“Oh, you’re an emergency doctor? That must be an interesting job.”

It’s true, it is. And I know what’s coming next.

“So, what’s the craziest thing you’ve ever seen?”

Why is it with the number of times I’ve been asked this question I still don’t know how to answer it? I have never once felt like I was able to give any type of a satisfying answer to it. I understand the question and the curiosity behind it. I work in a fascinating world that few people regularly see into. For a time, every day before work I would ask myself, “What crazy thing am I going to see today?” At the end of the shift, I always had a few good answers. So why is it I never know what to say to you, at the dinner party, the church function, barber shop, games night, or whatever it may be when you ask me?

Yes, I do this job to help people – to listen, test, diagnose, treat, refer, comfort and reassure – as do all of us in the health care field. But it’s true- some parts of my job sometimes seem like a human side show. Drama, tragedy, comedy, pathos, heroism- some days are like seeing a parade of people and events straight out of a Shakespearian play. As many before me have observed, we in the emergency department see people at their worst, and in their most desperate of times. Sometimes, because of that, we also see them or those around them, rise to their best. Some people we see over and over again, and wonder how long they can stay at their own rock bottom.

It’s not like we don’t share our stories with each other. Those of us who spend our days working in this strange place regularly exchange vignettes about some of our recent noteworthy encounters. A rare disease we saw, or a diagnosis we just barely made, and how we did it. A difficult patient, an exceptionally bizarre or unlikely injury, a death we didn’t see coming and couldn’t prevent. A story of a patient we felt inadequate in helping, along with the asked or sometimes just implied question; “would you have done anything different than I did?” Sometimes we just need to share our experience of a crazy shift full of a statistically unlikely number of simultaneous severe medical emergencies- always followed by the legions of less urgent patients and their accusing “I’ve-been-waiting-for-six-hours-to-see-you-so-you-better-not-brush-me-off” eyes. It’s easy to share with one another, because we know what the job is like, and we know what makes one shift stand out from the others. We do it to bond, to commiserate, to teach and to learn from one another. My colleague knows how exciting and difficult it is to catch an early diagnosis of a dissecting aorta in a patient who is still stable enough to fly out and into emergency surgery before it is too late to survive. You, asking me at the dinner party might not think that experience was as cool or crazy as one more guy who accidentally shot himself in the hand with a nail gun. Yawn.

Maybe I don’t know what to tell you because as curious as you may be, you don’t know what I see on a daily basis, and have no idea what is or isn’t normal in the ER anyway. My crazy story is lost on you because you don’t know my world. On the other hand, your fascination with injuries or emergencies that are the bread and butter of my days work is lost on me, because I am too deep in my world to remember that anesthetizing, cleaning and closing a gaping 10 inch knife wound on another person’s forehead is not part of a normal person’s day.

My wife gets asked this question on my behalf too she tells me. Her first reaction is “Do you think he tells me the most crazy thing he’s seen?” Oh, she hears a lot of it, for sure. We have a little routine where she asks me how work was today. I tell her briefly about a few unusual things I saw or did that day (all respecting your confidentiality of course). She listens, shakes her head and says, “you have a crazy job.” She tells me how she often answers the question these days. By explaining that the longer I’ve been working in the ER, the less crazy the things that happen there now seem to me.

I also often wonder what you mean by the “craziest thing” that I’ve seen. If I stop and think, I can remember a lot of people, events and circumstances that qualify as “crazy” in my books, but they are all very different. Are you wondering what the most horrific injury is I’ve ever seen? (often I know you are). Yes I’ve seen limbs amputated, blood spurting to the ceiling, brain where it shouldn’t be, and other things out of a Tarantino movie. Not normally dinner conversation. Maybe you’re asking about the rarest medical condition that I’ve encountered? (I know you never are). Those might mean something to a medical student or another physician, but few else. The most tragic death? Most sudden? Most people I’ve told at once that their father/son/husband was dead in a car accident and the noise they made? Most tumor you can have growing in your abdomen and pelvis before the poop starts leaking out of your skin from a dozen places? Most people my age or younger I’ve seen dying of cancer in one shift? Youngest dead child I’ve seen? The feeling in the ER when we were trying to bring life back into a dying toddler, and got word that a second child under one year old was coming in with a possible cardiac arrest at the same time? Oh yes, that counts as crazy in a department that sees at most a handful of child deaths a year. I know the question is never asked as an insensitive one, nor do I take offense at being asked; we want people to know something about the world we live and work in. Yet when the truly tragic events that we see all too often are fresh in our minds, there is really no other response to this small talk question at a casual social function than a shrug and a, “it’s all a little crazy sometimes.”

