Missionary to Emergistan

This is my EM News column for May.  I hope you enjoy it!  I’ll put up a link to EM News as soon as it’s available.

Missionary to Emergistan

I know a fine, caring physician who has a heart for God and a heart for people. He often goes overseas to serve the poor and needy in the third world. I saw him in his lucrative practice, where he recently asked this question. ‘Ed, do you do any mission work?’ ‘No,’ I replied. ‘Well, maybe someday’ he said, and patted my shoulder in encouragement.

It bothered me. It seemed like a kind of pity. It bothered me because, like so many great moments, I hesitated. Later, I knew what I should have said: ‘Yes I do! Every day that I walk into that emergency department!’ But I didn’t say that. I smiled and went on my way.

I thought about it some more. Mission work, mission work, where do I go….and it hit me. Every day I travel to work in Emergistan.

Emergistan is less a place than a state of mind. It is a place that is so unlike the rest of the human experience, many individuals find it hard to believe the stories we bring back. ‘People actually suck on their fentanyl patches…and die?’ ‘Yes, yes they do.’ ‘People come to the ER in ambulances for…for colds?’ ‘Yes, yes they do.’ The customs are difficult to explain.

In Emergistan, there seems almost a different kind of language. Spend enough time there, as we do, and you understand some of it. You understand tingling and buzzing, squeezing and spinning, burning and vomicking, and any of a dozen words for genitalia or a hundred words for drugs…tabs, bars, ruffies, Special K, K-2, bath salt and all the rest. You know that two beers means two dozen, that disability doesn’t always mean disability.

But it isn’t just the words. It’s the content, the meaning that evades so many. Even after years we don’t fully understand leaving, with staples in one’s scalp, to go ‘finish the fight.’ We don’t understand a 15-year-old child whose parents are excited about her second pregnancy, or a 22-year-old man thrilled to be committed, once again, because it will help get his disability. We have difficulty with an old lady ignored in her home while sores develop on her back, or a new-born with a broken skull because its cry interrupted someone’s television show. We weep, out loud or silently, at the young father with a new brain mass.

Emergistan is not only a different mindset, it’s practically a different dimension. A place of bizarre time and space. In it, a woman can have an exam, CT scan, labs and pain medicine in a two hour period, even as her husband stamps the floor and curses because, ‘we been here two hours and ain’t nobody done nothing!’ Two hours is interpreted as four, four hours as eight. What most would call a one, or a five is always a ten on the pain scale. And a work excuse is a civil right in the endlessly shifting constitution of the land.

Perhaps it’s no surprise. While we travel there, and while we see many patients like ourselves who do not desire to be there and who are in great peril and great need, we do not grasp the mindset or philosophy of the native Emergistanis…those whose lives seem to revolve around the triage desk, the patient room, the CT scanner, the coveted prescription. They are unfortunate, in some ways, many having been neglected their entire lives. Never nurtured by parents, never loved by spouses, never taught to cope (as evidenced by their constant anxiety), never taught to learn or to strive. Only taught to need, to dramatize, to expect.

I know, our experience in Emergistan makes us cynical. But it may be because so much bad, so much manipulation, so much need, so much pain ends up there. We see it. We see the refugees from normality, the abused and wretched, all mixed in with the abusing and hateful, the dishonest, the reckless and addicted, the slothful and cruel mixed with the dying and broken. It’s hard not to mix them all up.

It’s also hard because we are expected to do it as if it were mission work. For some it is. For some, whose faith or philosophy call them to give altruistically, it is a genuine mission work. For others who do not hold that view, who are compelled by government to work in Emergistan for free, it is a place of bitterness and anger that grows (understandably) with every passing mandate, every new rule about our travels and travails there, imposed by those who have never, ever truly crossed the border with us, who only know that it saves money when we do so at our own expense and risk.

Emergistan gets inside you. Sometimes you love it. It can be a land of thrills and challenges, rescuing hapless Emergistanis from disease and accident, and sometimes from their own bad decisions. Sometimes you hate it because it is all consuming and overwhelming. Or because the tragedy, like a parasite, has found its way into your heart and mind and made you fearful of every cough, every fever, every car you pass on the highway, every person you pass on the street. Emergistan’s doctors bear emotional scars that may never heal in this life.

Here’s the thing. They can call me bitter or angry, burnt out or hateful. But I love Emergistan. It is a kind of home for me, where I spend days and nights, where I make my living, where I support my family. In some ways, I am a dual citizen. I understand the regular world, the world of normal rules and behaviors, of clean offices and polite conversation, where sobriety is expected and work rewarded. But I understand addicts and drunks, violent criminals and irritable, dying old men, fearful mothers with sick children and frustrated, beat-down physicians and nurses. I see so much. I have seen so much.

I can criticize and observe, I can lay out the truth as I see it because I have been there, I have served there. I am a veteran of the daily battles of my second home in Emergistan. I know the truth as no policy maker ever will. I am, and have always been, committed to that other country that daily seems to suck out my soul and daily calls me back again; that rejuventates me with every save, every successful intubation, every good diagnosis, every smile of gratitude from the sick or fearful.

