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Second Opinion

Pull Out the Spear, Even if No One Else Will

Leap, Edwin MD

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doi: 10.1097/01.EEM.0000349236.85503.55

    How many times in your career have you heard these words: “I'm not comfortable with that?” It's pretty common where I practice. Because we're a small facility, lacking many subspecialties, I hear it a lot.

    “I'm not comfortable operating on a child.” (The child may be 16, mind you.)

    “I'm not comfortable with a hypertensive cerebral bleed.” (The patient may be telling jokes and eating Jell-O, of course.)

    “I'm not comfortable with that trauma or that MI, that facial fracture or that dental injury, this esophageal foreign body or that gunshot wound.” The list goes on and on.

    The reasons for “discomfort” are legion. Sometimes the discomfort of consultants is a reflection of genuine concern. They may not have done a procedure since residency, or may know someone in the next town who does it much better. Some physicians simply fear violating the established science, or may fear malpractice litigation over difficult or high-risk patients. (Better the unstable MI should die in transport than die with the physician's hands on the body. Nobody wants to be the last one to touch the corpse, as it were.) And of course, some physicians are uncomfortable because of their fear of negative comments on patient satisfaction scores or increased rates of infection or other complications. (We can't have any “never” events, can we?)

    I don't think it's a stretch to say, even in medicine, that there are also those rare doctors who are just lazy. We've all met them. They'll spend four hours arguing to avoid work that would have taken one hour. The avoidance of work or responsibility is a kind of religion to these folks, who ironically are often the first to complain of falling reimbursement. They don't understand that you have to work to be paid.

    But beyond and behind all of it, the “I'm not comfortable” mentality reflects a deeper, more disturbing trend in medicine. The thing is, medicine exists because someone, ages ago, did something uncomfortable. They probably did it because someone else was uncomfortable. A friend or family member lay screaming in agony, dying from an injury or infection, from childbirth or beast claw, stone spear or fall from a precipice. In the face of the misery of another human, that proto-physician bent, with heart racing, hands sweating, mouth dry, and others looking on in amazement, and pulled the spear from the chest, helped the infant stuck in the birth canal, dressed the bite, or straightened the leg. At some point, it worked. At some point, the risk of intervening in what seemed like nature or the will of malevolent gods resulted in the good of life saved. The screaming ceased. The mother and child smiled and lived on a while. The hunter returned to the hunt. A physician was born. And he was born because he overcame his discomfort.

    Over the ages, we have been uncomfortable in the face of plagues, parasites, warfare, natural disaster, and untold numbers of miseries visited on humanity. Physicians didn't learn because they had libraries full of evidenced-based medicine. They learned because they observed, plowed through their discomfort for the greater good, and took risks. Medicine didn't advance because it was a great science. It became a science because physicians did things that no one had done, took chances, and endured danger, all for a higher good.

    What was that good? Let's not lose the point. The good we sought and the good we seek is not the pursuit of perfect science or the error-free path. The good we desire is not flawless records without mistakes or excellent satisfaction scores resulting in promotion and bonuses. The good we seek, as did our ancestral proto-doctor, is the well-being of humans. All of our attempts to avoid error, to be comfortable in the things we do, those are part of the path perhaps. Those are, in a way, tools to the good. But they are not the good.

    The good is the return to normality of the injured. The good is the rescue from peril of the dying. The good is to sometimes share in their suffering by being uncomfortable. The good is sometimes to take a chance and do what seems right, even though no one else will try.

    I practice in a small hospital. I have done thoracotomies, though I am not comfortable doing them. I could have not attempted the procedure and said, “Pulseless with stab wound to heart.” I have delivered babies, though I am not comfortable doing so. I have intubated and placed chest tubes in infants who our pediatricians would have insisted on immediately transferring. I have opened abscesses that made me uncomfortable, and observed suicidal overdoses that no one else wanted to admit because they were uncomfortable.

    I've been wrong. But mostly, I've been right. Discomfort, you see, is part of what we do in emergency care. It's comfortable to be a museum curator, to sell coffee at a bistro, to mow lawns, and to balance books. Those are wonderful things vital to our happiness.

    But if you want to be a physician, then you'll have to learn discomfort. Accept it, embrace it, use it, and feel emboldened and empowered by it. Medicine is full of comfortable physicians whose answer is always consult or transfer. But sometimes, we can't do that. And sometimes someone has to step up to the plate, hands sweating, heart pounding, and do the right thing.

    That's our job. And no study on earth can quantify the delight it brings to succeed, or even to fail, in the struggle to help another human. So pull out the spear, ladies and gentlemen, even if no one else will. Discomfort may become the most comfortable thing you've ever felt.

    Only Online Ed Leap's Blog on EM-News.com

    You know his candid and touching columns from Emergency Medicine News, and now Dr. Edwin Leap's blog is available on EM-News.com.

    Whether you're interested in Dr. Leap's thoughts on emergency medicine and the stimulus bill or his reaction to a consultant who refused to help his patient, it's all in his online journal, now on EMN's home page.

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