If you’ve ever found yourself in an emergency room—whether as a patient, family member, or provider—you already know how fast things can move. Decisions that in other settings might take hours or days often need to be made in seconds. I’ve spent nearly three decades working as an ER physician, and one of the most important skills I’ve learned, refined, and passed along is the ability to make high-stakes decisions quickly and confidently.

Rapid decision-making isn’t just a feature of emergency medicine—it’s the heartbeat of it.

Training the Reflex

When I first started practicing, I thought good decision-making was mostly about knowledge. Memorize enough clinical facts, master the protocols, and you’d be fine. And while knowledge is obviously critical, it’s not the whole picture. Over time, I came to understand that decision-making in emergency medicine is more like a muscle—it has to be trained, exercised, and developed under pressure.

Medical school and residency taught me the science. But it was years of standing at the bedside, with monitors beeping and patients crashing, that taught me the art. In those moments, you don’t always have time to double-check the textbook or run every possible test. You learn to trust your training, your instincts, and the patterns you’ve seen play out hundreds—sometimes thousands—of times before.

It doesn’t mean we guess. It means we make the best possible decision with the information we have, in the time that we’re given.

Triage in Action

One of the most important aspects of rapid decision-making is triage—the ability to quickly assess who needs attention right now, and who can wait. It might sound simple on paper, but when the ER is full, the waiting room is backed up, and a trauma alert is rolling in, triage becomes both an art and a moral weight.

I remember a night where three critical patients arrived nearly at once: a heart attack, a stroke, and a car crash victim. Each needed immediate care. There’s no time for lengthy discussions or hesitation. You quickly assess the severity, make a call on who needs what, delegate to your team, and move. It’s a constant balancing act of urgency, risk, and resources.

Over time, you learn to keep calm amid the chaos. You learn to scan a patient in seconds and notice what’s not right. You learn to listen—to your nurses, to the patient, to that gut feeling that something’s off, even when the numbers look okay. That internal radar becomes one of your greatest tools.

Leading Under Pressure

During my time as an ER director, I saw how decision-making plays out on a broader scale. It’s not just about the patients in front of you—it’s about the whole department running smoothly, especially during surges or disasters. Leadership in those moments requires clarity, calm, and the ability to prioritize fast.

It also means knowing when to step back and let your team lead. ERs run on teamwork. Nurses, techs, medics, and physicians each bring critical skills. A good leader—and a good decision-maker—knows how to trust the people around them.

I’ve learned that the best decisions aren’t always made in isolation. They come from communication, experience, and being humble enough to know you don’t have all the answers. Sometimes the nurse sees something you missed. Sometimes a younger doc has a fresher take. Being open to those insights can mean the difference between a good outcome and a tragic one.

Faith, Failure, and Finding Peace

Not every decision in the ER ends the way we want it to. Sometimes we do everything right, and things still go wrong. That’s a hard truth of this field. It’s also why having something to anchor you outside of medicine is essential.

For me, my faith and my family keep me grounded. I’ve found peace in knowing I’m doing what I was called to do—even when the outcomes aren’t perfect. I’ve leaned on prayer, on community, and on quiet moments of reflection after tough shifts. It helps me show up the next day with a clear mind and an open heart.

Teaching the Next Generation

Now that I’m further into my career, I’ve taken great joy in mentoring younger physicians. Watching residents and new attendings face their first real emergencies reminds me of where I started. I try to pass on the things I wish someone had told me—not just the clinical pearls, but the emotional ones too.

I tell them: You’ll feel fear sometimes. You’ll doubt yourself. That’s normal. But over time, those instincts will sharpen, and the fear will fade. You’ll develop a rhythm, a confidence, a calm. And one day, you’ll look back and realize that what once felt overwhelming has become second nature.

In Closing

Emergency medicine isn’t for everyone. It demands speed, resilience, and an ability to operate in high-stress, high-stakes environments. But for those of us who feel at home in the adrenaline and intensity, it’s more than a job—it’s a calling.

The decisions we make may be fast, but they’re never careless. They’re built on years of training, a deep commitment to our patients, and a drive to bring order to chaos, one case at a time.

And that, to me, is the true art of emergency medicine.