There is a list of names in every Emergency Department that is well known to each individual that works and fuels that ER. And I’m telling you, it is never a good thing when you are the patient with the name that we immediately recognize upon popping up in our waiting room. For the most part, it indicates that you are chronically sick and chronically in need of emergency healthcare.  This runs the gamut of chronic illness.  You may have a weak heart that frequently gets overloaded and you end up short of breath with fluid filling your lungs.  This may mean you have failing kidneys that cause your electrolytes to go dangerously high as they cannot be filtered through your kidneys. This may mean you are an alcoholic with poorly managed diabetes coming in with abnormally high blood sugars. This may mean that you have mental illness that causes unmanageable panic attacks or leaves you feeling unsafe and suicidal.  This may mean that you have chronic pain and frequent exacerbations of uncontrolled pain.  This may mean you are addicted to narcotics and doctor shop for refills on pain prescriptions. This may mean you look for providers that will give you IV medications to give you the high that some pain medications can provide.  Whatever the reason, a familiar name in the Emergency Department is never a good thing.

On this particular day, I stepped into the chaos of an already bustling Emergency Department.  My colleagues mid-hustle, moving swiftly and deftly about the chaos of a busy day.  And there, waiting to be seen was a name I was all too familiar with. She is a mother, a wife, a member of our community, a person who struggles with mental illness and self-harm.  Triggered by events that send her stress into an insurmountable wall.  I don’t pretend for one second to know what she lives through on a daily basis.  I don’t pretend to understand these uncontrollable urges.  I don’t pretend to understand what it must feel like to come to the same emergency department, see the same healthcare providers, anticipating how they may react, judge, or act. I don’t pretend to comprehend how difficult, how humiliating, or how much courage that must take. What I know is that she comes into our emergency department on a regular basis with undeniable self-inflicted wounds that take a prolonged period to repair.

There was a time when I called for social services every time she came in.  She always gently declined their services.  Even when they came to talk to her anyway, she dodged and ducked out of their way.  She will assert how she has a therapist appointment right around the corner. That her therapist knows she is here.  That she is working through some very hard things.  I’ve called her therapist on occasions and she has corroborated what she has told me.  It is a difficult case, her therapist tells me.  During one instance, she was admitted to the hospital for a more intensive mental health evaluation and management.  It turned out, this only snowballed her mental illness and made her spiral deeper down a dark hole.

I’ve seen her enough to know she means it when she says she is not suicidal.  She often greets me cheerfully.  Talks about the weather, about her day and her week and her kids, as if she wasn’t there for self-inflicted injuries, but just for a regular slip and fall. In the same conversation, she gives instruction and suggestions on how she would like her repairs done.  I slow my breathing and try to wrap my head around how I should act.  This is not normal and I cannot help her normalize this behavior.  On the other hand, she is a mother, a wife, a member of a community that is deserving of basic human courtesies and respect.  She is a human being that is struggling.  Struggling so hard to just live a daily life accepting all the triggers and finding a way to assimilate them in a healthy fashion.

If I am being one hundred percent honest, it can be hard for us with patients we see frequently to not see them through a lens of judgment.  The patient with a weak heart that is on a low salt diet that eats ham and gravy over the holidays with his family.  The patient with failing kidneys that routinely misses one or two rounds of dialysis and is in need of immediate intervention to ensure his heart doesn’t go into a lethal rhythm.  The alcoholic patient that has uncontrolled high sugars and will continue to drink when he is discharged from the hospital.  The young patient with debilitating anxiety convinced he is having a heart attack that comes in monthly to have it checked and is in need of persistent reassurance.  The patient with chronic pain that comes in with abdominal pain regularly and requests large doses of narcotics.  The patient who has been to every Emergency Department in the local vicinity in the last week, accumulating narcotic prescriptions, who yells aggressively when confronted.  My patient who inflicts harm on herself on a regular basis and wants us to do nothing but fix her wounds.

It is easy to make quick judgments. It is easy to feel as if they are less than.  It is easy to push all the fault on their shoulders.  But who are we to judge?  We come from a place without heart failure where we can excitedly enjoy an unrestricted holiday meal when reuinited with our families without worrying about our breathing.  We come from a place without three day a week dialysis, a place where we are sober, a place where we are not crippled with anxiety, a place where chronic pain doesn’t have a vice grip on our lives, a place where we haven’t fallen to the addictive properties of narcotics, a place where we have never experienced or worked through mental illness that urges us to harm ourselves.

