The health care tradeoff
Living in rural beauty often means waiting longer for care
ALPENA — Responding to emergencies in a timely manner can be difficult in rural Northeast Michigan, delaying potentially critical care for residents.
The isolation of living in Northeast Michigan means there is one hospital, MidMichigan Medical Center-Alpena, serving the region. Residents here also face a shortage of doctors and longer ambulance response times in the outlying areas of the region, according to an analysis by The News of state and local data.
Depending on where a person lives in Alpena County, it can take up to 22 minutes for an advanced life support ambulance to arrive at the location of the emergency for transport to the hospital. And, though the hospital is equipped to handle most emergencies, patients are transferred to other hospitals for care twice a day, on average, according to hospital officials.
However, communities are working together to provide emergency medical coverage.
Alcona County’s Curtis Township is the only community without dedicated medical first responder coverage in the four-county area.
Paul Grabstanowicz, who is both a Curtis Township trustee and the assistant medical chief of the South Branch Fire Department, said the township currently relies on Alcona County’s emergency medical services station, located less than a mile outside town, to serve the township’s 1,236 residents. The township can’t afford its own service, Grabstanowicz said.
“We don’t have the funds to support it at the start,” he said. “We don’t have the folks that would be able to — or be willing — to take the time and energy of going through six months of classes and taking a national exam to be able to provide emergency medical coverage.”
However, the service provided by Alcona County’s EMS station “seems to be sufficient” for the township at this time, Grabstanowicz said.
The City of Alpena has Alpena County’s only advanced life support ambulances and paramedics, the only way patients can be transported from an emergency scene to the hospital. The townships employ medical first responders or emergency medical technicians who can respond more quickly and provide basic care until a paramedic arrives.
From June 16, 2018 through June 19 of this year, Alpena County’s ambulances were sent out 1,578 times, according to data provided by the county. The average response time for residents living in the city was 5.33 minutes, but residents in the farthest corners of the county waited far longer.
In Long Rapids Township, the average wait time was 20.67 minutes.
In Hubbard Lake Township, it was 21.64 minutes.
That’s just for the ambulance to get to the scene. It’s that long again to make it from the scene to the hospital.
That’s the medical first responders are so important, Alpena Deputy Fire Chief and Fire Marshal Bob Adrian said.
Those medical first responders are trained to assess the scene and condition of the victim and can check vital signs, put on splints or tourniquets, treat wounds, and perform CPR.
Adrian said those first responders are in constant contact with the paramedics en route to the scene, so those paramedics can perform more complex treatments as soon as they arrive.
“Medical first responders are our eyes and ears in lifesaving intervention,” Adrian said. “They are often the first boots on the ground.”
‘SICKEST … TAKEN CARE OF IMMEDIATELY’
The emergency room at MidMichigan Medical Center-Alpena is currently operating as a Level III Trauma Center, according to Tanya Rouse, the hospital’s trauma program manager.
That designation means the ER has demonstrated the ability to provide prompt assessment, resuscitation, surgery, intensive care, and stabilization of injured patients in emergency operations, according to the American Trauma Society website. Trauma centers can range from Level V, meaning a patient is evaluated and transferred, to a Level I trauma center, which can treat every aspect of an injury.
The Alpena hospital’s ER posts mixed statistics when compared to other ERS. According to the most recent data available from Medicare.gov, it took six minutes longer than the national average for patients to receive pain medication in 2017 and 2018, but the hospital did twice as well as the national average on the share of patients who give up and leave the ER before ever being seen.
It took 26 minutes, on average, for an emergency patient in Alpena to see a health care professional, compared to 20 minutes nationwide and 18 minutes statewide, according to Medicare.gov.
About 2,000 patients visit the Alpena hospital’s emergency room each month, according to data provided by the hospital.
“A lot of what we see are related to the demographics of our community,” hospital President Chuck Sherwin said. “We have an older population, so we’re going to see cardiac issues, falls, illnesses that older people get — flus, fevers, diabetes.”
The hospital’s emergency room underwent a $7.5 million renovation in 2017, which expanded the number of rooms from 14 open bays to 21 private rooms. Technology and medical equipment also was upgraded.
Emergency Room Director Ann Lorenzi said the hospital’s emergency staff are excellent at assessing patients when they walk in the door.
“The ones that are sickest get taken care of immediately,” she said, noting hospital staff are quick at both assessing stroke patients or patients experiencing heart problems and getting them the tests they need.
For what they can’t do, the Alpena ER doctors can get immediate help.
Alpena Vice President of Nursing Deb Pokorzynski said the hospital’s telemedicine program allows ER personnel to pull up a television-like monitor and connect immediately with, for example, a neurologist down at the University of Michigan when a patient is having a stroke.
“The physician at the other end can give our physician immediate direction and feedback about and collaborate on the patient’s care and what the next best course of action for that patient,” she said.
‘I WOULD BE WASTING PATIENT DOLLARS’
MidMichigan Medical Center-Alpena, owned since April 2016 by the Midland-based MidMichigan Health, has more than 120 active physicians and advanced practice providers in 25 specialties.
Last month, the Leapfrog Group, a nonprofit organization that rates hospitals, gave the hospital a C, a full letter grade lower than last fall.
