It has been a rollercoaster of a month in my emergency medicine clerkship. I finally got a taste of the grit, the grime and the glory of this profession. I wanted to share a few thoughts about my experiences in the emergency department — because there is so much more to this place than most people imagine. Many of us have this romanticized version of the ED in our heads from some TV drama. We imagine a world where beautiful physicians are sprinting next to flying gurneys, pounding chests and snarling, “Get me epi, STAT!” We imagine a war zone rife with Shakespearean tragedy, with heart-breaking moments that leave grizzled doctors weeping. We tend to overlook the less glamorous parts of the job — the long waiting lines, the drug-seeking behavior and the awful smells. Those aspects doesn’t make for great TV, but it’s part of the job in real life.
The truth is that there’s plenty of real drama in the ED. At least once or twice a shift, we get an overhead call for a life-threatening emergency, and everyone hustles to the trauma bay to prepare for the ambulance. The adrenaline kicks in as we wait to see what’s going to come through those doors. The patient could be bleeding out from gunshot wounds, gasping through collapsed lungs or having a massive heart attack. The only way to be ready for any of this is to have a good team and a good plan of action. Everyone has their role: nurses draw blood and check blood pressures, residents intubate airways and place lines, patient care assistants hang bags and perform CPR and technicians snap portable X-rays. It’s a beautiful, synchronized exercise in calmness and coordination. There’s no feeling in the world like working together to save a human life. It’s one of the reasons I’m drawn to emergency medicine and surely why so many people love working here.
Those ‘traumas’ and ‘codes’ are the hallmark moments of the profession. But the reality of the day-to-day proceedings isn’t quite so theatrical. The ED deals with many run-of-the-mill cases, like back pain and stomach bugs. These are dealt with swiftly, usually with nausea medications and referrals to primary care doctors. These aren’t medical emergencies, but they chew up a lot of time and space in the ED. It’s no surprise that many emergency physicians are obsessed with the public’s ‘misuse’ of the ED. After all, emergency departments are exorbitantly expensive, and they aren’t designed to handle minor inconveniences. Patient overflow tends to prolong waiting times and clog up the system. It also creates a culture of ‘kicking the can down the road’ by offering short-term treatments for chronic problems. The ED ends up functioning as stopgap medicine. Unfortunately, many patients never get the long-term treatment they need.
One of the attendings in the emergency department framed the issue differently to me, however. He told me that there will always be cases of unnecessary visits to the ED. If you dwell on it, you’ll go crazy. Worse than that, you’ll burn out. And when you burn out, you lose your empathy. That’s when the game is over.
The trick to beating this, the attending explained to me, is to maintain a focused empathy for every individual patient. Remind yourself that many of the country’s most underserved people have no medical recourse except the ED. Not everyone comes in needing a defibrillator and a CT scan, but nearly everyone comes in frightened or in pain and your job is to help them, period. Even if they just need an aspirin and a pat on the back — someone with a white coat to tell them that they aren’t going to die.
It doesn’t make for exciting TV but many patients just need reassurance. On the other hand, many patients need much more than you could possibly give them. These patients arrive in the ED only when they are falling apart. They show up when they’re having trouble breathing, eating or walking. At that point, it’s often too little, too late.
There are times like these when all your work seems futile — and you feel like a hamster spinning on a wheel, going nowhere. Patients are either unfixable, don’t want to be fixed or expect to be fixed too much. If you dwell on this, you become cynical. And cynicism is poisonous in this profession. My trick is to find humor in the sheer absurdity of these situations. Most of us have a wicked sense of humor, and our day is peppered with an endless stream of jokes. A French-Algerian philosopher named Albert Camus once wrote: “Basically, at the very bottom of life, which seduces us all, there is only absurdity and more absurdity.” The ED certainly embodies ‘the very bottom of life.’ Between the delirium and the Dilaudid, you can see the full spectrum of comedy and tragedy of the human condition. What else can we do but laugh about it? It’s how we cope. “Only by living absurdly is it possible to break out of this infinite absurdity,” wrote the author Julio Cortázar.
Working in the ED is not an easy job. It takes a lot out of you. But it gives plenty back. The ED teaches you that it’s okay to laugh when you’re scared, or in pain, or just fed up. It teaches you how to maintain your empathy in the face of relentless tragedy. Most importantly, it teaches you to keep on smiling as you stare down the rabbit hole — to the absurdity at the very bottom of life. That’s something truly special about this place. When I see true human suffering, I’m reminded that good humor isn’t just a blessing — it’s a necessity.
If you can keep laughing, you’re bulletproof.
Contributing Writer Emeritus
University of Pennsylvania
Matt Trifan is a current resident of emergency medicine at Thomas Jefferson University Hospital in Philadelphia. He was a former medical student at the University of Pennsylvania. In his free time, he reads, writes, travels, and never misses a chance for brunch. He owes his life philosophy to Albert Camus and Adventure Time, equally.