The night of Sept. 20, 1986, began like most others at Alexandria Hospital's emergency ward. Before it was over, the Virginia facility would find itself enmeshed in the contradictory and intricate rules that apply to undocumented aliens who face life-threatening medical situations in their new country.

Shortly before 9:30 p.m. Enrique Portillo, a 25-year-old Salvadoran, was leaving his job at a restaurant in Alexandria's West End. His life was going well, he had relatives in the area, his English was improving and he was beginning to feel that his "outlaw" days as an illegal alien were behind him.

As he crossed the dimly lit street in front of the restaurant, a car sped up and struck him. Portillo was admitted to the emergency room at Alexandria Hospital at 9:50 p.m. with severe head trauma and internal injuries. He lingered in a coma for eight months while physicians and hospital staff provided round-the-clock care. From time to time, a brother, a sister and her husband came to see him.

"One day, he woke up and said, 'Hey, where am I?' " recalled Susan Coursey, a financial counselor at the hospital who works with undocumented aliens.

Regaining consciousness did not mean that Portillo's problems were over. Neither were the hospital's. He was, and remains, severely handicapped as a result of his injuries. By the time he left Alexandria Hospital nearly three years later, his medical bills reached $675,000, charges that were shared by the hospital and the city of Alexandria because he had no insurance and no means to pay. But legal and financial complications prevented him from being moved to a less expensive setting long after he stopped needing hospitalization.

"We were hoping possibly to send him home with the sister and brother-in-law," said Mary Mulligan, the nurse who helped care for Portillo during his final year in the hospital. The sister decided not to take him after learning she was pregnant.

The hospital also approached the Salvadoran embassy, without success. "Our policy is very clear, to help every Salvadoran in any way we can," said Eduardo Torres, press attache for the embassy. "But we do not have a budget to give financial support to individuals."

Hospital officials, however, said they believed the embassy should have done more to help Portillo. "The only thing they'll do is, if you die, they'll transport you home, and then they'll probably send you a bill for that," Coursey said.

Thus began a lengthy trip through the maze of immigration law as the hospital tried to obtain a Social Security number and Medicaid assistance for Portillo, something his illegal status in this country precluded. Without Medicaid to guarantee payment, no nursing home would accept the indigent patient, even though he was disabled enough to need round-the-clock care.

Because Portillo was the victim of a hit-and-run driver who was never arrested, there was no one to sue to recover damages that might have helped cover the cost of his treatment and subsequent care, according to hospital officials.

"There's no question that his was a very, very unusual case," said Hal Stern of HHL Financial Services, who was called in by frustrated hospital officials when their efforts to persuade Medicaid to pay for Portillo's care failed. HHL is a national corporation that represents hospitals in reimbursement and collection cases.

"Literally, what were they going to do with him?" said Stern. "They couldn't wheel him out into the street. The family had no ability, financial or otherwise, to take care of this man."

Under the 1986 Immigration Reform and Control Act, Medicaid must pay for emergency medical treatment for undocumented aliens on a one time only basis. An emergency case is defined basically as one that is life-threatening or due to an organ-damaging illness. Portillo's problem was that he needed continuing care.

Stern's firm had to prove to immigration officials that Portillo was in this country illegally and then get the Immigration and Naturalization Service to initiate deportation proceedings against him.. The goal: a stay of deportation based on humanitarian reasons. Given the lack of comparable nursing services in Portillo's native El Salvador, "to deport him would have been to condemn him to death," said Stern.

After months of working with the INS and the Virginia Medicaid office, HHL secured a Social Security card for Portillo based on humanitarian need. The card entitles him to Medicaid assistance only.

The matter of finding a nursing home still loomed. Alexandria Hospital officials say they contacted 35 facilities in Virginia before finding one that was willing to accept a long-term Medicaid patient. Last November, more than three years after the accident, Portillo entered the Oakwood Health Care Center in Alexandria, a private nursing facility a few miles from the hospital.

Currently diagnosed as quadriplegic with severe brain dysfunction and dementia, Portillo, now 29, continues to depend on others for all his basic care. He must be fed through a feeding tube, because the accident left him unable to chew and swallow. His mental capacity is believed to be that of a 3-year-old. He can communicate and respond on a very simple level; but he has forgotten the English he had learned and communicates only in Spanish.

For Portillo, as for other undocumented aliens, poverty and an inability to obtain treatment are compounded by the fear that illegal status will be discovered.

Juan Romagoza, director of Clinica del Pueblo in the District's Mt. Pleasant section, said he grapples with this problem every day: Patients routinely refuse to go to the hospital because of their economic situation, their legal status or their inability to speak English. By the time they get to a hospital, they are usually sicker and require more expensive and more prolonged treatment.

There are an estimated 100,000 illegal aliens in the Washington area alone, and many of them have no health insurance, according to Michael Maggio, a Washington attorney who practices immigration law. While they currently account for a small percentage of the cost of uncompensated care, Maggio predicts that the burden such undocumented refugees place on the health care system is likely to grow.

District hospitals provided approximately $176 million in free care to city residents in 1988, up from $156 million in 1987. According to a 1988 D.C. Hospital Association study, 7.5 percent of uninsured patients were aliens who lacked green cards.

"There is no moral solution to the problem of uninsured patients at the present time, short of making some arrangement so that there is insurance for all comers," said Robert Veatch, a biomedical ethicist at the Washington-based Kennedy Institute of Ethics. But that, he added, may be a long time coming.

"We've got 40 million working people in the U.S. who do not have health insurance, plus another 20 million who are indigent, not working, and who are totally beyond the health care system," said John Fletcher, director of the Center for Biomedical Ethics at the University of Virginia. "What's at work is a kind of hidden eugenics, where if you don't help people who need help, and if you systematically avoid it, you place whole populations of people at high risk."

According to Laurence Sartoris, president of the Virginia Hospital Association, roughly one in six Virginians has no meaningful health insurance, including Medicaid. A private physician can refuse to see a patient with no means to pay, but hospitals are legally obligated to treat anyone coming into an emergency room. "When these people come to the hospital, they tend to be either very sick, injured, or on the verge of delivering a baby," said Sartoris.

Virginia's total bill for uncompensated care in 1989 was $250 million, of which about $50 million was recouped from Medicaid. The rest, Sartoris said, will be passed along to paying patients and their insurance companies.Meg Bryant is a freelance writer who lives in Annandale.