The Place Where They Have To Take You In

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

The entrance to the Hennepin County Medical Center Emergency Room is a set of double glass doors under a wide concrete canopy. They're routinely locked; only patients get through, some arriving with lights and sirens, more under their own steam. "Can I help you?" the security guard inquires as someone walks up. "Yes," comes the password. "I need to see a doctor."

Facing the double doors is a big, glass-walled counter where a nurse sits 24 hours a day. The word triage originated in the battlefield to describe the practice of separating the wounded into three groups: those who will live regardless of what you do, those who will die anyway, and those for whom treatment is crucial. Here it means something similar, with one difference. No one is refused care.

Triage has its well-worn rhythm. The morning nurse takes over from the night shift at 7 a.m. and little happens for the first couple of hours. Things pick up as people get up and decide they're sick. Three p.m., when the kids come home from school, marks the beginning of rush hour, which runs through about bar-closing time. Then it slows down again until morning--except for the obligatory cardiac arrest who will come in from a nursing home, like clockwork, at 5 or 6 a.m.

Today's early risers aren't so bad. A lady with a raspy voice fell on the ice in her yard, thinks she hurt her back. "Feels like someone slammed on my crazy bone, or whatever it is," she explains jovially while the nursing assistant takes her blood pressure. "Like knives down your spine. Do you know how terrifying that is?" She carries on, then wants to know if she can have a cigarette. An aide wheels her out; it's early yet, time for small favors. Next comes a man with his arm in a sling, who needs a doctor to write him a slip explaining why he missed work last Friday. Then an eight-year-old who has a high fever that came on fast. "The clinic said it sounded like he was shutting down," his mother says. "They told me to get him down here right away."

The triage nurse types each name into the computer, adding a line to the multicolored spreadsheet that fills some 60 monitors around the department. It's a state-of-the-art, touch-screen system, and Hennepin County was only the second in the country to get it. Each patient is assigned an acuity level, one through five, shown in vivid colors on the screen. The lowest acuities, yellow and green, are for minor complaints--toothaches, head lice, or just feeling out of sorts. Pink is for level 3, Compromised, like the woman with the sprained ankle. The kid with the fever is a Level 4, Serious, which shows up in red. Level 5--Critical--patients are coded black.

By 10 a.m. the screen is mostly pink. "Dizzy," begins the column that shows a shorthand version of each patient's complaint. "Vag Bleeding. Cough. Fatigue with SOB [shortness of breath]. Fell Shoulder Pain. Vomiting Diarrhea. Chest Pain. Abd Pain. Back Pain. Stiff Neck. Chest Congestion. Fatigue. Cat Bite." Next to the complaint column is the patient's time in the department; the wait depends on your acuity and can range from zero to several hours.

A girl walks up, carrying a toddler. "Yes?" "I brought my baby here today. He's got problems--his arms are out of place." The kid lets out a scream when the nursing assistant touches his elbow. "She says she picked him up last night, was swinging him around," Carol, the triage nurse this morning, says softly as she types up the complaint. "But we always have to wonder, was it on purpose?" She peeks furtively at the young mother, who's cooing over the baby and smiling at us from the waiting area. "When they X-ray him, they'll be looking for old fractures."

There's a lot of guesswork in triage, and the ER as a whole. People can't or won't always tell you what's bothering them. Some complain of a cold, and hours later allow how they've been having chest pains for days. Others have learned, with a precision that could get them into med school, just how to work the system; teenagers are especially good at this, delivering a great abdominal-pain impression so they'll get a pregnancy test. It's one reason why only experienced staffers get to work out here.

Carol is the undisputed triage queen. A real estate agent in her spare time, she has the ageless face of a mother, and the cool needed to make split-second decisions. "What's hard," she says, "is when it's real full and you have a 60-year-old with chest pains, a 20-year-old with chest pains, and maybe a renal patient vomiting. Then you have to make some quick decisions, and they're not always what you'd think. The 20-year-old with chest pains doesn't look like too much trouble. But if he's been doing cocaine, that's a whole other story.

"When I train triage nurses now, I tell them: You may place a lot of people who really don't need to be placed, but the worst thing you can do is not to place someone who should be."

Not everyone who walks into triage ends up being seen in the emergency room. Like every hospital, HCMC has made efforts over the years to divert patients who aren't in danger of life or limb; it operates six primary-care clinics and has affiliations with a dozen more. There's also an Urgent Care Center, two doors down from the ER, which sees people with rashes, sore throats, and the like. Psychiatric patients go to a separate mental-health emergency room, the Crisis Intervention Center, which began in the 1970s as a suicide line.

