'We're At Our Breaking Point'

Enter Grady Memorial Hospital's ER and your senses come under attack. Mangled, blood-coated bodies lie in the trauma bays. Shrieks of pain pierce the din. Rank smells curdle the air, released by flesh that has been battered, gashed and infected. The place throbs with frenzied, unrelenting activity. Hospital workers race about, struggling to prioritize patients, leavening the mood with sardonic cracks. Just when it seems the staff can't be pushed any further, paramedics burst in with another critical patient, setting off yet another spasm of mayhem.

To get a closer look at Grady's inner workings, a NEWSWEEK reporter and photographer spent five days in the ER last summer. Such access is rare, and NEWSWEEK agreed not to publish the names of patients—or photograph them in identifiable fashion—unless they agreed to it and signed releases. The portrait that emerged was disconcerting. Like many ERs across the country, Grady's is perilously near collapse. The reasons are familiar: cutbacks in funding, a growing pool of uninsured people, and an older and sicker population that requires more costly treatment, among others. Grady has been sending distress signals for years, but those warnings are now direr than ever. The facility is losing $3 million per month. It's 120 days behind in paying some creditors. And it almost failed to meet payroll in March. To put it simply, the hospital cannot survive much longer in its current state. Were it to shut down, the impact on Atlanta and the surrounding area would be devastating. What follows is the account of one revealing, and utterly routine, night.

It was Saturday night at Grady Memorial Hospital in Atlanta, and the emergency room was getting crushed. An unrelenting wave of severe head-injury cases was sucking up most of the trauma section's resources. Among the victims filling the four trauma bays: a middle-aged woman who had been shot in the left eye, a young man who had been shot in the right temple and a young woman whose head was pummeled when she was ejected from her vehicle when it rolled over in an accident. Doctors and nurses darted from one patient to another, medicating, bandaging and intubating them. Amid the tumult, one nurse exclaimed: "This is Lebanon! This is Afghanistan!" The neurosurgery team was overwhelmed. One resident drilled a hole into the female gunshot victim's skull, so he could insert a tube that would relieve the pressure on her brain. Another resident re-bandaged the other gunshot victim's head, which oozed blood and brain matter all over the sheets. Why all the head injuries? It turned out that most hospitals in the area at that hour had either no Intensive Care Unit beds or no neurosurgeons available, said Dr. Arthur Kellerman, the attending trauma physician. "So all the brain stuff is coming here."

But the night was about to become even more hectic. Just before midnight, Kellerman burst into the trauma room. Two more car-accident victims were on their way, he announced. He quickly scanned the four trauma bays, all of which were taken. Who could he move to make way? He selected the only patient not on a ventilator, even though her condition—six broken ribs and a lacerated liver—was precarious. "I would not have chosen to take her out of the room," said Kellerman afterward, "but I had other people coming in who were even more critical." That freed up only one spot, though. Minutes later, the two accident victims arrived simultaneously. So paramedics crammed both into the free space. The ER staff descended on the patients—clearing their airways, checking their circulation, cutting away their clothes—all the while struggling to avoid colliding with one another.

With so many ER personnel tied up in the trauma bays, patients in the rest of the trauma zone received only scant attention. "There's a catastrophe happening out there because we're so focused on this," said Kellerman, in a quick aside. Beyond the trauma-bay doors lay a multitude of the sick and maimed. Every ER room was taken. Overflow patients lay in gurneys lining both sides of the hallways. Scores more sat anxiously in the waiting room outside. Yet as chaotic as it all was, this was a typical Saturday night. "There's nothing unique about this," said Kellerman, who's the chairman of Emory University's Department of Emergency Medicine and currently a Robert Wood Johnson health-policy fellow in Washington, D.C. "This is trauma care in the U.S. today."

Grady is stretched to the breaking point. It lost more than $20 million last year, up from $13 million in 2005 and $10 million the year before. In 2006, it incurred around $170 million in costs to treat uninsured patients, including both outpatient care in the ER and inpatient care in the hospital. As a public institution, it receives about $105 million annually from Fulton and DeKalb counties, but that figure has remained flat for years and covers only 17 percent of its operating budget (the bulk of the remainder comes from Medicaid, Medicare and commercial insurance). It's hard enough for such a strained system to handle the routine flow of patients. How would Grady deal with a major disaster or terrorist strike? In the midst of the Saturday-night crunch, Kellerman evoked the 1996 Olympics bombing in Atlanta, which flooded Grady with scores of victims. Back then, he said, the ER was less burdened. "Imagine what we would do with an Olympic Park right now."