Aeron Garcia, who suffers from congestive heart failure, has been in the Los Angeles County-USC Medical Center emergency room for almost 24 hours.
Paramedics dropped the 37-year-old uninsured trucker from Pomona in the emergency room the night before because his body suddenly swelled. He spent eight hours waiting for a cubicle and 15 hours inside one, lying on a gurney and waiting for a bed to open up in the relative calm of an intensive care ward upstairs.
The patient in the next cubicle is screaming for her mother. Other cubicles hold a middle-aged homeless woman recovering from a seizure; a woman with an unknown ailment that has caused her to lose two-thirds of her blood; and a 40-year-old woman with heart problems stemming from rheumatic fever.
Dr. William Mallon surveys a traffic jam of patients on gurneys stretching along the corridors and mutters a curse.
Emergency rooms are intended as thoroughfares, where the seriously ill can quickly be diagnosed and dispatched to appropriate specialists. But at County-USC, this is where the gridlock begins.
Doctors say long waits and other roadblocks are increasingly jeopardizing patients at this hospital, the linchpin of Los Angeles County's financially pressed emergency and trauma network, with one of the busiest ERs in the nation.
It typically takes nine hours for the most seriously ill patients to get out of the emergency room and into a hospital bed, according to a study of recent visits by an emergency room administrator, Dr. Kirsten Kalder. Waits of more than 20 hours are not uncommon. The record is 84.
Long backups are common in the emergency rooms of urban public hospitals nationwide. Although experts could cite no statistics to compare County-USC with other places, doctors at the Los Angeles hospital say the waits there are intolerable. The congestion is worsened by a severe nursing shortage that forces officials to close vacant hospital beds for lack of staff.
Even a few hours of delay can be fatal, and cursory tests are no substitute for careful examinations, doctors say. One ER patient complaining of chest pains late last year got an EKG suggesting no problem. His pains went away, and he waited six hours to see a doctor. Almost as soon as he did, he died of a massive heart attack, said emergency room Dr. Michael Orlinsky.
Orlinsky says there are too few people to sort through too many patients. He compares triage under these circumstances to "a form of Russian roulette."
For every patient like the seriously ill man whose EKG was normal, "I've got 15 guys where the pain didn't go away and the EKG doesn't look so good," he said. "We're trying damn hard here. We just need some help."
One day in January, 31 patients were waiting to see doctors. Amid the chaos, one was all but forgotten. Ill and apparently suicidal, he was strapped to a gurney for 19 hours before anyone gave him anything to eat or drink, a physician complained in a memo. Then the patient waited an additional six hours for more water. Later, he had to be treated for dehydration.
The heart of the emergency room is a partitioned area the size of a large bedroom called C-Booth, where ambulances bring gunshot and car crash victims and others on the verge of death. Conditions are so cramped that doctors desperately trying to resuscitate someone there must also take care not to jostle a colleague who may be delicately drilling a hole in the skull of a neighboring patient.
Doctors who train and work in this cramped critical care environment describe it with awe. Physicians in training are solemnly instructed that it has seen more lives lost and more saved per square foot than any place on Earth.
On a recent night, a comatose teenager who tried to hang himself with an electrical cord languishes on one of the gurneys in C-Booth. He occasionally twitches, shaking the thick black bracelet on his ankle that marked him as someone who had been under house arrest. "It looks like he's going to be dead," observes Mallon.
In the gurney next to the boy, a middle-aged woman with blood clots shrieks as doctors stick a tube in her neck. "Help me, help me. Oh my God, the pain."
And next to her, a heavyset man sits up quivering and quizzical, wondering why his bare chest is wired to machines and strangers are hovering about. "You had a stroke," a man in a white coat tells him.
C-Booth is surrounded by 18 smaller curtained cubicles, each just big enough for a gurney and a monitor. They are all filled with patients. Aeron Garcia is lingering in one.
Garcia said he recognizes there are limits to the quality of service at a public hospital. But "the help they give is about the same" as a private hospital, he says.
Garcia, like others in the cubicles, was being offered treatment in the ER. But doctors said the best place for him, and many other patients in the emergency room, is upstairs, where he can be monitored more closely by specialized nurses and doctors with fewer distractions.
All patients in ER cubicles are attached to machines that monitor their vital signs, but the harried staff often does not have a chance to watch them.
"Who's watching that monitor?" asked emergency room Dr. Marc Eckstein one busy night. "No one."
By the front door and ambulance ramp is an area designated as triage, where nurses evaluate newcomers and prioritize their care. Pedestrians pour through the doors, as bells go off to alert medical staff that ambulance crews are radioing for instructions.
The night Garcia finally gets a hospital bed, nurse Joann Dalmore gestures toward the half-dozen patients on gurneys who are vying for his cubicle.
"She's a belly, he's a belly. Belly pain, abdominal pain--nobody's been worked up," she says.
A man so broad that it takes two pairs of handcuffs to connect his wrists behind his back sits primly on a metal chair next to the nurses' station, a disposable thermometer jutting from his mouth.
The place is so saturated with patients that it is already "closed" to ambulances, although the term is something of a misnomer, because even when closed, County-USC is legally required to accept critically injured patients and walk-ins from the street.
A moaning woman on a gurney in triage catches Dr. Mallon's eye. "Suze," he says to a nurse, "can you get her some Demerol?"
The nurse gives her the painkiller. Then she returns to the line of new arrivals and resumes the drill: asking them to describe their level of pain on a scale of one to 10--10 being "worse than childbirth."