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EM Lessons from ‘The Princess Bride’

Mattu, Amal MD

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doi: 10.1097/01.EEM.0000481769.87073.f8
    Inigo Montoya, played by Mandy Patinkin, left, duels with Westley, played by Cary Elwes.

    I was watching TV when the greatest movie ever came on. It's about fencing, fighting, chases, monsters, giants, true love, and miracles. Of course, I'm talking about “The Princess Bride.” This movie was an epiphany, an allegory of emergency medicine and acute care medicine.

    How so? We have fencing and fighting. We have torture: fingers and tubes in every orifice. The patients get revenge on us as well. There are giants and monsters. There are chases — finding admission beds — and there are escapes — patients who leave. There is also true love. And there are miracles, like bringing back the mostly dead. There are incredible truisms about life and medicine in “The Princess Bride:”

    • “Death cannot stop true love. All it can do is delay it for a while.” That's pretty optimistic.
    • “Never get involved in a land war in Asia.” Maybe we'll throw the Middle East in there also.
    • “Inconceivable!” The most useful word in the English language. It will save you from trouble. You're working in the emergency department: There are no beds available? Inconceivable! The consultant is going to be three hours late? Inconceivable! Even at home: “You missed our anniversary.” Ugh, inconceivable! (And then walk away.) It's a great word for all occasions.
    • “There is not a lot of money in revenge.” And that's very true. Don't spend your time trying to get back at people. It's a waste of time.
    • “People in masks cannot be trusted.” Hmm.
    • “Don't mock people's pain.” Very true.
    • “Chocolate coating makes it go down better.” And it's good for your heart if it's dark chocolate.

    I hope all the junior folks reading this will walk away with ideas, just like the other lessons from “The Princess Bride.”

    “He's only mostly dead. Mostly dead is still partly alive.” Miracle Max, who utters this line, seemed a bit cynical, but he was an optimist. It's really important in life and in medicine to be a positive person. Even the glass that is three-quarters empty is still one-quarter full. The late Randy Pausch, the author of the amazing book, The Last Lecture, talks about being a Tigger, not an Eeyore. Eeyore is depressed; everything's awful. What's it like working with Eeyore? It's awful. You know the type who says, “You don't want to be here today. There are no beds available, consultants aren't coming down, hospital administration doesn't care, there's overcrowding.” And what's the mood in the ED? It's terrible. Everybody's unhappy. It's like a giant rain cloud over the ED.

    Do you have a Tigger in your ED? It's good working with Tigger. You can have dueling cardiac arrests going on, some mom who comes running in with a kid who is wheezing, and another guy who comes in with a knife in his chest, and Tigger says we're going to get through this, and we're going to have fun. Everybody's running around, maximum efficiency, and an eight-hour shift flies by.

    What kind of team would you want? You create your team based on the way you behave. Dale Carnegie said miners move tons of dirt just for a couple of nuggets of gold. Granted, you have to dig a little deeper on some people, but everybody has gold. You just have to look for it. Be an optimist. Find the best in other people. It's very important if you're a leader.

    Prepare for the Future. Inigo Montoya, one of my favorite characters from “The Princess Bride,” was 11 years old when his father was killed by Count Rugen. He trained for years to be his very best as a sword fighter so that when he found Rugen, he'd walk up and say, “Hello. My name is Inigo Montoya. You killed my father. Prepare to die.”

    He didn't know if he was ever going to find this man, but he trained his entire life for that day. Everybody has that in his life or career. You have to prepare for that day now. Maybe it's a person; maybe it's an awful perimortem C-section. Maybe it's a thoracotomy in the community hospital. Maybe it's the condition that you hope you never face, but you have to be prepared for that scenario, and now is the time to start training.

    The same is true for your career. If you want a career in academic emergency medicine, learn how to do that. Now is the time to start putting money away. Even if you're not married or have any kids, start thinking about saving for that kid's college account. It was still sunny when Noah started building his ark. Unfortunately, some people are so intimidated by how long it takes and how much work it is that they never start the journey.

    Develop a resistance to iocaine powder. This odorless, tasteless powder is one of the more dangerous poisons known to man, according to “The Princess Bride.” What is iocaine powder in the ED? Criticism. Young physicians have to develop a thick skin and a resistance to it. Acute care medicine lives in a fish bowl, and everybody in the hospital, including administration, will be more than happy to criticize you for anything that goes wrong. Toughen up. I'm not saying ignore it. Consider whether you could have done something better, but don't let the criticism defeat you. You cannot survive in this specialty unless you develop resistance to criticism.

    Life isn't fair—get over it! “Who says life is fair? Where is that written?” says the grandfather to his grandson in “The Princess Bride.” Life isn't fair. Accept it, and move on. There will always be people with bigger houses and more money who work fewer weekends and nights. They have faster cars, more fame, are invited to write more papers, and are involved in more research, and it's not fair. Deal with it. No one ever said life is fair.

    I made the schedule when I was a chief resident. I was always amazed at how the majority of people would say to me, “I don't understand why so-and-so has fewer nights than I do.” And my response was always, “Why are you spending more time looking at other people's schedules than your own?” Don't worry about other people. Focus on your career. The only person you should ever compare yourself with is who you were yesterday. And you're doing pretty well if you can beat that person most of the time. If you spend time comparing yourself with other people, you're going to become vain or bitter because there will always be people above you.

