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.

Pulling up the EMS ramp, the son-in-law got out, approached a pair of medics and said, “I need help.” They promptly wheeled him into Room 3 and yelled, “We need a doc!” Airway intact and a brief history aside, I noticed the bloodless white handkerchief on his right wrist and immediately called for my PA to help reduce the pulseless hand. We opted for immediate reduction sans analgesia. As we overpowered the spasm of the forearm; my new favorite patient screamed, “I want a Pepsi!” To our wide eyes and the PA’s chuckle, we felt a satisfactory clunk and brisk return of color and pulses.

Of my nurse, I requested x-rays and “two milligrams of morphine IV; and give it again until it works.”

We began charting and the transfer process to our regional trauma center. Our patient remained upset by his NPO status. His Pepsi out of reach, he jabbed my order “two of morphine IV, and give it again until it works” as requests for more analgesia. We loved him from the start. But he was nearing mascot status with his pithy sarcasm and recounting of the morning’s events. He was successfully transferred and his father-in-law was discharged with rib fracture precautions and treatment.

The same team was back when our patient arrived at triage on the way home from the trauma center. He was thankful and said the doctors at the trauma center reported that we saved his hand. I thanked him and wished him a speedy recovery.

As I sat down next to my PA and casually remarked the guy from yesterday was just here and looked good, my PA jumped up and sped thru triage. He returned with a wide smile; when I inquired he replied “I asked him if he got his Pepsi.” The patient said he’d been assured he would get one if had still wanted it.

With this tale of near insurmountable ability to cope, the medical students grasp the prudent layperson standard that we will lie down and die for. The next time you have no idea what to do with a routine complaint that has been plaguing someone for decades, take heart. You only need to improve the patient’s coping ability enough to make it to definitive care.

Dr. Carter is an attending physician at the Southern Ohio Medical Center Emergency Department in Portsmouth.