How “Casino Shifts” Help ER Doctors Work into the Night and Save Lives

Time: 6:25 p.m.

“Dr. Goldman, it’s the emergency department calling,” says an emergency room ward clerk named Vivica.

At the dinner table, my family sees me flinch.

“Sorry to bother you, but the department is backing up,” says Vivica. “We’re hoping you can come in early.”

There are times I want to let these calls go to voicemail, but our group of ER physicians long ago agreed to pitch in and arrive as early as two hours before the start of a scheduled shift when we’re needed.

“It’s no bother at all,” I reply. “On my way.”

The twenty-minute drive to the hospital gives me time to steady my nerves. When I arrive, I walk through the revolving door at the back entrance to the hospital and enter the lobby. To my right, close to the front entrance, sits the emergency room, separated from the lobby by a wall. But I head in the other direction, down to the ER physicians’ offices, to change into blue scrubs. I never pass through the ER on my way to work because I don’t want to see what awaits me until I’m ready to dive in.

Time: 7:01 p.m.

There’s chaos in the waiting room.

A glance at FirstNet, the app we use to track patients, shows that forty-three people have been triaged by nurses and are waiting to be seen. Nine have minor issues, such as ankle sprains and sore eyes. Eight have intermediate problems, such as abdominal pain and first-trimester bleeding. The other twenty-six have illnesses and injuries deemed major and in need of a full workup and a stretcher. It’s far too many patients for my colleague Tawny to see. She started her shift at 6 p.m. That’s why I’ve been called in early.

The challenges faced by doctors who work nights are well known. Fatigue occurs after you’ve been up for sixteen hours or more. Working even one night, which means not sleeping when your body’s clock says you’re supposed to, puts you at odds with human circadian rhythms. I’ve worked night shifts for four decades and found it stimulating for a lot of reasons but also difficult because of its physical and mental impacts.

Casino shifts are one tactic ERs are using to address those impacts. Not surprisingly, given the name, the idea was borrowed from casino employees, who typically work a six-hour shift, from 10 p.m. until 4 a.m. or from 4 a.m. until 10 a.m. The theory is that having two doctors split the twelve to fourteen hours of the night shift is better than having one work all night because it allows both MDs to sleep at least part of the night in their own beds.

In the ER at my downtown Toronto hospital, where we see as many as 200 patients a day, the casino shift begins at 9 p.m., and its end time is flexible. We still have a night shift doctor who starts at 11 p.m. and stops seeing incoming patients at 6 a.m., when the day physician starts work.

If it’s quiet, I might be able to leave at around 2 a.m. That, of course, assumes things will stay that way. If it’s busy, I’ll stay as long as needed to see as many patients as possible and move them through the system. I can’t predict which scenario I’ll face. It turns our casino shift into a game of chance.

“There were eighteen majors when I arrived,” says Tawny as I enter the triage area. “I’ve seen nine, and they just keep coming.”

The triage area is one of the newest additions to the ER. It’s a long, rectangular room. On my right, there’s a bank of workstations for attending and trainee doctors, nurse practitioners, and physician assistants, as well as one exclusively for the team leader, the nurse in charge. Tonight, that nurse is Cynthia.

“How many nurses are we short?” I ask her.

“Two,” she replies. She’s doing her team-leading duties while covering for one of the missing nurses.

Cynthia and I have worked together for more than ten years. She’s unflappable, except when it comes to patients who are both emotional and noisy.

“Fire!” screams a dishevelled woman named Molly from atop a stretcher across the hall from the triage area. “Put out the fire!”

Molly has chronic schizophrenia and a fixed delusion that someone has placed a tracking device in her belly. Despite this, she hasn’t been admitted to a psychiatric hospital in years because she doesn’t possess any of the red flags that would make doctors think she’s a danger to herself or others. She’s homeless, in large part because she’s been kicked out of every shelter in downtown Toronto.

When I first entered the triage area, I couldn’t hear Molly’s voice. Now it’s all I can hear.

“This is her third visit in three days,” Cynthia says. “I know she’s not first to be seen, but do you mind sorting her out now?”

“No problem,” I say. I grab the chart and step through the plexiglass door and into the waiting room.

The waiting area has the usual rows of chairs for people who can sit. Surrounding that are rooms for paramedics bearing patients on stretchers. They’re always full. Molly is one of several patients on stretchers down a long hallway that connects to the waiting area and serves as a temporary holding space for additional paramedic stretchers. It all feels like a fishbowl. Every major patient waiting to be seen is outside the ER and crammed into the waiting area—people with pneumonia, chest pain, abdominal pain, bowel blockages, and dizziness. Any one of them could be seriously ill, their lives possibly hanging in the balance.

