The 50-something man with a shaved head and brown eyes was unresponsive when the paramedics wheeled him into the emergency room. His pockets were empty: He had no wallet, no cellphone and not a single scrap of paper that might reveal his identity to the nurses and doctors working to save his life. His body lacked any distinguishing scars or tattoos.

Almost two years after he was hit by a car on busy Santa Monica Boulevard in January 2017 and was transported to Los Angeles County+USC Medical Center with a devastating brain injury, no one had come looking for him or reported him missing. The man died in the hospital, still a John Doe.

Hospital staffs sometimes must play detective when an unidentified patient arrives for care. Establishing identity helps avoid the treatment risks that come with not knowing a patient’s medical history. The workers also strive to find next of kin to help make medical decisions.

“We’re looking for a surrogate decision-maker, a person who can help us,” says Jan Crary, supervising clinical social worker at LA County+USC, whose team is frequently called on to identify unidentified patients.

The hospital also needs a name to collect payment from private insurance or government health programs such as Medicaid or Medicare.

But federal privacy laws can make uncovering a patient’s identity challenging for staff members at hospitals nationwide.

At LA County+USC, social workers pick through personal bags and clothing, search the contacts of an unlocked cellphone for names of family members or friends and scour receipts or crumpled pieces of paper for any trace of a patient’s identity. They quiz the paramedics who brought in the patient or the dispatchers who took the call.

They also make note of any tattoos and piercings and even try to track down dental records. It’s more difficult to check fingerprints because that’s done through law enforcement, which will get involved only if the case has a criminal aspect, Crary says.

Unidentified patients are often pedestrians or cyclists who left their IDs at home and were struck by vehicles, says Crary. They might also be people with severe cognitive impairment, such as Alzheimer’s disease, patients in a psychotic state or drug users who have overdosed. The hardest patients to identify are ones who are socially isolated, including homeless people — whose admissions to hospitals have grown sharply in recent years.

In the last three years, the number of patients who arrived unidentified at LA County+USC ticked up from 1,131 in 2016 to 1,176 in 2018, according to data provided by the hospital.

If a patient remains unidentified for too long, staff at the hospital will make up an ID, usually beginning with the letter “M” or “F” for gender, followed by a number and a random name, Crary says.

Other hospitals resort to similar tactics to ease billing and treatment. In Nevada, hospitals have an electronic system that assigns unidentified patients a “trauma alias,” says Christopher Lake, executive director of community resilience at the Nevada Hospital Association.

The deadly mass shooting at a Las Vegas concert in October 2017 presented a challenge for local hospitals that sought to identify the victims. Most concertgoers were wearing wristbands with scannable chips that contained their names and credit card numbers so they could buy beer and souvenirs.

On the night of the shooting, the final day of a three-day event, many patrons were so comfortable with the wristbands that they carried no wallets or purses.

More than 800 people were injured that night and rushed to numerous hospitals, none of which were equipped with the devices to scan the wristbands.

Staff at the hospitals worked to identify patients by their tattoos, scars or other distinguishing features, as well as photographs on social media, says Lake. But it was a struggle, especially for smaller hospitals, he says.

The Health Insurance Portability and Accountability Act, a federal law intended to ensure the privacy of personal medical data, can sometimes make an identification more arduous because a hospital may not want to release information on unidentified patients to people inquiring about missing persons.

In 2016, a man with Alzheimer’s disease was admitted to a New York hospital through the emergency department as an unidentified patient and assigned the name “Trauma XXX.”

The police and family members inquired about him at the hospital several times but were told he was not there. After a week — as hundreds of friends, family members and law enforcement officials searched for the man — a doctor who worked at the hospital saw a news story about him on television and realized he was the hospital’s unidentified patient.

Hospital officials later told the man’s son that because he had not explicitly asked for “Trauma XXX,” they could not give him information that might have helped him identify his father.

Prompted by that mix-up, the New York State Missing Persons Clearinghouse drafted a set of guidelines for hospital administrators who receive information requests about missing people from the police or family members. The new guidelines include about two dozen steps for hospitals to follow, including notifying the front desk, entering detailed physical descriptions into a database, taking DNA samples and monitoring emails and faxes about missing people.

California guidelines stipulate that if a patient is unidentified and cognitively incapacitated, “the hospital may disclose only the minimum necessary information that is directly relevant to locating a patient’s next-of-kin, if doing so is in the best interest of the patient.”

