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.
"In Dallas County, we're blessed to be supported by taxpayers. They gave us $400 million a year. But we do $550 million worth of charity care work."
He hopes the public and Washington will recognize the crisis -- and quickly.
"[Emergency medicine] is as much a part of homeland security as anything else can possibly be. Without trauma systems, without these emergency systems, it's a disaster waiting to happen. And it will happen."
The hour 7 p.m. brings a shift change at Parkland, while an ambulance across town brings in a man suffering the ravages of diabetes and HIV. To a veteran EMT like Lindon Britt, you can't talk about the health care crisis without talking about poverty, addiction and crime.
"Everyone is quick to pull a knife or gun," he says. "They shoot and stab rather than settle things with their fists."
While Parkland is not the sort of "knife and gun club" ER seen in many cities, it sees its share of crime wounds, which is one more factor weighing down the entire system.
"We need to be able to provide care for everyone," says Pillow. "But a person who drinks and smokes crack and shoots himself in the head -- it's hard to know how liable I should be. I care about people. But they get in that position for a reason."
At 3 a.m., an apartment fire rages across town, and Debbie Jackson is brought in coughing smoke and shaking with fear. Her daughters jumped from their third-story balcony but survived with scrapes.
"I was so scared," she says. "I was about to pass out from all the smoke."
She needs more comfort than medical care, and despite the waiting crowd, she still gets a few moments of TLC from the doctor and nurses.
"What's surprising to me is how quickly I become attached to the patients even though you may only see them for a very short period of time," says Dr. Heather Owen.
"You can't insulate yourself. If it didn't bother me, I wouldn't do it."
At 7:35 a.m., 24 hours after our arrival, Dr. Paul Pepe, the head of emergency medicine, stands before a room full of star medical students, all of them searching for a residency.
"If you are here to wear the white coat and be an important doctor, we don't want you," he says. "We're like the Statue of Liberty. Give us your poor, tired, huddled homeless yearning to breathe free. This is a safety net hospital."
If they need further convincing, they can simply step down the hall where another 24 hours of trauma has already begun.