On a Friday afternoon, after a 12-hour day treating patients in Greeley, Dr. Rick Budensiek got into his little sedan and headed east – to a town in need of a doctor.
After an hour’s drive across a flat and sparse landscape, Budensiek reached the Eastern Plains town of Brush.
He drove past the Brush Correctional Facility, past the sign pointing the way to Brush High School, “Home of the Beetdiggers,” to East Morgan County Hospital.
For the next 36 hours, Budensiek would be the doctor for the 25-bed hospital and for the entire town.
Whatever ailed Brush’s 5,100 souls for the next day and a half – from congestion to cancer – would be Budensiek’s responsibility.
While nearly a quarter of the U.S. population lives in rural areas, only 10 percent of the nation’s doctors practice there, according to the National Rural Health Association.
There are about 8,700 physicians who treat patients in Colorado. Almost 90 percent of those doctors work in urban areas – most of them along Interstate 25 from Pueblo to Fort Collins, according to Peregrine Management Corp., a Denver-based medical data consultant.
Only about 1,000 are scattered across the rest of Colorado.
Eight Colorado counties have just one full-time doctor, and three counties have none at all.
The impact of those shortages is deeply felt.
In Crowley County in southeastern Colorado, people die in traffic accidents at a per-capita rate nearly four times that of Denver residents, according to the Colorado Health Institute.
In Baca County in southeastern Colorado, people died of diabetes at more than twice the statewide rate in 2004.
In Gunnison County on the Western Slope, 18.5 out of every 1,000 babies born in 2004 died before their first birthday. That’s nearly triple the statewide rate – and higher than that of Sri Lanka and Uruguay.
The U.S. Department of Health and Human Services lists 53 of Colorado’s 64 counties as rural or “frontier” – and 75 percent of those are cited as “health professional shortage areas.”
“In the past 20 years, rural health care has steadily fallen behind,” said Alan Morgan of the National Rural Health Association.
A taste of a small town
Five days a week, East Morgan has three physicians on staff and specialists who come in each month.
“But you can’t expect employees to be on call 24/7,” said Karen Temple, a hospital spokeswoman.
The hospital’s owner, Banner Health Systems, found a solution: doctors, like Budensiek, who were willing to work night and weekend shifts.
Fill-in doctors have become a lifeline for many rural hospitals. In 2003, 16 of Colorado’s 33 rural hospitals used temporary doctors, according to the Colorado Rural Health Center survey.
The need has even spawned companies such as Salt Lake City-based CompHealth Inc., which provides fill-in doctors in both large cities and small towns.
Doctors’ fees range from $800 to $1,500 a day, according to David Baldridge, CompHealth’s vice president for physician services.
A 52-year-old family practitioner, Budensiek has worked weekend shifts at East Morgan off and on for four years.
As he began his shift, the two elderly patients in the hospital, both being treated for pneumonia, were eating dinner. The emergency room was empty, and the radio that signals coming crises was silent.
Gossip, chatter and the clatter of jelly beans being dumped into a glass jar were the only sounds from the nurses’ station.
Budensiek decided to take advantage of the lull and eat dinner.
“I had a dream of being a small-town doctor,” Budensiek said, sitting in a booth at a local steak house, True Grits.
He lost any desire, however, to practice in his hometown of Phillipsburg, Kan., after a stint there while he was still a medical student at the University of Osteopathic Medical Sciences in Des Moines, Iowa.
“Going to the place where my mother grew up, you carry some baggage,” he said. “The hardest part was that you never got away from it. You go to church and somebody asks you about this or that.”
In Brush, Budensiek says, he has the best of both worlds. He can tend to a small community – and then he can leave.
An interrupted sleep
At 1 a.m., after treating walk-in patients for stomach pains and an asthma attack, Budensiek walked down the hall to the hospital room reserved for sleepy, visiting doctors.
Three hours later, a nurse woke him.
An ambulance was bringing in a frail, elderly man who spoke little English but who managed to communicate that his chest hurt.
For the next two hours, Budensiek and the nurses gave him beta blockers and aspirin, nitroglycerin for the chest pain, and stabilized him.
An ambulance arrived to take the man to Greeley’s hospital about 6 a.m.
Although Budensiek didn’t return to Kansas, his inspiration remains his hometown doctor – who saw Budensiek through a case of strep throat that morphed into a life-threatening illness, and cared for his mother, who died at 26 from breast cancer.
“He was really charismatic,” Budensiek said. “Just by talking with him or having him give you a pat on the shoulder, you felt better.”
The sun was just beginning to rise, and Budensiek took the time to check on the two pneumonia patients.
He looked in on 89-year-old Lois Waite, who came to Brush in 1945 when it was home to 2,481 people.
She married a tractor repairman, taught school for 32 years and had her two children at the town’s old Eben Ezer hospital – which was once the only hospital between Denver and Omaha.
“I still get around pretty good. I still drive, or at least I did until I got sick,” Waite said.
Financial reprieve
Although only 9.7 percent of Colorado’s population is older than 65, in Morgan County, senior citizens make up 13.3 percent of the residents. In rural areas across the state, the average is 15 percent.
The graying of rural America has been heightened by a general decline in rural population, which has dropped 10 percent since 1980, according to the U.S. Department of Agriculture.
Rural hospitals, as a consequence, depend heavily on government payments. Last year Medicare – the federal health insurance program for seniors – paid 82 percent of the bills at East Morgan.
When Congress cut Medicare payments in the 1990s, rural hospitals were hit harder than urban facilities, said Lou Ann Wilroy of the Colorado Rural Health Center. From 1987 to 1997, more than 280 closed, according to federal health officials.
