Long Road to Careby Steve Miller

On the 14th second of every minute, the green punch clock on the wall of the Lame Deer Emergency Response Service's kitchen emits a pressurized snap.

Paramedic Sandy Bruised Head and on-duty dispatcher Karilyn Brady don’t seem to notice it much as they play one of their countless games of Yahtzee. Fellow paramedic Charlee Prince looks on, resting her chin on a Diet Coke bottle. A black cordless phone sits off to the side of the game—silent, for now.

It’s Friday night on the Northern Cheyenne Reservation, where about 4,500 Cheyenne live on land located about 100 miles east of Billings. It’s the start of Easter weekend and a day after tribal payday, a combination that may well mean a busy night for the ambulances. Because the reservation prohibits alcohol sales or consumption, some reservation residents drive to one of the bars just beyond Northern Cheyenne borders, like the Kirby Saloon and Jimtown Bar. Judging by the number of crosses on the roadside between Lame Deer, the heart of the reservation, and its outlying areas, this trip back from a night out can be short and brutal.

The EMS building—more of a trailer, really—is located a block away from Lame Deer’s only stoplight. Its interior is lit by two panels of fluorescent lights, enough to illuminate the kitchen area while the rest of the main room remains in darkness. Bruised Head and Brady each grab a slice of banana bread on the stovetop as Prince goes into the dispatcher’s room located past the TV and the L-shaped couch. Brady takes the dice and rolls two fours, a one, a five and a six.

Just after 8, the phone rings.

“Ambulance services,” Brady says. She listens for a moment without making any movement, then quickly marches to the dispatcher’s room, with Bruised Head on her heels. A 40-year-old woman named Vanessa is vomiting and having seizures. Vanessa lives in town, which won’t be a long drive — at least compared to what this crew is used to. Prince walks down a dim corridor to a room where ambulance driver Maurice Little is sleeping.

“Come on,” Prince says to Little. “Get those baby blues moving.”

Prince, Bruised Head and Little pile into the ambulance and pull out onto Highway 212 for the three-minute trip to Vanessa’s house. Inside, a young girl—Vanessa’s granddaughter —stands in a dimly lit hallway, holding an Easter basket. Vanessa lies prostrate on a bed in a room with purple walls; her shoeless feet dangle off the bed. Her sister tells the paramedics Vanessa has been drinking whiskey and has snorted ground-up hydrocodone, a narcotic painkiller. Family members, including her granddaughter, filter into the room and watch with seemingly little emotion. Soon a seizure overtakes Vanessa. As she convulses, she lets out high-pitched, laughter-like gasps with each spasm.

The paramedics transfer Vanessa from her bed to a gurney and into the ambulance, all the while holding a bucket for her. The ride to the Northern Cheyenne Service Unit, the reservation’s health-care facility, takes a little more than three minutes from Vanessa’s house. Once admitted, she’s placed in a hospital bed and given another bucket. Prince says Vanessa will stay here for observation while she sobers up before she is sent to jail for a night because of her illegal alcohol and pill intake.

Shortly after 9 p.m., the EMTs get another call, this time to an emergency involving a woman in Ashland, some 20 miles away. The steep and winding roads are treacherous this time of night, so they’ll need to be as careful, and swift, as possible.

•••

The Northern Cheyenne Reservation, located about 20 miles south of Colstrip, spans more than 440,000 acres in southeastern Montana. On a clear day, one can see jutting buttes of red shale and rolling hills of sage grass stretch toward the horizon. Lame Deer sits at the intersection of Highways 4, 39 and 212. Branching off these highways are numerous dirt roads, some of which lead to ranches, houses, or serve as roundabout routes to get from one end of the reservation to the other.

While the reservation’s remote location gives it a certain Wild West allure, the distance to a major medical center can cause problems for those suffering from severe trauma or in dire need of emergency care. Though the hospital facilities are equipped with 24-hour urgent care, they lack the means and personnel to perform surgeries, do more than stabilize heart attack or stroke victims, or deal with other serious ailments. In the case of a life-threatening emergency, patients must be transferred to Billings. Sometimes, an ambulance carries patients 60 miles across Highway 212 to I-90 and then another 40 miles to Billings, which takes about an hour and a half. In particularly severe instances, some patients are transported via Life Flight helicopter into Billings, which takes about 30 minutes.

