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The emergency room: That high-drama, high-adrenaline place you go when your sick or battered body suddenly fails you — where they pull you back from the brink of disaster.

But the truth is, if you're in serious trouble in Tucson and in need of specialty emergency care, there's a dangerously good chance you simply won't get it.

At any given time in a Tucson ER, there will be no neurosurgeon to stop your bleeding brain, no plastic surgeon to fix your flailed flesh, no orthopedic surgeon to handle your complex fracture, no gastroenterologist to stem your internal hemorrhage, no hand surgeon to save your mangled fingers.

"What kind of ER is that?" asked Dr. Steven Pike, an emergency physician at St. Joseph's Hospital.

"The ER is really the window into our health care system, and it has gotten so bad, the system is broken. It no longer functions. You can no longer rely on the ER to save your life.

"Our job, as ER doctors, is to keep you alive long enough to get you to the specialty care you need. But if we can't find that care in time — and we too often can't — you lose. This is a crisis now. The safety net in our health-care system is gone."

Although the breakdown in emergency care in this country is an extremely complex phenomenon, it boils down to a simple double-whammy: too many patients and too few doctors, nurses and beds to handle them.

At the crux of this problem in Tucson is the rapid loss of many, if not most, specialty surgeons — neurosurgeons, plastic surgeons, vascular surgeons, hand surgeons, gastroenterologists, to name some — willing to respond to emergency calls.

Many simply no longer will come when called in to see an ER patient, or do so far less often than in the past. The severe shortage of many of these specialists has made doing so a huge burden on their finances and family lives.

"If we don't restrict this in some way, we would be on call at multiple ERs every night — you'd never get a night off; you'd never get a chance to take care of your scheduled patients, much less see your family," said Dr. Eric Sipos, a Tucson neurosurgeon deeply concerned about this problem and working to fix it. Several years ago, Sipos took ER calls at four Tucson hospitals; today, only one.

"I completely understand the anger of the ER physicians," he said. "On every shift, night after night, they know they have a high likelihood of having a patient show up that they won't have the resources to treat.

"Of course they're angry."

To give a snapshot of the problem, at least 18 orthopedic surgeons shared emergency calls at St. Joseph's Hospital in recent years. Today, it's no more than six. During a six-week stretch this spring, no orthopedic surgeons at all were available there for emergencies.

That pushed ER physician Dr. John Bush, also at St. Joseph's, nearly to the breaking point when he found himself performing procedures he was not trained to do.

"There are times when the emergency is so acute, I have to act then, immediately. I don't have time to start shopping around all over town, trying to find a surgeon," Bush said, describing amputation patients badly in need of a specialist whom he was forced to handle.

"I was very uncomfortable treating patients I had no business treating," he said.

" It's to the point I don't know what to do."

These drastic changes — from having almost universal specialty care for emergencies to having none at all at times — have occurred in Tucson just in the last three to five years, doctors say. And it's a citywide deterioration, affecting all ERs, and potentially any patient who ends up in a serious emergency.

It took a perfect storm of complex factors — falling insurance reimbursement, rising malpractice rates, too many uninsured patients, fear of lawsuits, changing lifestyle choices — to create this crisis, to destroy what was once seen as a civic duty to treat emergency patients. These factors have led to the overall doctor shortage plaguing Arizona — a shortage especially acute among specialty surgeons.

"This is a severe problem in emergency care across the country. But Arizona is affected to a more alarming degree than almost anywhere else," said Greg Angle, CEO of St. Joseph's Hospital, noting Arizona has one of the largest uninsured populations and most severe doctor shortages in the nation.

And no longer are the horror stories striking only the usual victims, the uninsured.

"Now, it doesn't matter if you're insured or not," said Pike, the ER physician. "You can be rich, famous and powerful, but you are not guaranteed medical care.

"We end up transferring patients all over town, or to Phoenix, or to San Diego, to Albuquerque, to L.A. We're doing that regularly now. That means delayed care, and that puts patients at risk."

It's difficult to say just how often that happens now. While hospitals record every time they transfer a patient to another hospital, they don't compile figures on why, or even where.

But proving Pike's point was the case of Bishop Emeritus Manuel D. Moreno of the Roman Catholic Diocese of Tucson, who died in November, several days after suffering a brain bleed on a Sunday night. No neurosurgeon could be found to treat him here, so he was flown out of St. Joseph's ER to Phoenix, for critical surgery.

"You have a brain hemorrhage crisis like that and you're shopping around for care?" asked neurosurgeon Sipos, who takes ER calls only at Tucson Medical Center, now struggling with no neurosurgeon coverage Friday through Sunday, when it's most critically needed.

"I don't know if this transfer caused Bishop Moreno's death, but it couldn't have helped. The system is broken."

Other cases don't make the headlines.

On a rainy day last winter, Mary Jo McClure slipped on wet concrete steps, slashing skin and tissue off most of her front lower leg. Bleeding profusely, in intense pain, she was taken to TMC's ER.

