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The ER is unlike any other place in the hospital. Tragedy, disaster, shock, pain, agony, fear linger unchecked around each patient bed. There is little room for comfort, reassurance, paced improvement, or doctor-patient relationships. Those can be found on the upper floors. The ER is not a place for healing, but rather for the stabilization and "packaging" of patients before they go to other places in the hospital. As such, the arc of illness is rarely completed in the ED. For sure, more people are discharged from the ED than admitted, but those people were rarely very sick to begin with. And, without a doubt, lives are saved every day in the ED, but saving a life is very different from healing one.

Because of this, and because emergent situations are best dealt with using algorithms, it is easy to dehumanize patients in the ER. Not only is it easy, it is expected and, to some extent, necessary. If you know that no matter what a patient looks like, where they come from, or what their name is you are, first and foremost, going to evaluate their ABC's (airway, breathing, circulation), the larger picture of who they are becomes less important. For certain you want to hear the story of their main complaint - their signs and symptoms - and a few important details about their social situation - where do they live, do they drink alcohol or use IV drugs, do they have anyone to take care of them when they leave here. This information, however, is not used to build relationships, but rather to determine the diagnosis of the patient and expedite the discharge. Doctors are often criticized for minimizing the patient and maximizing the disease, but in the ER, this actually makes sense. Here we are taught to sort sick from not sick. Names make less sense, so you remember patients by their diseases.

This dehumanizing runs counter to most of what I am drawn to in medicine. But I also find something very appealing, and almost comforting about it. The ER is, to some extent, the most socialist, egalitarian place in our country. Without a doubt, the people who see the ED as a place for primary care and urgent care needs come from a certain underinsured, underserved demographic, but they aren't the only people who come to the HX ED. Trauma knows now boundaries and as the major trauma center for the state and several surrounding states as well as a world-reknowned orthopedic and burn center, people from all extremes of society pass through HX ED. And everyone gets care. As they pass through the ED doors, they (more or less) become their condition, and they receive whatever care their condition asks for. In determining what a condition calls for, no one asks, "what is the patient's insurance," and that is a beautiful thing.

That said, the flip side of not asking "what is their insurance," is that no one is asking, "is this test really necessary." Actually, that's not entirely true. Everyone asks that question, but everyone follows it up with, "It's very low yield, but we might as well do it to rule X out," or "It's not necessary, but it is standard of care, so. . ." Clinical judgement is a dying art and we, as medical professionals, need to revive it if health care reform is going to stick.