In life, and especially in high-stakes fields like medicine and business, success isn’t just about knowing the protocol. It’s about the mindset you bring when the protocol falls apart. Excellence isn’t perfection; it’s showing up, stepping up, and staying agile when the plan goes sideways. It’s the grit to grow, the guts to adapt, and the grace to learn from both triumph and trainwreck.

Whether figuring out how to save a life with limited resources or mentoring someone to take on the mantle, the driving force isn’t just technical skill; it’s the mindset to approach every situation with determination and care. Excellence is about engaging fully, even when the outcome is uncertain.

Most “ordinary” days at work in the ER usually involve riding an emotional rollercoaster with a side of caffeine.” It was 03:30 in the morning, and I’d just finished my shift. Tired doesn’t even begin to describe it. I wasn’t “ready for bed” tired; I was “ready to crawl into the nearest closet and pretend the world didn’t exist” tired.

The night had been “one of those nights”. You know, the kind where you question every career choice you’ve ever made because circumstances have become overwhelming. We had a young patient, barely in his 40s, who came in by ambulance. He coded, and we worked with him. And by “worked him,” I mean two hours of intense resuscitation efforts; bringing him back, losing him again, bringing him back, and losing him again. It was an emotional ping-pong, except the stakes were a human life.

But then something amazing happened. We got him back, not just what we call “ROSC” or “Return of Spontaneous Circulation” (which is, in fact, not spontaneous, but rather a result of often hundreds of critical interventions), and managed to stabilize him. By the time he hit the ICU, he was moving purposefully, which indicated that his brain may not have taken too much of what we call “a hit” or anoxic brain injury.

Essentially, your brain, during a resuscitation, is often starved of oxygen, no matter how hard we try to keep your blood pressure high enough to get circulating blood to the brain vessels. The result is almost like a stroke – starved of oxygen, the brain dies quickly, and even though the body survives the resuscitation, the person is never the same and is often left with severe neurological deficits.

During resuscitation, however, our thoughts are focused on the patient in that moment, and we strive to provide the best environment for a positive outcome. Any survival is a victory, making the sleepless nights and endless heartaches worth it. I popped up to the ICU the next day and peeked into his room. He had not only survived but was off the ventilator with his family at his side. I didn’t say anything, but had a huge freaking grin on my face starting the next shift. Seeing that he made it was the ultimate win. Sure, it’s exhausting, but there’s rare satisfaction in saying, “Yep, people lived tonight.”

Of course, not every shift ends like that. There are good days when you save a life and bad days when someone doesn’t make it. The extremes are… well, extreme. But you still give it your all, 100% of the time. Because sometimes, no matter how hard you try, the outcome isn’t under your control, no matter how good you and your team are. And those are the nights when your soul feels just a little heavier heading home.

Jobs in which you are so emotionally vested will suck the life out of you – a friend called emergency medicine a “soul vampire,” and I agree wholeheartedly. The same can be said for any job, depending on the circumstances. Stressors are not simply for life-and-death situations, but also economic (“How am I going to pay my bills?”), situational (“My boss needs this report by tomorrow, and I have no time to get it done!”), familial (“I am at work so much I never see my kids.”), or physical (“I broke my foot and can’t dance again…what am I going to do now?”).

Even “non-stressful” jobs have their own set of challenges, including stress, travel, email management, client acquisition, and finding the next opportunity. The myth of “find a job, love, and you will never work another day in your life” is real. Work is work. Vacation can be “work” for people because uncertainty, though occasionally exciting, often leads to stress, as dopamine (alertness), serotonin (relaxation), and norepinephrine (concentration) become unbalanced.

Even the strongest person must find a way to process the emotional highs and lows, or they’ll consume you. Early on, I learned that trying to “shut it off” doesn’t work for me. Some people can leave an ER night shift and go straight into mowing their neighbor’s lawn like they’re living in a sitcom. I’m not one of those people.

Like many, I process in layers. First, there’s the moment where you survive the situation. Then, you sit with the emotions and let them roll over you. And finally, you come to terms with the fact that you’re a human being doing your best. It’s a bit like being a terrible waitress, something I’m familiar with as one of those grad school jobs that I was tremendously bad at (“Welcome to Howard Johnson’s, your home on the highway…how the hell can I help you?”).

You try, mess up, and learn to laugh about it later. The stakes are higher when someone’s life is on the line, but everyday repercussions can be just as devastating if they result in the loss of money, finances, or personal relationships.

