An excerpt from Those Shoes: A Physician’s Reckoning with Life, Death and the Medical Machine.

The nurse caught me before I walked in the room, “This next patient says he knows you.” I looked in the room and saw Jim, the gate guard in my neighborhood. “What’s he here for?” “Back pain,” she said, with a look I recognized. “You know what he wants.” I knew what she meant. Back pain at 11:00 p.m. on a Tuesday night means one of two things: Something is genuinely wrong, or someone wants pain pills. The ratio, in any honest ER physician’s experience, tilts heavily toward the second. I didn’t think Jim the gate guard was that type, but you never know. I walked in the room.

Jim was on his feet, pacing. Not the pacing of someone in agony, or so I thought. The pacing of someone impatient, someone anxious with somewhere to be. He was round, middle-aged, and allergic-to-exercise. He looked up when I came in and his face opened into a grin. “Hey Doc! Good to see you,” he said. “My back’s killing me.” He had no cardiac history. No chest pain, no shortness of breath, no sweating, no nausea. Just the back. Aching, he said, since that morning. He’d taken some ibuprofen. Hadn’t helped much. He’d tried to walk it off. Hadn’t helped either. His wife had finally told him to go get it checked out. I examined him. Musculoskeletal back pain. Paraspinal tenderness, pain with movement, the whole presentation. Classic. The nurse’s impression wasn’t wrong on its face, but I ordered an EKG mostly out of habit, the way you do with middle-aged men who come in with any kind of vague or poorly explained pain above the belly button, because the heart is a liar and you learn that early.

The EKG came back normal. I stood at the nursing station and looked at it. Normal. I looked back towards Jim’s room. He was pacing again, visible through the glass. Something was bothering me. I couldn’t have told you what exactly. Not a specific finding, not a textbook red flag. Just a sixth sense after years of watching people that every experienced ER physician knows is real and has learned, sometimes at great cost, not to ignore. I ordered serial EKGs and a full cardiac workup. I called the hospitalist and admitted Jim for observation. Benny the hospitalist, a grizzled old warthog with a heart like dried beef jerky, was skeptical. The patient had a normal EKG and his presentation was suggestive of musculoskeletal cause. He didn’t only question me, he downright ridiculed me. “Overly cautious Birdstrike wants to admit everyone. He’s going to admit the janitor and the whole cafeteria, if you don’t hide them! Haha!” I was not 100 percent sure the guy was having an atypical heart attack. But that was exactly the point. I wasn’t sure he wasn’t, either.

I went back to the rest of my shift. There were 12 patients waiting, three of them genuinely sick. I put Jim in the back of my mind the way you have to put things in the back of your mind when the board is full, trusting that the admission had bought him time and that time would tell us what I couldn’t. A few minutes later I hear “heart cath team to ER. Heart cath team to ER” announce over the loudspeaker. I look around and they’re funneling into Jim’s room like a swarm of bees. I walk over to Benny the hospitalist and he shoots me an embarrassed glance. “I did another EKG on him. Massive STEMI. You were right. Massive heart attack. Nice work, man.” I nodded an annoyed look back at him. “If only we had a stupid ER doctor around that could have told us that.” He went to the cath lab, got heart stents, and recovered with no heart damage at all. Pretty cool. It was a save not only by myself but also a whole team of people. But it felt more lucky than heroic, more accidental than brilliant.

And so, you move on. The waiting room fills up, the next shift starts, the next patient is already waiting. Jim became one of thousands of faces filed away in the archive of the job, not forgotten exactly but not present either, the way most of them are. Then I pulled up to my own gate one evening after a shift and Jim was there in the guardhouse. He leaned out the window with that same grin, wider now if anything. “Doc! That’s Dr. Bird, everybody,” he announced to no one in particular. “He saved my life.” I laughed and waved and drove through. The next time I came home, he did it again. And the time after that. For years, every visitor who came to see me, every delivery driver, every friend or family member who pulled up to the gate and mentioned my name or my address, got the full Jim treatment. Yep, that’s Dr. Bird. Great doctor. Saved my life.

I heard about it secondhand, from guests who’d mention it with a smile when they came inside. My wife heard it. My kids heard it. The pizza delivery guy heard it. I thought about the nurse’s look before I walked into that room. “You know what he wants.” I thought about the normal EKG sitting on the counter, giving me every reason to send him home. I thought about the thing I couldn’t name that made me stop anyway. I don’t know what to call that thing. Instinct, experience, stubbornness, and dumb luck. Probably some combination of all of them. I’ve been wrong in both directions before, having sent people home who came back sicker, and admitted people who turned out to be fine. The practice of emergency medicine is the practice of uncertainty amid chaos, and anyone who tells you otherwise is probably selling you something. But Jim was at the gate. Every time I came home after a shift where nothing went right, after the satisfaction surveys and the medical board letters and the days when the board never emptied and the patients never said thank you and the system ground on indifferent as weather, I pulled up to the gate and Jim was there. “Yep, that’s Dr. Bird. He saved my life.” You can’t plan for that. You can’t manufacture it. It just happens, or it doesn’t, and when it does you try to be grateful enough to let it mean something.

The author is an anonymous physician and author of Those Shoes: A Physician’s Reckoning with Life, Death and the Medical Machine.