A 22-year-old G4P2 female is brought to the emergency department by her boyfriend for pleuritic right sided lower chest pain that she has had for approximately 18 hours. The pain is in the low anterior right side of the chest and radiates to the scapula and upper abdomen. It has been constant, but is not associated with nausea, vomiting, fever, chills, diarrhea or shortness of breath.
“If you are given a second chance in life, don’t blow it,” you advise
your eager resident. It has been an overwhelmingly busy day in the
department. Interspersed between the motor vehicle collisions, hypoxic
and hypotensive CHF exacerbations, and patients with florid sepsis, your
team is trying to see and help all of the ankle pains, throat pains,
and dysuria that have also walked through the waiting room doors.
Your next patient is a young African-American female with no history of
sickle cell disease, ocular conditions, or any other medical problems.
She was triaged with a chief complaint of “floaters” in her right eye.
“Let’s move it, guys, the bus is unloading!” You cringe as you hear the
jaded tone in your nurse’s voice. Your department has been especially
busy this past month with high-acuity patients, and your hospital is
slowly and surely running out of space and resources.
Paramedics bring in a 60-year-old male who collapsed at work and
remained unresponsive. They state that there was bystander CPR and a lot
of freaking out by coworkers. The only past history they have was from a
coworker who thought he had high blood pressure. There was also a
witness who told them he was just walking, then doubled over and
collapsed without saying a thing.
“I have to do a cost-benefit analysis of the situation,” your eager
intern replies. It’s the end of the academic year and you are forcing
your soon-to-be R2s to become more autonomous and confident in their
management plans. You are amazed at the various answers you now get when
you ask the simple question, “What do you want to do?”
It’s busy. There are twenty-eight patients in the waiting room with the
longest waiting 4 hours. The queue for CT scans is over 2 hours and the
one for ultrasounds is even longer; a staggering 4 hours, plus another
hour to get results. Lots of people are frustrated. Your next two
patients are both pregnant females in their first trimester with vaginal
“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.