Minutes after receiving a call to assist a man in a wheelchair complaining of leg pain, firefighters from Billings Fire Station No. 2 and paramedics from American Medical Response arrived at the corner of Montana Avenue and North 28th Street.

The patient was a familiar one, and the pain came from an infected cut on his foot.

“There is a contingent of people that we see on a regular basis,” said firefighter Cameron Abell. “He is one of them.”

When the call came in at about 3:30 p.m. on Nov. 30, the temperature was 9 degrees and falling. The wind chill made temperatures feel more like minus 8. The patient’s beard was coated in a thick layer of frost.

The man, who later identified himself as Billy Ray Jones, 62, has been homeless for the last 47 years. 

Orville Kassner, one of the three people Jones was with when the leg pain set in, said they were all homeless.

Earlier that same day, Kassner had also requested an ambulance after he suffered mild frostbite on his hands, he said. “They were so damn cold and frozen.”

Jones and Kassner are both banned from the Montana Rescue Mission for behavior deemed destructive to the rehabilitation of others at the shelter.

“I’ve been outside since the mission kicked me out," Kassner said.  

According to the 2014 Annual Homeless Assessment Report to Congress, the number of chronically homeless — those homeless for at least one year, or for more than 15 days on at least four separate occasions in the last three years — in Montana has increased from 83 in 2007 to 256, an increase of more than 200 percent.

The assessment is produced by the U.S. Department of Housing and Urban Development and based on data collected during "point in time" surveys across the state. They're conducted yearly on a single night in January. 

As the number of chronically homeless people increases, public services are being stretched, and Billings is struggling for solutions.

Responding to medical calls is a daily responsibility for Billings firefighters, costing the department money and resources, said Billings Fire Department Chief Paul Dextras.

Roughly 8,300 of the more than 11,300 calls that firefighters responded to in 2013 were medical.

“EMS calls constitute 70 percent of our overall call volume,” Dextras said. 

Many of the medical calls for intoxicated people come from downtown.

In 2013, the firefighters at Station No. 1 — which takes calls in a two-mile radius from their location at 2305 Eighth Ave. N. — responded to 156 calls for public intoxication. The firefighters from Station No. 2, 501 S. 28th St., worked 103.

In comparison, the firefighters at Station No. 7, located at 1501 54th St. W., responded to only six intoxication calls.

The fire department has been responding to medical calls for about 40 years, but even today some people still don't understand why a fire engine arrives with an ambulance, Dextras said.

“People don’t realize that we come for medical purposes, not just fires.”

American Medical Response ambulance services and the fire department each arrive on the scene first about half the time, and both crews are trained as emergency medical technicians. 

Detective work

As soon as the firefighters got to Jones, they began asking questions, trying to determine the medical emergency.

“You really have to do a lot of detective work to make sure you’re not missing anything,” said Cameron McCamley, the fire department’s EMS coordinator. “You always treat anyone as a true patient until proved otherwise.”

Figuring out what’s wrong with a patient is difficult, especially if he or she is intoxicated or under the influence of other drugs, but a missed diagnosis could or prove fatal for the patient, so great care is taken.  

Police presence

Billings Police also are involved in medical calls, especially for intoxicated people downtown. Complaints from local business owners or calls from concerned citizens are all taken seriously, said Matt Lennick, the BPD's downtown resource officer.

The Billings Police Department reported that between Jan. 1, and Sept. 30, 2014, 74 repeat offenders were arrested more than 3,300 times, cited for open container more than 2,700 times and for trespass nearly 1,100 times. The department estimates those people cost the city an average of $8.5 million annually.

The Yellowstone County Detention Facility won’t accept intoxicated people because it can’t provide proper medical supervision. 

“If they’re so drunk they can’t stay awake, they can’t stand on their own, they’re vomiting,” Lennick said. “You call in medical.”

Police also call for medical help if they see drunken people injuring themselves, he said. “If they fell and hit their head, whether they want to or not, they’re going.”

Waiting with a patient until medical help arrives can drain the already stretched police resources — only nine officers are on the street during a typical shift.

“Once you’re on a call, you have to finish it, generally speaking,” Lennick said. “Whatever is holding has to wait.”

The same goes for the fire department, Dextras said.

“Every alarm has an impact on our other coverage areas throughout our community.”

