The Place Where They Have To Take You In

Days and nights on the front line at Minnesota's busiest emergency room.

The story plays out over and over, in medicine and beyond. When detox closed, the drunks came here. When shelter beds are cut, the homeless come here. The list goes on--policies that kick people out of mental health institutions, laws that deny medical benefits to undocumented immigrants. Battered women's shelters that have no room, clinics that close. Emergencies that turn routine.

Everyone in the department has a metaphor to describe what's going on. Some talk about a funnel, a vortex that draws people through the doors; Paul Finney, one of the nurses, sees it as "lines of trouble that run all over the city, and they all go to the ER."

It's getting close to the end of the shift. There's a head-on collision flown in from up north; he goes into the stab room next to the man who was found in a snowbank this morning. Within 10 minutes another critical arrives, an asthma patient whose breath is so constricted his chest whistles. They're putting him on oxygen, waiting to get into stab as soon as the accident goes up to surgery. Sterner settles into the observation room to watch.

"I never really planned on staying down here," he says after the first three minutes of silence all day. "But one of the reasons I did is that this is such a tremendous place to work. We practice a brand of emergency medicine that is practiced at only a few places in the country. With trauma, penetration wounds to the heart, if they have any sign of life when they're found in the field--I don't think we've lost one of those in years. We have enzymes that can dissolve coronary artery clots in 15, 20 minutes from when they hit the door. We're doing truly exciting things. But we've also become the safety net for everyone that someone else doesn't want or doesn't know what to do with.

"We've paid for that over the years through cost-shifting--we take some of the money we make from the insured patients, or the ones who are not as sick, to pay for the uninsured and the sickest patients. But we're coming to a point where the smart businesspeople are running all the health care companies, all the HMOs. They're not interested in having cost shifted onto them, and they're very good at making sure it isn't.

"So far, even with the emphasis on managed care, we've been able to just about hang on. But it's like all those corporations. You can cut and cut and cut, but there's a point where things start falling apart. And I have a feeling that we're approaching that point.

"Now we have two alternatives. Either we figure out another way to provide care for the people who don't fit into the system--if it is a system--or we're not going to provide care for them. And at this point, after the national health care debate we've had, it looks as if each community is going to have to decide that for itself."

Some have already begun. Los Angeles County last year contemplated staving off bankruptcy by closing three of its five hospitals and 35 of 40 neighborhood clinics; in New York City, mayor Rudolph Giuliani wants to privatize the entire public health system. Similar stories are playing out around the country in an inevitable and disastrous logic. Since strapped hospitals can't turn away the sickest patients, other things--prevention, public health nurses, social workers--must go instead.

"We have doctors and nurses right now going out and giving people shots in the shelters," Sterner notes. "If you pull that out, something like tuberculosis could become an epidemic. People are going to be afraid of going to public places, going to the theater, the grocery store, because of these people with untreated TB running around. And immunization--you may know that immunization only works when you have a very large number of the population immunized. If we get huge numbers of people who don't get their shots, we're going to get epidemics, and your kids are going to get them no matter how well-insured you are and how well you immunize them. The consequences, when you start losing your public health system, are far beyond what most people can imagine."

The fallout, as always, lands in the ER--which, in a final bit of irony, serves as the ultimate social equalizer. In some large hospitals, if you come in with a sore throat or a feverish kid, you may as well be prepared to camp out for a day; if you're having a heart attack, you'll have to step over the people camped out. "There are a lot of places in Mexico where you'd rather have an emergency than in New York or L.A.," Sterner says. "You can be the highest-paid executive in New York City, and if you get into a catastrophic accident, you can't get the care that an uninsured person in Minneapolis can. They have cardiac patients in the hallways, waiting 12, 24 hours for a bed in the coronary unit."

"You can turn the screws down on your health care system until the resources aren't there for the uninsured, the disorganized, the hard-to-manage. But then you're also going to have problems taking care of motorvehicle accidents and strokes. I'd call it an early warning signal. When things go bad here, that's when you know that you have a very sick system."

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