I am a missionary, I suppose. And so are you. And we can hold our heads high, for we have worked in one of the hardest, darkest places in the world. The psychotic, overwhelming, frantic, tragic Republic of Emergistan.

May her streets be paved with oxycodone.

37 thoughts on “Missionary to Emergistan

  1. Just this week I was speaking to a frustrated consultant who asked me, “Didn’t the patient even try to call her own doctor (who she had just seen recently for the same problem, before coming to the ER at 6 p.m. on a Friday)?” Without pausing even a moment I said, “Do any ER (Emergistani) patients ever do the responsible thing?” She accepted the truth of the statement, and (I imagine) realizing that we who practice in Emergistan have it so much harder, dropped her attitude.

    Brilliant article. Like any place, you have to spend a lot of time in Emergistan to truly understand it. Unlike most places, many will not enjoy their increased understanding.

    Your message will resonate with those who understand, though no matter how many amazing articles we write or serious discussions we have with those who don’t, they will continue to view us as misfits with tragic flaws of our hearts and minds, and will continue hand down more edicts in a horribly misguided attempt to fix us, rather than ever consider the root problems of Emergistan, which of course cannot ever be fixed.

    This system’s core message seems to be, “If we can just impose equal coercion and suffering on everyone, then everyone will be equally (not) prosperous, (un)healthy, (un)educated, and (un)happy.” Or as our President puts it, it’s about “fairness.”

    Such a system deserves to, and will inevitably, go down. Unfortunately it will take down with it as many as it can.

  2. I have spent 25 years in emergency medicine, almost all of it in urban trauma centers where I have seen all of the phenomena you describe in this article. I have no argument with your scenarios but I would dare say that if you would go to another country where nearly everyone is very poor, where resources are extremely limited, you would write a very different article. People who have not experienced medicine in a poor country have no idea how good we have it here, no matter how bad we think it is. If you really want to appreciate Urgistan, go spend a month in Haiti or Nicaragua or any one of several countries where you will have a life-altering experience.

    • Dr. Phil,

      I understand your point. But I think you missed mine. You just did exactly the thing that bothers me. You took the very real, very difficult service provided in emergency departments all across the land, and reduced its validity in comparison to work in other countries. Fair enough, I understand there are struggles in those places. I know there is crushing poverty and the resources are few. But I wonder if physicians there are routinely lied to for narcotics. If they are assaulted or threatened for not giving the ‘customer’ what he or she wants. I wonder if those who go there, particularly on a short-term basis, endure the daily grind of negativity and administrative fiat. Certainly, they go there out of the goodness of their hearts, for no compensation. But in our departments, where physicians go to make a living, they are often denied it due to EMTALA. I have spent 19 years in emergency medicine (22 years if you count residency). I have spent my entire career in a busy semi-rural hospital, where poverty is common, and where our income is not derived from anyone but the patients we see; where we collect a small fraction of billing, and where we continue to do the right thing with few specialists and often, limited resources at our facility. Maybe I won’t get it until I leave the country. But then again, may be I already get it. Would I write an other article if I worked in the third world? Most certainly. But I’d be practicing a different kind of medicine, too. My point is merely that modern emergency medicine is a very difficult, often very sacrificial kind of practice. I just hope you won’t deny our brothers and sisters that pride by telling them ‘yes, but if you’d just go overseas you’d really appreciate things!’

  3. Dr. Edwin,

    Your article was absolutely on target! I’ve been blessed with 23 years in emergency medicine, like you. About 12 years ago, I decided a medical mission to Nicarauga would help me rediscover my compassion in my Level 1 Trauma Center. Indeed, it changed my viewpoint, but made me LESS tolerant to the situations you described so well. My patients in rural Nicaragua were respectful and appreciative, dressed in their Sunday clothes, and waited in lines for hours. When we went to Leon, the city with our Americanized meidcal welfare system….patients lied, temporariy “adopted” more children so they could get more free drugs, were angry about their wait and were clearly from Emergistan. When I returned to my ED, empathy was evn more recluse….. What we do is mission work…when we have done it so long. Doc J

  4. In my family there are only two professions, physician or missionary. So I am uniquely qualified to comment on the patients I have taken care of in the ED in the U.S. as compared to the patients that my brothers care for in Uganda. After seeing patients wait patiently for hours in a village where there is no medical care, and having experienced the gratitude in their eyes for any kindness that you show them, it was very hard for me to come back to the metropolitan ED in the U.S., where we have created an entire culture of entitlement and disrespect. Sadly, while I would like to feel like a missionary, I know in my heart that I spend most of my time merely facilitating the self-destructive life styles made possible by our own government. I must be honest. I have worked 38 years in Emergistan. I’m no missionary. I’m an epinephrine junkie. And Emergistan gives me just enough of what I need to tolerate the rest.

