Faceless children throng through the doors of the Peds ER; parents, illnesses, charts all flowing into one feverish, runny-nosed amalgamation.

The waiting room is full of these kids. Anyone who didn’t have the flu before, does now. It takes 7 hours to be seen, plenty of time for snotty hands to wipe all over the tables, the chairs, the playthings.

I vaguely listen to my voice on autopilot, droning on about the benefits of motrin and tyenol for fevers. I’m surprised to hear myself lose patience with a particularly insistent mother who wants her daughter hospitalized for a fever of 101.3 and a cough. Her kid is fine. She won’t take no for an answer. We get security to escort her out.

This isn’t fun. At one point I see 8 children in a row who I diagnose with the cold. The monotony is broken by a child with a cut on his finger, but he starts screaming the second I enter the room. We have to sedate him before I can sew it up. He hates me for it, and his mom judges my repair every step of the way. I look too young, she explains. My next 5 patients all have the cold. Nothing about this is enjoyable or fulfilling.

The shift ends with a whimper, as we finally clear out the waiting room 15 minutes before I’m scheduled to leave. My last patient is a kid with a cough. I send him home with tylenol for the fevers. The parents can’t believe they waited eight hours for me to tell them that. I can’t believe they did either.

Working the pediatric ED overnight, I got called to a room for an urgent transfer. An attending physician at another institution had decided this child was beyond his scope of care, and sent the kid by ambulance to us for further workup.

The story as I got it: Previously healthy 5 year old boy with a retropharyngeal abscess so big it was starting to swell out the back of the neck. Feverish, lethargic, sick looking kid. The other doctor had started him on very hefty IV antibiotics, drawn blood cultures, loaded him with fluids, and shipped him to us as quickly as possible. This child needed ICU monitoring and surgery for the abscess.

I walked in the room and was immediately struck by how wrong the other doc was. Even to my fairly untrained eye, I could tell this “abscess out the back of his neck” was just a lymph node.

Odd, because only two diseases commonly cause enlarged lymph nodes on the back of the neck. The first is HIV (much less likely in this particular 5 year old)… and the second is mononucleosis, colloquially known as the kissing disease, requiring only lots of TLC and chicken soup.

So, instead of sending him to the PICU with urgent surgical consult like the transferring doctor wanted, I ordered only one test – a confirmation for mononucleosis. 20 minutes later it came back positive.

I was walking on a cloud for the rest of the night.

And just like that, I felt like it was my first day of internship all over again.

The patient was a middle-aged, obese, ill-appearing diabetic woman in chronic kidney failure. Thrice-weekly dialysis was all that was keeping her from spilling so much water into her lungs that she drowned in her own fluids.

I walked in the room and realized I had no idea what to do with this woman. “That damn dialysis ain’t workin’ no more, doctor.” she said, “and them fluids, they jest keep buildin’ up. Jest buildin’ on up.”

To my best exam, there was not much wrong with her except some soggy-sounding lungs, and possibly a swollen ankle from where she had sprained it a few days before. Even with her extensive medical history, I couldn’t make a good case for a heart attack or lung clot causing her breathing difficulties.

So, I sent her off for an X-ray and some basic lab work. An hour and a half later the tests came back stone cold normal – except the aforementioned soggy lungs. I called the kidney doctor who regularly dialyzes her, to see if we could get her in that night for an extra treatment. He called back 30 minutes later. I had interrupted dinner with his family.

“Well, she’s scheduled for dialysis at 6:30AM tomorrow morning. Didn’t you bother to check? Can’t she just wait until then?” He was not happy with me.

I paused. She could probably wait until morning, I thought. I apologized, and told him I’d call back after I asked my attending.

It was another 30 minutes before I got a chance. My attending, an impeccably brilliant man, asked me a few pertinent questions… and came to the conclusion that there were many plausible explanations for her progressive shortness of breath. Including a heart attack or lung clot.

Her emergency department stay ballooned into 6+ hours, what with the leg ultrasound and the cardiac lab studies tacked on after the fact. All negative, of course. She was admitted to the hospital anyway.

I suspect, in the end, that she’s right. Her dialysis “jest don’t work no more”. People aren’t meant to function without kidneys. But that horrible feeling that I made a mistake today, and overlooked something potentially life-threatening… that doesn’t sit well with me.

She’ll die soon… I wonder if she knows? Once you start failing dialysis it’s pretty much end-game, and she’s not a candidate for a kidney transplant. She just wanted me to help her. I had nothing to offer.

Frustrating patient. Frustrating workup. Frustrating day.

