Patients say the strangest things. Perhaps it's their lack of underwear, as though the forced physical intimacy would be incomplete without some emotional nakedness.  For some situations, it's a matter of course. When the removal of a foreign body is preceded by, "I slipped in the shower," more is spoken in the silence between two strangers than hours of conversation could divulge. Respect meets shame, confidence meets fear, and privacy destroyed is at the same moment restored. 

In other situations, it's as though the captive audience of a medical provider is the first time someone asked, "What happened?" The verbal diarrhea that comes forth is often as unstoppable and unrelated to the acute crisis as the frightened second cousin with "medical experience" who can't stop questioning you on how to do your job.  We hear all about their biology, job history, relationship failures, and so many medical problems. Some of my patients could have been the single case study that wrote half of the Annals of Emergency Medicine.  But what can we do, when someone has something they need to get off their chest?  Well, we use the tools of our trade. With scissors, science, surgery, or sincerity; we'll do the best we can. 

What about the angry patient? That disturbed individual who makes an enemy out of everyone.  I'm not talking about those with mental psychosis, I mean the teenager out with friends "working on job applications" when they were suddenly shot in a drive-by.  Or the new recruit to the local gang trying to impress his friends by getting into prison and "making something of himself".  Honestly, these are my favorite patient because seeing someone behaving so nasty and aggressively turn to tears and wipers when it's time to take his blood somehow validates the inner badass that I am.  Despite the 10 hours of tattoo work that he flaunts from between the buttons of his hospital gown, a lab draw is still more terrifying than a policeman's taser.  I donate blood every year, and that 16 gauge straight needle stays in the whole time.  I don't need a tattoo to prove I'm tough. My service to my community is twice as scary as taking a bullet and blame for a friend trying to steal a car.  At least, that's what my patient thinks.

But every once in a while, a patient tells you something that makes you think.  Maybe it's someone relatable. Maybe the similar age reminds you of someone, maybe they are just that one patient a month that sneaks into your heart to remind you that you still have one.  Maybe it is a young lady, studying to get into nursing school, finishing her last semester at junior college.  Driving home and somehow ends up in a car accident.  She was probably like every one of us. One drink an hour ago, 5 miles over the speed limit, cell phone giving directions, a friend in the car.  Each distraction so minuscule they would never have mattered, but add another erratic drive; some unexpected event that needs you to be a half second faster and you miss the turn.  A car wreck, a bad leg break, and concussion.  The next day, as the mind starts to put it all together, she started to wonder what happened to her friend. 

I was in an accident, thank God I'm OK. 

I never thought I would end up this way. 

But I killed someone.

I didn't mean to. It was an accident.  I was so scared, I didn't even see it coming.  

It wasn't my fault, at least I don’t think so.

Her brain injury keeps her from making memories for a couple days, so for days she revisits this situation, cries, pain becomes uncontrollable, and we sedate her.  She wakes up, starts to make sense again, and relives the accident.

I was in an accident, thank God I'm OK. 

I never thought I would end up this way. 

But I killed someone.

I didn't mean to. It was an accident.  I was so scared, I didn't even see it coming.  

It wasn't my fault, at least I don’t think so.

Tears, pain, sleep.

Repeat.

It's hard enough to treat people with the problems that are consequences of a lifetime of bad choices. When life comes to collect, everybody loses something. Smokers get cancer, IV drug users get aneurysms and vascular issues, Meth users get bad teeth and heart failure.  The chronically stressed gets heart attacks, bad dieters get pancreatitis and gallbladder issues, drinkers lose their liver.  The suicidal lose their grip, the abused lose their trust, the homeless lose their self-respect. The rest of us, the "functional" group, we lose days at work, PTO, all hopefully not too much that we are set back. 

But this little girl, in her relived nightmare, revealed to me my own nightmare. That I go to work, and by doing nothing wrong or grossly negligent, I miss something. I just one second behind, or fail to notice a change, or don't ask just the right question.  My patient really needed me, and I miss it. 

What if I kill someone? 

I never thought I would end up this way.

But I killed someone.

I didn't mean to. It was an accident.  I didn't even see it coming. It wasn't my fault, at least I don't think so.

Oh, God... What if I kill someone?