“Fire, fire!” Molly’s cries sound more urgent.

In optimal times, patients who arrive by ambulance are off-loaded to an ER stretcher and handed over to the nurses. When there are no available stretchers, as is the case today, the paramedics are in what’s known as “off-load delay” and, by law, must continue caring for their patients until the nurses can take over. A 2022 analysis of Ontario Health data by the Toronto Star found that off-load times had nearly doubled in just three years.

“Somebody put out the fire!” Molly screams again.

I approach her stretcher. “I’m Dr. Goldman. Remember me?”

Molly utters a blood-curdling scream.

“Molly, what’s wrong?” I try to focus my patient on the chief complaint.

“Please put out the fire.” She momentarily looks right at me.

“What fire?” I ask.

“She’s been saying that since we arrived,” explains a paramedic named Virginia. “She was just moaning when we picked her up on the curb outside a shelter. She’s thirty-six years old and has a history of polysubstance use, anxiety, and schizophrenia. She vomited two times at the scene. We gave her Toradol for the pain, but it’s not helping.”

I’ve never seen Molly this agitated.

Virginia uses her paramedic-issued equipment to monitor Molly’s vitals. She has an elevated heart rate and lowish blood pressure that could be signs of pneumonia or a kidney infection—or possibly even sepsis, a life-threatening condition that happens when the body’s immune system has an extreme response to an infection. The reaction causes damage to the body’s own tissues and organs. Molly’s normal temperature makes an infection less likely, though not impossible.

“Put out the fire!”

“You keep talking about the fire.” I hear myself sounding exasperated. “Where is the fire?”

“Fire over there.” She raises her arm and points a finger toward a window near the ambulance bay.

That’s when I see the alternating red-and-blue flashing lights of a parked ambulance. I point to the lights. “Is that what you mean by fire?” I ask Molly.

Virginia radioes her partner. “Unit 8375, can you cut your emergency lights?”

The lights stop flashing. Instantly, Molly goes quiet.

And I calm down as well. Noise is a major distraction in ERs—loud conversations between health care providers and patients punctuated by even louder alarms and beeps. To me, the most annoying noise, by far, is the long, non-musical tone that precedes each intercom announcement.

“Beeeeep. PSW to room forty-five.”

“Beeeep. Service assistant to room thirty-one.”

“Beeeep. Pink-zone nurse pick up line thirty-eight.”

Now that Molly is no longer screaming, I can focus more closely on her and her distress. I notice the furrowing of her brow and the tiny beads of sweat on her forehead. These are subtle but important physical signs of distress.

“Are you in pain?” I ask her. She doesn’t reply. I listen to her heart and lungs and then start pressing on her belly.

“Owwwwww!” she hollers and pushes my hand away. Her abdomen is as rigid as a plank of wood and tender all over.

“Holy shit!” Virginia says. “Her belly was soft and non-tender when we picked her up outside the shelter.”

Tenderness in her belly means that Molly likely has peritonitis. It’s a serious condition in which the lining of the abdomen, or the peritoneum, is acutely inflamed. There are many causes, but the most common are a burst appendix or an infection caused by a perforation or hole in the stomach or intestines.

Peritonitis is life-threatening. Some patients deteriorate so rapidly they need intensive care. Patients may also require surgery to deal with the source of the infection by removing the inflamed appendix or repairing the torn bowel. But before I ask the surgeons to see Molly, I have to confirm that she has a surgical condition. Generally, that means getting a computerized tomography (CT) scan of her belly. To get more detailed pictures, the radiologist may want to inject the patient with radiocontrast or dye by IV drip. Since radiocontrast can be toxic to the kidneys, we must first obtain blood work to make sure the kidneys have enough functional reserve to tolerate the dye.

When the ER is well staffed and has lots of beds, there’s a great deal I can do to stabilize Molly. I can order bags of intravenous fluids to raise her blood pressure. I can use IV antibiotics to treat a suspected infection inside her belly. I can move her to the resuscitation room to receive one-on-one nursing.

But that’s no longer the norm. In some ERs, patients with serious and even life-threatening illnesses routinely wait six, eight, or even ten hours just to be brought in. Some patients wait all day to be seen by an ER physician. Rarely, some patients die waiting to be seen.

I rummage through the fanny pack on my belt and pull out an ultrasound probe with a long electrical cable, which I plug into my phone. An app pops up on my display. I tear open a small pack of ultrasound conducting gel and spread it on the probe.

