“Yeah, I’m working on it. I’m going up to the floors now to tell the docs to get people moving.”

I reached out to the ER medical director, leaving a voice mail, text, and email asking for the higher-ups to mobilize hospital beds and to continue our diversion status from transfers from other hospitals in light of this Monday morning madness. As was typical of the ER leadership in this institution, there was no answer, no return message, no help.

I asked myself: How much inpatient medicine could I safely perform while still attending to the care of the steady stream of brand-new ER patients? I knew that the new ER patients had to be seen. Could I safely leave those boarding patients to linger in the ER unattended? Even if it was safe to do so, was it ethical?

To the layperson, these may sound like silly questions, but would you expect an auto mechanic with a full schedule to stay on task with each new vehicle and at the same time help each client get directions home, coordinate vehicle pickup and child care, and schedule follow-up appointments? Of course not. Yes, these details fall under the category of “it’s not my job,” but that’s what doctors are often called to do, and it’s what makes it impossible for us to excel at what is actually our job. In emergency medicine, as in the case of the overworked mechanic, working outside one’s prescribed duties makes the work dangerous. All this, of course, doesn’t answer the most important question I was forced to answer: How many of the shortcomings of this modern health care system was I willing to put up with? Or, perhaps better, would my healing mission be better served in other ways?

So, at 9:40 a.m., with a growing backlog of patients and still no sign of the second attending physician, I wondered what to do. First, I knew, was to do no harm: My patients were all stable, with the exception of the man with the newly altered mental state. I would evaluate him first and, if necessary, order additional labs, an EKG, a head CT, and vitamins, as he was a known alcoholic and could have a vitamin deficiency that put him at risk for permanent brain damage.

Next, I would see any new patients who were waiting.

Then, to heal: I would initiate any plans I anticipated the inpatient teams would have for the boarding patients who had been waiting the longest in the ER. While adding this to my list of tasks would make my work exponentially harder, it wasn’t the patients’ fault they were still stuck in the ER.

The best way to start, I thought, was to get another cup of coffee and then dive in.

I called Cardiology to come see the patient with chest pain, and I called GI to see my GIB (gastrointestinal bleed) patient. Both services were very confused as to why they were getting a call from me, rather than the inpatient teams, and they asked if the admitting physicians could call for the consultations once the patients were on their floors, as this was standard hospital procedure. I explained that I, too, was confused by the chronic delays in patient care in the hospital, and that I was trying to expedite these patients getting care while they waited in limbo. The departments agreed to see the patients in the ER. Similar calls followed, to Neurology and the Echocardiography Lab, and the people there were similarly accommodating.

Next, I had to decide what to do with Mr. Clements. The notes from the last two attending physicians indicated that he was being admitted for pain control and a metastatic cancer workup. He had received one dose of pain medication since last night, and his vitals were normal. I had just passed his room and saw a well-dressed, slender man walking around, speaking calmly and comfortably on the phone—not the picture of a pain-control admission. A CT of his abdomen had revealed scattered swollen lymph nodes “too numerous to quantify,” as the report read.

“Dr. Harper,” Nurse Carissa called. “I just put a young guy in Room Six. He only has a psych history of some depression and anxiety, but he comes in today with fever, tachycardia in the one-thirties, infection from shooting drugs.”

Putting my phone calls and Mr. Clements on hold again, I followed Carissa directly to Room 6.

“Good morning, Mr. Spano,” I said.

He was seated on the stretcher, looking contained and anxious. I turned to the man standing at his side, who appeared to be a carbon copy of him. “Hello. Are you two related? You must be. You look exactly alike.”

“Yeah, I’m his brother.”

I turned back to the patient. “What brings you in today?”

“An infection, ma’am.”

He had long brown hair, olive skin, and the stocky build of an ex-athlete. It was clear that before the depression and before the drugs, he had been an attractive young man. He was only twenty-nine, but with the pallid skin of a man thirty years his senior.

He grimaced as he bent his right leg, pointing to a sausage-like calf with puffy, flaking black skin that looked like charcoal. As he looked at his leg, tears rolled down his cheeks, and he wept out loud.

“How did this happen?” I asked him.

“Ma’am, I’m not gonna lie. I shot up crack. There might have been some heroin in there, too. I don’t know.”

“Hmmm,” I said, nodding as his shoulders shook under his sobs. “This is a very serious infection. We’ll need to—”

“What? What do you mean? Why do you say that?” he yelled.

“Well, you have a fever and—”

“A fever?” he interrupted again, his face twisting in agony. He covered his mouth as he whimpered and shook his head. “I didn’t have a fever before!”

I recoiled from him. It might have been the volume of his exclamations or maybe the drama unfolding before me that caused me to cringe.

“As I was saying, you have a fever here, and your heart rate is very fast. Those two things tell us your infection is significant. Do you have pain?”

“Pain? I have tremendous pain—one hundred out of ten!”

“Okay, what we’ll need to do is check your blood, get X-rays, and give you antibiotics and IV fluid. I’ll also give you medicine for fever and pain while we sort everything out. Because your infection looks quite serious, I’ll need to speak to a surgeon, in case you need an operation to fix this. No matter what, I’ll have to keep you in the hospital, because you’ll need to be continued on intravenous antibiotics for a couple of days or so.”

“Oh, no!” he shrieked, in a voice much higher than one might guess his two-hundred-pound frame would be able to produce. “Am I going to die from this? Could I die from this?”

I spoke slowly, my voice soft, my tone deliberate, as I tried to tamp down his frenzy and instill clear boundaries. “It’s too early to say. You have a very serious infection. People can die from infections like this. Most people with this are fine as long as we do everything to treat it well. That’s what we’re doing here today.”

“Pull it together, dude!” his brother interrupted, sounding intoxicated. He had a beard as scruffy as his voice and wore a black T-shirt that rolled over a loose stomach and soft silver athletic shorts.

His brother’s words only seemed to add fuel to the fire of agony in Mr. Spano, who now began to weep inconsolably. “Oh my God,” he whimpered, burying his face in his hands.

Carissa and I looked at each other and tried not to raise our eyebrows. His reactions were so far out of proportion to what was going on. Patients who are struck by cars or who receive new diagnoses of cancer demonstrate more composure than this young man was showing. Sure, he was ill, but the odds were that he would rapidly improve after a couple of days of intravenous antibiotics before switching over to antibiotic pills.

Carissa placed an IV in him and drew blood. I completed my physical exam. He was awake and alert throughout—no lethargy. His heart sounds were fast but regular, with no murmur. It seemed that his drug use hadn’t damaged his heart. He had no rash. Good blood flow to his skin. His right leg was normal down to the shin. The area between the knee and the ankle was swollen but soft. While the leg was markedly swollen, red, and warm to the touch, his tenderness was greater than his physical exam suggested. When I pressed the tissue of his calf, I didn’t feel the crackling that would have indicated necrotizing fasciitis, what the media had taken to calling “flesh-eating bacteria.” The inner aspect of his calf had a necrotic abscess about the size of a silver dollar, though. I couldn’t feel a collection of pus anywhere else, and yet, given the extent of his pain, and the swelling and tachycardia, I couldn’t be sure there wasn’t a deeper area of abscess or gas formation in the leg.

I explained to the patient and his brother that I was leaving the room to enter all his orders and call the surgeon. I informed them that this was time sensitive, so we needed to start his treatment quickly, but first I looked the patient squarely in the eye.

“Do you have any questions before I go?”