"Do You Want To Die?"

By NANCY GIBBS

"We do traumas; we do heart attacks; we do orthopedic fractures; we deliver babies; we do it all," explains Peter Moyer, chief of emergency medicine at Boston City Hospital. "I think of us as the urban GP." Tonight Moyer's trauma team is summoned to save a man who has overdosed on heroin. They cut his clothes away, thump on his chest and connect an IV tube, all the while talking to him, trying to keep him awake. "Do you want to die?" resident Stuart Kessler yells at the man, who is feebly pushing the doctors away. The man shakes his head. "Good," says Kessler. "I don't want you to die either." He administers Narcan, a heroin antidote. An hour later, the patient regains his strength and wants to leave before the police come. He gets angry when a nurse tells him his clothes were cut to pieces. She tries to hide her annoyance. "You understand, sir, that our first priority was saving your life."

The gray Cadillac was going more than 50 m.p.h. when it swerved off the road onto a Little League field in Riverside, Ill. By the time the car rolled to a stop, the bodies of children and parents were strewn across the infield. Ambulances came whooping and screeching to Loyola's McGaw Hospital, 23 blocks away, and the trauma team went to work. Research shows that if basic life support is used on serious trauma victims within four minutes and advanced life support within eight, nearly 50% of them survive. McGaw beat the averages. The first child was in cardiac arrest, and two more died on the operating table. But five others with severe head, chest and abdominal injuries survived. "It could have been my child," murmured one doctor, whose boy was only slightly injured in the accident. "My son could have been sitting next to the children who got killed."

It's not really all the blood on the gunshot victims, or the long wait for a doctor, or the smell of the street people that bothers patients in the / emergency room at Booth Memorial in Queens, N.Y. It's the indignity. "Forty- year-old people come in with terminal cancer, and this is where they die," says Dr. Mark Henry. "With the lights on, no privacy, no curtains, with their bedpans and medical charts in clear sight of other patients and their relatives forced to crowd around their gurney and cry."

In large cities and small towns, the emergency room is the abused child of American medicine. Overburdened, understaffed and underfinanced, emergency departments across the country are reeling from multiple blows. Start with 37 million patients who have no health insurance. Add a graying population with a growing need for expensive treatment. Subtract government reimbursements, which often cover only half the cost of treating the poor. Factor in the effects of the AIDS epidemic and drug violence. Under such pressures, the miracle is that the system shows any vital signs at all.

Fighting hard to keep it alive are some 110,000 doctors and nurses, plus technicians, social workers and paramedics, employed by roughly 5,700 emergency departments nationwide. Last year they treated 90 million patients for everything from hangnails to heart attacks. In the busiest hospitals, emergency-room personnel minister to an average of 200 patients in a single, brutal twelve-hour shift, while stretchers stack up in the waiting rooms, hallways and even closets. Staffers eat large meals before going on duty, since there will be no breaks once they start. They treat wounds they hoped never to see outside a war zone: it is to Los Angeles, which had more automatic-weapons victims than Beirut last year, that the U.S. Army sends its physicians for combat training, at Martin Luther King Jr./Drew Medical Center. "What gives out is not patient care," says Dr. Elisabeth Rosenthal of New York Hospital, "but our sanity."

With each passing month, a few more hospitals decide they can no longer stand the strain. Chicago has lost four of its ten trauma centers -- specialized units set up within hospitals to handle victims of car wrecks, violence and other life-threatening injuries. In Dade County, Fla., every hospital has dropped out of the trauma network, except James M. Jackson Memorial: one trauma center for more than 2 million residents. Many other emergency departments across the country have "down licensed," or substantially reduced the scope of their emergency services.

When emergency rooms and trauma centers shut down, either permanently or temporarily, the impact sends a shudder throughout the entire medical system. Though patients may be able to choose where they go to have brain surgery, they cannot choose where to have a heart attack, or crash their car, or stumble into cross fire. "The hospitals don't just close their doors to poor people," says Virginia Price-Hastings, director of Los Angeles' trauma hospital programs. "When they're closed, they're closed to everyone." Furthermore, if hospital beds are filled with emergency patients, doctors cannot schedule elective surgeries like breast biopsies, gallbladder removals and cardiac bypasses. Delay a bypass too long, and it can turn into a heart attack -- which brings the patient back to the crowded emergency room.