At LA County+USC, most John Does are quickly identified: They either regain consciousness or, as in a majority of cases, friends or relatives call asking about them, Crary says.

Still, the hospital does not always succeed. From 2016 to 2018, 10 John and Jane Does remained unidentified during their stays (of varying lengths of time) at LA County+USC. Some died at the hospital; others went to nursing homes with made-up names.

But Crary says she and her team pursue every avenue in search of an identity.

Once, an unidentified and distinguished-looking older man with a neatly trimmed beard was rushed into the emergency room, unable to speak and delirious with what was later diagnosed as encephalitis.

Suspecting the well-groomed man likely had a loved one who had reported him missing, Crary checked with police stations in the area. She learned, instead, that this John Doe was wanted in several states for sexual assault.

“It is a case that I will never forget,” Crary says. “The truth is that I am more elated when we are able to identify a patient and locate family for a beautiful reunification, rather than finding a felon.”

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. KHN is not affiliated with Kaiser Permanente.

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It’s early morning in an operating theater at Providence Hospital in Portland, Ore. A middle-aged woman lies on the operating table, wrapped in blankets. Surgeons are about to cut out a cancerous growth in her stomach.

But first, anesthesiologist Brian Chesebro puts her under by placing a mask over her face.

“Now I’m breathing for her with this mask,” he says. “And I’m delivering sevoflurane to her through this breathing circuit.”

Sevoflurane is one of the most commonly used anesthesiology gases. The other big one is desflurane. There are others, too, like nitrous oxide, commonly known as laughing gas.

Whatever gas patients get, they breathe it in — but only about 5% is actually metabolized. The rest is exhaled. And to make sure the gas doesn’t knock out anyone else in the operating room, it’s sucked into a ventilation system.

And then? It’s vented up and out through the roof, to mingle with other greenhouse gases.

These two gases are actually fairly similar medically; sevoflurane needs to be more carefully monitored and titrated in some patients, but that’s not difficult, Chesebro says.

Generally, unless there’s a reason in a particular case to use one over the other, anesthesiologists simply tend to pick one of the two gases and stick with it. Few understand that one — desflurane — is much worse for the environment.

And that bothered Chesebro. He grew up on a ranch in Montana that focused on sustainability. “Part of growing up on a ranch is taking care of the land and being a good steward,” he says.

Now he lives in the city with his three kids and has gradually started to worry about their environmental future. “When I look around and I see stewardship on display today, it’s discouraging,” he says. “I got depressed for a while, and so I hit the pause button on myself and said, ‘Well, what’s the very best that I can do?’ “

He spent hours of his own time researching anesthesiology gases. And he learned desflurane is 20 times as powerful in trapping heat in Earth’s atmosphere as sevoflurane. It also lasts for 14 years in the atmosphere, whereas sevoflurane breaks down in just one year.

Opening a big black notebook, filled with diagrams and tiny writing, he shows how he computed the amount of each gas the doctors in his group practice used. Then he shared their carbon footprint with them.

“All I’m doing is showing them their data,” Chesebro says. “It’s not really combative. It’s demonstrative. Ha, ha ha.”

One of the doctors he shared his analysis with was Michael Hartmeyer, who works at the Oregon Anesthesiology Group with Chesebro. “I wish I had known earlier,” Hartmeyer says. “I would have changed my practice a long time ago.”

Hartmeyer says he was stunned when Chesebro explained that his use of desflurane was the greenhouse gas equivalent of driving a fleet of 12 humvees for the duration of each surgical procedure. It’s “only” half a hummer if he uses sevoflurane. Hartmeyer notes that outside the operating room he drives a Prius.

“You try to be good,” he says. “You take shorter showers or [don’t] leave lights on, or whatever else. But you know there’s always more that we could probably do. But this was, far and away, a relatively easy thing that I could do that made a huge impact.”

The anesthesiology carts that get brought into operating theaters tend to have a row of gases to choose from. So Hartmeyer was able to switch pretty much overnight.

Other anesthesiologists made the switch, too. And it didn’t hurt that sevoflurane is considerably cheaper.

Hartmeyer’s change saved his hospital $13,000 a year.

When Chesebro shared his findings with the anesthesia departments at all eight Providence Health hospitals in Oregon, they prioritized the use of sevoflurane. They now save about $500,000 per year.

