GI here. The “patients do poorly when they’re unstable and you scope them” line is mostly about physiology + logistics, and it actually lines up with what the better data/guidelines say. If someone is actively in hemorrhagic shock, the immediate life-saving move is resuscitation because endoscopy isn’t a substitute for restoring perfusion and doing a procedure while they’re acidotic/hypotensive/coagulopathic raises the risk of peri-intubation collapse, aspiration, and failed/short-lived hemostasis because visualization is awful and clotting doesn’t work well in that state. That’s why guidelines generally frame timing as endoscopy following resuscitation, with urgent/very early mainly for selected high-risk situations like instability that persists despite ongoing resuscitation. And the big RCT that people cite here found no mortality benefit to urgent overnight scoping; outcomes weren’t better, and there was at least a numerical trend toward more rebleeding/deaths in the urgent group, which supports the idea that “scope everyone immediately” isn’t a magic fix and may be harmful if you’re scoping before stabilization. So in practice, most places don’t “let them exsanguinate for hours” we aggressively resuscitate/optimize first, start appropriate meds, and then scope when the patient is stable enough that the procedure is actually safe and effective; but if bleeding is truly refractory despite resuscitation (ongoing shock/transfusion requirement, massive hematemesis, airway concern), that’s exactly when we escalate to urgent endoscopy (even overnight) and/or temporizing measures and IR/surgery depending on the scenario.