Medicaid and morphine: the real ER

/Dr Gretchen Fahrenbruck is looking for a telephone number. "Did you see those cards?" she barks. "The ones for Victims of Violence." It's 10.30 on a Friday morning and Dr Fahrenbruck is three and a half hours into her 12-hour shift.

"We use them every day. Where are they?" she shouts. The emergency room at Newark University Hospital, New Jersey, is hyperactive, just like the one in Channel 4's American import ER, so nobody offers to help Dr Fahrenbruck, the senior attending surgeon, in her quest.

She scrabbles beneath the admissions counter. Finally she finds what she's looking for. "Yes! Here's a whole box." Dr Fahrenbruck extracts a card and heads for her patient.

JB takes the card but is not happy. "What good will this do me, man?" Dr Fahrenbruck grips his hand, which is waving violently while attached to an intravenous drip. "I think you should call. They can give you counselling. Now, let's check this wound."

JB has been attacked by four men, each wielding a metal pipe. They left him unconscious. He shrieks as Dr Fahrenbruck probes his bashed and bloody scalp. "Did you get hit here?" she asks. "No, man. That's where I got shot in 1989. I have a detached retina."

JB is a heroin addict. His attackers were probably other addicts, or maybe dealers to whom he owed money. Probably the former. If they'd been dealers their weapons would have been guns.

Newark University Hospital is 10 miles from Newark international airport. If you leave the airport and head due east, the New Jersey turnpike takes you to the heart of Manhattan in 45 minutes. Make a false turn to the north-west and the road snakes through miles of chemical plants to Newark's First Ward. It's a place where poverty defines every moment, where escape is often a stolen car and a black-market gun.

From this soil to the University Hospital ER come more than 2,000 blunt and penetrating traumas every year. In ER- speak "blunt" means assault with something like a baseball bat; "penetrating" covers guns and knives. These numbers made Newark the crime capital of the US last year. They also made University Hospital the place military surgeons are sent to train so they can see real bullet wounds. When a patient is saved here, or lost, the credits don't roll. Music doesn't swell. The surgeon just leaves the patient to be wheeled away and moves to the next bed.

"I find the TV ER annoying. I can't watch it any more," says Cathy Conway, one of six senior nurses on duty. "In the TV show the doctors are the stars. Around here we're in charge." Conway is tending to a young black man called Kareem. He's handcuffed to the stretcher. "About one tenth of our patients come in chained," says Conway as Kareem writhes on the trolley. "He's hurt bad," she says, cutting off his jacket. "Get me two units of morphine."

Kareem was arrested two hours ago for parole violation. After 90 minutes in police custody he was left alone in a second-floor interrogation room. He decided to escape by throwing himself out of the window. "Sonofabitch landed on our new squad car, head first through the windscreen," says a Newark police officer, on the phone to his partner. "There's blood all over the seats. I wish he'd been on the fourth floor."

The city of Newark has a population of around 300,000, but more than 2 million live within a 10-mile radius. And it's surrounded by three of the busiest highways in the US. More than a third of America's chemical products are produced in nearby factories, there's the international airport and the second largest container terminal on the East Coast. Even without the social problems, Newark's University Hospital would have its hands full. With endemic unemployment, drug abuse and crime, the hospital is, at times, overwhelmed. The Newark shock-trauma unit is the busiest in the nation, a title it shares with Kings County Hospital in New York City.

Last year UH saw more than 60,000 patients in its emergency room. Over 12,000 of them were admitted for further treatment. That's an average of 30 admissions per day. Eighty per cent of the emergency unit's costs are picked up by the public purse through Medicare, Medicaid or charity. This year there will be less money. Cuts imposed by New Jersey's Republican governor, Christine Todd Whitman, will leave UH $80m short compared with 1994. Next month the hospital will announce job cuts. At least 240 positions are expected to be lost from of a staff of 3,600.