Providence’s chief executive, Lisa Vance, says the hospital system didn’t change its use of the gas because of the money. It changed because the World Health Organization now says climate change is the No. 1 public health issue of the 21st century — and because of Chesebro.

Vance said Chesebro teared up in front of 2,000 people when talking about the gas, his children and the Lorax from Dr. Seuss. “Unless someone like you cares a whole awful lot, nothing’s going to get better — it’s not,” says Vance, quoting the book.

Jodi Sherman, an associate professor of anesthesiology at Yale School of Medicine, calls Chesebro’s efforts remarkable and important.

She says several hospitals around the country have tried to make this shift, but with mixed results. Some just gave anesthesiologists the information, and not much changed. Other hospitals took desflurane away, but that left many anesthesiologists feeling disrespected and angry.

She thinks Chesebro succeeded because he chose to persuade his colleagues — using data. He showed doctors their choice of gas, plotted against their greenhouse impact. And it helped that he showed them over and over, so doctors could compare their progress with that of their peers.

“Providing ongoing reports to providers is the best way for this movement to catch on and grow,” she says. It can reinforce over time, she adds, not just what their carbon footprint is, but also what progress they’re making.

Sherman says efforts such as Chesebro’s are sorely needed because the U.S. health sector is responsible for about 10% of the nation’s greenhouse gases. “We clinicians are very much focused on taking care of the patient in front of us,” she says. “We tend to not think about what’s happening to the community health, public health — because we’re so focused on the patient in front of us.”

In an emailed statement, Baxter International, the manufacturer of the anesthesia gas, says it is important to provide a range of options for patients. The firm also says inhaled anesthetics have a climate impact of 0.01% of fossil fuels.

“The overall impact of anesthetic agents on global warming is low, relative to other societal contributors, especially when you consider the critical role these products have in performing safe surgical procedures,” the statement reads.

It’s a fair point, Chesebro says, but he has a counterargument.

“Well, if it’s there, it’s bad. And if I can reduce my life’s footprint by a factor of six … why wouldn’t you do it?”

The surgery Chesebro was involved in that morning at Providence was a success. Chesebro estimates that by using sevoflurane on his patient, the same greenhouse gases were produced as in a 40-mile drive across the Portland region.

If he had used desflurane instead, he says, it would have been like driving the more than 1,200 miles from Seattle to San Diego.

Now Chesebro’s hospital bosses are hoping other doctors will follow his lead, research their own pet peeve, and maybe solve a problem no one’s thinking about.

This story is part of NPR’s reporting partnership with Oregon Public Broadcasting and Kaiser Health News, which is an independent journalism program of the Kaiser Family Foundation and not affiliated with Kaiser Permanente.

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Scientists who recently announced an experimental genetic test that can help predict obesity got immediate pushback from other researchers, who wonder whether it is really useful.

The story behind this back-and-forth is, at its core, a question of when it’s worth diving deep into DNA databanks when there’s no obvious way to put that information into use.

The basic facts are not in dispute. Human behavior and our obesity-promoting environment have led to a surge in this condition over the past few decades. Today about 40% of American adults are obese and even more are overweight.

But genetics also plays an important role. People inherit genes that make them more or less likely to become seriously overweight.

While some diseases (like Huntington’s and Tay-Sachs) are caused by a single gene gone awry, that’s certainly not the case for common conditions, including obesity. Instead, thousands of genes apparently play a role in increasing obesity risk.

Many of those gene variants contribute a minuscule risk. Sekar Kathiresan, a cardiologist at Harvard and a geneticist at the Broad Institute, set out to see whether he and his team could find a bunch of these genetic variants and add up their effects. The goal was to identify genetic patterns that put people at the highest risk.

This genetic information “could explain why somebody’s so big, why they have so much trouble keeping their weight down,” Kathiresan says.

His team identified more than 2 million DNA variants of potential interest. He figures most of those variants are irrelevant, but his hunch is, hidden somewhere in there are a few thousand changes that each contribute at least a tiny bit to a person’s risk of developing obesity.

No single gene can do much to move the needle. But he says the composite result, called a polygenic risk score, is still potentially useful. Those with the highest risk scores were more likely to be severely obese (with a body mass index over 40). In fact, 43% of the people with the highest genetic scores were obese.