But it’s not all heavy stuff. There are moments of introspective fun, too, like when I learned that actual stacks of cash make things feel more real. A friend once told me they’d take out their day’s pay at least once a week in 5-dollar bills to appreciate their hard work tangibly. It sounded ridiculous until I tried it. Sure, it was “bill money,” but physically counting it felt oddly satisfying.

Memories like this are funny things, as they don’t just live in your head; they echo in your body. Recalling a painful or high-stakes moment can activate the same stress pathways that fired during the original experience, releasing cortisol and reigniting the amygdala’s alarm bells.

But here’s the kicker: stress isn’t always a threat. When processed with awareness, those charged memories can become catalysts for emotional growth, helping us reframe past pain into present wisdom. It’s not the memory itself that defines us — it’s what we do with it.

For example, I rarely wear makeup, except when I’m speaking professionally or on a rare night when I dress up for an event. Once, I bought a face powder that sent me spiraling into childhood memories of my grandmother when I opened the lid. The scent was so distinct and specific that it hit me like a freight train. Suddenly, I found myself sitting in her bathroom, watching her meticulously apply makeup while she told me stories.

That’s the power of sensory triggers. They unexpectedly connect the past to the present. Smell, especially, is like a time machine for your brain. It’s why hospitals always seem to smell vaguely of antiseptic and hope. Every time I walk through those halls, I’m reminded of all the lives I’ve touched—and the ones I couldn’t.

Let’s talk about skill acquisition because that’s the backbone of a genuinely fulfilling intellectual life. Humans are designed to seek knowledge, and acquiring a fact or skill causes our brains to grow. In medicine, we live by a little mantra: See One, Do One, Teach One. It’s exactly what it sounds like. First, you watch someone perform a procedure. Then, you do it yourself. And finally, you teach someone else how to do it – “muscle memory.” It’s a simple cycle, but it’s what turns chaos into calm in the middle of an emergency.

One of the most nerve-wracking experiences of my career started with a call from upstairs. It was a “crash C-section” situation; code for “drop everything and sprint.” The mother had arrived hemorrhaging and unresponsive. Per the family, they had no prenatal care and had no clue how far along in the pregnancy she was.

The ER team faced an incredibly complex situation that had not one but two lives at stake. A perimortem cesarean section is a high-risk skill performed rarely, often with bad outcomes. It’s a damned if you do, damned if you don’t situation, though: no c-section and the baby and mom die. If you do the c-section, both mother and baby have a chance of survival, as delivery increases the possibility that the mother will achieve ROSC, AKA “Return of Spontaneous Circulation” (her heart starts beating again).

It is incredibly rare for an obstetrician, trauma surgeon, and emergency physician to be working together in the ER on a single patient, and it is a testament to how functionally adaptable we must be, not only in our everyday roles, but also in incorporating new team members into chaotic circumstances.

It comes down to breaking down the problem into bite-sized, easily digestible pieces rather than being overwhelmed by the situation at hand. The OB needed to do a C-section: check. The trauma surgeon had to assist the OB and then stabilize surgical repairs without the benefit of their usual operating room equipment or additional diagnostic testing: check. The ER doc needed to resuscitate the mother as, without her blood pumping through chest compressions, artificial ventilation, and trauma resuscitation drugs, blood products, and procedures, the baby had no chance at all of survival.

Within minutes, the baby was delivered, not breathing, and weighed less than 3 pounds. The neonatologist was on the way into the hospital but stuck in traffic, ironically near the site of the motor vehicle collision that was the cause of the mother’s traumatic death—time to turn on a dime again. The OB took over the abdominal bleeding, the trauma surgeon took over the resuscitation along with an emergency department senior resident, and I was then tasked with resuscitating a premature neonate.

It was loud and chaotic, and each team was talking to each other, not with each other. Everyone was listening to their respective physician team leader, but not to one another. A nurse had started performing chest compressions on the baby, and I had about two seconds to decide: fight or flight. I always chose to fight (mainly because there usually isn’t another option), and, after all, this is what I trained for. Deep breath, and let’s go.

As a quick sidebar, it’s not common knowledge that not all hospitals have all specialties. Many times, your survival is very dependent upon your proximity to a hospital that has the specific specialist you need in your crisis moment: a cardiologist with a cardiac catheterization lab for a heart attack, a neurosurgeon for a brain hemorrhage, or a neonatal specialty unit for the delivery of a premature baby. There are geographic and systemic disparities in access to advanced specialty care, and over 45 million Americans live more than an hour from a Level I or II trauma center with all these specialties.