    Beware the three hazards of the fire swamp. There is the lightning sand, the flame spurts, and the ROUSs — the rodents of unusual size. The flame spurts to me represent arrogance. It's bright, it's warm, and it's kind of attractive, but it's going to burn you if you get too close. Be very careful about arrogance in your career. It's not all about you, your CV. People will love you for how you make them feel, not what's on your CV. It's all about what you do for other people that determines your success. Focus on others, and they will love you.

    Lightning sand can swallow you whole without you even knowing it. To me, it represents ignorance, or, in medicine, the failure to keep up. Medicine, especially acute care medicine, changes so fast, and you will be replaced faster than you realize if you don't keep up. The ignorance swallows you up that quickly. If you are going to practice acute care medicine, you have to be really good at it. You can never, ever ease up. Push yourself all the time. The teacher, Mr. Miyagi, says in the original “Karate Kid” to his student, “Daniel-san, you know, man walk left side of road. OK. Man walk right side of road. OK. Man walk down middle of road. Squish like grape. Karate same way. Either karate do or karate do not. Karate ehhh, squish like grape.”

    And then he said, “Medicine, same way.” They deleted that line, but it's on the director's cut. If you're going to practice emergency or critical care medicine, you have to know your stuff. Otherwise, people die. You have to show up all the time. You can't just do a cameo shift here and there; you're hurting people. Either do it all the way or don't do it.

    For folks here in the United States, rodents of unusual size are plaintiff attorneys. It's a legal minefield out there. Know your stuff, document well, and be careful. You don't have to change your practice because of this concern, but you have to change your documentation. You don't have to start ordering more, but you have to change your documentation.

    “Boo! Rubbish! Filth! Slime! Muck! Boo! You had love in your hands, and you gave it up. You treated it like garbage.” In academic emergency medicine especially but in medicine in general, we're really good at saying yes to speaking opportunities, writing, research, joining a new committee. The only thing that we're really good at saying no to is our own family, the people we love the most. I'm going to tell you honestly, very few people truly, unconditionally, unquestionably love you. And it's not because people are bad but because people are busy. When you find those people who really give you everything of themselves, hang onto them tight and give it back to them. Because if you lose them, you will never get them back.

    Figure out what the important things are in your life and prioritize those. Say yes to those things first. It doesn't matter how many committees you're on, how many papers you write, how many research projects or grants you get. None of that matters when your kid looks up to you, and says, “Can you come to my game?” And you say, “No, I'm too busy.” You never get that back.

    One of the final scenes in “The Princess Bride” is when the grandfather finished the book. He put on his jacket, and he's feeling a little unappreciated. The boy grew to like the book he was reading, but never actually said thanks. At the very end, he got his validation when the grandson said, “Grandpa, can you come back and read it again to me tomorrow?”

    I always think about how he felt after spending the entire day with his grandson and not getting a thank you. How many times have you ever felt that way at the end of a shift? You busted your butt for these patients, for the hospital, for whatever it is, and not a single thank you. We don't get that from our patients. When you save a life — you diagnose a subtle STEMI and send her to the cath lab — who does she thank? The people upstairs. You save that cardiac arrest patient, and he goes upstairs. Who does he thank? The people upstairs. We don't get thank yous from our patients so we have to give it to each other. You owe it to your colleagues, to your nurses, to each other at the end of your shift: just say thank you.

    I can't tell you how many times I've said to a nurse, “Thanks so much for keeping your pod of patients going. We wouldn't have made it through this shift without you.” And you should see the response that gets. Because you know what? They never hear thank you. Your colleagues, your residents never hear thank you. I'm sure you never do either. Remember that you are making a tremendous difference. Don't ever leave a shift feeling like you didn't. Every day you get the opportunity to change someone's life. You get the opportunity to change the world for 20 or 30 people. Every day. How many people can say that? The opportunities you have are amazing, and that's something most other professions don't have. Appreciate what you do. You make a tremendous difference.

    People ask me why I like “The Princess Bride” so much. I love this movie because it's all about optimism. It's all about hope. The good guy beats the bad guys without even having to kill them, and he gets the girl. What else? “Death can't stop true love; it can only delay it for a while,” says Westley. How optimistic is that! “You're not completely dead; you're just mostly dead.” That's tremendous optimism to me, and that's why I love it.

    We're surrounded by so much horror and horrendous stuff that happens, whether it's on TV, in the headlines, or in the ED. We always feel tremendous stress and lack of support, and it can make us cynical. Don't devolve into becoming that person.

    A grandfather is sitting with his grandson and telling him a story. He says, “Within every human, there are two wolves. One wolf represents optimism and good and hope and promise. The other wolf represents pessimism, negativity, anger, hate, jealousy, cynicism. And in every human these two wolves are always battling and fighting with each other.” The little boy says, “Grandpa, which one wins? And he answers, “The wolf that you feed the most.”

    Which wolf do you feed the most in yourself? That's the person you will become. Feed the good wolf.

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