Let me explain.

This was not a regular emergency department shift. I was working triage—an initiative many hospitals have adopted to get patients “seen faster.”

The idea is simple enough: place a physician alongside the triage nurses. Instead of waiting six, eight, or sometimes twelve hours to be assessed in a treatment space, patients get rapid orders at triage. Bloodwork. Imaging. Pain medication. Fluids. The hope is that by the time a stretcher opens up, part of the workup is already done.

In theory, it improves flow.

In reality, it means seeing a hundred or more patients in rapid succession, often without privacy, without examination, and without asking any questions. You don’t truly own any patient. You are trying to make good decisions with incomplete information.

You are perpetually interrupted—ECGs, requests for pain orders, returning results, and the constant stream of incoming patients to triage.

I was entering the final stretch. The last hour.

I listened to the nurse triage a patient with abdominal pain. She looked uncomfortable but not critically ill. I ordered analgesia, fluids, and routine bloodwork.

Then the pregnancy test came back unexpectedly positive.

Some of her other labs were critically abnormal.

When I went back to discuss with her, she was adamant.

Impossible.

Unless this was immaculate conception, she said, there was absolutely no way she could be pregnant.

Fair enough.

Medicine occasionally surprises us, but when a patient’s that certain, you pause.

I repeated the bloodwork.

At almost the exact same moment, a man burst into triage yelling for help.

He had found someone outside.

“In the bushes.”

I followed him with one of the triage nurses.

In a small, forested area on hospital property sat a confused elderly male.

Soaking wet.

Disoriented.

Hypothermic.

Barely responsive.

We pulled him out of the bushes and wheeled him back into the emergency department. While evaluating him and sorting out what had happened, we discovered he was actually an admitted inpatient who had somehow gone missing for hours.

Meanwhile, patients kept arriving.

And I was falling behind. Orders weren’t being entered.

Even while trying to manage an emergency outside the department, there is an invisible clock ticking.

Metrics.

They track how many patients receive orders in triage. Miss too many and someone notices.

Efficiency is measured. Performance is monitored.

The influx never stops.

I checked back on the repeat bloodwork.

Negative pregnancy test.

Some of the previous abnormal values had normalized.

Which raised a much worse question.

Whose bloodwork had I been looking at?

Had somebody else’s critical abnormalities ended up in the wrong chart?

In a department packed with hundreds of patients, was there someone sick with seemingly normal labs?

A dangerous jigsaw puzzle.

One that needed urgent investigation.

But that problem would have to wait.

Because a nurse handed me an ECG showing a massive heart attack.

One glance.

STEMI.

I looked up immediately.

“Where is this patient?”

Everything else paused.

Again.

Nothing else mattered in that moment except getting that patient to the Cath lab.

Immediately.

Most of the stress is not the medicine.

It is cognitive overload.

Competing priorities.

Trying to make good decisions while knowing something important may still be unfolding somewhere you cannot see.

One problem down.

Another immediately in front of you.

It was the last hour.

But I swear it aged me.

ROSC.blog

A pistol.

I had never held a gun before.

Somehow, without incident, I managed to confiscate it and walk out of the room carrying a loaded firearm.

Only afterward did the reality of the situation fully register.

How badly that encounter could have gone.

How vulnerable I actually was.

Having trained in some particularly rough hospitals during residency in New York, it was instilled in me early that aggressive patients were simply part of the job.

The experience prompted me to launch a resident project on violence in the Emergency Department. I surveyed staff and was not surprised to learn that virtually every provider had experienced aggression or violence within the previous year.

I researched the laws, reviewed best practices, analyzed gaps in hospital safety, and developed recommendations to improve safety and prevent situations like an agitated patient sitting in the ED with a weapon.

Hospital management was not thrilled.

My recommendations were politely tolerated, I quietly received credit for the project, and the message—though never explicitly spoken—felt clear:

Let it go.

Bury it.

Two months later, a paramedic was shot in the ambulance bay of one of our residency hospitals.

As a public-facing profession, there will always be some degree of risk. But the old adage that “it’s just part of the job” is unacceptable. Every effort should be made to reduce modifiable risks.

Practicing in Canada, I experience nowhere near the same level of aggression I felt in New York. In fact, I often find myself minimizing difficult interactions because they simply do not compare to what I experienced during training.

But that comparison misses the point.

No provider anywhere should fear for their safety at work.

Over the past several years, I have been verbally abused more times than I can count. Physical aggression has been less common but not absent.

I have been punched.

Scratched.

Spit on.

Most episodes involved intoxicated, delirious, or demented patients—people lacking insight or control, often impossible to predict or prevent.

Some danger will always exist when caring for vulnerable populations.

But danger should never become normalized.

Violence is just one of the many hazards Emergency Medicine providers face.

Some are obvious.

Others are invisible.

As frontline clinicians, we are often the first to encounter emerging disease.

COVID was a prime example.

Before vaccines existed—when recommendations for the general public were isolation and avoidance—Emergency staff still showed up to crowded departments, often with limited PPE and very little understanding of what we were facing.

In those early months, fear was everywhere. Many physicians quietly suppressed their own anxieties in order to care for patients. What is discussed less openly is the psychological cost of repeatedly walking into danger. These experiences leave marks long after the shift ends.

We wear protective equipment, follow protocols, vaccinate ourselves against preventable disease. And yet exposures still happen.

Every so often, I receive a notification that a patient I cared for later tested positive for tuberculosis or another highly infectious disease. Then comes the waiting—testing, observation, uncertainty.

Many physicians fear less for themselves than for the possibility of bringing danger back to the people waiting at home.

Will this affect my family?

At some point, nearly every physician experiences an exposure to bodily fluids—being spit on, splashed, stuck with a needle, or cut during a procedure.

These moments are profoundly stressful.

You wait to learn whether the source patient tests positive for HIV or hepatitis C.

It is difficult to describe the stress of wondering whether one moment at work might permanently alter the lives of the people you love.

I have lived through the anxiety of a high-risk exposure and the month of antiviral medications that followed in an effort to reduce transmission risk.

Emergency Medicine will always carry some degree of risk. But we should refuse to accept that danger is simply part of the job. Risk must be minimized wherever possible.

That requires providers to avoid complacency, institutions to prioritize safety, and leaders to remain accountable.

Physicians should be altruistic.

But caring for patients should not require sacrificing our own health and safety in the process.

There’s a strange truth about the emergency department: it’s the most visible part of the hospital, but the least in control of its own destiny.

Every day, the ED absorbs the overflow of the system—patients who can’t get a family doctor, clinics that are full, wards that can’t discharge, long-term care beds that don’t exist. The waiting room becomes the symptom, not the disease.

1. Start with the Patient, Not the Metric

We talk a lot about “improving performance.” Shorter wait times. Faster disposition. Lower left-without-being-seen rates.

But metrics can be gamed.
Good care can’t.

If you want to fix the ED, start with the only metric that matters: how well we actually care for people.

2. The ED as a Biopsy of the Hospital

Crowding isn’t an ED problem—it’s a hospital problem. It’s the biopsy that reveals systemic disease:

• No inpatient beds.

• No long-term care capacity.

• No weekend discharges.

• No accountability for flow.

Adding more stretchers to the department doesn’t solve it. You don’t treat constipation by making the bowel larger.

3. Input, Throughput, Output

Every hospital executive loves this framework, but it only works if you understand what actually happens inside it.

Input: The demand keeps rising. Immigration, aging, lack of access to primary care—all roads lead to the ED. You can’t “divert” people who have nowhere else to go.

Throughput: Inside the ED, efficiency collapses under administrative burden. Clinicians spend more time documenting than diagnosing. Overnight imaging access remains limited. Porters are scarce. The EMR, while improving data access, has quietly robbed us of time and efficiency.

