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

When you’re understaffed and overwhelmed, you have to catch the right signs—and some luck

“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.

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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.........

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