n response, Darrin flexed his biceps, delivering four gorilla thumps to his chest. This provoked giggles from two medical students at the table, but Steinberg and his three interns smiled politely and awaited his answer. Darrin concentrated on supper.

One intern broke the silence. “I was on 28A when they admitted this man at two a.m. Abdominal pain and a mass. The ER resident says it might be nothing, but he needs an evaluation. I walk into the room. Patient gives a huge fart. No more abdominal mass. He feels fine.” Snickers from the students but no one else. “But he’s officially admitted. You can’t send him home. I had to do a workup and writeup and discuss him on rounds.”

Darrin clucked sympathetically. Darrin was beginning his first shift as emergency room resident. Covering all of Medicine that night, Steinberg and his interns were performing the ritual “browbeating of the ER resident.” While done in good humor there was a deadly serious purpose.

At night most of the staff went home. The clinics closed. No one came into the hospital except through the emergency room. Steinberg and his interns were responsible for their ward plus three others. If too many patients had problems, it would be a bad night, but this was beyond anyone’s control. Too many admissions also made for a bad night. To a certain extent, this was also beyond control. But a great deal depended on the ER resident’s judgement. Some patients were sick enough for admission except... maybe...they weren’t. Maybe one could treat them at home for a few days, then reconsider. Some patients needed admission, but no harm would come if they returned the following day when everyone was working. Some patients were seriously ill, but could be handled in the clinics. Some were crocks. Nothing shamed a resident more than letting a crock slip through.

Steinberg had served as ER resident and would do so again. For now, however, he was doing his duty as ward resident: ensuring that the ER doctor thought twice before admitting to the cruelly overburdened ward.

“We have three late admissions from clinic, one in liver failure. The interns haven’t even begun the workup. Colby went home leaving two admissions with nothing in the chart. So we’ll have to do them.” Colby was a phenomenally lazy intern from another ward. Darrin shook his head compassionately and continued eating. “Tony has a G.I. bleeder that won’t quit. He’ll be up with him the whole night. We have four patients in the ICU, all in bad shape.”

“Things pretty busy up there, are they?” A cool, Midwestern drawl was his best defense against big-city intensity.

“A couple admissions could kill us. Could you hold them off? Send them to clinic? Have them come back in the morning?”

“Do my best. If they need to be admitted, I admit them. If they don’t, I don’t.”

The conversation turned to other matters. Darrin felt he had handled himself well. Some residents became snappish at the pressure, but this was unnecessary. The ER resident had all the power. Or at least all the material power. The worst sin during medical training is not incompetence but dumping work on your colleagues. Everyone has too much work. Most give in to the temptation to dump now and then. Those who do it regularly become unpopular. Colby was unpopular, but he had a very thick skin.

“Are you a rock or a sieve?” was a traditional question, delivered in a joking manner but with a clear meaning. A rock barred the hospital to all comers. A sieve....

All this seemed necessary because the ER resident’s job was so easy. Physically it was hard; the resident might work nonstop until the small hours. But it was easy where it counted. If a hospitalized patient presented a difficult problem, the doctor had to deal with it. Not so in the ER If someone was seriously ill, the resident had two choices: (1) admit the patient who then became someone else’s responsibility or (2) send him out with medicine or a clinic appointment. In this case, the resident was not off the hook. Would the patient keep the appointment? Would he stagger back to the ER the following day at death’s door? Would the entire world shake its head, wondering why the resident missed such an obvious admission? It was risky to send out doubtful patients. Admitting them was one hundred percent safe.

Or was it? Faced with this frightening possibility, the ward staff rushed to point out the painful consequences of admitting borderline patients. One burdened one’s comrades. It showed lack of balls. Or brains. A few inappropriate admissions were tolerable. No one was perfect. But no resident wanted to be accused of too many. As the only resident who had not interned at the hospital,

Darrin knew he was a still greater source of worry. That he had served at a pleasant hospital in a middle-class area of Des Moines lost him more points. The place had no reputation at all. He had chosen it after getting married in his fourth year of medical school. His wife already had a small child, was soon pregnant with his, and lived two blocks from the hospital. Setting up a household elsewhere was out of the question.

As it turned out, the hospital was pitifully grateful at acquiring an intern who was not only American but had done well in medical school. Local doctors knew his wife, so they treated him with more consideration than fellow trainees, and he learned a lot. Moving to a high-powered big-city hospital held no terrors. He was smart. He didn’t mind work. Only his colleagues took getting used to. They oozed intensity. Even when they were funny--and half seemed natural comedians--fierce competitiveness lay behind it. Almost everyone was so. . .Jewish. Growing up in a small town, the only Jews he had encountered appeared on television. Now they were everywhere. In fact, they made up only half the staff, but Darrin couldn’t pick out the genuine ones.

