Keep Calm and Think Zebras

The Tempest was one of the first plays I read while taking a crash course on all things Shakespearean in college. Prospero is a commander of nymphs, an engineer of enchantments and a conjurer of magic that is exiled onto a tropical island, using his talents for his own needs whether they be for vengeance or protection. Taking the opportunity to seek retribution upon a ship carrying those that banished him, Prospero, through the aid of his nymph, turns a placid sea into a roaring storm, capsizing and shipwrecking all on board. The pace of the emergency room often seems determined in the same capricious manner.  One minute, the day’s moving at a snail’s pace with non-urgent patients meandering in with a sore throat or two and minor discomfort, taking time for granted, when without warning, we’re slammed with a wave of burst appendices, pulsatile aneurysms, and aches from every inch. The divide between calm and chaos can be a fickle one, gossamer at best, and while we’re all attempting to maneuver our own way through Prospero’s devices, it’s easy to underestimate the full force of tumultuous tides when you’re in the midst of tranquil waters.

Six weeks of psychiatry followed by six weeks of emergency medicine resulted in twelve weeks of two very different types of chaos. One was more of an inner turmoil while the other presented as an outward maelstrom, while both settings challenged me to maintain my own course. The ER served as our habitat for most of both rotations (three weeks of psychiatry consults), where we identified the patient, evaluated their relative level of distress, and tried to extract a thorough history of present illness. However, that’s where the paths diverged. In psychiatry, we were taught to chase the stories—any significant life changes occur recently?, what caused your relapse?, can you tell me about your childhood?— while emergency medicine coached us to chase the symptoms—where is the pain?, when did it start?, how would you characterize it? 

Nevertheless, both fields advised us on becoming oriented to being disoriented. Some 20 years of lecture experience were swept by the wayside as I entered my first rotation, before I could even register how to transmute everything I learned in the classroom to the clinical setting. You stand helplessly as each and every day your comfort dissipates like ether from your clasp, doing the best with what you know and what you do not. The true wonders of medicine can’t be appreciated when it’s your first day as an MS3 against the gaggle of interns, fellows, and attendings who swiftly seem to know it all and do it better.

It isn’t that you, as a clinical student, gain more comfort as you gain experience as it is overcoming the challenge of becoming comfortable with the discomfort: the discomfort of not perceiving enough, not anticipating enough, not inquiring enough. Enough: an elusive word with a paradoxical meaning in the ER setting where achieving sufficiency is not adequate, even though the very definition of being sufficient is to be adequate.

English author Zadie Smith, in her debut novel, succinctly wrote:

Every moment happens twice; inside and outside, and they are two different histories.”

It made me think that some times, it isn’t just about the storm brewing around you that needs attention, but the storm festering within you. Obviously we’re just students, and nothing is solely dependent on us except to become uninhibited in our learning, but it’s taxing trying to shake off the “deer-in-the-headlights” look at every turn. My stomach borrowed from folklore and transmogrified into a giant butterfly whose fluttering sought no end as I wavered between nauseam and self-doubt any time I had to round on a new patient.

After all, it’s a tough responsibility to be accountable for a patient’s health, to actually gather all the information, to present to an attending a plausible assessment and plan in a matter of minutes, and then, hoodwink everybody into thinking you have the teensiest idea of knowing what the hell it is you’re doing. On top of it all, the ER tries to reprogram us to  start thinking of zebras when we hear hoofbeats: the immediate killers, the emergent events, often the unlikeliest but deadliest of circumstances. Thus, chaos wasn’t just something we saw, it was the guideline by which we dictated our diagnoses and catered our responses.

On one of my first psych consults, my psych attending asked me what my plan and assessment was for a patient with severe alcohol withdrawal. In the moment, my panic took over and all I could blabber out was ” he needs….help.” My attending chortled perhaps because it was the only alternative to actually physically strangling me with a stethoscope. Although my response was far from the worst suggestion I could’ve presented, it was a little revealing as to how my mental process operated in a fuddled atmosphere. Learning how to stay calm when calm is the last word you would use to describe your surroundings is not just a suggestion, it’s a requirement and often the first lesson a medical student to should master, one that is constantly mentioned but not often taught. If you can’t manage yourself, how are you going to manage your patient, especially in a setting that emphasizes both efficiency and efficacy, where enough still is never enough? How is one to begin the journey of finding serenity among instability? Ultimately it just comes down to embracing the question marks that punctuate so many of the situations you encounter in rotations.

The Tempest was the aging Shakespeare’s swan song to theater, one of his final plays if not his last. Prospero loses his magic, forgives those who exiled him, and asks for forgiveness himself, urging the audience to release him from the island by way of applause and intimating that all he sought was to bring pleasure into the world. And pleasure he did bring. It was his magic that drove the plot, that served to captivate. And while we long for days of slow tides and gentles waves, it is the ultimately the violent surge that we prepare for yet never prepare for quite well enough that reminds us of both our futility and our faculty. It is true for both life inside and outside the ER. You just have to get acclimated to never feeling acclimated. Sometimes that’s what’s enough. Only then can the hunt for zebras commence.

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