At three in the afternoon, the only action on the "stretcher side" of D.C. General Hospital's emergency room is a disheveled bum who had had two seizures since 7 a.m.
Dr. Robert Vowels is keeping an eye on the man, hoping he won't have another seizure. A third might mean something more serious than alcohol withdrawal, and Vowels would feel he had to admit him. The man snores on a stretcher, to odor of his peeling bare feet blending with the smell of antiseptic. A policeman with a billy club is watching the bum, too -- he has been charged with burglary.
Vowels surveys the unusually calm 10-bed section, where patients too sick to walk are sent. "Any moment now," he says, "we could have eight ambulances come through the door."
Then the tempo picks up. A man arrives with "belly pain." Then another man, recovering from a seizure. He is being transferred from George Washington University Hospital because he had no health insurance. Next, a sobbing crossing guard who has just been hit by a car.
Over the next few hours, the crises follow in rapid succession:
An enormous, bearded mental patient is wheeled in, tied down on a stretcher. He shouts profanity when anyone comes near.
A man recently recovered from a heart attack arrives by ambulance, with new chest pain. The whites of his eyes are lemon yellow and his urine is red -- possible signs of hepatitis.
A silent, glowering 70-year-old woman is brought in. The report on her reads, "Patient found nude on floor and unresponsive yesterday, attacked niece with knife today."
An ambulance brings an emaciated old man from D.C. Village. He is blind, mute, covered with bedsores and has a temperature of 104. One arm and leg have been amputated, and the others are bent at bizarre angles. A resident (a doctor in training) goes to draw blood and cannot find a usuable vein.
The emergency room at D.C. General Hospital is the city's busiest, with more than 86,000 people using it in a recent year. In comparison, Greater Southeast Community Hospital's emergency room sees about 65,000 people yearly and Washington Hospital Center's nearly 40,000.
For those tens of thousands of people who come in and out of D.C. General's emergency room, there is a larger significance. For them, the emergency room and the hospital's outpatient clinics are also in effect the District's busiest doctor's office, serving mostly people in Wards 7 and 8 east of the Anacostia River, an area critically short of doctors and one that has been felt isolated from the rest of the city.
"The people of this area have become ER-wise," said Dr. Mona Harrison, D.C. General's chief of ambulatory services. "Many of the people only trust this system. They feel at home, even if it's a bad home. They've been coming for 15, 20 years -- they won't go anywhere else."
The patients arrive on buses that ferry them across the city straight to the emergency room door. They arrive by ambulance from other hospitals, which are legally allowed to send patients who lack health insurance to D.C. General if they can be transported safely. They arrive day and night, the patterns difficult to predict since they are based on such variables as the weather or when minibuses serving the elderly show up.
About 10 percent of those who arrive are sick enough to be admitted. Seventy-five percent come with problems that could be treated by a family doctor -- if they had one. Many are referred to the hospital's specialty clinics, which saw 156,598 patients in the same yearlong period, doing everything from foot care to abortions.
The large number of patients with routine problems -- about three-quarters of the 150 to 250 patients who visit the emergency room each day -- sometimes slow the treatment of patients with serious illnesses, since those with colds and back sprains must be sorted out from those with heart attacks, broken bones and mental problems.
At present, there is only one rule: Those who arrive by ambulance or who are judged sick too sick to walk go to the stretcher section. Everyone else goes to the walk-in-side.
While D.C. General's emergency room shares many problems with other hospital emergency rooms in the city, it is unique in a number of important ways:
It is the only gateway to the hospital. A new patient cannot call and make an appointment to see a doctor. Except at a few of the hospital's 33 adult outpatient clinics, he must go through the emergency room first.
Unlike other hospitals here, D.C. General has no real system to separate the minor illnesses from the true emergencies and funnel them to different places. So the truly sick are sometimes swamped by those with common colds.
Because it is the doctor for the city's poor, it sees a higher percentage of minor ills than other emergency rooms.
Yet it also sees the advanced, severe stages of sickness that has been left untreated too long: diabetes, high blood pressure, tuberculosis, heart disease, and so on.
Because of its mandate, D.C. General's emergency room doctors work against a common backdrop that is social more than medical: alcoholics, prisoners, mental patients sent there for medical clearance, indigent people abandoned by their families and isolated from society.
In medical terms, any emergency room is a bad place for routine health care. It is impersonal -- patients see a different doctor each time. And it is expensive for both hospital and patient.
Still, the patients come through, often bypassing city-run neighborhood clinics out of habit or convenience.
So far, the hospital has done little to encourage them to change. If a person sees a doctor at his neighborhood clinic and needs an X-ray at D.C. General, he must be evaluated in the hospital's emergency room before he can have the test. So most patients find it easier to go to the emergency room in the first place.
And even though D.C. General tries to provide more regular care through a system of outpatient clinics, a patient can only get a clinic appointment if he is referred by an emergency room doctor. Except for six or seven specialty clinics -- such as the obstetrics clinic, the birth control clinic, and the dermatology clinic -- the only way to seek care is to come to the emergency room.
Once a patient with, say, diabetes is referred to the medical clinic, he can call for appointments and expect to have the same doctor (as resident) for two or three years. But if he stops coming to the clinic for more than a year, he must start all over in the emergency room.
The D.C. General emergency room has come a long way since 1971, when a federal judge had to order the hospital to keep three doctors on duty between midnight and 8 a.m. Now, between four and 10 doctors are on duty at any one time.
The waiting time to see a doctor for a non-emergency has been cut to an average of one or two hours, according to administrator Carol Troutman. A sign on the wall used to proclaim a waiting time of six hours.
