Nov. 25--Two years ago, Dannie Bee Tiffin was working in the tiny town of Guthrie when he started experiencing chest pains.
Unfortunately for Tiffin, he was in King County, population 282, the second least-populated county in Texas and third-least populated in the United States.
There was no doctor in Guthrie. No clinic. Childress Regional Medical Center was 60 miles away. Between Guthrie and Childress was Paducah, where the hospital closed in 1985.
So Tiffin, 62, an electrician for the famed Four Sixes Ranch, was loaded into an ambulance for the ride north.
"He had a heart attack," said his widow, Keitha Tiffin. "There was no help, no help at all."
All King County has is basic ambulance service, where the state requires one EMT riding in the vehicle in addition to a driver.
He didn't make it.
"I just know he was too far away," said Keitha Tiffin, who works at Childress Regional Medical Center. "I still have sleepless nights thinking what if."
Such is the problem in many parts of Texas where there are no hospitals and sometimes no doctors.
King County is one of 27 counties in Texas that does not have a licensed physician. Another 22 only have one, according to the Texas Department of State Health Services
"You really should live within 30 minutes of a hospital for emergency care services -- that's not a problem in the Metroplex, but it is in West Texas," said Don McBeath, director of government relations for the Texas Organization of Rural & Community Hospitals (TORCH).
Counties without doctors
In some parts of Texas, patients may drive to another county to even see a doctor. In fact, 27 counties have no physicians and 22 only have one doctor.
And those gaps are likely to grow.
Since 2013, 15 rural hospitals -- located in counties with no more than 60,000 residents -- have closed across Texas.
"After 15 closures in the last four years, we need to keep what we got," McBeath said. "If we get more gaps between the dots on the map, more people will die."
Rural hospitals face many challenges including competition for doctors from larger cities and ever-increasing student debt for doctors coming out of medical school.
There's also uncertainty about another round of government reimbursement cuts.
"Starting in 2011, those cuts have been collectively taking away an estimated $100 million a year in payments to Texas 163 rural hospitals," McBeath said. "The majority of the cuts are from the ongoing federal budget sequestration reduction, penalties associated with the Affordable Care Act, and reduced payments in Texas Medicaid outpatient care to Texas hospitals. Most of the 2011 state Medicaid cuts were restored by the Legislature in 2015, but the federal Medicare cuts continue."
At a Sept. 13 hearing of the state's Senate Committee on Health and Human Services, legislators discussed the future of rural healthcare.
State Sen. Charles Schwerter, R-Georgetown, an orthopedic surgeon and chair of the committee, questioned whether all rural hospitals could -- or should -- survive.
"Is it best served by a system of rural hospitals or is it better to get that person to a higher level of care in the most expeditious manner?" Schwertner asked during the meeting. "Texas has changed since all of these hospitals were created. Many of them are left over from many decades ago and we're sustaining them financially through supplemental payments primarily."
If Texas legislators cut Medicaid payments in the upcoming session as they did in 2011, more rural hospitals could fail.
"I'm pretty comfortable with saying at least a third of our rural hospitals are in stress today," McBeath said. "We've had 15 close the last four years. Prior to that, we were having one or two every other year. There's no question in my mind that's what made it happen."
Bowie feels the impact
One North Texas community to feel the impact of a hospital closure is Bowie, in Montague County about 70 miles northwest of Fort Worth, where Bowie Memorial Hospital shut down a year ago.
Now residents must travel about 25 minutes to get to the nearest hospital in Nocona or Decatur. But the economic toll has been even greater.
At the same time the hospital was closing, Bowie was hit hard when Energy Service Company of Bowie, which provides oilfield services, was laying off employees.
Bowie has seen its sales tax collections drop about $800,000 from a year ago.
"It's substantial," said Bowie City Manger Ricky Tow. "It's hard to say how much of it is related to the oilfield and how much of it is the hospital closing but our sales taxes are off about 35-40 percent."
