Patient states she was feeling fine until around 10pm when she suddenly developed abdominal pain and “bloating”. She describes the pain as generalized, but mentions that it feels more severe around the edges of her abdomen, in the suprapubic area, and at both costal margins. The upper abdominal pain is most severe in the midline and is worse when she breathes in or presses on it.

“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.

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.

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.

You 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.

You 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.

“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.