But the score is far from perfect. For instance, 17% of the people with the highest scores had normal body weights.

The team, with lead author Amit Khera, published its results in the journal Cell.

“The impact of the genetics — and this was a huge surprise to us as well — starts very early in life, in the preschool years, around the age of 3,” Kathiresan says.

That finding suggests prevention efforts are more likely to succeed if they also start in childhood. Kathiresan has a more philosophical takeaway from his work as well.

“I hope this work will hopefully destigmatize obesity and make it very similar to every other disease, which is a combination of both lifestyle and genetics.”

A lot of elaborate genetic analysis is behind the study, which involved more than 300,000 individuals. But the broad conclusions aren’t new.

Scientists already knew genetic risk factors can contribute significantly to obesity. And other studies show that obese children are at high risk for becoming obese adults.

Epidemiologist Cecile Janssens, a professor at Emory University, doesn’t think much of this strategy of adding up the tiny risks from millions of genetic variants to come up with a cumulative risk score.

“In all fairness, we don’t know whether all of these variants really matter,” she says. When asked about the value of doing a study like this, she says, “I have no clue.”

“It is not really answering a very relevant question from the biological perspective, and not really answering a very relevant question from a clinical perspective,” she says.

This type of analysis doesn’t reveal anything about the individual genes that are contributing to obesity, which means you can’t use it to understand the underlying biology. If obesity were a rare disease, a test like this could be useful to identify people at elevated risk. But since it affects 40% of Americans, Janssens says prevention efforts should include everybody.

She is among a group of scientists informally rebelling against the gene-centric way of looking at disease. It’s frustrating for them to see so much money poured into this kind of genetics work, rather than into efforts to change the environment and the behaviors that contribute to diseases like obesity.

Janssens also says that, despite the daunting effort involved in studying 2 million genetic variants, the resulting score still doesn’t explain even 10% of the variation the scientists observed in body mass index. (Kathiresan, who couches his conclusions differently, says the score explains about a quarter of the genetic risk.)

Scientists doing this kind of work hope that data like these, when presented to individuals, will prompt them to change their behavior.

Alas, that’s not supported by scientific reviews.

“This kind of personalized risk information has little [or] no impact on people’s actual behavior,” says Theresa Marteau, who directs the Behaviour and Health Research Unit at the University of Cambridge.

In fact, researchers have worried that when people learn that they are at high genetic risk for diseases like obesity, people would become fatalistic and stop trying to change their behaviors. Fortunately, Marteau says “in a review, we didn’t find any evidence for that.” It seems they just ignore the information.

Ewan Birney, who heads the European Bioinformatics Institute, has been watching this debate play out over the years. Birney agrees with the critics who say obesity isn’t the ideal disease for this kind of analysis.

“One needs to do more than just be able to show a strong statistical association,” he says. “One really needs to show that you can then use that to do an intervention.”

Birney also is wary of making too much of this information because it’s based primarily on data from the UK Biobank, as well as U.S. samples, in which racial minorities aren’t well represented.

There are other instances where these polygenic risk scores can be useful, he says. For example, a score that identifies people at high risk for heart disease identifies people who get the most benefit from cholesterol-lowering drugs called statins. (But it’s unclear whether it would be beneficial to give statins to people who score high on this test but wouldn’t ordinarily be identified as candidates for this medication).

Using a different method of analysis, called a genome-wide association study, scientists have identified more than 140 genes that can slightly increase the risk of obesity. Though their individual influence is small, they do provide clues about the biology of the disease.

For example, one of the relatively potent variants “actually relates to calorie-seeking behaviors,” says Ali Torkamani, who is director of genome informatics at the Scripps Research Translational Institute. Other variants are, unsurprisingly, related to the function of fat cells.

It’s also possible that a careful probe of the genes – rather than the abstract risk score – could identify genetic variants that actually reduce a person’s risk of obesity. A paper in the same issue of Cell as the one that featured work from Kathiresan’s group points in that direction.

While genes influence a person’s risk of obesity, the epidemic in this country is obviously far more extensive than simply people at high risk. And Torkamani notes that the risk score isn’t destiny. “It’s just a probability,” he says. “And you know, when you flip a coin sometimes it comes up heads and sometimes it comes up tails.”

You can contact NPR Science Correspondent Richard Harris at rharris@npr.org.

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