February 7, 1995



By Don Colburn

Five days before Christmas, Marcelino Corniel, 33, was shot by a U.S. Park Police officer on the sidewalk in front of the White House. Wielding a hunting knife taped to his hand, he had chased an officer from Lafayette Square across Pennsylvania Avenue, where he was confronted by two Park police officers and two Secret Service agents, their pistols drawn. After Corniel ignored orders to drop his weapon, one of the officers fired from close range.

Two 9mm bullets struck Corniel. One lodged in his upper right thigh. The other, which proved fatal, entered his chest just left of the breastbone, narrowly missed his heart, tore through his liver and exited through his back.

It was the kind of case that has become all too familiar in city hospital emergency rooms: a gunshot wound to the chest. No insurance. No medical record. For this particular patient, no home address.

Corniel was rushed by ambulance seven blocks to George Washington University Hospital, where he got the medical full-court press: three major surgeries, 10 hours on the operating table, more than 30 blood transfusions. There was nothing elective about this case. Emergency rooms don't choose their trauma patients, nor vice versa. Corniel received the same level of intensive care at GW, his doctors noted, as President Reagan had in 1961 after he had been shot in an assassination attempt.

Yet after 36 hours in the hospital, with all the medical throw-weight a state-of-the-art trauma team can bring to bear on a massive bullet wound, Marcelino Corniel died.

In his day-and-a-half in the hospital, according to GW officials, Corniel ran up a medical bill of $70,169 -- an average of nearly $2,000 an hour. The charges for blood alone exceeded $16,000.

The bill like those of most patients treated for violent trauma at District hospitals, will not be paid.

"It reflects a problem that has only gone away in he minds of politicians," said Thomas Chapman, chief executive officer of GW University Hospital.

"Here's a guy who came here after an unfortunate incident and spent 36 hours in the hospital.' Chapman said. "and at the end of the pipeline, out pops a bill.

"Resuscitation 101"

When paramedics wheeled Corniel into the emergency room about 9:15 in the morning, he was barely conscious and bleeding profusely from his chest, back and thigh; his blood pressure was plummeting. He stayed there 22 minutes. The trauma team could tell that their only hope of saving his life was to get him to surgery right away.

"lt's Resuscitation 101," said Robert F. Shesser, the attending physician in the GW Hospital emergency room that day. "You do A. You do B. You do C. You do D. He had A through Z.

Five doctors and three nurses worked on him at once, keeping the airway free, replenishing fluids, assessing the bullet wounds, inserting tubes everywhere. One down his throat to the stomach, another to the bladder, a central intravenous line through the major vein in the groin, drainage tubes into the chest: cavity on either side.

The first priority was to try to replace the fluid loss and revive his flagging blood pressure. Even starting an intravenous line wasn't easy, because, of heavy scarring from second- and third-degree burns Corniel had suffered over 70 to 80 percent of his body in a fiery car crash in 1992. Through the main intravenous line in the groin, the trauma team started transfusing salt solution, medications and blood. They used O-negative, the ''universal blood type" that works for anyone, because it would have taken five or 10 minutes to test Corniel's blood type and' "we didn't have that amount of time," Shesser said.

There was no time for X-rays either. Of Corniel's two gunshot wounds, the one n the leg was serious, but not life-threatening The one to the chest might kill him. "The leg wound we just wrapped and figured we'd deal with that later," Shesser said.

If Corniel's heart was being squeezed by massive bleeding in the chest, he wouldn't make it to the operating room. Two tubes were inserted into Corniel's chest, between the ribs, to drain blood from the chest cavity. Not much came out. Wherever the internal damage was--and it must be huge, because he continued to lose blood pressure -- it didn't seem to be in the chest. It was some where in the abdomen. They'd have to open him up to find just where.

In a case like Corniel's, "stabilize" and "resuscitate" are relative terms. After 22 minutes in the ER, unconscious and in shock, he was whisked to the operating room.

It was still impossible to say whether Corniel would live or die. "We suspected his heart wasn't involved, but we didn't know for sure," Shesser said. "We were just happy he wasn't having a cardiac arrest.