The Alpena hospital scored among the worst when compared to other hospitals in the MidMichigan Health group and other rural northern Michigan hospitals. Among 12 hospitals reviewed by The News, three got a C, five got a B, two got an A, and two were not scored.
Sherwin, the hospital president, said his hospital took a hit for its lack of intensive care unit doctors, and would have received a B, otherwise. Staffing such doctors is a challenge, he said, but progress has been made.
Sherwin said the grade is somewhat deceiving, because it’s based on nearly two-year-old data and doesn’t account for improvements the hospital has made in that time.
“Based on the latest data we have, I’m confident a B grade will be given in the future,” he said.
Sherwin said MidMichigan and all hospitals are limited by a state-issued certificate of need that dictates which treatments, procedures and practices allowed at the hospital.
“The state tells us what we can and cannot do, based on the volume of patients we see and the geographic location,” he said. “If Alpena was smaller, we wouldn’t have a CT scan machine and would have to transfer (patients to other hospitals), but, because we have the volume, the state allows us to have two of them.”
But, because of its size, the Alpena hospital can’t offer other procedures, such as heart operations and neurological surgeries. Sherwin said it would be cost-prohibitive to hire specialty doctors who only see patients sparingly.
“I would be wasting patient dollars on things we shouldn’t be doing,” he said. “The state makes sure there is a demand for the service.”
Sherwin said patients with conditions not spelled out in the certificate of need must be transferred to another hospital. That typically happens about twice a day, he said.
‘THERE IS A SHORTAGE’
Rural hospitals can often struggle to attract talent.
When trying to recruit a doctor, Sherwin said, the hospital must also try to attract that doctor’s spouse, who is often a medical professional, themselves. Those doctors also want quality housing, which can sometimes be a challenge in smaller communities.
“Trying to recruit physicians, male or female, as well as clinical staff and others that are highly specialized, is a challenge for rural areas,” Sherwin said. “There is a shortage nationwide, but rural areas like Alpena feel it at a greater rate.”
Alpena County has one primary care physician per 1,440 residents, according to countyhealthrankings.org. Alcona County has one per 2,070 residents. Montmorency County has one per 1,150. Presque Isle County has one per 6,380 residents, the second-worst ratio in the state.
Sherwin said Alpena does have enough nurses, which he credits to Alpena Community College’s nursing program feeding students to the hospital and other clinics.
“We’re actually in a little better place than some rural communities that don’t have a nursing school close by,” Sherwin said. “If you have a hospital that doesn’t have one near, they are going to struggle more than us.”
‘WE TRY TO HELP ONE ANOTHER OUT’
Meanwhile, mild to moderate mental health concerns, from depression and anxiety to post-traumatic stress disorder or phobias, can be treated through outpatient services at MidMichigan Medical Center-Alpena or by counselors at Catholic Human Services.
Primary care offices at the Alcona Health Center and Thunder Bay Community Health Services offer counseling services under the same roof as primary care physicians, and also provide mental health consultation in local schools.
Severe or persistent mental health issues are treated by Northeast Michigan Community Mental Health, which offers emergency and crisis treatment, as well as ongoing, long-term services. The Alpena hospital operates the region’s only inpatient facility, which offers 15 beds. Residents would have to drive 130 miles to Traverse City or 150 miles to Saginaw to get to the next-nearest inpatient facility.
Northeast Michigan Community Mental Health served 2,183 people during the 2017-18 fiscal year, according to the organization’s annual report. Nearly a quarter of their budget — a little over $6.6 million — was spent on adults with serious mental illness, such as schizophrenia and personality disorders.
The ruralness of the region limits the care that can be provided, according to Mary Crittenden, who supervises several of the services provided by Community Mental Health. That makes it necessary for mental health care providers to work collaboratively.
“We try to help one another out,” Crittenden said. “We know that there may be limitations with one clinic or facility, so we reach out. If we can’t provide a resource, maybe somebody else can.”
‘MORE THAN ANY ONE OF US COULD DO ALONE’
Despite the challenges of providing health services in rural areas, Alpena Fire Chief Bill Forbush said teamwork, training, technology and planning helps medical professionals save lives.
He said all involved are always reviewing the current system, as well as practices, and looking for ways to improve them. Being able to rely on neighboring departments to help respond to large emergencies is crucial, he said.
“It is more than any one of us could do alone,” Forbush said. “We depend on each other to work in unison together make things work.”
* CORRECTION: This story has been updated to reflect that 1,236 people live in Alcona County’s Curtis Township. The township’s population was incorrect in the first version of this story.
Crystal Nelson can be reached at 989-358-5687 or firstname.lastname@example.org. Steve Schulwitz can be reached at 989-358-5689 at email@example.com. Follow him on Twitter @ss_alpenanews.com.
About this series
For the past several weeks, News reporters have interviewed health care providers and compiled and reviewed local, state and national data to compile a comprehensive picture of the challenges of providing timely medical care in rural Northeast Michigan.
∫ A overlook at some of the strengths and weaknesses of Northeast Michigan health care.
∫ A closer look at the time it takes for medical teams to respond to an emergency.
∫ A look at behavioral health care in Northeast Michigan.
∫ The challenge of caring for Northeast Michigan’s athletes.
∫ A look at plans for future improvements to health care our region.
∫ Our view: The News calls for residents, officials to share responsible for area care.