(narrator) Coming up on Life on the Line.

With much of rural America medically underserved and hundreds of hospitals closing for good, Lost Rivers Medical Center, a 35-minute helicopter flight from the nearest trauma center, works to defy the odds and keep their doors open.

(clinician) During an emergency, it can be the difference between life and death.

Are you able to say anything to me?

You know your name?

We've got an air ambulance en route, and they should be here within the next 10 minutes.

♪ [dramatic and driving musical score] ♪ [faint voices] [helicopter whirring] [male voice on a radio] [wind rustling through brush] [distant sound of a train whistle] [music continues] [music fades] [twangy guitar solo] So, right now, um, I'm working a 96-hour shift.

During that time, I spend two days in the clinic and also am on call for the ER the whole time.

The ER nurses stay at the ER 24 hours a day.

They're working in 12 hour shifts.

And if a patient presents to the emergency room, they give me a call and give me a rundown of what's going on, and I give orders over the phone to start the patient off and head that way immediately.

Coming from a larger ER, the intermittent time period, it absolutely was nerve-wracking.

I can remember the first time, I think I woke up every hour on the hour to check my phone, make sure it was still on full volume and still had no missed calls.

And to be completely honest, you're still on high alert no matter what when you're working the emergency room.

[music continues] We are the only facility for hundreds of miles in each direction.

If you have a stroke or a heart attack or some sort of trauma accident up here, and there's no facility, no way to help you or administer first aid, without being overly dramatic, it would cost people their lives.

A joke that people always ask us is if we're a rural hospital.

I say, no, we're not a rural hospital.

We're actually a frontier hospital.

We're smaller than rural, and that means we're less than one person per square mile.

We're literally outnumbered by the bear and the elk.

And if something happens to you up here and there's no facility to help you, you're not going to make it.

[twangy guitar] (cow) Moooo (Dustin) This is Dustin.

[voice on phone] (Dustin) Well, I'll be right there, okay?

[dramatic musical beats] (Dustin) Gunshot wound, accidental gunshot wound.

We're actually stabilizing this patient who was bleeding quite rapidly.

We've used some trauma protocols to get him stable, and now he's going to be transported to a level two trauma center.

(Dustin) Bleeding was quite unstoppable.

It was very difficult to control the bleeding.

(Pilot) We'll be up within about five minutes.

(Dustin) Sometimes leg injuries with gunshots, or traumatic injuries, you wouldn't think that they would be that bad, but because of how much blood loss you can actually have through the legs, you can have a very big injury there, including death.

(Narrator) Lost Rivers Medical Center is one of over 1300 critical access hospitals in America, hospitals that are keeping essential medical services accessible for rural communities.

(Brad) The irony of it is, when I went to graduate school at the University of Colorado, my Master's thesis was literally on the unsustainability of the model that supports critical access hospitals.

Ironically, I've found myself now as the chief of one.

(narrator) Nearly a quarter of rural hospitals in America are at risk of shutting down, and over 40% are operating at negative margins.

(Brad) When I started at Lost Rivers Medical Center, the hospital was on the verge of collapse.

They were deeply in debt, had filed a bankruptcy, and they were on the verge of shutting down.

And so on my very first day, I talked to the acting CEO, and she took a sip of a coffee and sat back and looked at me, and she said, "Payroll's on Friday.

We only have about $7,000 in the bank."

We ran into a gentleman who runs a farm, and he offered to cover the payroll if I paid him back in two weeks.

So basically I would get a check every other week from Health and Welfare, CMS, Medicare, Medicaid, but it seemed like it was always on the off-week of the payroll.

And so we would get this a $100,000, $150,000 from this farmer, and the next week I'd get the $100,000, $150,000 from CMS.

I'd turn around and go pay the farmer back.

And then the next week I'd go back and say, "Well, hey, it's payroll again.

I need another $150,000," and so forth.

And so this cycle just went on for probably about six months.

(narrator)Beyond providing life-saving medical care, rural hospitals are the economic backbone of their communities.

(Brad) You close this hospital, a good part of our community leaves with it.

