The Last Hour

An immaculate conception, a missing inpatient in the bushes, misplaced bloodwork, and a STEMI—inside sixty minutes of emergency medicine.

In the final hour of my shift, I dealt with an immaculate conception, a missing inpatient found hypothermic in the bushes, someone else’s bloodwork in the wrong chart, and a massive heart attack.

Let me explain.

This was not a regular emergency department shift. I was working triage—an initiative many hospitals have adopted to get patients “seen faster.”

The idea is simple enough: place a physician alongside the triage nurses. Instead of waiting six, eight, or sometimes twelve hours to be assessed in a treatment space, patients get rapid orders at triage. Bloodwork. Imaging. Pain medication. Fluids. The hope is that by the time a stretcher opens up, part of the workup is already done.

In theory, it improves flow.

In reality, it means seeing a hundred or more patients in rapid succession, often without privacy, without examination, and without asking any questions. You don’t truly own any patient. You are trying to make good decisions with incomplete information.

You are perpetually interrupted—ECGs, requests for pain orders, returning results, and the constant stream of incoming patients to triage.

I was entering the final stretch. The last hour.

I listened to the nurse triage a patient with abdominal pain. She looked uncomfortable but not critically ill. I ordered analgesia, fluids, and routine bloodwork.

Then the pregnancy test came back unexpectedly positive.

Some of her other labs were critically abnormal.

When I went back to discuss with her, she was adamant.

Impossible.

Unless this was immaculate conception, she said, there was absolutely no way she could be pregnant.

Fair enough.

Medicine occasionally surprises us, but when a patient’s that certain, you pause.

I repeated the bloodwork.

At almost the exact same moment, a man burst into triage yelling for help.

He had found someone outside.

“In the bushes.”

I followed him with one of the triage nurses.

In a small, forested area on hospital property sat a confused elderly male.

Soaking wet.

Disoriented.

Hypothermic.

Barely responsive.

We pulled him out of the bushes and wheeled him back into the emergency department. While evaluating him and sorting out what had happened, we discovered he was actually an admitted inpatient who had somehow gone missing for hours.

Meanwhile, patients kept arriving.

And I was falling behind. Orders weren’t being entered.

Even while trying to manage an emergency outside the department, there is an invisible clock ticking.

Metrics.

They track how many patients receive orders in triage. Miss too many and someone notices.

Efficiency is measured. Performance is monitored.

The influx never stops.

I checked back on the repeat bloodwork.

Negative pregnancy test.

Some of the previous abnormal values had normalized.

Which raised a much worse question.

Whose bloodwork had I been looking at?

Had somebody else’s critical abnormalities ended up in the wrong chart?

In a department packed with hundreds of patients, was there someone sick with seemingly normal labs?

A dangerous jigsaw puzzle.

One that needed urgent investigation.

But that problem would have to wait.

Because a nurse handed me an ECG showing a massive heart attack.

One glance.

STEMI.

I looked up immediately.

“Where is this patient?”

Everything else paused.

Again.

Nothing else mattered in that moment except getting that patient to the Cath lab.

Immediately.

Most of the stress is not the medicine.

It is cognitive overload.

Competing priorities.

Trying to make good decisions while knowing something important may still be unfolding somewhere you cannot see.

One problem down.

Another immediately in front of you.

It was the last hour.

But I swear it aged me.

ROSC.blog