It's 6:06 p.m. on a Wednesday and the emergency room at Doctors Medical Center in Modesto is filling up fast.

An elderly man who fell face-first off a curb staggers in. A security guard rushes to get him a wheelchair. He waits to see a doctor.

A teen-age girl twirls her blond ponytail as she chats on a cellular telephone, telling a friend that she's suffering dizzy spells. She waits to see a doctor.

A young man in a shiny blue sweat suit saunters in, clutching his left elbow. He signs in at the counter and takes a seat. He waits to see a doctor.

Soon, 26 people -- some of them patients, some friends and family members -- settle in for the two-hour wait that has become typical at many Northern San Joaquin Valley hospitals. It is a scene that is played out throughout the state and nation.

The reasons are legion: The population is growing; hospitals have closed; nurses are in short supply; patients with nonemergencies turn up at ERs instead of going to doctor offices and urgent care centers; regular hospital rooms are unavailable, so people ready to be transferred from the ER have no place to go.

But that doesn't matter much to the patients who wait. Phyllis Castillo rushed her boyfriend to the emergency room at Memorial Medical Center in Modesto last year when he slashed his palm on a jagged piece of metal while fixing a faucet.

The Modesto woman said her boyfriend waited four hours to see a doctor, his bloody hand wrapped in towels.

"It was packed. They were treating people in the hallways," Castillo said. "I had never seen anything like that in my life."

ER doctors say care is not suffering here -- yet. Nurses conduct short examinations when people come in, putting those who need immediate care at the top of the list. Doctors treat life-threatening emergencies, such as heart attacks, right away.

But doctors agree that long waits and crowded hospitals are proof of problems in emergency medicine.

"It's a symptom of a system that is stressed, and there's no light at the end of the tunnel," said Dr. Robert Donovan, medical director of the emergency room at Doctors Medical Center.

Consider:

Doctors Medical Center reported 51,555 visits to its ER in 2000, up from 37,383 in 1996, an increase of nearly 38 percent in five years. Visits to the ER at Memorial Medical Center increased from 39,789 in 1996 to 64,697 in 2000, an increase of more than 62 percent.

Of the 38,931 ER visits at Turlock's Emanuel Medical Center last year, about 40 percent could have been treated at urgent care centers, hospital spokeswoman Pennie Rorex said. Stanislaus County's five urgent care centers treat patients with severe cuts, ear infections, sinus infections and other ailments that are not life-threatening.

Ambulance officials say ERs in Modesto are so busy that they send ambulances to other emergency rooms at least once a day. They say this practice, called diversion, rarely happened in the past.

"Five years ago, we went on diversion maybe once a month," said Doug Buchanan, deputy director of the Mountain Valley Emergency Medical Services Agency, which regulates ambulances.

Health care officials here are quick to point out that ER crowding is worse in other areas.

A hospital in a suburb of Washington, D.C., installed extra call buttons, so emergency patients waiting in the hallways can summon nurses. Las Vegas ambulance companies have proposed telling paramedics that they must leave patients unattended in busy emergency rooms if hospitals cannot find ER beds within 30 minutes.

The reasons behind overcrowding, however, are similar throughout the nation:

The population has increased and hospitals have closed.

Stanislaus County's population grew by about 60,000 from 1990 to 1998. Meanwhile, the county closed its public hospital in 1997, citing financial concerns. Other hospitals here, including Del Puerto Hospital in Patterson, also have shut down.

Thirty-four hospitals have closed in California since 1995, said Jan Emerson, a vice president with the California Healthcare Association. In the past 10 years, about 500 hospitals have closed throughout the nation.

"Long ER waits are not unique to Modesto, the Central Valley or California, for that matter," she said.

A growing number of people have no insurance and no regular doctors. So, when these people are sick, they go to emergency rooms.

Federal law requires hospitals to give care whether or not patients have insurance.

Other people are covered by Medi-Cal. Many private doctors do not accept the government insurance plan, saying it pays poorly.

Some insured patients find that their doctors are busier than ever under managed care, making it difficult to get timely appointments.

"If the doctor says wait three weeks and you're in pain, what else are you supposed to do?" said Graham Pierce, director of emergency services at Doctors Medical Center.

Many people use the ER in nonemergency situations.

