altYou breathe a small sigh of relief when your senior resident begins presenting his next case to you. The patient is a 17-year-old G1P0 who found out she was pregnant via a home pregnancy test last month. She presents to the ED at 6 AM because she has been vomiting all night and can’t sleep.

altYou are about to start your shift after a somewhat lengthy department meeting where one of the main topics discussed was utilization review with a special emphasis on cutting down the number of unnecessary advanced imaging studies. The physician champion for cutting down on unnecessary imaging had a lot of valid points.

alt“We have 6 traumas coming our way, Doc. ETA is 15 minutes. We’ve mobilized backup. The ultrasound machines are in the rooms, and the residents are gowned and ready to roll. Is there anything else you need help preparing?” You give your favorite charge nurse a thankful smile and start preparing yourself for the organized chaos that is about to ensue.

altYour next ED patient is a 47 year old male with a history of diabetes, hypertension, coronary arterial disease and CHF who presents with 2 weeks of gradually worsening leg swelling, abdominal swelling, and trouble sleeping due to orthopnea. He states that he has had the leg swelling and trouble breathing in the past from his CHF, but he has never had a “jelly belly” before. He denies any change in his medications or dietary indiscretion.

altYou find yourself working in a small - I’m talking very small - rural hospital in South America for your summer “break”. The only imaging modalities available are plain X-ray and a small portable ultrasound machine your group-of-four brought along for the trip. There is no MRI, no CT, and no formal ultrasonography. It might not help much if there were any of these however, as the are no radiologists, or any other specialists for that matter, in the hospital. It’s just you and your three friends: a general surgeon, an OB/GYN, and an orthopedist. The two local doctors who are general practitioners have taken the week off. There is, however, a much larger hospital in the nearest city, but it is over a day’s journey away.

alt“Aaahchoo! Ugh, please excuse me.” You simultaneously introduce yourself while sanitizing your hands after what feels like the 100th sneeze of the day. Most of your patients that morning have been very sympathetic to your congested and less-than-peppy state, and you’ve even received a few shameful apologies from patients who note that they shouldn’t be in the emergency department if they look and feel better than their doctor.
“My 14-year-old has Gallstones!” At least that is what the mother of this teen tells you. He’s had abdominal pain off and on for a year, and it has been getting worse. An ultrasound done at an outside institution last week revealed a “gallstone”. Despite feeling better tonight, this pushy mom wants an admission and surgery. But his history is completely negative for gallstone risk factors. Plus, he’s just not sick. Against your better instincts you do labs. And they are negative as well. He won’t be admitted, not on your shift, but you’d like to see what they are talking about.
It’s the middle of a slow weekend shift in the rural ED where you work when a 72-year-old female patient with a history of hypertension comes in complaining of pain and redness on the dorsum her left foot. 
It’s Monday night and you are thankful that you put on your running shoes. After a seemingly calm holiday weekend in the emergency department, you walk in to find every nook and cranny filled with weekend warriors who pushed the envelope just a little too far on their extra day off of work. You smile compassionately as you walk by the poor mom who broke her ankle skydiving for the first time, and quietly shake your head at the gurneys full of college students who are still sweating out alcohol through their sunburned bodies.
“Doctor, I can’t get the blood pressure cuff around her arm.” You aren’t surprised by your trauma nurse’s comment as you stare at the 450-pound woman lying on a backboard in front of you. EMS miraculously cut her out of her tiny two-door sedan with the jaws of life and dropped her off in your ED, with a 22 gauge IV in her right hand and her left leg extended in traction.

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