COLUMN ONE : Hospitals’ Walk-In Powder Kegs : Violence and threats are common in Los Angeles County’s emergency rooms, where patients endure endless delays. ‘It’s like a war zone in there,’ a County-USC worker says.

In Room 1050 of County-USC’s General Hospital, dozens of patients squeeze into row after row of plastic chairs. Feverish or in pain, they often wait more than eight hours for medical care.

Their attention and frustrations are riveted on the doctors and nurses who sit at the triage desks at the front of the room. And sometimes, as happened Monday when a patient critically wounded three physicians, their anger gives rise to outbursts of violence.

Room 1050--a stuffy auditorium where patients languish while enduring cattle call-like procedures--typifies a county health care system that is overloaded, understaffed and underfunded.

“I’m amazed people haven’t just blown the hell out of the whole place,” one doctor said.

Doctors and nurses say the conditions also make them extremely vulnerable to attack. Studies in Los Angeles and elsewhere confirm their fears, concluding that long waits in uncomfortable surroundings are key factors in many violent emergency room outbursts.

During a six-month period in 1991, officials at County-USC’s General Hospital logged 1,400 incidents of violence or threats. So Monday’s tragedy came as no surprise to many County-USC emergency room workers.

Many of them have experienced sudden, terrifying violence firsthand.

“It’s like a war zone in there,” said clerical worker Ruby Brown, who once saw an angry patient hit an emergency room doctor with a telephone.

Emergency room nurse Vicki Miller said she was threatened with a gun and a knife in two separate attacks three years ago.

Ken Wong, another emergency room nurse, fended off a female patient who came at him last year with a dagger made from a shard of glass.

Doctors and nurses describe emergency rooms as pressure cookers, boiling over with an array of medical and social problems. But even against the backdrop of a national medical emergency in which trauma centers have closed and public hospitals have been deluged with uninsured patients, the emergency rooms at the county’s General Hospital are special.

Every day, hundreds of patients go through the hospital’s three emergency rooms, among the busiest in the country. Most patients seeking emergency treatment pass through Room 1050. That is the room where, according to police, Damacio Ybarra Torres, 40, drew one of three firearms he brought into the hospital and shot three of the doctors who rank patients in the order in which they will be examined.

Those who are in the worst condition and those with cuts, broken bones, chest pains or difficulty breathing get moved quickly into treatment. But the vast majority of people in Room 1050 will wait hours to be examined by a doctor.

Studies have documented the consequences--in violence and making illnesses worse--of the long waits that face poor and uninsured patients who already have encountered many hurdles in their search for medical care.

A study of hospital crime in 1989 found a sharp upswing in assaults in 300 hospitals across the nation. Half took place in hospital emergency rooms.

In recent years, assailants have killed people at hospitals in San Diego, New York, Washington, Danville, Pa., and Utah. During their careers, two out of three emergency room nurses have reported being assaulted, according to a 1991 study of 1,200 emergency room nurses.

The California Emergency Nurses Assn., in a 1992 survey of 103 hospitals in Los Angeles and four other California metropolitan areas, found that almost 60% of the hospitals had injuries suffered by staff members, visitors or patients, and that guns and knives were the most common weapons.

The study concluded that prolonged waits were a major trigger of violent episodes. Besides patients angered by delays in care, the study found that drunk or drug-intoxicated patients were violence-prone, as were those with psychiatric illnesses.

One of the most hazardous jobs in a hospital is working in an emergency room’s triage area, where nurses or doctors act as gatekeepers, sending the sickest patients for treatment and telling the rest to wait.

“You’re sitting bait out there,” said one nurse at Los Angeles County Harbor/UCLA Medical Center. She recalled how a patient once went berserk: “He yelled, ‘I’m not going to wait any longer’ and started grabbing the patient charts and tearing them up.”

Some hospitals have installed metal detectors, surveillance cameras and panic buttons. Others have security guards armed with stun guns. At two Los Angeles County Hospitals--Martin Luther King Jr./Drew Medical Center in Watts and Olive View Medical Center in Sylmar--triage nurses sit in cubicles behind bulletproof glass.

The doctors doing triage at County-USC have no such protection. They simply sit at desks facing the crowd of restless patients.

“The hostility level goes up, up and up,” said nurse Miller, who has worked in Room 1050. “We open at 8 a.m. and by then there can be 100 people already waiting. It’s like an assembly line.”