It’s more than just the reservation’s distance to adequate facilities that makes it challenging to respond to emergencies — it’s the reservation itself. Because of its vastness, it can take 30 minutes or more for crews to arrive at a scene, then an additional half hour or so to get back to Lame Deer to have the patient evaluated. Tack on the extra time for critically ill or injured patients to be transported to Billings and the remoteness can have life or death consequences.

Ken Sattler, a former EMT on the Northern Cheyenne Reservation, can attest to this harsh reality. One instance, he says, best illustrates the difficulties of responding to calls in such a remote location.

It was early in his career, so early that he hadn’t even administered CPR on a patient yet. He remembers being dispatched to Birney, 21 miles southwest of Lame Deer, where a man had been kicked and beaten with baseball bats. The drive took more than 20 minutes through inclement weather on winding roads. Sattler and the other EMTs couldn’t tell how long the man had been unconscious. The patient bled profusely and paramedics lost vital signs on the way back to Lame Deer. But there was no way for them to get blood because their facilities didn’t have the means to store any, and because of the stormy weather, Life Flight wasn’t an option. Sattler performed CPR on the man in the ambulance and ER for more than an hour before they lost him. Both men were covered in blood at the end.

In 12 years as an EMT, this race against the clock was something Sattler faced too often.

“It’s just the remoteness we deal with,” Sattler says. “A lot of times, as a medic, it was quite frustrating.”

Compounding the problem is the fact cell phone reception—with the exception of a few sporadic patches — is virtually non-existent on the reservation. If an emergency arises, Sattler says, the only way to notify the EMTs is by calling on a land line, and with miles separating neighbors and houses, merely finding a phone can be a major obstacle. Although many road accidents are called in by patrolling officers, incidents occurring on ranches or residences outside of the communities may take much longer to report.

“There’s just no (cell phone) service,” Sattler says. “There isn’t immediate response.”

Debby Bends, CEO of the Northern Cheyenne Service Unit, acknowledges the difficulties brought on by the reservation’s rural nature, but thinks a better understanding by tribal council members of the reservation’s medical needs could improve emergency response. Bends, who was born and raised on the reservation, says she’d like to install satellite phones, which would require close cooperation with tribal government. But it doesn’t appear that will happen soon. “We have a long ways to go in that area,” Bends says.

One obstacle is funding, which is appropriated yearly by Congress to the Bureau of Indian Affairs, which divides it between 564 federally recognized tribes nationwide, and there is never enough funding to meet all the needs. The Northern Cheyenne Service Unit had a total budget last year of $23.2 million to serve approximately 9,800 enrolled tribal members. For treatment the reservation health clinic can’t provide, Bends says, the contract health care budget is about $3.5 million.

Medical transfers to Billings, whether by ambulance or Life Flight, are covered by IHS funds, though sometimes reimbursement is secured if the patient has private insurance or is covered by Medicare or Medicaid. One helicopter trip to Billings costs nearly $11,000 and last year Life Flight was used for transporting tribal members from the reservation 19 times. In five cases, the IHS was reimbursed. Though funds for these off-reservation services may be tight at times, Bends says, she insists the well-being of the patients outweighs the need to keep costs down.

“If it’s needed, if it’s a life-saving measure, finances don’t come into consideration,” Bends says.

But that’s not how Sattler remembers it.

During his time as an EMT, he recalls how budgets dictated the quality of care patients would receive. At times, he says, administrators discouraged the Life Flight and ambulance transfers to Billings in order to save money, and, on several occasions, they talked of discontinuing Life Flight trips.

“The budget is kind of the driving force,” Sattler says. Now a teacher at Lame Deer High School, Sattler describes himself as critical of the health-care system on the reservation, but only because he wants to see improvements.

“This community deserves better,” says Sattler, who was made an honorary member of the tribe in 1993.

Among the services not provided at the Northern Cheyenne facilities is a dialysis center, but because 18 people on the reservation need dialysis, IHS provides a daily shuttle called Rez Run to take them and other patients to Billings. Charles Medicine Bull is one of them.