“It’s going to feel a bit cool and goopy,” I tell Molly. I place the gooped-up probe on her right side where the lower ribs meet the uppermost part of her belly. My phone shows a clear and crisp image of Molly’s right kidney, just underneath her liver, with an ominously large, triangle-shaped black blob in between.

Virginia sees my expression and looks at the display. “What’s that?” she asks.

“There’s fluid in the belly,” I tell her. “And a whole lot of it.”

The peritoneal cavity normally contains a small amount of fluid that lubricates the tissues lining the abdominal wall and the walls of the vital organs. Molly’s belly contains as much as a litre, if not two. But what kind of fluid is it?

If Molly has blood in her belly, it means there’s a hemorrhage somewhere. The most common cause of acute bleeding inside the belly is trauma from being hit by a car or beaten badly. But there is no indication that Molly has been hit.

Molly has started moaning softly. The portable monitor sitting on her gurney says her heart rate has crept up to 132.

“What’s Molly’s BP?”

“Ninety over forty-five,” Virginia says with a tinge of alarm.

By itself, a blood pressure that’s dropping slowly or a heart rate that’s creeping up at a leisurely pace might not indicate anything life threatening. But occurring together along with an ultrasound showing a belly full of fluid—they suggest a condition that’s much more ominous.

“She’s going into shock.” I speak my thoughts out loud.

Hemorrhagic shock has four clinical stages, each with symptoms and signs that reflect a particular amount of blood loss and degree of danger. Molly’s symptoms and signs tell me she’s going into class three shock. If I’m right, she’s in grave danger. Class three means up to two litres of acute blood loss.

“She could be bleeding to death,” I tell Virginia, grabbing the foot end of the gurney. “We don’t have a lot of time.”

Virginia and I push Molly’s stretcher towards the entrance to the ER.

Time 7:30 p.m.

“Service assistant to room sixty stat.” Cynthia’s voice on the intercom sounds calm but purposeful. Molly’s moans fill the air as Virginia and I push her stretcher through the sliding doors of the resuscitation room. This fully equipped suite has almost everything we need to save her life.

Lance and Rishna, the nurses working the resuscitation area, have just started their twelve-hour night shift. They’re already priming IVs and gathering medications.

“Two fourteen-gauge IVs running wide open with Ringer’s lactate,” I tell Lance. Ringer’s lactate is an intravenous fluid we administer to replace lost electrolytes and fluids in patients who are dehydrated or in shock.

Virginia and I slide Molly’s paramedic stretcher alongside the gurney in the centre of the room.

Tawny walks briskly into the room. “Can I help?” She’s followed by Cynthia.

“Let’s get Molly on the gurney on three.” I grab the orange paramedic blanket underneath Molly at the foot of the stretcher.

Tawny moves to the head of the stretcher, and Virginia and Cynthia take the sides. “One, two, three.”

“I’ll take the airway,” says Tawny. She prepares to do a rapid sequence intubation.

“Get me a hundred milligrams of ketamine and sixty of rocuronium,” she calls out to Rishna. Ketamine is a powerful sedative, and rocuronium is a muscle relaxant. “And call the respiratory therapist to grab the video laryngoscope.”

More nurses join in. Lance has already collected tubes so he can get blood work and insert the IV with one poke. “Do you want a trauma panel?” he asks me. A trauma panel is a group of standard blood tests ordered on trauma patients: a complete blood count, electrolytes, creatinine, amylase, coagulation screen, blood alcohol level, venous blood gases, lactate level, and a blood group and screen.

“Affirmative to that,” I say, “plus type and cross for four units of packed red blood cells.” And then I add, “Get an HCG stat. And get a service assistant to run the blood work up to the lab.”

The HCG, or human chorionic gonadotropin, is a pregnancy blood test. Because Molly is a thirty-six-year-old of childbearing potential, it’s essential to find out if she’s pregnant.

Cynthia and another nurse, Jason, put adhesive electrocardiogram leads on Molly’s chest and extremities.

“Brian, how much TXA do you want?” Rishna is drawing up tranexamic acid into a syringe. This is a medication that binds to a receptor on a protein named plasminogen, found in blood plasma. Plasminogen plays an essential role in dissolving blood clots. By blocking the receptor, TXA helps slow down the rate of bleeding by coaxing Molly’s blood to clot.

“Two grams, please.”

Rishna pushes the dose. Meanwhile, a respiratory therapist named Rebecca wheels a video laryngoscope up to Tawny at the head of the bed. “What size tube do you want?” she asks.

