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Life in Emergistan: The Most Important Patient

Leap, Edwin MD

doi: 10.1097/01.EEM.0000481767.41332.2b
Life in Emergistan

Dr. Leap is a member of Blue Ridge Emergency Physicians, an emergency physician at Oconee Memorial Hospital in Seneca, SC, a member of the board of directors for the South Carolina College of Emergency Physicians, and an op-ed columnist for the Greenville News. He is also the author of four books, Life in Emergistan, available at, and Working Knights, Cats Don't Hike, and The Practice Test, all available at, and of a blog, Follow him @edwinleap, and read his past columns at





My most important patient requires my constant diligence. I am seldom far away from him. Only a few minutes' inattention, and problems will arise. I cannot forget my patient; I am trained to attend to him constantly. I am a professional, and my patient is, ultimately, my customer, and the customer's service is paramount, so they tell me. I am reminded by policies and procedures as well, and there are those who will contact me, day or night, about my failure to do what my most important patient requires.

I have seen many wounded and sick patients of varying degrees of complexity and interest since I started medical school 29 years ago. Legions of fevers and columns of colds, tribes of chest pain and nations of bruises, entire cities of coughs, herds of nausea and vomiting, and battalions of sprains. But none of them, not one, occupied me like my most important patient.

Teachers guided me in urgency and priority. They taught me to hurry here, take time there, and always be attentive. Wise physicians shepherded me, but never did any of them put a patient on a pedestal the way my most important patient has been. Neither snakebite nor sepsis, aneurysm nor arterial blockage, pneumonia nor parasite has ever been thrust before me as the most important patient ... until now.

What could he have, you ask? Who could he be? Celebrity? King? Judge or politician? My child? Parent or priest? Hardly. Not one, not even captains of industry who endow hospitals, have the power of this patient.

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Sordid, Tragic Details

This patient, this most important patient of all, stares back at me all day long. I examine and treat him with my hands and sometimes my voice as I stare intently back into his face. I wander off to other patients, but all pale in comparison with this one. He violates all privacy and priority and knows absolutely everything. I see a chest pain next door, a pelvic pain across the hall, or a weeping suicidal woman a few rooms down. I come back and tell my most important patient each secret. I whisper the sordid or tragic details of every life to him.

Once my hands loved examining other patients, the shape of normal and injured bone, the sound of clear and diseased lungs, the nuance of stroke, the tenderness of the abdomen that took so long to understand. Now I have no time. I must touch my patient, enter the password, and let my trained fingers run across plastic, not skin or bone. Or I speak into his ear with a microphone, far more expedient than time wasted with others. Far more important and billable.

Every time I wander away, my most important patient calls me back. “Hurry, hurry, tell me about the others! Don't take too long!” And other humans, more important than I am, remind me, “Don't neglect your most important patient! Finish everything he needs as soon as you can! He is the key to all of our money! And if you don't, we will fine you or punish you in some other way for failing to care for the most important one of all! But make sure the flesh patients are happy. Give them a little time or they might be upset and not come back, and then what will you tell your most important patient?”

My most important patient is now everyone's most important patient. He is in charge. Sometimes he is shy and recalcitrant and will not wake up, will not look at me with his glowing eye. Then nothing can happen. No orders for labs, x-rays, or medicine. He is an angry god, and when he is angry, no one else can be happy. Sometimes he is confused and plays pranks on me, so that what I said to him is turned on its head or made unintelligible. He is capricious but ultimately far better than people who say and do things that my most important patient isn't programmed to understand or record. He doesn't like that, and forces me to do things in a confusing manner because he is angry.

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A Kind of Sacrifice

And he is a time miser. He wants all of my time and those who brought him to me (or rather brought me to him, a kind of sacrifice) know that he is greedy and yet expect everything to run as before, when other patients were important.

But you and I know those days are gone like electrons on a wire. Now, the most important patient of all takes the most time and the most effort and the most diligence because data and billing and tracking and policies are what he does, and his handlers love those things the way we used to love humans. And as spoiled as my most important patient is, it is unlikely that anything will ever be the same again.

Pity. Humans are interesting. But sick or well, they simply cannot stand in the way of data entry.

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