An emergency in rural America

In Oklahoma a hospital is losing a fight to survive, says journalist Eli Saslow in The Washington Post. It’s the story of hospitals across America—and the struggling counties that rely on them.

The hospital had already transferred out most of its patients and lost half its staff when the CEO called a meeting to take inventory of what was left. Employees crammed into Tina Steele’s office at Fairfax Community Hospital, where the air-conditioning was no longer working and the computer software had just been shut off for nonpayment.

“I want to start with good news,” Steele said, and she told them a food bank would make deliveries to the hospital and Dollar General would donate office supplies. “So how desperate are we?” one employee asked. “How much money do we have in the bank?”

“Somewhere around $12,000,” Steele said.

“And how long will that last us?”

“Under normal circumstances?” Steele asked. She looked down at a chart on her desk and ran calculations in her head. “Probably a few hours,” she said. “Maybe a day at most.”

The staff had been fending off closure hour by hour for the past several months, ever since debt for the 15-bed hospital surpassed $1 million and its outside ownership group entered into bankruptcy, beginning a crisis in Fairfax that is becoming familiar across much of rural America. More than 100 of the country’s remote hospitals have gone broke and then closed in the past decade, turning some of the most impoverished parts of the United States into what experts now call “health-hazard zones,” and Fairfax was on the verge of becoming the latest.

The emergency room was down to its final four tanks of oxygen. The nursing staff was out of basic supplies such as snakebite antivenin and strep tests. Hospital employees had not received paychecks for the past 11 weeks and counting. A technician had gone $100,000 into debt after having an emergency preterm birth, because none of the hospital’s employees had benefits or insurance.

The only reason the hospital had been able to stay open at all was that about 30 employees continued showing up to work without pay, increasing their hours to fill empty shifts and essentially donating time to the hospital, understanding what was at stake. There was no other hospital within 30 miles of two-lane roads and prairie in sprawling Osage County, which meant Fairfax Community was the only lifeline in a part of the country that increasingly needed rescuing.

“If we aren’t open, where do these people go?” asked a physician’s assistant, thinking about the dozens of patients he treated each month in the ER, including some in critical condition after drug overdoses, falls from horses, oil field disasters, or car crashes.

“They’ll go to the cemetery,” another employee said. “If we’re not here, these people don’t have time. They’ll die along with this hospital.”

“We have no supplies,” Steele said. “We have nothing. How much longer can we provide quality care?”

Everyone in the room turned, as they often did, to the longest-serving member of the hospital staff—James Graham, 67. He had worked as a primary-care physician at Fairfax Community for 41 years, writing his cellphone number atop new prescriptions, making rounds while on dialysis through two kidney transplants, and hand-delivering medication to indigent patients out the window of his pickup truck.

Graham had been an honorary pallbearer at more than 160 of his patients’ funerals, watching the cemetery expand as Fairfax’s population declined from almost 2,000 to fewer than 1,300 through 40 years of attrition. The hospital remained the area’s largest employer, and the town had sunk more than half of its annual budget into legal fees to file a lawsuit against the hospital’s ownership company, hoping to retake control of Fairfax Community. There was still a chance the town could save the hospital in some form by partnering with a new management company, if the bankruptcy court would allow it.

Fairfax’s vice mayor had promised employees he would come by at the end of the week to deliver an update, and possibly even paychecks if new management could be found. “Maybe we’ll get good news,” Graham told the staff. “But we’re holding out for a miracle, and if some of you can’t afford to keep waiting and working for free, you can walk away now and nobody will blame you.”

He looked around the room as his co-workers stood in place. A call came over the hospital’s intercom. “Medical assistance up front,” a receptionist said. Graham waited for another second, until the silence sounded to him like a decision. “OK,” he said, moving toward the emergency room. “Let’s keep the doors open until someone tells us we can’t.”

The hospital was the first building on the winding road into Fairfax, positioned atop the only hill in town, and for 65 years it had served a county that was larger in area than a few U.S. states. Patients came from all over northern Oklahoma, traveling through cattle farms and across rolling prairie, sometimes driving up to an hour to reach their closest full-service hospital. It was a single-story building about the size of an average elementary school.

“A small community is only as healthy as its hospital,” read one sign near the entrance, but lately, that relationship in Fairfax and hundreds of other small towns had gone from symbiotic to ominous. In the past decade, emergency room visits to America’s more than 2,000 rural hospitals increased by more than 60 percent. Hospitals like Fairfax Community treat patients who are on average six years older and 40 percent poorer than those in urban hospitals.

Fairfax Community had survived a previous bankruptcy in 2011 and then passed through four outside ownership groups before being purchased in 2016 by EmpowerHMS, a Florida company that operated more than a dozen rural hospitals across the Midwest. The company promoted itself as “a savior for struggling rural hospitals,” but within months of taking over, its corporate office began defaulting on bills and cutting Fairfax Community’s budget. Eventually, four of the company’s hospitals shut down and nine more entered bankruptcy, including Fairfax. It could no longer afford to provide X-rays or CT scans. No more blood tests.

