My ongoing affair with Emergency Medicine has been what I love most: an exponential learning curve. It is almost constantly unsettling. It forces you to keep moving, on a thin edge, keep thinking; Is there anything else I can do for the patient, is there something I’m missing, is there anything more that I can bring to this situation, or learn from it? It is a study in human behaviour, and one in adaption. The second I begin to get used to one kind of protocol, or one pathway of an algorithm, or settle into one kind of daily routine, Emergency Medicine flings me out of my comfort zone, and teaches me a lesson.
One of the biggest lessons that the ER has taught me is that I cannot be afford to be complacent. I cannot blindly AND peacefully follow any seemingly obvious pathway without understanding the rationale behind it, otherwise my patient, and therefore I, will eventually have consequences to bear. It has taught me that there is no such thing as ‘routine’. All protocols, guidelines, drug indications, indications for investigations are guidelines based on studies done on similar patients. But our job as physicians is to apply our knowledge of these guidelines to the specific patient and his or her particular scenario. It is simply inadequate to follow the ‘routine’ and put the patient through an investigation ‘package’. The whole point of us being there, is that we acquaint ourselves with the ins and outs of the patient’s history and circumstances, enabling us to do just what will help us treat the patient optimally. As much as is possible in the amount of time we have with the patient.
This is, of course, idealistic. In India at least, we often do not have enough time with the patient. But in the time that we do have, I think it is unforgivable that we should do so mechanically.
By this, I mean, let’s not miss out on things, let’s not ignore a finding in the hope, that its insignificant. If I’m unsure that what I heard were some crepitations in the left side of the chest, how can it possibly harm me if I ask a colleague or a senior to confirm the finding.
But I also mean, why do anything extra, just because ‘it’s what’s usually done‘. It always makes more sense to me that I should know why its usually done. Either I’ll learn the reason behind it, and I will have learnt something new. Or I will find out that it is not required. Why waste precious energy, money, time and resource in doing something that is without logic. But for any of this processing to happen, I have to think about what I’m doing, and ask questions. Irritating, persistent, nagging questions that are often considered stupid, and irrelevant. Frankly, I’m always a little afraid of asking them, because, shouldn’t I already know this? Do I really want to risk sounding stupid, when I have finally begun to make a good impression on my senior? Will it really be noticed if I do or don’t do this one investigation, or give or not give this one antibiotic? What if my question gives away my vast lack of knowledge, that I am simply not reading enough? These are the weakest thoughts in my head
I realized, that all these questions were centered around me. Its selfish.
And here’s another thing the ER has taught me. It is dangerous for me to be selfish. I cannot afford to be worried about myself, and as trivial a thing about my appearance, because my action or the lack of it, will not have a direct effect on me at all. There is another person, the patient, involved in the equation. It may not be a life or death question, it may be just less pain or more pain or just a bit more emergence delirium. I may never even know if it made a difference or not. But my only job, is to make the situation better. And if I have to look a little stupid for a while in order to do so, then it is an infinitesimally small price to pay.
Doctors, for a lot of reasons, especially young doctors, (and in Medicine, young does not refer to chronological age), are riddled with insecurity. It is the root of a lot of mistakes we make. There will always be someone who knows more, who has done more, who has read more about any given subject. I have learnt that I have to channel this insecurity to push me to learn more, so that my knowledge is rooted in firmly established facts, and any treatment I prescribe is rational, and effective. What I have usually found is that, it is sometimes, that one question, that someone fearlessly asked, has changed the diagnosis or prevented a gross error, if not saved a life. It is in fact much safer to ask the question.
I do not mean for this post to sound preachy. These are just things that I have learnt, that I am still striving to do, things that I end up not doing on a busy shift or a day that I lack motivation.
I also do not think, that any of this, is exclusive only to the ER, or as a reader pointed out, even to my profession. If we love what we do for a living, we must learn to find a way to lose our insecurities, and raise questions where they arise.
It is again, clich-ed, but I love what Tagore said,
“Where the mind is without fear and the head is held high
Where words come out from the depth of truth
Where tireless striving stretches its arms towards perfection
Where the clear stream of reason has not lost its way
Into the dreary desert sand of dead habit
Where the mind is led forward by thee
Into ever-widening thought and action
Into that heaven of freedom..”
I never want to have anything to do with dead habit. What I want, is clear thought, and knowledge, to set me free.
As always, please feel free to comment, fight me on this, teach me something new!
Doctors' Ink 