Quiet Emergencies
When a teen’s OD shatters a night shift, a Kentucky med student confronts the shadows of his past—and the unseen crises shaping rural America.
The emergency department was unusually still that night, its typical controlled chaos replaced by a subdued calm. Only four patients occupied the beds.
A man who had walked twelve miles through the cold in a methamphetamine-fueled haze was now snoring peacefully. A woman with a flare-up of chronic lung disease bided her time until a bed opened on the wards. A worried mom and her infant daughter awaited a viral panel result for what would likely be a rhinovirus or another relatively unremarkable infection. And an unfortunate frat boy spent the night marinating in electrolytes and regret while his brothers took turns commentating his poor decisions live on Snapchat. The staff moved quietly, lulled by the rare slowness of a night shift in our rural ER. Catching up on documentation. Snack time. For once, things weren’t burning down.
Then the EMS radio crackled to life. Every head turned to listen, a sense of unease settling over us before the first words even registered.
“Fourteen-year-old male found down and unconscious with…” The signal cut out abruptly as the ambulance slipped into one of the countless dead zones in the winding hollers of our remote Appalachian hills. We exchanged quick glances, already imagining what awaited us. The lull of the night shattered twenty minutes later as sirens screamed in the distance, drawing closer. The ambulance bay was suddenly all scarlet and lapis, wide eyes and sweat-slick brows.
The boy was rolled through the automatic doors seconds later, bits of gravel clinging to his skin, his body limp and flushed. The texture of the sharp stone fragments clinging to his otherwise unblemished, pink skin sticks with me even now. His pupils were unresponsive, his abdomen soft and flat. A faint, sickly, pink stain clung to the corners of his mouth, the same hue as the scant fluid we suctioned from his stomach. Somewhere in the woods between the sill of his bedroom window and the highway, he had vomited—an involuntary cry from a body fighting the very substance that might kill it. He could not speak for himself, but his unresponsive body screamed of an overdose, quickly spiraling out of control.
Neurologic signs loomed ominously: from unreactive pupils to sluggish reflexes. His condition was deteriorating before our eyes. Fourteen years old.
There was something uniquely haunting about the stillness of his body in distress—no cries, no flailing, just the eerie calm of a life at risk. Rural emergency medicine is often a strange dance between resourcefulness and resignation, between doing everything you can and knowing it still might not be enough. In the quiet of that night, as we scrambled to stabilize this boy, I thought of how fragile life feels out here, how the distance between safety and tragedy can shrink to nothing in one dreadful night.
I had seen it before. In high school, on a vacation to Lake Oconee in Georgia, I found a man who had walked off a poorly lit terrace after too many drinks and cracked his skull. I remember the eerie stillness of his body, his confusion, my calls for help in the dark, the long delay until help arrived, and how quickly an ordinary night by the pool unraveled.
Back in high school, I was not the one expected to act beyond calling for help—but now I was the help.
That night in the trauma bay, watching the boy’s unresponsive body, that memory surfaced: how fragile life can be, how quickly it can shift. That night, it was the boy’s story unfolding before me, but echoes of my boyhood felt close enough to touch. A familiar pang settled weightily in my chest. It was the same weight I had carried when I was younger, standing by that pool in Georgia, helpless, stunned. I remember how unreal it felt, how time seemed to slow as I watched someone else's life teeter. The feeling had returned, but now it was sharper.
And yet, as we worked, there was a stubborn rhythm to our actions—a refusal to accept that this might end here, in this moment, under these fluorescent lights.
As we adjusted the IV and checked for hidden injuries, our gloved hands moving swiftly over his flushed skin, the EMT spoke: “Just after 12:15 a.m. he was found face down on a gravel ribbon out the county highway leading west out of town. He was found by a sheriff's deputy on routine patrol. No outward evidence of blunt trauma or a fall. Tried to punch the deputy and immediately went limp again before the blow landed.”
Urgency replaced the earlier stillness. Fluids poured through his IV, medications kept his blood pressure from crashing and fought to steady his racing heart. We struggled to decipher the full scope of his injuries. Neurologic signs loomed ominously: from unreactive pupils to sluggish reflexes. His condition was deteriorating before our eyes. Fourteen years old.
When his grandparents arrived, worry and exhaustion etched into their faces, we learned the boy had been in their care while his father, newly sober, worked on his recovery from prescription opiates. I knelt before them to share the gravity of the situation, choosing my words carefully.
