The popularity of the television show ER might give some idea of the responsibility shouldered by an ER physician, but I doubt that it can adequately convey the pressure an ER doctor faces while working in a busy emergency room. For example, it is not at all uncommon for several patients to arrive almost simultaneously in the ER, virtually on their deathbeds. Each of these people might require extensive interventions — like CPR, cardiac pacing, central venous line placement, and lumbar puncture — in addition to requiring intensive medical therapy. As the physician runs from patient to patient, he is often besieged by requests from nurses, ER assistants, residents, medical students, radiology technicians, patients, relatives of patients, paramedics, police officers, respiratory technicians, other physicians, hospital supervisors, and local TV stations and newspapers. Let’s step into the ER for a few minutes . . .

Nurse A shoves an EKG in my face, saying, "It's from the new guy they just brought in room 8; he's short of breath." The nurse scurries away, and I find that there is no chart for this patient. (Since that hospital had a policy against nurses taking verbal orders, it was incumbent upon me to assemble a chart so that I could begin writing orders on the patient. Great, I get to be a ward clerk, too.) Nurse B says, "The lady in room 12 is seizing, and we can't get an IV in her; the IV team tried, and they said that you'd have to do it." Nurse C demands, "When are we going to do the pelvic exam in room 10? The patient says she's tired of waiting." Nurse D informs me that the intoxicated, suicidal female patient in the Isolation Room walked out of the hospital three minutes ago. I requested the assistance of the hospital guard, and this insolent character had the temerity to refuse, saying, "Why don't you go get her?" Nurse E tells me that the family of the patient in room 7 is demanding to see me now. The clerk announces, "Dr. M. wants to speak with you on line 1, and Dr. V. is on line 3; he's mad because he's been on hold."

Another person announces on the PA system, "Dr. Pezzi to the radio room stat!" (to give orders on a critical patient coming in by ambulance). The respiratory technician tells me, "I couldn't draw his ABG (arterial blood gas). Do you want to try?" The radiology technician wants me to look at a cervical (neck) x-ray of a trauma patient who is clamoring to get out of his neck brace and off the backboard. The Internal Medicine resident approaches me, asking me to discharge a patient from the ER who was seen by the prior ER doctor and referred to the Internal Medicine service for admission. That's a tough position to be in, as the chart dictated by the first ER doctor will undoubtedly stress the need for the admission (to palliate the Utilization Review Committee). If I discharge the patient, and the patient has an adverse outcome, I am a sitting duck for a malpractice attorney.

An ER staff member tells me that I should go examine the police prisoner in room 2 so that the guy can be discharged back to the prison; the patient realizes that it is more pleasant to be in a hospital than in jail, so he decides that he's having chest pain and screams, "And I'll sue you if you don't admit me!" The patient in room 4 leers at me whenever I walk by, eventually yelling out, "Hey, Doc, I've been havin' this belly pain for three years. I want you to see me next!" The hospital public relations person is waiting to talk to me about three patients brought in with carbon monoxide poisoning; he tells me that Channel 12 wants to interview me "when I get a minute." A psychiatric patient follows me around like a little puppy, saying, "I'm depressed. I'm suicidal. Admit me." I discussed this with the on-call psychiatrist, and he refused to admit the patient. He declared, "That person is just a junkie!" The mother of the patient in room 6 screams at me, "My child is vomiting!!!"

Imagine 15 minutes of this, with ten hours to go until the shift is over. In reality, the scenario that I just depicted was even worse than how it was presented. For purposes of clarity, I relayed the dialogue from the first four nurses as if it occurred sequentially. Actually, those four nurses approached me at the same time and all four spoke simultaneously. After that, they darted away in unison, apparently complacent in their perfunctory discharge of their duty. I immediately implored, "Wait! I cannot understand what you’re saying when four people are speaking at the same time. You’ll have to repeat your messages one at a time."

Ever try to run three codes at once? I have, and you don't know what pressure is until you have. It's commonly accepted that a human cannot be in more than one place at a time, but ER physicians are expected to be immune to this limitation. If all patients who are being coded — and every other patient in the ER — are not treated as if they were the only person in the ER at that time, the doctor faces the very real possibility of a lawsuit. Realistically, ER physicians can be flooded with more patients at one time than they can optimally care for, but this fact is legally irrelevant, and cannot be used in their defense.

Imagine that you're a cashier in a supermarket, and a dozen customers with overflowing grocery carts come into your line, in addition to the ones who were already there. Imagine that you could be personally sued (losing your home, your car, money for your children's education and Christmas presents, and future wages) if you didn't check everyone out as fast and as flawlessly as you usually do. No, you can't simply make them stand in line and wait their turn. The analogy to ER is that some patients cannot wait; a patient who isn't breathing can't be scheduled for an appointment next Tuesday.

Imagine that one of the customers in your line, Mrs. Jones, has two carts full of groceries, a handful of coupons, and she must be checked out within the next four minutes — or else she can sue you, and she'll win. You'd love to accommodate her, but Mr. Smith and Mrs. Clinton are demanding the same thing, too. How would you feel if you were in this predicament? If you think it is so impossible that no one would ever be expected to deal with it, you're wrong. This is exactly the predicament which ER doctors find themselves enmeshed in every time the ER is swamped with critically ill patients — and that is not an uncommon event in an ER. If cashiers were subject to such potential liability, anyone who became a cashier would have rocks in her head. I feel the same about people who go into ER medicine.

To make matters worse, the efficiency of the ER is often impeded by a number of factors. Although I could fill a book with these snafus, I will mention only a few of them.

A couple of the hospitals at which I worked had trouble with their phone systems. Once, the phones were totally inoperable, but the hospital had a backup plan:  they allowed me to use the cellular phone in someone’s pickup truck in the parking lot. Consistent with Murphy’s Law, it was raining cats and dogs that night. Outgoing calls were a pain, but incoming calls were even worse since they’d often occur during the middle of a procedure. Another hospital spent one million dollars (hard to fathom, but it’s true) to upgrade their phone system, but the new system was a disaster. The volume of the handset was so low that I could barely discern what the caller was saying even when the ER was quiet — which it usually was not. I’d sometimes have to ask the caller to repeat himself so many times that it would have been comical had people’s lives not been at stake.

That latter hospital seemed to believe there was no task which could not be made more difficult by the implementation of ill-conceived technology. Rather than allowing us to read x-rays directly, they scanned them in the radiology department and we read them in the ER by viewing the x-rays on a monitor. Or, more precisely, we tried to read them. The problem arose because of inherent degradation in the resolution of the image imposed by limitations of the scanner and the monitor. As a consequence, subtle findings—which are often crucial—would be blurry. I could usually obtain the original x-rays, but that would require me to issue a request for them, then keep checking to see if they had arrived. On busy days, this was more than an annoyance, since anything which wasted my time limited the time I could devote to patients.

At another hospital, a couple of the consultants I’d often have to call at home were difficult to converse with, since one was invariably drunk and the other, from the background sounds, was evidently having sex with a 14-year-old girl. Must have been good stuff, because he’d ask me to "hold on for a minute" and then I’d hear them going at it. A minute or so later, he’d pick up the phone again, panting as the jailbait begged him, "Don’t stop now!" He would put his hand over the receiver of the phone, and I’d hear muffled voices and giggling. Then he’d pop back on the phone, "Sorry about that, Pezzi. Can you repeat the case again?"

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