While night shifts are a brutal subjugation of my natural diurnal instinct—yes, I prefer to conduct my life during the day and sleep at night—I have to admit that sometimes they’re a refuge. Sometimes it’s nice to leave the distractions of the daytime and let myself be swallowed whole by the night. I don’t have to respond to emails, or make phone calls, or schedule meetings, or do much of anything else when I’m working in the emergency room at night. In this way, it’s a nice break from my administrative work.

Don’t get me wrong, I signed up for admin. It was my habit, my well-worn groove. I wasn’t comfortable if I wasn’t in a leadership role. It was a routine I leaned into. After all, back in the early 1990s I had started a club I called Future Doctors of America at my high school (although, at the time, I wasn’t entirely sure I wouldn’t be an architect or an attorney instead), I was student government president my senior year, co-chaired our local branch of the American Medical Women’s Association while in medical school, and was a chief resident my final year in residency. Naturally, I thought I wanted to continue in leadership roles in the hospital while I worked as an attending ER physician.

So, here I was, at Philadelphia’s Andrew Johnson Hospital, a large teaching institution where I would have to prove myself. I started small, as the director of performance improvement in the emergency department. It was fascinating reviewing cases to investigate potential clinical errors, cases where, for example, a doctor or nurse practitioner (each called a “provider” in health care lingo) had made an inaccurate diagnosis or prescribed suboptimal treatment. These cases were typically referred to me based on grievances about patient care in the emergency department made by physicians in other hospital departments, by the hospital legal department, or by patients. Initially, I enjoyed the detective work involved in uncovering subtle system failures. It quickly became clear to me, however, that no matter how deferentially I approached my colleagues on these matters, they were not thrilled to hear from me. A physician who has made a mistake (a misdiagnosis, a procedural misstep) never wants to hear the doctor in charge of case review ask him, “Remember the case . . . ?” While I had gotten over the need to be liked or feel externally validated sometime before, it was still unpleasant to be received like the in-law you are obligated to speak to at Thanksgiving dinner despite not really wanting to.

But while working nights in the ED, I found all of that melting away. In preparation for those shifts, I take off my administrative hat, close my laptop, and silence my phone. During night tours, I am able to budget time for one morning activity, plus sleep, before heading back to work again. I choose carefully what will occupy this prized morning slot. On a beautiful morning in late summer, I might have my pick of the most succulent blueberries and the most verdant kale at the farmers’ market, but I usually head straight to the gym. All the nine-to-fivers are on their way to the office by the time I get there, and anybody who isn’t working is still making their first cup of coffee, so I can enjoy the gym in peace—just me and the eighty-year-old man who seems never to leave.

When I’m done, I go home to a cup of Sleepytime tea and the most indulgent nap on the softest, cotton candy pink organic sheets. When else can an adult intentionally sleep the day away and be called responsible for doing so?

Later, at 4:30 p.m., the alarm on my phone will chirp, and it will be time to get up, as my next night shift begins. I’ll walk through the hospital doors just before 7 p.m., in time to see the big smile on the face of the doctor at the end of the day shift. Things always start the same way: I consult the “sign-out,” a list of the outstanding tasks the day physician couldn’t resolve during her time on, and begin digging myself out of a hole. It never matters if the sign-out list contains two items or ten; it always feels like too many given the inevitable backup of patients currently waiting to be seen and the steady influx of new patients arriving over the course of the next twelve hours.

On one particular evening, I was the sole physician in the ED and was sharing the shift with the night nurses Crystal and Deb. It’s always a blessing to have a strong and amusing team when you’re on nights. When everything is stripped to bare bones, it’s a boon to have a sturdy foundation. I notice that the nurse Pam is on, too, and I tell myself that you can’t expect everyone on the team to be great. Pam is reasonably intelligent, but her clinical insight is often hampered by a bizarre emotional instability. I couldn’t figure out how she’d ended up in emergency medicine, but why she hadn’t been fired was obvious: Pam was committed to nights. The committed night crew is untouchable. Hospitals need them to reliably absorb the burden of the shifts other nurses don’t want to do.

We chugged along uneventfully until around 1 a.m., at which point we heard an ambulance backing into the ambulance bay. Then EMS rolled in a CHFer (our abbreviation for heart failure patients) puffing away on a portable BiPAP (bilevel positive airway pressure) machine. A plump elderly woman dressed in what looked like a housecoat lay on the gurney. The nurses established intravenous lines and informed the woman that they wanted to administer the medication Lasix into her vein to help her urinate the extra fluid backing up into her lungs, as the respiratory tech switched her over to the hospital’s BiPAP face mask to help her breathe. I leaned over and asked her, in a voice raised just enough to overcome the blowing of the BiPAP machine but not quite approximating a yell, “Ms. Yang, how are you feeling?”

She smiled behind the mask as the forced air made her cheeks flap, then flashed a thumbs-up to let me know she was improving. Her EKG and physical exam indicated that her heart was stable, so we were on autopilot for now. The EMS team headed back out the door, and then one of the EMTs returned to give us a heads-up that we might be getting a pediatric code. He said he had been listening to the radio and had heard a call about a baby not breathing and he wanted to alert us in case it was coming our way.

“I certainly hope not! Last thing I need in the middle of the night,” Pam said, loud enough for all twelve beds in the ER to hear.

My physician assistant had just left, there were six patients in the ER, one had just been brought in, and three more were in the waiting room, so the news of the baby wasn’t something I was enthusiastic about either. The truth is, there is never a good time for a pediatric code. When an adult gets sick, we can reason about how or why. After all, Grandpa has to die of something. And if Dad binge-drank every week for the past forty years, we’re not shocked when his liver fails. If Mom was a diabetic who loved to smoke, we understand when she has a heart attack. Even in cases of seemingly random illnesses, such as breast cancer in a thirty-six-year-old man, while these are painful and difficult to absorb, we can concoct for ourselves a kind of piecemeal comprehension to get through somehow. But when a child is brought in with a critical illness, such as cancer or organ failure, we experience a different kind of suffering. Because we see them as both innocent and invincible—too young to justify the affliction and certainly too perfect to succumb to it—it is that much harder to wrestle with.

I moved on to Mr. Nu?ez, in Bed 3, while I awaited Ms. Yang’s test results. Depending on her labs, I would admit her to a regular floor bed with heart monitoring, or to the cardiac intensive care unit for her CHF exacerbation. While I assisted the tech in splinting Mr. Nu?ez, who had come in with a wrist fracture, the alert came through.

Pediatric code blue. ETA five minutes. Pediatric code blue. ETA five minutes.

I knew it was too much to hope for that we’d be spared.

I asked Crystal to place Mr. Nu?ez in a sling and quickly printed his discharge papers. Deb’s phone rang. One of the medics was calling with an update—a benefit of having someone on shift who is friends with a local paramedic.

“Doc, neonate not breathing,” Deb said when she got off the phone. “They coded in the field ten minutes, couldn’t intubate, but have IV access. They’ll be here any minute.”

Ms. Yang, the CHF patient, was doing well. A quick look at the computer revealed that her labs were coming back normal. It was likely that she hadn’t had a heart attack, just a serious flare-up of her congestive heart failure. I asked the clerk, Wendy, to call the hospitalist, the doctor overseeing the medical admissions for the shift, and put the patient’s name in for a bed. We needed to admit her immediately to clear the decks. There was no telling how long a baby code would take.