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Volume 3, Issue 1
Spring 2007:

And Then... She Ate My Cake

Melanie Austin, MD

Cell 2 Soul. 2007 Spring; 3(1):a10

My first day of residency started at three a.m. after a sleepless night when the fire alarms went off in my building. After trudging down fifteen flights of stairs and waiting half an hour for the fireman from Company One — right next door — to turn off the alarm then trudging back up fifteen flight of stairs, its no wonder I couldn't get back to sleep. Anyway I had to be up at 5:20 A.M. Not only was I in the first intern group to start in the NICU (neonatal intensive care unit), I was also the first of our group to take call. On call you worked a full day from 6AM to 5PM, then you stayed overnight at the hospital managing all the babies and attending all the high risk deliveries and C-sections. There was a senior resident in house, but not only was it a sign of weakness to call him, he was often to busy in the ER with the other interns to be bothered with you. Anyway the best learning (they reasoned) occurred when you tended to matters on your own.

So, I was starting my first call day a bit early. During orientation we were certified in neonatal resuscitation. We did bag-valve-mask ventilation and intubation on stiff plastic dolls. And for added fun, we had to role-play common "life or death" scenarios. I was so terrified in that moment I couldn't act, I couldn't think and I couldn't remember that the stiff lifeless plastic doll was not even real. In those moments of shear terror I let the "baby" die while frozen with fear. And with that as my only preparation I was sent to all high-risk deliveries usually without an attending and occasionally without ever seeing a senior resident.

My first day in the NICU was doomed from the start. The nursery had been at an all time high census of thirty neonates for three weeks, the nurses had been mandated to stay six hours over their regular twelve hour shifts. The staff was overworked, overtired, crabby and not too thrilled about new green interns in their midst. I tried hard to make rounds on my nine new babies; some so small they fit in the palm of my hand. To me they were awful. I was reminded of the dead baby sparrows in my backyard each spring. You know, the naked, helpless, scrawny, horribly tragic creatures that fell prematurely from the nest. Here was the human equivalent. There were rows of alien appearing fetuses in plastic boxes — catheters in their belly buttons, tubes down their throats, probes on their skin. Each one appeared like futuristic science projects gone awry. Every parameter imaginable was measured of these little creatures on what seemed like a second by second basis.

I peered into the box of the child named Gwenna — my very first patient. I wondered how I would know if she were getting sicker. She looked so dreadful to start with. With great difficulty I gathered my numbers not always correctly but with great enthusiasm and started rounds. Rounds were unlike anything I had ever experienced. I had to stand in front of an ever-growing group of attendings, fellows, pharmacists, meds students, nurses and parents and "present" the child in question. What I soon came to find was that although the child was "mine" — I knew less about her than everyone else present. The attendings and fellows knew the babies over long periods of time. The same nurses were with the babies on a daily basis attending to their every need, and those parents who were present for rounds had been there from day one. They all had a history together and now I was expected to step in and own everything from a three paragraph off- service note provided by former interns rushing off to enjoy their one week of vacation before becoming second year residents. And for every small and often insignificant detail that escaped you, you were berated by everyone from the attendings right down to the parents in a public display meant to break your will. I wasn't alone in this, but it sure did feel that way.

My classmate Lesley was with me in the NICU. We couldn't have been more different. From day one of residency, maybe medical school, maybe even birth, Lesley wanted to be an ICU doctor. Preferably the pediatric intensive care unit, or PICU (another one of my ideas of hell). She would come to work pretty damn chipper and proclaim she had an awesome PICU dream last night. Often her dreams went as follows: There was an accident at a football game and Lesley would fly in by helicopter to intubate and stabilize the teenage hometown football hero with the broken neck. She was always the doctor heroine of her dreams. I admired that. I thought about her "wonderful dreams" and realized in my own head that would be a nightmare. Lesley was very lucky. There was no competition for procedures because I couldn't bring myself to do any of them... well until it was gently pointed out to me that I would have to repeat the rotation if I didn't. Even so, I vomited after each attempt.

