DALLAS -- Adam Fira found himself in a hospital room after a car crash last year with half his skull missing and his head sunken in like a deflated basketball.
The high school football player couldn't run, lift weights, or wrestle with his sisters. The slightest bump or fall could harm his brain, protected only by skin etched with a road map of pink scars.
For months, he wore a skateboarding helmet to school and waited for doctors at Parkland Memorial Hospital to schedule surgery to implant a plastic skull.
Doctors said it might happen before Christmas, but it didn't. When it was delayed again in May, the popular athlete lost confidence. He stopped talking to friends and wouldn't leave the house. Finally, on July 12, the phone rang. Parkland had scheduled surgery for the next morning. Fira's mother used up her cellphone minutes spreading the news to family, coaches, and church members. Before dawn, they drove two hours to Parkland.
In room 229, his black curls shaved, Fira waited for his new skull. Hours went by. Fira grew more hungry and frustrated the longer he waited. After 13 hours, doctors told him to go home. Another patient's aneurysm and other emergencies at the public hospital had tied up doctors and operating rooms all day. Fira's surgery, considered elective, would just have to wait.
"I didn't want to believe them," said Fira, now 18. "I could have exploded, but that wouldn't have done anything."
Fira's experience is common at Dallas County's only public hospital, even though he is among the 7 percent of its patients with insurance. That makes him one of the few paying customers of a hospital in desperate need of more money.
Because Parkland doctors saved his life, Fira's parents wanted his surgery done there.
The financial crisis that erodes patient care and, some doctors say, threatens lives at Parkland is part of a larger crisis threatening to unravel safety-net health care at many of the 1,100 public hospitals across the country.
Since their origins in the 1700s as almshouses and sanitariums, public hospitals have relied on taxpayer dollars to provide care to Americans who couldn't afford it otherwise.
Some, like Parkland, branched out over the years, teaming with medical schools to become state-of-the-art teaching institutions that draw patients who could afford to go elsewhere. In some cases, public hospitals offer the only top-level trauma or burn care in a region.
But in recent years, public hospitals have been hit hard by government health cuts, just as surging numbers of uninsured Americans and illegal immigrants are turning to them for care.
Nearly 82 million people -- one-third of the US population under 65 -- lacked health insurance at some point over the past two years, according to a recent study by Families USA, a private consumer group. Texas had the highest rate in the nation, with more than 43 percent of its non-elderly population uninsured.
The National Association of Public Hospitals and Health Systems says about half of its 100-plus members lost money in 2002, the latest data available. Many are cutting jobs, shuttering clinics, and postponing surgeries to keep the doors open.
"The situation, which is generally always grim, is even grimmer now," said Rick Wade, a spokesman for the American Hospital Association. "You look at every part of the public health care system and you see enormous strain and you see everybody hollering for help. And the answer is unclear."
And patients, it seems, are paying the price.
At Parkland, which delivered nearly 16,000 babies last year, women are giving birth in the hallways. In the emergency room remembered across the nation as the place where President Kennedy was taken after he was shot, patients without life-threatening injuries wait an average of 7 hours for care. They get in line before dawn to pick up prescriptions. A woman with a lump in her breast can wait three months for a biopsy. Dying cancer patients are spending their last days waiting up to 10 hours for chemotherapy.
Like triage on the battlefield, doctors and nurses ration the hospital's shrinking resources and space. They take care of the car crash and gunshot victims, the patients closest to death, and they put off the rest.
"Anything that can be delayed will be delayed," said Dr. Ron Anderson, Parkland's CEO for 22 years.
Parkland is the primary teaching facility of the University of Texas Southwestern Medical Center at Dallas, which touts four Nobel laureates, more than any other medical school in the world. And, under Anderson's leadership, Parkland has made US News & World Report's best hospitals list for the past 11 years.
But Anderson believes Parkland is facing the direst moment of his tenure. Without new funding, patient care will suffer, along with the hospital's reputation.