None of these things has significantly stemmed the flow at the ER--not because they don't work, but because the need keeps growing. Some services tap into a whole new market; the Crisis Center is now on the answering machine of just about every shrink in the county. Others barely make up for what's being lost elsewhere. A number of other hospitals in the city have closed or consolidated. A few have simply done away with their ERs in favor of urgent care centers that charge cash up front.

Generally, emergency rooms aren't popular among health executives, in part because, unlike any other unit, they can't perform what's known as a "wallet biopsy." The reason goes back to the mid-1980s, when "patient-dumping" began to make headlines. In one high-profile incident, a Texas ER sent an uninsured woman in high-risk labor on an almost two-hour ambulance ride to a public hospital. She delivered on the way. Elsewhere, patients with minor injuries developed complications during transfer and ended up disabled for life.

Congress's response was an amendment to the 1986 Consolidated Omnibus Budget Recon-ciliation Act (COBRA), prohibiting emergency rooms from sending a patient away unless the person was "stabilized." It sounded obvious, and few people paid much attention until the lawsuits began. Eventually, court rulings made it clear that with one little amendment, Congress had created a kind of last-ditch national health care guarantee. The reasoning, as assistant Hennepin County attorney Ann Russell summarizes it, goes like this: "The decision whether a person truly has a medical emergency in most cases can't be made at triage. They have to be seen by a physician in a thorough exam. And since the exam makes up 90 percent of any medical encounter, it basically means once they're in you might as well do the treatment too."

Health administrators grouse a great deal about this "unfunded mandate," and there has been a lot of experimentation with COBRA loopholes for "appropriate transfers." The act has not been aggressively enforced, and few hospitals or doctors are ever punished under it. Studies estimate that a quarter-million patients still get dumped from private ERs around the country every year.

Dumping, though everyone in the HCMC ER has a story or two to tell, isn't as common here as in a lot of places. But Minnesota has had no respite from ever-tightening insurance rules on who gets to go to an ER, for what, and where. At Hennepin County, says Russell, "We see cases all the time where men will come in with chest pain, freaked out, and Group Health or whoever will say 'send them on over.'" Usually, she says, the hospital will take its chances--treating first, and worrying about the proper justification later. So far it's worked out. But the policies are always being revisited.

Past triage, and down a couple of corridors, is the kids' emergency room--pediatrics, or Peds for short. It's a bright place, with mobiles hanging from the ceilings, colorful stickers, and a few private rooms. One of them, with a dinosaur on the door, is also used for sexual assault exams. Some 16,000 patients came through here last year. The most common complaint was ear infection, with respiratory problems a close second

At 5 p.m. on a weekday, Peds is in high gear. There's a six-year-old with stomach pain, a pregnant 15-year-old, and the intrepid who stuck his tongue on a metal railing at 20 below. An eight-year-old is coming down the corridor, his arrival heralded by furious sobbing as he struggles to get air into his lungs. He's placed in cube four, from which he can see the TV monitor in the waiting room. The movie is The Lion King.

An hour later the doc is still standing outside the cube, talking softly to the father. The kid is quieter now, sucking on a nebulizer and winking at anyone who'll catch his eye from the nursing station. Someone's moved the bed out from the wall so his mother can sit next to him and hold his hand. The worry in her eyes seems out of proportion to an asthma attack.

"When you have a minute," the doc says to the social worker, "I need you to talk to this family. We're in the middle of a financial crisis." Debbie nods and heads in. Another hour goes by.

The little boy, it turns out, is one of five children. His mom works full-time at near-minimum wages. His dad does odd jobs for $50 here, $100 there. They don't qualify for Medical Assistance. They've applied several times for state-subsidized insurance under MinnesotaCare and were turned down each time. Apparently it has something to do with being unable to document the father's income. So when the doc suggested that the kid be admitted overnight, both parents panicked.

"And my job," Debbie says, "is to tell them, 'We have to think about what's best for John right now. We'll get him up there and we'll have someone else call in the morning, and hopefully get this resolved.' But the truth is, I don't know if they'll get it resolved. And even if they do, if it's MinnesotaCare, that's not retroactive. So it's quite possible that they'll get billed for this admission. And the thing is, she's got five kids, she works full time, her husband works. What is she supposed to do?

"Plus, the kid knows all of this. We try not to discuss it in front of him. But he knows." She shrugs, then starts to fill out the admission paperwork--fast, before the parents change their minds. The bill could run them upwards of $1700. "Call me cynical," she says to the doc when he comes to check back, "but I get the job done." He's still shaking his head as he leaves, mumbling something about "national health care."