Community hospitals have great resources…just not ALL the resources of a major teaching institution, which tends to have every specialist known to man on staff and call. So, suppose you happen to deliver a very premature infant in a hospital that has limited resources and no immediate specialist intervention. In that case, we do our damn best to stabilize that patient with the resources we have and ship the patient out STAT (from the Latin “statim” or “immediately”) to the closest specialty hospital. In other words, always plan to have your emergency care close to a hospital with specialists who can provide specialized care for that emergency (as if life always gives you that choice and control over the unexpected).

Back to our newborn; It had been years since I’d done a neonatal resuscitation on a baby born so prematurely and from a traumatic arrest. However, suppose you know your basics so well that you can continually adapt to unexpected situations. In that case, you start from the ABCs (remember: Airway, Breathing, Circulation…yup…here we go again) that comprise every single resuscitation, from preemies to geriatrics.

There I was with a baby who wasn’t breathing and a team looking to me for answers. The respiratory therapist, bless his heart, was a part-time NICU (neonatal ICU) RT so while the nurses were performing chest compressions and inserting an intraosseous needle (“into the bone”) into the baby’s femur (brutal, but often necessary for this type of patient), the RT and I tag-teamed intubating this 3 pound infant.

A challenge, indeed, but it went smoothly despite the circumstances; interestingly, keeping that artificial airway (what we call an “endotracheal tube, or “ETT”) in a good position can be more complicated than the actual intubation, as tape must be carefully used on neonatal skin due to potential for significant damage.

OK: A and B done. Check. Next…C…chest compressions being done, but that child needed volume replacement and cardiac medications. The IO was in, but the added challenge is that all pediatric medications are dosed according to weight. This tiny baby required tiny doses of drugs that must each be individually calculated, drawn up, confirmed, and given – all my team members who are not often needed to perform dosing on this small a level. Yup, added stressor. Math under pressure. And calculations in which a 0.01 unit or milligram difference means a fatal dose.

We used a Broselow tape, a color-coded tape measure that helps reduce medication errors and standardize pediatric resuscitation. 2 rounds of drugs were given, and suddenly, we got a heartbeat back. We almost didn’t believe it, and less than 2 minutes had passed since the delivery (though it seemed a lifetime).

The baby then started to “pink up”, meaning they transitioned from a terrible grey, mottled color to a pink hue, starting at the chest, as the heart took over circulation. The pulse was slow, unstable, and irregular, but it was a sign of life.

Now, gaining more intravenous access became even more critical, as many stabilizing fluids, blood, and medications needed to be administered urgently. This means insertion of an umbilical cord line.

It had been at least a decade since I had done this procedure, which is rarely performed in the ER. The process was far from smooth, as I had to innovate on the fly. The baby had poor perfusion at that time, and the anatomy of the cord was a bit of a mystery.

I used sterile saline to figure out which part of the cord was the vein by looking for the bubbles produced by the arterial pulsations and then using the OTHER opening, which would be the veins (umbilical cords have two arteries, one vein in a mushy gel called Wharton’s Jelly) – something I saw years prior at an obstetrical emergency conference.

Have I mentioned that I HATE obstetrics…because I fear delivering babies. Please give me a gunshot wound to the chest every time at midnight with a skeleton staff over a delivery any night of the week. Yes, in deliveries, about 90% of the time, it goes great; mom does all the work, and there are no problems or complications. But it’s that 10% that scares the living shit out of me: high stress, high stakes, high liability, especially in an emergency department with few resources.

So, I take a LOT of classes in the things that scare me to be the best I can be at those things. Practice doesn’t always make perfect, but it damn sure helps, especially in controlling your stress response.

This umbilical line wasn’t textbook perfect, but it worked. By the time the neonatologist and NICU team arrived, that tiny fighter was moving, breathing, and trying to scream – hallelujah! When I finally stopped to take a deep breath, I realized that there was little movement across the trauma bay where, less than 30 minutes earlier, there had been a loud and frantic resuscitation of the mother. I saw multiple staff members sitting on the ground crying, and the OB and trauma surgeon were in chairs by the patient’s head. It was devastatingly silent.