Not designed as such, the ER was a large room with six curtained alcoves at one end and a nurse’s station at the other. Patients waited in a room down the hall.

Even emergencies paused for dinner, so traffic was slow till after seven. By half past there was a steady stream that could not slacken until midnight. Almost immediately a lady with gallstones needed admission. But she went to surgery, not medicine--a different ball game. Surgeons loved doing surgery and snatched up any admission where this was even a remote possibility.

At eight a man arrived with a bleeding ulcer. Steinberg made no objection when Darrin phoned to announce the admission. At 8:30 an ambulance quietly disgorged a very old lady. Although she did not appear distressed, this in itself was a bad sign. Her arms and legs were permanently bent. Turning her over, he saw the usual hideous bedsores. This was a nursing home dump. The result of neglect, her contractures and sores were beyond help, but she couldn’t be sent back. Feeble as she was, she might linger for months, bedridden, incontinent, suffering one infection after another. Although not Darrin’s fault, the arrival of such a patient always put the ward in a foul mood.

Within half an hour he saw a confused alcoholic with a high fever and headache. While meningitis was the obvious diagnosis, Darrin hesitated to take a chance so soon after sending up the nursing home dump. Despite the nurse’s grumble that patients were waiting, he did a spinal tap. It was meningitis. Steinberg not only accepted the admission with good grace but thanked him for helping out with the tap.

Soon after, he lost points by admitting a diabetic with a foot infection and an alcoholic with pneumonia, the fourth and fifth within two hours. Steinberg sounded depressed.

Like any ER resident who feels he is burdening his comrades, Darrin tightened his standards. An old smoker with a bad cough got antibiotics and a clinic appointment. It was a close call; the man was wheezing but not enough to tip the balance. Afterwards, Darrin tried unsuccessfully to feel virtuous. If told, Steinberg or the interns would not thank him. If the man didn’t need admission, it was Darrin’s job not to admit him. He felt uneasy. Not admitting patients avoided flack but left the responsibility on his shoulders. Surely he had not sent the man away as a favor to his colleagues. He was not that sort of doctor.

Still feeling guilty, he examined another man with a bad cough and decided he was in heart failure. Steinberg accepted him without comment plus two very sick admissions that came in during the next hour.

At midnight the cafeteria served coffee and leftovers. Darrin joined Steinberg and one of the interns. The intern glared sullenly, but Steinberg seemed philosophical.

“Looks like an all-nighter. Bleeders on 5A. Sepsis in the ICU. Two arrests so far. We barely looked at your admissions.” Darrin made a sympathetic noise.

“That fellow in failure: an inappropriate admission. Diuretics would have cleared him up.”

“Nope. He needed to come in.”

“I asked the cardiology fellow to take a look. He agreed.” Darrin tried to feel sympathy for Steinberg and his overworked crew. Later he would be a ward resident, at the mercy of whatever the emergency room sent up. Nights on call were often rough. The ER resident had only a marginal influence over this. Why make him feel bad? It seemed so unfriendly. Returning from his midnight snack, Darrin admitted a young man in the last throes of AIDS, an out-of-control diabetic, and an old man dying of cancer.

“This is the worst night of my life,” Steinberg said wearily after the third call. “I’ll never hear your voice over the phone without feeling nauseated.”

Ten minutes later Darrin’s heart sank at the sight of a young man doubled over in pain. His exam and the X-ray were benign. The resident from surgery looked and declined; not a surgical abdomen. But was it a medical abdomen? The man had a crazy look, and the chart showed several psychiatric admissions. Darrin summoned the psychiatric resident.

“We all know Charlie. Looks like he’s having another break,” said the resident after talking with him.

“So he’s a psych admission?”

“Except for his bellyache.”

Darrin gnashed his teeth.

“We can’t handle medical problems on psychiatry. You fellows figure it out. Then give us a call, and we’ll take him.” What would you expect, Darrin muttered. Doctors go into psychiatry so they won’t have to practice medicine or admit patients at one a.m.

Darrin admitted four during the next two hours. At three a.m. the nurse called him to the phone. One of the interns wanted a word.

“I just saw Charlie Blalock. Why did you admit him to medicine?”

“Psych won’t take him. He has abdominal pain.”

“He doesn’t.”

“He did down here.”