Output: Patients pile up because the wards are full. And the wards are full because long-term care beds are scarce and discharges stop Friday at 4 p.m. The predictable Monday crisis isn’t an act of God—it’s an act of culture.

4. Culture Eats Capacity for Breakfast

Expanding physical space doesn’t fix a broken process. What does?

• Consultants who see patients promptly.

• Social work and addictions teams that work 24/7—because emergencies don’t clock out at 5pm.

• Better use of allied staff to move patients, find patients, room patients, so physicians can actually see patients.

• Computers where they’re needed—every exam room, not just every hallway.

5. Rethinking Physician Productivity

Emergency physicians aren’t lazy; they’re drowning. Crowding, complexity, and EMR drag have all cut into productivity. Yet most physician evaluation models still assume that faster equals better.

Maybe it’s time to reward what matters—efficiency, teamwork, and outcomes that center the patient, not the spreadsheet.

6. The Way Forward

Fixing emergency medicine means fixing the hospital. And fixing the hospital means accepting that:

• True improvement is systemic, not cosmetic.

• Quality trumps quantity.

• Culture drives flow more than any algorithm.

The ED is the hospital’s vital sign—a direct reflection of its overall health. When the system clogs, the pressure shows up here first: in crowded hallways, ambulance offloads, and exhausted staff trying to hold the line.

You spend years learning everything—

and then, suddenly, you’re expected to choose one thing to do for the rest of your career.

There were no guidance counsellors or aptitude tests to guide our decisions. We were encouraged to pursue whatever interested us—or, more realistically, whatever we were likely to match into based on the competitiveness of our medical licensing exam scores. There was little point applying to ultra-competitive specialties like plastic surgery or ophthalmology unless your scores sat in the top percentiles.

At the start of third year, I thought I wanted to be a surgeon.

Tangible problems that could be fixed with your hands.

Open. Fix. Close.

Definitive management.

That illusion ended early in my surgical rotation.

I was scrubbed into a bowel resection that started shortly after lunch. I had eaten a large meal beforehand.

That was a mistake.

Six hours later, I was still there retracting bowel. Sweating through my scrubs. Clenching every muscle I had—because the last thing I was going to do was fart in the OR.

You hear stories.

Someone lets one rip in the operating room. The smell spreads.

The surgeon worries there’s a perforation.

Now everyone is running the bowel looking for a leak that doesn’t exist.

I was not about to become that story.

Finally, after hours, we closed the abdomen.

The surgeon paused.

“Stoma looks dusky. We’re going back in.”

We reopened and started all over again.

Somewhere around hour nine, it hit me. I didn’t have the temperament for this.

I lacked the patience, attention span, and endurance to start over after ten hours in the operating room.

I kind of wished there was some magical sorting hat that would tell me which specialty I belonged in.

I wanted intensity, but I also needed closure.

I liked too many things. I couldn’t imagine relegating myself to just one.

Emergency Medicine pulled at me. It had everything.

Excitement. Procedures. Critical interventions.

A heart attack in one room.

A delivery in another.

A psychotic break down the hall.

Medicine on shuffle.

And so I chose it.

When you’re young, you feel invincible.

Not yet mature enough to think about what years of missed sleep and shift work might do to you. I didn’t think about what constant circadian disruption might mean for my health—or the added pressures of one day trying to raise a family while working nights, weekends, and holidays.

Medicine asks you to choose your future before you fully understand the cost of the decision.

If I had the opportunity to choose again, I would probably think harder about lifestyle. About longevity. About what kind of doctor—and father—I wanted to be twenty years down the road.

But every specialty comes with tradeoffs.

And truthfully—

I still don’t think there is anywhere else in medicine where I would belong more.

I like bringing order to the chaos. The variety. The privilege of walking into someone’s worst day and trying to make it better.

The patient who lives because you were there when it mattered.

Emergency Medicine may not have been the healthiest choice.

But it was probably the right one for me.

ROSC.blog

Emergency physicians tend to share a few of them.

We are restless, curious, and often easily bored. Most of us are oddly comfortable in chaos. Not uncontrolled chaos—but the kind that constantly forces you to adapt. We like movement. Stimulation. Unpredictability. Many of us are drawn toward anything carrying even a hint of adrenaline.

There is a running joke that emergency physicians all have ADHD. Whether that is true or not, there is probably something to it. Emergency medicine rewards people who can pivot instantly, tolerate interruption, and function while constantly shifting between priorities. It is not a specialty for people who need predictability.

If you struggle with constant interruptions, changing pace, or fragmented attention, emergency medicine can feel brutal.

And yet—even within these shared traits—there is enormous variation in personality and practice style.

We do not all practice the same way.

Some physicians are driven by anxiety while others appear almost carefree. Some are loud and confrontational. Others are quiet and reserved. Some dominate a room while others barely seem to occupy space at all.

During residency, I realized something important.

You are not only learning medicine.

You are learning who to become.

Every attending physician becomes a model of practice. You study not only what they know, but how they move through the department, how they respond under pressure, how they speak to patients, and how they carry themselves during difficult moments.

Looking back, there were four archetypes of emergency physicians who left a lasting impression on me. They were not necessarily the best physicians, nor the worst. But each represented a different way of surviving inside the emergency department.

The Yeller

The Yeller ran the emergency department like a drill sergeant. They moved fast, expected others to move faster, and had very little patience for hesitation. Yelling was not unusual. It was simply part of the atmosphere surrounding them.

Nurses and residents feared them.

And strangely, many admired them.

The Yeller never appeared uncertain. Decisions were made quickly. Consultants were called without hesitation. Patients moved through the department with efficiency. There was no lingering over possibilities or endlessly debating what to do next.

Teaching often came through interrogation. Questions fired rapidly. Diagnoses demanded immediately. If you missed the answer, you knew exactly what topic you would be reviewing that night.

They believed emergency medicine should move. No delays. No wasted time. No messing around. You learned quickly not to show up late, not to drag your feet, and not to leave loose ends.

The Yeller had no tolerance for abusive behavior. If a patient became violent or verbally aggressive, security was called and they were ejected without hesitation. Boundaries were firm. Consequences were immediate.

Working with them felt like standing beside a thunderstorm. You were always slightly tense. Always trying not to disappoint. But you also learned to think quickly, commit to decisions, and stop hesitating.

The Yeller taught me that decisiveness matters.

Even if fear should never be the mechanism.

The Worrier

The Worrier was often among the brightest physicians in the department. Intelligent, meticulous, and deeply thoughtful, they practiced medicine as though every patient was a potential disaster waiting to unfold.

Some were naturally anxious. Others seemed shaped by experience. A bad outcome. A complaint. A lawsuit. A diagnosis missed years earlier that still lingered in memory.

Whatever the reason, they practiced carefully.

Their charts looked like novels.

Documentation was exhaustive.

The Worrier ordered more tests, more imaging, and more consultations than almost anyone else. They admitted patients more readily and documented every possible contingency.

As a resident, this could be frustrating. You would present what seemed like a straightforward case and suddenly there were additional labs, repeat reassessments, imaging studies, and delayed dispositions.

At the time, it felt excessive.

Defensive.

CYA medicine.

But over time, I began to understand something.

The Worrier was not practicing from weakness.

They were practicing from memory.

They remembered the patient who looked fine and wasn’t. The diagnosis missed at 3 a.m. The complaint that arrived months later. The subtle finding that almost got overlooked.

These physicians often saw possibilities others missed. They could imagine the rare diagnosis hidden beneath a normal presentation.

The Worrier taught me humility.

They taught me that confidence without caution can become dangerous.

The Zen Master

At first, The Zen Master seemed detached.

They were impossibly calm.

Almost suspiciously calm.

They rarely looked rushed. Rarely appeared stressed. Rarely seemed particularly invested in supervising every detail.

