EM Mindset: the Fickle Gravity of Fear

Author: Shannon Moffett, MD (EM Attending Physician and Clerkship Director, Rutgers New Jersey Medical School) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) and Brit Long, MD (@long_brit)

Reading through my predecessors’ work on this topic, I am struck by the absence of any specific mention of fear. Perhaps it is because fear and anxiety, like bad odors, are omnipresent in the emergency department, and so we become accustomed to them.  Like city smog, the sulfur in your hometown’s tap water, or the pop-pop of gunfire outside your ambulance bay, live with anything long enough, and it becomes background.  Which is as it should be – on any given day, an EM doc should be blind to fear – examining fear on shift is as unhelpful as a lecture on gravitational acceleration during a tightrope act.

Or it would be, if fear were constant, like gravity: a steady tug on your arm as you intubate, the pit in your stomach the exact same depth day after day.  Which, for stretches, it is.

But conditions fluctuate during our medical high-wire acts, and our muscle tone varies. Often, the change in our conditioning is linear and slopes up.  We are scared the first time we stick a needle through the skin of another human being, the first time we order a paralytic, the first time we discharge a patient we haven’t diagnosed. But for long periods, we proceed in our fear-grapple like a baby hitting milestones – we cruise on by.

There comes a time – perhaps you are in that glorious period now – when you feel wary but confident; you have so much under your belt.  There is little that surprises you – you’ve learned from your mistakes, or been super-blessed and been able to learn from others’ mistakes (all the knowledge, none of the pain!).  You are a sprinter, not an aerialist – your movement is in a different plane.

And then, later, something happens – the earth tilts on its axis; you’re chucked into a human centrifuge; the bottom drops out and your epigastrium plunges into the canyon where your umbilicus once was, like a stone off a cliff. Suddenly, like an astronaut just back from the space station, your usual tasks take all your accessory muscles – “what if…?” whines incessantly in your head as you plan your work-ups, send patients to the floor or home on the bus.  As with food-poisoning, it’s usually hard to pinpoint the source of the disturbance.

Or worse – you develop one of the flavors of emergentologist’s periodic paralysis: Type A (spastic) – the moment you’ve glimpsed the vocal cords in your zone two stab wound, your arm starts joggling and your ears start whistling and suddenly it’s like trying to intubate in the back of a flatbed truck whizzing down a gravel road at midnight. Or Type B (flaccid) – the unresponsive infant arrives, and you lose all tone while your brain goes still and dead-white as the baby. And then there’s Type C (mixed with cognitive/axis 2 features) – you reach the bedside of the agitated patient with the deeply creepy eyes, and a single quaver in your voice betrays you and alienates your patient, so you leave the room to re-set, snapping at the nurse for it-doesn’t-matter-what on the way out. Meanwhile, you feel your grip on the department slip, slipping, sliding, until suddenly: tunnel-vision.  The rest of the department falls away, and you sit down to take care of some charting.

And this is where the problem with our usual fearless funambulism presents. We become so accustomed to fear, even to the odd intermittent surges in the fear-force, that we fail to recognize when we are in the free-fall commonly known as panic.  And, because we’ve become so good at masking our response to fear, even if we ourselves know we are scared, we fail to give off the signs that would tell someone else we are in trouble and allow them to help.

We are ashamed of our fear, of what it says about us, and most of all of what fear has made us do.  Even now, I’m scared to write down here the stupid things I’ve done while in the grip of fear.  Snapped at nurses, sure.  Just gone ahead and done something despite suboptimal conditions? Check! From removing a urethral foreign body in a teenager in a semi-public area to trying to intubate a crashing kid in an ambulance in a parking lot, resisting suggestions that we scoop him up and move him the few feet into the ED, I’ve failed in my attempts to stay sensible in the face of fear, allowing panic – masquerading as efficiency or commitment – to force my hand.  That second one died, by the way.  As did the man whose critically low calcium I didn’t notice before quickly discharging him to jail in my fearful pursuit of an unclogged ER.  There are more.  But already my fear is telling me to shut up and quit exposing myself as the rotten doctor I’m terrified that I am.