There are about 24 million Americans in the same boat as the boy's parents now, including some 400,000 in Minnesota. At one time they might have been treated in a lot of hospitals and doctors' offices under the rubrics of "charity care" and "bad debt"--balance-sheet notations for patients who couldn't pay and weren't really expected to. But that practice is fast falling out of favor in a health business where the new buzz-words are "demarketing of services" and "management of patient mix."

What's left is the county hospital, charged by statute and history with providing care for the indigent--or, as they like to say at HCMC, treating "regardless of ability to pay." That doesn't mean patients won't be billed: Statements are duly printed, sent out, even turned over to collection agencies. The eventual collection rate from the uninsured is around 10 percent.

Frank knows all this. He was waiting in the Peds corridor one night for his daughter to get an athletic injury sewn up. Normally, he said, the family stayed away from doctors. But the school said Jeanie could be left with a permanent scar, and they didn't want to take the chance.

Frank graduated from college in '76, with a degree in electrical engineering. Back then, he remembers, "They pretty much fell all over themselves to get us. Offered us benefit packages, profit-sharing, retirement plans, the works. Health insurance was just a given.

"Then the bottom fell out of the industry, and my company sold the engineering department to the Japanese. Eventually they closed the whole thing. By the early '80s, even the engineers were taking jobs as senior techs--if they could get them. Some of my friends ended up making $6 or $7 an hour; I've been doing more like $10 or $11, which isn't really that bad." Frank had his own home remodeling business in Chicago before he moved his family to Minneapolis. He hasn't had health insurance in years. "We've been lucky," he says. "We have seven kids, but other than athletic injuries here and there we really haven't had anything. When we do--well, they send you the bill, you scratch your head and try to figure out a way to pay it off over time. We're pretty much done with the last one."

Does he ever worry about what might happen if someone in the family got really sick? "I told you, we're programmed not to. Seriously. We can't worry about that."

Unlike some of its big-city counterparts, HCMC has been lucky so far, not yet overwhelmed by the growing stream of people for whom it is the last resort. It's clean, bright, well-equipped and ranked in the top 100 in the nation for some of its specialties. It was also just recertified by the American College of Surgeons as a Level 1 trauma center, which means it's qualified to treat any injury; the only other Level 1s in the state are St. Paul-Ramsey Medical Center and the Mayo Clinic in Rochester.

Partly as a result of its credentials, HCMC has maintained a pretty diverse revenue base. A good number of its patients have private insurance; many more are on Medicare or Medical Assistance. The fact that most bills are thus covered by "third-party payors" allowed the hospital to write off almost $30 million last year in charity care and bad debt (three times higher than the highest figure for a private hospital), and to still serve all who need it. "We've had millionaires here," says hospital administrator John Bluford, "literally millionaires. They got into a catastrophic accident, and they got exactly the same care as the person in the bed next to them who was penniless."

But the squeeze is on. While Bluford touts the surplus HCMC managed to turn in 1994, he acknowledges that the system was barely in the black in 1995. For 1996, HCMC faces a potential deficit of up to $5 million. And the federal government is preparing to cut (or "slow the rate of growth") in programs that make up as much as 60 percent of the hospital's revenue. Medicaid losses alone could come to between $650 million and $850 million for Hennepin County over seven years. If you add cuts in Medicare, and potential matching reductions in state funds, the total could reach $2 billion.

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.

John Eppolito is the only doc back here tonight, and he's working hard--the hardest, he'll say later, he's ever worked as a physician. He's actually a family practice resident, which makes his performance remarkable: Most of the family docs who rotate through the ER don't tolerate the work very well. They always want to treat the whole person, and you can't do that here. The maxim is "treat and street"--deal with the presenting problem, write a referral to a clinic, and hope they follow through. If not, they'll be back here anyway.

Now Eppolito swings around to point at the man with the bus ticket. "Look, I'm busy. I'm real busy. Do you understand me?" Denver shrinks a little and points at a large wet spot on his pants. "I just want to dry these." "We don't have anything to dry them here. I don't mean to be impatient with you. You've been a real good guy, and I'm trying to take care of you. But I can't stop and talk to you every time I walk by." "It's just because I'm cold." "Okay. We'll get you a blanket. All right."

Minneapolis has a law against public intoxication, and the cops are required to pick up anyone who's drunk or high to the point where they can't handle themselves. For years, they brought their charges to the Hennepin County detox on Chicago Avenue. But in 1992, an investigation found a string of violations at the facility, and the state pulled its license. The shelters didn't want the detox cases; nor did the jail. That left the emergency room.

