“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 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.

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.