Chaos. Hypomania. I can't hear myself think.

3pm shift. Wednesday afternoon. Rainy day.

Arrived at the ER in a scene of surprising calmness. It's been so chaotic lately. Numbers have been record high for weeks. Seeing the tracker down to only a few people waiting was a treat to start my shift. Even had time to catch up on some paper work. Chatted with some colleagues.

Feast or famine. That's the nature of this work. Mostly feast though. Not the enjoyable type.

The bus arrived. That's the term that we use. Patients must know something. They always arrive in bunches. Not they are not all related. There is no plausible reason for this finding. But they come, in bunches, and all of a sudden you are flooded with long waits. It's still only just one of you though. Patients don't seem to get that. They all arrive at once. But you still have to see them one by one.

Red phone ring. That's the phone that rings when the paramedics notify me something big is on its way. 75-year-old male, cardiac arrest, they are working on him at the scene, ETA 8 minutes.

I looked at the tracker. I might have time to get two other patients' assessment on its way. One is an elderly with confusion from a suspected urinary tract infection. I can order a bunch of labs for and "eyeball her". The other, a man sent by by his doctor for chest pain. He looks okay. Let me talk to him. I told him I can be pulled away any minute, but let's get started right away. Focused questions and exam, targeted investigations. Ordered. He looked fine. Put him on the monitor. Promised I'll be back once labs are back.

Went back to see confused granny. Finished my assessment. 8 minute is up. Cardiac arrest guy at the door. Paramedics doing CPR at the doorway. CTAS 1 called overhead. Get gloves. Rushed over.

Trauma bay. Airway somewhat protected, will do for now. Continue CPR. Let's get pads on. Get the 5-second story. Mobilized all the forces. I have already told them my plan and what I would need when I took that initial phone call. So everybody knew their roles. Everybody on task.

Code status. I need to know how far we are going with this case. Send someone to hunt down the history. Let's focus on running the show. Control the room. Too many noises around. Quiet everyone. Only my voice for now please. Step one this. Step two that. Keep it simple. Get on with it.

Colleague did the intubation. Done. Airway secure. Pulses returned. Great. Let's get moving on more access. Lined him. Phone call to daughter. Difficult phone call, always is. She's crying on the other end. Here's what we know, I told her, Dad is alive, but he's not doing well. Do you want us to continue? What would Dad have wanted? Who is family? Yes please come in. Come in now.

Stabilized. But prognosis not good. On life support, but for the time being nothing more to be done. Moving on to further management. Internal Medicine consultant at bedside. Pass the torch. I'll stay involved, I told her, but I gotta see more patients now. It's flooded outside.

Back to the ER. Five charts already stacked, waiting to be seen. 68-year-old man, can't breathe. Nurses say can you see him now please. Fine, let's go. Red phone ring again. 65-year-old male, intentional overdose in a suicide attempt, at least five drugs involved possible more, don't know what. Guy is drowsy. Five minutes away. Fine. Let's finish of those shortness of breath guy first. Hi Sir, I'm Dr. Tang, what can I do for you today...?

Overdose man shows up. Nurses want me to go see him quick. I'm sorry, Sir, but I'll be right back. See overdose man. Luckily don't need to intubate. Quickly got the story. Surveyed the suspected pill bottles. Okay, nothing that dangerous, just need to watch him. Ordered tests. Promised to be back.

More ambulances show up. Three more stretcher patients now waiting in the triage area. I still have to finish my assessment on the man who can't breathe. Next up, a young girl threatening to kill herself. She's safe right now, but needs some talking to. Let's go, let's have a chat to see what we can do for you.

Nurses stopped me. Can I please order some pain medicine for this other lady who's in pain. Who is it? Oh I haven't seen her yet. But sounds like kidney stones. Let's do this, please order that. Tell her I'll see her as soon as I'm done here. Got it. Took the name down. Added that to the list.

Nurse handed me another chart. A guy who just had a seizure. Is this new or has he had this before? Nurses checked the chart. Ah, history of seizure, likely didn't take his medications. He's okay now. Great, let me seem him after these other patients. Keep an eye on him please?

Handed me a ECG and some lab results for overdose guy. Oh right that guy. Looks safe. Keep him on the monitor. Let me revisit when all the numbers come back.

The guy with the chest pain. All his tests are now back, normal. Let's go re-assess. Had a good discussion. Low risk case, felt safe to discharge. Discussed plan. Ok done.

Oh right, the girl who had thoughts of suicide. Let's sit down and have a talk about this. Isolate from the chaos outside. Let's take a brief moment here and explore.

Nurses wanted me to re-assess the elderly lady with confusion and now confirmed urinary tract infection. Ah right, almost forgot about her. Let's talk to her and her daughter about the plan.

By now I am very much behind, because another bus load of patients have arrived. Quickly looked at the tracker. Seems most patients are doing okay. They can wait. Let's wrap up some of these cases first. We won't have beds to see new patients otherwise anyway.

Looked at the clock, gosh when is the next doc on this side going to show up. I need help. The other part of the emerg is also swamped. Sigh. Let's just keep going here.

People often wonder what my day is like. No we are not like the ones on TV, who seems to have endless moments to chatter and gossip. My mind is constantly being pulled in all directions, many of which requires much concentration and deliberate decision making, often without the luxury of time or solid information. In the past, I have found that if I waiver on a decision, or I sit on it for too long, then I can't keep up. Decisions must be swift, but cautious. And I have learned to maximize my efficiency, by prioritizing which tasks to do first because they may take longer, and how to keep all possible doors open such that if I change direction in my approach, I do not have to restart from step one. On days like this I often feel very hypomanic, very on edge. There are reasons I don't eat and drink much when I'm on shift. Part of it is time, but the other part is that I just don't have the stomach for it when I'm stressed. It's no wonder that after my shifts, I'm usually quite physically and mentally drained. But at the end of each tough shift, when I look at my list and realized how much I have done, I feel a sense of pride that I cannot get had it not been that tough. It's a challenging field for sure, but it's also highly rewarding. And the ER is truly an arena where you can do so much, have so much tools and resources at your disposal, and make some of the biggest difference anyone can ever make to anyone else and their families.

On days when you feel all your cylinders are clicking, it's a good feeling, and it's part of why we keep doing this job.