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Two 20-something-year-old women arrived in the emergency department (ED) within 1 hour of each other. Both were unrestrained drivers of single-vehicle rollover accidents. Both had been traveling about 35 miles per hour.

Neither was drunk.

The first will never walk again. A 23-year-old part-time student at a nearby college, she suffered a complete transection of her lower thoracic spinal cord. Long dark hair brushed aside revealed her thin back with an obvious deformity. The diagnosis was clear. While writhing in pain, her legs lay motionless.

The second, a 27-year-old mother of two, walked out of the ED in time to pick her children up from day care. Embarrassed for the accident and apologetic for taking up a stretcher in a crowded ED, she left with barely a scrape. She thanked me by showing me a wallet-sized picture of her children. “I'm glad they weren't in the car.” I agreed.

I politely but sternly reminded the mother she had not been wearing her seatbelt and I held the hand of the college student as she cried. In the back of my mind I could not help but think that a seatbelt would have prevented this. But it was no time for righteousness.

In the ED, we see the wide spectrum of luck and choice, and we quickly learn that the two are not mutually exclusive. Good choices come with bad luck, like a young healthy father feeling fatigued, diagnosed with cancer in the ED. And bad choices can offset with good luck, like the drunk who fell down the stairs for the hundredth time, but always seems to elope from the ED without a bruise. There are teachable moments, moments that leave you shaking your head in frustration or awe, and moments where all that is needed is to hold a patient's hand and listen. It is the art and beauty of medicine and the nature of the ED.

The young mother made a bad choice but had good luck, and I hope she will never forget to wear her seatbelt again. I hope she learned her lesson. But the college student compounded a bad choice with worse luck, and I wish that she will one day forgive herself.

For every patient status post motor vehicle crash who passes through my ED under my care, I positively reinforce the use of seatbelts. My patients earn gold stars for using their seatbelts, and I remind them of what saved their life while handing them discharge paperwork. But for the patient who made neither a good choice nor had the benefit of good luck, I choose not to rub it in. A steep price has been paid for the lesson learned, and expressing my own personal feelings would only magnify the pain. I save teachable moments for those who have had better luck.