Life on the streets has taken a toll on Alberto Rodrigues.
For years, he's bounced in and out of the Queen's Medical Center. Outreach workers say he's there about a dozen times a year. He's gone in for everything from alcohol withdrawal to heart problems to serious wounds on his feet.
A few months ago, he sought care after a pit bull ripped off his ear. "One dog got this," he said, pointing to his left ear lobe.
When asked why he went to the ER earlier this month, he replied, "Pain in my body. Pain, pain, pain."
As Hawaii's homeless crisis continues, Hawaii's largest private hospital is cracking under the strain of helping chronically homeless people like Rodrigues, who have no access to primary care and so turn to ERs for both urgent and non-urgent health needs.
The Queen's Medical Center says it's seen ER visits surge in recent years. And the greatest spike is among the homeless population.
In fiscal year 2013, homeless people accounted for nearly 6,958 ER visits to Queen's. At the end of the 2016 fiscal year, the figure hit nearly 11,000.
The cost of caring for the those high-needs homeless patients is astronomical -- about $90 million a year for Queen's alone. And because Medicaid doesn't cover all of the costs, the hospital has been forced to eat almost $40 million in health care expenses over the last four years.
"Without the financial support that this mission-driven hospital has, it would bankrupt a hospital," said Dr. Daniel Cheng, assistant chief of the ER at Queen's.
The problem is multi-pronged, but one of the biggest issues is that only about 15 percent come into the ER with a true emergency, Cheng said. Most just need to be cleaned up and given some prescription medications.
"What they really need is good access to primary care," Cheng said.
The strain on the hospital's ER was noticeable on a recent Thursday afternoon, when all 36 beds were full. With 60 people in need of immediate care, nurses were stashing patients anywhere there was room.
The issue of 911 and emergency room "super-users" isn't a new one in Honolulu, but the problem has grown more acute as the number of chronically homeless people in the islands has grown and as the cost of their health care grows.
Queen's Medical Center records show that from Sept. 1 to Nov. 30, some 39 homeless people accounted for at least 734 ER visits.
Half arrived by ambulance or were brought in by police. And one person went into the Queen's ER 60 times in those 90 days.
"The cost is so great right now," Cheng said. "What we're paying as a community in terms of not being able to access 911. Paying in terms of actual cost. Paying in terms of not being able to be seen timely when we do have life-threatening emergencies."
State Sen. Josh Green, chairman of the Senate's Human Services Committee, has been working on a plan to help shoulder some of the burden. He's proposed building a new facility in Downtown Honolulu where patients could go for basic health care needs.
The senator is working with Queen's and local businesses to generate funding, and hopes to have a facility up and running in six months.
He's hoping the state and city will chip in to help cover some of the costs. He estimates the cost of launching a new facility will likely cost $30 million to $50 million.
"Right now, it's just a crazy system," Green said, "to have a hospital being occupied by individuals for $4,000 and $5,000 visits when they need $30 worth of care and a roof over their head."