The Intern Blues(26)

One of my other renal patients is a twenty-year-old with Down’s syndrome [a condition caused by an extra chromosome that leads to mental retardation and other abnormalities] who also happens to have chronic renal failure. He’s extremely high-functioning for a Down’s patient and he understands everything that’s happening. He came into the hospital last week because his BUN and creatinine were going up. He had had a cadaveric transplant [his transplanted kidney had come from a dead donor] a year ago, and they thought he was in rejection. They scheduled a biopsy [a procedure in which a needle is passed into the donor kidney and some tissue is removed; the biopsied material is analyzed under a microscope for signs of rejection] for Friday and told me to make him NPO [nothing by mouth] starting at midnight the night before. Well, of course they didn’t say a word to him about the biopsy, and when the breakfast trays showed up on Friday morning and he didn’t have one, he started to yell. I had to tell him they were going to do a biopsy. Nobody from the renal team had the decency even to talk to him about it!

The biopsy was done and it did show signs of rejection, so they rolled him back to the ward and started him on ATG, too. I’ve got five patients on ATG now. The drug doesn’t seem to cause any harm, so having all those patients on it isn’t making my work any harder, but since it’s only given to patients who are in the process of rejecting their transplant, there’s a lot of misery attached to giving it. This ward is filled with gloom and doom.

Things with Marie have calmed down. She and I have been on good terms since I changed services last week. I think she’s relieved I’m not coming home for lunch anymore. And I don’t think she minds very much that I’ve been sending her home early two out of every three days. So, all in all, if things keep up like this, I don’t think I’ll mind the rest of my internship. Of course, I doubt that it’ll keep up like this!

Tuesday, August 13, 1985

I was on call last night and I’m tired. It was my hardest night so far this month and I got only an hour and a half of sleep. Ricky’s been really sick. He had to go back to the operating room yesterday because of complications. I really thought he was going to die.

I guess he started to go bad last Thursday night. He started complaining of belly pain. His mother told me about it when we were on rounds on Friday morning and I told her I’d check with renal but I forgot to mention it to them. I was on Friday night and he seemed to be in pretty good spirits even though his BUN and creatinine had gone up a little. He did complain that his belly was hurting a few times but whenever I examined him, I couldn’t find anything wrong. He slept well and didn’t get a fever or anything, so I just forgot about it. But I guess the pain got worse on Saturday afternoon and his mother told Margaret Hasson, the intern who was on call, about it and she examined him and found that he was tender all over the place and that his belly was distended. She called the renal fellow and he told Margaret to get a CBC and a sed rate and another BUN and creatinine and that he’d call ultrasound and try to arrange an emergency renal scan. Margaret said he seemed to be a little better when she went back to draw his blood, so the renal fellow wasn’t as concerned when it turned out he couldn’t get the scan done because there wasn’t a technician available during the weekend.

Things got worse again on Sunday afternoon when the third intern, Janet, was on call. Ricky’s belly became very distended again, he was complaining of more pain; now he had pain shooting down his leg. The renal fellow came in and got all the information together. He found out that Ricky’s urine output had steadily dropped over the past couple of days, so he called Dr. White [the renal attending] at home and discussed the whole thing with him. Dr. White must have called the radiology attending at home because within an hour there was somebody there to do an ultrasound exam. They found that the kidney looked fine but that there was some problem with the ureter [the tube connecting the kidney with the bladder]. Dr. White thought that Ricky’s ureter had detached itself from his mother’s kidney and that the kidney was making urine that was slowly leaking into the abdominal cavity and causing the pain.

This was an emergency, so Janet called the urology resident and he came to see Ricky and agreed with what Dr. White had said. The resident called the urology attending at home and the urologist refused to come in! He just refused to come in; he said it wasn’t such an emergency that it needed to be fixed on a Sunday night and that he’d be in the next morning to assess the situation and, by the way, that it probably would be a good idea to keep Ricky NPO and pre-op him [do everything necessary for surgery]. By this point Ricky was in intense pain and his temperature went up to 102, so Dr. White was called and he went nuts! He called the urologist at home and they yelled at each other for a while, but the result was still the same, the guy wasn’t going to come in until the next day. Since there was nothing he could do about it, Dr. White called Janet, told her to start Ricky on broad-spectrum coverage [antibiotics to cover a wide range of possible bacteria] and pain medication. It was terrible; his mother and Janet and Ricky’s nurse were up all night with him.