Life had to get easier. There had to be a day, and soon, when I could coast for a little while. I was exhausted.

Then I autocorrected to remind myself of a more effective affirmation: Today is a good day, I thought. (I breathed it in.) Today is a day of blessings and gratitude. (I breathed it out.)

I sipped my favorite coffee, Fair Trade French Roast, that I had ground fresh and hand-poured this morning, and kissed with coconut sugar and cream. Today is a lucky day. This moment is a blessing.

I folded up my half-read medical journal and headed over to the ER.

As I rounded the corner, I peeked at the tracking board. Six patients slated for admission, three patients up for discharge. One of the dedicated night physicians, Marlee, was just wrapping up her shift. She worked at the VA on a per diem basis, so we saw her only rarely. Marlee was also leaving the VA soon. (With the constant turnover of staff in the department, we were used to having colleagues come and go.)

“Hello, Marlee. How was the night?” I asked.

“Girl, same ol’ same ol’!” I never could figure out how Marlee did it. Every time I saw her after a night shift, she looked as bright-eyed and dewy and hopeful as if she’d just walked in to work. The chaos of the shift never left one hair out of place in her smooth ponytail. Her skin was still so fresh and well hydrated—presumably from the strawberry-infused water she always brought with her. She was a wonder to behold.

“You know this place really robs you of momentum,” she added. “It’s just so hard to get things done here. Four patients waiting for admission since yesterday—how is that okay? All the while, I’m here alone trying to see new patients while managing patients who are already admitted. It’s not right for anyone.”

I nodded. “I know. Always the same. We tell the powers that be,” I said, making air quotes around “powers.” “But for—”

“Nothing!” she interjected.

“Oh, Marlee.” I sighed, smiling at her. “Maybe it’ll get better soon. You know we’re supposed to get some new administrators in the hospital. Maybe they won’t abuse the staff, and folks will actually stick around. Who knows? Maybe, instead of creating fraudulent logs of hours worked to milk the system, the leaders will actually work to improve the care of veterans. We might even get enough provider coverage in the hospital . . . So maybe . . .”

Marlee gave me a sideways glance. “Michele, you keep believing! You go right ahead and keep on believing those nice thoughts!” Then she joined me in the only thing we could control: laughter.

She was right. As emergency medicine doctors, we commit ourselves to evaluating patients who come in “sick” before their root illness is known. We assess these patients to figure out if they are acutely ill, and then we determine treatment plans to address their individual needs. We do not do the work of the specialty teams who narrow their vision to one organ, we do not do the work of primary care providers who coordinate five different services to work up a tumor over the next two months and chase minor abnormalities in a patient’s lab work for weeks. We are the ones who help people right now. We determine what is critical, what has to be addressed immediately, and then we address those critical issues before we send patients either off into the world, where they can manage it themselves; or to the hospital, where others will help them manage it for a time.

That is the understanding, the agreement, the contract that we emergency medicine physicians have with the patients, the hospital, our colleagues, and ourselves. When that contract is violated, it is a painful breach. Now, in an ER with so many patients boarding, in a department with a policy that the ER staff is to care for all boarding patients so that the ER physician now adds to her workload the duties of the other specialists as well as the general medicine teams until the patients are transported from the department to their hospital beds—despite this being in violation of VA policies and procedures, despite all the studies showing that admitted patients boarding in the ER have increased adverse outcomes—that contract had been violated.

So, I fell back to my contract with myself: First, do no harm; then heal.

No new patients had come into the department yet. It was a perfect time to scroll through the list of boarding patients to make sure nothing had been missed and nothing was still due.

Ms. Craig, who had been admitted last year for chest pain and had a history of a positive cardiac catheterization, which showed evidence of significant heart disease, was due for her second blood draw for her troponin level, to look for evidence of a heart attack.

Mr. Hornsby would need his third dose of antibiotics in three hours, for his cellulitis.

Ms. Grant had been admitted for renal failure and a urinary tract infection. The ceftriaxone she received would give her twenty-four hours of antibiotic coverage. We hoped she’d get a bed within six hours, so the next dose could be ordered by her admitting team.

Mr. Khan’s blood pressure was stable after the seven doses of antihypertensive medication the last two shifts had given him.

Ms. Chen was comfortable and waiting for a bed for her lower GI bleed workup, with a plan for gastroenterology to scope her today.

Mr. Clements was waiting for a bed and workup on the source of his cancer and for pain control.

The four patients on the psychiatric side of the emergency department were all well and waiting for final disposition by the psychiatrist.

After reviewing all patient information, entering orders, and updating my patient list, I was caught up, with no new patients in the waiting room.

Nurse Sean pulled up a chair next to mine. “So, where’s the next trip?” I asked him.

Sean and I had worked together years ago, at Andrew Johnson. Although he was probably twenty years my senior, our lives seemed to parallel. Back when he was leaving his marriage to be with the woman it made sense for him to marry, and I had freshly completed my divorce from the man I thought I was supposed to marry, we were both working in administrative positions. I was new to the role, and he was a seasoned veteran. Now, several years later, we had met again, in new phases of life. I had left academic medicine and administrative work to resume the clinical work I cared most about.

Sean was Irish American, with more rust-colored hair sprouting from the V-neck of his scrub top than on his head. Thanks to his wife’s Sierra Leonean heritage, he had the distinction of being the best Irish cook of West African cuisine in all Philadelphia. He had given up his lifetime of administrative work for a per diem gig that allowed him to have the schedule of his choice, so he could travel with the woman he had anointed his “queen.” It is no exaggeration to say that every several weeks, the two were on their way somewhere: Martinique, Niagara Falls, Hawaii, Tennessee. Their life together was entirely intentional and, in that way, entirely inspiring.

“Next we go to Paris,” Sean said, leaning back in the chair, arms folded behind his head and feet propped up on a stool. Before the next five patients registered to be seen, he and I had time to catch up on their plans to visit the Louvre and his desire to see General Patton’s grave.

Ten patients and two and a half hours later, the second attending should have arrived. I looked at the board and noticed that none of my patients from the night shift had been assigned to admitting physicians. One patient was waiting to be seen by my colleague—whenever he deigned to show up for his shift. Three patients were being sent to the ER for evaluation from outpatient clinics—this despite our being “on diversion,” that is, unable to accept transfers from other facilities due to our not having the capacity to care for them. One of those outpatients had even been called in from home. Four other patients were in the waiting room about to come into the ER; and now five patients were waiting for admission. The one psychiatric patient who was to go home that morning was now sober from his alcohol intoxication, but he was confused. The nurse called me to assess him; he knew only his name but had no idea of the date, place, or situation. Reviewing his records, I could tell that this was not the baseline for this otherwise healthy middle-aged white man. I started his medical workup and then made a string of phone calls to find out when the boarding patients would get inpatient beds and teams to manage their care.

Gloria, the trusty and hardworking bed coordinator, informed me that not only were there no beds available, but there were “negative beds.”

“What do you mean by negative beds?” I asked.

“I mean the OR has a full schedule, and I have no place to put all the post-op patients, nowhere to put the ER patients waiting for admission, and there are no discharges planned. Negative beds.”

“And it’s only nine a.m.,” we said in unison.

“Awesome,” I said. “Well, Gloria, please keep me posted.”