Emergency & Ethics

A 27-year-old man suddenly collapses at work. He is pulseless and apneic. A coworker has attached an AED that advises “shock.”

A 33-year-old woman with peanut allergy develops hypotension, wheeze, stridor, and hives minutes after exposure.

A 64-year-old with chest pain and ST-elevation in inferior leads, hypotension, clear lungs, JVP elevated.

A 22-year-old asthmatic with severe dyspnea, silent chest, RR 34, SpO₂ 88% on oxygen; not speaking full sentences.

A 70-year-old with fever, hypotension (MAP 58), confusion, lactate 5.2 mmol/L; suspected pneumonia.

A 58-year-old with K⁺ 7.1 mEq/L, peaked T waves, wide QRS, weakness.

A 24-year-old presents with severe epigastric pain and repeated vomiting; HR 120; dry mucosa; glucose 420 mg/dL; pH 7.12; anion gap high; K⁺ 4.8.

A 36-year-old after house fire: soot in mouth, cherry-red skin; he is confused with headache.

A 28-year-old in a smoke inhalation presents with hypotension, lactic acidosis, and almond odor on breath.

A 45-year-old with narrow QRS tachycardia at 180 bpm, stable vitals; adenosine fails; ECG shows irregularly irregular rhythm with narrow complexes.

A 30-year-old motorcyclist with blunt trauma is hypotensive, tachycardic, cool clammy skin; chest clear; abdomen distended; pelvis unstable.

A 19-year-old with sudden pleuritic chest pain and dyspnea, tracheal deviation away from the left, hyperresonance, absent breath sounds on left.

A 72-year-old with massive hematemesis, hypotension, and melena.

A 29-year-old with severe headache, photophobia, fever, neck stiffness; no focal deficits; no papilledema.

A 65-year-old with sudden painless monocular vision loss; pale retina with cherry-red spot on fundus.

A 37-year-old diver ascends rapidly, then develops pleuritic chest pain and dyspnea; hemoptysis; subcutaneous emphysema.

A 54-year-old found in a hot warehouse: temp 41.2°C, confusion, hypotension, dry skin.

A 22-year-old with suspected cauda equina: severe back pain, saddle anesthesia, urinary retention, bilateral leg weakness.

A 31-year-old with crush injury; severe calf pain, pain with passive stretch, paresthesia; pulses present; compartment pressure 45 mmHg.

A 40-year-old with salivation, lacrimation, bronchorrhea, bradycardia after pesticide exposure; pinpoint pupils; muscle fasciculations.

A 19-year-old ingested unknown pills; ECG shows QRS 140 ms, terminal R in aVR; hypotension; seizures.

A 45-year-old ingested antifreeze; anion gap metabolic acidosis, calcium oxalate crystals in urine, AKI.

A 29-year-old took an unknown quantity of acetaminophen 8 hours ago; asymptomatic.

A 66-year-old on warfarin presents with ICH on CT and INR 3.6.

A 34-year-old arrives agitated, tachycardic, hyperthermic, tremulous after MDMA at a festival; hyponatremia present.

A 48-year-old woman with severe epigastric pain radiating to back, hypotension, amylase/lipase high; tetany noted; EKG with ST depressions; Ca²⁺ low.

A 72-year-old with fever, hypotension, and confusion has a Foley catheter. UA positive for nitrites/leuks.

A 24-year-old late-pregnancy patient with generalized tonic–clonic seizures, BP 170/110, edema.

A 29-year-old postpartum with heavy bleeding, boggy uterus after delivery.

A 52-year-old with tearing chest pain radiating to back; BP 210/110; asymmetry in arm pressures.

A 68-year-old with fever, cough, confusion; CURB-65 = 3.

A 14-year-old boy with depressed skull fracture after fall; GCS 7; snoring respirations.

A 22-year-old with suspected PE is hemodynamically unstable with right heart strain on POCUS.

A 56-year-old with severe hypercalcemia (Ca 15.5 mg/dL), confusion, dehydration; likely malignancy.

A 35-year-old Jehovah’s Witness with capacity refuses life-saving blood transfusion for GI bleed.

Parents of a 10-year-old refuse antibiotics for life-threatening bacterial meningitis for religious reasons.

