Terms like “the golden hour” and “the platinum 10-minutes” emphasize the urgency with which a trauma patient must receive care in order to survive. But Montanans live in a trauma center desert that stretches over four states, meaning accessing timely care isn’t always possible.
Montana is second worst in the nation when it comes to surviving severe trauma, partly due to geographic isolation. The nearest tertiary care facility is 548 miles away in Salt Lake City, Utah, meaning severely injured Montanans are spending their golden hour simply getting to a facility with the necessary resources.
To address the issue, leadership at Billings Clinic announced plans Thursday to become the region’s first level I trauma center, the highest designation for trauma centers in the U.S.
The hospital’s trauma department has seen a steady increase in volume over the last several years, making the designation a natural next step, said Dr. Michael Englehart, director of trauma services at Billings Clinic.
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“I believe that people in Montana and the region deserve to have the same quality level of care that they can get anywhere else in the country with a level I trauma center,” Englehart said.
Currently, Billings Clinic operates as a level II regional trauma center along with St. Vincent Healthcare, Providence St. Patrick Hospital in Missoula and Benefis Healthcare in Great Falls.
At level II centers, hospitals are able to assemble advanced trauma care for the region by calling in general surgeons and some other specialists, according to Rich Rasmussen, CEO of Montana Hospital Association. Tertiary care needs that require cardiac surgery or microvascular surgery are usually flown out to level I trauma centers.
With the level I designation, Billings Clinic will be required to have in-house coverage at all times by general surgeons and specialists in orthopedic surgery, neurosurgery, anesthesiology, emergency medicine, radiology, internal medicine, plastic surgery, oral and maxillofacial, pediatric and critical care.
Additionally, level I centers are required to have research pursuits and demonstrate a commitment to education.
Billings Clinic started revving up its research efforts about a year ago looking into ideas and concepts surrounding unique injuries and barriers to care in Montana. The questions have already yielded evidence of unparalleled challenges in care.
While falls and motor vehicle accidents are the most common traumas in the state, injuries unique to Montana include animal-related injuries, particularly equine traumas.
“We actually believe that we may have one of the largest series of equine-related trauma in the United States,” said Dr. Gordon Riha, trauma surgeon at Billings Clinic.
Even experienced trauma surgeons across the nation see animal attacks so rarely that a single case of a bear attack presented at a national meeting was laughable, Englehart said.
“I was laughing for a different reason because I see this all the time, regularly,” Englehart said. “So we very clearly have a niche area of expertise that is not seen elsewhere in the country.”
About 63% of Montanans live in rural communities that often have a severe lack of services, creating health disparities that are unique to the region. Driving times and a physician shortage heavily felt in rural places results in a lack of primary, preventative and emergency care.
Billings Clinic announced a general surgery residency program earlier this year with a focused rural track to create a pipeline to facilities and build a network of care.
The first general surgery resident will begin training in June 2022.
Educating physicians while also conducting research ensures the next generation of doctors will be trained with the most recent literature, placing Montana on the cutting edge of medicine, Riha said. With Billings Clinic at the center, the hope is that the advancements will trickle down to Montana’s rural facilities.
“There’s a lot of other facilities in Montana (where we can) develop a network through education through support of these other facilities to help raise the level of care … the end goal is to get (rural facilities) where they need to be, but we also want to keep people close to home, so not transferring people out of state,” Englehart said.
Christy Baxter, director of critical care at Billings Clinic, shared her own stories of family trauma on their ranch in Cohagen, Montana.
In 2017, Baxter's father was in an ATV accident on a dirt trail about 12 miles from the highway.
"For those of you who know Eastern Montana, (it's like) get to the highway. The ambulance will meet you there," Baxter said. Her father was then transported to the nearest rural hospital where doctors told her that her father likely wouldn't survive.
Luckily, Baxter had the number of a thoracic surgeon at Billings Clinic who was able to arrange his transport to Billings. Today, Baxter's 81-year-old father continues to ranch in rural Montana.
Data shows that seriously injured patients have a 25% greater survival rate at a level I trauma center.
And from a clinical standpoint, Billings Clinic has been operating as a level I trauma center for several years, but in order to meet all the criteria for level I designation, which requires in-house immediate services, there are multiple other commitments the hospital must make to bridge the gap from level II to level I.
For trauma I designation, a hospital must have operating rooms available and ready at any time to serve an injured patient. Now, Billings Clinic operating rooms are booked solid on a regular basis, making it hard to fit in emergent trauma surgeries.
To meet the designation criteria, operating rooms and the emergency department will be expanded and a new surgical intensive care unit will be built.
The Clinic will also need to serve 1,200 patients a year with a major trauma or an injury severity score (ISS) greater than 15. To support the demand, new construction on an inpatient cancer care unit, intermediate care unit, neonatal intensive care unit and a transfer center is needed.
Since the COVID-19 pandemic hit, Billings Clinic inpatient capacity has been pushed to the breaking point, forcing the hospital to turn away some trauma patients, said Englehart. To accommodate for the increasing volumes, 56 new patient rooms will be added.
But how long it will take for the hospital to become a level I trauma center is unknown. Not only does the hospital need to bulk up its infrastructure, but the research team is being built from the ground up.
“One of the reasons we’re moving forward with the capital campaign is we need foundational money too to keep these projects ongoing,” Riha said. “This takes a lot of manpower, it takes a lot of hours and it takes a lot of effort.”
The project comes with a $30 million price tag, the largest capital campaign in Billings Clinic's history. So far, the Clinic has secured $13 million in pledges with $5 million coming from an anonymous donor.
The Philip N. Fortin Foundation has contributed $7 million to the campaign and will provide the name for the center as The Philip N. Fortin Trauma Center. The philanthropic organization has already given thousands to the trauma center at Billings Clinic, according to previous reporting by The Gazette.
Another $1 million came from former Navy SEAL Tim Sheehy, CEO of Belgrade-based Ascent Vision Technologies and Bridger Aerospace, an aerial firefighting company.
At the press conference, Sheehy talked about his own brushes with the golden hour during his deployments to Iraq and Afghanistan. He added that he was closer to a level I trauma center during his deployments in the Middle East than anyone in Montana.
"I was unfortunate enough to see the golden hour pass on some folks and see just how quickly that rate of survival dropped off," Sheehy said. Since his time in combat, Sheehy and his wife, Carmen, have been passionate about contributing to advancing trauma care in the state.
In 2021, Sheehy donated millions to Bozeman Health to bring integrated pediatric care to the hospital.
"Elevating our game from a trauma perspective means elevating everybody. Everybody rises and gets better, complex care," Englehart said. "Building a network of facilities that can handle those beyond what their currently able to do is the eventual goal. All boats rise."