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It's 9:50 a.m. in the ER, and it's slow. A nurse comes over and says to this other resident and me: "You'd better get over here. They're bringing in a guy with a serious burn. 13,000 volts to the face and hands. Two minutes out."

We walk over to the resuscitation room and put on gloves and pace in circles a little bit.

After a few minutes, the patient isn't showing, so I go outside the room with the physician's assistant, who obviously knows more than I do about everything down here, and he starts talking to a paramedic.

"How you doing?" he says.

"Oh, OK. What you got?" she says.

"Oh, a burn guy coming in."

"This is him right here." She points. A guy in a bandana drinking a cup of coffee is standing right next to me. He looks totally fine.

Anticlimax. "This happens all the time," the PA says.

People who come into the ER get frustrated sometimes at the long wait. I think they expect things to happen like they do on TV. You know, lab tests come back after the next commercial, and we find out what's really wrong before the hour's over.

But things in reality are slower than that. If you have a sore knee and three dying people come in after you, you'll have to wait until they're taken care of. Some lab tests can take hours. And you're being observed in the ER, watched while your disease evolves.

And, of course, you're in the safest place in the world to have a heart attack, for example.

I remember one guy with a head wound I was evaluating as a student. He looked great, was walking and talking, joking with me. I checked out his scalp, and there was an 8-centimeter cut that would obviously need some sort of repair. What I didn't know was that the nurses had already cleaned off a great many golf-ball-sized blood clots from this guy's clothing, and taken away a few blood-soaked bath towels.

I walked over to get the attending physician before I sewed him up, and when we came back 90 seconds later, he was unresponsive. The attending yelled and shook him, and all he'd do was grunt with his eyes closed. It turned out he was in shock from blood loss.

The attending sent me to get a bag to ventilate him, and when I got back in less than a minute, there were about four doctors working on the guy.

The attending looked annoyed. "This f-----'s trying to die on us," he said.

The patient spent the evening on a ventilator and was as good as new after a few liters of IV fluid.

A 30-year-old guy comes in with a minor orthopedic problem. He looks 45.

He works odd jobs, so with a few hundred bucks a week, he's too rich for Medicaid and too poor to buy insurance on his own. He has asthma but doesn't take any of the standard medications because he doesn't have a prescription, and he couldn't afford them anyway. He spends most of his time slightly short of breath.

He smokes, too, a pack a day or something, about the worst thing he could do with his asthma. He's addicted, obviously. He probably would need medical help to quit; heroin addicts say it's easier to quit intravenous drugs than to quit smoking.

I listen to his lungs, and they're full of wheezes. His fingernails and toenails have "clubbing," a deformity consistent with on-going lung damage.

His lungs are falling apart. Chronic inflammation due to the asthma and cigarettes will eat up his lung capacity over the years, and he'll certainly die younger than someone with good medical care.

I give him an inhaler to take with him, about all I can do under the circumstances, and he walks out the door.

In every other industrialized country in the world, except South Africa, this man could receive regular medical care just by virtue of being a human. In the United States he has to be either dirt poor, or middle class and lucky, and he fits neither category.

I'm talking with an attending who was recently assaulted here. A 45-year-old man basically went out of his mind without any good medical reason and threw him against a wall. It's not the first time it's happened to this attending.

"What you need," I say, half joking, "is a good talisman. You know, something to ward off all the negative attention from these patients."

"Well, look at this, Mike," he says, and shows me a tangled, hard, white clump about the size of a walnut. In a second I realize it's an old horse chestnut -- a buckeye -- whose shell has fallen away.

"Where'd you get that?" I ask.

He looks at me. "Well," he says, "when I was a young boy, about 5, my family was on a vacation in the Finger Lakes. I was walking with my father, and we came upon a buckeye tree that had just dumped hundreds of buckeyes on the ground.

"And I, a young child, picked one up and gave it to my father, and you know how much of a treasure such a small thing can be to a child. He put it in his pocket.

"About three years later, when I was 8, I noticed that my father was carrying around a buckeye, and I asked him, 'Where did you get that?' and he said, 'You gave it to me. It reminds me of you, and of how much you mean to me, and of that day.'

"When my father died several years ago, I found a buckeye in his pocket. I took it and now I carry one with me. Of course, it's not the same one anymore. They wear out, and I keep getting new ones."

He looks at his latest buckeye, which looks to need replacing, and puts it back in his pocket.

The cardiac monitors beep out their music around us.

Mike Merrill, M.D., is a resident in internal medicine at Buffalo-area hospitals. His first-person accounts of medical training appear regularly in Viewpoints.