San Diego — Once known as San Diego's "county hospital," UCSD Medical Center in Hillcrest is now a teaching hospital for one of the nation's most prestigious medical schools. As the old county hospital, it was known as the place where poor people went; its reputation was less desirable than nearby Mercy, a private Catholic hospital.

Today, UCSD's reputation equals or exceeds that of any local hospital, but many of the poor and uninsured still find themselves there when there's nowhere else to go. This is especially apparent in the emergency room.

According to Dr. David Guss, "We see about 110 patients a day. We're seeing about 39,000 patients a year here. We also see about 19,000 patients a year at our Thornton facility." Guss is the director of UCSD's Department of Emergency Medicine. "I have responsibilities for all the components of the department and ultimately all of their functions. That includes running two emergency departments and two urgent cares -- here and Thornton Hospital in La Jolla.

"We have a residency in emergency medicine, with six residents a year spread out over three years for a total of 18 residents. We have a division of hyperbaric medicine, where we treat patients with diving emergencies and 'the bends.' We have one of the four nodes of the California poison system...a medical toxicology service that does consults and manages inpatients with toxic emergencies, and we're also involved in the physician staff for an air medical service."

A native of Brooklyn, Guss, 49, is tall, lean, and muscular. He speaks in a soft, raspy voice with an East Coast accent. "I did my residency in internal medicine here, joined the faculty of the newly developed department of emergency medicine back in 1979, and I've been doing this ever since."

Besides his regular hours in the ER, Guss is available twice a month on a 24-hour shift as a backup physician. "It used to be a rare occurrence to be called in, but it has increased steadily. Now it occurs about half of the time that I'm on call." The increase in calls reflects the difficulties all hospitals are facing. "More patients, sicker patients, more acuity, and more complexity."

Another increasing occurrence in the ER is the number of uninsured patients who can't make an appointment with a family doctor. "In some respects, the word 'emergency' is misleading; there's never been a time that everybody seen in an emergency department had an emergency that was life or limb threatening. It's always been the case that a minority of the patients really fit that category.

"Most of the patients that utilize emergency departments are a mixture of those with potentially life- or limb-threatening injuries and those with new, acute medical problems that the patient feels needs immediate attention. Over the last decade, there's been an increase in the number of patients coming to emergency departments because they do not have access to alternatives. It's one of those fine points that gets overlooked when people are trying to analyze the problem. They'll say, 'Well, we just need to triage the patients more effectively,' but it's not as simple as that. There's not really resources to triage them to, nor do we have the tools to properly identify those that don't need to be evaluated. It's more complex than many people would make it out to be."

A common complaint about ERs is the long wait. Guss understands the frustration but explains, "There are definitely times where people will end up waiting six, eight, or ten hours to be seen, turn out to have a minor problem, and therefore not require elaborate evaluation and treatment. Unfortunately, there's not a great deal we can do about that. But in general, the way our emergency department is set up -- most places are set up this way -- the first person that you see is the triage nurse. Her job is to determine who has a potentially life- or limb-threatening problem. That determination will dictate how quickly you're seen if there are limited resources to see you or if there's an imbalance between resource and demand -- all the rooms are filled, all the doctors are busy, and there are patients waiting.

"We take them first come, first served, but that is supplanted by medical needs. So you may be waiting for four hours, and somebody comes in with chest pain, and if the triage nurse decides that could be a heart attack, which could kill that person in minutes, that person's going to be put in a room immediately, even if it means taking someone else out of a room. That's often a source of frustration for patients who are waiting because they can't tell just by looking at someone how sick they are, and they think there's preferential treatment going on.

"In fact, we really treat everybody the same, regardless of race, religion, or economics. Most of the emergency departments in this town work with the same general ethic. We see the patient, we investigate what the problem is, and we take care of the medical problem. We really have blinders on with respect to the other issues."

