Робин Кук - The Year of the Intern

“Is this what you mean, Doctor?” The nurse handed me a bottle of papers designed to test urine for sugar.

“No, a hydrometer, a little instrument you float in the urine. It looks like a thermometer.” She disappeared again while I looked at the label on the bottle she had given me. Perhaps I’d test the urine for sugar anyhow; no reason not to.

“Is this it, Doctor?”

“That’s the baby.” I took the hydrometer and unhooked the catheter bag. Holding my breath to avoid the smell, I poured into a small vial what I guessed would be enough urine to float the hydrometer. Carefully I lowered the instrument into the urine, but I couldn’t get a reading. The damn thing kept sticking to the side of the flask rather than floating free as it was supposed to. I held the flask in my left hand and tapped it with the knuckle of my right index finger, trying to free the instrument. I only succeeded in splashing urine on my arm. By adding more urine to the vial, I finally got the hydrometer to bob up and down. The specific gravity was within normal limits — in fact, was absolutely normal — so Marsha wasn’t dehydrated. For some reason, medical people shy away from the word “normal” without its qualifiers; if s always “within normal limits” or “essentially normal.”

Marsha groaned again. As I drew in a big breath, I was whacked by a symphony of smells in the room. As far back as I could remember, I’d never been able to cope with bad odors. In grammar school, when one of my classmates vomited I had been sure to follow with a sympathetic reflex once the smell reached me. In medical school, despite three masks and all sorts of mental tricks, I had been known to retch in the middle of pathology lab.

Still trying to think of an explanation for Marsha Potts’s condition, I wondered if she might have Gram-negative bacteria in her blood stream, perhaps a bacterial infection like pseudomonas, for instance; pseudomonas sometimes leads to a condition called Gram-negative sepsis, which is one of medicine’s most terrifying sights. One minute the patient is all right; then a shiver and everything goes to hell. Maybe that could explain the venous-pressure problem. But I saw no sign of sepsis.

Marsha was moaning regularly now, and each moan was like a new indictment passed down against me. Why couldn’t I figure this out? Walking around to the other side of the bed, I directed the nurse’s attention to the cockroach, which had moved a few feet, down to shoulder height. She jumped and vanished, returning almost instantly with several yards of toilet paper, which made quick work of the bug. A bug like that didn’t bother me much — not like the rats in the hospital in New York. The grounds people there had always said they knew about them and were working on the problem, but I had seen them again and again.

Perhaps something was wrong with the three-way stopcock on the intravenous line. When I opened the stopcock to the position for measuring venous pressure, it didn’t budge from zero. Flipping it closed again, I filled the column with the IV solution and then connected the column with the patient. The level stayed up for a few seconds before starting to fall rapidly, then slowly, as the nurse said it would, first to 10 cm. and finally to zero. Confusing, especially those three-way stop-cocks. I had never quite gotten them straight, never quite known which knob to turn for what connection.

I asked the nurse for a large syringe full of saline and unhooked the whole tangle of tubing from the catheter going into the femoral vein, just below the groin. Marsha had been sustained intravenously for so long that her arm veins were useless for IV’s, and the doctors had begun using her leg veins. To my surprise, no blood from the vein came back up into the catheter tube, even with the pressure of the maintenance solution gone. When I flushed about 10 cc. of saline fluid through the catheter with the syringe, I felt a definite resistance; then suddenly the saline fluid went more easily. As I withdrew the plunger of the syringe, a red streak of blood appeared in the catheter.

Obviously there had been a plug at the end of the catheter inside Marsha’s vein, probably a small blood clot, which had acted like a ball valve, allowing the IV maintenance solution to enter but keeping anything from coming back. A venous-pressure reading depended on blood being able to rise through the catheter. All this I told the nurse, but I didn’t tell her that the blood clot was now probably in Marsha’s lungs. If so, though, it had to be small, thank God.

Hooking up the column once more, I filled it and lined it up with the patient. After I was certain it showed a normal venous pressure and was going to stay there, I restarted the IV.

“I’m sorry, Doctor, I didn’t know,” the nurse said.

“No need to be sorry, no sweat.” I was glad to have solved a problem, even a miniproblem. Considering that I had started with a blank mind, the achievement seemed notable, although the patient was the same. She moaned again, her lips twitching. She was just a shadow of a person, really, and my awareness of her erased the feeling of accomplishment. All I wanted to do now was get out of there, but it was not to be.

“Doctor, as long as you’re here, would you mind looking at Mr. Roso? His hiccups are keeping the other patients awake.”

As the nurse and I walked down the corridor toward Roso’s ward, I thought what an unusual building the hospital was, something entirely new in my experience. Its halls communicated directly with the outside, at least in the old, low section, and grass grew right up to the edge of the hallway. A large monkeypod tree dominated the courtyard, leaning and rustling in the wind. The ground were immaculately manicured and studded with enormous tropical trees. What a difference from other hospitals I’d worked in. There had been one tree on the grounds of my medical school in New York, but it was cut down before I left. The rest was cement and brick, all yellow. But the wreck of them all was Bellevue, where I had done my fourth-year clinical clerkship (working essentially as an intern, although I was officially still a medical student). The halls there were covered with depressing brown paint, everywhere peeling away and so disgusting to touch that we had been careful to walk in the middle, away from the walls. My on-call room had a broken window and uncertain plumbing. It stood on the other side of the hospital from the medical wards, which could be reached only by navigating the respiratory center, where all the TB patients were. During the journey, I had sometimes unconsciously held my breath as I passed through the respiratory ward and so arrived breathless at my destination.

If Dante could have seen Bellevue, he would have given it a prominent place in the Inferno. How I had hated those two months. I saw a movie once that reminded me of Bellevue; it was Kafka’s The Trial, and in it characters were forever moving down endless halls. That was Bellevue, endless halls, especially if you were holding your breath. Any window clean enough to see through revealed only another dirty building with more halls. Even an innocent act of nature could be dangerous. I once went into the men’s room rather hurriedly, unzipping as I walked through the door, and literally fell into a group of patients who were busily mainlining heroin with hospital syringes. That was the first time patients threatened to kill me, but not the last.

Hawaii was nothing like Bellevue. Here I hadn’t been threatened, not yet, anyway, and all the walls were clean and carefully painted, even in the cellar. I had supposed all hospital cellars looked alike, but here they were clean, even bright.

I don’t know why TB worried me so much. Part of the irrational in all of us, I suppose, when you decide some things are bad and others won’t affect you. After I read about malignant hypertension, I thought I had it every time I got a headache. Maybe TB bothered me because my first patient for physical diagnosis had had TB.