Daniel Cabrera — The Chaos Organizer and the Fear Tamer

Author: Daniel Cabrera, MD (@cabreraERDR) // Editors: Alex Koyfman, MD (@EMHighAK) and Manpreet Singh, MD (@MPrizzleER)

This is not news, our job as Emergency Physicians is difficult, very difficult. Every shift is a complicated balancing act managing tens of patients, with multiple complaints, varying degrees of acuity and suffering. We are limited by the resources available, our brain’s ability to process complex information, but mostly by time, uncertainty and fear.

The Emergency Medicine mindset is to assess the risk, make decisions, control fear, lessen suffering, and create clarity of the chaos of our universe.

We deal with an overload of information and emotions in our clinical practice. Stimuli come from endless sources; the interaction with the patient, lab data, consultations, images, and our own inner state. The amount of information is overwhelming. The big challenge is to make sense of all these in a very constrained space and time and in a way that is scalable from the single patient encounter to running the entire department, without becoming victims ourselves.

Organizing chaos is about the context, reduction, and parsimony. We make sense of chaos every day and uncertainty is our currency. Success for us looks like finding the solution to a puzzle.

We understand that context is everything; we have insight in how it can bias our thinking and acts, both in positive and negative ways. It is the context that provides meaning to the patient encounter and the other way around. We know fever in a 2-day old is different from fever in a healthy young adult, we know vomiting in a pregnant woman is different from vomiting in an elderly gentleman.

Emergency physicians know they can’t do all and take care of every single problem; we need to prioritize, we allocate limited resources, we triage. The only way to survive in the jungle of tasks, trepidation, and information overload is to focus completely on the meaningful issues and ignore most meaningless things aggressively. We have the ability to identify and concentrate on the most important, significant, and time-critical component of the problem. This occasionally means not to manage the entire issue, but that is acceptable in a limited-resource setting like the emergency department. We treat hyperkalemia fiercely and leave the search for the etiology of the renal failure for another day. We choose our battles carefully.

Data and emotions are our friends; data and emotions are our enemies. They provide all we need for our decision making and justification for our acts, but at the same time we know we can get overwhelmed by their wealth. Emergency physicians understand that time needs to be spent efficiently; we understand that our brains need to be used precisely. We understand that information overload cannot be processed and more is not always better. We spend our time on critical tasks and we look for information that is able to facilitate our mental process. We spend time figuring out what makes a patient different from the norm and not trying to make a patient fit in a pattern that is not really appropriate. We use Occam’s razor, we are precise and parsimonious and at the end, we double check just to be sure.

Emergency Physicians learn, we are constantly learning. First and foremost; we learn from our errors; we have insight into our decision making and every time we make a mistake we spend considerable amount of time thinking about how we thought in that moment, we apply metacognition. We love to learn, but we know we don’t need to know everything, we just need to know where to find the answer to a question or if the situation merits, how to create the answer to the question.

Fear surrounds Emergency Physicians, in our practice we are the unwilling witness to the best and worst of humankind. We see how lives can change in a minute, catastrophes can destroy towns, and how people fall and stand back up to fight.

We are not cowboys, we walk into our shifts with fear. We know that we will never know what will come across the door of the emergency room today, we know that sometimes the circumstances will overpower us and we have to be on our best game to succeed against adversity. Fear is normal in what we do, if we don’t have a bit of fear when we go into our shifts, probably we shouldn’t be doing this. We don’t panic, despite the situation we understand we need to be leaders, guide our team to success and do what is best for our patients. We can’t indulge ourselves in the luxury of being petrified while running a resuscitation or dealing with the weak and dizzy. Fear is OK, panic is not.

When our patients walk into the emergency department, many of them are having one of the worst days of their lives, or at least, they are under quite a bit of distress. They are scared, they are in an extremely fast-paced, chaotic, unchartered and violent environment. They are afraid of what is happening to them, is this chest pain a heart attack? Will my mother be able to talk again? Is my son having meningitis? They are suffering, not because of the pain or the bleeding, but because of despair. Our duty is not only making a precise diagnosis or performing a flawless procedure, our goal is to lessen suffering, ameliorate pain, but above all, calm the fear. It takes a few minutes to talk to the patient and reassure them or at least guide them through this terrible moment. Knowledge is comfort, uncertainty leads to fear and fear leads to suffering.

Emergency physicians fail, every day, but we understand that we have to recover and keep organizing the chaos and taming the fear. We have a sheer sense of optimistic reality. We have an altruistic meaning justifying our acts and existence. We are able to adapt to new situations and circumstances and triumph over adversity. We try our best to leave our biases at the door, we try to abandon our negative emotions outside of our mental process; we try to be fair and just.

Emergency Medicine is even more complex than may appear but we can make it simpler than we think; that is our mindset.


Originally published at www.emdocs.net on August 17, 2015.

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