The first couple of weeks were crazy, with cops dropping off patients at triage a half dozen at a time. Nurses lined them up on the floor, for fear they might fall off chairs and hit their heads. The staff went into overdrive and within two weeks turned what had been the Urgent Care section into a special unit, separate from the main ER and with its own entrance out back. More than 10,000 patients went through it in the year before the county and the Salvation Army worked out plans for a new detox. It's up and running now, but when its 19 beds are full--or when they, and a scaled-down facility at 1800 Chicago, feel they can't handle someone--it's back to HCMC.

Besides drunks, Specials is also in charge of admitting patients who come from the jail and the workhouse, and those who "got arrested and got hurt somewhere along the way." The beds all have leather restraints that can be fastened to ankles and wrists; the holding rooms have doors that bolt shut when needed, "to decrease the stimulus."

Dawn is one of the nurses who works Specials a lot. Blonde, a mother of two, and married to a paramedic, she is quick with the kind of humor that cuts through the bullshit. She's been in the ER for five years since coming over from Riverside Hospital. "It was a big change. Real big. I grew up in a sheltered environment, suburban family. I could never go downtown. And now this. I was like, wow, people live like this?"

"415, 415," the ambulance beeper squawks, "possible sexual assault. Bloody, ETOH [intoxicated], and combative." Dawn scurries over to Holding Room 1, rousts a patient, and leads him out in his slippers and hospital gown; he'll sit in the waiting room for a while. A minute later the paramedics wheel in the gurney carrying a figure in restraints covered with blankets. "Why are you doing me like this?" a voice groans from underneath. "I'm not an animal. Please take these off me. Oh Lord. I won't say anything." "Okay," one of the medics grins. "Why don't you try that for a little while?"

Dawn kneels at the bottom of the bed, her face level with the man's. "Dave, I don't want you to fight, and I don't want you to spit. Okay?" The minute the restraints come off, his hands go flying and she catches a whack. "Okay, Dave. You're here at the Hennepin emergency room. Do you want me to help you?" "I want to talk to somebody." "Yes. We're going to have a talk." A man in green scrubs walks in, and Dave's body jerks. "You're going to whip me," he moans, and to Dawn: "Don't go. Please, please don't go." "I won't go." She introduces the doctor. " We're here to help you."

"I'm dying," Dave says. "Why are you dying?" "It's inside. There's something inside." "Did they try to put something inside you?" "I thought they were my friends. But they shot me up." "Where did they shoot you up?" He points to his arm, which is covered with needle marks and what looks like cuff scars on the wrist. "But that's old," says the doctor. Dave looks at him wide-eyed. "You're gonna shoot me up with something, and I'm gonna die. You just tied me up."

A woman in a flowery dress shows up with a name tag that says she's with the Sexual Assault Resource Service (SARS), a group of nurses specially trained to handle rape cases. Dawn briefs her on Dave's complaint and the cops' report, which wasn't very clear. "It's weird," she says. "I don't know if this rape is a now event, a past event that's coming back to him, or what." The SARS nurse goes in and shuts the door. Ten minutes later she emerges, shaking her head. Dave doesn't want a forensic exam, which involves sampling bodily fluids from every orifice. He wants Dawn. "What is it?" she glares, after the nurse tracks her down a few cubes away. "I just wanted to tell you," he says with a sly smile, "you look a little butch."

Eventually Dave is put to sleep with a shot of tranquilizer, the SARS nurse leaves, and Dawn pulls up his old chart. "I can't believe this," she groans after the first couple of pages. He was here with the same complaint recently. And again a few months before that. And several times before that. For the rest of the night she spends spare moments perusing the chart, searching for clues.

There are plenty of regulars--"frequent flyers"--in the emergency room. One guy comes in every month or so, hurting in his shoulders or his back, demanding a heavy-duty painkiller. One woman appeared at triage every morning for a while, carrying two shopping bags. They'd take her blood pressure and she'd be on her way. Occasionally guys will come in from the cold to hang around the waiting room. When they are told to leave, some start to cough and grab their chests. Most of the frequent flyers, though, come through Specials, and they are the ones who get the staff worked up. "Minneapolis is too kind to the poor," one of the doctors says between checking on people too drunk to control their breathing. It's enabling, he says, to take people in like this over and over again.

In some ways, the regulars are the dirty little secret of the emergency room. No one wants to admit that money is spent, night after night, on people who may need no more than someone to watch so they don't throw up and choke; yet no one can face what it would mean to turn them away. Some of the chest-pain malingerers have had heart attacks; some of the guys who stumble and weave actually have internal head injuries. The only way to find out is through a thorough medical examination. By the time that's done, they may as well sleep through the night.