Sirens screaming, we ran the red light. Cars stopped, necks craning, pedestrians waving, all watching the ambulance with sirens at full blast tear through the intersection. The EMT flipped the siren switch on and off to alert that we were coming through.

The call: “Ambulance 33 to Charlie Alert, we have an 11 year old with an unknown cause for acute change in mental status”.

The two EMT’s and I, joking around at a fire station only a moment before, were now grimly trying to figure out the fastest way to the house. Sick children bring out a protective response in everyone.

Arriving on scene, a fire truck and 2 squad cars were already parked outside, lights flashing. Neighbors peeked their heads through windows, the streets eerily devoid of onlookers. Two muscular, salt-and-pepper haired firemen stood outside the door, looking decidedly nervous… incongruous for these men who looked capable of handling anything.

The girl was floppy and almost unresponsive. Eyes closed, head lolling to the side. Sternal rub barely able to wake her. The EMT looked over at me and said “honestly, doc, since I’ve got you here… do you want to handle this?”

And so, I did. Airway intact, as long as she stayed awake enough. Breath sounds equal bilaterally. Pulses good, heart rate normal. Physical exam unremarkable except for some nystagmus in her eyes. Family hysterical, wanting to know if she was going to be ok. She had just come back from a friend’s house. He’s a 13 year old in the neighborhood who was grounded last week for drinking his mom’s tequila.

And suddenly, I knew what to do.

I put my nose close to her mouth. The acetic tang of barely metabolized alcohol washed over me. I’ve seen enough drunks in the hallway beds – and smelled them – to know exactly what this was.

I pulled one of the police officers aside, and asked him to give her a breathalyzer before we left for the hospital. She blew a .16, twice the legal limit for an adult.

Smiling to myself, I asked her if the world was spinning in front of her eyes. “It’s like there’s two of you,” she responded, and then promptly threw up all over the inside of the ambulance. The EMT and I rode back with her all the way to the hospital, chuckling at her drunken ramblings.

She’s gonna have one hell of a lot of explaining to do when she sobers up.

At 4:45 AM I sat, head in my hands, trying to figure out who I needed to call first: Vascular Surgery for the bullet in my patient’s calf, Trauma Surgery for the girl who nearly sliced her thigh in two on a plate-glass window, Orthopedic Surgery for the guy with the infected tendon from the cat bite, or OB/GYN for my 40-something who was hemorrhaging out of her nether regions.

It was too much for me. Tired, confused, nervous; with far too much on my plate for an intern with 2 month’s experience at playing doctor. Decisions that are clear and simple in hindsight were insurmountable obstacles in the wee hours of the morning.

What transpired was this: I spent 30 minutes running around like a chicken with its head cut off, filling patients’ requests for pain medications while trying to decide who I needed to take care of first. I was scared. I knew none of my patients were trying to die on me, but all needed emergent care.

Surprisingly, I have never seen a “vag bleed” in the ED before. Insulated from this common complaint during medical school by well-meaning residents, I had no idea how to work her up. She was terrified that she was hemorrhaging out of her vagina. One quick look at all the blood and I was terrified too.

I’ve also never been responsible for working up a gunshot wound; fragments of the bullet were clearly present on the XRay, although fortunately for him it missed the bone. There was a lot of blood, and he was in a lot of pain.

Fearful of the unknown, I spent the next hour fretting over the gunshot and the vaginal bleed.

Knowing what I do now, I should have flipped my priorities. The vaginal bleed had stable blood pressures and heart rates, with normal hemoglobin. Urgent OB/GYN followup, but discharge home. The gunshot wound, although impressive (mo’fucka SHOT me, doc! It HURTS!) had normal neurologic and vascular exams – no major structures hit by the bullet – and also went home. The surgery to remove bullet fragments is more dangerous than keeping them in.

The thigh wound and cat bite, by contrast, both needed admission to the hospital and truly STAT treatment. The infection from the cat bite was rapidly advancing up the patient’s arm. Luckily the nurse had asked me for antibiotic orders when she first saw him… I can’t thank her enough. I shudder to think what the several hour delay in treatment could have meant otherwise.

The thigh wound, as I suspected, required a trip to the OR. However, with a large, open wound like she had, the sooner the better. She’ll be fine with plenty of operative cleaning and antibiotics, but I got a scolding from the trauma surgeon for not calling them earlier.

It’s amazing how far removed from book learning reality in the Emergency Department is. Do I have the cojones to send a dude with a bullet through the thigh home, just based on an article I read? I sure don’t. At least not until someone who has seen it 50 times says I can.

This marks 1/50 for me. Give it time.