A typical May afternoon in the District of Columbia's George Washington University Medical Center: half a dozen suspected heart attacks; a man who was mowing the lawns at Oak Hill cemetery and caught his foot in the mower; another who was cleaning the meat-slicing machine at a restaurant and cut off his fingertip. A 40-year-old man with black hair and gray skin is complaining of sharp stomach pains. He is HIV positive and taking AZT. "That's what someone looks like who's going to die soon," Dr. Michael Bourland explains quietly as he moves on. Doctors here agree that they make the vast majority of their decisions within the first 15 seconds of seeing a patient. But some things simply demand more time. When a patient cannot be saved, Dr. Bourland says, "you have to go tell the family that their loved one died, and you know that you only have about 120 seconds to do it -- to get them to cry, to get them to yell and scream, to get them calm enough to give them all the facts so they won't wonder later what we did to try to save him. But I've only 120 seconds to do all that, because if I don't get out of there, then three other people are going to die while I'm sitting talking to a family."

"If people think this is a problem only of big inner-city hospitals, they are wrong. They may be dead wrong," says Dr. Stephan Lynn, the director of the emergency department at Manhattan's St. Luke's-Roosevelt Hospital. It is true that there are healthy suburban hospitals that have been largely spared the city's crises. But many rural hospitals are also swamped with trauma cases: farming, fishing and forestry are the most dangerous occupations in America. Isolated from major urban centers, rural hospitals are struggling to recruit and train emergency physicians and to pay for the sophisticated trauma networks that make all the difference in saving accident victims. At the same time they are coping with the AIDS patients, drug overdoses and hospital overcrowding that were once largely confined to the cities. "Sometimes this place is like a M.A.S.H. unit," says Dr. E. Jackson Allison Jr. of Pitt County Memorial Hospital in Greenville, N.C. "The patients don't stop coming. We end up putting people in the hallways and numbering the beds H1, H2, H3 and so on."

But it is the cities like New York, Chicago and Los Angeles that are suffering a meltdown. During the busiest periods, paramedics talk of "medical gridlock." They cannot even unload their ambulances because the emergency room is full, and the emergency room cannot open because every last bed in the hospital is taken. At this point the hospital may go on "bypass" and ask that ambulances be sent elsewhere. But many hospitals that used to go on bypass once or twice a year now do so every week. In California emergency rooms open and shut like tollgates depending on the traffic. Because surgeons were too busy, one homeless woman who was transferred to Harbor-UCLA Medical Center to have a kidney stone removed was released with a waste-collection tube protruding from her body. She was told to come back for surgery -- in one month.

Doctors are loath to admit that patients may be dying because they cannot get proper treatment in overcrowded emergency rooms. Indeed, under such harsh conditions, they are rightly proud of the high level of expert care they maintain. But in some hospitals, as volume grows, there are bound to be errors: in 1988, for example, the New York State health department reported that poor patient care was at least partly responsible for twelve deaths that year at Lincoln Hospital in the South Bronx. In one case, a 30-year-old woman with chest pains died after waiting 5 1/2 hours for a chest X ray; she was never given oxygen or an EKG. At Martin Luther King Jr./Drew Medical Center, an 18-year-old woman who needed a tracheotomy had her throat inadvertently slit and both jugular veins cut by the hospital's trauma doctors. Despite massive bleeding, she managed to recover.

"I know from observation that there have been preventable deaths," says an emergency-room doctor at a private New York hospital. "Ambulances don't get there soon enough. Nurses can't get medicine to patients on schedule. Physicians can't assess all the critically ill patients early. The IVs, the antibiotics and the cardiac medications are delayed. There are no monitors available and sometimes no one to monitor the monitor."