“Your grandson is critically ill,” I said, trying to steady the tremble in my voice. “We need to know everything we can—what he might have ingested, what could have driven him to this—anything to help us save him or give our team context.”
The boy’s father returned soon after, all downcast eyes and wringing hands. Rapid, shallow breathing between words. At my attending’s request, he left the hospital shortly after arriving to search his son’s room and medicine cabinet for clues. When he returned, his hands trembled. He handed over a single pink pill he found embedded in the bedroom carpet and a spiral-bound journal from the boy’s desk. Its pages revealed a suicide note, heavy with grief over the death of his boyfriend just four days earlier in a car accident.
We worked for another hour to stabilize the boy, pouring every ounce of our energy into keeping him alive. When his vitals were steady enough, we transferred him to a university hospital over an hour down the interstate, the sirens fading into the night as the ambulance disappeared into the hills. The quiet returned, but it was the aching kind, heavy with uncertainty.
For the next two days, a rare time during which I did not work a shift, my thoughts lingered on him. Would he survive? Would he wake up?
I could not help but think of the isolation he must have felt, and I saw echoes of myself in his story. Growing up queer in a rural Kentucky town, I knew the weight of the pain he must have carried all too well—the whispered insults in hallways that stung worse because they were meant to be heard, the Sunday sermons laced with condemnations from the pulpit, the talk radio hosts spewing warnings about people like me, the well-meaning but bigoted advice offered to my mother by classmates' parents who thought they were doing her a favor. At night, I sat alone in my childhood room, arms crossed on the windowsill, mountain breeze from the cracked window hugging me, feeling like the only one in the world carrying this secret. The fear of reaching out—of being met with rejection, or worse—was paralyzing. I became an expert in hiding parts of myself that felt unsafe to share, smiling when expected, nodding along to jokes at my own expense. And yet, those nights of feeling like the world didn’t care if I was dead or alive made me hyperaware of the isolation others might feel, because I sure as hell felt it. That boy’s pain—shoved down, swallowed, carried in silence—felt all too familiar to me. Looking at him was like looking in a mirror.
Maybe that is one thing we can hope for in this work: to hold the line between despair and resilience, to find meaning not in certainty, but in the messy, raw spaces where life stubbornly persists.
When I returned to the hospital on Monday at dusk, the foothill horizon glowing gold and violet, my attending greeted me with a rare smile and an unexpected hug.
“He made it,” she said. “No residual neurologic deficits. He’s awake and stable, admitted to the behavioral health unit.”
Relief rose in me like a flooding creek. Relief, yes—but not the neat kind. We had not stitched his life fully back together in our fluorescent-lit ER. His life was handed back to him raw and full of questions, with no promise of what might come next. Rural medicine can mean stabilizing patients and sending them off into the unknown, rarely hearing what happens next. But this time, we had some of the answers.
That night, as I began my shift, the echoes of the boy’s survival lingered in my thoughts, but not in the tidy, celebratory way I might have imagined. The edges of his story were hardly contained, and the shadows of his pain still loomed. He was alive, but what now? What does it mean to hold someone together long enough for them to face the very pain that broke them in the first place? I did not know. I still don’t.
The hills outside our hospital were cloaked in darkness, but the ambulance bay glowed faintly under the sodium lights, as though it, too, was holding its breath. There are rarely guarantees—perfect resolutions—in medicine. More often, there are moments like these, where chaos flirts with hope and survival feels simultaneously triumphant and fragile. Chance and evidence-based care keep people alive against the odds, and we hope the next chapter, the one to which we may never bear witness, finds its own kind of healing.
The boy’s survival was not a clean slate—it was a beginning steeped in uncertainty, the kind that feels both heavy and full of possibility. And maybe that is one thing we can hope for in this work: to hold the line between despair and resilience, to find meaning not in certainty, but in the messy, raw spaces where life stubbornly persists. As my first night back in the ER stretched on, beeping monitors and sirens punctuating silence, I carried his story with me, unsure of where it would end but grateful, at least, that it hadn’t ended here.
About the author
Bradley Firchow is a medical student in the University of Kentucky College of Medicine's Rural Physician Leadership Program, training to become a rural Family Physician dedicated to improving health outcomes in underserved communities. His commitment to rural healthcare stems from his upbringing in Appalachia and the rural South, shaping a passion that blends medicine, research, communication, and advocacy. Bradley serves as chair of the National Rural Health Association’s Student Constituency Group and is a founding member of the Kentucky Storytellers Community of Practice, Narrative Medicine at UK, and the Sawstone Writers Guild.