Our patients have their high waterlines as well. Some of these marks, such as amputations or concentration camp tattoos, are visible reminders of previous storms in their lives. Many have marks lurking in memory but unrevealed to us.

These high waterlines can color interactions and cloud perceptions. Anger, hate, depression, apathy, and hopelessness are born of these marks. There are stories behind the flat affects and inappropriate behavior we often encounter in our work and high waterlines to go with them.

The ED seems to be the high waterline clearinghouse. These souls are drawn to us like sheep to the shepherd. They are our people. They are the unwashed and the downtrodden. They live in unhappy solitude. They fight addiction or mental illness. They suffer chronic illness. They endure physical and emotional abuse. They live at the edge of independence, and they fear we will take it away.

These patients are usually thought of by many other caregivers as “undesirable.” Well, it would be nice if all our patients showed up in go-to-church clothes and had some problem we could easily fix, like a dislocated shoulder or fishhook imbedded in the hand. This is not and never will be the case. Our patients are complicated on many levels and can be quite vexing.

For all the talk of universal care and moving patients into a “medical home,” I doubt this will change our situation much. I suspect these patients will continue to call us home for some time to come. And why would that be?

Anyone who spends much time in the ED knows this is because we listen attentively and we address their problems. We can do in 4 hours what might take a week otherwise. Our light is always on, and we always find a place for everyone. We insist that the right thing be done when others observe suspiciously from a distance and reluctantly acquiesce.

I figure my high waterline is midcalf. I consider myself blessed. I know many people I encounter are marked right below the chin. These folks might not spill their life story to us, but it doesn’t take much imagination to figure out what some have been through. This knowledge does not excuse every action our patients take but does go a long way to explain them.

Dr. Baehren lives in Ottawa Hills, Ohio. He practices emergency medicine and is an assistant professor at the University of Toledo (Ohio) Medical Center. Your feedback is welcome at David.Baehren@utoledo.edu.