One thing about healthcare professionals is they can get a job anywhere, and that would just hollow out the very center of our community.

Schools would no longer be able to operate because they'd take all their kids with them.

Businesses would shut down because there's no volume, no one's buying groceries, no one's getting gas.

It would really just be this tumbling effect, these dominoes that would just collapse.

And so it is critically important that the hospital stay afloat and be viable and successful.

(narrator) Rural healthcare is also facing a crippling shortage of providers, and it's getting harder and harder to recruit and retain people for critical jobs.

(Brad) It's incredibly hard to recruit a physician anyway.

It is impossible, near impossible to recruit one who's willing to move to a rural area.

We're trying to recruit a nurse practitioner right now, and it's been six months, and I don't even think we've gotten an application.

Hospitals need providers, and if we can't be open and offer the critical care that's needed, then you're just a big empty building, really.

(Mark) I worked in really busy level one, level two sort of ER trauma centers, for about 10 years, which if you read the data is roughly when most ER doctors start kind of burning out.

And eventually I found this niche that I've spent my adult life in, critical access hospitals.

(narrator) Dr. Bolton has a business helping staff critical access hospitals with seasoned providers like him.

His physicians travel to these remote towns to work long shifts that often last well over 100 hours.

(Mark) Over my career, I've staffed 30 to maybe as many as 50 critical access hospitals, and I'll be doing, God willing, rural health until I can no longer work.

It's trite, but it's an accurate way to describe it.

It's like a mission field.

(narrator) Commuting to Arco from his home in Columbus, Ohio, Dr. Bolton will soon start a five-day shift at Lost Rivers Medical Center, taking over in the emergency room from Dustin.

(Mark) People will sometimes ask me, "Why don't you live here?"

Because I do love these places, but the simple reason that we don't live there is we have a son, Cameron, that's autistic.

So that tethers me to Columbus because his whole support network is in Columbus.

I kind of feel like I live in the United States in a sense because what most people consider vast distances to me are just part of my life.

(narrator) Dr. Bolton traces his passion for rural medicine back to the influence of his medical school.

(Mark) The motto of the school was, and probably still is, 'To Make Man Whole.'

It directly led me into choosing rural health as a career choice, but also recognizing how important the impact you have on individual lives is.

It's true everywhere, in any setting, but it's easier, at least to me, to see it in a rural setting.

You have to do a lot more with a lot less and wear a lot of hats, and everybody just has to work together and make it happen.

[folk music on guitar] (Tara) I own this flower shop.

I have actually been here now for almost 30 years.

My grandmother bought it for me when I was a single mom so that I would have a job.

I have been an EMT for the last 25 years, a volunteer EMT.

Decided when I was 25 that that's something I wanted to do to give back to my community.

And then in 2014, I ran as the county coroner and was elected to that position as a write-in, and I've been reelected two times since.

The local joke here is, because of the flower shop, the EMT and the coroner, if I can't save you, I will pronounce you dead, and then I will do your funeral flowers.

That's become a running joke because I am involved in all three.

But I do try to save you first.

Did he want a card?

No, he's going to buy a card.

Oh, he didn't want a card?

Nah, he wants a big card.

Okay, perfect.

[beep, beep, beep] (radio) Lost River ambulance, Butte control.

Just got a report that there is a lady down at 427 Lost River Avenue.

She seems to be conscious, but she is not talking.

She is approximately 80 years old.

Please respond.

(Tara) Four-Eight (radio) Three-One (narrator) Tara quickly shifts from florist to lead EMT, heading out to meet the town's other volunteer EMTs and respond to the emergency call of a woman who's down and unresponsive.

[dramatic music] [voices on radios] [siren blaring] (Dustin) Hello guys.

Let me jump up in there with you really quick.

Are you able to say anything to me?

You know your name?

Can you move your feet?

No?

Okay.

All right.

Let's go straight to the CT scanner, guys.

(Tara) She will not straighten that leg.

[whirring of CT scanner] (Dustin) I'm told the helicopter is approximately 45 minutes out now.