Not that the staff is happy about it. To varying degrees, almost everyone complains--out of earshot--about "people who don't make good choices in life." There's a good deal of hostility in the phrase. Patients are crabby most of the time, and almost everyone on staff has been punched, kicked, or spit at. Some staffers come to harbor a profound resentment about the way "these people take everything for granted." It comes out in odd places, like the extended tug-of-wars over whether someone can have a cab voucher or needs to take the bus. People who take all this very seriously usually end up leaving.

Those who stay put have other targets for their anger. The way cops and ambulances keep dropping the drunks here, when any hospital could treat them. The way any problem can be let go until it becomes a medical emergency. The way all this seems to be a comfortable arrangement for "the outside." What evolves between them and the patients is a kind of grudging solidarity among people who know the game being played. Staff and regulars know each other by name and tacitly work the system together to extract medications, food, a better shelter placement. When word comes that someone froze to death on Franklin Avenue, people will ask each other who's missing.

"It's funny," Dawn says one night as we're blowing smoke into the freezing air outside the Specials door. "You get yelled at so much, some days you think your name is 'fuck you.' But somehow, you learn to blow that off. And you come to care for them. A lot of days, I get home just enough to tuck the kids into bed. I see more of our regulars than I do my family."

It's a weekend night, and the only gunshot wound in sight is a guy whose blackpowder rifle discharged, fracturing his thumb. In cube 6, a resident is sewing up a piece of skin protruding from a mountain of towels; next door is a guy who's been vomiting all day. Soft pieces of conversation float in from the cubes as you walk by. Occasionally the flow is punctured by a scream from the nursing-home patient in cube 8. People here learn quickly which cries of "Help me!" to ignore. Two of the docs are discussing baseball.

A piercing beep tears through the room as all the red pagers worn by select staffers around the department go off at once. "Stab room personnel to the stab room," the speaker squawks. "Stab room personnel to the stab room now." (The word is pronounced "stabe," as in stabilization.) I follow the flurry of blue and green scrubs, the gurney flying past, and squeeze into the doors that say ABSOLUTELY NO ADMISSION. "Get the restraints off," someone calls. "Anyone have a key?" The four leather bands around the man's wrists and ankles come off. With the help of some sharp blades, his clothes follow. "We need IVs," someone yells. "Quick." "This guy's under arrest," says one of the cops who came in with the gurney. No one pays attention.

"We have a cardiac standstill here," the senior resident--the "pit boss"--says. "Get me an IV. Start CPR." Nurse Mike McCloskey puts his hands on the chest and starts compressions. There are at least five people huddled around the patient. "Go ahead. We need an IV. Stop CPR for a moment. Sounds good on the left." The man's chest moves. "Someone check for a pulse. No pulse. CPR please. Five milligrams of epine-phrine please." A nurse hooks another bag to the metal stand overhead; someone pumps on the bed until the man's feet stick up in the air.

Suddenly, something goes thump. They've wheeled a machine over to the patient's left, with a piston that goes up and down on his chest. This must be the sound the woman from admissions was talking about yesterday, when she peeked in the door during another critical case. "He's dead," she said. "Whenever they bring out this machine, I know it's over." They call it the Red Ram.

The cop's head sticks in again through the door. "This guy, do you have anything going on him yet?" His expression is hard to figure; it's a tough face, but there's an odd glimmer in the eyes. "I placed him under arrest," he says, squaring his shoulders in the leather jacket. "Who's the doctor in charge here?" "I am," the pit boss answers, not looking up. "This guy," the cop tries again, "is probably cracked up on crack cocaine."

The Ram keeps pumping while someone goes to fetch blood. The voices quiet a bit. A couple of nurses talk about who's going on break next. "Anyone know who he is?" calls the doc to the cop. "No. He wouldn't even tell me his name." There are six lines on the monitor above the patient's head, all different colors, all flat. One of the docs is holding on to the man's wrist.

And then the red beepers go off screaming again. "411, three minutes out, male, stab wound," crackle the speakers. Everything freezes for a second, then another team materializes at the second bed. The far doors fly open and paramedics blow through, barely stopping to unload the patient. "What's your name?" the pit boss says, leaning into the guy's face while shreds of clothes fall to the sides. "Jake? Jake, where are you hurt? Hold real still now. Watch, everyone--he's gonna throw up." He does.

"We picked that guy up at a party," says the paramedic watching from the sidelines. "Big party gone bad. Couple of hundred people in a fight. He walked up to us, says 'do I really need to go to the hospital?' Yep, I says, I think so. 'Do I need stitches?' Well, you're going to need stitches where your eyebrow's pierced. He says 'my eyebrow's not pierced.' Well, I says, what's that piece of metal? So I pulled on it and it didn't move. I thought, uh-oh."

