Silvia Flores / The Press-Enterprise Evelyn Arciniega, 22, with a photo of her mother, Gloria Ramirez. This week is the 10-year anniversary of Ramirez's mysterious death in the emergency room at Riverside General Hospital.

And to this day, the source of the fumes remains a mystery. But the case has not faded from memory.

Ramirez's children plan to put a headstone, with her picture, at her grave in Riverside's Olivewood Cemetery.

Her emergency room physician now works at UC Irvine Medical Center. The physician, Julie Gorchynski, hobbled by knee pain, embittered by 20 knee surgeries in the past decade, remains determined that her experience should benefit the emergency room doctors she trains.

Ramirez, 31, suffered from ovarian cancer when an ambulance crew brought her to the hospital with chest pains. She died that night of kidney failure brought on by the cancer, the coroner's office later concluded.

Her death has had an impact beyond the death of one woman, the emotional drain on her family and the lasting medical problems of the health workers who tried to save her life.

The case prompted Riverside fire officials to rethink how they handle hazardous materials cases. And it underscored the need for a new coroner's facility, where autopsies could be performed without jeopardizing the health of those performing the work.

The coroner's office has since abandoned its old Riverside quarters, where her autopsy was performed amid yards of plastic sheeting and space-age protective suits. The coroner's department, much criticized for the handling of the Ramirez case, is now under the wing of the Riverside County Sheriff's Department and works from new quarters in Perris.

The hospital where Ramirez was treated is now gone, bulldozed to make way for a shopping complex. A new county hospital with a new name, Riverside County Regional Medical Center, opened in Moreno Valley four years after her death.

Dr. Tim Nesper, the hospital's emergency department director, said many things have changed since the Ramirez case. The hospital has a large decontamination center outside its emergency department, and it now has trained its staff in how to better handle patients contaminated with chemicals.

Still, the emergency room will never be completely risk-free for those who work there, Nesper said. In the months following her death, several theories emerged to explain the source of the fumes, including that Ramirez drank a pesticide in a suicide attempt; that she used a solvent as a home cancer remedy; and that the hospital's plumbing emitted a noxious gas. A Los Angeles alternative weekly even suggested that a secret methamphetamine lab operated in the hospital and that Ramirez was inadvertently given the drug in a bag of intravenous fluids. County officials vehemently denied the theory.

Maggie R. Garcia still firmly believes her sister was not the source of the mysterious ammonia-like fumes that sickened so many. No one in the ambulance that brought Ramirez to the hospital fell ill, she said.

"I've always believed the source of fumes was within the hospital," Garcia said.

"The situation was a fluke and it was unexplainable," said Mary Dilley, the county's risk manager. "That is the mystery and it probably will remain a mystery forever and ever."

The family sued the county for medical malpractice and for general damages stemming from the coroner's autopsy. The cases eventually were settled for $800,000, without the county admitting any wrongdoing.

Much of that money went to buy annuities for Ramirez' two children, Evelyn Arciniega, now 22, and Buddy Angel Arciniega, now 19. Evelyn is now a student at Riverside Community College. Buddy is serving a 12-year sentence for voluntary manslaughter.

But Dr. Gorchynski, who treated Ramirez, ended up with little more than long hospital stays, 20 knee surgeries and debilitating pain that prevents her from working more than three days at a time. Whatever the source, the fumes apparently triggered a bone-killing disease in her knees. Gorchynski expects some day to need and get prosthetic knees.

Gorchynski sued the county, but lost. The county sought legal expenses from her. Gorchynski said she had to pay the county $40,000 in costs. County spokesman Raymond Smith said the figure was $15,000.

"Surfing was my only stress reliever. Now I can't surf because of my bone disease," she said by phone.

Gorchynski now is an emergency room physician at UC Irvine Medical Center, treating patients and training new physicians. She believes her experience as a patient - she spent a month in intensive care - has made her more sensitive to the fears and needs of patients. Gorchynski now makes time to talk first with her patients to explain what's happening. She insists that her residents do the same.

Her nightmares have faded, but Gorchynski worries that another case could occur. Gorchynski is still unsure whether the fumes came from Gloria Ramirez or the hospital.

Whatever the source of the fumes, Gorchynski believes emergency room workers remain at risk.

"It'll happen again. It's just a matter of time," she said.