  5. Poor Baby .. deprived of earning $600,000.00 each year by working in the ER ..what Doctors don’t seem to grasp is that they are the only ones who work on a unit basis and set their own prices ( as a group) for doing that work .. then complain when they don’t get paid full ticket on an overpriced billing.. If they worked on what the market would bear without the collusion with the Insurers and we radically reduce the cost of medicine where everyone could afford it.. As users isolated by the insurance companies and employer paid premiums we really don’t give a lick about the fairness of what each procedure should really cost ..compare the cost of an MRI in Japan at about $350 to America at $2000 ..why .. because in Japan the rate is set by a group outside the medical community who can really look at what it should be .. You whine like a child treated unfairly in doing you work in “Emergistan” .. degrading those people to a third world country well below your social status.. do you really think a policeman chooses his beat or a plumber chooses only to do fresh water repairs .. lose your arrogance .. become a real doctor who believes in creating health rather than wealth ..you spend your days dealing only with sickness ..what have you done to make people more healthy ?? Or is your job just to treat the sick ?/ If so you are not in Health Care .. you are in Sickness Care..and your prime interest is just getting that patient out of your office (or ER slot) prescribing the drugs that the Corporate Salesman gave you samples of .. and getting your billing done so you have time to whine about how bad your life is .. you should be ashamed of your attitude and spewing trash like you do ..

    • Dear David,

      Thank you for your insightful diatribe, which certainly adds to the discussion. First of all, I don’t know anyone who goes into emergency medicine to make $600,000/year; or ever expected to do so. While we do set our prices, the government, and insureres, do a nice job of paying only what they desire to pay, which we accept at prices often below the cost of providing the care (in the case of Medicare and Medicaid…which often are below the cost of practicing). By the way, if we worked in the ER at a low price, and only a portion of patients still paid their bills, we couldn’t afford to come to work. And hospitals couldn’t stay open. The elevated prices paid by insurers are a kind of social program, in a way, though not a very efficient one. Your insured bill probably covers several others who aren’t. Is that unfair? Would it be better if it were run through taxation and a federal plan?
      Do you work at an amount less than the cost of providing your service? Please inform me if you do. Furthermore, many of us are small business owners, and we pay all our own benefits, plus malpractice and all the rest. Despite the fact that it violates your ‘rich SOB doctors’ narrative, such a business costs quite a lot of money and results in far less than you’d think. Of course, you likely won’t believe that. Oddly enough, I do agree that prices are far too high. But then, in those places where prices are set outside medicine it’s likely every bill is paid. I’d love to charge a much smaller amount and be paid for all that I do. But that wouldn’t make me a greedy doctor, would it? Oops, narrative violated once more. As for sickness vs. health, I am an emergency physician. I don’t see patients for well visits or prevention, but I do try to treat them in a cost-effective manner with inexpensive drugs and reasonable testing. I also care very much for them. Many of them are folks you wouldn’t let in your front door, being drunk or stoned are dangerous. Or in your place of business, I suspect. By the way, drug companies rarely visit ERs because so much of our care is given for free because of federal mandate. There’s little money for drug companies to make. Sorry to smash yet another steretotype. My life isn’t bad. In fact, I’m very happy. What you fail to understand is that this job of helping people in the ER is often very difficult, very frustrating and frequently dangerous due to assaults or disease. But then, we deserve what we get being rich doctors, I suppose. I don’t spew trash, but I do try to 1) encourage those who work in this environment and 2) speak the truth about the social ills that we see, and which cost the system dearly. Tell me how much of your work goes uncompensated. Tell me how much of that happens in the middle of the night. Tell me about your threat of lawsuit. Perhaps you do something very similar. But be careful about judging what others do when you don’t know the whole story.

      When I disagree with someone, I try to have the courtesy to discuss the issue without insulting them first.

  6. Edwin, perhaps “David” could reply to tell us where he is ‘coming from’. It might frame his sarcasm better for us. I would certainly respect him more (but not his opinion). This sounds a lot like sour grapes. Maybe he wanted to be an MD but did not or could not do so. No matter…his comments do speak of his lack of real knowledge about medical financing.

  7. Edwinlea, your non-reactive, thoughtful, and patient response to David’s diatribe speaks as much as I imagine your practices in the ER do. That was a beautiful and compassionate reply for which i want to congratulate you.

    As far as i am concerned, the ER is where REAL medicine is practiced: address the trauma and get the patient stabilized and back to life (and these days, based on what you wrote, keep yourself alive, too!)

    Coincidentally, my father was a doctor, and of course i was to be one, too. My desire even back in 1965 when i began pre-med was ER/Trauma. Because there was no such specialty then, my profs in pre-med scoffed at my wanting to do that work full-time. Oh, well, next time around.

    thanks for your good work in the ER.

  8. I spent 35 years playing nurse. Many of those years were in three different ER,Frequently, the job was a no-win situation where admin did its damndest to grind one down to the cheapest,most compliant,level of mediocrity. Working with good doctors who were not on ego trips was a real pleasure. We were often coarse crude and vulgar; and sometimes we were known to cry with or for people. Yeah, I miss emergenstan and I’d go back in a heartbeat.

  9. Edwin,
    Thanks for the new coinage. I can now rename what I formally referred to as the $#!+hole. Yeah, I’m burned out several times over. Keep up the good work, you are one of my pitifully few sources of inspiration. The only easy day was yesterday.

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