When the ER Is the Only Door Left Open
Why emergency physicians are walking away—and what happens to the public when we do
Update: He Called Me an Asshole. Then He Found 400cc of Pus.
After I published this, someone asked what happened with that patient — the one I wrote about near the end. The one with scrotal cellulitis and a perineal abscess who clearly needed source control.
Here’s what happened:
The urologist who refused to come in that night — the one who called me an asshole — finally took the patient to the OR the next morning.
This is what his own operative report says:
“There was approximately 400 cc of purulent foul-smelling discharge… necrotic tissue was sent away for tissue culture… cellulitis at the base of the scrotum… wound left open and dressed with 2 ABD pads.”
That’s four hundred cubic centimeters of pus. Nearly half a liter.
Necrotic. Deep. Involving the perineum and scrotum.
The kind of infection that kills people.
I was right. He was wrong. Spectacularly wrong.
Not just in clinical judgment — in how he spoke to me.
In how he dismissed my concern.
In how quickly he weaponized hierarchy to shut me down.
This wasn’t a “misunderstanding.”
This was arrogance that nearly delayed critical care.
And this is what emergency doctors deal with every day.
We advocate. We push.
We get called assholes for being right.
And we keep going. Because the ER is the only door left.
And if we don’t hold that line, no one else will.
But don’t get this twisted. This isn’t about me. It’s about you.
When this kind of thing happens — and it happens far too often — it’s patients who suffer.
Patients who don’t get admitted.
Patients who sit in the ER for hours because a specialist decided their ego mattered more than doing their job.
The patient upstairs doesn’t get their bed. The patient on the gurney doesn’t get their room. The person in the waiting room stays in pain for another hour.
So the next time you’re in an overcrowded emergency department, waiting to be seen — remember this:
There are a lot of reasons for delay.
One of them is doctors like this guy — putting themselves before you.
Even though they agreed to do the job.
If you want to know where the healthcare system ends, look at the emergency department. Nights. Weekends. Holidays. Whenever the rest of the system shuts down, we stay open. We see everyone. And I mean everyone: the neglected, the unstable, the undiagnosed, the dying, the abandoned. Our doors don’t close—not because of some noble creed, but because we’re the only ones left with keys.
But we’re breaking. Not from the hours. From the betrayal.
Last week, I had two surgical consultations go sideways because I asked specialists to do their jobs. Both involved complex perineal abscesses that were beyond my scope. In one case, radiology recommended an MRI to assess for a potential fistula. In the other, a urologist openly refused to come in and got hostile when I stood firm. He said, “What’s your name?” I told him. Then I asked for his, and he called me an asshole. Apparently, saying no to doing a procedure outside my scope of practice is now a provocation.
Let me be clear: this wasn’t laziness. This wasn’t turfing. This was a medically and ethically appropriate refusal to do something that should never be done by an emergency physician alone. And yet, I was met with condescension, anger, and threats—because I dared to request a surgical consult for a patient in need.
This is the state of emergency medicine: we absorb risk that doesn’t belong to us, and we get punished for pointing that out.
We’ve Always Been the Catch Basin. But It’s Overflowing Now.
Emergency medicine was built to handle the unexpected. That’s the job. But the problem now is everything is being treated as unexpected. When primary care becomes impossible to access. When specialists gatekeep behind office hours and “not my patient.” When social services collapse. When long-term care discharges without a plan. When mental health supports vanish after 5 p.m. Where do patients go?
They come to us.
And the system has normalized that. Not just normalized it—institutionalized it. There is now a cultural expectation that the ER will handle everything no one else wants to. Not because it’s right. Because we can’t say no.
Consultants Can Say No. We Can’t.
Hospitalists can refuse soft admits. Surgeons can say, “Call me when the abscess is bigger.” Psychiatry can delay evaluations until business hours. But emergency physicians? We’re expected to say yes to everything—every time, under any condition, without question. Even when it puts our license or our patient at risk.
And when we don’t? We get hostility. We get labeled “difficult.” We get retaliated against.
There’s a reason emergency medicine is the most burned-out specialty in the country. But let’s stop calling it burnout. Let’s name it: moral injury. Systemic abandonment. Chronic betrayal by the very institutions that claim to support us.
We’re Not Fighting for Ourselves. We’re Fighting for Patients.
Every time I push back on an unsafe consult, I’m not doing it to lighten my load. I’m doing it because the patient deserves real care, not a half-measure performed by someone outside their scope of practice at 3 a.m. I don’t want to see another patient hurt because someone was too proud or too lazy to come in.
When I escalate, I’m not trying to make a point. I’m trying to protect a patient.
But that distinction is lost on the people who should know better.
If This Doesn’t Change, The Collapse Will Accelerate
Emergency doctors are leaving. Fast. And not because they can’t handle the hours. Because they can’t handle the bullshit. The gaslighting. The silence. The abandonment. The pretense that this is normal.
It’s not.
Emergency medicine is what holds the whole system together. If we break, everyone breaks. Because when your mom has a stroke, your kid has a seizure, your partner collapses at dinner—you’re not calling a specialist. You’re going to the ER.
But what if no one’s there?
We are already at the brink. And if specialists and hospital leaders continue to treat emergency physicians like disposable triage clerks—expected to manage everyone else’s risk while being berated for saying “this isn’t safe”—then that collapse will become irreversible.
Why I’m Telling You This
You think I’ve never been called an asshole by a consultant before? I’ve heard every version of “you do it”—even when it’s unsafe, even when it’s outside my scope of practice. I’m not a surgeon. I’m not a urologist. I’m not a psychiatrist. I’m an emergency physician. And I’m being asked to do everyone else’s job simply because I’m the one who shows up when nobody else will.
As physician shortages deepen and care gets harder to access, the answer cannot be to turn emergency doctors into the fallback for every specialty that doesn’t feel like coming in. Nights. Weekends. Holidays. Indigent patients. Awkward cases. Risky calls. If they don’t want to do it, it lands on us.
But we can’t do it all. And you shouldn’t want us to.
Because one day, it’ll be you on the gurney. And when things go sideways, the last thing you want is for your care to be delayed because a specialist threw a tantrum.
Help us help you.
We need respect. Protection. Resources. Boundaries.
This is your healthcare system. It will not get better until you demand that it does.
Healthcare isn’t about ego. It’s about patients.
And the people entrusted to care for them should act like it.