Local medical professionals and public health officials worry that a bad situation is about to get much worse.

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In the cool night air, an ambulance’s rear doors fling open and a bloodied Asian man, who minutes earlier was pistol-whipped in the head by a street thug, is carried into Natividad’s emergency room on a gurney. Moments later, a woman who’s just given birth is rushed in with bleeding so severe that her life is in danger. A little after that, a handcuffed and burly looking prisoner in an orange jumpsuit is escorted in by three armed prison guards.

Dr. Jeffrey Arnold, the ER doctor on duty this night and the hospital’s new chief medical officer, rushes to attend to each patient with the assistance of nearly a dozen nurses. Aided by a steady stream of coffee, they work fast and make decisions on the run. People’s lives are hanging in the balance and they know it. All the while, the incessant beeps and clicks of medical equipment permeate the air as new patients keep flowing in.

The scene is just as most people might imagine a graveyard shift at an emergency room, with plenty of blood and agony and high drama. But in the last couple of years, a change has been taking place inside this particular ER.

While doctors and nurses at Natividad still see their fair share of patients brought in due to car crashes, heart attacks and other sudden trauma, they’re also seeing a larger number of patients who simply have no place else to go. These are patients who, because they have no insurance and can’t afford to pay for their own care, have put off treating their chronic illnesses until they’ve become acute. They know doctors will have to treat them at the ER.

“We are seeing a larger percentage of patients without access to primary care,” says Arnold, a fast-talking man in his early 50s who sports a goatee and reading glasses slung low over his nose. “About 75 percent of the people we see here [out of 30,000 annual visits] have no healthcare at all or only have insurance plans like Medical or Medicaid.”

While Arnold has 15 years experience working in emergency departments at big-city hospitals like Cedars Sinai and UCLA/Harbor Medical Center in Southern California, he’s still impressed by some of the patients he sees at Natividad.

“Here you see the kinds of cases that you just won’t see in suburban hospitals,” he tells me as he multitasks between filling out a patient’s form and peering at someone else’s cardiogram chart. “We see chronic diseases that are more spun out of control and that could have been treated earlier, but weren’t. We kind of interface with the Third World.”

An elderly woman he’s treating at the moment is a case in point. In her 60s, she is lying on her back in a corner bed, meekly uttering a few phrases in Spanish. (Arnold cannot release her name or allow me to talk to her because of the hospital’s strict confidentiality rules.) A relative, probably her granddaughter, hangs near the foot of the bed nervously.

Arnold checks in on the woman for a few minutes. “She has one of the largest goiters I’ve seen in years,” he says when he returns to the desk. He picks up a phone and calls an internal medicine physician at the hospital who will treat the woman overnight.

“She came in with chest pains, shortness of breath, heart racing,” Arnold says. “She’s a great case, medically speaking. It’s something dramatic that you don’t see other places.”

Arnold describes another patient whom he treated in the ER not long ago who had no access to health care. “We had this woman from Mexico with a breast tumor that was so large it was bleeding through her shirt,” he says matter-of-factly before moving on to another patient. “Very dramatic.”

Jeff Brody, another ER doctor at Natividad, says he’s seen cases where the emergency room turned out to be a patient’s best shot at getting care.

“Not long ago a woman came in with rectal bleeding,” says Brody as he sips from a large coffee cup. “She had no insurance, so at the clinic they were requiring her to pay $1,000 up front to get a colonoscopy. She didn’t have the money.”

When the woman learned she could make monthly payments for the same procedure if she came through the ER, she checked herself in.

“They finally did the procedure,” he says. “She was able to make the monthly payments, and learned that she had a precancerous condition.”

While some patients treat the ER like a clinic, asking for the same doctor who treated them previously to fill their prescriptions or to get a needed shot, it’s not the correct way to treat chronic illnesses.

For one, it’s very expensive—either to the patient or to the hospital, if the patient doesn’t pay their bill, which can easily run up into the tens of thousands of dollars.

More importantly, says Dr. John Silva of Clinica de Salud, the ER is not designed for people who need to manage their illnesses.

“In Monterey County, diabetes is becoming an epidemic,” he says. “Those patients need long-term care, and an ER doesn’t help those people in the long term.”

Dr. Laura Osorio, the medical director for Monterey County Health Department’s clinic system, agrees. But she goes a step further. The people who need help the most are those who aren’t going to the clinics or even the hospital’s ER.

“I think the largest uninsured population is the one we don’t know about,” Osorio says. “And that’s very problematic. Because Type II diabetes, for example, is usually diagnosed five years after its onset. So people without insurance will go to a doctor only after they’ve already developed severe complications from diabetes and it’s a lot harder and more expensive to treat.”