Who am I to judge? I am no different. I am a person with my own issues; I am just exceedingly lucky my issues do not lead me to the Emergency Department on a regular basis. So, I’ll work harder to challenge myself.  I am not here for judgment.  I am never here for judgment.  I won’t fault myself for being human, but I will check myself and know the bottom line is that my patients are in need.

They are in need.

Whatever that need may be, in the Emergency Department, we are better equipped to help them navigate it at this moment than they can do by themselves.

That day I took a deep breath.  I checked my judgment.  I repaired all of her injuries.  The Emergency Department outside her room was bursting at the seams, but she deserved my full care like everyone else.  It took me about an hour.  I looked her in the eyes, mother to mother. Wife to wife.  Human being to human being.  I asked her openly if there was anything else I could do for her today.  “No”, she said.  “That is all.”

Most love stories we see in the movies begin with a young man, a young woman, a chance encounter, or these days—maybe a swipe right on an online profile. But the greatest love stories are those that go untold. And this love story—this is one of the greatest I have had the honor to witness, if only for a few hours of their story.

She started with her confusion four months ago. Initially, it started as small things that most would not have noticed. A misplaced purse. Forgetting where the car was parked. Forgetting to mix the eggs into the cake she was baking. Nothing any ordinary person hadn’t done. But soon it turned into something more, he explained.  Getting lost in their apartment. Realizing she had opened the closet door instead of the bathroom door and the shame that followed that he couldn’t shoulder for her. The full out heaves of tears he couldn’t calm when she couldn’t find the bathroom after all. The heart ache of watching her grab armfuls of clothes from the closet and place them on the floor with such purpose, knowing there was only a mass jumble of thoughts and hysteria behind her frantic actions. It was a test of stamina to care for her, to look after her, to help her find the way in this narrowing, dark tunnel of her mind. It tired her too. And she slept. She slept after breakfast, she slept after lunch, she slept after dinner. Her waking hours became so sparse, but when she was awake, it was so filled with hyperactive conviction and activities that were seemingly purposeless. He would spend her sleeping hours placing all her shirts, pants, and dresses back in the closet. Washing stains off her clothes that she had spilled soup on. Salvaging what he could out of the trash of the oranges he bought yesterday that she had thrown away.

And soon, she lost her ability to dress herself. And it angered her. With such frustration, she would pick a dress, throw it on the floor, not knowing how to put it on. She would pick something else out of the closet, throw it on the floor, acting as if it wasn’t that she didn’t know how to put it on, but that she no longer wanted to wear it. Yesterday, she settled after picking a towel, laying it neatly on the ground, and with a satisfied content look, declared that this towel was in fact the dress she had decided to wear that day. He told me this, then fell into silence; keeping his eyes locked on my reaction, as if he couldn’t believe his own words, as if he wanted me to tell him they were not true.

He shared most of these things with me in rapid succession, with the same low, quiet, monotonous voice. His eyes tired but gentle; he spoke with such tenderness and love for his wife. This was a love that had grown over 51 years of marriage. Four months of hardship was worthwhile so long as he still had her.

She lay in the hospital bed with her eyes closed. I talked to her softly as I examined her. He chuckled at me, “you know she is probably stone cold asleep, don’t you?” She awoke when I sat her up to listen to her lungs. “Marty?” She said, startled by my presence. “Yes, May? It’s okay. It’s just the doctor. She is just taking care of you.” “Hm.” she grunted as her shoulders relaxed.

Last night had frightened him. “It scared me the way she was acting.” For the first time, he had seemed to slip from her mind. It had been different when it was the location of her purse, the location of the bathroom, or even how to put on her pants. Last night, she couldn’t remember him. She had asked for her pain medication, and when he gave her only one tablet as prescribed, she had become upset. Looking straight at him, she had said, “I don’t know why Marty wouldn’t give me the whole bottle so I could take what I want. He would only give me one tablet! ONE tablet! Can you believe him?” she had shouted at Marty. She proceeded to ask him to call the police, as there was a man in their home. She tried to leave the apartment without her shoes on with the car keys in hand. “And she doesn’t drive. She’s never been like this. It scared me.”

They met 60 years ago in fifth grade. They spent much of their adolescent years getting to know one another, and at the age of 20, they married. They spent the next 51 years married, 20 of those years married with multiple sclerosis grabbing a hold of her and settling into their marriage with them—an unwanted, dreaded third wheel. There have been good days and bad days, early on the good days outnumbering the bad days and making them tolerable.   These days, the bad days like a storm cloud ravaging all their days. There are days with falls. There are days with anger. There are days with forgetfulness. And every day that slides by, he tenderly holds onto the girl he met all those years ago. His one love.