"Blood Everywhere"

The senior trauma surgeon on call, A. Matthew Philip, was in his office on K Street NW, when the page operator alerted; him that a life-or-death case had arrived in the emergency room. He headed for the hospital--and still didn't beat Corniel to the operating room.


Robert F. Shesser, the attending physician in the George Washington University Hospital emergency room the day Corniel was brought in, said President Reagan was treated in the same area after he was shot in a 1981 assassination attempt.

Marcelino Corniel's case exemplifies the cost squeeze that urban teaching hospitals are caught in when they provide high-tech, high-cost emergency care to uninsured patients.

Corniel's medical bill for 36 hours of care in the emergency room, intensive care unit and operating room at George Washington University Medical Center totaled $70,169, according to hospital officials.

The bill for blood transfusions alone was $16,584. Total charges for the roughly 160 clinical laboratory tests carried out on his blood and urine reached $7,700. Doctors' fees totaled $6,500. Nine nurses treated him in the ICU. The charge for use of the operating room and supplies--not counting doctors' fees, lab tests or transfusions--was $23,418. None of it will be paid. More precisely, the bill will be absorbed by GW hospital as "uncompensated care" and spread inconspicuously across thousands of other bills in the form of higher charges to patients, insurers and taxpayers.

As the biggest hospital in downtown Washington and the closest to the White House, the State Department, the Federal Triangle and much of Embassy Row, GW cannot help getting involved in VIP medicine. It's the hospital where President Reagan and press secretary James Brady were rushed after they were shot outside the Washington Hilton Hotel in 1981.

"We are a part of official Washington whether we like it or not," said Thomas Chapman, the hospital's chief executive officer.

One measure of that: A couple of Secret Service agents were posted at the nurses' station outside the operating room where doctors were trying frenetically to save a homeless man's life--because he happened to be shot in front of the White House while carrying a knife.

Because it's a Level 1 trauma center--equipped to handle all cases--in a central downtown hospital, GW's emergency room also sees a high number of trauma patients--victims of traffic crashes, construction accidents, attempted suicides and violent crime.

But while most VIPs have health insurance, the homeless and the demonstrators who gather in front of the White House usually do not. Nor do most victims of penetrating trauma"--shootings and stabbings. Most victims in penetrating trauma cases treated at GW have no health insurance, said A. Mathew Philip, who headed the surgical team operating on Corniel. "We take care of them, and the hospital eats the cost."

But while most VIPs have health insurance, the homeless and the demonstrators who gather in front of the White House usually do not. Nor do most victims of "penetrating trauma"--shootings and stabbings. Most victims in penetrating trauma cases treated at GW have no health insurance, said A. Mathew Philip, who headed the surgical team operating on Corniel. "We take care of them, and the hospital eats the cost.

Marcelino Corniel had been living in Lafayette Square since late summer, when he was reported missing by relatives in California. He had a lengthy police record in California, where he had served five years in state prison for armed robbery and assault. Corniel's shooting remains under investigation by District police. Park Police officials have said it was justified because he was armed with a knife and appeared ready to lunge at two officers.

Trauma patients at every hospital are more likely than others to lack insurance, said Robert Shesser, GW's vice chairman of emergency medicine.

Among District hospitals, D.C. General, Howard University Hospital, Washington Hospital Center and Children's National Medical Center take care of the biggest proportion of uninsured patients. GW ranked fifth among the 12 nonspecialized District hospitals in 1993, delivering $10.3 million in uncompensated care.

Victims of violent crime in the District accounted for $20.4 million in hospital charges in 1989, according to a study by the D.C. Hospital Association based on case-by-case analysis of medical records over two months. More than two thirds of those emergency patients had no health insurance, and 85 percent of the charges went unpaid. Out of every $100 in uncompensated care by District hospitals that year, $9 was for treatment of people injured during a violent crime.

The high and largely unpaid costs of such care get shifted onto "paying patients" and their insurers. The hospital association study found that in 1989 D.C. hospitals would have to raise charges to insured patients by anywhere from $25 to $380 per admission to offset losses from unpaid bills for care of victims of violent crime.

"Everyone gets cared for, Shesser said. "It's just a question of how the pie gets cut up.

-- Don Colburn