PARK FALLS - Jocelyn Jacobs and Mark Musolf were driving into a snowstorm last winter when the driver of a pickup truck lost control and hit their car head-on near Park Falls, a small town in the shadow of the Chequamegon National Forest.
The couple suffered grave injuries, but medical helicopters were grounded by the storm. An ambulance took Musolf, 67, to Park Falls and then to the nearest trauma center - in Marshfield, nearly 100 miles away. He died en route, three hours after the crash.
Jacobs, 57, with more than a dozen broken bones, had to be pulled from the wreckage without pain medication because the volunteer medics weren't trained to use it.
"It was torture," she said.
The Madison woman wonders if the outcome would have been different if the crash hadn't happened in the North Woods.
"I think that's one of the reasons why my husband died right in front of me," she said. "What if we had been near a major hospital?"
Emergency care is one of many ways in which the health care system can fall short for the 50 million Americans in rural areas. From a shortage of doctors and specialized services to an abundance of patients who are poor, elderly or have little or no insurance, health care in rural areas such as Park Falls can be precarious.
The Wisconsin State Journal, which is undertaking a special reporting project on rural health care this year, found similar hurdles in small towns across the state. From Boscobel and Darlington to Friendship and Merrill, cash-strapped hospitals have dropped important services, following a national trend.
Even so, Wisconsin and Midwestern states fare better than other parts of the country in rural health, said Greg Nycz, executive director of the Family Health Center of Marshfield, which serves many rural counties in northern Wisconsin.
"We struggle with brain drain - finding the health professionals we need in rural areas," Nycz said. "If we don't turn that around, we're going to be sliding in the wrong direction."
The fragile, fragmented care in rural settings is thought to be responsible for a startling mortality gap nationwide: The death rate, adjusted for age, dropped only slightly in rural America the past two decades while declining significantly in cities, according to the U.S. Department of Agriculture. Previous decades saw identical decreases in rural and urban areas, as overall health care improved, suggesting rural areas are now losing ground.
‘It's a crapshoot'
Park Falls, a city of 2,300 along the Flambeau River about 250 miles northwest of Madison, illustrates the challenges of providing good, consistent health care in rural areas.
Its Flambeau Hospital, considered the most remote in the state, can't perform many surgeries. The demand for dental care is so great that a new clinic was booked for months before it even opened. Mental health care is also scarce. Even wellness is a struggle, with the only fitness center in all of Price County stuffed inside a smoky bowling alley and hotel in Park Falls.
"There is no 90-minute window here for heart attacks," said Dr. Scott Carpenter, the hospital's emergency room chief, referring to the widely accepted goal for getting patients to major hospitals for blockage-clearing angioplasty. "You can't get from here to anywhere in 90 minutes."
Emergency doctors in Park Falls give heart attack patients blood thinners right away, even though the drugs can cause extra bleeding when the patients eventually get angioplasty. "It's better than doing nothing at all," Carpenter said.
There often aren't enough nurses, medics or ambulances available to quickly ship patients to a trauma center, said Dorothy Weigel, emergency room manager.
In those cases, an ambulance crew must drive up from Marshfield or Wausau and take patients back to those cities for surgery or other care, Weigel said. Largely because of the two-way trips, she said, it takes more than four hours for most trauma patients to make it to a trauma center.
"It's a crapshoot some days," she said.
Long-distance deliveries
Like many other rural hospitals, Flambeau Hospital has stopped routinely delivering babies. Managers couldn't attract doctors willing to perform Cesarean sections at any time of the day - a requirement to offer the service, said hospital administrator Dave Grundstrom. After two surgeons left in 2006, the hospital dropped deliveries.
"It was a very difficult decision," Grundstrom said.
The next closest hospital that delivers babies is in Minocqua, 42 miles away along desolate, two-lane Highway 70, with frequent deer and bear crossings and scant cell phone coverage.
Katrina Polencheck faced that scenario when she went into labor in Park Falls about 2:45 a.m. on Jan. 14, 2009. Her contractions were about 20 minutes apart when she called the obstetrician in Minocqua, who told her it was too early to drive over.
