In my third year of residency, moonlighting in the rural emergency room is terrifying, but it also helps me to think in emergency mode. Which is different from clinic.

One day I am in the residency clinic and walking by the procedure room, glancing in.

I stop and back track.

There is a kid on the exam table. A faculty member putting an oxygen mask on the kid. A panicked looking mother, and a nurse inserting an iv. A first year resident helping with the iv. The kid is breathing really really fast, too fast.

Another nurse standing by the crash cart. "Blood sugar," I say. The faculty glances up. The nurse grabs the glucometer and sticks the kid's finger on the other side.

"Ambulance?" I ask.

"On their way." says the nurse. "Too high to read!" about the blood glucose. So over 500. Normal is up to 140.

IV fluids are running in. "Insulin." says the faculty. The nurses have the crash cart open. We have the diagnosis: this child is a new type I diabetic, in a high glucose coma. The fast breathing is his body trying to keep his acid base balance in his blood by blowing off CO2.

The ambulance crew are there and loading. His breathing is slowed a little, insulin on board and the iv fluid following the normal saline has glucose in it, because you have to bring the blood sugar down slowly. Mom is crying, partly in relief. They go.

And my next patient is in a room.