It’s going to be one of those shifts. You just sent a 29- year-old male to the cardiac cath lab for a bona-fide ST elevation MI. Your patient with a chief complaint of “eye pain” ended up having metastatic cancer within his right orbit, and your seemingly straight-forward post-partum woman with a headache had an MR venogram showing a dural vein thrombosis.

It seems like your entire shift has been non-specific abdominal pain, peppered with a few non-cardiac chest pains and some non-organic headaches that are only relieved by Dilaudid. No one feels your pain from taking care of patients that don’t really need to be in the ED in the first place, but hey, it’s job security, right? So you suck it up and grab the next chart in the to-be-seen box. The chief complaint reads “gas pains.”

Just when your evening can’t get any worse, two of your stellar EM residents come up to you and inform you that the internal medicine team is trying to “block” yet another admission. This is the 5th attempt at refusal today. The patient in question is acidotic, thrombocytopenic, altered, and bleeding from around the PICC line that was placed while he was in the hospital last week.

You got stuck with another holiday shift. As usual it starts off slow, but eventually a bolus of patients arrives, to make up for lost time and then some. Fortunately most of your patients aren’t that sick.

“There is no such thing as a ‘black cloud’,” your colleague jokingly retorts. “We all get the same chances to make the diagnosis and to do what’s right.” You give him your best pseudo-evil-eye as you continue to recount the number of unfortunate cases you’ve seen with the residents this evening already.

It’s one of those average days in the ED where you work. It’s not too busy, but it’s not exactly what you would call slow either. Your shift has been a little bit on the boring side: lots of URIs, non-specific abdominal pain, low-risk chest pain, ankle sprains, and the occasional mild CHF or COPD flare. Also, too many people with the dreaded “multiple complaints” presentation.

“Get them out of here,” you hear your colleague next to you exclaim. “Treat ‘em and street ‘em. We need to open up some more beds.” You wrinkle your nose and wonder quietly if we’ve all become so focused on throughput that we’ve somehow lost sight of why we all signed up for this job in the first place.

“Is it a full moon out?” your charge nurse asks as she takes the 5th EMS patch in the last hour. “We have two more traumas en route, and there are 4 patients that need to be seen at the door by our triage doc. Our beds are full and the hallways are getting awfully crowded…”

“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”.

 “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.