I walked into room 14 of our emergency department, 4 hours into their visit. I found him sitting still next to her bed holding her hand in silence. The TV off, her eyes closed, the lights dimmed. Her presence—even in these dark days that have consumed them, even when he is losing his ability to care for her in the way he has for 51 years—her presence still his greatest comfort.

Where they go outside of the doors of our emergency department will be a new chapter in their lives. Their story is one of the great love stories that deserves to be told. A love that knows no end.

8 years old. Blond hair, neatly cut. Fair skin with flushed cheeks. Curious, trusting, clear blue eyes. Rosy, red lips in a perfectly content, relaxed grin. Wearing a plain red cotton t-shirt and blue jeans with the elastic waist and Velcro sneakers. I meet you in your wheelchair. I asked your dad what was the best way to get you onto the hospital bed to examine you. He picked you up easily in a bear hug, and your lanky, skinny arms wrapped around him, as your tight, contracted legs held their bent position as he plopped you gingerly on the bed. I listened to your heart and lungs, I pressed on your soft tummy, I noted the pull-up you wore with Buzz Light Year printed on the front. You never took those calm, trusting eyes off of me. You never smiled, but your whole face smiled at me. You never spoke, but your whole being spoke to me.

This was maybe two weeks ago, but my visit with you still pops into my mind frequently. It’s unpredictable which patients stay with us. We see patient after patient, and some just settle into our hearts and mind, lingering in our thoughts, reminding us that after they leave our care, they are still here.

What I remember about you is how sweet and happy you are. How you didn’t have to say a thing to let me know you trusted me. You trusted your dad. You trusted this world that you live in. On this day when you weren’t feeling well, you still smiled with your whole face.

What I remember is how well cared for you are. Your styled hair. Your clean clothes and newly changed pull-up. Your new Velcro sneakers and socks without holes.

What I remember about you is how much you are like my own son. Your lanky arms, your lanky legs, your fair skin with flushed cheeks. Your big, curious eyes, trusting me.

You came in for nausea and vomiting.  While this is something that has plagued you in the past, this time, it was just a stomach bug rippling through your daycare.  Your dad relayed this in sighs of relief.  Because this was something common. This was something other kids were going through. This was a “just-like-everyone-else” problem and not a “just-unique-to-you” phenomenon.

See, there are milestones that you and your family have not experienced. Your first word. Your first steps. Your first laugh. But there are milestones that are like gold. Those first hugs. Those first nods of understanding and communication. The realization that you are taking it all in, and those eyes are your window to experiencing and memorizing this whole world around you.

I cannot begin to comprehend how hard this life is for you, for your parents, for the three brothers that came before you. I also cannot speak for the immense beauty and happiness in your life.  But the one thing that I do know is that you are loved. You are enriching and touching the lives of your family, of those like me that have had the honor of meeting you. This I have experienced first hand.  You are louder than you could ever be in your steadfast ways.

You didn’t have to say a word, but you have touched me. I see you the way I see my son. A wonderful boy that is filled with love and that is loved.

Life is hard. It is hard in different ways for different people. But it is these moments of strong, quiet beauty that keep it tender and keep it worth our hardest work.

This moment has been rolling around and around in my head. I sat down on the stool. I turned to my patient. He was intoxicated. I realized I had seen him here in my emergency department just six days ago. “Hey.” I said gently. “What happened?” Tears welled in his eyes. He went into the story of his past six days. I had seen him six days ago, and he had begged to go to rehab. As he had innumerable times in the past. He really wanted help. He needed help. But it never helped. He had gone to a Detoxification Center and had stayed there three days where they ensured he went through withdrawals safely. Then he went home. And he started drinking again. And here he was. Back again. “Please. I need help.”

I leaned in. I listened. I nodded. I felt his sadness. He suddenly stopped talking abruptly. And he just stared at me. “Why do you care so much?”

The question startled me. Took me off guard. No one had ever asked me that. And trust me. I have been asked some fairly awkward questions. Why do I care. How do I even answer that question? Isn’t it just a fundamental part of what I do?   At the time, I had no eloquent answer.  I just stared back.  And dumbly said, “I just DO. I care because I know you need me to.”  At the time, I thought, I care because you are hurting. I care because you are human and everyone makes mistakes. And I believe you. You need help. This is your hellish cycle: You get help. It fails you, or maybe you slipped back away yourself.  Or maybe it is a combination of both.  It doesn’t matter. Then you need help again. I don’t know. The system is broken. It is so broken. And for you, something is failing, time and time again.  I do care. I don’t know. I can’t explain it, really.