As an intern, this unsettled me.

I wanted structure. Oversight. Validation.

The Zen Master offered very little of that.

You would present a patient. They would nod. Maybe ask one question. Then quietly return to whatever they had been doing.

At times it felt like they barely saw the patients at all.

But what initially looked like indifference was usually something else.

Trust.

They trusted residents to think. To struggle. To learn.

They stepped in only when needed.

And when they did, it was often because they had noticed something no one else had.

They could walk past a patient and quietly tell you who was sick. They could identify ketosis before labs returned. They sensed withdrawal, sepsis, or intoxication almost instinctively.

One shift as an intern, an overhead code was called to the hospital entrance bathroom. Before I even stood up, The Zen Master casually told me to grab some Narcan before running over.

When I arrived, the patient still had a dope needle hanging from his arm.

At the time, it felt supernatural.

Years later, I realized it was not magic.

It was experience.

Pattern recognition repeated enough times that instinct begins to resemble clairvoyance.

During resuscitations, The Zen Master often stood quietly at the back of the room. Never dominating. Never controlling. Simply present.

They would step in if needed.

But otherwise they watched.

As a junior resident, they terrified me.

As a senior resident, I valued them more than almost anyone.

They taught autonomy.

They taught calm.

And they taught me that confidence does not always need to be loud.

The Yoda Master

The Yoda Master rarely commanded attention.

You had to lean in to hear them.

They never raised their voice. Never argued. Never made sure people noticed how much they knew.

And yet, everyone listened.

These physicians were often deeply accomplished. Very experienced. Highly respected. Quietly brilliant.

But they carried their expertise lightly.

They practiced medicine with gentleness.

They focused not only on what was medically correct, but what mattered to the patient. Shared decision-making came naturally to them. They understood that medicine was not something done to patients.

It was something done with them.

They treated everyone with kindness and respect.

Even difficult patients rarely seemed to provoke frustration.

The Yoda Master understood something many physicians lose over time.

That kindness is not separate from competence.

It is part of it.

As trainees, we spend years chasing knowledge. We focus on diagnoses, treatments, procedures, and algorithms. But the Yoda Master reminded me that medicine is also about how people feel when they leave your care.

They taught me that you can be respected without intimidation.

You can lead without dominating.

You can be excellent without making sure everyone notices.

Residency is strange. You think you are learning medicine. But you are also collecting pieces of people.

A little decisiveness from The Yeller.

A little caution from The Worrier.

A little calm from The Zen Master.

A little kindness from The Yoda Master.

Over time, those pieces settle together. You incorporate what fits. You reject what doesn’t. And eventually, without fully realizing it, you become your own version of an emergency physician. Not identical to any mentor, but shaped by all of them.

The truth is that emergency medicine does not produce one type of doctor. It produces adaptation. We function in the same environment. We just learn different ways to survive it.

More and more, we are the system of last resort.

Not for stabilization.

For containment.

Acutely psychotic patients—severely agitated, disorganized, unsafe—need us.
That’s clear.

But the majority don’t fit that category.

They come in with depression.
With suicidality.
With something heavier than we can fix in a single shift.

Because unlike chest pain or sepsis, there is no rapid treatment for mental health.
No protocol that reverses it in hours.

So our job becomes something else:

Risk assessment.

Are they safe to go home?
Or not?

If the answer is no, we admit or push for urgent psychiatric evaluation.

If the answer is yes, we discharge them—with a plan.

Follow up.
Resources.
Safety-netting.

A plan that too often doesn’t hold.

And they come back.

Days later.
Weeks later.

Sometimes after an overdose.
Sometimes after something worse.

Casualties of a system with too few places to land.

Psychiatry in the ED is challenging.

Unpredictable.
Time-consuming.
Resource-heavy in ways people don’t see.

One agitated patient can occupy an entire team.

And sometimes they arrive not because they chose to—but because no one else knew what to do with them.

Police bring them.
Families bring them.
The system redirects them.

And we absorb it.

One case has stayed with me.

A man with known schizophrenia arrived in severe distress.

Sweating.
Pacing.
Shouting at someone only he could see.

“The government put a tracker in my head,” he yelled.
“They did it through my ear. It’s transmitting. It might explode.”

He was terrified.

And loud.

And, on paper, familiar.

The triage note told the story we see all the time:

Chronic psychosis.
Multiple ED visits.
Failed follow-up.
Medication non-adherence.

He was sent for psychiatric assessment.
I was asked to medically clear him.

Routine.

But something felt off.

His distress wasn’t just psychological.

It was… localized.

Focused.

Physical.

So I picked up the otoscope.

Looked into his ear.

There it was.

A live insect.

Wedged deep in the canal.
Buzzing against a perforated eardrum.

He wasn’t wrong about the noise.

He wasn’t making it up.

I removed the insect.

And with it, most of his psychiatric symptoms.

The agitation settled.
The paranoia unraveled.
The urgency drained out of him.

We treated the injury.
Observed him.

And discharged him—calm, oriented, back to baseline.

It’s easy to label everything as psychiatric.

Especially when the story fits.

But that day was a reminder:

Psychosis and pathology can coexist.

Delusions don’t come from nowhere—
they build around something.

A sensation.
A fragment of reality.

And sometimes…

There really are bugs in your head.

The handover.

The moment someone either helps carry the load,

or criticizes your decisions at the exact moment you’re most exhausted.

I wrote this piece months ago, before many of you were here.

But given how many conversations I continue to have about exhaustion, resentment, and survival inside modern healthcare…

I think it deserves another read.

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The Malignant Handover

In residency, I had an attending who would always ask, near the end of a shift:

“Who are we handing over to?”

At the time, I didn’t get it. Handover was handover. Why should it matter who received it?

So I finally asked him.

He looked at me and said, without blinking, “Because some people are benign… and some people are malignant.”

I laughed back then.

Fifteen years later, I’m no longer laughing. I know exactly what he meant.

The Expiry Time

Emergency medicine is hard work. Not “tired-at-the-office” hard—cognitively wrung-out, decision-fatigued, emotionally wracked hard. By the end of a shift, the tank is empty. No matter how tough you are, your brain hits its limit.

And that’s the whole point of shift work: when you expire, someone else takes over. The incoming doc is supposed to slide in, accept the remaining threads of your workup, and keep the department moving. It’s how the system stays safe.

The worst thing at that moment—the exact minute when you’re depleted and ready to leave—is having to defend, justify, or explain yourself to a colleague who seems intent on turning handover into a cross-examination.

Yes, handover is risky. Continuity breaks. Details fade. Investment drops.
It should be structured and thorough.

But that’s not what this is about.

I’m talking about the malignant sign-out.

The colleague whose name on the schedule makes your stomach tighten, because you know you’re about to face a pop quiz at the moment your brain has logged off.

My Rule

One might hope karma balances these things out. It doesn’t.

So I made a decision early in my practice:

I will not torture a colleague who’s trying to go home.

I’ll listen to their story.
I’ll ask what I need to ask.
And if something is unclear, I’ll go to the bedside myself. That’s my job.

But I will not nitpick a tired physician into the ground over tiny decisions made twelve hours into battle.

Some colleagues give immaculate sign-outs—threads tied, bows tightened. Others hand over a bomb that detonates the moment they leave the building. Even the best sign-outs can unravel before the elevator doors close. That’s the nature of EM.

Once you’re in the driver’s seat, the department becomes yours—whether the engine is humming or on fire.

What Kills Me

It’s the colleagues who make sign-out so miserable that I’d rather stay an extra hour past my shift than hand anything over to them at all.

And the irony?

Those who demand the cleanest sign-outs often give the worst ones.

If you’re going to be a challenging colleague, fine.
But you’d better hand over a case like it’s gift-wrapped.

