NBC 10 takes you inside Southern New England's only Level I trauma center: Rhode Island Hospital. It's where the most critical of the critical patients go or are transferred. It's sort of a hospital with in a hospital.
It's 11 p.m. on a Friday night when photographer Paul Tierney and I first arrive at Rhode Island Hospital's emergency room, and we hit the ground running.
"Critical care is busy right now. We just got a couple Level 1As, which is our top trauma type patient that we get. The sickest patients," said Colleen Printer, a charge nurse.
"This gentleman was in a motorcycle crash earlier this evening," said Dr. Shea Gregg, a trauma surgeon.
The motorcycle collided with a car. The police report indicates the victim was trapped under the car tire and that he was wearing a helmet.
"And thanks to the efforts of combined EMS and air transport, they actually saved his life," Gregg said.
The man was stabilized at a Fall River hospital then flown here. He remains in critical condition, given the severity of his injuries. His hands are restrained so he doesn't pull out his chest tube.
Social worker Jessica Hornig is working with his family.
"They're anxious. They're agitated. Very nervous," Hornig said.
Each of the rooms in the critical care unit of the ER is full. In some rooms, there are two patients. And the holding area is filling up. By this time it's 12:45 a.m.
There are accidents victims, one of them severe enough to require dozens of stitches by a plastic surgeon at her bedside.
There's an elderly woman with a suspected stroke.
"Her brain itself looks like there's nothing acute going on," Dr. Nicholas Monu, of the radiology department.
A man is brought in so short of breath, he is gasping for air. His blood pressure is through the roof. He is not being very cooperative.
"There's a chance I'm going to need to put a tube in your throat and breathe for you. Is that OK with you?" Dr. Catherine Cummings asks.
And there are a number of intoxicated patients. A few of them are disruptive. One has to be tackled to the ground by at least four security guards.
He is wheeled to a room, where he has to be restrained for his safety and that of other patients and hospital staff.
Then there's Luis Rosa, of Providence.
"He came in as a transfer from another hospital complaining of throat pain and unable to open his mouth or swallow," Cummings said.
"We're going to have our honeymoon in the hospital," Rosa said.
The scans show this newlywed has what is known as a retro-pharyngeal abscess, an infection behind the throat that is spreading.
"And it looks like it's filled with gas and some fluid, which is consistent with a gas-producing abscess," Monu said.
Rosa is in good spirits but all indications are his infection is severe.
"I haven't seen an infection in that location to that extent," Dr. Lynn Sweeney said.
Meantime, a stabbing victim from New Bedford arrives.
"We're going to take you to the operating room," he's told.
It's a stab wound to the abdomen. He suffered a rather large gash and a foot of his small bowel is protruding, but he's stable.
The bigger concern is Rosa.
There's a team of doctors in on his case. He's already on IV antibiotics. But should he go in to surgery right away, ahead of the stabbing victim?
Two things concern doctors.
"One is, always his airway," Cummings said. "The second is a life-threatening condition. In his case, this infection -- if it turns out to be an infection -- could have traveled to his heart rather easily."
THERE ARE TWO WAYS to enter the emergency department at Rhode Island Hospital: by ambulance or as a walk-in.
Your first conversation will be with a triage nurse.
"They're the most highly trained nurses in the department, and their job is to make that call right away. Does that person need immediate care or can they wait?" said Megan Gernt, a registered nurse.
The emergency room is a hospital with in a hospital.
"We have 431 clinical staff, by that I mean physicians, nurses, technicians," Dr. Frantz Gibbs said.
And separate pods depending on your ailment, for more focused care. For instance, there's a chest pain unit, a behavioral health care unit, a pod with beds for general emergencies and the critical care unit.
And just because you're brought in by ambulance doesn't mean you'll be seen first.
"We base a lot of it on their complaints and their vital signs. Sometimes, that doesn't tell the entire story. So there are some objective tools that we use to identify the sickest patients," said Dr. Brian Clyne.
Rosa qualified as one of the sickest patients.
Even though when we met him in the wee hours of Saturday morning, he was laughing and joking. Bottom line, he could barely swallow.
"I haven't eaten for three days," Rosa said.
Ear, nose and throat specialist, Dr. Jan Groblewski was the attending that night and the fourth doctor that Rosa saw in a few hours.
"What we're seeing here on his scan and exam is that he's got a significant amount of air in that space, and we don't typically see air in that space behind your throat. That could be concerning for infection. It could also be concerning for a small tear in the back of his throat," Groblewski said.
Just a few rooms down, the stabbing victim with his small bowel protruding. Both need surgery.
Who goes first? Rosa.
"We all felt that he was the more emergent case, he had a higher risk and needed the operating room more tonight," Cummings said.
To help make any diagnosis, this Level I trauma center has pretty much everything doctors need within the ER. It's one of a few hospitals in the country to offer MRI scans in the ER. Doctors can perform CT scans here and cardiac catheterizations.
And they are prepared for pretty much anything.
"We've seen it all: stabbing, shootings and every scenario you can possibly imagine," said Jodi Cullen, a registered nurse.
In a different unit of the ER, we found the former Rhode Island Hospital chief of medicine, now retired, Dr. Milton Hamolsky.
His attending, Dr. Elizabeth Nestor, just a few months ago, received the Dr. Hamolsky Outstanding Physician Award.
Just about an hour before our shift here ends, a Cranston woman, Paula Koch, arrives with a dislocated shoulder.
The ER team works to relocate her shoulder. Mission accomplished.
"Some of it you can't avoid taking home with you, but in order to protect myself I take good care of myself at home, eat well, sleep enough, exercise, play, be grateful, hug my kids," Hornig said.
We spent two nights in the ER at Rhode Island hospital. One of them was a Monday night, traditionally one of the busiest nights of the week.
Between 3 and 11 p.m. that night, 308 patients were seen, about one-third of them were admitted. About 20 percent of the patients they see are uninsured. The hospital has to absorb the cost of treatment.
As far as intoxicated patients, the numbers vary but during one recent month, 758 intoxicated patients were seen.
And for Rosa, the patient with the serious throat infection, doctors said his surgery went well.