Kareem cries out: "I need some water." "Don't move," Nurse Conway replies. "If you move, you could sever your spinal cord. We don't know what's broken yet." Kareemignores her. He tries to sit up. "Jesus Christ, Kareem. Get me some help here!" Conway is joined by John Horning, the senior medical resident. "Lie still, Kareem," he says. "If you move you could become paralysed. Do you know what paralysed means? It means your dick won't work."

This gets Kareem's attention. He relaxes, at least for the moment. He's now surrounded by two doctors, three nurses and four police officers. His journey to the ER has already cost at least $5,000. He has no medical insurance.

It takes Cathy Conway another hour to treat Kareem, who has plenty of bad cuts but, it turns out, no broken bones."That's the most frustrating kind of patient," she says. "Ibasically achieved nothing, because he fought me all the way. We get this all the time. Thirteen-year-old kids come in here with gunshot wounds and think they're men because they have a piece. A gun doesn't get you respect. It gets you shot."

Mary Beth Lave, nurse manager, knows the score. "On ER they never talk about budgets, they never consider the dollars that are spent every second in here," she says, stacking up special packs used to treat gunshot wounds. "Research hospitals like this keep pushing out the frontiers of emergency medicine. Today we can save people we would have lost in the past. Tomorrow we'll save people we lose today. But the costs are enormous. A gunshot wound to the head costs over $100,000 to treat, a stomach wound at least $60,000. Without less violence or some change in medical economics our days are numbered."

There are changes in hand, but they are not welcomed by Mary Beth Lave. "Health management organisations [HMOs] administer health insurance for most Americans. They need to make a profit out of insurance contributions and that means controlling costs. The process is way out of hand. I have to call HMOs from the ER and discuss what drugs to give. I've had patients who weren't stable, who needed more intervention and an HMO administrator miles away in an office - not a doctor - has insisted the patient is stable. Of course, we go ahead and give the treatment but without approval the HMO won't pay, so we're left with the tab."

Doctor Horning has seen the same process. "There are two professional bodies. The American College of Emergency Physicians and the American Association of Emergency Physicians. ACEP is now run by contract groups. They offer to take over a hospital's ER and run it at much lower costs. The contract group makes its money by hiring inexperienced physicians. The standard in the industry is $100 per hour. ACEP's groups often pay $25."

Horning looks exasperated. He paid his way through medical school by working as an emergency medical technician, driving an ambulance every night for eight years. Now his standard of living is at risk.

"Inexperience is often the least of an ACEP contract doctor's problems. Some of them are plain bad. But they're never in one place for long, so they don't pay the price for their screw-ups. I earned more than $25 an hour as a technician."

The dispatch radio comes to life. Newark ambulance drivers can report patient conditions directly to the ER. "Two incoming, one male and one female. Motor vehicle accident. Unrestrained victims ran into a tree. Male has leg and arm fractures. Female has suspected hip fracture and breathing difficulties." Dr Horning puts on his gown and mask. He sighs. "When they say 'unrestrained' they mean no seatbelts."

The trauma team stands poised in yellow robes. The next drama can begin. "Twenty-two-year-old female. Definite dislocation of left hip, suspected fracture and possible arterial bleeding." The ambulance technician delivers her report. Doctors and nurses surround themoaning victim. "Oh God, oh God - my hip, please oh God help me." They lift the patient. Everybody nearby feels the scream inside their heads, down their spines, in their toes.

Morphine is given and clothing cut away. Six IV lines are in place within as many minutes. Arterial bleeding at the groin can cause death in moments.

"More morphine," shouts Lave. "Let's give her six units." The girl spasms. "Hold her tight," says Lave.

The girl is still screaming, louder now. A doctor by her side lifts her leg and with a sharp twist the hip is back in place.

Later Nurse Lave smiles. "On ER the doctor would have leapt on the stretcher to do that. There's less drama here, but it's more interesting." Does she take it home with her? "Only sometimes. We had a three-year-old last week. Choked to death on a piece of hot dog. We couldn't save him. I had to tell the mother." Lave pauses. "If I'm still thinking about it next week I'll see the counsellor."

There's more work to do. She walks over to the injured girl. "How are you doing honey?" Mary Beth Lave asks, taking her hand. "Can I get you anything?"