A Quiet Confession

I don’t love getting chaos on sign-out. No one does. But I accept it as part of the job. I never belittle. I never scoff. When it’s time for someone to go home, I respect that.

Still—when I peek at the schedule and see a malignant handover coming?

I’ll be honest.

In that last hour, I may not pick up as many new patients.

Not because I’m lazy.

But because sometimes, the most stressful part of an emergency shift isn’t the airway, or the trauma, or the crashing patient.

It’s the colleague waiting to receive your sign-out.

You’ll hear it.

Laughter.

Not the polite kind.
Not the kind you expect in a place filled with pain, death, and fear.

The wrong kind.

The kind that makes outsiders uncomfortable.

A patient just vomited across the room.

Someone cracks a joke.

A trauma rolls in—bloody, chaotic, barely holding together.

There’s a comment. A smirk. A line that shouldn’t be funny.

And yet—

It is.

People assume this means we’re cold.

Detached.

Broken in some fundamental way.

They’re wrong.

Humour isn’t a failure of empathy.

It’s a coping mechanism.

Emergency medicine runs on contradictions.

You’re expected to care deeply—

But not so deeply that it slows your hands.

You’re expected to feel—

But not so much that it clouds your judgment.

You’re expected to walk into a horrific scenario—
where every instinct says panic—
and function calmly and professionally.

So we adapt.

And one of the ways we deal—

is through humour.

Not because these situations are funny.

Because some realities are too absurd, too tragic, or too overwhelming to process normally.

Humour is what happens when the brain collides with something that simply doesn’t fit.

A 30-year-old in cardiac arrest.

A child with a disease that shouldn’t exist.

A man who came in for “indigestion” and leaves with a life-altering diagnosis.

The mind pushes back against the incongruity.

And instead of breaking—

we bend.

Sometimes the humour is darker.

More uncomfortable.

Even… inappropriate.

We joke about situations we can’t control.
About outcomes we couldn’t change.
About cases that frustrate us.

Not because we don’t care—

But because caring without boundaries is unsustainable.

There’s another layer to it.

A quiet one we don’t talk about much.

Humour creates distance.

Just enough to function.

Just enough to keep going.

Because here’s the truth:

Helplessness is the most dangerous feeling in emergency medicine.

We can manage chaos.
We can manage risk.
We can manage uncertainty.

But helplessness?

That will eat you alive.

So we push it back.

With a joke.

With a laugh.

With something absurd enough to remind us we’re still in control.

And then there’s the release.

The moment after.

When the room exhales.

When the tension breaks.

When someone says something ridiculous—

and suddenly the weight lifts, just a little.

That moment matters more than people realize.

Because without it…

the accumulation would be unbearable.

There’s science behind it, sure.

Laughter lowers stress hormones.
Improves pain tolerance.
Sharpens thinking.

But honestly—

we don’t need studies to tell us what humour does in an emergency department.

We feel it every shift.

The joke that resets the room.

The laugh that keeps the team moving.

A brief moment of levity cutting through something otherwise too heavy to carry.

Humour isn’t a luxury in emergency medicine.

It’s a defence mechanism that shields us from what this job would otherwise do to us.

And yes—

sometimes it looks wrong from the outside.

Sometimes it sounds harsh.

Sometimes it makes people uncomfortable.

But if you took it away—

you wouldn’t make us more compassionate.

You’d just make us quieter.

Heavier.

Closer to breaking.

Because the truth is—

If we didn’t laugh…

We would cry.

Daily.

Right when I think I’ve seen it all…

something walks into the emergency department and reminds me:

I haven’t.

Some shifts feel predictable.

Chest pain.
Broken bones.
Abdominal pain.

Algorithms. Flow. Familiar ground.

You start to think:

I’ve got this.

And then—

the shift flips.

One minute you’re talking someone down from suicide.

The next, you’re trying to figure out how someone’s tongue got vacuum-sealed into a bottle

and how to get it out without making things worse.

You move from negotiation to resuscitation.
From life-saving to problem-solving.
From controlled medicine to controlled chaos.

No warning.
No transition.

Just:

Next patient.

This is the part no one can teach you.

Emergency medicine isn’t defined by what you know.

It’s defined by what you’ve never seen before.

Because there is no manual for half of what comes through the door.

No guideline for the patient who hasn’t read the textbook.

No protocol for the situation that should never happened—

but did.

So you build something in real time based on:

Pattern recognition.
Experience.
Judgment.

And you hope it’s enough.

Because most of this job isn’t algorithmic.

It’s controlled risk—

under pressure,
with incomplete information,
and no perfect move.

This is where the job actually lives.

knowledge will get you through the medicine.

But it won’t get you through the shift.

To survive, you need something else.

Something no one teaches early on.

What psychology calls radical acceptance.

Not passive.
Not indifferent.
Not giving up.

Acceptance of reality as it is,

not as you wish it would be.

You accept the uncertainty.
The limitations.
The fact that sometimes there is no good option—

only less bad ones.

You accept that some patients will leave.
Some will come back.
And some will die—

despite you doing everything right.

And then—

you make the best decision you can anyway.

Because that’s the job.

In emergency medicine, radical acceptance isn’t resignation.

It’s survival.

I barely knew how to use a stethoscope.

But somewhere over the Atlantic, that didn’t seem to matter.

It started with a sound.

A choking noise.

Violent. Desperate. Wrong.

Heads turned.

A man halfway down the cabin was clawing at his throat.

His wife was screaming.

Flight attendants rushed in—but you could feel it instantly:

They were out of their depth.

Then the announcement came.

“Is there a doctor on board?”

Silence.

The kind that tells you everything you need to know.

No one stood.

No one moved.

I looked at my classmates.

We didn’t even need to speak.

Two months into med school does not make you a doctor.

We stayed in our seats.

Then came the second announcement.

More urgent.

“If there is a doctor on board, please make yourself known immediately.”

Still nothing.

The man’s wife was now screaming, “He’s dying! Please—someone help him!”

And then—

Stella.

She was sitting closer to him. She saw it up close.

She jumped into the aisle, turned toward us, and pointed straight at me.

“Mikey—do something!”

Every head in the cabin turned.

Not at the patient.

At me.

Mikey.

The medical student.

I remember thinking:

Why me?

I had no more training than anyone else on that plane.

But no one else stood.

So I did.

By the time I reached him, it was chaos.

His wife had her hand deep in his mouth, blindly trying to pull something out.

He was choking. Panicking. Getting worse.

“Let go,” I said—more firmly than I felt.

She hesitated.

Then she pulled her hand back.

We hauled him into the aisle.

I stepped behind him.

And suddenly—

I wasn’t a med student anymore.

I was the only person doing anything.

I wrapped my arms around his abdomen and thrusted.

Once.

Twice.

Three times.

Pop.

A peanut shot out onto the floor.

The choking sound stopped.

Just like that.

Air rushed back into his lungs.

His color changed—from blue to pink—in seconds.

He coughed.

Then breathed.

Then spoke.

“Thank you.”

The cabin erupted.

Applause. Relief. Breathing.

But I barely heard it.

Because something quieter had just happened.

That was the first time I “saved” a life.

Not in a hospital.

Not with a team.

Not with training I could lean on.

Just instinct.

And the realization that sometimes—

no one is coming.

That was the moment medicine stopped being an idea.

And became a responsibility.

And for the first time, I thought:

Maybe I belong here.

It changed the patient before they walk through the door.

I saw a patient recently who was certain they had chronic Lyme disease.

Not worried.

Not wondering.

Certain.

They had the symptoms.
They had the explanation.
They had the video that matched exactly what they were feeling.

What they didn’t have—

was the diagnosis.

Some patients arrive with symptoms.

Others arrive with a diagnosis.

Not from a doctor.

From their phone.

You can tell within seconds.

They don’t just describe what they feel.

