Note: Names and certain details in this story have been modified to protect patient privacy.

Each day in the emergency department starts with not knowing what's coming. During my recent two-week elective rotation as an internal medicine resident, the automatic doors would slide open and the day would begin. Every patient brought a different story.

Samuel Edusa, MD. "An AI Generated Painting of a Patient in the ED." 2025, Digital artwork generated using Google Gemini. Personal collection.

The ED is where clinical medicine and social reality crash into each other. A middle-aged woman arrived septic, her leg wound infested with maggots. She clutched a bag of cornbread, thick with the stench of fecal matter that had clearly not been cleaned for some time. Despite the EMT dispatch noting she lived with a husband and son, and that she had called EMS herself, the conditions suggested severe neglect. Her Class III obesity made self-care challenging, but the situation raised immediate questions about potential psychiatric components or family neglect. She lived in a basement apartment without running water, making proper wound care impossible. The disconnect between having family present and the extreme state of her condition was jarring, a reminder that social support networks can sometimes exist in name only.

Then there was the gentleman convinced he had Creutzfeldt-Jakob Disease when presenting with chest pain. His internet research had led him down a rabbit hole of rare diseases, while his actual hypertension and hyperlipidemia remained untreated for years due to lack of insurance. Surprisingly, his ECG didn't show any concerning changes, but a review of his chart revealed multiple visits for similar presentations. As a veteran, could his PTSD and military experiences be contributing to these somatic symptoms? His chart had a previous diagnosis of conversion disorder, a psychiatric component that complicated his care and reminded me how physical symptoms often intertwine with mental health needs, especially in those who've served.

An elderly man returned with his third CHF exacerbation in two months. "I couldn't pick up the medications," he explained with downcast eyes. The pharmacy was three bus transfers away, and his monthly social security check hadn't stretched far enough to cover both the co-pay and his rent.

I sutured a retired surgeon who had slashed his head when a branch fell on him while gardening. He joked and offered technique suggestions as I worked, a reminder of the continuity of our profession. His case was straightforward. He had resources, follow-up care, and a support system at home.

A young woman was brought in after overdosing on THC gummies. Through her hazy state, she revealed she'd been self-medicating for PTSD after experiencing sexual assault. She'd never been able to afford mental health treatment, despite working two jobs.

Late one night, we treated an inmate with multiple stab wounds requiring complex suturing. As I worked, I wondered about the circumstances that had led him to incarceration, and what healthcare he'd receive after returning to the correctional facility.

An elderly woman arrived by ambulance, severely dehydrated and confused. Her caregiver daughter explained through tears that she'd been juggling three jobs to make ends meet and couldn't afford professional help. The guilt on her face was familiar. I've seen it in parents of sick children, in adult children caring for aging parents, in anyone trying their best against impossible odds.

A young man presented with diabetic ketoacidosis, his blood glucose over 600. He'd been rationing insulin, taking half doses to stretch his supply until payday. "I know better," he said, "but I had to pay rent or buy insulin. I couldn't do both."

Between the clinical patterns, each patient had their own set of impossible circumstances. I kept thinking about my time practicing in Ghana, where limited resources were just the reality. What caught me off guard in this American ED was seeing the same kind of poverty in a country that's supposed to have opportunities for everyone. The barriers weren't just medical. They were financial, logistical, educational, and systemic.

Every delay in seeking treatment had turned a manageable condition into an emergency. Every discharge that didn't address the underlying social issues risked a readmission. We were good at treating what was in front of us, but often had no way to change the circumstances that would send these patients right back through those doors. When discharging patients, I began asking different questions. Not just "Do you understand your medication instructions?" but "Do you have a way to get these medications?" Not just "Follow up with your primary care doctor," but "Do you have a primary care doctor? Do you have a way to get to appointments?"

The days were busy and each one was hard in its own way. Knowing that you're discharging someone back into the same situation that brought them in is a difficult part of the job. Sometimes unavoidable, but never easy.

I keep coming back to these experiences because they changed how I think about medicine. Without reflecting on them, two weeks in the ED is just a series of interesting cases. With reflection, it becomes something that actually makes you a better doctor.

As I return to inpatient medicine, I'm carrying these patients with me. Medical care doesn't happen in isolation. It's delivered inside social systems that either help or undermine what we're trying to do. Recognizing that is the starting point for actually helping.