But her contractions quickly grew stronger and more frequent. It was below zero, and the highway was covered with ice. She figured she'd never make it. Polencheck and her husband, Lee, rushed to the emergency room in Park Falls, where she had her daughter, Chloe, in less than 20 minutes.
"I was totally terrified," said Polencheck, 27, who has since moved to the Wausau area. "What if we had had our baby on the side of the road that night?"
The anxiety didn't end after the delivery. Flambeau Hospital is no longer equipped for babies, so doctors shipped Polencheck and her newborn in two ambulances to the maternity ward in Minocqua.
"It was really hard to be separated like that," she said.
Upgrade on hold
The lack of doctors willing to come to Park Falls has led to other reductions in services. Foreign doctors help fill the gap, but most leave after a three-year stint that secures a visa.
After the two surgeons left in 2006, the hospital also started sending patients to Minocqua for surgeries previously done in Park Falls, including operations on knees, gallbladders, intestines and appendices. Flambeau Hospital is owned by Marshfield Clinic and Milwaukee-based Ministry Health Care. The hospital in Minocqua, Howard Young Medical Center, is owned by Ministry.
The economy has added to the challenges. Smart Papers, Park Falls' largest employer, shut down in 2006. It reopened six months later as Flambeau River Papers, which hopes to expand this year by adding a biofuels refinery.
Unemployment soared to 13 percent in Price County over the summer, well above the state average, and administrator Grundstrom remains cautious about the hospital's future.
A $20 million upgrade is needed to bring the hospital's lab up to date, replace its 50-year-old boiler and make emergency room beds private in accordance with federal laws, among other improvements, he said.
The hospital became a federally designated "critical access" hospital eight years ago, which has brought some financial stability through more money from Medicare. But when local jobs are in question, so is health care spending, Grundstrom said. For now, the upgrade is on hold.
"We're waiting to see if the biofuels project takes off," he said.
‘A vicious circle'
Jacobs, still recovering from the car crash that killed her husband, said the undisturbed beauty of rural, northern Wisconsin is what led them to be driving near Park Falls the day of the crash.
Jacobs, an attorney, and Musolf, a former state revenue secretary, lived in Madison until 2003. After retiring, they bought a lumber baron's home near the Lake Superior shore in Bayfield and converted it to a bed and breakfast.
They kept a home in Madison but considered Bayfield their new residence, with Musolf serving on the city council and Jacobs on the library board. They hiked, biked, camped and enjoyed scenic views of the lake. The draw, Jacobs said, was "being able to look at it every day."
The couple were traveling from Madison to Bayfield about 2:20 p.m. on Dec. 16, 2008, when a southbound pickup truck entered their lane on Highway 13 about 15 miles south of Park Falls, according to the police report. The vehicles collided head-on.
Nobody knows whether Musolf would have survived if a helicopter were able to fly or if the crash had happened closer to a major hospital.
But the rural location, along with the snow, appears to have caused delays. An ambulance took Musolf to Flambeau Hospital to be stabilized - as is customary, hospital officials say - but didn't arrive there until 3:43 p.m. After an emergency room doctor got in the rig, the ambulance headed for Marshfield Clinic.
Musolf was declared dead along the way at 5:20 p.m., from massive head and internal injuries.
Jacobs was taken to Flambeau Hospital, where she was finally able to get pain killers, and then to Marshfield Clinic. She transferred to Mayo Clinic in Rochester, Minn., where she had surgeries on her shattered pelvis and other broken bones.
Weigel, the emergency room manager at Flambeau Hospital, said the delays and medics' inability to give pain drugs are unfortunate realities of rural emergency care. She said there aren't enough people in Price County to support a trauma center and highly trained paramedics, forcing patients to travel much greater distances for that care than in metropolitan areas.
"It's a vicious circle," she said.
Jacobs, now living in Madison, underwent another surgery last month on her leg. She plans to return to Bayfield this summer to reopen the bed and breakfast on a part-time basis. She isn't ready for full time.
"I'm still trying to get used to the idea of a Mark-less world," she said.
[Editor's note: This story has been updated to reflect a correction: Howard Young Medical Center is owned by Ministry Health Care.]
