium. He was thankful to get some more.

As evening spread into night, my steps became labored and slow, and my fear mounted, giving rise in my imagination to a series of hopeless cases waiting to descend upon me. There was no pause in a continual stream of patients that kept me always five or six people behind. My suturing became more rapid, out of a combination of necessity and diminishing interest. Whenever I sutured, the people waiting stacked up, so I had to be fast, dispensing with trimming the edges and other fancy stuff. I was not haphazard, just less careful, and perhaps more easily satisfied. As, for instance, with the man who had a flap laceration on his arm. During the daytime I probably would have excised the flap and closed it as a linear cut. Now I just sewed it up, flap and all, hoping for the best.

In the eye-and-ear room a four-year-old boy sat forlornly on the examining table. His grandfather stood nearby. As I entered, the boy started to whimper, putting his arms to his grandfather, who held him while I read the chart. It said, “Foreign body, right ear.” After talking quietly with the little guy for a few minutes, I convinced him to let me look in his ear. Far up in the canal I could see something black; it looked like a raisin or a small pebble.

Since the grandfather didn’t know an ear, nose, and throat man, I picked one out of the M.D. roster, a Dr. Cushing, and gave him a call.

“Dr. Cushing, this is Dr. Peters at the ER. I have a four-year-old boy here with a foreign body in his ear.”

“What’s the family name, Peters?”

“Williams. The father’s name is Harold Williams.”

“Do they have health insurance?”

“What?”

“Do they have health insurance?”

“I haven’t the slightest idea.”

“Well, find out, my boy.”

What a scene, I thought, retracing my steps into the eye-and-ear room. With a dozen people waiting, I’ve got to find out about the health insurance. No, the grandfather said, they were not insured.

“No, no insurance, Dr. Cushing.”

“Then see if any of the adults are employed.”

Once again I returned to the eye-and-ear room to quiz the concerned grandfather. Actually, I knew that this information gathering was easier than calling a dozen or so physicians until I found one who wasn’t so concerned about getting paid; but it seemed gross and inhumane, just the same.

“Both the parents are employed, Dr. Cushing.”

“Fine. Now, what is the problem?”

“Little David Williams has a foreign body in the ear, something black.”

“Can you take it out, Peters?”

“I suppose so. I can try.”

“Good. Send them to my office on Monday, and call me back if you have any trouble.”

“Oh, Dr. Cushing.”

“Yes?”

“I had a little girl in here this morning with infections in both middle ears.” The Pablum child suddenly came back into my consciousness. “One drum was ruptured, and the other was bulging out. Should I have drained it?”

“Yes, probably.”

“How do you do that?”

“Use a special instrument called a myringotomy knife. You merely make a tiny incision in the lower, posterior part of the eardrum. It’s very simple, and the patient gets immediate relief.”

“Thanks, Dr. Gushing.”

“Not at all, Peters.”

Thanks for nothing, Dr. Gushing. After all that nonsense, I had to go fumble for the foreign body myself. As for incising the eardrum, I decided that I should consider myself instructed on the procedure.