Chaos, Cacophony, and Conundrums: The Rhythm of a Night in the ED

Sunday nights in the emergency department. Patients singing in discordant tones, taunting one another through the curtains, commiserating together about their subpar treatment by doctors and nurses. People from all walks of life screaming in unison… The article by Teri Reynolds, who worked as an emergency physician in Oakland, comes to mind, Dispatches from the Emergency Room. There is one patient who regularly greets him with “Yo bitch, get me a sandwich.” It was one of those nights.

(Tangent: I am often frustrated by the way the emergency department operates – I wish that we could take care of patients more quickly than we do. But so often our hands are tied. More on this later.)

And now for the thoughts of today: the doctor persona. I think this is something which I have subconsciously developed over the last year. I had a moment on my shift yesterday when I realized this – I was talking to a patient and noticed that I had a comfortable, confident, but very informal and honest manner towards him. He seemed content. I was only aware of my interaction because a fourth-year medical student, who was standing in the background, was glancing in our direction with some kind of interest or curiosity – as if this were unfamiliar to him, to act this way with a patient. As I observe fourth-year medical students now, I realize how stiff they appear – not comfortable in their own shoes, if you will. And it’s no wonder – here they are wearing white coats, for the first time, still trying to figure out what that means for both them and their patients.

One of the small-town doctors who trained me used to say that being a doctor is similar to being an actor: you need to walk into the room with a persona and establish rapport with a patient right away. First impressions are everything and when you walk in that door, shake the patient’s hand, and introduce yourself, you set the tone for the visit. You are on stage. You are not exactly a friend, nor are you an authority figure. You are a physician, a provider of medical care. I view my role as more of an advisory one – I have an area of expertise outside of my patients’ which gives me the ability to care for their overall health as best I can. But I am well aware that my medical opinion is not the only medical opinion, and I am also aware that, just as with everything else in life,  nothing is 100%.

Should we really act as physicians? Perhaps that word gives the wrong impression. We cannot completely be ourselves when we walk into the room – we cannot talk about our woes, our frustrations, our personal problems, or even our medical problems. Our job is to be an ear for our patients, and to respond in the way that they need. Maybe this is not acting as much as it is focus, and purpose. Just like an athlete preparing for and competing in a race, we need to be focused on our task in order to do it well – we need to be fully in our role, in the mindset that we are here to accomplish something specific. The rest of our soul needs to be set aside for the moment.

Nobody teaches us the “doctor persona.” We are taught the skills of listening, of delivering bad news, of responding to a patient’s concerns, of being sensitive. But, over the course of training in residency and afterwards, everyone develops their own style. Some people walk into the room with such an extroverted style that they are almost oppressive to the patients. Others enter with such meekness that patients wonder whether their doctor is really present or not – these physicians often let the patient run the show. Others are more middle of the road. Some use sarcasm or humor, others use a gentle approach. Many use a false sense of optimism.

We are doctors just as we are human beings – trying to establish rapport with patients, to earn their trust, to respond to their needs appropriately. And we struggle in deciphering our role in the physician-patient relationship just as people struggle in all kinds of relationships with families, friends, co-workers, and children. Often our personal tendencies in “real” life become our tendencies as physicians – and depending on the patient and his or her needs, these can be viewed as assets or flaws.

Sometimes our patience runs thin – as mine did last night when I felt like I was working in a veritable jungle. Let’s take that metaphor a bit further: the ED can be a place where it’s every man for himself, where patients fight to get to the top of the CT scan list, where impatience and anxiety run high. This is living on the edge – where the next storm of a full trauma rumbles through the ED at any moment, bypassing all the patients in the hallway – blood, crushed limbs, and broken faces flying by them at lightning speed as they make their way to the trauma bay. And the sounds are of the jungle – one woman retching over and over again, one man belting out notes like a hyena, another content in his discontentment as he incessantly belts out “doctor, nurse, doctor, nurse,” and still another who shouts in response to this “they all went home.” Another who is crying, crying, her mouth gaping open, sobbing uncontrollably. Another who is shouting “I am going to die, I am going to die.” And the smells are of the jungle, or worse – the indescribable smell of melena, the smell of gangrenous, infected feet, the scent of clothing which has not been washed for days.

As I go through my shift, a drumbeat pounds in my head. Think Jungle Rhythm, African Drums And Soukouss. It’s only the drums or sheer laughter that can get you through a night like this in the emergency department – and if you start laughing your patients and colleagues look at you oddly (they don’t always see the humor when they’re smack dab in the middle of it).

When it comes down to it, emergency medicine is expected chaos. As soon as you grow accustomed to that, your feet fall into rhythm and you bow your head. You let the rhythm of the ED, rather than your own breath, set the pace. You listen to it, embrace it, allow it to overtake you like a wave. And you march on through those 12 long hours, in a job which so few people could ever truly imagine, sometimes helping patients, more often helping them help themselves. And laughing every now and then (as inconspicuously as possible) in pure disbelief, considering with gentle wonder if you really signed up for this in the first place – but only for a passing moment until the next episode of expected chaos booms through the doors.