San Diego — Chet Varns takes a lot of guff from people he doesn't know and likely won't see again. A volunteer at the sign-in desk at Palomar Hospital's emergency room in Escondido, Varns passes new patients a clipboard and tries to keep everyone in the ER waiting room happy. No matter how irate they get, he smiles and shows patience, but it doesn't always work. "They get angry with everybody, including themselves; they can get belligerent. It's mostly patients who have to wait for a long time because there's not enough room to accommodate them in the back."

Varns and volunteers like him are the first people patients see when they enter an emergency room. "I try to triage patients and have them fill out a form so the triage nurse can decide their severity of illness and process them through the paperwork. I've been here when there isn't seating room in the waiting room and all the beds in back were full. If someone wants to cause a big problem, I just call one of the medical staff." Varns has been volunteering for six months, since his retirement from the Air Force Medical Corps.

The wait in emergency rooms can last for hours, even after getting a bed. About one percent of that time will be spent with a doctor. Most of the care given in the ER comes from volunteers and nurses.

Randy Ball is the charge nurse for Palomar's ER and has been for 12 years. She makes sure that the patient load is equitable for the doctors and nurses. "I handle all the problems. I'm, basically, the captain of the ship."

Ball understands what Varns faces when the ER starts to get crowded. "We see people based on acuity. Every patient is seen by a registered nurse at triage. Based on complaint, the way the patient looks, their vital signs, and their history, that nurse assigns a classification. Our classifications go from urgent to emergent to immediate. If you come in with a splinter in your finger, you're not going to be seen very soon, especially if we're busy, because your injury isn't life-threatening. But if you come in clutching your chest, looking pasty-white, telling me you have an impending feeling of doom, you're going to come right back. And an ambulance patient takes precedent over anyone. So if an ambulance rolls in, that bumps others back." Ball points to a big board with slots holding file folders. "The charts come in from triage color-coded. Blue means that it's very, very minor, and they can sit out there if need be. Green means a little sicker, yellow means a little sicker than green, and red means they have to come back immediately or as soon as possible -- chest pain, someone's amputated a body part -- that kind of thing. They come to me to decide where the patient should go. Let's say I have a yellow chart here with a patient with abdominal pain. If I have an ambulance come in, even though this patient is supposed to be the next one back, that ambulance takes precedent."

Ball's assessment of the changes in the ER seems to mirror the changes at other hospitals. "It used to be that our busiest times were weekends and during the week after 5:00, but that's no longer true. We're busy all the time, whether it's patients from the waiting room or ambulances coming in from the community. There's no downtime anymore. Weekends are usually a little bit heavier because people tend to partake of risk-taking behaviors. Doctors' offices are closed, so we tend to see more people who are sick. They either don't want to take the time during the week to go to their doctor, or they decide to come in here on the weekend. Usually, after 3:00 in the afternoon, we really get slammed. It can last all night. Sometimes, when I come on at 7:00 in the morning, we're still busy."

The patients at Palomar don't always come in with the same complaints one would find at urban emergency rooms. "We have a large catchment area -- over 100 square miles for our trauma. We get a lot of people from the desert, motorcycle riders from Palomar Mountain, that kind of thing. Usually, the all-terrain vehicles, the motorcycles, they tend to do...I'm not really sure what it is they do out there! Ride the sand dunes, that kind of thing. Then, on the weekends, we usually get at least two motorcycle accidents off of Palomar Mountain. We're real close to Barona Racetrack, so we get patients from there -- motocross races. We just got a patient from out there Monday. I guess they're filming a Disney movie out there, and he had a motorcycle crash and came in to us. And we get your routine shootings and stabbings, car accidents, that kind of stuff.

"It just seems like on sunny weekends, people like to ride their motorcycles on Palomar Mountain, and those things are like rocket ships! They're faster than a motorcycle needs to go, and they crash with regularity. Since the helmet laws went into effect, head injuries aren't as prevalent as they used to be. They tend to have more orthopedic injuries -- more broken arms, broken legs, broken pelvises. I read somewhere that the organ-donation rate has gone down since the helmet laws went into effect, because you don't have as many fatalities. You also get the chest and abdominal trauma from the motorcycles."

Another sign of the changing times is the nursing shortage. "It's the same as everywhere else -- not enough qualified nurses. When someone leaves our department, there's not the experienced nurses out there to hire and come in. That's countywide -- I should say nationwide."

Like most ER workers, the unusual has become routine for Ball. "It never ceases to amaze me, the things that can happen to the human body. We see a lot of motor-vehicle accident injuries, since we're right on the I-15 corridor. I've talked with the CHP officers when they come in, and it's such a straight shot. Once you get past Escondido there's nothing between here and Temecula to slow you down. I think they drive faster on 15."