But when he asked that question, I felt it knock the wind out of me. All of the caring I had bottled and neatly packaged into some crevice of my chest resurfaced into this avalanche of emotions. Yesterday, I saved a life. I brought his heart back from a standstill just as my daughter and son’s kindergarten open house was starting. I missed the open house waiting for his brother to arrive so I could talk to him. But I got there (mostly) in time for the kindergarten meeting. I sprinted up the walkway to the elementary school entrance, out of breath, just in time to see my daughter’s face light up when she saw me.  I mouthed an apologetic “sorry” to my son’s kindergarten teacher who was in the middle of addressing all the on-time parents as I slipped into a seat in the back of her classroom.

Before I walked into this room, I delivered a 16-week-old baby that the mother had spontaneously miscarried. I left her to grieve in private with her husband. And her baby girl. Tiny fingers. Tiny toes. Lifeless. Limp. Wrapped in a warm blanket. I’ll remember my heart-broken patient’s face. Stunned, sweaty, strong, brave. So many questions. So many fears. So much loss.

I care because it is all so much bigger than me. It is about lives. It is about families. It is about death. It is about surviving. It is about hopes.  It is about milestones. And I don’t know how to make sense of it all, how it all strings together and falls into place. Sometimes, I don’t know what else to do but care. To be present. To listen. It seems so very, very surreal that I can grieve the return-to-life of someone that I am not sure will make it to tomorrow as I race in the door, breathless, to my son and daughter’s kindergarten meeting.

I care because I am the best friend you never wanted.  You come into my space and tell me your most personal thoughts.  You tell me how this was unexpected.  How this is a horrible day.  How you had so many exciting hopes and daydreams for this growing baby in your womb.  How ecstatic you were to be a cozy family of three.  You tell me that my dying patient is your brother and you are the only family he has and how you wished he and his daughter had made amends.  You tell me you have been in and out of 14 different rehabs and you just want help.  You just want help.  Is there anything else I can do?  These are all the things you want to tell your best friend.  The best friend that you haven’t had a chance to call yet as you were rushing to the hospital.  The best friend you never had but wished you did.  The best friend that has given up on you because you have had one too many chances.  But here we are, just you and me, staring at one another.  So, you tell me your story.  It is about your hopes, your fallen dreams, your gut-wrenching day of heartbreak.  And it is all so real and I can’t help but feel fallen with you.

This is what we do. My colleagues and I. We care. We care more than you know. We don’t know the best way to express it all the time, but we do. We wonder if you have already started setting up the nursery that you will now have to let sit empty.  And we secretly hope you have not, as we can’t imagine the heartache of deciding whether to leave it as is or take it down.  We wonder if you will live to walk out of the hospital.  We wonder if this time, maybe this time, you will get the help you need.

We are far from your best friends.  But today, we will be who you need us to be in your life.  We will time and again–without question–put our lives on hold for yours. We will grapple with the balance between life at home with lives at work. But we know what is important. I can’t explain it better than to say, our hearts are with you.

I met you on the worst day of your life. You will always remember the day. December 28, 2015. I walked into your patient room, I shook your hand, I told you who I was, and you told me your story. You told me why we were meeting that day. You told me that you were pregnant, 7 weeks along. You started bleeding that morning. But you didn’t have any pain. You looked anxious, but hopeful. You had your game face on. I told you what we were going to do. Some blood work. An ultrasound. These would be a long three hours for you to wait while fearing the worst and hoping for the best. To me, it was another day at work.

I didn’t know your whole story. I knew the man in the room was your husband. I could tell he was most worried about you. I could tell that he shared in your dreams. I didn’t want to pry. I let you tell me what you wanted to tell me.

Three hours passed. To me, it was a quick, fast-paced three hours. To you, it was the longest wait. You were trying to hang on to your patience. Why was this taking so long?

And then I got the results. And it was what you had been fearing. You were no longer pregnant. It was a jab to my heart. I sat at my desk and looked at the results. I paused. My shoulders slightly slumped, and I took a deep breath and walked to your room. I knocked. I sat down. And I told you the news.

It was your worst nightmare.   It has been your greatest daydream to have a baby. You stared at me, hanging onto my every word. Maybe hoping I had made some type of mistake. Maybe waiting to hear what was to come next. Maybe to comprehend every bit of what was going on. Maybe to distract yourself from your heartache.

