It is a cold, blustery winter night in the ED.  You are the on-duty flight physician as well as ED physician for your particular patient care area, and you get toned out for a scene in a nearby county.  Having arrived on scene, you enter the ambulance to find a middle aged man belted to the backboard with cervical collar on, verbally and physically struggling with the paramedics who are trying to restrain him.  

By report, he was found at the bottom of a deer stand, presumably having fallen out. Initial GCS was 11 (3- 3-5) with a R parietal cephalohematoma and abrasions to his arms and  face.  

You are working an overnight shift at a Level 3 Trauma Center Emergency Department in a community hospital with most subspecialties available by telephone when EMS calls the charge nurse to report they are inbound with a new patient. As they roll through the ambulance doors, you note that the patient “looks” to be acutely ill and is immediately rolled into your resuscitation bay…

Working overnight in a busy community hospital, you’re starting to hit a mid shift wall.  There are some shifts in the ED where your job is glorious, where every patient has obvious pathology, where your interventions and treatments provide immediate relief of pain and suffering, and where the volume is steady though never overwhelming.  This is not one of those shifts.  Seemingly every patient has had a myriad of vague complaints to the point where you’re considering contacting the local health department to inform them of an exploding epidemic of “weak and dizzy” patients arriving in your ED.  Taking a breath between patients, contemplating whether or not to consume your 5th cup of coffee, you glance over to the triage desk to see 4 squads lined up.  Looking at the EMR you see all 4 of them carry the chief complaint of altered mental status…