Night Shift: The Mavericks

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I just celebrated my 70th birthday recently.  It was a wonderful time with my family.  But all the well wishes from my colleagues, all of whom are much smarter than I, reminded me of all the lies told about people at their funerals.

It made me wonder if they knew something about my health that I didn’t.  It reminded me of the guy who asked his old family doctor if his condition was terminal.  The old timer just looked at him and said, “I don’t really know how long you have.  But if I were you, I wouldn’t make any investments in all day suckers or long playing records.”

So just in case, I thought I might make some reflections on the past and suggestions for the future.  I was still in high school when the first ER docs took the plunge to commit their professional lives to our specialty.  The year I graduated from medical school was the first year the conjoint board exam for the specialty of emergency medicine was offered.


I was simply in awe of the pioneers in our field.  They were mavericks.  Many left behind the safety and celebration of being specialists in other fields to launch out in this new area of ‘expertise,’ that frankly no one at the time much respected.

My residency advisor in medical school sent a note to professors that I respected asking them to talk me out of wasting my time training for this field.  ER docs were the ‘eternal interns’ to many in medicine.  We had to fight for every ounce of respect that flows to us so freely today.

I recall one night shift shortly after I became an EM attending when I called the surgeon on call to tell him he needed to come in to see a patient that required emergency surgery.  He told me to send the patient to his office the following day.  I refused and threatened to call the Chief of Medical Staff if he did not come in immediately as was his responsibility.


When he arrived with fire in his eyes, he asked to speak to me in the office.  I don’t remember anything specific about the conversation except that it was toe to toe, eye to eye, and at such a volume that the nursing staff called the local police to stand outside the door in case we came to blows.

It wasn’t just hospital politics, though, where ER docs had to challenge the powers that be.  Emergency medicine was the only voice advocating for patients who otherwise had no voice.  Emergency medicine flourished first in hospitals treating patients that no one else wanted.

Once the word was out that the ER would treat everyone regardless of their ability to pay, ER patient volumes exploded.  Where private physicians often did a “billfold biopsy” before agreeing to treat the patient, ER docs acted like the ability to pay was not even an issue.  Advocating for our patients is in our DNA.

Another real impact of emergency medicine specialists started to emerge as every day ER docs took fresh looks at problems simple and complex to find new ways, new methods, invent new techniques and tools, to tackle problems previously assumed unsolvable.  Emboldened by lessons learned on the battlefield, both foreign and urban, survivability in trauma started to increase.  Repurposing of drugs for new problems was a common trait.  Sometimes things worked.  Other times not.  But everyone was trying new ways of attacking old problems.


We were called ‘cowboys’ for attacking problems with little information by internists that we referred to as ‘fleas’ because they would suck the blood out of everything and everyone before acting.

Over time though that maverick attitude has changed.  For one, we are now one of the most respected and sought-after specialties in medicine.  Published research in emergency medicine has gone from not much more than book reports in the early days of EM to widely respected examinations of a variety of significant problems.  I will never forget the pride in the eyes of all the EM faculty at my residency when I took home the top prize in research at our institution.

Now no one is surprised when a top medical student chooses emergency medicine or some of the most impactful research can be seen in the Annals of Emergency Medicine.  But that pride has a price.  Like a team who is expected to win, emergency medicine can play too conservative, trying hard not to make mistakes instead of going for the win.

So I, like many of my generation, was sadly not surprised when our specialty played conservative with early intervention treatments for COVID.  Home going instructions to newly diagnosed COVID patients was commonly something along the lines of ‘go home and isolate.  Come back if you start to turn blue.’  Really?

I’m not here to re-litigate the efficacy of hydroxychloroquine or ivermectin.  But what happened to the ‘try something’ attitude?  Everyone used to concede that trying unorthodox things in an emergency was acceptable.  Whatever happened to the attitude of “Any port in a storm”?  Well, I don’t need to tell you, we are just coming out of a Cat 5 hurricane.

Now to be fair, the social pressure to conform to medical orthodoxy is a hundred times stronger today than in the early years of emergency medicine.  In my second year out of training a patient was brought in to our community hospital ER with a single GSW to the mid abdomen.  He was pulseless and brought in for death pronouncement.

In a crazy impulse to just see if he was really as dead as the medics thought — oh, and we didn’t have ultrasound — I took a scalpel and enlarged the entrance wound enough to allow my hand to slide in tamponade his gently pulsating aorta.  The patient regained palpable pulses.  The respiratory therapist intubated the patient. The surgeons were called and we went to the OR with my hand buried in his abdomen.  I didn’t have privileges to do that procedure.  Nor did the RT.  But no one said a word.  We were congratulated for trying.

Today, if someone writes an off-label drug for a COVID patient while informing them that the research is not conclusive that it will help them, the doctor can lose his board certification, his license, or both.  This is insane.  People no longer just disagree about a therapy.  They go to war.  But this is where the mavericks of the world need to stand up and fight for rational discussion and debate, not personal vilification and cancelation.

I had a philosophy professor in college who was speaking to a large crowd of students about moral courage.  In the gentlest of voices, he told the story of an organ grinder who would stand on the sidewalk cranking his music box with his pet monkey in a general’s uniform at his side.

When he had gathered a crowd, he said to the monkey “Salute.”  And the little monkey stood erect and gave a perfect salute.  The crowd laughed and cheered.  “Now watch this” the organ grinder said to the crowd.   He put a cup of cool water down in front of the monkey for the day was very hot.  Each time the monkey would lean down to take a drink he would shout “Salute.”  And the monkey would stand erect and salute.  But then the crowd began to see a darker side of the organ grinder.  While he went back to his merry music box, he watched for the monkey who was eyeing the water.  Each time he went for it, he would shout louder and angrier “Salute.”  Until the little monkey’s salute was quivering with fear.

I can still remember that gentle professor shouting to a quiet auditorium “The music will be lively as world shouts for you to ‘Salute.’  What you do next will determine who you are.”

My prayer for all of us is that we can regain the spirit that made them call us mavericks.

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