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I came up the companionway of our boat, ready to take over the night watch from my daughter who was standing alone at the helm. “I see that the wind has freshened,” I said cheerily. This a term sailors use when it’s blowing like crazy. It’s a little like a doctor telling a patient that their pain is going to be “a little uncomfortable.” The truth was that we were 500 miles into a 1000+ mile offshore sailing adventure that our family had dreamed of for years. But we were having a few problems. The engine wasn’t working. After several days of clouds our solar panels could no longer keep up with the power demand on the batteries. So the autopilot was about to be shut down. We had discovered that our water tanks were near empty due to a faulty valve. It was going to be a long night any way you cut it, but now the conditions were changing for the worse. The wind speed indicator was topping 30 knots, driving us hard into every wave we didn’t take perfectly. The swells, which had been a manageable 5 to 8 feet high all day now looked the size of one story houses. Take them too timidly and you rolled wildly. Race down the backside of them and you risked pitching stern over bow. It felt like we were wildly racing through a hilly countryside in a storm with the headlights off.

“Are we going to be OK?” my daughter asked with a hint of anxiety.

“We’ll be fine,” I said with all the confidence I could muster. “You go down and get some rest. I know you must be tired.” She looked at me hard to see if she could read my face. But thankfully, it was dark, obscuring my worried brow. “You go ahead,” I repeated. “We’ll be fine.” As she climbed below my mind drifted back to all the times I’ve been asked similar questions in equally dire circumstances.

**********

“Are you OK in there?” the second coverage doc asked as he breezed by the code room on his way to see other patients. The truth was that after a well-prepared rapid sequence induction, the intubation was not going so smoothly. After an equipment malfunction on the videoscope, I had resorted to direct visual intubation. The patient’s bull neck, not a problem with the videoscope, was presenting some real difficulties. Between repeated attempts at intubation, the patient was experiencing desaturation. “We’re fine,” I replied confidently, returning to work the problem.

“Is she going to be OK?” a mother asked me as I examined her four-year-old with crowing respirations. She was in a tripod stance with her jaw thrust forward. “She’ll be OK,” I said confidently. “I just need to go with her to X-ray with some equipment, just in case.” The truth was that I was moonlighting in a small country hospital that had no ENT and backup from a nurse anesthetist could be a half hour or more. My guts were roiling with anxiety, but on the outside I was the picture of calm confidence. I can take care of this problem, I thought. That’s my job. That’s what I’ve been trained to do.

As any emergency physician can appreciate, that’s not blind confidence. It is not bluster. It is a confidence that comes from years of study and experience and has produced a long algorithm for any problem that arises. “If step A fails, go to step B. If step B fails, go to ...” But the trick is to know what you know, just as you know what you don’t know. Confidence without knowledge is a disaster. But knowledge without confidence is almost as equally problematic. Sometimes, knowing when you don’t need help is more difficult than knowing when you do. From time to time, we’ve all experienced calling for help, only to find that the consultant has less experience and skill than we do. Then we end up standing by, wringing our hands, trying to be helpful, and trying to keep the consultant from making a bad situation even worse. We’ve also seen colleagues who punt every problem, no matter how small, to someone else. It may be a sign of humility or lack of confidence.

But sometimes it’s just laziness.

Years ago patients expected to see a bewildered intern in the ER, being herded about by an all-knowing head nurse. But those days are past. Patients and medical staff alike now expect emergency physicians to be experts in their field. If we can’t do something, chances are, no one else can do it better. The realization that we truly are responsible is what drives me back to the books, constantly relearning my profession. Being alone in the ED at night only accentuates that feeling.

That’s why constant learning is so important. Personally, I think the ABEM is doing a noble but impossible job by trying to use LLSA to keep EPs up to date in their knowledge and skills. They have the right idea. But constant re-learning is a personal responsibility. Mastering – then coasting – is simply not acceptable.

Visitors to my home often comment upon a beautiful painting that I have hung prominently in the entryway. It is a reproduction of Rembrandt’s painting, Christ in the Storm on the Sea of Galilee. It’s fun to tease people by reminding them that the ‘real’ painting was stolen from a museum 20 years ago and never recovered. It’s also fun to point out that this is the only seascape that Rembrandt painted and that he painted himself into the picture as the 14th person in the boat. But the theme of the painting is what I enjoy the most. Jesus is sleeping peacefully in the back of the heaving boat, even as terror can be read on the faces of those around him. His calm, unlike mine, is not just on the outside. He knew a thing or two about the sea that the others, though they were experienced seamen, did not.

**********

A rogue wave struck the side of the boat with a loud crack, sending a hundred gallons of cold seawater into the cockpit and drenching me as I stood at the helm. It was a harsh wake up from my ruminations. This will indeed be a long night, I thought as I studied each wave and listened to the high pitched whine of the wind in the rigging. Problem by problem, I began to formulate a plan of attack with secondary and tertiary plans. But the first problem was the wind. If the winds began to inch up to gale-force speed, I would have to awaken the whole crew and send everyone up on the thrashing deck to change the sails. Keeping too much sail up was like being frozen with your foot on the gas pedal as the car careened out of control. It wouldn’t be easy and it could be dangerous. But we would do it. The only thing remaining was to make the decision. It was not a committee vote. That decision would fall to me.

“Hey gang,” I finally called out into the darkness below deck. “Everybody put on your foul weather gear, life jackets and harnesses and come up top. We’re going to have a little fun.”

Mark Plaster, MD, is the founder and executive editor of Emergency Physicians Monthly.

 

Comments   

# Calming?EDR 2010-12-30 10:18
What is the best way to respond to the sea? From where do you draw confidence?
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# Executive EditorMark L Plaster MD 2011-01-03 10:03
While the sea was definitely real that night, it is used as a metaphor in this story for the challenges we all face, many times alone. We can "respond to the sea" by: a) never venturing out, staying a landlubber, b) only go out on a big ship with someone in control, a cruise ship sailor, c) sail into the night hoping for the best, or d) prepare the best you can, try to make good judgements, and lead others with good seamanship and confidence, knowing there are still doubts. A has no business in the ED. B oftens works in the ED, but does little good for anyone. C is a fool and often hurts people. And D is a hard working EP, doing the best he can under difficult circumstances. I draw my confidence from preparation. You have to know what you know as well as what you don't know. And finally you have to have faith that at the end of the day (or night) you have done your best, and that is enough. God is big enough to handle the rest.
Reply
# Thank youGrateful 2011-01-04 16:30
Thank you for writing this -- encouragement is needed and is much more motivating than negativity.
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