When an ambulance brought Derrick Washington to the Prince George's Hospital Center emergency room in Cheverly on an early morning in September, doctors and nurses had no idea whether he had health insurance to cover the cost of his care.
They did not know that he had been released from prison three months earlier, that he was a resident of the District and that he had been injured in a car accident in the county.
They did not even know his name, referring to him as John Doe until police found his cellphone in the back of his mangled car hours later and dialed through its contact list looking for family members.
All they knew was that the man's feet had been severed and that he was on the verge of bleeding to death. And so, like thousands of others who arrive sick and injured at the financially ailing hospital each year, he was treated.
Like half of the 180,000 patients who are cared for in the county's health system, Washington, 30, did not have insurance. Although he has since been enrolled in Medicaid, some of his bills might never be repaid. The problem for the hospital is that it has as many patients like Washington as it does fully insured patients whose bills are paid.
The result is a hospital caught in an endless cycle: Its reputation for crowded, antiquated and low-tech facilities is so widespread that it cannot attract the insured customers whose regular payments could be used to fund improvements that would attract more patients like them.
"They were already $250,000 into it before they even knew he was out of the dark," said his aunt, Loretta Washington, 47, who recalled the events and estimated Washington's five-week hospital stay cost double that. "Who knew that he would even live?"
Studies have shown that 57 percent of Prince George's residents, including many middle-class professionals who have private health insurance, leave the county for care. Hospital system executives think that enticing more of them to the three county-owned facilities would make caring for uninsured patients such as Washington economically viable.
Executives of Dimensions Healthcare System, the nonprofit company that runs the county-owned hospital center and hospitals in Bowie and Laurel, think the situation has become so critical that it would take a $100 million infusion to upgrade its hospitals to begin attracting more paying patients.
Without the improvements, hospital leaders think the system will always bleed cash, risking a closure that health officials agree would be a disaster for the region, sending thousands of poor and needy patients such as Washington to other facilities.
"The fix has not been applied because the fix is going to involve big numbers," said Dimensions chief executive G.T. Dunlop Ecker, the system's fourth top leader in the past five years.
After weeks of negotiations, the county gave Dimensions $5 million last week, the latest in a series of periodic government bailouts, this one intended to last through next month. Intense negotiations are underway in Prince George's and Annapolis to find a way to stop the hemorrhaging for good.
Hospital leaders suggest major renovations would be a start.
The needs are immense, going beyond aesthetics. For example: $1.7 million to replace a CT scanner that takes 30 minutes to produce pictures that other hospitals can take in five; 24 top-of-the-line intensive care beds that rumble and vibrate to prevent bedsores, at $30,000 each; and eight fetal monitors at $16,000 each.
At the Cheverly facility, where a county-run hospital first opened in 1943, the doors of one set of elevators have a dull shine from decades of use. An elevator sometimes shuts down, trapping hospital staff members and the occasional patient between floors. A boiler room holds a noisy ventilation system installed in 1957. Strips of insulation hang from the pipes, and a makeshift pan collects water that regularly drips from joints.
Small repairs will not be enough, hospital leaders said. A $2.5 million renovation in February to the labor and delivery wing brought private rooms with individual showers and two birthing suites designed for natural childbirth, rarities for the region. The walls were covered with deep wood paneling, and shaded lamps that cast a soft glow in the hallways were installed to appeal to expectant mothers with insurance.
"It looks like a hotel," said Tanya Mitchell, a nurse who directs the unit.
But it has still not been enough. Most of the estimated 3,000 women who will give birth at the hospital center this year still will not have private insurance, she said.
County Executive Jack B. Johnson (D) said he thinks replacing Dimensions, which he has accused of mismanagement, is a key to restoring the hospital system to financial stability. He has said he is negotiating with a company that could take over, but a deal is not at hand.
Johnson and the County Council members also think state leaders should do more to help the facility, given its importance to health care across the region. And the county executive has proposed that the system consider declaring bankruptcy in hopes that a court-ordered restructuring will help wipe out long-standing debts and help the system start anew.
Dimensions leaders say they, too, think new managers are needed. With major advertising, a new name -- preferably that of a well-known organization such as the University of Maryland or Johns Hopkins -- could convince more affluent residents that the hospital system was doing something new.
But Johnson and other negotiators have found that Dimensions is not a tempting offer for other companies. The county owns the hospital's land and buildings, meaning the system brings few assets to the table.
Payments Dimensions makes each year bite deep into reserves: $7 million to repay bond debt that helped build a surgery wing in 1995 and $18 million to support a 1970s-era pension plan.
"The underlying financial infrastructure is so fragile that the periodic incremental payments of $5 million here or $5 million there is not sufficient to solve the problem," said Ecker, who advocates a regular and stable source of yearly government funding to pay for the uninsured, on top of money for improvements.
Another costly problem is that many patients arrive from homeless shelters or off the streets and occupy their beds long after doctors have treated them as social workers try to find somewhere for them to go after their release.
"We're a pretty good example of how bad the health-care system is in this country," said Debbie Wilkes, a neonatology nurse who has worked at the hospital for three decades.
Doctors, nurses and some patients say that if there were more money for marketing, they could get the word out about the excellent care they say they provide, despite difficulties, to some of the region's sickest and neediest patients.
"I keep telling people, if you don't have experience, don't say a word, until you taste it," said Mercy Peterson, 35, who was rushed to the hospital in August, when she woke up in the middle of the night after six months of pregnancy, bleeding profusely.
An ambulance took her from her Lanham home to the hospital, where she was convinced that she would lose the baby. Instead, Chisom was delivered by Caesarean section at 1 pound, 7 ounces. Peterson remained in the neonatal unit for more than three months before bringing her daughter home in December at 6 pounds, 7 ounces.
"We don't know the value of what we have until it is gone," said Peterson, who is insured. "P.G. Hospital is one of a kind."
In Annapolis, legislators and Gov. Martin O'Malley (D) are trying to find a long-term solution for the hospital's problems but have not made a financial commitment.
"Shouldn't it be the number one priority to keep a hospital open?" asked Washington, who is trying to adjust to life with a disability.