We passed time in the car talking, reading, listening to the radio, and playing games. It was a great time for family bonding before saying good-bye to our son. We encountered little traffic on this late-summer journey, save rush hour in Nashville. Our daughter learned the nuances of the regional dialect in the McDonald’s in rural Alabama. No time, however, to stop to see the world’s biggest ball of twine or Ruby Falls. Overall, our trip to New Orleans, loaded with the belongings needed to begin a freshman year at Tulane University, had been uneventful – until we reached the Desire neighborhood.

We had seen the storm clouds forming in the distance since passing through Slidell on I-10. The nearly completed twin spans and the damaged spans to the north were tangible reminders of the mighty destructive force of Hurricane Katrina and the slow rebirth of a city deluged 5 years before. We made it over the Industrial Canal in drenching rain. By the time we reached the Franklin Street exit, hazard lights blinked all around and the limit of visibility was the back wheels of the next car. My wife drove down the ramp warily, and we took refuge in the Winn-Dixie parking lot after splashing through 8 inches of water.

So goes August weather in the Crescent City. This storm was typical of the midday storms that gather regularly that time of year in the gulf south. We knew it would pass, and after 20 minutes it did. Pumps would clear the standing water, which rested below sea level, within the hour.

As we maneuvered back to the highway in light rain, I could see more signs of rebirth. Buildings were under construction, and new trees had been planted. Still, there were boarded-up buildings essentially untouched since Katrina left her high waterlines – reminders of the destruction and pain.

We spent 5 days in the city moving in, eating, laughing, and reconnecting with old friends. The contrasts were remarkable. On one hand I saw a vibrant city emerging from disaster. Crews fixed streets, the trolley traveled St. Charles Avenue, and Saints fans packed the Superdome. When reading the newspaper or talking to people, however, I was left with the impression that the wounds were healing but still close enough to the surface to be painful when touched.

The Katrina flood was a whopper, but floods are not unusual in America. Anyone who lives near a river basin has seen this. After the cleanup of a flood, many towns will leave a post unpainted to display the high waterline. In a generation the pain will be forgotten, but the mark on the post endures as a reminder of what was overcome.

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.