Adding to patients’ feelings that they are ill treated, Room 1050 is poorly ventilated, noisy and extremely hot on many days. When the chairs are filled, patients slump onto the floor, sometimes spilling out into the corridor. A few bring bag lunches or magazines to help pass the time while they wait hours for such routine services as getting a prescription filled.

Emergency rooms in county hospitals are doing double duty, doctors said. Their resources are already strained as shootings, knifings and drug overdoses escalate. At the same time, emergency departments are clogged by people without health insurance who need basic medical care. In California, 6 million people lack health insurance; 2.7 million live in Los Angeles County.

In this highly charged environment, with its volatile mix of patients and inadequate resources, violence is inevitable, said Dr. Carl Stevens, an emergency physician at Los Angeles County Harbor/UCLA Medical Center in Torrance.

“There will be incidents like this until we find some way to provide patients better access to primary care,” he said.

Some patients, including those with urgent medical needs, simply give up and leave before they are treated, researchers at two California public hospitals found in 1991.

They interviewed patients leaving the emergency rooms of Harbor/UCLA and San Francisco General Hospital without seeing a doctor and documented how long patients who stayed had to wait for care.

In some cases at San Francisco General, patients waited up to 17 hours, the researchers reported in the Journal of the American Medical Assn. At Harbor/UCLA, patients waited an average of 6.4 hours, but many waited more than 10 hours.

Of those who walked out of Harbor/UCLA, 46% were judged--by nurses performing the same triage role as the doctors shot Monday--to be in need of “prompt medical evaluation,” according to the study. Ten percent of them were so sick they had to be hospitalized within a week.

The findings were the first to upset the widely held belief that people who walk out of emergency rooms generally have minor problems and do not suffer greatly by going without care. The study was heralded as concrete evidence of dangerous overload in public hospital emergency rooms, inundated by a growing number of patients shut out of the nation’s private health care system.

Doctors at County-USC have repeatedly warned of powder keg conditions in recent years, as county budget cuts have forced staff and service reductions at the hospital.

“It is terribly frustrating that we have been unable to keep up with the demand for care,” a weary Dr. Gail Anderson, County-USC’s chief of emergency medicine, said Tuesday as he tried to reassure staff members that it was safe to return to their posts in Room 1050.

In 1991, Anderson was joined by other doctors at County-USC in describing conditions that had forced them to deny care to sick people and caused delays that had resulted in patients’ deaths.

Dr. Edward L. Newton, an emergency room doctor, documented cases of patients waiting up to 24 hours in the emergency room for a bed to open up in the main hospital. Several critically injured patients died, Newton said, because operating rooms were full.

A little more than a year ago, patients, some of whom were naked and strapped to gurneys, overflowed the main emergency area and lined a public hallway in what hospital staff members called a shocking new example of the emergency area’s acute overcrowding.

County health officials quickly instituted what they called stopgap measures to alleviate the load on General Hospital’s emergency rooms. But they warned that a permanent solution would require the opening of 24-hour backup emergency services in the county’s six comprehensive health centers, and new links to private hospitals to take up part of the load.

But six months later the state’s latest budget crises dashed any hopes for new programs. County health officials were forced to slash $83 million in expenses to cope with state budget cuts.

“Rather than proceed upward with more hours and more support, we have had to basically try to hold our own with what we have,” Edward J. Foley, the county director of hospitals, said Tuesday.

Foley said the county has attempted to ease congestion at County-USC Medical Center by hiring 100 additional nurses and opening up 24 additional intensive care beds.

“The patient load (in the emergency department) is terrible, but it’s stabilized and we’re doing our best,” Foley said.

Busy Hospitals

This chart compares emergency room visits to visits to on-site hospital outpatient clinics in fiscal year 1991-92. Hospitals listed are some of the largest public hospitals around the country, ranked by number of emergency room visits.

PUBLIC VISITS OUTPATIENT HOSPITAL TO ER VISITS * Grady Memorial Hospital, Atlanta 281,460 528,794 * L.A. County-USC Medical Center 247,109 423,549 * Cook County Hospital, Chicago 205,000 400,000 * Kings County Hosp. Ctr., Brooklyn, N.Y. 147,846 652,042 * Dallas County Hospital District 140,482 341,264 Parkland Memorial Hospital * Jackson Memorial Hospital, Miami 103,453 317,729 * MLK/Drew Medical Center, L.A. 79,420 119,444 * All Public Hospitals (1,429 nationwide) 17.9 million 67.7 million

SOURCE: Hospitals; American Hospital Assn.

Compiled by researcher TRACY THOMAS