It was soon after I started getting into the "game" that I met Kelly. Given my stunningly poor ability to judge people by first impressions, I should have been more wary. I thought Kelly was awesome. A graduate of my residency program I thought she knew all the inside information. Existing in the NICU on a daily basis — a place which I found to be an ethical and moral quagmire — Kelly was an ethicist. She was one of the few people I heard admit that it may not be right to resuscitate a 24 week preemie. I often thought about these wee suffering creatures in the plastic boxes. I wondered how they affected the US mortality rates. Do we have one of the highest infant mortality rates because we have the hubris to insist on resuscitating miscarriages? And then I'd think about the hundreds of thousands of dollars their hospital stays cost and the suffering they endured before they would eventually succumb to one disease or another to which they were particularly predisposed, because they had been born far too early. Then I'd think about the approximately one in ten micropreemies who seemed to emerge from the experience essentially unscathed, and I'd wonder some more. Did I just hate the work and thus decided each little creature in her box was an obstacle to my getting a descent night's sleep. And that was the real reason for my not wanting to resuscitate them? Maybe it wasn't about costs or equitable distribution of resources or even the prevention of suffering — maybe it was about sleep deprivation — and that was a damn scary thought. Had I turned into a heartless monster? These creatures in the boxes were somebody's children. And all those people had dreams and hopes for their children before they were even born. And I had given up on them in the delivery room.

I never acted on my feelings that what was happening in the NICU was really wrong. I dutifully resuscitated each baby. The endotracheal tubes always went right back in after they were inadvertently dislodged, all labs were dutifully checked and abnormal results called to the attendings. And when the little creatures would die despite our efforts I would tell myself they were better off — and then I would cry for that family's loss of dreams and hopes for their child. But never publicly. That was unprofessional. Maybe if I had not needed to place my feeling in an impermeable fortress, it would never have happened.

Not many people have their defining moment of residency in the first two weeks. On day one of week two we got a new attending. Her name was Judy and she seemed really compassionate — insisting that we round on my patients first after I had had a particularly bad night. I was obviously falling asleep on my feet as we moved from incubator to incubator. I thought maybe things might be looking up. Finally! (Don't forget my incredible ability to make an erroneous first impression.) Day two. Kelly the ethicist fellow joined us. At first things were going smoothly. I still sputtered and stuttered a bit on rounds but it was somewhat better. And then it started. It took awhile to figure out that Kelly and Judy had started to systematically rip apart my presentations on rounds until I left unable to even speak. Theirs was a swift and well directed attack, much like when the evil stepsisters destroyed Cinderella's dress as she stood in the foyer minutes before leaving for the ball. Each day I dressed back up in that "ball-gown" only to present the vital signs and watch the pearl chocker fall apart and ping against the cold linoleum floor. I presented the overnight events and they'd rip away the taffeta. I presented the "Ins" and "Outs" and they'd destroy the bodice. By the time I arrived at the assessment and plan I was humiliated, naked, and in tears. Where was my fairy godmother? How could everyone watch this travesty on a daily basis and do nothing at all to stop it?

Lesley would tell me what was happening was horrible yet she was clearly relieved that she was not the object of Kelly and Judy's shared vehemence. It was becoming obvious that Kelly and Judy greatly disliked each other. In fact, the only thing they seemed to agree on was that I was easy prey.

I returned to work the next day to find I was on call with Judy. The day started off innocently enough. Kelly wasn't there so Judy was not in her usual state of vitriol. Life was as good as it gets in the NICU. It was a pretty average day until one feisty little creature pulled out her breathing tube. I was there with Meegan the senior resident and Judy. Judy said, "Okay, you (referring to me ) have one shot." I stepped up and took a deep breath and with the largyngoscope in my left hand inserted it into the preemie's tiny mouth. I located the vocal cords and with my right hand I slid the breathing tube into place and in my best "ER" fashion exclaimed "I'm in!" The ventilator was hooked up and by golly it was really working. Even Judy was impressed. Meegan hugged me and whispered "See you can do this." Midnight approached. It was my birthday. Soon after, I was called to the delivery of a tiny full-term baby. What we refer to as small for gestational age. Another way to put it would be "runt." The baby was just shy of 5lbs but not small enough to bring back to the NICU. I felt a lot like that baby. Small, but for the first time since starting residency, I had arrived. I wished him a Happy Birthday and wished myself the same. What a gift. A birthday baby.

In fact, I had received two more gifts. For my birthday, Meegan helped me gather numbers on the babies in the NICU. This allowed me a whopping, uninterrupted 2 hours of sleep. As rounds approached I felt great. The babies appeared stable. There had been no new admissions overnight. I had intubated a preemie for the first time with ease. And it was my birthday. By noon I could expect to finally be going home. Judy had gotten rest too. Other than the one baby who pulled her breathing tube out, she had not been called. We were all rested. Things would go smoothly. Rounds began. I was still sputtering a bit, but methodically going through my "numbers" on the patients. Judy impatiently demanded I pick up the pace. I tried but that made the sputtering worse. My voice cracked, some from fatigue, some from stress. At this point in my training picking up the pace was not really something I could do. I wasn't yet sure which factoids recorded by the nurses of overnight events were critical and which were not. Trying to think it through and speak at the same time became impossible for me. It was distracting and it only served to slow down the process. This only served to make Judy angrier. I got through it, but my level of anxiety was acute — I could feel my mouth becoming dryer, my palms sweating, my heart pounding in my ears.

