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— The number of doctors staffing the ER varies according to the time of day. "We have anywhere from one attending physician to two attending physicians during peak times. And we have at least one resident and as many as three residents during peak times, and there may be a medical student as well."

While finding available doctors is not a problem, finding competent nurses is. "It's very tight. There's been an aging of the nursing population. I don't remember the exact figure, but I believe the average age of a nurse is now in the late 30s or early 40s." Given the growth of demand for medical services, Guss believes "there's not enough new nurses coming into the field to match the attrition.

"Emergency medicine is a particularly challenging field. Nurses have a lot of responsibility -- not to suggest that they don't in other areas -- but they particularly have a lot in emergency medicine. They have to have a tremendous breadth of knowledge and very good judgment, because they're right there when a patient's condition can be changing from minute to minute. They need to know when to react and when not to and how to prioritize things. Do we have enough nurses? Yes we do, but it's an ongoing struggle to maintain that balance."

The peak times in the ER are consistent but not always predictable. "They're generally between 10:00 and 11:00 a.m. up until midnight. Days of the week have no reliable pattern. Mondays tend to be busy. I wonder if people save up their complaints over the weekend and present what they haven't resolved on Monday -- but that's not hard and fast. Holidays...frequently the day of the holiday is not very busy, but the day after the holiday is. It's definitely worse in the winter months from December through February, because of viral illnesses and upper-respiratory infections. People will come in for those as well as all the complications -- the pneumonias, the exacerbation of asthma -- and all that travels along with viral illnesses. That's been the case as far back as I can remember."

Guss's memory stretches back for 22 years of emergency-medicine experience. "I've been doing this for a long time. I also used to fly on the Life-Flight helicopter as a physician crew member. I've seen a fair amount of very dramatic events. What makes emergency medicine very exciting and enthralling, but also very stressful, is that you can't predict what's going to happen. At any given moment at any given time," he laughs, "anything can happen."

"Generally, there will be times -- because we do not schedule patients and we do not turn them away -- where the sheer volume of cases you have to manage and the severity of those cases feels like it's going to tip you over the edge. It never does -- or at least it hasn't yet, because I'm still here! And, by and large, still loving it."

Like most doctors, Guss has one particular case that stands out. "When I was flying on the helicopter, a family had been forced off the road by an intoxicated driver and slammed into a concrete wall. There were three people in that vehicle, a man, woman, and their child. Unfortunately, the young child -- in a car seat, properly restrained -- was dead at the scene. The father was severely injured and required extensive, aggressive therapy in the field. We had to put in chest tubes, IVs, intubate the patient -- just about everything you could imagine doing in the pre-hospital arena was done to him. The woman was a little less injured, but she required a fair amount of intervention. The two of them were brought to the hospital and both survived.

"About a month later, I was in the cafeteria and a woman came up to me and asked, 'Are you Dr. Guss?' I said, 'Yes,' and she said, 'I just wanted to thank you for saving my husband's life and saving my life.' Initially, I made no connection. I said, 'I'm sorry, I don't remember,' but she went on to describe the accident, and then I remembered.

"It turns out that her husband survived with a significant, lifelong disability. They lost their child." His voice softens as he wipes his eye. "It makes me almost cry whenever I tell this story and think of the horror. Yet it was important to her, a month later, to search me out and thank me, even in the setting of all that misery! I'll always remember that."

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