“Take one more look. Surgery will prep the neck in the meantime.”

Emergency medicine is a cruel field. The more I learn, the more I realize my deficiencies, my weaknesses, my fears. As I uncover the intricacies and nuances of this specialty, questions continue to arise. The scope of practice is ever growing and self-doubt seems to only grow with experience.

If I’m being brutally honest, some things haven’t changed since intern year. I still get nervous before every shift. My heart skips a beat whenever the trauma phone rings and my hands get a little shaky every time a critical patient is wheeled into the resuscitation bay. In many ways, I feel like an imposter as I head into my last year of training.

Why? Because there is so much that I don’t know. And in a year’s time when I graduate, there will still be so much to learn. One of my mentors, Anand Swaminathan, loves to state that we are humbled every day in the emergency department as providers. We all have those cases that forever change how we practice. I know I have mine: the massive PE who I intubated and subsequently coded a short while later in the MICU, the GI bleed who lost her mental status in the waiting room, or the pulseless nineteen-year-old jumper who returned with bilateral chest tubes. They have been some of my greatest teachers.

One of the luxuries of being a resident, is the ability to pick and choose the type of clinician you want to be. You get exposed to a wide array of various practice styles and habits. And ultimately you get to decide what you like and don’t like. I’ve always believed that my goal in residency was to become an amalgamation of those clinicians who I look up to. Over the years, I have come to learn that the most inspiring attendings are those that still remain humble, even after 20-30 years of practice. They are the ones that come to work willing to learn – who understand that ego has no place in the ER, who place the patient before their pride. They are the ones that taught me that ACS can present anyway it wants to, that you need to respect every GI bleed that walks through the door, and that your scariest airway is always the next one.

You know the quintessential “difficult airway” that we are all taught as trainees? Obese, thick neck, big tongue, retrognathia, facial hair and diaphoretic – the type of airway that you can tell is a Mallampati IV even before opening the mouth. That was my last patient during a recent evening shift. As I was wrapping up my patients, EMS rolled in an unresponsive young male who they were bagging. Within two seconds of looking at my attending, we knew this patient needed a definitive airway. We also knew this wouldn’t be easy. My first pass revealed what everyone in the room already knew – an abundance of soft tissue, copious secretions, and much to my chagrin, nothing that looked like cords. “Patient’s desatting to 70. Get out and bag him up.”

Being an emergency medicine resident, to a certain degree, is a lesson in acting. A lesson in projecting a sense of calm and instilling security in those around you. When the world is falling apart, it is our job to maintain poise, to steady the ship during the storm. Managing the airway of a critical patient is a role we all know very well – it’s playing the lead in a Broadway play, it’s shredding on your six-string in front of a stadium full of screaming fans, it’s getting the ball with 5 seconds left when your team is down by one.  All eyes are on you. And everyone in the room is willing you to succeed.

“Like a duck on the pond. On the surface everything looks calm, but beneath the water those feet are churning a mile a minute.” Oral airway. Bigger blade. And eventual success.

I believe that emergency medicine demands perfection. The problem is that we cannot be perfect and must acknowledge it. We cannot master everything. Humility is our greatest virtue.

To the NYU/Bellevue Class of 2019 – a band of big brothers and sisters for the past 3 years of my life; thank you all for your support and guidance. Stay humble. Stay hungry.