The benches in the waiting room of Mary Washington Hospital's emergency room are all spoken for, as are the ones outside, where smokers are puffing back at a sunset that's brought no respite from the day's heat.

The reasons why about 40 people are waiting on this weeknight are typical for Mary Washington: nail gun to the foot, black-widow spider bite, heart pains, scrapes from a motorcycle wipeout. And two sisters brought their 83-year-old mother, who fell down her trailer steps.

The wait is typical, too: anywhere from two to 10 hours. It's a bit much in Fredericksburg, a city of 20,000 where the only other activity that seems to require major patience is grocery shopping because everyone still makes chitchat at the checkout. But there's nothing small-town about Mary Washington's emergency room, the third-busiest of the 82 in Virginia by some counts, and the second-busiest by others.

Mary Washington is the only major hospital within a 45-minute drive in any direction -- the nearest ERs are at Chesapeake Bay to the east, in Prince William to the north, in Culpeper County to the west and in Richmond to the south. And Mary Washington has the only substantial emergency room in a part of the country where potential patients arrive in moving vans by the dozen every day.

The hospital also sits a few miles off Interstate 95, a magnet for ailing travelers and accident victims, and many patients travel long distances to get there. And, doctors said, Mary Washington serves the region's Bigfoot demographics: commuters, who come and go in the dark when their local doctors' offices are closed, and newcomers who haven't found new doctors.

The emergency room crowding and the travel time are not limited to the Fredericksburg area. As Americans cluster around suburbs and exurbs, hospitals in many places are consolidating, and the American Hospital Association has said ER use and average travel time to the hospital is increasing.

Mary Washington's ER treated 73,805 people in 2002, behind only Inova Fairfax, which had 96,197, and VCU Medical Center in Richmond, which treated 80,921, according to the most recent statewide data submitted to the nonprofit Virginia Health Information service. But Drew Garvie, chairman of emergency services at Mary Washington, said the hospital's doctors treated 83,000 people last year, and VCU officials said they think their emergency room is now third, behind the Fredericksburg hospital.

Like everyone and everything else on this north-central Virginia corridor of I-95, Mary Washington's ER is trying to keep up with growth. Two years ago, the hospital's parent company, MediCorp Health System, rebuilt the then-81/2-year-old ER to double its size from 25 beds to 51, and within a week it was full again. In January, the hospital added 94 inpatient beds, for a total of 412, in a move that was supposed to take pressure off the emergency room -- but doctors and patients said the wait hasn't decreased.

"When you come here, you're signing up for an eight- to 10-hour shift," Sean Colley, who was born at Mary Washington 19 years ago, said while waiting one night last week with a friend who wasn't feeling well.

Colley, who has made several visits to this ER himself, represents a key slice of the hospital's demographic: He lives about 45 minutes away, in King George County, east of Fredericksburg, at the northern tip of the Northern Neck.

Although a trip of 45 minutes to an hour for an ER is relatively short for sparsely populated states such as Wyoming, such lack of competition is unusual for the crowded Eastern Seaboard, said Jim Bentley, a senior vice president at the hospital association, of which most U.S. hospitals are members.

Garvie, who came to Fredericksburg from Bellevue Hospital in Manhattan, said he and other physicians who trained in big cities were amazed by patients' long travel times, which mean that they might receive their first hour of care in an ambulance.

Because of the distances, Garvie and other ER physicians said, paramedics can administer such painkillers as morphine -- something they aren't allowed to do in many places, and one of several accommodations to the drive time.

The hospital's service area includes 290,000 residents. The most remote corner is the Northern Neck, an area between the Rappahannock and Potomac rivers where land is being snapped up by Washington area residents looking for second homes. The Northern Neck's health care isolation was driven home in February, when its only two obstetricians had to close their joint practice in Kilmarnock after being denied malpractice insurance. Since then, the 60,000 residents there go to Fredericksburg or Richmond for prenatal care or to deliver.

James F. Hamilton, one of the obstetricians, said the long drives are more than an inconvenience.

"For maybe 20 percent of our patients, who are having a very hard time and are very poor, that travel is a huge burden and they just don't get there," said Hamilton, whose practice is now limited to gynecology, though he is planning to open a free-standing, nonprofit birthing center. "They don't drive, can't afford it and -- to be honest -- sometimes motivation is a problem. The concern is inadequate prenatal care."

The increase in travel times for care is occurring in many growing areas of the county, Bentley said.

"The rule of thumb used to be that people traveled 15 to 20 minutes for an ER and an hour for inpatient care," he said. "But what we're finding now is that people are willing to travel further. I don't know if that's because they are placing a premium on living further away. . . . People realize part of the convenience of living where they want is sometimes the inconvenience of having to go further for medical care."

Many of the commuter patients have medical insurance. Although they contribute to long waits in the emergency room, insured commuter patients are desired, Bentley said. "It's not as if someone were bringing a busload of poorly insured people to your community," he said. Some insurance plans charge higher co-pays for ER visits than for doctor visits, and many plans require patients to obtain referrals from their primary-care physicians before going to the emergency room for non-emergencies.

Longtime employees of the emergency room at Mary Washington, which opened in 1899 in an eight-room cottage on the Rappahannock River, notice another change: in the reasons people come in. More gunshot wounds, and more people suffering injuries and illnesses while living on the street.

Hospital officials said they work to overcome their image as a small-town community hospital -- somewhere you don't go if you have complicated, serious health issues. Recent ad campaigns focus on the fact that Mary Washington has neurosurgeons and open heart surgeons on staff, as well as radiologists on duty 24 hours a day. "Mary Washington Hospital -- The Highest Quality Care is in your own backyard," one ad said.

The two sisters who brought their mother in that night said their family still travels to Richmond for regular medical care, though they moved to Spotsylvania County more than 10 years ago. The sisters, who work in nursing homes in the area and would not give their names, said they have waited as long as 10 hours at the emergency room. This time, their mother waited just 21/2 hours to be seen for a possible pelvic fracture.

Alicia Harris, 44, drove her husband about a half-hour from Spotsylvania to have his leg checked after a motorcycle accident. Her husband, who has a two-hour commute each way to work, had opted not to go to the doctor during the day. But Harris, who works at a car dealership, said she was the one who was worried about infection.

"I came in expecting to wait, and you see people with more of an emergency once you get in," she said. They arrived about 2 p.m. and left about four hours later.

Mary Washington still is establishing its place in the region's health care picture. It is not considered a Level 1 trauma center, so the most serious trauma cases are sent to Fairfax or Richmond. But that could change. MediCorp is considering adding surgical specialists to upgrade Mary Washington to a Level 1 trauma center and opening a second hospital in the area.

Douglas Johnson, right, a physician, works in Mary Washington Hospital's emergency room, which is one of the busiest in Virginia.