Under a new rate system that went into effect in October, the fee for an outpatient clinic visit actually fell -- from $29 to $10. (The emergency room fee rose, from $40 to $50. Both prices include X-rays and blood tests.)
The hospital recruited Harrison early this year from Boston City Hospital to run the emergency room and the outpatient clincis. And on May 15, Rosalynn Carter formally opened the newly renovated emergency room area. The construction was aimed at correcting life-safety code violations -- such as inadequate numbers of exits and fire-proof partitions -- but it also gave waiting areas bright new walls and upholstery. Despite the sweltering heat in the lounges -- the emergency room is not air-conditioned -- patients say it is a big improvement.
But problems remain. The training of the doctors who staff the emergency room varies widely, according to Harrison. Most are specialists in one area of medicine, not in emergency room work, and many have trouble supervising residents and doing the administrative tasks needed to run the emergency room properly, she said.
Some speak English poorly or with an accent, and have difficulty understanding and being understood by patients. One night in the emergency room, for example, a Vietnamese doctor interviewed a patient with jaundice. The man pointed to the red letters on a sign and said his urine had been that color for a week."How long has your urine been white?" the doctor asked.
Many doctors training at teh hospital regard emergency room duty as a chore, complaining they see too much uninteresting "minor medicine." Until a recent crackdown, some didn't bother to show up. Harrison has begun to work on morale by scheduling teaching conferences and providing more supervision for residents. But she said many staff members are still frustrated by treating the medical consequences by poverty, alcohol and other social ills.
There is no radiologist to read X-rays after midnight. While this is also true at some other D.C. hospitals, at D.C. General there is no system for calling back patients if films are misread during the night by inexperienced residents. Other hospitals do have such a system.
On one evening doctors working in the emergency room were trying to read films themselves even though a radiologist was supposedly on duty. He took a two-hour dinner break as soon as he arrived at work.
Because the beds upstairs are often filled and because many patients, once admitted, become "placement problems," waiting to get into a nursing home, Harrison said, residents often are too reluctant to admit patients to the hospital, and send some home who ought to stay. They work on others for hours in the emergency area, trying to improve their condition enough so that they will not require admission. But patients sometimes get so tired of waiting for a decision that they sign out before they have been fully treated.
An elderly woman with a shopping bag was ushered into the "stretcher side" one evening. "Oh my God," said a nurse, recognizing her. "Has she been here since last night?" The woman had arrived in the emergency room at 4 the preceding afternoon, and was treated then with insulin for out-of-control diabetes. By midnight her blood tests had improved, so a resident decided not to admit her and instead to continue to give her insulin in the emergency room through the night. The patient had signed out at 3 in the morning and gone home. Now she was back, her blood sugar almost as high as before, and the whole process began again; a resident ordered fluid and potassium for her, and the woman went to sleep on a stretcher.
On the "walk-in" side of the emergency room, residents on duty are in-undated with patients and receive less supervision than on the stretcher side. Under pressure to move along, they spend little time with each patient and may miss diagnosing a serious illness.
Billie Johnson of Southwest Washington said she was forced to bring her teen-aged daughter Lisa back to the walk-in side twice in a week, because the first time the intern who saw her had given her antibiotics for a cold and sent her home, without doing tests to find out why the girl was losing weight.
Johnson, who had already spent an hour waiting with Lisa and two 2-year-olds, said she had brought her daughter back because she was worried something was seriously wrong.
"He spent about three minutes with her," she said. "I wanted her to have a chest X-ray. The service is not that indepth."
Yet many patients are willing to put up with the wait and the impersonality because the emergency room is reliable: It is always open, and care is available if they was willing to wait.
Carol Slater, a young Northeast Washington resident, said she had lived near the hospital all her life and remembered being brought to the emergency room from the time she was a baby. Now, when she needs a doctor, she still goes there. This spring, she came with a gynecological problem. Her last visit had been in 1971.
Mary A. Couch, an emaciated woman with liver disease, said she had tried another hospital but had returned to D.C. General -- traveling from Northwest Washington -- because she like it better. "I decided to come back here, she said. "I was in here once for 15 days [in 1973] and I gained 27 pounds."
She was pleased with the renovated lounge, unconcerned about her 2 1/2 hour wait, but disappointed that the candy and soda machines had been taken away.
D.C. General administrators say they are aware of the system's shortcomings and are doing their best to change things. Emergency room specialists from Georgetown's emergency medicine training program have begun supervising D.C.General residents, and will spend even more time there after July.
Nurses at a triage desk -- a place where medical priorities can be set -- will soon begin interviewing patients as they come in the door, sending some with minor or chronic illnesses directly to clinics and cutting the wait for those with true emergencies.
Outpatient clinics, will began to offer real appointments, more like a private doctor's office, instead of asking patients to register en masse and wait half a day to be seen in turn.
And the hospital has received funds from the National Health Service Corps to open a primary care center, where federally employed doctors would provide continuing care to patients from under-doctored Southeast Washington. The center would lighten the emergency room's load, and its patients would see the same doctor each time.
To a newcomer, D.C. General's emergency room and outpatient clinics will appear impersonal.But administrators and patients say the atmosphere has improved.
Kenneth Ball, who resigned as assistant comptroller Feb. 1, told of watching a woman a year and a half ago as she approached the glass registration window. When the clerk on the other side asked her problem, the woman said quietly, "I think I've got V.D."
"I'm sorry, what?" asked the clerk.
"I think I've got V.D.," repeated the woman a little louder.
"Oh, you've got V.D.," said the clerk in a resounding voice. Then, a moment later, "Oh, you've got no insurance either."
"In the first couple of week, I had that glass torn down," said Ball. When clerks complained that patients might assault them, he replied, "Then you have to talk to them like human beings."