Frontier Medicine, and Forty-Five Miles to Billings

Dr. Casagrande’s Quest to Heal Big Sky Country

Frontier Medicine, and Forty-Five Miles to Billings: Dr. Casagrande's Quest to Heal Big Sky Country

Forty-five miles stand between Dr. Jeri Lynn Casagrande and her patients.

Those forty-five miles of yellow-striped Montana highway, which separate Roundup Memorial Healthcare from her hometown of Billings, may not seem like much. After all, her car is reliable, the roads and scenery are routine, and the comforts of familiarity await her at each end. For the patients that visit her 25 bed Critical Access Hospital in Roundup, however, that quiet two-lane road can be the difference between life and death. When it comes to healthcare access, those dotted yellow lines serve as the dividing lines between two very different worlds.

“I don’t think people realize the limitations we face here,” explained Dr. Casagrande. “The challenges we face every day are things people don’t even think of. Calling Roundup ‘rural’ is an understatement. In reality, this is frontier medicine.”

Each morning at 6:45 a.m., Dr. Casagrande leaves home and heads north toward Roundup, her forty-five mile commute serving as a reminder of the immense challenges facing her three provider healthcare team, and just about every patient they encounter.

Ranching is, and for generations has been, the prominent industry in Roundup. The seat of Musselshell County, Roundup is nestled in a valley between the soft-flowing Musselshell River and the Bull Mountains, making it a famously impeccable geographic space for ranchers to round up their livestock — hence the name. The people of Montana are famously tough, and many of Dr. Casagrande’s patients are living proof of that. When they come in to see her, they often carry the scars of their arduous work.

Dr. Casagrande and her team are regularly confronted by the brutal damages that often accompany the laborious professions of her patient base, including bones crushed by spooked livestock, pelvic fractures from horse riding accidents, catastrophic chainsaw wounds and, really, just about every imaginable thing that can go wrong over a lifetime of hard, dangerous work.

When she first began working at Roundup Memorial Healthcare, the hospital’s lone computerized tomography (CT) scanner — which she often relies on for diagnosing patients — was so old that it required a “cool down” period of at least 30 minutes between scans, forcing her to make a life-or-death choice each time she was faced with a trauma patient. Often, the choice between first completing a head CT or chest CT came down to a gut feeling of which was more urgently needed.

Compounding the issue, her emergency treatment options for such patients are limited to just two units of blood that are stored in a buzzing Blood Bank refrigerator and, thanks to a lack of a ventilator, require one of the three members of her team — including herself — to provide oxygen to patients by continuously squeezing the bag of a manual resuscitator. Thankfully, with the assistance of tremendous grant work, her hospital was able to purchase new equipment, including a portable ventilator, a CT Machine, a Dexascan, new IV pumps, facility wide bed replacement, and an Omnicell, just to name a few.

While Montana’s rich mineral reserves have landed it the nickname of “The Treasure State,” Dr. Casagrande does not operate out of anything resembling a medical goldmine. “Physicians practicing in rural areas face unique challenges and opportunities,” said Alan Morgan, CEO of the National Rural Health Association. “In smaller communities, they often see an older, sicker, and poorer patient population than their urban counterparts.”

“In smaller communities, they often see an older, sicker, and poorer patient population than their urban counterparts.”

Despite all of those challenges and more, Dr. Casagrande’s love for Montana, and for her fellow Montanans, carries her along that forty-five mile road to Roundup each morning.

In the past, that forty-five mile stretch of road has morphed her emergency room into a mass casualty setting. Take for instance the three-car pileup that struck a school bus not too long ago, landing ten patients in the hands of Dr. Casagrande, two physician assistants, and her nursing staff. While that, along with any event that brings more than three people to her emergency room at once, has the potential to become a resource-depleting juggling act of epic proportions, the road is more than just a crash risk. For many residents of rural Roundup, it is an unnavigable path to health.

“Traveling to Billings is a huge burden for many people,” explained Dr. Casagrande. “A lot of the people I see don’t have the transportation, or the means, to make that trip.”

For two frigid months last year, that perilous trip became the lone option for many of Roundup Memorial Healthcare’s patients.