"Guess whoever did it did some prison time," says his partner. "That's what they do in prison--whenever you get stabbed, they break it off so you can't pull it out and use it against them."

By the other bed, the thumping has stopped--maybe just now, maybe minutes ago. A couple of residents head for the door, shrugging. The one doc is still holding the guy's wrist.

"We got some heartbeat," she says after a while, looking at the monitor. "There's no pulse, but this is the first time he's registered anything." "Let's start again," the other doc says, "just once." Thump, the machine cranks up again. Thu-ump. The man's chest heaves. "He's dead, isn't he?" says the nurse next to me. "Guess they haven't pronounced." "He's not dead," comes a voice with an affected British accent. "He's me-ustly dead." A hand twitches as someone pushes a button.

"Here's the X-ray," calls the pit boss from the other bed. The films show Jake's skull, plus something long and narrow that doesn't look like it belongs. "Think it's a pencil?" one of the docs asks. Laughs all around. "Neurologically intact," someone comments.

On the first bed the CPR has stopped. Lines are being disconnected. Two men in suits and long wool coats materialize at the other end of the room, looking straight out of central casting--one stout, one thin, both with little sardonic twitches at the corners of their mouths. "Homicide," the paramedic says under his breath. "Did you see that cop who brought the first stab in? He's all freaked out. It's his first dead guy."

The stabilization room is one of Hennepin County's contributions to the world of emergency medicine--an ER within the ER, dedicated to patients for whom a bumpy elevator ride or a trip down miles of corridors could make a fatal difference. Its purpose is to turn catastrophe into a kind of equilibrium; they'll put in artificial airways, hook up fluids, stitch up gushing wounds. Most patients go on to surgery or intensive care. Some--two or three, out of 20 to 30 stab cases in an average week--go to the morgue.

Not everyone likes to work the stabilization room. "I get gastritis the minute that beeper goes off," says Marsha. "And I need to go to the bathroom really bad." "That's because the beeper is hooked up to the bladder, didn't you know that?" Dawn says earnestly. "What you're saying is you're not a trauma junkie." Trauma junkies like the adrenaline rush, and the high that comes from working on instinct; there are times when the three docs and two nurses required on any stab case seem to function as a single body, in a tight choreography that leaves little to chance.

"I like the feeling that you can have an impact," Dawn adds. "Out in the cubes, you have to treat them for hours, and you never know what the outcome is going to be. In stab, it's a lot more simple. They're going to live or they're going to die. And you can make the difference."

You also get to do some top-notch medical work. "Good stabs" (the staff uses the phrase without any irony, as firefighters might talk of "a good four-alarm") challenge skill and imagination; they can crack a chest in here if needed, breaking ribs to reach in and plug a hole in the heart with a few staples or a finger. "I remember when I saw them use a Foley catheter [a kind of inflatable balloon] on the heart for the first time," Dawn says. "The guy didn't live, but it was neat. When you look at it as a person, it's sad. But when you look at it as 'here's the lungs, here's the heart, here's how it all works'--that's fascinating."

When a patient dies in the stab room they don't break the news over the phone. There's a family room reserved for those occasions, a tiny, windowless place with an African-themed wall hanging and a pastel landscape. If they want, relatives are taken into the stab room; nurses and doctors will go with them and touch the body, so the relatives feel comfortable doing it too. Security is not far behind, because people often "act out their grief" by going after the equipment or the staff. Some family members have ended up back in Specials, with four-point restraints and tranquilizer shots.

Apart from dealing with the families, they don't talk about death much in the ER. It is, Mary Ellen explains, just one of many events you deal with by the appropriate set of procedures. "There was a student from the U here once," she chuckles, "trying to do her master's thesis on emergency nurses' response to death. She had to give up, because she didn't get any."

"Some people deal with it by telling sick jokes," Lynnell says. "I drive 22 miles to Lakeville, and by the time I get home I'm usually through with it. Stuff with kids bothers everyone; with a SIDS death, usually the whole department is upset for days. But you don't really want to talk to anyone about that." Hennepin County offers debriefing sessions for medical and law-enforcement personnel who have been involved in high-profile traumatic cases. Attendance from the ER is notoriously light.

"You develop this teflon around you," Mavis, another veteran nurse, muses over coffee. "Stuff doesn't stick. It can't. Because if it did, pretty soon you'd be stuck all over, if you know what I mean." She pauses. "It's just there all the time. You're driving to work, and you think 'are my closets in order?'"