A 45-year-old with depression wants to leave the hospital AMA after evaluation for chest pain; troponin pending; he explains risks and repeats back understanding; no SI/HI.

A 26-year-old requests HIV test results; her partner is your patient and is HIV-positive but refuses to disclose.

A 60-year-old intubated patient with metastatic cancer has an advance directive refusing CPR and mechanical ventilation; his daughter insists “do everything.”

During a mass-casualty incident, you have 1 ventilator left and 3 hypoxic patients: one with high survival chance, one with moderate, one with poor prognosis despite maximal care.

A 36-year-old with status asthmaticus is intubated for exhaustion. Peak pressures are high and the ventilator alarms for air-trapping.

A 54-year-old with fever, severe back pain, and new leg weakness; ESR markedly elevated; history of IV drug use.

A 2-year-old swallowed a button battery 30 minutes ago. X-ray shows a coin-like object with a “double-rim” in the esophagus.

A 28-year-old ingests liquid drain cleaner (strong alkali). He is stable and protecting his airway.

A 66-year-old with sudden eye pain, halos, mid-dilated fixed pupil, cloudy cornea, IOP very high.

A 22-year-old with painful erection >5 hours; cavernosal blood gas shows hypoxia and acidosis.

A 15-year-old boy with acute unilateral testicular pain and high-riding testis; absent cremasteric reflex.

A 58-year-old coughing up large amounts of blood (≈300 mL). He is hypoxic but protecting airway.

A toxic-appearing 5-year-old with high fever, stridor, and poor response to nebulized epinephrine; purulent secretions; vaccinated.

Minutes into a transfusion, a patient develops fever, flank pain, hypotension, and dark urine.

A 72-year-old with profound hyperglycemia (glucose 980 mg/dL), serum osmolality 330 mOsm/kg, no significant ketones; altered.

A febrile thyrotoxic patient with agitation, tachyarrhythmia, and heart failure.

A 70-year-old hypothermic, bradycardic, obtunded patient with myxedema features.

A 28-year-old with Addison disease presents with shock, hyponatremia, hyperkalemia after gastroenteritis.

A patient with syncope has polymorphic VT in the setting of QT prolongation.

A stable patient with regular wide-complex tachycardia at 160 bpm, no clear diagnosis.

A 50-year-old ingested a large amount of verapamil; now hypotensive and bradycardic with hyperglycemia.

A 23-year-old with massive propranolol ingestion; hypotensive, bradycardic, hypoglycemic.

A hiker bitten by a rattlesnake 1 hour ago; progressive swelling, ecchymosis, and coagulopathy.

A deep dog bite to the hand sustained 8 hours ago; wound irrigated in ED.

A tibia open fracture with exposed bone after MVC.

A 49-year-old with rapidly progressing erythema, severe pain out of proportion, bullae, crepitus; septic.

Frostbite after overnight exposure; pale, hard digits, then reperfusion blisters.

Severe hypothermia (core 28°C) with J (Osborn) waves, bradycardia, and VF refractory to shocks.

A near-drowning victim is awake with cough and mild hypoxia; chest exam with crackles.

High-voltage electrical injury with entry/exit wounds; arrhythmia at scene; now rhabdomyolysis (CK 30,000) and dark urine.

Hydrofluoric acid hand burn with severe pain out of proportion.

Chemical splash to the eye at a factory 10 minutes ago.

Marathon runner with confusion and seizures; serum Na⁺ 118 after drinking large volumes of water.

A 2-month-old had a brief resolved episode of cyanosis and limpness at home; now well in ED; exam and vitals normal; low risk by criteria.

Post-ROSC after VF arrest: comatose, intubated, hemodynamically stable.

You plan moderate procedural sedation for fracture reduction.

A patient presents to ED without insurance; triage is crowded.

You administered the wrong dose of insulin; the patient developed hypoglycemia but recovered fully.

You suspect your colleague is intoxicated before a procedure.

A pharmaceutical representative offers you an expensive dinner in exchange for attending a “talk.”

Your cousin asks you to prescribe antibiotics for a “sore throat” over the phone.

A mature 16-year-old requests contraception and asks you not to tell her parents.

You suspect non-accidental trauma in a 3-year-old with patterned bruises on torso and back.

A head-injured patient lacking capacity is eligible for an ED clinical trial; no surrogate is immediately available.