Medicine Bull suffers from hereditary kidney disease and takes Rez Run every other day. The shuttle leaves Lame Deer around 12:20 p.m., Medicine Bull says, and returns around 10 p.m. But Medicine Bull lives 25 miles from Lame Deer and has no car, so he must rely on friends to drive him to and from his house.

Medicine Bull’s house lies off of a dusty tract of country road near Birney. His nearest neighbors, whom he doesn’t know, are about a quarter-mile away. He lives by himself, with no cell phone and only a Dell laptop to connect him to the outside world. Some windows on his house are boarded up, others shattered. A mangled barbed-wire fence surrounds his property and charred sections of earth are remnants of one-time fire pits. In his front yard is a dilapidated shed, its roof caved in with several wooden beams scattered about. An orange Toyota pickup sits on wheelless rims and a rusted mattress frame rests in its cab.

A cool breeze rustles the stray wisps of Medicine Bull’s long, black hair. A plastic bag with Pepsi and Mountain Dew bottles flaps in the wind as he peels back the gold tin of a small Reese’s peanut butter cup. “I like my sweets,” Medicine Bull says. “Even though I’m a diabetic.”

There’s a considerable amount of risk living so far out of town, he says, and, if something were to happen, he doesn’t know how he would contact anyone.

“I’m scared out here,” he says. “What if I have a heart attack?”

But as he sits in his fold-away chair Medicine Bull is reminded of why he remains here: It allows him to be free, on the land where his family has lived for generations.

“I live here on Mother Earth,” Medicine Bull says, adding simply, “It’s Cheyenne.”

•••

After a 20-minute drive down the tortuous path of eastbound Highway 212, the paramedics arrive in Ashland at a house draped in American and Marine Corps flags. A first responder crew is already on the scene and gives the EMTs the rundown: A 60-year-old woman named Henrietta is unconscious and unresponsive. Her family members told the first responders she suffers from a severe case of cirrhosis that renders her liver 10 percent functional, and she stopped taking her medication for a couple of days, causing her ammonia levels to skyrocket.

The paramedics find Henrietta sitting on the couch — eyes closed, head falling limply back.

“Henrietta! Henrietta!” Prince shouts to try to rouse her. No response. Prince, Bruised Head and Little can’t lift her large frame onto the gurney so they recruit family to help. Once in the ambulance, Bruised Head sticks an IV needle into Henrietta’s arm and blood streams from the wound.

On the ride back to Lame Deer Prince keeps up her one-way conversation with the patient.

“Henrietta, open your eyes for me! You know where you are?”

She’s stable now, here in the reservation ER, but because she needs to have the impurities in her blood flushed out, she must be transferred to Billings.

Little, who’s been an EMT for almost 13 years, doesn’t really mind the drive to Billings, but on especially busy nights, it can be draining. The dark expanse of Highway 212 stretches out in front of him; he’s traveled this way so many times, he’s memorized the treacherous curves and drastic elevation changes. Still, he keeps his speed around 75 miles per hour — the speed limit — and is alert for wandering deer.

At night, the countryside is reduced to a seemingly interminable abyss, occasionally interrupted by a roadside light, or the sprinkled lights of small communities like Busby.

Prince furrows her brow as she checks Henrietta’s vitals and movements, frequently jotting down her observations on a medical form. Even when the ambulance catches an asphalt ripple in the road, Henrietta shows no response, save for the occasional knee jerk and mouth quiver. Once they reach I-90, the road is bathed briefly in the lights from the Crow Reservation casino and gas station, but after they pass Hardin, it’s back to the all-encompassing blackness.

Prince lifts Henrietta’s eyelids to check if her pupils are responsive; instead, they are fixed, not seeming to detect the stale rays from the overhead fluorescent panels, and move back and forth only as Prince moves Henrietta’s head from side to side. A layer of cotton-white saliva forms on her lips, and Prince dabs it with a cloth.

The ambulance passes mile marker 473 at 12:44 a.m. A faint glow from Billings looms in the northern sky — a sign that Henrietta’s journey is almost over, at least for tonight. But Little and Prince still have miles to go.