The doctors and nurses of St. Bernard Hospital in Chicago already had their hands full when the Trans Am nearly crashed into the emergency room. The driver, who had been shot in the neck, lost consciousness as he approached the hospital and ran into a retaining wall just out front. Five more feet and he would have landed in the waiting room. The trauma team dragged him out of the car, raced him into the emergency room, cut off his clothes and tried to use suction equipment to get the blood out of his lungs. A thoracic surgeon was called in to locate the bullet, which had entered his Adam's apple and been deflected into his lung. Hospital officials figured that they would get roughly $71 from the state for treating the patient. The first two hours of his care had already cost $2,000.

The crisis is all the more ironic in light of the revolutionary advances in trauma care during the past decade. A generation ago, emergency rooms were dumping grounds for bad doctors and training grounds for young ones. But the experience of two world wars, Korea and especially Vietnam taught doctors that saving injured patients depended as much on speed as on skill. Doctors refer to "the golden hour" after a trauma, before irreversible shock sets in, when lifesaving treatment is most likely to succeed. Beginning in the early '80s, states organized themselves into trauma networks and began tailoring training programs for physicians interested in emergency care as a specialty. The goal was not entirely altruistic: the hope was that most accident victims would be middle class and well insured. "A lot of hospitals looked to trauma victims as $250,000 pieces of meat, and everyone wanted them," says Fred Hurtado, president of the United Paramedics of Los Angeles.

Whatever the hospitals' motives, the advantages for patients were obvious. Trauma is the leading cause of death for people under 44, killing more than 140,000 in the U.S. each year. By improving paramedic training, integrating ambulance services and diverting critical patients to hospitals that specialize in burns or limb reattachment or spinal injury, death rates could be dramatically reduced. In the year after setting up their trauma networks, Peoria, Ill., saw traffic fatalities drop 50%, and Orange County, Calif., saw deaths among non-head-injured auto-accident victims drop from an estimated 73% to 9%.

But in gearing up their emergency-care capacity, hospitals didn't bargain on a crucial economic fact: in the cities, at least, the patients most likely to need such treatment are least likely to be able to pay. Hospitals have always subsidized nonpaying patients by tacking excess charges on to bills of those with health insurance. But when it comes to emergency care, hospitals cannot handpick their clientele. A 1986 law forbids hospitals to turn away poor patients at the emergency room before they are "stabilized." The typical trauma-patient bill last year was $13,000; on average, hospitals took a loss of $5,000 on each. Says Dr. Robert Hockberger of Harbor-UCLA: "It's amazing to me that in 1983 all the hospitals didn't realize that most of the people who shoot and stab each other and wreck their cars at 3 a.m. don't have insurance."

At the same time that the trauma centers were expanding, government subsidies were collapsing. To cap soaring health-care costs, the federal and state governments tightened the controls over how much hospitals could charge Medicare patients for any procedure. Private insurers soon followed suit, with the result that patients who have used up their quota of covered costs are often discharged too early -- only to return sooner and sometimes sicker to the emergency room.

Under pressure to contain their costs, many hospitals began eliminating beds, including some in their intensive-care units. ICU beds are the most expensive because they must be vigorously monitored by nurses. But by cutting back on ICU beds, hospitals simply shifted the burden to emergency rooms and other facilities. "A young man who needed neurosurgery waited eight days before he could get a bed," says Dr. Albert Lauro, director of emergency medicine at New Orleans' Charity Hospital. "Another woman, who had had a stroke, waited four days. They sit in the emergency department hours and days trying to get into the intensive-care units."

In some cases, private hospitals dump expensive patients on public facilities -- not because the private institutions are losing money but because they are not making as much money as they are accustomed to. "Hospitals have shifted resources away from emergency care to drug and alcohol rehabilitation or outpatient psychiatric care," says Dr. Hockberger. "These are the things that make money." According to the National $ Association for Hospital Development, by the year 2000, 40% of the nation's 2,200 acute-care hospitals will be closed or converted to other uses.