At the hospital

Even before Jones' ambulance pulls up at the Billings Clinic emergency department, information is relayed to hospital personnel who prepare to treat the patient.

“It doesn’t matter who comes through our doors,” said Dr. Peter Light, medical director for emergency medicine at Billings Clinic. “There’s a potential for a life-threatening problem, and alcohol masks a lot of those life-threatening problems.”

Whether it is slurred speech, broken bones, chest pain, an infection or a small cut, tests are performed to ascertain the problem.

In 2013, 41,808 people either walked in or were transported to the Billings Clinic emergency department and more than 38,789 have already received services in 2014.

“Everybody’s emergency is their personal emergency,” he said. “It varies from one person to another.”

The advantage of getting in and being seen quickly leads some patients to choose emergency response for problems that aren't life-threatening, instead of making an appointment with a primary care doctor or going to an urgent-care facility.

“Emergency departments are effective, efficient and they provide a very good product,” Light said. “The higher the level of service the higher the level of care, the more volume you will have.”

The hospital also provides care to anyone, regardless of ability to pay, and some patients with limited means visit the emergency room or get an ambulance ride knowing they cannot pay their bill. 

About 20 percent of ambulance rides in Billings go unpaid, AMR spokesperson Ron Cunningham said. He declined to provide specific figures. 

“It doesn’t matter if they’re the poorest or the richest in the community, we’re trying to take care of everyone,” Light said.  “We are bound by the standard of care.”

At Billings Clinic, care provided to patients unable to pay totaled $15,819,027 in 2013 — about $3.5 million of that was from patients first seen in the emergency department.

St. Vincent Healthcare provided charity care totaling $15,682,140 in 2013, said Angela Douglas, St. Vincent's public relations specialist.

The two Billings hospitals recently conducted a study comparing non-identifying data such as socioeconomic status and age, said Jeanne Manske, the community benefit coordinator at Billings Clinic. “We found that we had an extremely parallel population.”

Who pays for care?

A hospital’s tax-exempt status requires the admission of any and all patients regardless of their ability to pay, but offsetting the unpaid bills increases the cost of care for all patients.

“It’s difficult to estimate how many people will come in for charity care,” Manske said. “It’s difficult to budget for.”

Billings Clinic has a Consistent Care Program, which allows people unable to pay medical expenses to get a waiver so they can see primary care physicians. For those who visit the emergency department more than four times in one year, the program tries to match up the patient with a social worker.

The idea is to come up with strategies to get ahead of patient care and decrease emergency department use. 

For those in crisis

The Community Crisis Center, open 24/7, provides care for patients with serious mental illnesses or chemical dependencies. More than 80 percent of the clients are homeless or on the brink of becoming homeless.

“The Community Crisis Center was created to house the people who needed a place to stay, and the Community Crisis Center has been a tremendous benefit to this community,” Light said.

But the Crisis Center, too, has seen increased demand and has a limited budget.

Regardless of the problem’s solution, change is needed, Lennick said.

“Let’s be honest, writing them tickets and putting them in jail for outstanding tickets has little effects.”  

People like Billy Ray Jones are soon back on the streets of Billings and continuing to utilize emergency services.

At about 11:30 a.m. on Dec. 14, Jones requested another ambulance after complaining of leg pain. 

Dextras said it's crucial for Billings to have fast, effective emergency care.

“I think there’s such a huge direct correlation between quality of life and citizen safety related to these medical calls,” Dextras said. “We have a huge, huge impact on the life safety in this community.”

Solutions are tough to come by, but progress is being made, he said. 

A 24/7 sobering center was one idea to emerge from November’s Moving Solutions Forward summit, attended by service providers and others in the community working to address the problem. 

The program might be similar to San Diego’s Serial Inebriate Program, in which police officers and case managers work together to lead that community’s most often-identified inebriates into treatment and off the streets.

A community center to bridge the gap between the Montana Rescue Mission and the street has recently been opened in the old Granny’s Attic Thrift Store space adjacent to MRM on Minnesota Avenue.

“It’s not just a municipality’s problem; it’s a community’s problem,” Dextras said. “We’re going to have to rely on the citizens of this community to determine what level of emergency first responder that they want." 

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Chris Cioffi covers city news for The Billings Gazette in Montana.