“He’s a fucking schizophrenic! He thinks aliens are eating his insides. Now he’s hollering and keeping the ward awake. I have four sick patients to work up. I’m reporting you to the chief of medicine tomorrow. You should never be in the ER. You’re not competent. You admit anyone...” More of the same quickly turned to obscene invective. Darrin hung up. The outburst itself was forgivable. Overworked interns sometimes cracked in the wee hours. They soon recovered; by morning it would be forgotten. But he was shaken because the intern had a case. Charlie was a bona fide inappropriate admission--and at a very bad time.

Now what should he do with his current patient? After three adrenaline injections plus inhalation therapy, she was breathing easier but not by much. A regular visitor to the ER, her asthma was genuine and had almost killed her more than once. It was time to think about admission. That would mean phoning Steinberg, now busy soothing a hysterical intern.

“Would you bring some aminophylline? I’m starting a drip.”

The nurse nodded. “Is she going to the ICU or the ward?”

“Neither. I want to see how she does down here.” The aminophylline might take hours to work, but if it succeeded the lady could go home.

A derelict lay trembling in the next alcove. “Possible D.T.’s” is a legitimate admission. But maybe it wasn’t D.T.’s. Darrin asked the nurse to start an I.V. and give a large dose of Valium.

“We can’t handle D.T.’s in the emergency room.” “He may just have the shakes. Let’s see how he does on the Valium.”

“Doctor, we can’t hold patients in Emergency. We don’t have the room. We don’t have the staff. Patients are waiting.”

“We won’t keep him long. Give the Valium.”

Fortunately patients weren’t waiting. Traffic had dwindled. Half an hour passed before the next arrival, a confused young man with a 105 fever. He looked ill, but a bad case of flu can do that. Perhaps he was dehydrated from the fever. Darrin decided to give fluid and observe him.

“I’m the only nurse! I can’t watch these patients and handle their IVs and take care of my other work. You have to send them home or admit them!”

“I apologize, but this is a special situation. I’ll watch them. I’ll take care of the IVs.”

Even on a busy night, the ER resident got to bed by four a.m. Five a.m. saw Darrin keeping a bleary vigil over his three patients. They seemed no worse, maybe a little better. A fourth arrived, having vomited for several days. While she looked bad and probably needed admission, Darrin had seen cases recover after a few liters of fluid. Bypassing the nurse, fuming at her desk across the room, he fetched a bag and started the I.V. himself.

An hour later, dawn lit the windows; the terrible night was ending. He knew Steinberg and the interns were feeling the same weary exhilaration. Even the patients seemed to perk up. The asthmatic wheezed more softly. The young man’s fever had fallen to 103, and he was almost rational. The alcoholic twitched less intensely. By shift’s end at eight Darrin hoped to discharge two or three, admitting the others to fresh interns just arriving.

Distracted by the struggle to keep awake, he noticed a figure at the nurse’s desk, too well-dressed for a patient. It was too early for his replacement. When the man turned, Darrin recognized the chief resident, who often arrived before seven. He was probably checking admissions and getting an earful from the nurse.

“The summer doldrums have ended,” proclaimed the chief cheer-fully, bearing down on Darrin. “Pretty busy last night?” Darrin shrugged modestly.

“We broke our record on admissions. I’ve just come from the ward. They’re still working on some that came in at midnight.” Darrin suppressed a surge of paranoia.

“What’s all this?” asked the chief, indicating the occupied stretchers. “Did they just arrive?”

“Not exactly.”

“Tell me about them.”

The chief listened in silence. At the end he shook his head quizzically. “What are you trying to do, Darrin? These are admissions. Admit ‘em.”

“I may do that before I get off. A couple can go home.”

“No, no, no, no, no!” The chief threw a fatherly arm around Darrin’s shoulder, guiding him toward the nurse’s desk. “We don’t save patients for the day shift.”

“The new interns will be fresh.”

“And the old interns hate your guts. Are you aware of that?”

He did not pause for an answer. “Of course you are. Being an extremely nice fellow, you didn’t harden your heart.”

“I didn’t take it personally. They’re swamped.”

“Big fucking deal! And I don’t believe you. Interns get swamped now and then. And they bitch and moan. You can sympathize, but don’t try to make things easier.”

“Why not? Give me a few hours with these patients, and they’ll be fine.”

“Or maybe they won’t. This isn’t Bangladesh. You don’t have to practice half-assed medicine. If the guys are swamped, they’re swamped. They’ll catch up.”

“What’s wrong with giving some to the day shift?”

“It looks bad to delay admissions. Also it screws up the lines of hate. The staff coming on won’t blame you. They’ll assume Steinberg pulled some trick.” He jolted Darrin with a jovial slap on the back. “And, of course, they’d be right! Let’s admit ‘em.”

He picked up the phone and dialed. One hour before going off duty, Steinberg’s ward would receive four admissions. Thank God, the chief resident was breaking the news.