Patients often show up in the ER with mild cases of the flu and other illnesses that could be treated in an urgent care center, said Bev Finley, managing director of the Stanislaus County Health Services Agency, which runs an urgent care center in what once was the emergency room of the county hospital in Modesto.

"We would prefer that they come here," Finley said.

But not everyone can afford the $45 the urgent care center asks of uninsured patients.

Donovan, the ER medical director at Doctors Medical Center, keeps a list of patients he says come to his hospital's ER after the county's urgent care center turns them away. He plans to ask the county grand jury to investigate the matter.

"It's not right," he said. "I'm in emergency medicine. I can't look at a patient's wallet before I see them."

Finley said she is looking into the problem. She pointed out that patients who cannot pay can see a financial counselor at the Health Services Agency and sign up for one of several government health insurance plans. Sometimes, they can get coverage right away.

But, she said, patients do not usually carry pay stubs, required to apply for insurance.

These people may end up at the emergency room at Doctors Medical Center, charged with caring for former patients of the county hospital who have no insurance. The county does not pay the hospital to care for these patients in the ER, however, Donovan said.

Once these patients have been treated in the emergency room, it is not likely that they will return to the county's urgent care center to complete applications for insurance that could cover the next emergency, Finley said.

"They go away and don't follow through," Finley said.

Modesto hospitals treat people who have been seriously injured in other regions, including Tuolumne and Merced counties and Yosemite National Park. This adds to the patient load in the city's ERs.

Helicopters often ferry injured rock climbers and rafters to Memorial and Doctors medical centers.

Patients with major head and chest injuries also are routed here. Doctors who specialize in treating these types of injuries are not available in outlying areas.

"If you get a gunshot to the chest, you're coming to Modesto," said Dr. Terry Sweeney, medical director of Memorial Medical Center's ER.

Patients linger in the ER because the hospital cannot accommodate them in regular beds. In turn, ER waiting rooms fill with patients who have less-serious injuries.

"Sometimes, we have no room for patients who have flulike symptoms or something like that," said Steve Mitchell, Memorial Medical Center's chief operating officer. "They have to wait."

Nurses are in short supply throughout the nation.

When ER nurses call in sick, it is not easy to find replacements, Mitchell said. This can add to wait time for ER patients.

Also, some hospitals do not have enough nurses to staff all the beds, adding to the backup in the ER, he said.

Northern San Joaquin Valley hospitals are trying to tackle the crowding problem.

Memorial Medical Center plans to relocate a portion of its radiology department to make room for eight to 10 more emergency room beds. The hospital has expanded its PromptCare hours and added staff to handle an increased number of patients year-round.

At Doctors Medical Center, workers recently converted a meeting room near the emergency room into an Express Care center for people with minor ailments, like flu, rashes and coughs. The hospital also plans to add staff.

Both hospitals have long-term expansion plans that would make room for more emergency room patients.

Ambulance officials have an idea that they say could help ease ER waits.

They propose that each hospital tell ambulance dispatchers when its ER begins to get busy, instead of waiting until it is overwhelmed. This way, ambulances could more evenly disperse patients between hospital ERs. The proposal is being considered by the Mountain Valley Emergency Medical Services Agency.

Many doctors are pinning hopes on bills in the state Legislature.

One proposal calls for a sweeping reorganization of the state's emergency medical system, including more government money for hospital emergency rooms and doctors. Another would provide for fair and timely reimbursement from insurance companies.

But some say such efforts are limited. The number of uninsured people in California is estimated to be 7.3 million and growing.

"The system is not on the verge of collapse, it's already collapsing," said Dr. Paul Windham, who works in the emergency room at Sutter Merced Medical Center.

"We need to treat emergency medical services like public services, like the police and fire departments," he said. "When we need emergency services, we need to make sure that they're going to be there."

Back at Doctors Medical Center, the wait is over for the elderly man who fell off the curb. A nurse pushes his wheelchair through the double doors and into the treatment area.

In the waiting room, the young man in the sweat suit cradles his arm, fidgeting in his plastic chair.

The teen-ager with dizzy spells rubs her head and makes another call.

"I'm at the emergency room," she says. "And I'm still waiting."

Bee staff writer Kerry McCray can be reached at 578-2358 or kmccray@modbee.com.