(female voice) He said 41 because I switched it.

(Dustin) 41.

No bleeding at least.

All right, very good.

(female voice) And you still want the C spine?

(Dustin) Yes, absolutely, please.

This is Dustin.

Hey, I've got a 78-year-old.

She has a left-sided facial droop.

She's not responsive to verbal commands, doesn't make any verbal response.

We've got an air ambulance en route, and they should be here within the next 10 minutes.

Patient exhibiting symptoms of acute stroke.

We'll send for higher level of care to Eastern Iowa Regional Medical Center.

She has a carotid terminus occlusion, left side.

(clinician) Left side, okay.

(Dustin) So she's got a big stroke going on.

We're going to take you to EIRMC over in Idaho Falls, okay?

(clinician) All right.

We have to pack you all in here, okay?

It's about 35 minutes from here by flight, okay?

(Dustin) Certain interventions are completely based on time, and if our hospital wasn't here, then the patient's timeline for treatment, for stabilization, would've been much greater, which would've been very bad on her outcome.

That's exactly why we came into emergency medicine.

Not that we want anything bad to happen to anyone, but we want to be there to help them.

(Mark) For as long as I've been practicing medicine, before I come out to these shifts to work, I pray that God will help me do no harm, because that's the first rule of any healthcare provider, to do no harm.

And the second thing is, help me to treat everybody with respect, patients, colleagues, coworkers, even when I don't feel like it, especially when I don't feel like it.

So if those things are true on a shift, I don't do any harm, I treat people with respect, and I keep in mind that I treat, but God heals, then it's a successful shift for me.

At the beginning of my shift, which is going to be about a five-day shift, one of the things I need to do is to check in with the person that's passing the baton to me.

So Dustin, I understand there was a stroke patient that presented?

(Dustin) That's correct.

Yeah.

Around an 80-year-old female that came in having been found down, unresponsive, by bystanders.

She was brought in by EMS, and we worked her up for stroke, activated flight.

That was, yes, one of our significant cases this weekend.

One of the things you never have to second guess is whether or not you're making a difference.

You absolutely are.

Yep.

(Dustin) After a busy week like this last one, it comes time when you need to relax a little bit.

And one of my favorite things to do is go hiking, or kind of get out and about.

And it just kind of recenters you.

It's very calming.

Listen to the sound of the water and the rustling of the leaves, all the birds and the wildlife that you run across.

It's absolutely great.

(Delyla) I think in any physician's, wife's role, they have to know what they're getting into.

That's a lot of dedication.

But if it works, it works great, and we work great.

(Dustin) I couldn't do it without her.

There's a lot of stuff, a lot of stress, a lot of trauma, a lot of death that you see working in any medical field, and especially in acute care areas.

And I think that rural health is no different, maybe even to some degree is a little worse because you get to know your patients.

When you get home at the end of the day, you need support.

And she does excellent for me.

I couldn't do it without having that support.

[guitar strumming] (Mark) He is coming in here because he's got this swelling and drainage in his groin area.

But I noticed in his labs that his blood sugar is really, really high, like close to 500, which is really high.

And when you guys were here a few days ago, it was in the 600 range, right?

So you are definitely diabetic.

(Joshua) There's natural remedies to kill it, to solve the diabetes, right?

(Mark) Well, yes, there are.

And diet and exercise.

So what I think we ought to do tonight is, I want to repeat a CAT scan to make sure there's no serious infection in your groin area.

(narrator) Over 7 million Americans like Joshua have undiagnosed diabetes.

Untreated, they face complications like stroke, heart disease, kidney disease, and potentially serious infections.

(Mark) He has a draining area kind of where the thighs come together with the groin.

And that area in a diabetic can develop a really bad infection called necrotizing fasciitis.

And if you have it, it's a surgical emergency, because it can be life-threatening.

And the CAT scan, it's very easy to see gas under the skin.

And fortunately for him, he didn't have it.

His bigger problem though is the diabetes, which he didn't know he had.

(Joshua) Type 2?

(clinician) Yes, type 2 is where you're taking pills.

