The Place Where They Have To Take You In

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

For now, Bluford puts a good face on the ominous. The HCMC system--soon, after the University of Minnesota/Fairview merger, to be the only public hospital in the Twin Cities--only gets some 6 percent of its revenues from property taxes; there is a chance that taxpayers and politicians will come up with a little more. But that will only go so far. The hospital has been cutting back for a while already, and it's starting to hit bone. Eventually, Bluford predicts the Twin Cities may well follow other cities into a health care system with three tiers--first-class treatment for those with money and really good insurance, decent care for others, and for the rest bare-bones medicine that merely fulfills the obligation of not leaving patients to die in the street. "A lot of hard decisions," he says, "are going to have to be made at our front door."

In some hospitals, they refer to the emergency room as "the pit," and the word accurately reflects its position in the system. Working there is rarely a choice, and never prestigious. More and more facilities are resorting to hiring temporary doctors and nurses, sometimes flown in by specialized services; a few of these have been accused of serving as a last resort for physicians who've lost their licenses.

By contrast, people actually stand in line to work at the HCMC ER. Its doctor training program attracts some 600 applicants for the ten residency slots that open up each year; residents stay for three years and do most of the floor work, along with faculty physicians and a gaggle of medical students and rotating interns. There's also never a shortage of applications for nurses, nursing assistants, and clerks.

Barely three decades ago, most hospital emergency rooms were little more than first-aid stations; patients in need of more were whisked straight through to the appropriate unit. That began to change in the 1960s, when the middle-class exodus from the city reached critical mass, doctors and clinics followed the population, and the ER was left to pick up the slack. It was Dr. Ernie Ruiz, a young surgery resident fresh from L.A., who cajoled the county into establishing a full-fledged emergency department, only the second in the country. "There was nothing else I could imagine doing," he remembers. "The need was just so tremendous."

Now the ER has 30 beds (actually metal contraptions on wheels, covered with thin plastic mattresses and surrounded by blue plaid curtains), along with a series of specialized rooms designed for everything from critical care to Ob-Gyn, dental, and eye exams. There's a social worker on duty 24 hours a day, to sort out things like nursing-home placements, drug treatment referrals, and whether to separate kids from their parents. Chaplains, battered women's advocates, interpreters and security crews are also on hand. A room up front, whose air goes through a special ventilation system, is reserved for patients with potentially dangerous infections; more will be built during an upcoming renovation, to deal with the resurgence of such diseases.

The renovation will add more space to the ER in general, and it's needed. A decade ago, the department saw some 70,000 people every year; last year it was more than 90,000 (including Urgent Care), and that's not counting 11,000 more who got referred somewhere else from triage. Right now, all the beds generally fill up by early afternoon; it's not technically legal to set up additional spots in the hallways, but they do that too when push comes to shove.

Despite the workload, the place feels oddly unhurried most of the time. Doctors and nurses move around at an even pace, working off lists in their heads--an IV in cube 8, discharge papers for 6, call the social worker for 5, set up X-rays for 4. The only time they seem to get nervous is when things are too slow; then you can see nurses actually fighting over who'll get the next patient.

As anywhere in health care, turnover is relatively high; a lot of people try working here for a couple of years, then burn out. But a striking number become addicted. It's the variety, they'll say, the adrenaline, the gut-level necessity that governs the place; then they backtrack and add that they can't really explain it to anyone from "the outside." The ER has its own dress code (everyone, from nursing assistant to physician, wears scrubs), language (purpleheads = heart attacks), and fierce camaraderie. "I wouldn't go for beers with a lot of the people who work here," says Lynnell, one of the senior nurses. "But when there's something I need to talk about--which isn't often--I'll talk to someone here. Because no one on the outside would understand."

It's 10 p.m., and Special Care is hopping. A man who came in foaming at the mouth, perhaps having a seizure, keeps yelling incoherently; sometimes you can make out what sounds like name, rank, and serial number. The yelling grows worse whenever the security guards walk by. In number one there's Sarah, who's been drinking mouthwash and vodka plus something else that's giving her gut rot. A man with a bus ticket to Denver, who was found sleeping in the Greyhound parking lot, is yelling "Doctor! Doctor!" from his seat in the lobby.

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