Diane chimes in: "Or, like your mother told you, make sure you have clean underwear. I tell my family every day how much they mean to me." She pops her food out of the microwave. "Remember that creamery fire you and I worked? At 11:30 at night? What you told the guy?" Mavis shakes her head.

"He had burns over 98 percent of his body, and he couldn't speak. But you could tell he could hear, and he was trying to talk. And you just said three things: That his family was coming over, that he was going to die, and that the pain was going to stop. And he calmed down. I'll never forget that."

Dr. Ernie Ruiz, the ER's godfather, works these days out of a small office in the parking ramp, a block away from his department. He has lots of projects in the works--fighting to establish an emergency-medicine specialty at the University of Minnesota, training rural doctors in the basics of crisis care. The only time his enthusiasm wanes for a moment is when I ask about the point that comes up almost every time politicians and administrators discuss emergency medicine--how expensive it is, especially when people come for the kind of "primary care" that could be provided at a clinic.

"I'm a very poor businessman," Ruiz says apologetically, "and I know virtually nothing about the cost of medicine and the managed-care milieu. I always felt that our job is to do the best we can by our patients, regardless of the cost. That's one of the reason why I'm not chief of emergency medicine anymore." He quit the ER two years ago and was replaced by Dr. Joe Clinton, one of the physicians he trained. The assistant chief is Steve Sterner, and he's the doctor I'm assigned to follow one day.

Sterner is a thin man with a hawklike nose, a crown of hair, and an unflappable disposition. He's barely started the shift when the ambulance beeper goes off; six minutes out, right side weakness. "Ugh," go the residents. "Stroke."

But there's no stab announcement when the paramedics bring the old man in on a stretcher. He's had this problem for a while, one of them explains; a doctor at the neighborhood clinic has been monitoring him. "So what's new this morning?" Sterner asks. "Nothing so much new as that it got to the point where the family couldn't handle it anymore. The incontinence is new, I guess, and he's more confused than he used to be."

Sterner nods and hands the case to the resident. "This is a typical case of what we see with all the managed care now," he says, walking away. "People have chronic, long-term problems, and there's a care plan set up with a high priority on conserving resources. But the patient, or the family, may not be happy with that. So a visit to the emergency room is a way of creating a crisis point when they feel they're not getting anywhere. Because they know that at least we'll see them. Then it's out of their hands and into ours.

"So we negotiate. We may get a social worker involved. We may talk to the primary care provider, and the HMO, and the family. This patient might at some point end up in a nursing home. But the nursing homes don't like to take people whose payor status isn't clear, and it's not easy to find a bed, and there's a strong emphasis on keeping people home as long as possible. And so he might be back here.

"We understand that the primary aim of managed care is to hold costs down by withholding services, and ideally you'd want to withhold unnecessary services. But that's a fine line."

This question of "withholding services" is something of a sore point with ER people. Like everyone, Sterner has heard the charge of "ER abuse," which comes down to the premise that anyone who's not critical shouldn't be here. He bristles a little at the figure generally thrown around--that an ER visit is three times as expensive as one at a clinic--noting that that's based on billings inflated to make up for insurance companies' discounts. According to a study published in last month's New England Journal of Medicine, the true cost of ER care for a noncritical case is only about 50 percent more than a clinic visit, due mostly to the expense of equipment and round-the-clock staffing.

That's still a fair chunk, and Sterner acknowledges that "a lot of the patients we see could be seen somewhere else in the health care system. But that's assuming"--now his trademark grin turns sarcastic--"that there is such a system."

If you've been sick lately, you probably know the story. You don't just walk into a doctor's office. You have to figure out which plan you're on, which clinics are approved, whether you have to call a help line first to get permission. You have to be prepared to wait a couple of weeks for an appointment. You need a phone, a babysitter, transportation, and of course you must be able to speak both English and insurance jargon. A recent study found that close to 40 percent of patients at large, public-hospital emergency rooms were "medically illiterate" to the point where they couldn't read the instructions on a prescription bottle, much less navigate the requirements of the average health plan.

"And even if they do all that," Sterner says, "and they finally get in to see a physician, if there's any barrier--education, language, whatever--then that physician is scheduled for six patients an hour. It's not like Marcus Welby. They don't have time to sit down and talk for an hour and figure things out."

"A lot of things are falling through the cracks. We're going from a cottage industry to a really, really big business that's turning out big dollars, and there are some very large corporations that are trying to make it a system by combining and coordinating services. But we have a tremendous number of patients who are bouncing all over the place, and they end up here."