Bowie, listed with a population of 5,200, is believed to have become smaller due to the recent job losses, Tow said, but city officials don't have accurate numbers of how many people have moved out.
There is hope for a revival of the hospital.
In May, the property was sold to Dr. Hasan F. Hashmi and his two sons, Farea Hashmi and Suleman Hashmi, according to the Bowie News. They currently operate Texas General Hospital in Grand Prairie and TGU-Van Zandt Regional Medical Center in Grand Saline.
Beyond keeping hospitals open, small towns also face the challenge of attracting and keeping doctors.
Doctors can often make more money in a city and work a regular shift rather than being on call at all hours in a small town.
"I think there's a crisis in recruiting physicians into rural areas," said Mike Easley, vice president of hospital operations for Preferred Management Corp., which runs seven small hospitals across Texas including in Coleman, 155 miles southwest of Fort Worth, and Van Horn in far West Texas.
"You've got freestanding emergency and urgent care clinics popping up all over the place in cities and they've got to be staffed by doctors," Easley said. "You're at a little bit of a disadvantage in a rural area. Plus the doctors coming out of medical school want to work a 40-hour work week. Out here, they have to carry the hospital and their own practice."
Concern in Culberson
If you're driving through West Texas headed to El Paso, the Culberson Hospital serves as a lifeline for those making the long trip along Interstate 10. Van Horn, which sits 120 miles east of El Paso and 480 miles west of Fort Worth, is the only hospital in a four-county area.
Over a one-year period from April 1, 2014 to March 30, 2015, the Van Horn hospital treated patients from 40 states, including Alaska. It also treated patients from all over Texas, including four from Arlington, three from Fort Worth, two from Keller and one from Burleson.
Yet like many rural hospitals in Texas, the Culberson Hospital has its share of obstacles.
Across Texas, some small-town hospitals have struggled to stay open. Since 2013, 15 rural hospitals have closed and officials worry that more of the state's 163 rural hospitals could close if they face more cuts to Medicare and Medicaid.
Its lone physician, Ed Garner, is in his 60s and the community has been recruiting a replacement for more than a year.
"I'm hopeful we will get somebody out there," Easley said. "Dr. Garner does a great job. He's in good health and shows no signs of slowing down but I don't think he's going to work forever."
Overall, Texas faces a physician shortage. The state ranks 45th nationally in the number of physicians per capita, according to the Texas Medical Association. A survey by the Dallas-based physician search firm Merritt Hawkins, in partnership with The Physicians Foundation, discovered that Texas ranked last in the United States in terms of doctor morale.
To lure physicians, some rural hospitals will help pay off student debt and also make the doctors employees so they can cover administrative costs and handle paperwork associated with cumbersome rules associated with programs like Medicare Access and CHIP Reauthorization Act (MACRA). Some recent changes to the penalties associated with MACRA have been changed, easing the concerns of some rural doctors.
Saving lives in Childress
In Childress, the hospital's presence has helped save lives.
On Oct. 15, 2-year-old Parker Hadley of Grapevine was bitten by a rattlesnake at his family's deer lease 23 miles from Childress, leaving four puncture wounds on his lower right calf. His parents rushed to town, where they were met by volunteer firefighters, including an EMT, and received an escort by the sheriff. After receiving an IV of anti-venom medicine at Childress Regional Medical Center, Parker was flown to Children's Medical Center in Dallas.
Even though he received the vaccine within an hour, Parker's leg swelled so tightly in the following days that his father, Trent Hadley, said "it was like gripping a steel rod. You could not press or indent his calf muscle. There was so much pressure."
In all, Parker would receive 26 vials of anti-venom and spend nine days in the hospital.
Now, he appears like a perfectly normal 2-year-old playing catch with dad and working puzzles with his mom, Amy Hadley.
Both parents say the presence of nearby hospital was a small miracle.
"It was absolutely life-saving," said Amy Hadley, who works as a nurse. "To me, if there wasn't rural hospitals, it would stop me from taking my kids out there."
