A 20-year-old male presents to your ED complaining of five days of throat pain and tactile fevers. He reports that the pain is worse on the left, and is associated with oropharyngeal swelling and odynophagia. 

“Are you sure I don’t need that magic stroke medication that I saw on TV?” you hear a patient ask through the curtains in your acute care area. “I am within the 3-hour window.” You pause to listen to your senior resident reassure the patient that she is not having a stroke and explain to her the risks and benefits of that “magic stroke medication”.

“You need to have a rectal exam” you explain to one of your patients. He’s a 47-year-old with chronic back pain who is in the ED for an exacerbation of his pain accompanied by many of the associated accoutrements, such as sciatica, numbness and trouble urinating.

 “Do you know the four A’s of being a great emergency physician?” a colleague asks. He just overheard you giving your “It’s a virus” lecture to a twenty-something with a bad URI and no PMD to call her in a useless prescription for Fogmentin or Maxifloxicin.

“Hey, save some pizza for me!” your resident exclaims as he joins the masses indulging in a late night treat from the ED administration. Over the past few months, the department’s “door-to-doc” times and “length-of-stay” times have improved enough to warrant a pizza party for the staff.

“I’m 0 for 2 tonight” your resident says after yet another exasperating interaction with one of your institution’s feisty surgery residents. “The first consult was called too early. The last one was called too late!” Overhearing your conversation, the charge nurse walks over and says, “Well Goldilocks, maybe this next consult with be just right…

The labs have all come back on a 38-year-old female who you suspected had pyelonephritis. She had presented with 24 hours of flank pain and fever but no vomiting, abdominal pain or dysuria. Her last menstrual period was 2 weeks ago and she denies any possibility of pregnancy.

“Seeing is believing” you mutter as you shake your head in amazement. You can’t believe your good luck tonight. You ordered a CT scan on a patient with pleuritic right-sided chest pain looking for a pulmonary embolism, and instead you found her leaking thoracic aortic aneurysm. And then, your senior resident performed a bedside abdominal ultrasound on a 40-year-old male with chronic back pain and discovered a 5 cm abdominal aortic aneurysm.

A 21-year-old male bicyclist is brought to the ED, fully immobilized by EMS, after being struck by a car at moderate speed. The patient was found on the ground a few feet from the road with an obvious deformity to his right lower extremity (RLE).

Your last patient of the evening is a 42-year-old veterinarian who recently returned from a trip to Mexico where he injured the dorsum of his right hand on a cactus spine. He states that he was able to remove the entire spine and the site subsequently became infected.