According to the RUPRI Center for Rural Health Policy Analysis, 16.1 percent of the United State’s independent rural pharmacies – or 1,231 stores – have closed in the past 16 years, leaving 630 rural communities which had at least one retail pharmacy in 2003 with none in 2018. On February 22, 2018, Roundup joined that list.

The pharmacy that once served as a one-stop-shop for not only vital medications, but also a plethora of clinical services, including medication counseling, blood pressure and glucose monitoring, immunizations, patient consultation, treatment of mild illnesses amenable to over-the-counter medications and more— closed its doors, with no clear signs of ever reopening them. That meant that, in the peak of Montana’s brutally harsh winter, the residents of Roundup faced a dangerous forty-five mile drive each time they need medicine.

For a child with an easy-to-diagnose medical issue, such as a sinus infection, a cure is often just an antibiotic dosage away. For the people of Roundup, however, accessing that antibiotic meant taking on a massive financial sacrifice.

For farmers and ranchers, the ninety-mile round trip drive to Billings meant losing a day’s pay. For parents in Roundup, the drive became the difference between a healthy child and hospitalization — or worse.

For parents in Roundup, the drive became the difference between a healthy child and hospitalization — or worse.

“We try to help our patients as much as possible, but there aren’t a lot of mail-order services in this area,” Dr. Casagrande explained. “We worked with other pharmacies to bring stuff to us, but it was still a 24-hour turnaround time. While that was better than nothing, those 24 hours posed devastating risks.”

Thankfully, the pharmacy reopened in April, returning a vital resource to a community that already has so few. For Roundup’s residents, the scare was further proof of how quickly things could go from bad to worse.

In her time in Roundup, Dr. Casagrande has helped many patients avoid the pitfalls of driving to Billings, bringing her unique combination of experience, knowledge and, perhaps most importantly of all, heartfelt care to the people she serves. While she still struggles to overcome a lack of vital resources — which include little aid for patients who desperately need meals or transportation, an overwhelming lack of specialists — including a massive need for more psychiatric services — an Ultrasound machine that only operates three days a week, debilitating staffing challenges and more — she has effectively revolutionized the healthcare landscape of Roundup in a noticeable, sustainable, and inarguably lifesaving way.

When she arrived, Roundup Memorial Healthcare had no controlled substance agreement, meaning that patients could call in for their narcotics freely with very little monitoring, which created a major potential for substance abuse. The hospital’s electrocardiogram (EKG) machine was outdated, and they’d all but given up on telemetry — a system capable of collecting vital patient data— thanks to a constant barrage of inaccurate alarms. Since her arrival, the hospital has implemented a controlled substance agreement, gotten a new EKG machine, and added functioning telemetry, which allows patients with non-emergency conditions to be monitored without having to stay at the hospital.

On top of those already massive improvements, she has also implemented Annual Medicare Wellness visits, which are a major part of preventative care and have proven to be very financially impactful for both patients and the healthcare system, started transitional care management visits, where she follows up with Medicare patients in the clinic following their hospitalizations, began conducting hemoglobin checks, and started performing obstetrics in a setting that didn’t even have a prenatal panel prior to her arrival. This has helped to bring in more pediatric patients, opening the door for more screening tests, including one for autism, a test previously unavailable in Roundup.

Perhaps most importantly of all, she has brought a stable group of healthcare professionals to Roundup, making the town’s residents more confident and comfortable when they consider going to the doctor.

“Having a stable group makes the community feel like things are good,” she explained.

Each night, Dr. Casagrande climbs back into her car and makes the forty-five mile trek back to her home in Billings. On the ride she tries to let the worries of her day drift away, out across the rolling, cow-dotted pastures that surround her; up and over the jagged mountain peaks that shape much of her home state.

She’s seen her dream of providing care to her fellow Montanans come true in the form of a three-year rural service obligation. When that three years is up, however, Dr. Casagrande isn’t going anywhere, despite the many challenges that she is confronted with each day.

“I plan on continuing my work in Montana long beyond any service obligations,” she explained. “I want to raise my family in this beautiful place, and give them an opportunity to grow up surrounded by the beauty of nature and the outdoors as I did. This is home for me.”