This is his first time knowing about it, and he was trying to prevent it.

So now it's just a big step from figuring out what he can eat and what he can't eat.

So it's just kind of a lot to take in.

(clinician) Okay, you guys.

Any questions?

(Jennifer) No (Dustin) No (clinician) All right.

Good luck with everything.

(Mark) Okay, Josh.

(clinician) It was nice meeting you, man.

(Joshua) Nice meeting y'all, too.

(Mark) What will I see this shift?

Who knows?

I expect it'll be probably a steady shift, because this is the middle of the summer, and there's a lot of tourists coming through town, but most of it'll be daytime visits.

And I'll probably get some rest.

Now, talk to me in four days, and we'll see.

The financial challenge of rural hospitals is enormous.

It is enormous.

The cost of healthcare is enormous.

Our margins are razor-thin.

And trying to make up that difference between what it costs and what you can earn is a staggering problem that keeps you awake at night.

And we don't get paid by quality.

We get paid by volume.

It doesn't matter if you perform really good medicine.

It just matters that I had 10,000 people walk through the emergency room door.

As long as our system is based on volume payments, rural healthcare is always going to be at a disadvantage.

The ones that make it, frankly, are the ones that find ways to generate revenue without necessarily finding unbelievable volume to do so.

What do we have?

What can we use?

What can we utilize that we're not utilizing?

And that was how we figured out the reference lab piece.

(narrator) The hospital opened their lab to overflow from other hospitals in the region.

Soon the state of Idaho, state police, and the Bureau of Prisons started sending work their way.

(Brad) Now we're processing labs all over Idaho.

We can do it quicker, better, faster, cheaper.

And now, that is the highest revenue producing service line we have.

(announcer) Bette works as a phlebotomist in the lab.

And her sister, Arias, works in billing.

Both are working towards future careers in medicine, and they're open to working in a rural place like Arco.

With less than 3% of medical students intending to practice in a rural setting, they are in a small minority.

(Eryeus) The opportunity to work in rural healthcare will be a huge benefit, considering all the knowledge we've learned working in this rural community.

(Bette) You get a far greater understanding of what exactly a community is lacking, what do they need, how do they function if they don't have this or that supply or provider?

How are they able to provide patients the best care?

And I think you learn to be far more adaptable.

Are we creating a list or anything?

(Mark) Seeing bright, focused young women like Bette and Eryeus wanting to go into medicine because of their experience in a rural setting is very encouraging to me.

(Bette) So I think last time we talked, we just got all our notifications about where we sat in the med school process.

Dr. Bolton and many of the providers here that have made such a huge impact and aided us in so many ways to be successful in our medical school application process, and being able to just talk to them as person to person about any struggles, and they understand our struggles, and being able to one day possibly be that person for a future generation.

That I think is amazing.

(Brad) It's nice to see some younger folks get in to rural health.

It does give you hope.

(narrator) Lost Rivers Medical Center has fought through bankruptcy, borrowed money from a local farmer to make payroll, and turned their lab into an economic success, fighting every day not to be one of the over 500 rural hospitals in America at risk of closing for good.

(Brad) Life is tough in a rural community, and running a hospital is really hard.

You're never going to make more than 1 or 2%.

It's enough to keep you going.

And I actually told my own board this my first day, I said, "I'm not here to make you money.

I'm here to keep the hospital open."

This is our legacy.

What a great legacy to have.

(narrator) Next time on Life on the Line.

I'm picking my son up from football practice, and I get hit.

So that kind of forced me to go see my primary doctor.

He felt a small lump.

I was like, dang, this is real.

Cancer.

(narrator) Only a few hospitals in the world perform the Jaw In A Day surgery.

We are taking a process that takes up to two years and compressed it into one day.

I can't taste nothing.

I'm throwing up stuff.

It hurts.

This thing is metastasized.

It's growing constantly, and we don't have months and months to wait.

I'm going to boss up, and let's go fight this thing.

This program was made possible by the Ralph and Carolyn Thompson Charitable Foundation, and Ed and Anne Zinke.