Every patient who has spent time in an emergency department knows it’s overcrowded. They’ve sat in the waiting room for hours. They’ve watched physicians move fast and nurses move faster. They’ve heard the department through the curtain: the monitor alarms, the overhead pages, the sound of a place where everyone is doing too many things at once.
What they haven’t seen is the board.
The board is how an emergency physician experiences the department. It’s a real-time display of every patient: Who’s waiting, who’s in workup, who’s been admitted and is now boarding in a hallway because there are no inpatient beds, who arrived ten minutes ago and is about to become the sickest person in the building. On a busy overnight shift, the board looks less like a clinical tool and more like a document of a system under sustained duress. Every number on it is a person. Every person is a negotiation between what medicine can do and what medicine actually has the bandwidth to do at that hour, in that department, with those resources.
I’ve been staring at that board for over a decade. I wrote a novel about one overnight shift in part because I wanted people to see it. Not to alarm them (patients should come to the ER when they need to), but because the gap between the patient’s experience and the physician’s experience is larger than most people realize, and that gap has consequences. For patients, it looks like waiting. From where I stand, it looks like math I can’t make work.
The second reason is harder to say without sounding like I’m editorializing. American medicine is in a difficult moment. The pressures, financial and administrative and structural, have accumulated to a point where nearly every physician I know is managing some version of the same quiet crisis. The causes are complex. The fixes, if there are fixes, require political will that doesn’t currently exist.
Fiction lets you say things sideways that are difficult to say directly. A single overnight shift is a contained space: one building, one night, one physician. But it holds the whole system in miniature. The boarding patients are connected to the housing crisis, to the workforce shortage, to the insurance authorization, to the administrator who arrives at 7 a.m. and says encouraging things and changes nothing. I didn’t want to write a polemic. I wanted to write something true and let the truth do what it does.
The third reason is the simplest: I’ve always wanted to write a novel, and emergency medicine is the content I know best. Not just the procedures and the pharmacology, but the texture of it. The way a department smells at 3 a.m. The quiet that settles in around 4, before the morning surge. The conversations you have with patients in the margins of the shift, the ones that don’t fit into a chart note but that you carry home anyway.
There is a version of emergency medicine in the literature: textbooks, journal articles, the occasional memoir. It’s accurate but external. What it rarely captures is what it’s actually like to stand in a hallway at the end of a long night, knowing you’ve done everything right, and still feel like something slipped past you in the dark.
That’s what I wanted to write. Not the dramatic shift. The ordinary one. Told by someone who has been doing it long enough that ordinary and extraordinary have blurred into each other, and who is still, despite everything, showing up.
Matt Barmmer is an emergency physician.
