Eighty per cent of the emergency unit's costs are picked up by the public purse through Medicare, Medicaid or charity This year there will be less money. Cuts imposed by New Jersey's Republican governor, Christine Todd Whitman, will leave UH $80m short compared with 1994 Next month the hospital will announce job cuts. At least 240 positions are expected to be lost from of a staff of 3,600.Kareem cries out: "I need some water." "Don't move," Nurse Conway replies "If you move, you could sever your spinal cord We don't know what's broken yet." Kareemignores her He tries to sit up "Jesus Christ, Kareem. Get me some help here!" Conway is joined by John Horning, the senior medical resident "Lie still, Kareem," he says "If you move you could become paralysed. Do you know what paralysed means? It means your dick won't work."This gets Kareem's attention He relaxes, at least for the moment. He's now surrounded by two doctors, three nurses and four police officers His journey to the ER has already cost at least $5,000.

He has no medical insurance.It takes Cathy Conway another hour to treat Kareem, who has plenty of bad cuts but, it turns out, no broken bones."That's the most frustrating kind of patient," she says. "Ibasically achieved nothing, because he fought me all the way We get this all the time. Thirteen-year-old kids come in here with gunshot wounds and think they're men because they have a piece A gun doesn't get you respect. It gets you shot."Mary Beth Lave, nurse manager, knows the score. "On ER they never talk about budgets, they never consider the dollars that are spent every second in here," she says, stacking up special packs used to treat gunshot wounds.

"Research hospitals like this keep pushing out the frontiers of emergency medicine Today we can save people we would have lost in the past Tomorrow we'll save people we lose today But the costs are enormous. A gunshot wound to the head costs over $100,000 to treat, a stomach wound at least $60,000. Without less violence or some change in medical economics our days are numbered."There are changes in hand, but they are not welcomed by Mary Beth Lave. "Health management organisations [HMOs] administer health insurance for most Americans. They need to make a profit out of insurance contributions and that means controlling costs The process is way out of hand. I have to call HMOs from the ER and discuss what drugs to give. I've had patients who weren't stable, who needed more intervention and an HMO administrator miles away in an office - not a doctor - has insisted the patient is stable.

Of course, we go ahead and give the treatment but without approval the HMO won't pay, so we're left with the tab."Doctor Horning has seen the same process "There are two professional bodies. The American College of Emergency Physicians and the American Association of Emergency Physicians ACEP is now run by contract groups. They offer to take over a hospital's ER and run it at much lower costs. The contract group makes its money by hiring inexperienced physicians The standard in the industry is $100 per hour ACEP's groups often pay $25."Horning looks exasperated. He paid his way through medical school by working as an emergency medical technician, driving an ambulance every night for eight years. Now his standard of living is at risk."Inexperience is often the least of an ACEP contract doctor's problems Some of them are plain bad.

But they're never in one place for long, so they don't pay the price for their screw-ups. I earned more than $25 an hour as a technician."The dispatch radio comes to life. Newark ambulance drivers can report patient conditions directly to the ER "Two incoming, one male and one female Motor vehicle accident Unrestrained victims ran into a tree Male has leg and arm fractures. Female has suspected hip fracture and breathing difficulties." Dr Horning puts on his gown and mask He sighs. "When they say 'unrestrained' they mean no seatbelts."The trauma team stands poised in yellow robes The next drama can begin "Twenty-two-year-old female. Definite dislocation of left hip, suspected fracture and possible arterial bleeding." The ambulance technician delivers her report Doctors and nurses surround themoaning victim. "Oh God, oh God - my hip, please oh God help me." They lift the patient.