My evening shift started as it always did, with sign-out. Bed 1 was a 2-year-old girl with pneumonia, hypoxic requiring oxygen. Despite oxygen saturations in the mid-80s while on oxygen, she looked well and her vital signs were otherwise OK.
She was accepted by the PICU of our closest children's hospital two hours away, but because of a snowstorm, we couldn't fly her there, so the PICU dispatched its ground transport team. I saw her and she looked well, so I started the rest of my shift.
Within an hour, her respiratory status started to deteriorate. Standing over her bed, I looked into her scared eyes. “I swear to you, I'm not going to let anything bad happen to you,” I said. We pushed the etomidate and succinylcholine, and I intubated her without any issues. Her sats only moderately improved. I repeated a chest x-ray, and her parapneumonic effusion was now much larger. The PICU team arrived on site, and a chest tube was placed. She was stable, and off she went into the night storm. My shift went on.
About 45 minutes later, I received a call from medical command. The PICU transport team had turned around; we were still the closest hospital. About 20 minutes or so into their transport, the child lost her pulse. They had been resuscitating her as they headed back toward us.
For 20 minutes, I resuscitated this child with a critical care team and a PICU fellow I had never met. I called in a team to try rescue-ECMO, but the child didn't make it. The last words she ever heard was a promise I couldn't keep.
I walked out of our resuscitation bay that night and crumpled to the floor. I cried for the first time in nearly a decade. I was emotionally exhausted. The PICU fellow came out in tears herself, sat down beside me, and hugged me. And then I had to go back to work. Because that's the thing about the ED. It never stops. No matter what happens, the show must go on, and you just don't get to stop.
I had nightmares about this case for weeks. I couldn't sleep. It haunted me in a way no case ever had because there just wasn't any explanation for why it happened, not even after autopsy. Now, nearly five years later, I still think about her, wide awake, scared, and staring at me, and me telling her I wouldn't let anything bad happen. It has weighed on my conscience for years, and without a doubt, it will never go away. I can still see her face. I always will.
A Tough Job
There are so many difficult things about emergency medicine. It's incredibly stressful seeing undifferentiated patients about whom you know nothing. Many of them are underserved with chronic problems that have been neglected by an American health care system that has failed them. All of the patients who are fired from their doctor for being violent, drug-seeking, or problematic—they are yours.
You will be pulled in a million directions. You will be threatened and maybe even physically assaulted. Seeing 2.5 patients an hour is hard enough, but you'll constantly be pulled out of rooms and interrupted to sign ECGs, take medical command, and field phone calls. Some consultants are just jerks, and will disrespect you constantly. When you work, you work from the time you get there until the time you leave, no matter what. Even when you are completely broken after watching a 2-year-old who seemed OK slip away and die within hours, 10 more patients who need you are waiting to be seen. There is no hiding when it seems like the world is crashing down within your ED.
After all that, why would anyone go into this field? And 15 years after I chose emergency medicine, why do I still do it?
For all of the negatives of emergency medicine, there are many great things. I love the shift work, and we are highly compensated for the time we spend in the hospital. There is no call after I leave. My shift is over, and I can live my life outside of medicine. The number of full-time hours leaves considerable time off to live a life and the lucrative nature of the field has given me a life I never had.
I'm a first-generation physician who grew up in a lower middle-class environment. I never dreamed I'd live the life I have now because of emergency medicine. More importantly, emergency medicine provides me with the ability to practice medicine how I always envisioned being a doctor when I was more naïve.
I grew up idolizing Sherlock Holmes. I love mysteries. Dealing with acute care lets me try to solve medical mysteries daily, with just about every resource at my fingertips. And the team environment is second to none. The people in emergency medicine are some of the best human beings you will ever meet, from the doctors and the nurses to the techs and support staff. I have never experienced a team environment like emergency medicine in any other aspect of medicine.
And let's not forget, you will always have the best stories at parties of any group of physicians. Every once in a while, when you least expect it, you will bring someone back from the brink of death, and from that moment on, for the rest of that person's life, they will be grateful that you were there in that moment.
Bored and Burned Out
Ironically, it wasn't a bad case that nearly ended my EM career but the complete opposite. Three years after residency, I started to become bored. Seeing the same things over and over made me feel more like an assembly line worker than a physician. Even the sick patients became easier, and as the challenge left, I began to lose enjoyment.
The job also became much more socially isolating than it was in residency because you are just working. There's no attending or resident with whom to work. No weekly conference to get together and share stories. It's just you and the virtual chart rack. As the shifts went on over several months and I began to lose interest, I started getting more and more anxious about my career decision. Did I make a mistake? My anxiety ate at me, and I got more and more burned out, and I really thought my career in emergency medicine was on the brink of imploding only a few years out of residency.
But I loved my time in residency, and I desperately missed working within the social and academic structure of one, so my last hope was academics. It was something I had always wanted to do, but I couldn't because the Navy had other plans after residency.
At the height of my burnout, after my time with the U.S. Navy was up, however, I took a job in a residency program. Everything changed for me. I began to see cases through the eyes of a learner again. Working with residents and students rejuvenated me. I quickly moved up the academic food chain and got into program leadership. I can honestly say, eight years later, I still don't feel burned out. I still love to teach, learn, socialize, laugh, and challenge the residents and students on every shift.
Academics brought back my love of emergency medicine, and I will be forever grateful for that. I have spent several years anonymously mentoring medical students online under the name of gamerEMdoc on the Student Doctor Network (SDN) and Twitter. My “EM APD-Ask Me Anything” thread on SDN has been active for more than three years, and is more than 40 pages long. I've shared tips about how to have a successful EM rotation and explained what makes a successful applicant, and I've helped countless students who have contacted me privately with their applications. Many people ask me why I spend my time trying to help as many students as I can online. This is why. Students and residents saved my career, and I will never stop paying them back for it.
Is It Right for You?
If you are a student, you may be asking yourself whether emergency medicine is right for you. I can't answer that for you, but I can confidently say now that I would never leave this field.
For the 50th anniversary of ACEP, Mel Herbert, MD, gave the keynote address and said numerous times, “You are all superheroes.” I realized how truly right he was. Superheroes are often deeply conflicted about their own personal flaws, and sacrifice having a normal life for the greater good. Now I know I couldn't leave emergency medicine even if I wanted to. I'm good at it, and ultimately, I have an obligation to society as an emergency physician to help people in their worst times of need.
No matter how dark times get and how much dark humor and sarcasm I use as a defense mechanism, I ultimately just want to make a difference. Even when I feel so broken that I can't empathize, I fake it because it is my job to make a difference, no matter what. After all, Batman doesn't get to take days off, and neither do we. In the end, we are the front door of the hospital. We are the safety net of the American health care system. Without us, our broken system would collapse. No matter how hard this job gets, we put on our cape (our Patagonia jacket), and we go to work.
That is incredibly difficult sometimes, but it also fills me with immense pride because this job takes skill that many physicians just can't do. For those of you who think you are skilled enough and a little crazy enough to do it, I will continue to be there to help you. We are all in this together because in emergency medicine, we are a team. Just like the Justice League.
Share this article on Twitter and Facebook.
Access the links in EMN by reading this on our website, www.EM-News.com.
Comments? Write to us at [email protected].
Dr. Galuskais an emergency physician at Conemaugh Memorial Medical Center in Johnstown, PA, where he is the residency program director. He is a veteran of the United States Navy Medical Corps, and was deployed in Operation Iraqi Freedom in 2009. He was also awarded the Navy and Marine Corps Achievement and Commendation Medals. Follow him on Twitter@gamerEMdoc.