Injuries and trauma aside, Ball is annoyed with patients who waste valuable time for everyone in the ER. "I have an issue with people who don't take responsibility for their actions or responsibility for their lives and expect us to fix them and take time away from people who really need to be here." Her tone grows ironic. "Several months ago, we had an ambulance come in with a patient who had woken up from a bad dream. He called an ambulance to come and get him. We've had people who've called an ambulance and come in because they don't have Tylenol."

Some cases are unforgettable for different reasons. "A year ago, we had a patient come in from Valley Center who was in a rollover accident and she should have been dead. She had bilateral collapsed lungs, bad pelvic fractures, a bad head injury. She died several times while she was here, but we were able to save her. She walked out and she should not have. She came in this past October 6th with a cake, awake and walking with no residual problems. It was an amazing thing. That makes it rewarding, when they don't have any residual deficits. She was alert as before. She speaks fine and walks fine. To look at her, you'd never know that she was as gravely injured as she was."

Many patients who come in with injuries aren't simply treated and released. A medical social worker may be assigned to the case who will decide if further intervention is needed -- especially in cases of domestic violence. Karen Wilcox has handled domestic-violence cases for Palomar's ER for the last seven years.

"We have kind of a tri-fold function here," Wilcox says. "We're part of the trauma team, so we're responsible for contacting family for trauma victims. We try to offer emotional support to the family and act as go-between between the doctor and significant others who come in. We're also the ones who do the initial mental-health assessment for all psychiatric patients who come in. We determine if they need to be put on a hold -- a 5150 -- or if they need outpatient services or to be transferred to another hospital. We deal with all 'VOVs' -- victims of violence and domestic-violence cases. We're called in to notify police at the onset and sometimes all the way to documenting the situation and notifying Child Protective Services, if necessary. Sometimes we're called back to court. We also handle placement of the elderly or any disabled that can no longer function at home. We see an average of 50 percent of the patients who come through."

If that number seems high, Wilcox is quick to agree. "There's definitely a big problem with domestic violence. We're in the news all the time. Most recently, it was the lawyer who killed the nurse that he was having an affair with. We get a lot of Camp Pendleton people from Oceanside.

"We deal mostly with abused spouses -- females. They come in after they've been beaten. Not too long ago -- this was in the paper -- the case of the older gentleman in his 80s, probably paranoid, shot his wife in the leg. She was a trauma patient with gunshot wounds. We see a lot of fist injuries, broken noses, black eyes, small fractures -- things that they can be treated here for, referred out, and go home.

"Palomar has its own family-violence program now, so I can refer them directly, and they are available to interview the patient while they're still in the ER, which is a wonderful thing. While they're still here and while they're still scared, someone other than the medical staff can come over and spend as long as they need with them." Wilcox insists that domestic violence is not more prolific in any racial or demographic group.

Another aspect of domestic violence -- child abuse -- does not cross Wilcox's desk very often. "I think it's because I'm on the day shift for ten hours. But the night-shift social worker sees a lot more for some reason. I guess a lot of things are found at school or after parents get home in the evening hours. We send a lot of people out to Children's Hospital for those cases. If the injury is questionable, we send them to Children's.

"I'm also usually in traumas when we have gang-related violence come in. I'm primarily there to notify that kid's parents and get them connected and get security involved if needed." Another trauma task requires greater delicacy. "In the trauma room, I'm the one who gets the wallets out of the pocket, trying to find ID, if the person's not conscious. Driver's license, names of family members. It's amazing what people carry in their wallets! Lots of people carry a lot of trash -- literally! And don't carry the number of the person you're having an affair with in your wallet if you don't want them to be the ones called! If someone is going through a divorce, I need to know if I'm the only one who's called and is anyone else coming in before the decisions are made. Few people realize how important it is to have a number where someone can be reached. There should be more public education about having identifying information on you. You should be aware of what's in your purse and what's in your wallet -- you never know who's going to be looking at it."

Wilcox is reluctant to discuss the most appalling case she has witnessed -- it is still being settled in court -- but she offers an outline of the basic facts. "It was a guy who had the skills from being a hired baseball player who had been throwing sharp objects into the wife's eye, with great accuracy. Fortunately, she didn't lose her eye, but it was still very dramatic.

"This job makes me real appreciative of my own family. I tend to be a positive person, but when you work in here, you tend to see the negative side of things, which can make you more grateful. You also realize how tentative everything is and how it can change. You have to be prepared."