Am I the only emergency physician who sometimes wonders who left me in charge of an ED? I should be confident in managing whatever comes through those ED doors after more than 10 years of single-coverage night shifts, but each night I hear a little voice in my amygdala questioning whether tonight will be the night I won't be able to handle something. Sometimes I feel afraid of the unknown and of what might go wrong. That doesn't make me a bad doctor; it makes me human. What matters is how I choose to deal with my fear.
This is how Elizabeth Gilbert put it in Big Magic: Creative Living Beyond Fear: “Your fear — programmed by evolution to be hypervigilant and insanely overprotective — will always assume that any uncertain outcome is destined to end in a bloody, horrible death.” She likely meant that as hyperbole, but it is not an exaggeration for EPs. The life-or-death situations, where immeasurable stakes ride on our every move, can be scary. We don't admit it because societal expectations and those we put on ourselves make us feel like we always need to be “on.” No matter how tough we appear on the outside, I think most emergency physicians secretly feel some butterflies on the inside.
For many, the nail-biting suspense and goosebumps lured us into emergency medicine because we crave the butterflies on some level. We are the skydivers, roller-coaster aficionados, horror-movie junkies, and constant thrill seekers. Pushing the envelope and seeing how much fear we can tolerate ultimately gives us a sense of satisfaction when we endure. The jitters and palpitations snap us out of web-surfing mode into being fully alert. There is nothing quite like the exuberant rush of energy we feel when we venture outside of our comfort zone.
Unfortunately, the enormity of the stakes in emergency medicine can overwhelm and paralyze us rather than energize us. We doubt ourselves fresh out of residency especially but also after humbling cases or medical errors. We fear failing our patients and sending them home to die, so we waver and waffle. We fear lawsuits, so we cripple ourselves practicing overly defensive medicine. We fear sounding stupid to our colleagues and consultants, so we hesitate. We fear the ramifications of negative patient satisfaction scores, so we impair ourselves with the impossible task of reasoning with the unreasonable, trying not to incur a complaint. We fear missing something, so we get bogged down ordering test after test. Our fear immobilizes us, so we don't send patients home or efficiently disposition them. Rather, we turn our EDs into parking lots, the EP equivalent of being frozen by fear.
Grit and Determination
I experienced being frozen by fear a few years ago. My life was at stake, or so I thought, during my first attempt at real rock climbing. I was a few feet into the second pitch when unwisely, in my inexperience, I unclipped the support gear my lead climber had left for me. I couldn't find hand or foot placements, so I spazzed, decided to climb back down, and blindly lowered my foot to where I remembered an outcropping had been. I missed. The next thing I knew I was freefalling until the rope tightened and halted my descent, and then, because I had imprudently unclipped the support gear above me, I was swinging across the crevice backwards toward a rock wall, half-screaming, half-whimpering, and then BAM! I smashed into the rock with my back. It was sheer terror, with some pain thrown in for good measure.
All I could do was not look down until my buddy hoisted me to within reach of climbable rock. When I finally saw footholds and handholds again, my amygdala assumed they were threatening seducers that would lure me in only to prove harmful. That fear was irrepressible and larger than life. I'd never understood people who are paralyzed with fear until that moment. I literally couldn't stand up. I couldn't trust my feet or my arms because they had failed me, and I was certain I was soon to misstep and go plummeting back down. The adrenaline that normally enlivens me with a fight-or-flight response enervated me, and I froze.
This n=1 climbing trial was more powerful to me than any double-blind, randomized, placebo-controlled experiment. Immediately after that kind of visceral response, evidence-based medicine goes out the window, or off the rock face, as it were. My fear was so profound that I felt every climbing attempt would end in a fall. That is the case after something horrible happens to a patient. If a patient comes in walking and talking with vague abdominal pain, ruptures an AAA, and dies in front of you, every future patient with abdominal pain is an aorta threatening to rupture, no matter evidence to the contrary.
Fear is normal after negative experiences; it does not mean we are undertrained or weak. How we respond determines whether fear will sharpen and motivate us or overwhelm and incapacitate us. A little bit of fear in the ED keeps us on our toes. The key is not letting our fear stop us from confidently and efficiently making decisions. We can't, however, swing on the proverbial rope forever. Instead of “looking down” and focusing on what could go wrong, we have to be bold and trust ourselves.
The roughest night shifts when I've been most afraid were also when I found the most grit and determination within myself. That day on the rock wall I found the same grit and climbed to the summit. Out of trepidation and fear spring tenacity and courage. Our butterflies give wings to our bravery, freeing us to fly onward and upward as we grow as professionals and people.
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