Which, I suppose, is my point with all this.  Because fear feeds on itself, and on the idiocies you commit while in its grip.  If you are in any way introspective, which based on the fact that you are reading this I assume that you are, the mistakes you make while in fear’s clutches will haunt you forever, festering and bubbling and tumescing out of sight, breeding more fear. The more calamitous fodder you give fear, the stronger it gets, and the stronger it gets, the more ravaging fear’s effects on your capacity to walk the tight-rope of our practice.

Even more difficult than admitting fear is admitting that we have two fears – we fear for our patients’ wellbeing, of course.  But when we really look in the dark crannies of our souls (in that place where we know that whatever we call it, what we are doing is deep sedation) we must admit that, perhaps even more, we fear SCREWING UP. That fear comprises concern for our patients, but also intense self-interest.  Usually, our systems are set up (and we should be deeply grateful for this) so both types of fear prod us to do the right thing for our patients. But retaining our clarity of thinking on this division allows us to consciously address the rare cases in which what is in our own self-interest is not in the best interest of the patient (Think repeat abdominal CT. Think the quick opiate prescription to avoid an argument. Think rushing a jail-bound patient out before sign-out so you can present a tidy ED and head home for a beer.)

So what to do? The first thing, I believe, is to acknowledge fear, something I’ve found remarkably difficult in the cowboy culture of EM. We acknowledge it obliquely (who hasn’t retrospectively discussed the tone – or lack thereof – of their own sphincters during a code), but when was the last time you said – or heard any other ER doc say, in the moment – “I’m scared.” I’m not advocating dwelling on your fear (at least not while on-duty), just a tip of the hat, a reminder to tare the scale.  And, once you trust your nurses and your colleagues, admit it to them as well.  Don’t dwell, just acknowledge.  You’ll burn up some of the fog surrounding your thinking, they’ll be ready to help, and you might just let them access and stabilize their own fear one day.

Then, of course, there is our balance-pole of knowledge, which well-tended and polished will consistently counter-act the eddies of fear. Don’t forget that if you don’t have a balance-pole, an umbrella might do the trick, by which I mean – grab a book, your phone, a friend – it’s so rare that there truly isn’t time to look something up, but so easy to let fear delude us into thinking we’re better off using that time elsewhere.

When you don’t have those couple of minutes, that’s when you may have to follow the famous twin-tower tight-rope artist Philippe Petit’s advice: “Wirewalker, trust your feet! Let them lead you; they know the way.”  Just don’t forget that he spent six years planning his twin towers walk, including hiring a helicopter to surveil the area, sneaking into the towers during construction, and building his own scale model of the towers to practice on.  He studied, he collaborated, he made friends with workers at the site.  You have, too.

Petit acknowledged that his performance is simple, a single path; it’s life on the ground that’s complex, and therefore hard. Due to the intricacy and monumental stakes of our own job, we will make terrible mistakes.  Deny your fears, allow their exposure to make you angry and defensive, and the winds begin to blow and the line to pitch.  Beat yourself up, hold yourself to the rigid and pristine standard we all have in our heads and you, and your patients, will suffer.  Perhaps you cannot be the doctor you wanted to be.  But ask yourself this: are you better than no doctor at all?  If the answer is yes, then you must tip your hat to fear, forgive your missteps, even the unimaginably appalling ones, then climb back up the ladder, grab your pole and set your eyes forward, and – trust your feet.

References / Further Reading:

-Wikipedia, https://en.wikipedia.org/wiki/Philippe_Petit, accessed 2017-03-03

-Philippe Petit, To Reach the Clouds: My High Wire Walk Between the Twin Towers. North Point Press (September 4, 2002)