They tell you what it means.

“I read that this could be…”
“I saw a video about…”
“I think I have…”

Sometimes they’re right.

Sometimes they’re not even close.

But either way…

the encounter has already started before you walked into the room.

Social media didn’t just enter medicine.

It rewired it.

Patients no longer rely solely on physicians to interpret their symptoms.

They scroll.

They search.

They watch.

And in doing so, they build a version of their illness before we ever examine them.

Not because they don’t trust us.

Because access has changed.

For the first time, a patient in a small town can hear directly from a subspecialist across the world.

They can find communities of people living with the same symptoms.

They can ask questions they might never feel comfortable asking in a clinic.

They can see what illness looks like—not just what it’s called.

That matters.

It creates understanding.

It creates connection.

And sometimes,

it creates confidence.

But there’s a cost.

Because not everything they’re seeing is true.

The algorithm doesn’t care if it’s right.

It only cares if it’s watched.

Social media isn’t regulated.

It doesn’t distinguish between expertise and confidence.

Between evidence and opinion.

Between someone who knows—

and someone who just sounds like they do.

Most misinformation isn’t malicious.

It’s shared by people who believe it.

Who are trying to help.

Who are certain.

But wrong.

And then there’s disinformation.

Content designed to mislead.

To sell.

To provoke.

To exploit attention in a system that rewards engagement over accuracy.

We see the consequences every day.

Patients convinced they have rare diseases.
Patients terrified by symptoms that aren’t dangerous.
Patients anchored to explanations that don’t fit.

And once the idea takes hold;

it’s hard to shake.

There’s a term for what comes next.

Cyberchondria.

Endless searching.
Escalating anxiety.
More information.
Less clarity.

The diagnosis becomes the problem.

And when that leads to misdiagnosis—

the consequences are real.

Unnecessary tests.

Inappropriate treatments.

Worsening symptoms.

Fractured trust.

But dismissing social media entirely would be a mistake.

Because it’s not just causing problems.

It’s solving them too.

Patients are finding something we don’t always give them enough of.

Time.
Understanding.
Community.

Spaces where they can ask questions without judgment.

Places where they don’t feel alone.

That matters more than we acknowledge.

And it’s not just patients.

Physicians are changing too.

Information doesn’t move the way it used to.

It’s no longer locked in textbooks or buried in journals.

It’s compressed.

Condensed.

Delivered in seconds.

A case.
A thread.
A video.

Short-form content can reinforce learning.

Concepts repeat.

Patterns stick.

You see the same idea from different angles until it becomes imbedded.

You follow someone across the world who does what you want to do.

You learn from them.

Interact with them.

Build connections that didn’t exist a decade ago.

Research spreads faster.

Ideas travel further.

Barriers disappear.

And maybe most importantly—

we see patients differently.

Because we’re exposed to how they experience illness outside of the hospital.

Not just clinically.

But personally.

Social media didn’t replace medicine.

It expanded it.

Messy. Unfiltered. Incomplete.

But powerful.

The patient in front of you isn’t just bringing symptoms anymore.

They’re bringing everything they’ve seen.

Everything they’ve read.

Everything they believe.

If we ignore that—

we miss the encounter entirely.

If we understand it—

we can guide it.

Because this isn’t about competing with social media.

It’s about recognizing that it already has a seat at the table.

And if we use it well—

it becomes one of the most powerful tools we have.

Not just to treat disease.

But to build trust.

Not angrily. Not dismissively.

But enough to remind me that conversations about gender inequity in emergency medicine are far from settled.

I wrote this in January.

Since then, many more people have joined ROSC — and I think this piece deserves another read.

Because some topics don’t become less relevant with time.

They become harder to ignore.

Emergency medicine is hard on families—but we pretend that’s a personal problem, not a structural one.

The schedule is erratic by design. Nights flip to days. Weekends vanish. Holidays become just another box on a calendar you’re scheduled to work through. When I chose this specialty, I didn’t think much about what that would mean for a future family. I was focused on survival—on competence, adrenaline, becoming good.

I’ve read bedtime stories over FaceTime from a hallway outside a trauma bay. I’ve missed birthdays because someone else’s worst day couldn’t wait.

I remember watching attendings in residency compress their shifts into the first half of the month and disappear on elaborate vacations for the second. It felt aspirational. What I didn’t notice then—what feels obvious now—is that almost none of them were married. Fewer still had children.

The only reason I can do this job with two young kids is because of my wife.

She has deliberately structured her life and career to be the default parent—the one who is always available, always reachable, always compensating for my absence. That isn’t accidental. It’s the scaffolding holding my career upright.

I genuinely cannot imagine how we would function if we were both emergency physicians with unpredictable schedules and no flexibility. And because of that, I have enormous respect for female emergency physicians who balance motherhood with this job. As difficult as I sometimes find it, I know—without question—it is harder for them.

And then there are the single-parent emergency physicians.

Mostly women.

They are doing something close to superhuman.

Emergency medicine, like much of medicine, is quietly but deeply gender-biased. Traits that advance men are liabilities in women.

A male physician running a code is “decisive.”
A female physician with the same tone is “bossy.”

Women are expected to lead without looking like they want power. To advocate without being labeled difficult. To negotiate for equal pay while performing gratitude for the privilege of being in the room.

Motherhood, meanwhile, is treated as a personal inconvenience rather than a structural reality. Child-care failures are absorbed quietly. Family emergencies are managed out of sight. The system does not flex; women do.

Female physicians are still routinely mistaken for nurses. They encounter more pushback from consultants, more resistance from staff, and more skepticism from patients. And despite equivalent—often superior—training and performance, they advance more slowly and earn less.

Which is particularly absurd given that studies show patients treated by women physicians have better outcomes.

None of this is about blaming individual men. It’s about recognizing systems that quietly reward availability over sustainability.

Despite everything I’ve described, the greatest injustice isn’t overt discrimination—it’s the quiet accumulation of friction.

A silent multiplier that compounds over years into stalled careers, burnout, and attrition. This isn’t just inequity—it’s a safety issue. Systems that exhaust and sideline their best clinicians eventually fail patients.

And unless we acknowledge this openly, it remains invisible.

Recognizing gender inequity isn’t performative—it’s structural. It requires policy, flexibility, sponsorship, and a willingness to confront uncomfortable truths about who the system was built for.

If we keep calling this resilience instead of design failure, we’re choosing the outcome.

We owe it to our colleagues.
We owe it to our patients.
And we owe it to the future of the specialty.

I didn’t—

because I couldn’t face being brought into my own emergency department on a stretcher.

By that point, the pain was already severe.

Constant.

The kind that makes you stop thinking clearly.

I’ve worked in emergency departments for years.

I thought I understood them.

I didn’t—

not until I became the patient.

I knew early that morning I was too sick to work.

So I did what we are supposed to do.

I called out.

What I didn’t expect—

was that I would end up in the emergency department anyway.

By early afternoon, the pain was unbearable.

Unrelenting.

At one point I was curled up on the floor, trying to decide if I should call EMS.

I couldn’t do it.

I made a quiet decision:

No matter how bad this gets—

I’m not arriving that way.

When my wife got home, I was still in agony.

That’s when I finally let go of the last bit of pride I had left.

And went in.

I walked through the patient entrance.

No badge.

No scrubs.

No identity.

Just another patient.

I passed staff who would normally recognize me.

This time—

they didn’t.

And for the first time, I understood what that felt like.

Registration came first.

The clerk was kind and professional.

He didn’t recognize me—but paused when he saw my name.

A coincidence, he said.

Same name as one of the doctors working that evening.

We both smiled.

Then he pointed me toward triage.

The waiting room was overflowing.

Not enough chairs.

Patients lying on the floor.

And suddenly—

I wasn’t observing it.

I was living it.