Maybe you mean the crazy people. The guy high on cocaine with handcuffs and Taser leads dangling from his chest yelling “Juice me again! Juice me again!” The vivid hallucinatory delusions of the untreated schizophrenic patient who’s yelling at the electrical outlets in the secure psychiatry room, warning the CIA agents on the other side preparing to gas him again that his alien friends are arriving soon. The drug addicted woman unhappy at being discharged making sure to stop by every staff member she sees on the way out to tell them to Eff-off. The homeless man who is so covered in bodily fluids that even a fully gowned and masked and very experienced ER nurse has to come running out of his room gagging several times while trying to get him undressed to get at the maggot ridden wounds on his legs. I won’t lie and say we don’t find amusement at times in the eccentric personalities that cross our path. But it’s a humor that is part of our coping mechanism at dealing with people on the bottom layers of society on such a regular basis who are so hard to meaningfully help. Drug and alcohol addictions, mental health disorders and crushing poverty are singly or in combination some of the primary contributors making people into our “craziest” patients – dangerous at times, entertaining at others, but always in unenviable circumstances. Although we may grin or shake our heads at one another at their words or antics, we will still clean them up, check them out, treat them if possible, and provide access to medical care, counselling or social services. Through the swearing, spitting and resistance they often put up we will make their lives a little better, and try to offer them the resources they will need when they choose to take on the colossal challenge of trying to make a bigger change.

Since the question of craziest thing is usually asked in casual light-hearted conversation, perhaps I should just think of the little things that we regularly laugh at in our jobs. There is always a litany of amusing, unlikely stories or situations that come through our doors. Like the men driving a poultry transport truck who opened the back door to find a very agitated cat among the birds “Attacked by stow-away cat in chicken truck,” the chart read. Or a colleague of mine who told me once about a group of guys unloading a clothes dryer from the back of a pick-up truck, as they had been unable to free their friend who was trapped inside it. The brief triage primary complaint note in itself can sometimes tell a whole story. “Lost sex toy- doesn’t know where,” “Drunk on trampoline at 3AM- leg deformity,” “Cat stepped on eye ball,” “Hit on head with frying pan by wife.”

Or there’s the “I can’t believe they came to the ER” people. The mom who comes in screaming carrying her toddler. He had been playing outside and now had a pinhead sized black spot on his foot. It was dirt. The guy who had been having sore feet at the end of the day ever since buying new shoes. Yes, he admitted after some questions, they were probably just too small for him. “Tight fitting shoes,” I wrote on the diagnosis line on the chart, wondering what the official disease code for that might be.

To be honest, I don’t think I could ever say what the craziest thing I’ve ever seen was, because every week or even day it seems like there is something else that I have never quite seen before. That’s the nature of the job and it’s one of the reasons we love it. It’s bringing order, comprehension and healing to the craziness that keeps us coming back. Maybe we are just adrenaline junkies who get our rush trying to solve the problems caused by other peoples’ poor judgement or misfortune. But there is nothing more satisfying about this job than bringing someone back from the brink of death or serious illness when you know they have a lot of quality time left to live because of the knowledge and skill brought by you and the health care team you work with.

An emergency department is a busy place to work, and literally anything can come through that door. Many people we see are upset about how long they’ve been waiting, but most understand that we are doing the best we can with what we have. It’s the only place you won’t be turned away, but no you can’t make an appointment. “Wow, you guys sure are busy today. Is it always this crazy here?” Most of the time my answer is “yes, it’s often like this.” Sometimes though I’ll admit that no, this has been a particularly crazy day. Crazy day usually means there a lot of people waiting with minor problems (still important, still ER appropriate often, but not urgent), AND we have an unusually high number of urgent “sick” patients. You don’t want an ER doctor to label you as sick. That’s not a man cold or even 2 weeks of diarrhea with mildly failing kidneys due to dehydration. Sick is the ER code for someone with a true emergency in danger of imminent death or significant disability from whatever is happening to them. A handful of especially sick patients can bring the rest of the ER to a grinding halt. They need doctors, nurses, IV’s, medications, lab tests, imaging, consultants, admissions or transfers. This takes time and people, and sometimes the “almost sick” and the walking wounded have to wait longer because of this. We all have stories of crazy days: multiple traumas, simultaneous cardiac arrests, bad drugs at a house party. More often it is just a case of several unrelated bad things happening to different people at the same time.

So with all the crazy things we see, and the number of people streaming through our doors, what does it take to raise an ER doctors eyebrows? For us, I think it’s something that is different or unusual enough from what we usually see to stand out. It’s those stand out events that usually come to mind when I am asked the question, even if I don’t have a quick or meaningful way in which to answer it.

I received an email recently from an ER colleague sent to our working group with the title, “we don’t see this every day.” It was a picture of an empty chart rack at 6:30PM. No patients to see. I looked back through some of my picture collection of notable cases at work. An x-ray of a pitchfork in a knee. A cardiac tracing of a rare, but potentially fatal heart rhythm that I had only ever seen in a text book before- a future sudden death averted only because we recognized it. A child’s nose nearly ripped off, texted to a plastic surgeon to convince him to come in to work late, and many others. There among them, was a picture of our patient tracking board at 3AM on a night shift a few years ago. It was empty. Not a single patient on it. Next to it is a picture of an empty waiting room. I remember that night. We went for 3 hours without a single patient in or arriving to the emergency department. It’s not always busy, but that was very unusual. And I think that just maybe that was the craziest thing I have ever seen in the ER.