Right away, the emergency staff realized McClure needed a plastic surgeon. But the surgeon on call declined to come in, saying she would instead see McClure in her office Monday — three days later.

So, with a gaping, bloody wound — looking almost like a shark attack — McClure, 73, was cleaned and bandaged and sent home for the weekend. She was told to stop by the drugstore for wet and dry wraps and to change them twice a day.

"I was getting a little scared by then. Nobody was kind; nobody seemed to care. I got the feeling they just wanted me out of there," she said.

This was no indigent, uncooperative patient. McClure is married to one of Tucson's premier longtime businessmen, Frank McClure, former president of Holmes Tuttle Ford. Not only are the McClures well insured, they're more than able to pay for care out of pocket, if needed.

Terrified at the idea she'd have to care for such a traumatic injury for days by herself, McClure requested home nurses, which TMC arranged. Meanwhile, the plastic surgeon, Dr. Gwen Maxwell, called the McClures to tell them she was strictly a cosmetic surgeon, not experienced in wound care, and would not be able to see Mary Jo McClure on Monday after all.

At that point, McClure fell into the black hole of emergency medical care in Tucson. For six days she and her husband called every plastic surgeon on their insurance list, but got only refusals: They do eyelids, they do face-lifts, they don't do wounds. With high-level contacts across Tucson, the McClures and their friends called surgeons they knew personally. No one they knew would treat such a severe injury.

Thoroughly frightened by then, with tissue on her leg turning black, her unclosed wound at high risk for infection, McClure remembered reading that the burn center at St. Mary's Hospital also is a wound center. She called them, and they accepted her case. Finally, nearly a week after she fell, treatment began on her leg.

"You don't know what a relief it was to find them. They took such good care of me," she said.

Treated by plastic surgeon Dr. Karl Hekimian at St. Mary's, McClure endured two surgeries, including a major skin graft and more than four months of intense care to heal her leg, which remains scarred.

"This was an open wound that was not healing when she finally got here," Hekimian said. "The problem today is that most Tucson plastic surgeons are focused on cosmetic surgery — they're really not equipped to handle an injury like this."

Maxwell — who has an excellent reputation as a cosmetic surgeon — flatly admits that, in explaining her decision to decline the McClure emergency.

"This was clearly a very bad wound, much more than just a skin wound — it could not be sewn up," she said. "I just didn't feel comfortable handling an injury that required skin grafts and many weeks of dressing care.

"I made the decision long ago to devote my practice to cosmetic surgery, as most of us have, and this is such a dilemma for us. If I see this wound, I'm going to own it, and I'm liable for the outcome. It puts me at risk for a lawsuit, to care for a case this severe that is beyond my practice."

Deeply chagrined at the role she played in letting McClure fall through the cracks, she finally said: "But I should have dealt with her. I am so deeply sorry. I owe her a formal apology. I feel horrible about this."

Even so, Maxwell said most plastic surgeons are extremely reluctant to sacrifice time from their lucrative, cash-only cosmetic practices to respond to emergencies, the same kind of situation many other specialists face.

"You try not to go in," she said. "Very often, there's really no need for a plastic surgeon — the ER doctors have gotten very good at taking care of most of these cases. But we get into a lot of tug-of-wars with them over those judgments.

"And what you get, usually, are drunk patients at 3 a.m. who've been in fights or car wrecks, who aren't insured. So it's pretty gross, and you don't get paid."

But she well knows, and regrets, the trouble this causes.

"What a waste of time and effort for the ER doctors trying to shop these patients all around. We are just a pain in the ass for them."

Amen, say TMC's emergency physicians.

"I don't think the public realizes what's going on here — not until they end up in the system," said Dr. Ronald Widman, TMC's director of emergency services.

"We are trained to act quickly, so when you have to sit on these patients, and wait and wait, and work the phones all night, and you still end up sending them to El Paso — that's not acceptable. That's not why we went into medicine."

Even at University Medical Center — where the ER is backed up by a level-one trauma center that must have 24/7 specialty coverage to keep its level one status — there is a never-ending struggle to maintain it.

"It's a constant battle, and we're always worried about it," said Eileen Whalen, UMC's vice president for trauma and emergency services.

"But everyone in town knows we're the only ones sure to have specialists, so we get called routinely. They know we have it, but they really have to plead a case to get a patient in here."

Federal law requires that if specialists provide care or perform surgery at a hospital, that hospital is obligated to have ER coverage in that specialty, even if only for a few days a month, Whalen pointed out.

"Sometimes we have to say, 'Why not call your own orthopedic surgeon?' " she said. "But then it's, 'We don't have one, he's out of town.' Our doctors get annoyed. There are definitely times they feel they're being abused."

But the true victims are the patients in an emergency crisis who end up in a place that has no way to care for them.

"In this country, in this day and age," said Mary Jo McClure, "to have to beg for health care, even when you have insurance for it — there's something really wrong."

Tucson hospitals are trying to fix the dangerous situation in the city's ERs, but it is costing them millions and threatens bankruptcy. Read more about why this ER crisis has occurred and what is being done about it.