For the first time, I felt it from the other side.

The discomfort.

The uncertainty.

The quiet dread of knowing I might spend hours here—

feeling the worst I ever felt.

I leaned against the wall.

There were older patients.

Sicker patients.

People who needed those chairs more than I did.

And somehow that made it worse.

My name was called quickly.

Faster than I expected.

I’d like to believe that’s the standard.

But I suspect that at some point—

someone recognized me.

The triage nurse was kind.

Reassuring.

“You did the right thing coming in.”

Simple words.

But they mattered more than I expected.

An ID band went on my wrist.

And just like that—

I was inside.

I’ve worked in those exam rooms for years.

Assessed hundreds of patients there.

But lying on the stretcher—

it felt completely different.

A personal support worker I knew brought warm blankets.

A nurse started an IV.

Drew blood.

Gave pain medication.

Five people had already cared for me

before I ever saw a physician.

The doctor who came to see me was a colleague.

A friend.

And for the first time in my career—

I let go.

I wasn’t the decision-maker anymore.

I was the one waiting for one.

He ordered tests.

Bloodwork.

Imaging.

A stool sample.

Pain control.

Things I order every day—

without really imagining what they feel like.

They gave me an opioid.

The pain eased.

And for the first time in hours—

I was still.

Not asleep.
Not awake.

Just… not in pain.

Staring at the ceiling—

grateful.

They called me for a CT scan.

A hallway I’ve walked hundreds of times.

But this time it looked different.

There was a patient bathroom I had never noticed.

I lay on the scanner.

Contrast running through my arteries.

And then—

that strange warmth.

The sensation patients always describe.

Like you’ve wet yourself.

I used to nod when patients told me that.

Now I understood.

I hesitated before getting up.

What if it actually happened?

What if someone found out?

It hadn’t.

And the tech reassured me—

it never does.

Then came the stool sample.

Something I’ve ordered countless times.

Without ever really thinking about what it entails.

It was more complicated than I expected.

A small plastic basin.

Multiple containers.

One that wouldn’t even stand upright.

Trying to coordinate everything—

one hand tethered to an IV pole—

under the haze of narcotics—

was surprisingly difficult.

And in that moment—

I understood why so many of those samples never make it to the lab.

Back on the stretcher, time blurred.

I didn’t check my phone.

Didn’t try to distract myself.

I was just…

relieved.

Eventually, my colleague returned.

The news was reassuring.

Pancolitis.

Unpleasant.

But not surgical.

Not life-threatening.

Fluids.

Medications.

Discharge.

I walked out feeling better.

Grateful.

But the moment that stayed with me—

wasn’t mine.

It was something I overheard.

Two patients talking in the hallway.

One turned to the other and said:

“The people who work here must have a special temperament… to deal with all this and still be kind.”

He wasn’t angry.

He wasn’t frustrated.

He understood.

And standing there—

as a patient—

I realized something.

We reduce emergency medicine to protocols.

Algorithms.

Decisions.

But from the other side—

it’s something else entirely.

It’s the clerk who greets you.

The nurse who reassures you.

The person who brings you a blanket.

The doctor who is patient and kind.

The quiet efficiency of a system that never stops—

even when it’s breaking.

I walked in thinking I understood this place.

I didn’t.

I understood how it worked.

I just didn’t understand what it felt like.

And in the end—

that’s the part patients remember.

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It doesn’t.

Not even close.

Every emergency department requires a small army to function.

Yes—if there’s no physician, the department closes.
We’ve all seen rural EDs shut down when there’s no doctor to cover a shift.

But here’s the truth most people don’t understand:

You can have a doctor.
And still not have a functioning emergency department.

Because the ED doesn’t run on one role.

It runs on a system.

And that system is fragile.

Nurses are the engine.

They don’t just assist.

They carry the department.

They monitor. Reassess. Intervene. Anticipate.
They are the constant presence at the bedside while everything else moves.

When nursing numbers drop, the ED doesn’t slow down.

It becomes unsafe.

Clerks are the control tower.

No one notices them—until they’re gone.

They coordinate flow.
They register patients.
They track movement.
They connect physicians to consultants.

Without them, the department doesn’t just slow down—

it stalls.

And they do all of it while absorbing the frustration of a waiting room that is staring them in the face.

Personal support workers are the backbone.

They do the work no one else can.

They lift. Clean. Turn. Support.

They perform CPR during codes.
They shower the patients who arrive covered in lice, or worse.
They step into moments most people would step away from.

They are the muscle—and often the humanity—of the ED.

Respiratory therapists guard the airway.

After the tube is in, after the moment passes—
they stay.

They manage the ventilator.
They fine-tune oxygenation.
They watch for subtle changes that matter.

They make it possible for me to move on to the next critical patient—

without leaving this one behind.

Protective services keep us safe.

This role is invisible—until it isn’t.

They step in when patients become violent.
They confiscate weapons.
They secure the department when threats emerge.

More times than I can count, they’ve stepped in before things escalated—

before someone got hurt.

Social workers hold the line where medicine ends.

Because not every emergency is medical.

Some are about housing.
Food.
Addiction.
Safety.

We don’t have the time—or the resource—to fix those in the ED.

But they do.

Or at least—they try to.

And when they’re not there?

Those problems don’t disappear.
They get admitted.

Testing makes diagnosis possible.

Lab techs.
Radiology techs.

Without them, there are no tests.

Without tests—there may not be an accurate diagnosis.

Porters and housekeepers keep the department moving.

Move one patient—and nothing happens.

Move fifty—and everything does.

Without them, rooms don’t turn over.

The entire system backs up. Immediately.

This is the truth about the emergency department:

It’s not a room.

It’s not a physician.

It’s not even a team.

It’s an ecosystem.

And when any part of that ecosystem is missing—

even one—

the whole thing starts to fail.

We don’t talk about this enough.

We appreciate the doctors.
We thank the nurses.
We recognize the volunteers.

But the reality is:

None of it happens without the people you don’t see.

And when they’re absent—

we don’t just struggle.

The ED stops.

This is what it feels like to carry it.

Some days I finish a shift and genuinely don’t understand how I made it through.

Not clinically.

Emotionally.

Because the hardest part of this job isn’t what we do.

It’s what we carry.

Every time I pick up a new patient, something settles into me.

Not their pain exactly.

The weight of it.

The responsibility.

The quiet, unspoken promise:

I will do my best for you.

Over and over.

Patient after patient.

Problem after problem.

That promise accumulates.

And it doesn’t discharge when the shift ends.

Our emergency department is under construction.

But emergency departments don’t close.

They don’t slow down.

They don’t get lighter while they’re being torn apart.

They just keep going — full capacity, half the space, twice the friction.

Patients stacked in hallways.

Rooms shuffled constantly.

Privacy reduced to a curtain and good intentions.

Wait times stretching into frustration.

And when people are uncomfortable—

they take it out on nurses.

On doctors.

On whoever is standing in front of them.

I was examining a patient’s eye at the slit lamp.

Their head inside the machine.

My hands steady.

Focused.

Working.

Their phone rang.

They pulled away.

Held up a finger.

“One minute.”

I stepped back.

Waited.

They finished. Apologized.

Put their head back.

I readjusted everything.

Started again.

Then the phone rang again.

They pulled away again.

Held up a finger again.

“One minute.”

But this time they kept talking.

Thirty seconds.

Forty-five.

No urgency to end it.

No awareness of the moment.

Of me.

Of what we were doing.

I stood up quietly and left the room.

I already had what I needed.

But the disregard for my time stayed with me.

Another patient left mid-workup to go home and eat.

I followed their labs.

Checked their imaging.

Couldn’t find them.

So I called.

“I just stepped out to grab dinner,” they said.
“I’ll be back soon.”

But I was already past the end of my shift.