I didn’t know your whole story. I told you what I knew, and then I sat in silence. I waited. Your husband said, “We’ve been trying for five years. This was our last embryo.” You didn’t take your eyes off of me, you reflexively said, “but it’s okay.” Because you had said it before, and it was an easy way to fill the silence.  But it truly wasn’t okay to you. This was your last embryo. That slight jab in my heart now felt like daggers. I wish I could help. I so wish I could help. I wish you had cut your finger instead and I could stitch it up. I wish you had broken your leg so I could put it in a cast.

But this. This was it. This was the end of your dream to become pregnant. Maybe down the line, it truly would be okay. Maybe you would decide to adopt and never look back. Maybe you would decide to travel the world and live an unexpected, but still wonderful life. Maybe you wouldn’t.

All I know, is that at that moment, you were devastated. I met you, and it was the worst day of your life. It hit me: everyday, I am meeting people for the first time on their worst days.   I wish it wasn’t that way.

It was another day at work, and I wouldn’t remember the date, but you would. As I processed the events of my day on my drive home, I felt that aching heaviness that hovers over me in these dark moments.  I vowed to remember this date with you. For you. For all my patients on the worst day of their lives. December 28, 2015. I’ll remember this date. I wish I could do more.

A 23 year old girl is roomed with abdominal pain. It is a busy Friday evening in the emergency department and on my mind is my patient that I just told is having a heart attack and am having sent to the cardiac procedure center where they can determine where the blockage is and hopefully open up the blockage before any more of his heart tissue is damaged.

I walk in to see my 23 year old patient, and see her near hysterics, writhing in pain on the hospital bed. She grabs the railings and thrashes back and forth yelling out in pain. I ask her quickly where her pain is, and she yells, “My stomach! My stomach! Please! Help! My stomach!” I try to get more of a story, but she is in so much pain. I find out that she thinks she may be pregnant but she doesn’t know how far along she is. She appears to be having contractions, lower back pain, maybe she is in labor, but she seems early along in her possible pregnancy. I tell her I am going to find her nurse so we can start an IV and get her some pain medication while I try to figure out what else is going on . So, I step into the hallway and look up and down, and see no one in sight. I step out further and see that all my nurses are in patients’ rooms taking care of other people.   I step back into the room, and see my patient sitting slightly up against the incline of the bed with her legs bent at the knees. She is calm. I also see under the edge of her hospital gown, an image I will never forget.  She has miscarried her baby.

I look up again at my patient. I’m not sure if she knows what has happened. I sit down next to her and rest my hand on her arm. “I am so sorry, but you have miscarried your baby.” I stare intently at her face, trying to read her expression. She stares at the warm glow of her smart phone. I want to throw my arms around her, comfort her, talk to her. She says, “Ok.” I tell her I am going to have to deliver the rest of her pregnancy, that I’ll need to deliver the placenta. She responds monotonously, “Ok. But please. I don’t want to see. Please don’t tell me how far along I was.” She never looks up from her phone. I finish taking care of her and sit back down next to her. I explain what I have done, but am sure to honor her wishes. I explain the next steps and what to expect. She nods, she is void of any expression. I ask her what questions she has, what concerns she has, how I can help, what resources she needs. She needs nothing. She has no questions. No concerns. How long until she can leave. Please don’t tell her boyfriend who is waiting in the lobby. I say again, “I am so sorry.” I linger. She nods again. I have so much empathy and support to give. She would rather not have any.

I think about her often. I wonder what I could have done differently. I wonder if she had questions or concerns. I wonder what thoughts were spinning through her head.

What I have learned over the years, is that everyone grieves differently. Some cry. Some panic. Some act brave. Some become frustrated and angry. Some are in denial. Some use humor to get them through. Some ask questions repetitively and talk in circles, as they are slowly processing this big moment in their lives. And some are like her. Expressionless. Detached. Dealing with whatever it may be in their own ways. And that’s the exact thing about grief. It presents in different ways. No two people grieve the exact same way. I may have wanted to throw my arms around her and I may have expected tears, but that is not what she needed. She needed space. She needed me to stop talking. And that is okay. Her grief and my grief and your grief are not the same. We need to respect that of one another and let each person take the lead on how they need to react and how they need to heal. No quick judgments that because there were no tears or outbursts, that she is not in pain. There is no need for her to explain her reaction.

I still wonder what more I could have done. But I was there. And I will be there again and again for my patients. And that is the best I can do and what I will promise to continue to do. I will wonder and ask what more I can do and be there however they need me to be there.