At the heart of the problem, health-care experts agree, is the absence of any national consensus or policy on how to care for the poor and underinsured. Many of those flocking to emergency rooms are working people whose employers are no longer able or willing to provide insurance. "The 9-to-5 executive with benefits can take time off to see his doctor," says Dr. Keith T. Sivertson, director of the Johns Hopkins emergency department in Baltimore. "The poor slob mopping the floor until 4 a.m. may be sick after work, yet has to be ready to go back on the job the next day because if he doesn't work he doesn't get paid. Where does he get a doctor at 4 a.m.?" For many people the answer used to be walk-in health clinics; but when funding for these clinics started drying up, some closed their doors.

In those neighborhoods that have functioning clinics, patients may still choose the emergency room because it is open 24 hours a day or because they think the care is better. At Chicago's Michael Reese Hospital, some pregnant women wait in the parking lot until they are close to delivery so they can be admitted through the emergency room. The deluge has forced most hospitals to adapt their primary-care systems. Triage nurses divide patients into two groups: the critically ill, who must be seen immediately, and the less serious cases, which can be sent to "urgent-care centers." For millions of Americans, the emergency room has become the family doctor.

But even the best emergency department is a poor substitute for reliable primary care. Fearful of the harsh conditions and long waits at hospitals, people often put off treatment as long as possible. When they do show up at the emergency room, they are sicker than if they had had regular preventive care, and often require longer hospitalization -- which further ties up valuable beds. "The longer the length of stay, the higher the occupancy rate," says Kenneth Raske, president of the Greater New York Hospital Association, "and the more pressure on the emergency rooms." This is especially true of AIDS patients. While the average hospital stay is around eight days, the typical AIDS patient remains between 20 and 30 days.

One day last spring, Dr. Peter Moyer at Boston City was tending to a young man who had been wounded in a shoot-out, presumably over the cocaine the staff found stashed in his underwear. Hovering nearby was the patient's bodyguard, an immense personage who kept his hand on a bulging object inside his jacket. He refused to leave when the security guards ordered him out. When they threatened to call the police, the patient climbed off the treatment table and walked out with the bullet still lodged in his arm.

The transformation of urban neighborhoods into war zones has turned many hospitals into combat units. "Intentional penetrating injuries" -- which is to say, gunshot and stab wounds -- used to be rare outside the worst inner- city areas. Now every hospital sees them. At the Washington Hospital Center, the number of violent injuries has jumped 94% since 1987, totaling 681 cases last year. Gunshot wounds were up 150%. Today roughly half of those with serious traumatic injuries in Los Angeles have been cut, stabbed or shot.

The drug war is often fought in the hospitals themselves. Patients try to steal drugs and syringes, and attack doctors and nurses who get in their way. At Philadelphia's Albert Einstein Medical Center, three-quarters of those screened at the trauma center tested positive for illegal or prescription drugs. Again, it is not only inner cities that suffer. "Drug pushers realize rural America is an easy mark," says Dr. Allison in Greenville, N.C. "Coke is color blind. It is overwhelming the community, particularly the poor." Adds Dr. Herbert Garrison III: "We have people who come in here carrying weapons and who are out of their heads. Sometimes we have police officers with shotguns in our parking lot."

Drugs and violence combine with a host of social problems that often overpower the medical ones. At Bellevue in Manhattan, a survey last year uncovered the astonishing fact that 42% of the patients in the hospital were homeless. As emergency rooms become the refuge of last resort, social workers are just as busy as the doctors and nurses. Victims of domestic violence are looking for a safe haven, homeless people for a place to sleep, addicts for a chance at treatment. Doctors at G.W.U.'s department of emergency medicine recall the day an elderly, malnourished woman from a local boarding home was brought to the hospital in cardiac arrest. As they were trying, unsuccessfully, to resuscitate her, doctors noticed that she had maggots on her legs under her stockings, and bedsores. "The paramedics said that home was the worst place they'd ever seen," social worker Mary Helen Harris recalls, "and they've seen a lot." She launched an investigation, testified in court about conditions, and the place was closed down.

Before crack, nurse Kathleen Paolicelli could handle drug addicts. "They would come in, they were quiet and you could treat them," says the 19-year veteran of the Elmhurst Hospital Center in Queens, N.Y. But crack, she says, has transformed her clientele and the dynamics of the emergency room. "With crack, it's overwhelming. They're wild, they go after patients, they swing from the IV packets, they jump out of the stretchers. They become paranoid. And they have enormous strength." Paolicelli, a robust woman herself, says the times for playing "little Nancy Nurse" in the emergency room are over. "You're tying people on top of stretchers, sitting on top of people and fighting with them constantly."