A 34-year-old with methemoglobinemia after nitrite exposure has cyanosis, low SpO₂ unresponsive to O₂, chocolate-brown blood; metHb 25%. G6PD status unknown.

A 26-year-old presents 1 hour after high-dose aspirin ingestion; tinnitus, tachypnea, anion gap metabolic acidosis with respiratory alkalosis.

A 72-year-old on apixaban has large spontaneous ICH.

A 58-year-old with digoxin toxicity (bradyarrhythmia, nausea, xanthopsia) and K⁺ 6.3.

A 30-year-old with bitter-almond breath after industrial exposure collapses; lactic acidosis profound.

A 45-year-old fisherman stung by a stingray; puncture wound with severe pain.

A 32-year-old hiker with high-altitude headache and ataxia at 4,200 m; confusion and hallucinations.

A 27-year-old climber with dyspnea, cough, hypoxia at altitude; crackles; no fever.

A 23-year-old diver suffers jellyfish (box) sting; severe pain and collapse on beach.

A 40-year-old unrestrained driver with suspected blunt aortic injury (widened mediastinum) is unstable.

A 29-year-old with cat bite to forearm 12 hours ago; erythema and pain; no tetanus in 12 years.

A triage during wildfire: one victim apneic with no pulse; second with severe burns >90% TBSA; third with open femur fracture and stable vitals; limited resources.

A 62-year-old with COPD fires a gun in public and is brought by police for evaluation; he threatens staff.

An unconscious trauma patient arrives without ID. Emergency surgery is required to stop bleeding.

A 68-year-old with advanced dementia pulls out lines and refuses antibiotics for pneumonia; healthcare proxy presents a valid POLST requesting comfort-only care.

A 24-year-old with a gunshot wound is hemodynamically unstable. Police demand you draw a forensic blood sample now.

A 56-year-old with new seizures is told to stop driving; he demands a letter clearing him to drive.

A 35-year-old woman requests STI testing and asks that results not be shared with her partner.

A non-English-speaking patient needs consent for an emergent procedure; family member offers to interpret.

A 52-year-old on chronic opioids presents with multiple lost prescriptions; PDMP shows early refills at different pharmacies.

A 36-year-old nurse sustains a needlestick from an unknown patient; source unavailable.

A 19-year-old sexual assault survivor arrives within 24 hours.

A 58-year-old with persistent vegetative state and feeding tube; surrogate requests withdrawal of tube feeding consistent with prior wishes.

A 44-year-old with TB refuses isolation and wants to leave.

A 28-year-old with suspected elder abuse of her 82-year-old grandmother (your patient) confides in you; injuries are unexplained.

A 30-year-old restrained driver after MVC with negative CT head; now persistent vomiting and worsening headache; on warfarin with INR 2.5.

A 59-year-old with massive PE and recent intracranial surgery (absolute tPA contraindication) is in shock.

A 35-year-old suicidal patient refuses treatment; he has a plan, means, and intent.

A 50-year-old with suspected stroke at 5 hours from onset; deficits disabling; CT perfusion shows salvageable penumbra and proximal M1 occlusion.

A 60-year-old with severe agitation from stimulant intoxication is placed in physical restraints.

A 36-year-old postpartum day 10 with severe headache, seizures, and focal deficits; BP normal; MRI/MRV shows venous sinus thrombosis.

A 7-year-old with anaphylaxis improves after IM epinephrine; parents ask for discharge immediately.

A 41-year-old with acute painless vision loss in one eye; afferent pupillary defect; normal retina; optic disc pallor later. ESR/CRP very high, jaw claudication.

A 70-year-old with dementia is brought by caregiver for dehydration; multiple pressure injuries; caregiver seems overwhelmed.

An EMT phones from the field: pregnant woman in active labor requesting transfer to your ED; your hospital is on diversion.

A 24-year-old with severe agitation after head trauma; CT pending.

A 47-year-old with suspected necrotizing pancreatitis and escalating pressor needs; surgical consult declines debridement “too early.”

A 52-year-old with suspected MERS/novel respiratory pathogen arrives hypoxic.

A 33-year-old requests to record the encounter on her phone.

A 65-year-old dies in the ED; family requests organ donation discussion.