The next baby was Justin. He was one of the babies, who as a birthday present, Meegan had rounded on for me. It is a common practice to gather data for your colleagues. And I was relieved for the help I had received from Meegan. I gave my presentation using Meegan's collected numbers. Unfortunately, Meegan had miscalculated something that I had not caught. Judy freaked out, telling me I was stupid and incompetent. I tried to explain to her that Meegan had helped me with Justin — that those were her calculations. The screaming escalated — now I was lazy, stupid and incompetent. Rounds stopped and Meegan was summoned from elsewhere in the hospital. Meegan and Judy exchanged words. She was forced to round on every patient she had helped me with as a punishment. All I could do was watch. I couldn't listen, I couldn't think, I couldn't process anything. I couldn't breathe. As I watched, this played out before me: a silent movie, a disaster. We moved ahead and I presented again. The screaming continued, but I don't know what was said. It occurred to me, that this was not far removed from what was happening to me on a daily basis on rounds. Just new people were bearing witness. As rounds drew to a close I could feel me face was hot with the tears that had been flowing for at least the past half hour, but I never uttered a sound. I believed if I cried out loud the sound might be deafening. I might completely fall apart. I might never stop bawling. Defeated and frightened I prepared to leave.

While this was happening, unbeknownst to me, Lesley had delivered a birthday cake and left. She never heard the yelling. I was so moved by the cake that cried harder. Some of my supporters — nurses and unit clerks hugged me asked if I'd like to blow out the candles. My tears flowed more freely. Hard. Like a three-year-old. Sniveling and gasping and completely out of control. Two weeks of this, and I was broken. I didn't know why I rose each morning. I didn't ever want to step foot in a hospital again. I never wanted to experience the verbal abuse and emotional rape I had endured this morning again. I couldn't stop wailing. After close to an hour when I thought I had pulled myself together enough to drive the 3/10 of a mile home, I saw it. Judy was eating MY birthday cake! I stood in the NICU stunned. It was then that the little ember of rage grew so hot and strong I thought I'd explode. Two residents restrained me and then removed me from the NICU. They were right to do so; because, if I could have gotten my hands around her throat I would have strangled her. And then, just like on the TV show "ER" I would have revived her… and then I would have strangled her again.

I've been pissed before; but now I was really pissed. This was not the first time in my life that I had been taken advantage of, yet somehow this time was different. Sleep and food deprivation I'm sure played a role. I get a bit irrational when my blood sugar is low. But I'd never felt the actual urge to kill before. I don't think I ever experienced anything quite like my first two weeks in the NICU. Judy broke my will, took advantage of my fears… and then, she ate my cake!

This isn't the end of the story. A little fire started to burn in my belly. At first I thought, "Now that bitch has given me an ulcer, too" Then I realized it was something more. It was anger. Pure, true and strangely motivational rage. Exhausted and overwhelmed I spent an hour digging through my still unpacked boxes to find — a tape recorder. I was determined to fight back. I was going to start taping rounds. I wanted the whole world to hear what I was subjected to on a daily basis. I wanted Judy censured, demoted, fired... arrested.

It turned out the tape recorder was unnecessary. I showed up to work with the fire in my belly and a completely new "don't fuck with me" attitude. When I was interrupted I snapped back. "You will wait until I'm finished. Don't you start with me." I guess this really freaked them out... because they was silent. For the first time I could remember, I finished my presentation. I wasn't crying on rounds, and I wasn't day-dreaming about jumping off the parking ramp after presenting my patients. I was in charge and in control... For three whole days, and then I finally left the NICU.

I'd love to say that I went through the rest of my residency confident and strong from what I endured in the NICU. It would be a lie. There were cycles of despair, and fear and short-lived confidence. I fought to complete my residency every day for 3 years. Yes, I was treated differently than my colleagues because I refused to "toe the line" and they saw me as vulnerable. Although I found it hard to fight for myself, I would not accept mistreatment in others. I learned that while my will could be damaged, it would not be broken.

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