Medical students often pose the question to me, “Don’t you get tired of the dental pain and all the little stuff that doesn’t belong here?” I reply: “Who is the most important patient in the emergency department?”

They invariable jump to the code, which we all recognize has one of the worst outcomes of all of our patients. We drift into a myriad of process conversations. My focus eventually returns, and I tell them the code is not important because their outcome is sealed more than 90 percent of the time. The most important patient is the one who needs intervention or is trying to die.

The next most important is the one who can go home because they keep the lights on. The routine patients deserve to not have their time or money wasted.

As that sinks in, we wax even more philosophical. We do not run emergency departments on any medical definition of an emergency; we would only see five patients a day, not 140. “I barely get excited any more when someone screams, “We Need a Doctor,” my colleague Dr. Kevin Casey remarks: “When they are stable I’m bored.” Instead, we operate on a prudent layperson standard and rely on our training and judgment to be able to decide when subtle illnesses could be critical.

More accurately, we run “an acute inability to cope department.”

Coping skills differ. I am sure you are all replete with examples of patients that have none. Some even lack that infrequently encountered, suspiciously described “common sense.”

A few years ago on a weekday morning in autumn on the northern edge of Appalachia, a nearly unflappable, mid-50s, third-career PA and I were working a morning shift.

Meanwhile, another 50-something was keeping his father-in-law out of trouble by going hunting. With a four-wheeler and trailer loaded with gear, they set out. And while ascending a steep climb the four-wheeler rolled backwards over them.

With chest pain, short of breath, but conscious, they assessed their injuries. The son-in-law looked at his right hand, which ended with white bone where his wrist should have been, the hand attached but displaced. He tied a white handkerchief around the wound. They righted their vehicle, reloaded the trailer and headed back toward the road. The vehicle would not start, so they pushed it 5 miles back to the road. They loaded the four-wheeler and drove to my emergency department.