The interns at the private hospital where I was working would very seriously and formally
announce the type of patient they did not want, "We are calling an ambulance to take you to THE COUNTY HOSPITAL," and give its address as though it was a grand hotel. A resident had just read the electrocardiogram of an elderly woman and told
her they were going to transfer her because (1) she did not have funds to stay, (2) they only had 80 beds on Medicine and (3) she had to stay in the hospital for three to four months. What they did not say is that they had too many like her already and s
he was not a good teaching case. A middle-aged woman was waiting for transportation to the County Hospital.
Private hospitals punting patients from their emergency room to County Hospitals.
She was restrained to the gurney with an attached intravenous drip. 
She did not answer any
commands and only stared into space. She seemed either psychotic, drunk, in a stroke, or perhaps she had a chronic illness for which no immediate medication was available. They also got rid of the drunks. It was easy if they were veterans and could be s
ent to the Veterans Hospital with another diagnosis, called anything but "drunk." I told one of the senior professors that I was going over to the County to see where these patients were sent. He quipped, "Where we send the garbage!"
I sadly replied, "Where we send OUR garbage."
Private hospital punting patients from their emergency room to County Hospital.
I parked where special guests were allowed to park at the County Hospital and climbed the outside steps to the emergency entrance. Inside were so many people! The cleavage between the staff and the patients was more sharply defined here. I felt like th e "White-do-good society lady" of my Southern background, where it was felt that the poor should be poor and the upper classes were offering them handouts.
I met the Chairman of the Department of the Emergency Medicine. He asked, "Weren't you bored with medicine by the time you finished your book, "The Art of Learning Medicine", at the other hospital?"
"No, I realized how much we didn't know and how glad we are for the little knowledge we do have. Of course, by the time the medical students graduate, they don't feel that way. They aren't even shy speaking into a tape recorder." He said he resented the other hospital for dumping everything they didn't want on him. He was even hesitant about taking me on from there. But he liked my pictures and invited me to work in his department. He was involved with 900 patients a day, 12 residents, sev en full-time professors and a budget of over five million dollars a year. Next year he would have 24 residents. At that time, he had the only Emergency Medicine Department in the country. I asked him what research he was doing. This was a usual questi on asked of a professor at the other hospital; the answer of which would take at least an half hour. I didn't get an answer.
Heightened interest in emergency medicine developed after the medical
corpsmen demonstrated the value of the immediate care given to the wounded on the battlefields during the Second World War. 
The infusion of blood, fluids and antibiotics was an heroic procedure which saved many lives and reduced morbidity. These on-the-spot measures came to
be integrated into civilian life and along with this came excitement and new activity in the trauma centers. Doctors gained interest in the emergency service and the patients appreciated finding a doctor on duty at all times.
This particular department had three wards: the main Emergency Room with a reception area and transportation waiting areas for patients assigned to the wards on upper levels and to other County hospitals, the Minor Trauma Clinic for X-Ray and suturing a nd the Walk-In Clinic for the less immediate problems.
My first reactions to the Emergency Room seemed disjointed. There was a reason for this. Each of the twenty cubicles around the sides of the three hundred square foot room had similar scenes individually, that is, a patient with an attendant. But the sc
enarios seemed to move as my eye flipped from one small room to another. It was like the early flickers made by running one's finger over the tops of still photos, each a little different. I flinched with the multitude of stimuli. One can only register
a small sphere at first. A pretty young woman on a gurney waiting under the transportation sign to the wards caught my attention. Later I noticed, in all the numbers of patients, a few more individuals. The open curtain of a cubicle revealed an alcohol
ic curled up in a fetal position after a shot of Valium.
In another, an old woman was b
eing examined by a paramedic who was also instructing a student paramedic on how to put in an intravenous infusion.
And all the while, the noise of the room was oppressive: the typewriters hammering out the computer data of case identification loud and fast, the entry doors swishing open and shut quickly, the din of the phones constantly repeating its rings and the pa tients screaming and groaning and cursing. It was painful to hear. The beginning resident, the Post Graduate Year 1 resident, becomes overloaded with the sights, sounds and smells of those waiting to be admitted to ER and the speed of care and he goes t o the staff lounge for a few minutes of relief. After a pause he can come back and can focus on a few more. Later he can include even more. But he has to build up gradually, otherwise his fuse will trip. There is a system which organizes the departmen t. But in the beginning that is not within his awareness.
A professor out of medical school forty years and a resident out two years both related their first memories of being an intern on Emergency Room service. The older doctor commented what a contrast it was to move from the exalted feeling that a senior m edical student has in the knowledge that he knows everything about medicine - even to being in the honor medical society - to the very next day after graduation in the E.R. when he was appalled by his abysmal ignorance about the practical aspects of being responsible for the treatment of patients. The younger doctor could remember a spectrum of feelings. He said he responded differently to each patient. His background feeling, however, was that of anxiety because he felt ashamed that he did not know an ything very well. Later, even though he had a good feeling that he knew exactly what to do and even when he did everything "right," the patient could still die "on him"! That shook him up a lot. Later he felt aloof towards those who hurt themselves, like the overdosers and the self-inflicted wounds. He felt angry toward them; he said it was their own fault... that living unhealthy lives caused such end results. He kept raw energy under control. "The game was to ride the waves, one patient after another." I asked him if he was ever curious what happened to the patients when they were sent into the wards, after he had done his part. "No, the following patient canceled out the one before him."