But Guss acknowledges this egalitarian approach wasn't always the case. "People were getting kicked around from hospital to hospital, sometimes egregiously so, but that is not the standard of care in San Diego. You can go to any ER, tell them what your problem is, and they will evaluate you for that problem. If they deem that it is not an emergency, or they've managed the emergency condition, they may refer you, and your referral options may be limited because of finances. But in terms of dealing with an acute emergency, whether it can be resolved in the emergency department or requires admission to the hospital, it will happen. I think that happens 99 percent of the time. I wouldn't have been able to say the same thing in the 1980s, but I can comfortably say that now."

Guss concedes that some people have a bad experience in the emergency department just as they do when they access anything -- be it a car dealership, buying clothes, or going to the grocery store. "If we have, in any way, contributed to that bad experience, which may be the case in isolated circumstances, we'll apologize for it. We'll investigate the circumstances and try to avoid any repetition."

The number of doctors staffing the ER varies according to the time of day. "We have anywhere from one attending physician to two attending physicians during peak times. And we have at least one resident and as many as three residents during peak times, and there may be a medical student as well."

While finding available doctors is not a problem, finding competent nurses is. "It's very tight. There's been an aging of the nursing population. I don't remember the exact figure, but I believe the average age of a nurse is now in the late 30s or early 40s." Given the growth of demand for medical services, Guss believes "there's not enough new nurses coming into the field to match the attrition.

"Emergency medicine is a particularly challenging field. Nurses have a lot of responsibility -- not to suggest that they don't in other areas -- but they particularly have a lot in emergency medicine. They have to have a tremendous breadth of knowledge and very good judgment, because they're right there when a patient's condition can be changing from minute to minute. They need to know when to react and when not to and how to prioritize things. Do we have enough nurses? Yes we do, but it's an ongoing struggle to maintain that balance."

The peak times in the ER are consistent but not always predictable. "They're generally between 10:00 and 11:00 a.m. up until midnight. Days of the week have no reliable pattern. Mondays tend to be busy. I wonder if people save up their complaints over the weekend and present what they haven't resolved on Monday -- but that's not hard and fast. Holidays...frequently the day of the holiday is not very busy, but the day after the holiday is. It's definitely worse in the winter months from December through February, because of viral illnesses and upper-respiratory infections. People will come in for those as well as all the complications -- the pneumonias, the exacerbation of asthma -- and all that travels along with viral illnesses. That's been the case as far back as I can remember."

Guss's memory stretches back for 22 years of emergency-medicine experience. "I've been doing this for a long time. I also used to fly on the Life-Flight helicopter as a physician crew member. I've seen a fair amount of very dramatic events. What makes emergency medicine very exciting and enthralling, but also very stressful, is that you can't predict what's going to happen. At any given moment at any given time," he laughs, "anything can happen."

"Generally, there will be times -- because we do not schedule patients and we do not turn them away -- where the sheer volume of cases you have to manage and the severity of those cases feels like it's going to tip you over the edge. It never does -- or at least it hasn't yet, because I'm still here! And, by and large, still loving it."

Like most doctors, Guss has one particular case that stands out. "When I was flying on the helicopter, a family had been forced off the road by an intoxicated driver and slammed into a concrete wall. There were three people in that vehicle, a man, woman, and their child. Unfortunately, the young child -- in a car seat, properly restrained -- was dead at the scene. The father was severely injured and required extensive, aggressive therapy in the field. We had to put in chest tubes, IVs, intubate the patient -- just about everything you could imagine doing in the pre-hospital arena was done to him. The woman was a little less injured, but she required a fair amount of intervention. The two of them were brought to the hospital and both survived.

"About a month later, I was in the cafeteria and a woman came up to me and asked, 'Are you Dr. Guss?' I said, 'Yes,' and she said, 'I just wanted to thank you for saving my husband's life and saving my life.' Initially, I made no connection. I said, 'I'm sorry, I don't remember,' but she went on to describe the accident, and then I remembered.

"It turns out that her husband survived with a significant, lifelong disability. They lost their child." His voice softens as he wipes his eye. "It makes me almost cry whenever I tell this story and think of the horror. Yet it was important to her, a month later, to search me out and thank me, even in the setting of all that misery! I'll always remember that."