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Second Opinion: The Psychotic, Frantic, Tragic Republic of Emergistan

Leap, Edwin MD

Emergency Medicine News: May 2012 - Volume 34 - Issue 5 - p 13
doi: 10.1097/01.EEM.0000414933.37792.32
Second Opinion

Dr. Leap is a member of Blue Ridge Emergency Physicians, an emergency physician at Oconee Memorial Hospital in Seneca, SC, and an op-ed columnist for the Greenville News. He is also the author of three books, Working Knights, Cats Don't Hike, and The Practice Test, all available at

Click and Connect! Access the links in EMN by reading this issue on our website or in our iPad app, both available on





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 developing nations. I saw him in his lucrative practice where he 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 pity. It bothered me because, like in so many great moments, I hesitated. Later, I knew what I should have said: "Yes, I do! Every day that I walk into the 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 then 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 that many individuals find it difficult to believe the stories we bring back. "People actually suck on their fentanyl patches and die?"

"Yes, they do."

"People come to the ER in ambulances for colds?"

"Yes, they do."

The customs are difficult to explain. Emergistan almost seems to have its own 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 and a hundred more for drugs: tabs, bars, ruffies, Special K, K-2, bath salts, and all the rest. You know that two beers means two dozen, that disability doesn't always mean disabled.

But it isn't just the words. It's the content, the meaning that evades so many. Even after years of practicing emergency medicine, we don't fully understand a patient who leaves, with staples in his 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 again because it will help him get his disability. We have difficulty with an old lady ignored in her home while sores develop on her back or a newborn with a broken skull because his 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. A woman can have an exam, CT scan, labs, and pain medicine in a two-hour period, and her husband will stamp the floor and curse because "we been here two hours, and ain't nobody done nothing!" Two hours is interpreted as four, four as eight. What most would call a one or a five on the pain scale is always a 10. 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 see many patients like ourselves who do not want 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, many having been neglected their entire lives. Never nurtured by parents, never loved by spouses, never taught to cope (as shown 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 many bad things, so much manipulation, so much need, so much pain ends up there. We see it all. We see the refugees from normality, the abused and the wretched, all mixed in with the abusing and the hateful, the dishonest and the addicted, the slothful and the cruel, the dying and the broken. It's tough not to mix them all up.

It's also difficult because we are expected to do it as if it were mission work. It is for some. It is genuine mission work for some whose faith or philosophy calls them to give altruistically. For others, who do not hold that view and who are compelled by the government to work in Emergistan for free, it is a place of bitterness and anger that understandably grows with every passing mandate, every new rule about our travels and travails there, imposed by those who have never 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 misfortune 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, burned 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, beaten-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 in my second home of 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 because 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.

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