Years of planning delivers top-notch emergency services

It was like a dream come true for the providers, nurses, EMS crew and the community when the newly remodeled emergency room at North Big Horn Hospital opened its doors about a year and a half ago.

“This is such a big upgrade from our old emergency department,” said Jack Carpenter, PA-C, who has been with the hospital for 17 years. “It allows for patient confidentiality. We have a room that’s dedicated for negative pressure for different infections, and we have procedure rooms and the trauma bays, which is huge.”

In the past, the ER had two beds, separated by a curtain, and the area was about the size of the area that now houses two fully equipped trauma bays. In addition to those two beds, there were three very small exam rooms and essentially no waiting area to speak of for family members. To say the least, it was a tight squeeze.

“I remember a time that, if you had five patients in the ER, you would be inundated with family members, too,” Carpenter said. “There was just no room, certainly no waiting room other than two chairs out in the hallway. Now we have the whole lobby as our entrance, and we have a room that we use for triage that can also be used for consult. Looking back at the old ER, it was amazing that we were able to do what we did at that time in such limited space.”

Carpenter pointed out that, though serving a relatively small community, the needs are just as big as a larger population.

 “Just because we’re little doesn’t mean we see only little problems,” Carpenter said. “We see everything every other facility sees.”

Michael Asay, PA-C started working at the hospital in 2016. This will be his eighth year working in the ER. Asay agreed with Carpenter that one of the biggest improvements was in patient privacy and noted, with that comes “patient comfort.”

“Before the remodel we had those two beds and a curtain, which offered no privacy,” he explained. “And, we only had three very small rooms for procedures. So, for example, if I was trying to suture a child, there would only be enough room for one parent in the room with them.”

Asay remembers times when there were several traumas occupying the limited space with little space left for staff.

“Now we can handle the same number of patients faster, without being so congested,” he said.

The door from the ambulance bays has moved, making it easier and more efficient to wheel patients into the emergency room. A spacious waiting room is available for family members just outside the ER, but there is also plenty of space inside for family members to be with their loved ones.

Asay said he finds it gratifying to be part of the team that takes care of acute or very sick people.

“I feel like I can make an immediate impact,” he said, comparing it to working in the clinic, which involves more preventative work and where providers don’t see the impact of their work as quickly.

Asay noted that the addition of a negative pressure room has been helpful, especially in cases involving highly contagious respiratory infections like Covid. The ER staff did not have the room during most of the pandemic.

“It offers patients more safety because it limits exposure,” he explained. “It’s useful for Covid, influenza and any respiratory infections. Viruses are literally sucked out of the room instead of lingering in the hospital or the ER.”

Dr. Nathan Johnson joined the emergency room staff around the same time the new emergency room opened. Johnson is a board-certified emergency room physician, overseeing the ER and the EMS staff and operations as medical director. Johnson brought more than 20-plus years of experience to the position and extensive experience and expertise in stroke care and cardiovascular disease. He came to NBHH from a “well-staffed” and “well-appointed” emergency facility in Ohio that served about 35,000 patients per year.

“Honestly, we have everything in this ER that I had in Ohio,” he said. “The physical plant is every bit as nice as any ER in the country. I would absolutely say that. Part of it is because it’s new, right, but it’s clean, it’s well-lit, and I really like the layout. As EMS director, I love having the ambulance bay right next to the ER where I can look out into the bay and anticipate what’s coming in next. I think it’s a great setup. Even the little things that we tend not to think about are taken care of, like security, which is not as necessary here in Lovell as in bigger cities, but still needed.”

The hospital Johnson worked at previously was not a trauma center like NBHH.

“We see as much, or even more, trauma here,” he said. “We see the whole spectrum really. I think that’s because the world ends east of here. If you’re up on the mountain and something bad happens or north of here and something happens, we’re the only ones around.”

The ER providers at NBHH see an average of 190 patients per month, with an average wait time of about five to 10 minutes. Johnson said the average wait was much longer where he came from in Ohio.

“The average wait where I came from was about three hours, and that was considered pretty good compared to larger cities with a six-hour wait time,” he said.

Johnson said one of the strengths of the emergency room is the personalization of services.

“It’s not just about the physical plant,” he said. “It’s as much about taking care of your friends and neighbors. We’re held to a higher standard because we see our patients on Sunday at church, or at the baseball games, or the music programs at the school. There really isn’t any margin for error when you know your patients as well as we do. There’s no anonymity in a small town.”

Johnson reflected on how emergency rooms are viewed in general has changed in the past 20 years. 

“When you look back 50 years ago or even 20 years ago when I started in this field, the old theory was that family practice and surgeries brought people into the hospital and the ER was just this backup, where if something went wrong, you would go there. That model has changed, and now the ER is many times the front door to the hospital. It seems like this hospital picked up on that before other hospitals did.”

Johnson commented on the hospital’s recent ranking as one of the top 100 critical access hospitals in the nation.

“We want every patient to come out of here feeling like they got great service, but I’ve been around long enough to know that is subjective,” he said. “Objective is when we get compared to a thousand other hospitals and come out in the top 100.”

A big part of Johnson’s job as medical director for both ER and EMS operations is to find ways to improve efficiency.

“The time aspect is so built into emergency medicine compared to family practice, where it’s much more about treating chronic disease,” he explained. “Everything in ER medicine is about doing everything quickly, especially diagnosis.”

Johnson praised the ER team and noted that the nurses are some of the best he has ever worked with in the field. He also spoke highly of the administrative team, which he has found to be committed to growing and improving the organization. He said one of the most rewarding parts of his job is working with EMTs and paramedics who are very dedicated to their work.

“The status quo doesn’t work in this field,” Johnson said. “If you’re not improving, you’re losing ground.”

NBHH CEO Eric Connell noted that the addition of a board-certified emergency room physician with Dr. Johnson’s extensive experience has allowed the hospital to evolve from a medical practice that was comprised of providers that were primarily in the clinic, but also sharing duties in the ER, to a more specialized practice. He said it allows the doctors in the clinic to focus more on their areas of clinical expertise, while at the same time allowing the three full-time providers in the ER to focus on emergency medicine as their main responsibility.

“Dr. Johnson brings all of the education and experience that allows us to make that change,” he said. “He also has a background in leadership. He’s been a medical director, and he’s bringing that oversight into the ER that we’ve never had before.”

He added that each provider brings his own unique skillset to the job, with Carpenter offering several areas of specialty, especially his emergency background and training.

“Jack is really unique because he has several areas of specialty in the ER, but he also has a surgical background, which allows him to assist surgeon Dr. Hill in the operating room,” said Connell. “In the ER, he brings a very good trauma skillset, and he’s really good in those areas. He also has outdoor medicine training, which allows him to go out on helicopter rescues with the local search and rescue team.”

Connell also noted the unique background Asay brings to the job.

“Michael Asay has been a homegrown talent, and that’s something you don’t see every day,” said Connell. “He grew up through our organization and continues to get more education and experience all the time. He is very good at dealing with chronic conditions when they come into the ER.

“Michael has cared for my own family, and he has a great bedside manner. He really knows how to meet people where they are and communicate with them very well.”

Connell spoke highly of the staff and providers at the hospital.

“I just can’t say enough good things about all of our providers,” he said. “I would trust the life of any member of my family with any of our providers in the ER. In fact, I would say the same about any of our providers at this hospital. We’re so blessed and fortunate to have these people who choose to be a part of our community. We can’t run our clinic or our hospital without them.”