She arrived in my emergency department in police custody around three o’clock, with legal documentation holding her, against her will, for an emergency psychiatric evaluation. The officer reported a chief complaint of suicidal ideation. The patient and her husband adamantly denied this, and her husband wanted to take her home.

The patient and the officer both told me the same story. Earlier in the evening, the patient had been playing an online video game on her laptop. She shared a group chat with online friends. Someone in the chat wrote something vaguely suicidal, and the patient read it.

More importantly, the patient’s computer read it. A ping was sent to her employer, by way of device management software installed on that computer by her company. Someone in HR called 911, the police were dispatched, and the patient was woken up and brought to the ER.

The officer knew there was nothing wrong with her, but told me apologetically that he was obligated by his departmental policy and his superiors to fill out the paperwork and bring her in. I reversed the psychiatric hold and discharged her home, having done nothing for her other than disturb her sleep.

Nothing about that night is remarkable. I have written many essays about the policies that produce nights like these but have never written down the nights themselves.

My long-form essays dissect the policies that have ruined American healthcare. They are technical and well researched. They make principled and empirical arguments for free market solutions to what I think are largely government-created problems. The truth, though, is that I did not and still do not think about these problems from a dispassionate, rational, twenty-thousand-foot view. I did not arrive at my conclusions from a cold and detached review of the evidence, at least not at first. Like any human being, my thinking is shaped by my circumstances and is molded more by their emotional impact than I often care to admit. I see, and I feel, what happens to me and to my patients on shift. It hits me in the gut. It angers me. Enrages me, actually.

My newsletter was born to try to make sense of that anger. I started writing because the anger was leaking out into the rest of my life. Turns out it still does; I just articulate it better now. I thought that if I started writing essays about what happens to me and to my patients, and more importantly why it happens and what I think we can do about it, I’d be better able to leave work at work and separate out my personal life. The trouble is that my work is deeply personal. Try as I might to compartmentalize and detach, each patient I see is a person.

My essays explain the principled arguments for what I think would fix healthcare, but lately I think it’s also important to simply show you what my shifts are like. You can read the arguments and understand them and agree with them, but you can’t know the impact or even the true genesis of the arguments without experiencing emergency medicine day in and day out.

In these new monthly dispatches, I won’t be making any arguments. There won’t be any data and figures, and there won’t be any citations or numbers. Instead these dispatches will each be a collection of vignettes and experiences, told from my perspective, as they happened to me and to the patients I was treating.

I can’t tell you when or where I worked these shifts, nor who the patients are. Each dispatch represents one single shift but is in fact a blend of stories from the many shifts I’ve worked throughout my career, with key patient details changed for privacy. These stories are not extraordinary. Any given dispatch will not be a concatenation of the worst experiences of my career, made to appear to be one nightmare shift. I will not cherry-pick and I do not aim to exaggerate. I aim to show you the unembellished reality of my job and nothing more. There will be no heroics, no tidy endings, and no preached morals or concluding lessons.

These dispatches will be released on the first of every month to paid subscribers. The free long-form essays that come every two weeks will remain free forever. They stay free because the dispatches pay for them. Thank you in advance to anyone who supports my work, and if you know someone who would recognize these stories, please send this to them.

I believe the arguments in my long essays are vital, but they can be made by anyone willing to research the topic. What actually happens in the ER at two thirty in the morning cannot.

Faithfully,

Julian Galt, MD