Every ED has their regulars. Those patients who seem to spend more time in the ED than at home (often because they have no home). The patients whose charts become a virtual visitors book, a record of which staff have worked in the ED over the past 5–10 years. The patients whose presence sometimes ‘blocks the box’ or provokes knowing looks between senior medical and nursing staff as an unsuspecting junior heads off to see them. The regulars present with problems that are known, often well documented and based on a recurring theme. Often, the most effective management strategies are a cup of tea, sandwiches and a kind word rather than interventions based on the latest research or advances in health care.

Jim (not his real name) was one of our regulars. He had been a successful businessman in his previous life, the life before alcohol. Whether his life now was by choice, or the result of some crisis, was never known. Whatever the cause, the bottle had consumed him and he now existed as he could, on handouts and social support. He lived in the park but occasionally managed to get a bed at one of the shelters. He usually presented alone and usually presented intoxicated. At one stage he held the department record for the highest blood alcohol – no mean feat in many an ED. Mostly he was cheerful, occasionally belligerent, but always quick to settle. Management was directed towards monitoring of his conscious state, excluding trauma and allowing him to sober up to the point of ‘safe to mobilize’. He was so regular at one stage that one of the trolleys was referred to as ‘Jim's bed’.

Staff had long ago given up on the prospect of a successful referral for managed alcohol withdrawal. It had been offered, it had been tried, it had failed. Not just once. Admittedly there were periods when he climbed aboard the wagon, but the path to sobriety was a rough one and always he fell off again. Not very surprising, given that his only social networks also lived in the park and drank with him. Loneliness craves company and what better way to share it than with a drink. When he did fall off the wagon it would be with a thump. He would drink what he could, and sleep where he would, often in the park.

One night Jim was brought in, not just by ambulance as usual, but with a police escort. This was different, something had happened. Somebody had poured a flammable substance over him while he slept in the park and lit him up. He had full thickness burns to both his legs from the lower abdomen down. He had minimal pain, which was quickly relieved. Full thickness burns on a background of peripheral neuropathy and an analgesic cocktail of morphine and alcohol.

He waved goodbye to us all as they loaded him into the ambulance for the transfer to the regional Burns Unit. We stood and waved back. A 60-year-old alcoholic with more than 40% full thickness burns. Do the maths yourself. We never saw him again. He died 2 weeks later.

Staff reacted differently. Junior staff were non-plussed by the effect this incident had on more senior members. Relatively crusty and battle-hardened individuals who didn't seem to blink an eye for most events seemed to be affected the most.

Fittingly or not, some of us raised our glasses to him the next time we had a drink ourselves. Did we let him down? Should we have tried harder to bring sobriety and moderation to his life? There were mixed views, but most who knew him thought not. Although life wasn't meant to be easy it is harder for some than others. He chose his road, whether it was the high road or the low road is personal opinion only. He had periods when he left that path but would always return to it. He was simply ‘having a holiday from his profession’.

Most careers have a defined period of optimum level of function. The US experience suggests 10 years for most Emergency Physicians. Is it the same for our regulars? Are they destined for their paths to shadow our careers? A talisman, or photographic negative image of ourselves, to watch over each generation of emergency physicians. A reminder that there is more to life than work, of how fortunate we all are with regard to careers, income stream and community respect. Sure work is hard, but we have work to go to and we are generally well looked after for it.

Jim would have laughed at these thoughts. He had worked hard and lived hard in both his lives. ‘Better to burn out, than to fade away’ he would have said. Is it really?

Competing interests

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PA is Section Editor, Disaster Medicine for Emergency Medicine Australasia.