The Tap

I have been practicing emergency medicine since starting EM residency in 1986. Yes, its been that long. For you youngsters, we did have penicillin back then, although CT scans were still fairly new. A “plain brain” took 45 minutes.

I have been thinking about this question a lot lately. I have been in this game for thirty-four years and most days I feel like I have another thirty-four years left. The question however is, how do you know when it is time to hang it up? Like George Costanza, I ponder, “You are going along, you think everything is all right and then all of a sudden, you get the tap. It’s like the manager coming out and asking you for the ball.” In medicine, unless you are overtly performing poorly, there is no one tapping on your head or shoulder that it is time to move on.

I was working the other day and the medics brought in a young woman who was unresponsive. As it turned out, she ingested a large amount of benzodiazepines (Valium or Ativan). Sadly, we found out later that she was trying to kill herself.

It was obvious when I walked into the room that she needed to have her airway protected. She was unresponsive with a GCS of 5, no gag reflex and hypo-ventilating. It was clear she needed to be intubated and placed on a ventilator. It was not going to be an easy intubation. She had a short, stocky neck, a small mouth, crooked teeth, and an anterior airway.

For the first time in my three-plus decades in EM, I said to myself, “I hope I can get this airway.” Until that moment, I have never not believed I could intubate someone, nail the spinal tap, reduce the shoulder or do any other procedure in the emergency department. It is not arrogance. I simply believe that to accomplish something, particularly when your (or your patient’s) back is against the proverbial wall, that you HAVE to believe that you are the best person for the job and that you will successfully accomplish whatever it is you are attempting. To date, that maxim has served me well.

Fortunately, despite her difficult airway and my initial lack of confidence, I was able to intubate her and she ultimately survived. Despite that, it got me thinking. What are the signs that you are past your peak? I want to be like Seinfeld and go out at the top of my game. Not like George and get the tap when my performance is below par. 

Until that moment of self-doubt, I believed I was not yet “tap worthy.” Now, I will be pondering this question and closely watching my skills to ensure that I still belong in the game.

My very next patient snapped me out of my funk when she told me that, “I had nine puppies come out of my vagina;” and, “That I am half animal and half human so I have a legal prescription for meth.” Fortunately, this time, I had no self-doubt when I looked to make sure no canines were where they should not be and more importantly, nothing bit me. 

I’ve still got it!