During rounds, Sterner stops at one of the back cubes, where an older man is sitting on his bed, bent down so far his head points toward the ground. He's been letting out long, low moans every now and again. "What's wrong?" the resident asks as Sterner hangs back. "I'm just tired." "What--tired of the waiting? Your kidney disease?" "No. All of this. My whole body hurts. When I try to sleep at night, it just hurts all over. I can tell you there's something wrong. I can tell I'm getting weaker." "Well," the resident says, "you know, there's a doctor who's been following you for this--"

"Please," the man interrupts. "I just want someone to do something. Run a test. Do something. If you have to put me in the hospital, put me in the hospital. If I'm going to be in a wheelchair, at least get me prepared for it."

"But, sir, this is the emergency department. We don't have a lot of the equipment that we could use to run tests. We can look at your records, and maybe get an appointment for you and get things going in the right direction."

"But that's what everybody is telling me," the man's head drops again. "I'm telling you, this is getting too much for me. I can't take this anymore. I've been trying, but--I'm only keeping going because of my poor mother. She's real sick. I know that if something happened to me, it would kill her."

From the bottom-up perspective of the emergency room, it looks as if almost every time things tighten somewhere up the line--even when the changes appear benign--the chips fall down here. Like the advances in medical technologies that have made it possible to do complex procedures without keeping patients overnight. This has allowed hospitals to eliminate costly inpatient beds, which in turn puts more pressure on the people guarding the door.

"Our patient population has gotten a lot sicker," Sterner says, "and there's more of an effort to keep them out of the hospital. Here, any patient who stays for less than 24 hours [after being moved from the ER to a unit] is considered an inappropriate admission, and we catch heat for that. We've been able to keep our rate down pretty well, to about 1 percent. But it's always at the back of our minds. So we treat patients very aggressively for six or eight hours, and send them home. There's a girl back there who probably has a kidney infection, and that would have been a no-brainer 10 years ago--stick a line in her and send her upstairs. Now we load her up with antibiotics, check her white counts, give her some medication, and send her home. And she might be here tomorrow and we might start the same thing all over again."

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."

It's the wee hours of a cold Saturday night; the stab cases are all gone, the drunks are all sleeping. Jeanie, who came in four hours ago complaining of blood in her stool, finally has a doc in with her. "I'm sorry you had to wait," he says, cutting off remonstrations. "But we had four critical cases in the last two hours, and you're doing better than they are right now." "I don't know about that." "Yes. You're talking to me." "But I had to wait for hours. I'm sitting here and they don't even give me a pill." "Yes. But your heart is beating, you're breathing, you're better off. Believe me."

Later, Jeanie ends up sitting next to me by the main desk, waiting for her discharge papers. The doctor gave her some Maalox, which she thinks probably would work to hang wallpaper with. But she's feeling much better, and very talkative. She has three kids, and a 57-year-old mother who's had a triple bypass. "She calls every day between 7 and 8 a.m. 'I'm feeling sick this morning,' or 'I'm feeling a little better this morning.' It's always something.

"Then one of my kids is asthmatic, and two are hyperactive, and their dad isn't worth two cents so I do everything. My mother lives 20 miles away, so I take the bus, and then I come back and take care of my kids. I'm always in between."

I ask if she's been here before. "Oh yes. My doctor's here. I wouldn't want to go anywhere else. I don't like the waiting. But I guess there's nothing they can do. There's a woman in that cube over there, tried to do away with herself or something." She looks around knowingly, then lets out a long sigh. "I don't know what's happened to me. I used to be a healthy woman. But now--they must think I like to come here or something." She falls silent.

This is the time of night when you suddenly realize you've been staring at the same blemish on the vinyl floor tile for about five minutes. No amount of coffee will work. The hands on the wall clock are frozen. Your ears seem wrapped in cotton, yet you suddenly notice the elevator music playing overhead.

Out at triage, an early-fortyish woman in a red coat leans on the counter, her whole body heaving. A man walks up to her, puts his hand on her shoulder. "Can I help you?" the nurse asks. "Yes," she sobs. "I think I may be having a miscarriage." The aide gets her vitals wordlessly and pushes her in.

Then it's quiet again. Back inside, one of the docs looks up from his chart. "Is there any sense to what we do?" he asks matter-of-factly. Two of the nurses and a secretary are making arrangements for breakfast after the shift. Someone is talking about this wind machine you can get, to make a soothing noise when you sleep during the day. A maintenance man pushes around a gigantic broom, spreading a smell of stale blood and lemon. CP

News interns Mary Ellen Egan and Neil Sexton contributed to this article.

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