“Seven point five,” Tawny replies. “Molly, we’re going to give you some medication to make you sleepy, and then I’m going to put a tube into your throat so you can breathe easier.”

“Shall I push the ketamine now?” Lance asks.

“Yes,” Tawny replies. “Then wait one minute before giving the rocuronium.”

Ninety seconds later, Molly is no longer moaning. Tawny looks into Molly’s mouth as she inserts the video laryngoscope. Rebecca turns on the video screen, which shows the inside of Molly’s oral cavity. Tawny looks at the screen and can see exactly where she’s going as she advances the scope over Molly’s tongue and towards her epiglottis. “I see the vocal cords,” she says.

Rebecca hands Tawny a 7.5-millimetre endotracheal tube with a bendable stylet inside. Tawny continues to look at the screen as she passes the tube through the vocal cords. “I’m in,” she says. She removes the stylet and holds the precious breathing tube in place as Rebecca attaches a sensor to track Molly’s carbon dioxide level and connects the sensor wire to the monitor.

“I’ll start setting up the ventilator,” Rebecca says.

“Rishna, start a ketamine drip at fifteen milligrams per hour and titrate,” says Tawny. The drip will keep Molly sedated for as long as she is intubated and on a ventilator.

Suddenly, the blood pressure alarm on the vital signs monitor starts chiming. The systolic blood pressure, which was ninety millimetres of mercury just a few minutes ago, is now seventy-five.

“What dose of Levophed do you want?” Cynthia is two steps ahead of me. Levophed is a go-to medication that raises the blood pressure. It’s essential for patients in shock.

“Start at twenty micrograms per minute and taper to maintain a systolic pressure of ninety,” I reply.

“Resus nurse, stat result on line thirty-eight,” says Vivica over the intercom.

Cynthia picks up the phone. She scribbles figures onto a scratchpad before hanging up.

“Hemoglobin is seventy-two,” says Cynthia. “Lactate six point seven. The HCG is positive.”

The positive HCG is the missing piece of the puzzle. It means that Molly is pregnant.

That fact almost guarantees that the fluid in her belly is blood. The most likely explanation for the blood is that she has an ectopic pregnancy that grew through one of her fallopian tubes until it ripped the tube apart and started to bleed into her belly cavity.

“Two units of O-negative blood,” I call out. O negative is the universal donor blood type, used most often in cases of trauma and any other occurrence of hemorrhage when the blood type is unknown.

“Sounds like a job for the rapid infuser,” says a colleague nicknamed Fix as he walks into the room pushing an IV pole with a box-shaped device mounted in the middle. An ER resident named Shirley and a nurse named Christine follow close behind. The rapid infuser is a device that warms and delivers extremely large volumes of blood products and intravenous fluids. When a patient has a rapid and uncontrolled hemorrhage, like Molly does, the rapid infuser is a lifesaver.

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Time: 7:45 p.m.

After two units of blood, Molly’s blood pressure is 100 over forty-five and her heart rate is 105. She’s still in pain, but she appears more stable. Soming, a senior resident in obstetrics and gynecology, and Ben, a second-year obstetrician-gynecologist resident, are seeing her in the resuscitation room. A service assistant arrives to help the two doctors and Rishna transport Molly to the operating room, where they’ll remove her ruptured fallopian tube and repair whatever damage they find inside.

“Good save, Dr. Goldman,” says Soming, who, at twenty-eight, is young enough to be my daughter. When I was her age and just starting out, I wanted to be called Dr. Goldman. Now that I’m close to retirement, I wish younger docs still called me Brian. “The team did an amazing job,” I reply, deflecting the accolade to its proper place.

All told, six nurses, three attending ER doctors, two learners, and one respiratory therapist converged on room sixty to save Molly’s life. That’s a good chunk of the resources and personnel of the ER. In the interim, nine more patients arrived in the waiting room.

I start to play “what if” in my mind. What if I didn’t see Molly before everyone else? What if I didn’t listen to Cynthia, who was just trying to deal with the noise Molly was making? What if I didn’t have my ultrasound probe with me? What if I didn’t pull her stretcher into the ER?

Molly is on her way to the operating room. She has a good chance of surviving, in part because we got lucky and found the needle in the haystack.

It’s not even 8 p.m. My actual casino shift doesn’t begin for another hour. It’s going to be a long night. I can feel it.

Author’s note: The patients described are mostly composites of people I have seen and treated; the same is true for many of the doctors, nurses, and other frontline providers portrayed here.

Excerpted from The Casino Shift: Stories from an ER on the Edge by Brian Goldman ©2026. Published by HarperCollins Publishers Ltd. All rights reserved.