Graham had been talking about retiring for a few years, but he was one of just two physicians at the hospital, and he didn’t want to abandon his patients. The past 40 years had turned him into a seasoned generalist, accustomed to treating whatever emergency came through the hospital’s doors. One day it was a mother who’d gone into labor on a nearby road. The next it might be a critical gunshot wound, or an allergic reaction to a bee sting, or a panic attack, or a child with a cockroach stuck in his ear, or a pill seeker trying to hustle the ER out of pain medication in the middle of the night. “The ER doesn’t have a routine,” Graham liked to say, and for much of his career that uncertainty thrilled him, but now he felt something different whenever a new patient rushed in, a sensation closer to dread. “Do we have the supplies left to help these people?” he wondered.

A woman arrived with what appeared to be a broken arm, but there was no working X-ray machine to confirm it. “We have to sling it and send you on to Tulsa,” a nurse told her. A child came in with his leg gashed in a fishing injury, but the hospital had run out of the correct-size thread to stitch it up. “This one will work just as well,” a nurse said, returning with a different-size thread from the emptying supply closet.

The doors opened again, and this time it was Cassie Fessler and her 16-year-old son, an elite high school basketball player who was bent over in the hospital lobby, complaining of chest pain and shortness of breath. His face looked pale. “My chest feels like it could explode,” he said, and two nurses took his vital signs while a lab technician attached electrodes to his chest to test his heartbeat and then immediately sent the results to a pediatric cardiologist in Tulsa.

Graham had pronounced the death of Fessler’s grandfather at the nursing home 35 years earlier. He had worked with her mother, a nurse, and he’d been Fessler’s primary-care doctor for the past 40 years. The hospital had saved her 2-year-old daughter after she was stomped by a horse; it had treated another of her sons for acute cardiac distress. Now Graham told Fessler that her son’s heartbeat looked abnormal on the test. Fairfax Community no longer had money to pay for remote cardiac monitoring.

“We can helicopter him over to Tulsa in less than 25 minutes, and a cardiologist will be waiting,” Graham told Fessler, as she signed a few forms. “That’s really the best thing for him.”

The helicopter landed behind the hospital, and two paramedics loaded the 16-year-old onto a stretcher to put him aboard. Fessler rushed to her car to drive 90 minutes to the hospital in Tulsa, since there wasn’t room for her in the helicopter. Graham watched as the helicopter lifted off, the thunder of its rotor shaking the hospital windows, and then he took out his phone. “Hi, Cassie?” he shouted. “You drive safe, OK?”

The original 60 employees on the hospital staff gathered in the main hallway. Some had already quit, others had stayed, and all of them were watching as Fairfax’s vice mayor walked through the door. Charlie Cartwright had his hands in his pockets, and he wasn’t carrying a bag. If he’d come with paychecks, they were still in his car. One employee knelt to pray. A few others slumped against the wall.

“I promised myself I wasn’t going to come up here acting like a mess,” said Cartwright. His wife ran the hospital’s physical therapy department, and he had spent months fighting to get the hospital back under the town’s control.

“I wish I had better news, but I’m coming to you with a major problem here,” he said, and then he explained what he’d just learned from the lawyers. A bankruptcy court in North Carolina had retained control of the hospital, and it refused to give it back to the town. Another management group from Oklahoma had made a bid to operate the hospital, promising to restock supplies, issue paychecks, and rehire at least some employees in an attempt to keep the hospital running, but any takeover was still weeks away. If the hospital closed even temporarily before then, state and federal laws would make reopening difficult, but Fairfax Community couldn’t afford to keep operating a full hospital, and the city had exhausted its budget on legal fees.

“We’re writing checks right now that our ass can’t cash,” Cartwright said. There was only one way for the hospital to survive until new management took over. “We become an empty shell,” he said. The hospital’s patients would have to be transferred out. All but a few employees would be laid off. Fairfax would close its hospital except for the ER, which would operate with minimal supplies and a skeleton staff—a nurse, an aide, and a doctor on call.

“I need you all to tell me if this is what we want to do,” Cartwright said, and he looked over at Graham.

“It seems like the only way,” Graham said, and then he stepped into the center of the hallway to face the rest of the staff. “It’s been a big try, everybody,” he said. “Might not be over yet, and hopefully a lot of us will be back when this place changes hands. I know all of you want to help take care of these people. I know you’ll do it for free. You’ve proven that. But right now, the best thing a lot of us can do is go home. We’ll drop down to just an ER. We’ll take people’s vitals and send them on.”

“We’re a family,” said Donna Renfro, the head nurse. “We’ll do whatever we have to.” Employees hugged and began to clear out of the hallway as Fairfax Community emptied out. One inpatient was transferred to a nursing home. The other was released into the care of a friend. The lab director locked the lab. The CEO shut off her computer. Graham walked to his truck and started dialing patients on his phone. “I’ll still be here,” he told them. “I’m always on call.”

He drove down the hill and away from the hospital, where life in a small town began and ended, and where on this night, what remained in the darkness were no patients, two nurses, and a lighted red sign. “Emergency,” it read.

Excerpted from an article first published in The Washington Post. Used with permission. ■