The mother did not survive, and I hadn’t even realized they called the code and declared her time of death – ironically, she died less than 2 minutes after we got a pulse back in her baby girl, who survived this near-unsurvivable event. It did not lessen the tragedy; it was a punch to the gut, but it was a miracle, nonetheless.

Moments like that are proof of what you’re capable of under pressure and that sometimes, even if you give everything you have and more, you may not win. The honor is in the fight itself, and in this case, a life was saved while another life was lost.

The pressure point is where everything falls apart, and you have about three seconds to decide whether to pull yourself together or let chaos win. In high-stakes or uncertain conditions, the cognitive load increases, often triggering instinctual or intuitive responses. These moments can amplify decision fatigue, bias, or clarity depending on training and context.

Spoiler alert: I’m firmly on Team “Pull It Together”, but not without a good sweat, a few internal curses, and a grim smile firmly in place for everyone in that room to see a calm leader. I leave the shaky hands and fear sweats in private after the crisis. That’s one of the most challenging things to master, but it’s essential for effective leadership. The second the team loses faith in you is when you lose control over the situation.

Let me tell you something I’ve learned: confidence is 90% bluffing, and another 10% hoping no one notices the bluff. You can’t walk into a room and have the demeanor that says, “I have no idea what I’m doing!” That’s a surefire way to lose the room—and the patient. So, I always plaster my “I’ve got this” face, even though my brain tends to do the mental equivalent of flipping through a Rolodex in a hurricane.

ABCDE: Airway, breathing, circulation, drugs, exposure. Assess, action. Reassess, Action. Evaluate and act – the same way every time. Start with what you know. In this case, although there were two patients, one wasn’t mine. Check. Divide and conquer.

The part they don’t show in medical dramas is the aftermath. I left that room looking like I’d just run a marathon. Sweat poured down my face, and my hands shook like I’d had too many espressos. I found a quiet corner, sat down, and let the adrenaline crash over me. My nurse brought me some water and a barf bag (yes, I looked like I was going to puke).

After a quick reset, I wiped my face, stood up, and walked back into the chaos of the emergency department, where 10 more patients had checked in to be seen as if nothing had happened upstairs…because that’s my job and the never-ending rhythm of the ER.

Turning your brain off like this and pivoting is not something taught in school and is incredibly detrimental to your psyche. It leads to burnout, a traumatic stress reaction, and flashbacks. But sometimes you cannot step away, no matter how much you need to. I am certainly not saying my situation is equivalent to being in a war zone. Still, in many ways, it’s similar in that when you are surrounded by events so horrific that you need to look away or be taken away, yet have to stay focused and physically and mentally present, it leads to this PTSD-like response.

Spending the next 2 hours listening to patients yell and vent their anger at me because I was “lazy” and “ignoring how long they had to wait”, yet not being able to defend myself was terrible. I love taking care of patients, but there is often an entitlement among ER patients that, regardless of why they are there, they do not want to wait, nor do they care who else has to wait as long as they get what they want, right then and there. Oh, and I’d better do it with a smile and a turkey sandwich.

One of my colleagues said to a patient, “This is not a fucking McDonald’s…just because you are here first, doesn’t mean you get seen first, so bugger off.” (And yes, he was docked a day’s pay and officially reprimanded; he said it was totally worth it.).

Is being in the weeds on a cooking line during a rush lunch hour less stressful because it doesn’t involve life or death? Not to that chef, it isn’t. It may be just as critical because stress is specific to an individual, a particular situation, and their unique coping mechanisms. Adrenalin junkies love stress, but it doesn’t mean they are unaffected by it. Perhaps they cope better in that moment, but just as some people thrive in that moment, some people crack – maybe then or maybe later.

Moments like these aren’t about brilliance or bravery but muscle memory. The hundreds of times you’ve practiced something drill it into your brain until it becomes automatic. This research shows that experts in high-pressure environments (e.g., athletes, military, surgeons) demonstrate lower cortical brain activity during performance, suggesting that automaticity reduces mental strain and improves performance consistency.^[1]

It’s why I can run through ABCD in my sleep, know how to troubleshoot when the equipment isn’t perfect, and make split-second decisions without crumbling under pressure. It’s not magic, it’s repetition. It’s how I shut off my brain after a traumatic event and move on to the next ER patient; honestly, I am giving the impression that I am paying attention, but the reality is I am just gritting my teeth and trying to make it through without crying.