In spring 2020, near the end of my intern year, I spoke with the mother of a 24-year-old man who had been brought in unresponsive to our resuscitation bay. “He was trying,” his mother told me. Hearing her own words out loud, she was struggling to believe what happened. “He had just finished rehab and promised he would stop,” she explained.
Explore This IssueACEP Now: Vol 41 – No 01 – January 2022
Medics wheeled him into our emergency department while performing chest compressions. Earlier that evening, after saying good night to his parents, the young man had climbed the stairs to his bedroom and closed the door. Twenty minutes later, his mother found him lying on the floor without a heartbeat. She tried using naloxone, once in each nostril, but he never woke up. Twenty more minutes passed before he arrived at our emergency department, still pulseless.
As an intern, I had some experience informing patients of serious new diagnoses, including the news of metastatic cancer, but this was the first time I was going to tell a mother her son had died.
I did not know what to expect.
How the Essay and Emergency Medicine Are Related
In the 1570s, at the age of 38, the French aristocrat Michel de Montaigne set out to write a series of trials, or essais in French, on an encyclopedic range of topics to figure out, through writing, how he felt and how those feelings made him who he was. In his trials, he experimented with ideas of friendship, cruelty, fashion, death, and even cannibalism. In doing so, he invented a new literary form: the essay.
His essays often deviated from their point, improvised, and evolved into an articulation of an opinion that was not always obvious at the outset of his writing. But that was part of the exercise. His aim was to challenge himself with a variety of experiences and situations, to test himself in real time by putting pen to paper in order to discover his true feelings.
Like the field of emergency medicine, the essay arrived late as a literary form, long after the poem, the play, or the earliest forms of prose. Like the essay, emergency medicine is a series of trials where we must sometimes treat diseases before making the final diagnosis. We improvise until the outcome is known.
The Combined Roles of Improvisation and Practice
Now in the second year of my residency program, I am placed in a new role at the center of the resuscitation bay, taking care of the sickest patients in Brooklyn for brief moments in time. And I’ve found that despite all my studying and pre-reading, I never feel completely prepared. There is no shortcut around improvisation. As in our simulation center, I grow and learn by working through cases in real time.
Despite all the algorithms and mnemonics, the unique details of each trauma, cardiac arrest, or intubation are different. Slowly but surely (and perhaps more slowly than I’d like), the experience has become easier, mostly through practicing the practice of medicine. As Montaigne wrote, “When we consider through what mists and how gropingly we are led to our knowledge of most of the things within our grasp, we shall assuredly conclude that it is familiarity rather than knowledge that takes away their strangeness.”1
“Essayons,” or “Let’s Try” in French, is the motto of the United States Army Corps of Engineers, and it does not refer to a lukewarm, half-hearted “try.” The motto recognizes that when failure lurks around every corner and when resignation would be easier, trying can be the greatest act of courage.
It seems strange to advance in my training before feeling that I’ve mastered my first year. From what I’ve heard from senior physicians, I may feel this way for a while, even as a third-year resident, a fellow, or a new attending. However, as the form of the essay teaches us, it’s the trial itself that helps us to grow.
All We Can Do Is Try
As I spoke with the mother about her 24-year-old son, her grief took the form of a series of questions. I was not entirely sure I could answer them. She said that she had checked on her son 20 minutes after he had said good night. What if she had checked on him sooner? How much time would she have had to save his life? If he had been unconscious for five or 10 minutes, would the naloxone have been enough? Was there any way to tell from signs on his body how late she had been to rescuing him?
I thought of all the cardiac arrests I had seen in my short time in training. Each time I wondered whether their lives could have been saved by someone more qualified than me or if my team could have done anything differently, if we had placed the central line faster or drawn the blood tests sooner or called anesthesia instead of attempting the intubation ourselves. I thought, on the other hand, what if I hadn’t tried at all? How would I ever become independent enough to take care of patients on my own? How would I ever get used to the feeling of possibly falling short?
No doubt, this mother had been dealing with her son’s opioid addiction for years. She had the naloxone ready. No doubt, she had rehearsed the scenario in her mind—first one nostril, then the other. However, nothing could have prepared her for the reality of what unfolded that evening. I told her that in administering the naloxone and calling 911, she had done all that she could do. She had tried. With that, she had done the best that any of us can ever do.
Dr. Lalley is an emergency medicine resident at Maimonides Medical Center in Brooklyn, New York.
- Montaigne M. Essays. Ringwood, Victoria, Australia: Penguin Books; 1966:87.
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January 29, 2022mert erogul
Excellent analysis, thank you for this fantastic piece!
January 24, 2023Lawrence Haines
Beautifully written and full of insight into one of the heaviest topics of our day. I’m proud to have been a small part of your path of discovery.