For some hospital administrators, the critical-care problem is essentially one of personnel. In New York, a hard-hit city, about 5,000 registered nurses' positions -- about 1 of every 6 nursing jobs in the city -- are vacant and about 900 beds are idle because of staffing shortages. Not surprisingly, emergency rooms are the ones that suffer the largest nurse shortages. Some nurses burn out; others leave because they are frustrated by a job that has come to demand as much baby-sitting of patients as emergency medicine. "I know one who's painting houses right now," says Dr. Thomas Coffee, director of emergency services at Cabrini Medical Center in Manhattan. "She left the profession because it broke her heart."

The doctors are often just a few steps behind. Some pioneering hospitals, like G.W.U. in Washington, have worked to give emergency medicine a higher professional status and to attract doctors to the specialty. The regular, albeit high-stress, hours are appealing, as is the chance to see a wide variety of ailments. "I think generally people see what goes on down here as either stress or excitement," says Dr. Bourland. "Those who interpret it as stress burn out, and those who see it as excitement don't."

Others flee the field because of the risk of malpractice suits. "In the E.R. you're a sitting duck for malpractice, and people here know it," says Dr. Rosenthal. For all their heroic efforts, emergency-room doctors have little chance to establish a continuing relationship with patients and little time for tenderness. The waits can be long, the treatments painful and the sheer volume of patients high. "You have to work quickly during an emergency," she says, "with a lot of angry people, in a climate in which lawsuits are used by people to express their anger."

The obvious solutions to emergency-room overload are expensive and controversial: give people access to affordable health care, pay nurses decently, allow doctors some flexibility in treating their patients and recognize that good preventive care is a sound investment. Though politicians may resist boosting their budgets for medical care, they might be surprised to learn that many of their constituents are willing to pay the price. According to a Gallup poll released this month, 73% of Californians who believe the government should provide better health care for the poor were willing to pay higher taxes for such expanded coverage; 84% favored mandatory employer- provided health insurance.

But in cities like New York, once again facing a crippling budget battle, the hospital crisis cannot be solved without huge new investments and new priorities. "In New York City," says Dr. Lynn of St. Luke's-Roosevelt, "we have a phrase: 'It always gets worse before it gets worse.' " By 1994, AIDS patients alone, who now fill 9% of the city's beds, will need an additional 2,300 hospital beds -- the equivalent of four new hospitals. The major municipal hospitals are crumbling; private facilities are eating into their endowments in order to pay expenses. "It's a crazy way to run a health-care system," says Dr. Alexander Kuehl, director of New York Hospital's emergency room. "Either give us national health insurance or give us an entrepreneurial system, but don't play games asking private hospitals to spend endowment to take care of patients. The endowment is the future."

Another, perhaps inevitable, answer is to ration health care more scrupulously. Already many hospital administrators are arguing that less money should be spent on highly specialized care -- patients with terminal conditions, babies born with multiple defects who are not expected to live long, elderly patients in need of organ transplants. "We have to let some babies die, some old people die," says Dr. John West, a trauma-care expert at the University of California at Irvine. "We have to look at the quality of life, and we have to look at the return on our health-care buck. You just can't keep everyone alive forever."

But the decisions and solutions will not come easily or soon. AIDS will not | be cured tomorrow, nor will the population cease to age. Drugs will continue to kill, as will people who use them. When the doctors and nurses who devote themselves to saving lives on the edge are also asked to be baby-sitters, bodyguards, street fighters and traffic cops, the burnout rate will only increase. And the last thing that a grievously wounded or ailing person needs to think about in a speeding ambulance is whether the hospital doors will be open when it arrives. Until the emergency room is made safe for emergencies, no one will be safe.

With reporting by Scott Brown/Los Angeles, Barbara Dolan/Chicago and Priscilla Painton/New York