“I need a breath of fresh air,” your senior resident states. He has had a pretty rough night. He missed an LP on a rather robust woman with “the worst headache of her life” and then the trauma team swooped in and “stole” his thoracotomy on a GSW that was dropped off at the ambulance door. You tell him to take all the time he needs as you turn your attention to the intern that has been patiently awaiting your emergence from the critical care bay.

Your next patient also has neck pain and since your hospital is full and your ED is boarding 14 inpatients currently, you are seriously hoping that this is going to be torticollis or a cervical strain that you can eventually send home.

“I think it’s time we go on ambulance diversion again,” your charge nurse suggests, looking as tired and frustrated as you feel. This is the third time this week that you have had to close your ED. All of the beds in the hospital are full, and your ED is bulging at the seams with sick patients that aren’t going anywhere anytime soon. You are holding 10 admissions at the present moment, and the hallways are lined with patients calling “doctor” every time you walk by.

“It’s all about how you play the game,” you explain to your intern. “As an EM physician, you are a healer, an educator, a detective, a diagnostician, and a master strategist all rolled into one.” He still appears rather frustrated that the internal medicine team is trying to “block” his admissions for the 65-year-old gentleman with newly diagnosed metastatic lung cancer and the 52-year-old lady with CHF and a BNP of 16,000 ng/L.

You just heard a great lecture on minimizing radiation exposure from diagnostic testing and your next patient may give you the opportunity to put the lecturer’s plan into practice. The patient is a 19-year-old male who thinks he may have food poisoning due to the fact that he developed abdominal pain last night after eating a burrito at a local “Roach Coach”.

“Nothing in medicine is black and white,” you hear your colleague explain to one of the rotating medical students. She looks perplexed as he goes on to explain that there is an “art” to medicine and just because she learned how to evaluate and manage a certain type of patient presentation one way, doesn’t mean there aren’t other “right” ways to do it.

During a busy swing shift, a 45-year-old male presents to the emergency department with two days of worsening right knee pain. He denies any injury, but states that the knee feels warm and swollen and now he can barely walk on it. He had a meniscal injury to the same knee about 8 years prior, and is now using crutches that he has left over from that time.

You really hope today’s shift is better than yesterday’s. You had to tell a really nice homeless man that internal medicine refused to admit him for his femoral DVT because he doesn’t meet “admission criteria” and that he would have to find the means to pay for his outpatient Lovenox on his own. Then a patient came into the ED with chronic pack pain, and you ended up diagnosing him with metastatic prostate cancer with spinal metastases.

Your next patient is a 28 year old female who has been triaged by one of the new nurses as” right lower quadrant pain for about nine hours”. Knowing that clothes generally stay on in the triage area, and the belly button usually remains unseen, the first thing you do after you close the curtain and introduce yourself is to have the patient pull up her blouse and point to where she feels the pain.

Why does it always feel like a battle between good and evil? You want to admit the 78-year-old male who had a syncopal event, but the internal medicine service feels that he can be worked up as an outpatient.