Working in an ER is unlike any other branch of medicine. Your specialty is unpredictable. You have no scheduled patients and no set pace. You could be fighting boredom one hour and running around with your hair on fire the next, or the next 11, for that matter. Your patients are not stratified by age, gender, body part, or severity of injury. Your next patient could have an infected cuticle, chronic constipation, or crushing chest pain. But for each, their presenting distress is unique and self-defined.
To care for human beings efficiently, whether you are a doctor, a parent, or both, one must develop a demeanor of objective calm. Most ER shifts will have at least one glaring emergency that fortunately isn’t, as well as a mundane presentation that is a disaster waiting to happen should it go unrecognized. Developing the requisite unruffled presence to manage either of these requires enduring multiple moments of panic, preferably supervised initially by an experienced mentor. One could explain how this process is called the “practice of medicine,” but that’s not likely to reassure my lay readers. I’ve advised young colleagues that projecting such reassurance has the twin aspects of looking like you know what you’re doing and actually knowing what you’re doing. In the ER, both are essential.
To manage this unpredictable flow of humanity, you might work with 3 to 4 colleagues, or as was my case 95 percent of the time, where you may be the only doc on duty. Your skillset must be broad and up to date. You can go from suturing a laceration to setting a bone to defibrillating a heart, all in 60 minutes, or on a rare shift, all at the same time. You need to be able to explain and project your diagnostic acumen and clinical advice to patients, their families, and your peers, not to mention that administrative suite of suits whose role is to retroactively question and verify the quality and outcome of your choices. And somewhere in this chaotic process, you must also find the time to accurately and comprehensively document all you see and do, knowing that those notes could be scrutinized under the relentless and unfriendly microscope of a potential plaintiff’s attorney in a year or two. It takes a rare breed to survive and thrive amidst this organized version of mayhem shift after shift, year after year, and decade after decade.
When the time comes, knowing when and how to say goodbye to this mélange of adrenaline rush and PTSD-inducing drama is more intuitive than concretely definable. The decision to leave this calling is in many ways more difficult than the ones that beckoned you onto this pathway originally. When I hear a colleague explain their career and then this eventual separation process, I am reminded of how some people talk about speaking their truth. I’d venture that there is no such thing. There is only your story. And down the road, when you reflect on your memories of that story with both wonder and regret, it remains to some degree uncertain to each of us how much truth we were able to live out in the historical continuum of small moments where compassion, frustration, heroism and just surviving defined our cumulative attitudes and actions.
Now I, in turn, move to close out the ER-based part of my professional clinical career after 24 years of the 36 I’ve spent in medical practice. I am about to count down those remaining twelve-hour shifts: 4, 3, 2, 1 … and I find the anticipation of exiting the hospital through that ambulance entrance for the last time-as the physician, to lie somewhere between liberation and dread, somewhat like a man must feel like when he comes up for parole, after serving a long sentence for a crime he didn’t commit.
We all serve a life sentence, I suppose. But we do get to choose to some degree the inmates with whom we serve and the parameters of the prison yard we inhabit. We all have limits that are the circumstances of birth, but our limits are often those of imagination and the willingness to walk out the front gate of the grounds to find a new adventure. As Red in the Shankshaw Redemption explained, the real danger over time lies in becoming institutionalized. Does there lie nearly dormant in our memories the recollection of the freedom that was our first estate? Can we reinvent it to invigorate the present? Will this become the moment of clarity where we understand that overcoming the fear of jumping is the essential first step in re-learning how to fly?
While I may love what I’m doing now, at some point, I must also be willing not to do it anymore. This dichotomy is inevitable in every avenue in life, and most necessarily true with medicine, where one’s repertoire of knowledge and skills must remain scalpel-sharp for each who entrusts us with their care, right up to that last patient.
Although we know that in life, all good things must come to an end, in practice, it is an uncomfortable and fundamentally disturbing concept to accept. Instinctively we believe, yes we know, that the Book of Life will contain a variety of chapters. Some more than others will require an uncertain, challenging, and ultimately revitalizing shedding and even shredding of the familiar. To fulfill one’s destiny, it may be true that only he who can write the word ‘end’ can also pen the first words of a new beginning. I hope that I will finish this chapter with the benediction of thanksgiving and humility it deserves. In the next chapter, I hope the lessons I’ve learned from this slice of life will make me a wiser and more compassionate man. I hope.
Jeff Baker is an emergency physician.
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