Already staying late.

Already missing dinner with my own family.

Waiting—not on medicine—

but on their schedule.

They did eventually return.

I reassessed them.

I wrote their prescriptions.

I made sure they were cared for.

But I felt something I haven’t been able to shake:

The esteem once held for doctors feels gone.

Patients don’t seem to respect our time or efforts.

It’s not just the workload.

It’s not just the system.

It’s the shift in something harder to name.

The reverence is gone.

Replaced with hostility.

Anger.

And a casual disregard.

For time.

For effort.

For the invisible weight of managing ten, twenty, thirty lives at once.

We absorb everything.

The delays.

The anger.

The broken system.

The expectations.

We stand between institutional failure and human suffering—

and somehow we’re expected to make it feel seamless.

To smile.

To apologize.

To carry it.

And somewhere along the way, I stopped questioning whether it was ever mine to carry.

Some of this is the system.

But some of it… isn’t.

And that distinction changes everything.

Because the cost of carrying what isn’t yours is something no one talks about—
and it’s quietly breaking people in this job.

Paid subscribers get the rest of this—what I’m starting to understand about where responsibility ends… and what happens when you finally put it down.

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Cardiologists? They’ll round into their seventies.
Psychiatrists? Eighties, even.
Surgeons may slow down—but many stay long enough to teach generations.

But emergency physicians?

We disappear.

The popular explanation is simple:
the job is too physical. Too many nights. Too much chaos. Too much cortisol.

At some point, the knees—and the circadian clocks—give out.

But that answer has always felt incomplete to me.

Too neat.
Too convenient.
Almost willfully naive.

Because the truth is darker.

In 2021, a paper in Lifestyle Medicine made waves across the specialty when it reported this:

The average age of death for an emergency physician was 58.7 years.
The lowest of any medical field.

The study was underpowered. Methodologically messy. Widely critiqued.

And yet—

It’s still the best mortality data we have.

And even if the number is wrong…

the signal is unmistakable.

Emergency physicians die young.

Why?

Because the job eats us alive in ways the public—and even most of medicine—never sees.

Hazard #1: Violence, chaos, and the casual threat of death

Emergency medicine is the only specialty where you walk into work knowing you might be assaulted.

Not “might” in the abstract.

Might today.

I’ve been punched, kicked, threatened, grabbed.

That’s almost expected.

But only once did I genuinely fear for my life:
the night I disarmed a suicidal patient and found myself holding his gun.

That story ended safely.

Some don’t.

But violence isn’t the primary killer.

Hazard #2: The carcinogen nobody wants to talk about

The real danger is quieter.
Cumulative.
Cellular.

In 2019, the International Agency for Research on Cancer classified night-shift work as a human carcinogen.

Let me say that again:

Working nights is a cancer-causing exposure.

Breast cancer.
Prostate cancer.
Colorectal cancer.

The data aren’t theoretical.

They’re consistent.

In 2021, the U.S. National Toxicology Program went further and classified night-shift work as a known cause of breast cancer.

The same category as:

• Asbestos

• HIV

• Tanning beds

Let that sink in.

You can’t see it. You can’t feel it. But it accumulates anyway.

Work the overnight shift…
or smoke a pack a day.

Pick your poison.

Hazard #3: The cardiovascular slow burn

Shift workers have:

• 23% higher risk of heart attack

• 5% higher risk of ischemic stroke

• Higher rates of hypertension, arrhythmia, and metabolic dysfunction

Even after adjusting for socioeconomic status.

Your body isn’t meant to flip time zones every three days.

Emergency physicians do it for decades.

Hazard #4: The quiet mental unraveling

We don’t talk about this one enough.

Shiftwork and circadian disruption drive:

• Depression

• Anxiety

• Insomnia

• Cognitive impairment

• Substance use

• Suicidal ideation

Even modest chronic sleep loss suppresses immune function—reducing natural killer cells, the ones that detect early cancers.

Miss enough sleep…

and your immune system ages before you do.

And suicide among emergency physicians is not rare.

It is quiet.
It is devastating.
And it is real.

Hazard #5: The adrenaline trap

The irony?

The same thing that draws many of us in—

speed
intensity
immediacy

—is the thing that shortens our runway.

Emergency medicine is an adrenaline sport.

A drug.
A high.
A calling.

But it’s also a grindstone.

One that slowly wears away sleep, relationships, physiology—and, apparently, lifespan.

So what do we do with this?

This isn’t a eulogy.

I love this job.

I can point to people alive today because I walked into the room.

But we can’t keep pretending the work is harmless.

We train for trauma.
Resuscitation.
Disaster.

No one trains us for the cumulative biological cost of the profession itself.

If the average emergency physician really dies in their fifties—

even if the number is off—

the message is clear:

This job is taking something from us.

Not metaphorically.
Not emotionally.

Biologically.

And if we want to survive this career long enough to:

watch our kids grow up
grow old ourselves
and still recognize who we are outside the department—

we need to start talking about it.

Honestly.

Publicly.

Without minimizing it.

Because the first step to saving a life…

is acknowledging the danger.

Even when the life is your own.

We talk about the risks of the job in abstract terms—
cancer, heart disease, burnout.

But what we carry, shift after shift, is harder to quantify.

I’m writing about that next.

If you want to understand what this job actually feels like from the inside,
subscribe to ROSC.

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Share ROSC - Return of Spontaneous Circulation

Every year we see a number of cases in the resuscitation bay.

“Young individual. Found outside. Profoundly hypothermic. Eyes open. Possibly conscious. Pulse faint. Heart rate… barely there.”

Usually ten minutes out.

They arrive with their eyes open.

They don’t look dead.

Just… paused.

Core temperature: Mid-20s Celsius.

At that temperature, most people aren’t conscious.

Most people aren’t alive.

And yet—their eyes track you.

Slowly. Deliberately.

Watching.

Their skin is rigid. Limbs frozen. Fingers pale and lifeless.

We place multiple IVs.

It feels like threading plastic into stone.

Warm fluids begin to flow.

In hypothermia, everything slows.

The heart becomes irritable—fragile.

Handle the patient too roughly, and you can trigger a fatal arrhythmia.

So everything becomes deliberate.

Measured.

Careful.

Airway. Breathing. Circulation.

Some can protect their airway.

Most can’t.

They need to be intubated.

We begin rewarming.

Forced-air warming blankets.

Warm IV fluids.

Warm oxygen.

A urinary catheter with continuous warm irrigation—trying to heat them from the inside out.

Every degree matters.

We examine them for trauma.

Head injury. Internal bleeding. Anything that might explain how they ended up outside, frozen.

Sometimes there are signs.

Sometimes nothing.

Just exposure.

Just cold.

Behind me, a medical student stands at the foot of the bed.

Watching.

This is the kind of case that lives in textbooks—

the kind tested on exams.

On the monitor, the physiology of hypothermia reveals itself.

Bradycardia.

Prolonged QT.

And then—

J waves.

Subtle, defiant deflections at the end of each QRS complex.

The heart whispering:

I’m still here.

In hypothermia, the body stops fighting.

Shivering disappears.

Metabolism slows to a crawl.

It’s the closest thing we see to suspended animation.

Not death.

Not life.

Something in between.

Rewarming carries its own danger.

As the limbs thaw, cold blood returns to the core.

The temperature can fall further before it rises.

Afterdrop.

Even recovery can kill you.

Their limbs are often already lost.

White.

Frozen.

The kind of frostbite that doesn’t come back.

But in resuscitation, we make one decision clearly:

Life over limb.

Vasopressors begin.

Blood is shunted to the organs that still matter—

at a cost we fully understand.

We think about invasive warming—

thoracic lavage.

Peritoneal lavage.

In some cases, ECMO—

an external heart and lungs.

A machine that could take their blood, warm it, oxygenate it, and give them a chance.