Trent Hadley said they both talked about what would have happened if there hadn't been a nearby hospital stocked with the anti-venom vaccine.
"If you get rid of rural healthcare and go to your next semi-metro area, you're talking Amarillo, you're talking Wichita Falls, which at a minimum was an hour and a half drive," Trent Hadley said. "You're talking two hours before he gets any treatment. By the time they had landed in Dallas, it was three hours after the bite and his leg was massive. That was with six vials of anti-venom."
The relative isolation of Childress, 222 miles northwest of Fort Worth, has turned the town into a mini-medical hub with nine physicians.
"For a lot of things, we're the only provider for more than 100 miles," said John Henderson, chief executive officer of Childress Regional Medical Center.
"It's not convenient to run to Amarillo or Lubbock or Wichita Falls," Henderson said. "We're the closest place to go for four to five counties around us."
Still, Childress is still too far away to save everyone.
On Aug. 28, a 45-year-old man had an allergic reaction to a wasp sting near the Cottle County town of Chalk, 45 miles south of Childress, and died before reaching the hospital.
Like King County, where Dannie Tiffin died, Cottle County does not have any doctors.
Cottle County, where Paducah is the county seat, spends roughly 20 percent of its $1 million annual budget on a countywide EMS service for its 1,452 residents.
"It's a good quality of life out here but when it comes to healthcare all of us are out here in the middle of nowhere," said Cottle County Judge Karl Holloway. "Honestly, our biggest challenge is funding the EMS service but ultimately, we've got to have it. We have no choice."
Bill Hanna: 817-390-7698, @fwhanna
Rural hospital closures
1995: Goliad County Hospital, Goliad County; Gilmer Medical Center, Upshur County; Brooks County Hospital, Brooks Clunty
1996: Crockett County Hospital, Crockett County; Garza Memorial Hospital, Garza County
1997: Shackelford County Hospital District, Albany
1998: Palo Duro Hospital, Canyon, Randall County
1999: Silsbee Doctors Hospital, Hardin County; East Texas Medical Center, Rusk, Cherokee County
2000: Medical Center of Winnie, Chambers County; Baylor Medical Center, Ennis, Ellis County
2001: Hi-Plains Hospital, Hale County; East Texas Medical Center, Gilmer, Upshur County
2002: Hall County Hospital, Memphis, Hall County
2006: Living Hope New Boston Medical Center, Bowie County
2007: Barix Clinics of Texas, Wylie, Collin County; Renaissance Hospital Terrell North Campus, Kaufman County
2008: Dolly Vinsant Memorial, San Benito, Cameron County
2010: Lakeside Hospital, Bastrop County (later replaced with freestanding ER)
2012: Colorado-Fayette Medical Center, Weimer, Colorado County (reopened in August 2015)
2013: Renaissance Hospital, Terrell, Kaufman County; Shelby Regional Center in Shelby County (later replaced with freestanding ER); Cozby-Germany Hospital, Grand Saline, Van Zandty County (reopened April 2015 as Texas General); Central Texas Hospital, Cameron, Milam County (reopened in November 2014 as Little River Healthcare)
2014: Lake Whitney Medical, Whitney, Hill County; Good Shepard Medical Center, Linden, Cass County; Cleveland Regional, Cleveland, Liberty County; East Texas Medical Center, Gilmer, Upshur County; East Texas Medical Center, Mount Vernon, Franklin County; East Texas Medical Center, Clarksville, Red River County
2015: North Texas Regional, Bridgeport, Wise County (acquired by Wise Health in 2013, closed inpatient services in January 2015 but continues as urgent care center); Hunt Regional, Commerce, Hunt County (inpatient hospital closed but continues as freestanding ER and outpatient facility); Bowie Memorial Hospital, Montague County
2016: Gulf Coast Regional Medical Center, Wharton (ER and outpatient services continue); Nix Community, Dilley, Frio County
Source: Texas Organization of Rural & Community Hospitals (TORCH), Texas Department of State Health Services and State Office of Rural Health