At 04:12 am, the monitors hummed their steady hymn. Green lines rising, falling, faithful as metronomes. A post-trauma child lay intubated and paralyzed, her small chest rising in mechanical obedience to the ventilator. Somewhere down the corridor a trolley clattered like distant artillery.

The department hovered in that familiar in-between: neither chaos nor calm, simply awake. Emergency Medicine permits no true silence, only gradients of intensity, waves that crest and recede but never quite break.

I closed a note at the workstation, three hours of human terror reduced to twelve sterile lines. My name glowed at the header, as it had for years, shift after night after shift. The contract was unspoken but ironclad: I appear; the department tests. It always does.

Another stretcher rolled in. No central pulse.

The registrar glanced across, seeking not permission but the quiet nod of confirmation. Hands moved, compressions began. We moved as one rehearsed body.

We were.

By six the sky beyond the glass doors had begun to pale. The emergency room thinned without ever emptying. Handover loomed. I scanned the roster. My name marched across the coming weeks in obedient black blocks.

For the first time, the sight did not steady me.

It pressed.

Here is Emergency Medicine’s first quiet deception: it persuades you that constancy is virtue. That unbroken presence is the measure of devotion. That fatigue is merely the honest tax on competence.

Exhaustion seldom arrives with drama. It seeps in as efficiency denuded of feeling, precision hollowed of presence. You function perfectly, and feel nothing at all.

Shift complete. Final handover, a patient’s troponin pending, observation advised. The colleague’s nod sealed the ritual.

Outside, the morning air felt almost indecent in its ordinariness.

By afternoon a leave request lay open on my screen. Casual leave, such a bloodless phrase for something that felt like treason. The cursor blinked. I entered the dates. My finger hovered a moment longer than necessary over the icon.

Click.

Send.

The second conflict arrived instantly.

No tremor through the corridors or calls asking why. The rota adjusted with bureaucratic elegance, and a colleague’s name slipped into my slot in clean black font. The system swallowed my absence before the walls could register it.

That evening the department rolled on. Trauma arrived. Someone intubated. Blood was ordered. Reassurance offered with steady gaze. Monitors blinked their indifferent code. Stretchers glided. Doors sighed open, sighed shut.

The war did not pause.

Emergency Medicine cannot afford to depend on any single pair of hands.

And yet, the third conflict, while you stand inside that current, it feels as though it depends entirely on yours.

Total attention. Total composure. Total vigilance.

Calm amid unraveling. Decisive as seconds hemorrhage. Sharp no matter how many nights have etched themselves into bone.

To step aside, even for a breath, feels like betrayal.

The first morning of leave I woke before dawn regardless. No sirens. Only the ceiling fan’s slow, deliberate turn. Quiet was not peace; it was vertigo.

The ER continued without me. Chest pains arrived on cue. Children seized. Old men fell. Another physician took my place at the workstation. Another name signed the charts. The world did not tilt.

There is something humbling, and strangely freeing, in that indifference. Emergency Medicine is larger than any one of us. It is a current that carries when you enter, flows on when you withdraw.

Leave is not desertion. It is exhalation.

Without the out-breath, lungs fill with ash.

Weeks later my name returned to the roster. There was no ceremony or banner, only black font on white, as if time had folded neatly around the gap. I walked back through the sliding doors. Lights hummed their familiar indifference. A stretcher passed. “Doctor,” someone said. My body remembered the purpose beneath it.

In Emergency Medicine, absence does not define you.

Return does.

The department does not love you, does not mourn you. It lives on. But to step once more into its current, knowing full well it runs perfectly without you - that is no longer ego. That is clarity.

Missing in action.

Only long enough to breathe.

Then present again.

Steady.

Where pulse meets panic, where blood meets light, and where the current carries on.

If this made you pause, forward it to someone who might need it.

More soon.

Another moment.

Another reminder that we are still, somehow, human in all of this.

Yours,

Adarsh Nath