Often—

they improve.

Slowly.

Almost impossibly.

Their mental status sharpens as their temperature rises.

A dangerous kind of hope.

A reminder of how far the human body can stretch before it breaks.

They go to the ICU.

Warming continues.

But physiology always collects its debt.

Hypothermia teaches a strange lesson.

It can preserve life in conditions that should end it.

It can hold someone at the edge—

long enough for you to believe you can bring them back.

There’s a saying in emergency medicine:

You’re not dead until you’re warm and dead.

But sometimes what you’re witnessing…

isn’t survival.

It’s the body thawing—

just long enough

to let go.

Not a missed diagnosis.
Not a bad outcome.
Not even a complication.

A complaint about wait times for imaging.

Something completely out of my control.

And yet—mine to answer for.

The kind that makes you pause—not because you did something wrong, but because you start to wonder if doing the job right even matters anymore.

It reminded me of something I wrote a few months ago.

At the time, it struck a nerve.

It still does.

Few things deflate a physician’s morale faster than a patient complaint.

We work under relentless pressure. Too few beds. Too few staff. Too many patients—needing help now.

We skip meals. Delay breaks. Push through fatigue.

And still, the complaints come.

Sometimes, they’re surreal.

I once had a patient pull open the curtain while I was performing CPR and yell:

“Just let them die already so you can see me.”

That’s not common—but it happens.

Most patients, to be clear, are reasonable. When they understand the situation—cardiac arrest, major trauma—they recalibrate. They wait.

But the initial frustration is real.

And sometimes, that frustration becomes a formal complaint.

And those complaints cut deep.

Emergency medicine is built on rapid decisions in unforgiving moments. A single complaint—especially one rooted in misunderstanding or unrealistic expectations—can plant doubt. Guilt. Fatigue.

We care more than we let on.

So when you’re accused of apathy—when you’ve given everything you have—it lands.

Hard.

Worse still, many complaints don’t reflect a failure of care.

They reflect a failure of the system.

Overcrowding. Resource shortages. Delays in imaging. Limited access to specialists.

None of which we control.

And yet—we become the face of it.

That misalignment is where burnout lives.

Sometimes, complaints come from pain. A patient whose life has just changed—suddenly, permanently—needs somewhere to direct that anger.

Sometimes, they come from expectation.

We live in an on-demand world. Uber. Same-day delivery. Instant access.

Medicine doesn’t work that way.

Most of the complaints I receive center around imaging—especially MRIs.

But I can’t order one unless there’s a true emergency.

Not because I don’t want to help.

Because those limited slots are reserved for patients with spinal cord compression. Brain tumors. Time-sensitive diagnoses.

If I move you ahead without indication, someone else—someone whose life or function depends on it—gets pushed back.

That’s the tradeoff.

And it’s not one we take lightly.

Medicine cannot become customer service theater.

Investigations must be guided by necessity—not preference.

Even when complaints don’t lead to discipline, they carry a cost.

Time. Documentation. Meetings. Emotional energy.

And they linger.

They push physicians toward defensive medicine—toward caution over judgment.

Over time, that shift erodes good care.

It also isolates us.

We don’t talk about it much.

We’re told it’s “part of the job.”

But each complaint chips away at something.

Especially when it’s undeserved.

We need better systems.

Clearer expectations for patients.

And institutional courage to say:

This physician did the right thing—even if the outcome wasn’t what the patient wanted.

Until then, emergency physicians will keep absorbing the pressure of a system stretched too thin.

Walking the line between compassion and exhaustion.

Between listening—and protecting ourselves.

But we need to stop pretending this is sustainable.

Moral injury is not “part of the job.”

They didn’t ease us in. They threw us straight into it.

I still remember the smell.

Not the lecture halls.
Not the textbooks.

The ICU.

It was my first real day on the wards—third year of medical school. After two years of theory, we were finally allowed near actual patients. I thought we’d be eased in. Maybe start with something routine.

We weren’t.

Our preceptor gathered us and said, “Come. You need to see this.”

No warning. No context.

Just a quiet walk into the ICU.

The patient had Toxic Epidermal Necrolysis.

If you’ve never seen it, imagine your body turning on itself.

Skin detaches.
Mucous membranes dissolve.
Everything that’s supposed to protect you… fails.

More than 30% of her body had dissolved into ooze.

She looked like a burn victim—but worse.

Because this wasn’t fire.

This was her own immune system.

She was sedated.

She had to be.

But it didn’t make it easier to look at.

The smell hit first—sweet, sour, unmistakably wrong. The kind of smell your brain doesn’t recognize at first… and then never forgets.

Her skin sloughed away under the lightest touch.
Blisters soaked through layers of gauze.

I stood there, pretending to be composed.

Trying to act like I belonged there.

But I didn’t.

Not yet.

That was the moment I understood something no lecture had ever taught me:

Medicine isn’t just science.

It’s exposure.

To suffering.
To decay.
To things most people will never see—and would never choose to.

They say medicine is a “calling.”

That day—

I saw what I was being called into.

Not just knowledge.

Not just skill.

But the willingness to witness.

Because once you’ve seen it…

You can’t unsee it.

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It isn’t.

It’s carrying them.

Not the patients themselves.
The outcomes.

Every shift, I inherit strangers at the worst moment of their lives.

Chest pain at 2 a.m.
A child who won’t wake up.
A mother who can’t breathe.
A man who thought it was “just indigestion.”

They hand me something fragile.

Trust.

And whether they say it out loud or not, they are asking one question:

“Are you sure?”

Are you sure this isn’t a heart attack?
Are you sure I can go home?
Are you sure my child will be okay?
Are you sure you didn’t miss something?

Medicine trains us to answer that question.

But here’s the truth no one tells you:

There is no such thing as sure.

There is probability.
There is pattern recognition.
There is experience layered on experience.
There is risk stratification and clinical gestalt and guidelines and algorithms.

But certainty?

Certainty is a myth we perform for the comfort of others.

The public thinks emergency medicine is about dramatic saves — chest compressions, defibrillators, trauma bays erupting into motion.

Sometimes it is.

But most of the time it’s this:

Standing in fluorescent light, knowing that if you are wrong, someone pays for it.

And still choosing to decide.

That’s the part that drains you.

Not the procedures.
Not the blood.
Not the chaos.

The weight of knowing you might miss something that matters.

People imagine burnout comes from overwork.

It doesn’t.

It comes from sustained hyper-vigilance.

From holding responsibility without pause.
From making a thousand high-stakes decisions in a row.
From never knowing which decision will come back to haunt you.

Every discharged patient carries a silent echo:

What if?

We don’t talk about that part.

We talk about resilience.
Efficiency.
Throughput metrics.
Patient satisfaction scores.

We rarely talk about moral load.

Emergency physicians are not just decision-makers.

We are uncertainty absorbers.

We stand between chaos and reassurance and say,
“I think you’re safe.”

And then we go home and replay it anyway.

The most dangerous myth in emergency medicine is that we are certain.

We’re not.

We’re responsible.

And that’s heavier.

But here’s what I’ve learned after years in the department:

It isn’t certainty that makes medicine safe.

It’s systems.
It’s teamwork.
It’s checklists.
It’s humility.
It’s asking, “What am I missing?”
It’s colleagues who will challenge you.
It’s patient safety layers designed because humans are fallible.

We don’t rise to the level of our confidence.

We fall to the level of our systems.

That’s not weakness.

That’s how lives are saved.

The public sees heroics.

I see something quieter.

A group of tired people, choosing — again and again — to care enough to double-check.

And maybe that’s enough.

—

If you’ve ever wondered what emergency medicine actually feels like — it’s not certainty.

It’s responsibility.

And the decision to carry it anyway.

ROSC — Return of Spontaneous Circulation
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