In 1997, Congress increased the Medicare payments for rural hospitals that had been certified “Critical Access Hospitals.”
To get that designation and financial boost, a hospital has to have 25 or fewer beds and offer 24-hour emergency care.
East Morgan was one of the state’s first Critical Access Hospitals. One reason it contracts with Budensiek for weekends is to stay open round the clock.
Now, 25 hospitals in Colorado have qualified. Since the law took effect, none of the state’s rural hospitals has closed.
Counting health dollars
At 10 a.m., the waiting room in the walk-in clinic next to the hospital was filling up.
Kimberly Rubalcava brought in her 15-year-old son, Daniel, with a swollen right eye and sore throat.
Rubalcava feared Daniel, a freshman wrestler for the Beetdiggers, had picked up some germ at a match. But she didn’t want any unnecessary tests or pills.
“We’re paying cash,” Rubalcava told the doctor.
A waitress at a local diner, Rubalcava has a job but no health insurance.
Most people in Brush work. The county’s 4.9 percent unemployment rate is lower than the state average of 5.5 percent.
But they earn less. The median income in Brush is $31,000 – a third less than the typical Colorado household.
And, like rural residents everywhere, people in Brush are less likely to have health insurance.
In Morgan County, 20 percent of the population had no health insurance in 2003 – the state average was 15 percent, according to the U.S. Census Bureau.
In seven rural counties, the number of uninsured is nearly 30 percent, the Colorado Health Institute says.
By noon, Budensiek had seen 10 patients.
He had ordered a rapid flu test for 6-year-old Jeron Petterson – a test that came back negative – and persuaded 60-year-old Carolyn Walter to get a chest X-ray despite her reluctance.
“I have a $2,000 deductible,” she argued.
The 2001 congressional study “Medicare in Rural America” noted that while most people do seek care, rural residents are 50 percent more likely to defer medical treatment because of cost.
About 1 p.m., as Budensiek was 19 hours into his shift, a page summoned him to the emergency department.
“We’ve got a man choking. Diggers Diner. Now in full cardiac arrest,” a voice crackled.
When Gary Shultz was rolled into the emergency room, a half-hour had passed since he first choked on a hamburger.
In that time, emergency medical technician Lori Hardy had inserted a suction tube into his chest and given him epinephrine to restart his heart.
Hardy recognized Shultz as a resident of Eben Ezer, the old hospital, now a nursing home. His records showed he suffered from seizures and cerebral palsy.
“Let’s get blood gases and cardiac enzymes,” Budensiek said as nurse Angie Baughman cut off Shultz’s shirt.
For an hour, Shultz was the focus of everyone’s energy and attention. He was X-rayed, injected and bandaged – and all the while, EMT DJ Eicher squeezed a bag that forced air into Shultz’s lungs and talked to him: “Can you hear me, Gary?”
Shultz rallied briefly. But his heart had stopped for several minutes, and Budensiek worried that he might have suffered brain damage. Shultz needed intensive care.
So the staff called the Greeley hospital once more, this time asking for an air ambulance.
Outside, Shultz’s brother and sister-in-law stood crying, as the rising helicopter threw dust and debris at them.
Shipping patients out
Stabilizing, then transferring is a common practice in the nation’s rural hospitals, many of which lack intensive-care units – too expensive for small hospitals to run.
A study by Dr. John Westfall, director of rural health at the University of Colorado, found that 69 percent of rural heart attack patients in Colorado were transferred to urban hospitals.
Barely an hour had passed when another call came in, drawing Budensiek back to the ER.
“Fifty-nine-year-old cancer patient, stopped breathing,” the dispatcher’s voice announced.
“I bet that’s Dixie,” nurse Karen Greenwood said.
As they wheeled Dixie Grippin into the ER, a piece of her purple flowered housecoat hung over the side of the gurney. She had gotten her hair done earlier and was getting dressed when she decided to lie down.
When her husband, Stan, checked on her a few minutes later, she wasn’t breathing.
That Saturday, two days shy of their 40th anniversary, the high school sweethearts had planned to renew their wedding vows.
Their daughter had come in from Yuma, and their son was home from Grand Junction. Now they were all in the hospital’s little waiting area, pacing.
Stan Grippin walked in beside the gurney. Behind him, two little granddaughters, their hair piled on their heads and entwined with little yellow daisies, started to cry.
In the ER, Budensiek, four nurses and a respiratory therapist – all dressed in clear plastic goggles, green paper gowns and latex gloves – hovered over Dixie.
At her head was EMT Eicher, once again squeezing the air bag, trying to coax breath into her.
For nearly an hour, they worked, struggling much of that time just to find a pulse. The epinephrine that kick-started Shultz’s heart barely caused a blip in Grippin’s.
Finally, Budensiek said, “OK, let’s try pulling back a little bit,” and he left to find Stan Grippin.
Baughman, her hand on Dixie Grippin’s ankles, asked for a blanket.
“She’s cold,” Baughman said.
Grippin had been Baughman’s very first chemotherapy treatment patient.
“OK,” Budensiek said, returning to the room. “Let’s all just stop what we’re doing.”
The room turned quiet. The medical staff left, and Grippin’s family entered.
No one turned back to look through the windows of the emergency room door as Stan Grippin lay his head on his wife’s chest.
And for a long time, no one saw Budensiek.
He had gone to the doctors’ room, alone, and closed the door.
Fourteen more uneventful hours passed. It was Sunday morning. A new crew was gathered at the nurses’ station.
Budensiek tossed his bag into his car and headed west. He’d be back in two weeks.
But for now, it was someone else’s turn to be Brush’s doctor.
Staff writer Karen Augé can be reached at 303-820-1733 or kauge@denverpost.com.
