It is 7:18 a.m. at Parkland Hospital in Dallas, and dawn brings the day's first case of blunt-force trauma. The woman fell from a second story and now lies just down the hall from where President John F. Kennedy took his final breath more than 44 years ago.
An assassination may have put this Dallas hospital on the map, but its reputation is built on the sheer variety and volume of pain it treats. On average, a person walks or rolls into this ER every four minutes of every hour of every day.
At 10:53, it is the loser of a brutal bar fight, transferred from Paris, Texas, two hours away because no place handles trauma better than Parkland.
"You never know," says Dr. John Pillow. "You never know what's going to walk through that door. I can't say, well, I'm a cardiologist and you have a stomach problem, go over there. It's my job to help you no matter what you have."
And Parkland helps no matter the patient's income, insurance or immigration status. Like many tax-funded county hospitals, it takes all comers, drawing a tide of hurt so constant that walk-ins use touch-screen kiosks to admit themselves. Triage ensures that the sickest are seen first. The rest settle in and give new meaning to the term "waiting room." Today's wait will average 10 hours.
"I've brought people back that have been in the waiting room 24 hours," says nurse Bunni Mayfield as she scans the hallway for precious bed space. "It's pretty sad. People who come to county know it's going to happen."
Ninety percent of Parkland's ER patients can't afford a family doctor or health insurance, so people like Tyler Sholz ignore the pain until they can't. He brought a friend and cooler of food to pass the time, hoping someone would eventually look at the painful abscess on his arm. He realizes that he would be better off getting care from a primary physician, but when he dropped out of college, he didn't realize he would be dropped from his father's insurance.
"I'm used to going to the doctors and being seen within like 45 minutes at the max," he says. Twelve hours after walking in, he is treated.
Across the room, Jesus Silva suffers the side effects of his cholesterol medication. Silva is a citizen with a landscaping business but not enough money for health insurance. One in four Texans are uninsured and of them, 80 percent have jobs.
"Most of them are working people," says nurse Lisa Mack as she walks through the packed room. "It's just 'do I put food on the table for my family or do I pay for a health care plan?'" Parkland also treats thousands of illegal immigrants each year.
At 2:45 p.m., Dr. Ron Anderson, Parkland's CEO, casts a weary eye around the trauma center.
"In America today, 43 percent of the people in the emergency room are really there for things that can be handled in a primary care physician's office," he says. "That's a big problem -- they don't need to be here."
If not for the staffing he receives from the University of Texas medical school, Anderson says there is no way Parkland could survive the nation's nursing shortage or the exodus of doctors fleeing to private practice and refusing on-call duty.