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Víctor Tadashi Suárez for Al Jazeera America

Oil industry accidents put North Dakota hospital $1.5 million in debt

An emergency physician talks Bakken shale injuries, how companies manage worker mishaps

Watch "Death on the Bakken Shale," Fault Lines' investigation into why North Dakota's worker fatality rate is so high. It airs Monday, January 12, at 9 pm Eastern time/6 pm Pacific on Al Jazeera America. | Click here to find Al Jazeera in your area.


Dr. Gary Ramage is a physician who has lived in Watford City, North Dakota, for 20 years. When he first arrived in the area, it was a farming and ranching community. Some of its fewer than 1,500 residents had wealth tied up in their land and the livestock they raised. “Land rich, cash poor or cow rich, cash poor,” as Ramage told Fault Lines.

Today, thanks to an oil boom that began six years ago, the town’s population has more than doubled. Land in western North Dakota that once cost a few hundred dollars per acre is now going for hundreds of times more. Some of Ramage’s friends are collecting royalty checks totaling $80,000 every two weeks for letting oil companies drill on their property. The boomtown economy has trickled down to the businesses that support the new drilling operations, like convenience stores, where Ramage said clerks are paid $17 per hour with benefits, even though the state’s minimum wage is only $7.25.

But there are other consequences to the oil boom: The people of Watford City, the largest town in McKenzie County, which is near the center of the new gold rush, say their cost of living now includes a so-called “Bakken surcharge”—named after the Bakken shale that companies are fracking for its crude. They incur higher prices for groceries and other goods and services than others in the state and those in neighboring states. Ironically, they even pay more for gas.

Another consequence is that Ramage’s caseload at McKenzie County Hospital has also picked up significantly. The influx of new, unskilled workers taking on relatively dangerous industrial jobs resulted in a sharp rise in accidents and injuries in the region. In fact, North Dakota’s oil and gas operations have the highest fatality rate in the industry nationwide. 

Fault Lines spoke with Ramage about Watford City’s transformation and the human cost of the rush to tap the Bakken shale. An edited and condensed transcript of that conversation follows:


Fault Lines: What was this place like 10 years ago?   

Dr. Ramage: When I first arrived here, it was 1,250 people in town. That was it. It was Highway 85 in and out, going north and south, and Highway 23 going east. I was seeing a half a patient per day in the emergency room. So I'd see 15 patients in the emergency room in a month.

What kind of issues was the town facing back then?

We had a lot of people emigrate from our community and, ultimately, our numbers dwindled quite significantly. We went from 1,250 to about 1,500 or 1,700 and then down. And we were losing a lot of our young people. The running joke was that the last person to leave Watford City should turn off the lights. And we were close.

That actually happened to a lot of small towns up here. They just died out. What happened when the oil came?

I don't think a lot of people saw this coming. The people who really noticed that oil was beginning to be speculated were people who owned the hotels and restaurants. They were seeing the land men come in. And then the people who were working in the clerk of courts where the land men were doing their research for what minerals were available.

Then all of the sudden the ranchers and farmers started being approached by land men wanting to purchase some of their mineral rights. And next thing you know, there's a few wells going out. And then next thing you know, everybody is talking about it and how much they got for their minerals and how much somebody else got for their minerals.

All of the town sort of morphed into this bustling sort of little mini-metropolis, and people started to come in. We had the initial oil companies come in and we had the ancillary services come in—it was the people with the trailers, the food trailers and then support for the oil field. They just grew and grew and grew to what it is now.

Dennis Whedbee lost his left hand in a well blow-out on an oil rig while working on the Bakken.
Josh Rushing for Al Jazeera America

And you were getting 15 patients a month here. What have you gotten in the last month here?

My last shift, I saw 31 patients in a day.

Wow, twice as many in a day now as you used to see in a month. What kind of accidents are you seeing now from the oil field?

On an average day, we have oil field traumas of some sort. It's usually extremity, muscular injuries—people who lose a finger or smash a hand or break an arm or break a leg or cut themselves. Things like that. It's usually minor oil field accidents. But we certainly do have our share of big traumas that come in every week.

What are those?

The most significant right now are car crashes. It's just the number of people on the road, and the number of trucks. We have 12,000 trucks that travel through Watford City every day, and when they are nose to tail, there's no room for any error if anybody loses traction or slips into the other oncoming lane. They are hit by a semi trailer. And there's a lot of fatalities and a lot of very serious injuries from car crashes.

What traumas do you typically see that are coming from actual oil field accidents?

We have explosions and we have burns and we have gas inhalation. We have simple accidents that happen in the workplace. People falling from ladders or falling off of tanks. Generally your whole spectrum of accidents you would see in any industrial work environment.

Have you had to learn different skill sets since all this started?

I was always trained to do a lot of the stuff that I do now, but now I actually get to do it. Part of being a doctor who works in an emergency room is to do your advanced cardiac life support, your pediatric advanced life support and your advanced trauma life support—which are the three cornerstones of emergency care. You have to be certified in all three, and there's a lot of principles and a lot of techniques and things that are taught to you that you never utilize but now I get to utilize almost all of them.

There's been lots of cases where we've had people who have come through here who are positive for either alcohol or drugs and are working for oil field companies involved in accidents.

Dr. Gary Ramage

Physician in Watford City, N.D.

When guys come in with major injuries from the oil rigs, do they have company guys with them sometimes?

They do. For the most part, a safety officer either phones me or accompanies in the injured worker.

How does that work out, your relationship with that person? What do they do?

They're fine. They're fine. They explain to me what their job is, and we tried to work within, you know, the parameter. I do what I do, you know, for everybody, irrespective of what comes in. Medicine is medicine. And I render the treatment.

But when we do the paperwork, each company will have different things that they need to have done. And some companies will mandatorily have their employee alcohol tested and drug tested, so we work with that. We have people here who can alcohol test and drug test. Sometimes they'll need to have forms filled out for prescription medications, if they require prescription medications. Sometimes they will have forms filled out for safety for things that are specific to that company. But I file a worker safety form for every injured person unless they decline.

I assume they must do alcohol and drug testing out there as well, they are not just doing it after someone has an accident? Are they?

They, the companies, are responsible to alcohol and drug test their own employees. ... There's been lots of cases where we've had people who have come through here who are positive for either alcohol or drugs and are working for oil field companies involved in accidents.

Does the company or company guy ever try to influence you to code things a certain way?

No. That hasn't been my experience. I've worked pretty closely with the safety officers. And sometimes they will ask, if at all possible, could I not prescribe a prescription narcotic or can I not prescribe a prescription medication for their worker, if I felt that it was within a reasonable parameter.

Is that weird to have a company guy not to give a certain prescription to a patient?

If it adversely affects their company, in terms of their insurance premium, if it adversely affects their company in some way ...

But were I in pain, and I found out my producer talked to the doctor and said don't give him that pain med, I would be like, “Wait, I thought I had a secret relationship, a one-on-one between my doctor and I on what I needed.”

That has happened.

And as a doctor, how do you respond to that?

I usually do what I feel is necessary, you know. And a lot of times, there will be a grey area where a patient certainly could get by with an anti-inflammatory instead of a low grade narcotic. And I would discuss that with the patient first. But I can understand where the safety officers are coming from in that respect as well.

Dr. Gary Ramage speaks with Fault Lines correspondent Josh Rushing.
Víctor Tadashi Suárez for Al Jazeera America

Aren't there HIPAA concerns though, about what you tell a safety officer, about someone's personal medical case?

Ok, again this is another gray area in the fact that this is a workmen's compensation injury, the safety officer is intimately involved with the workmen's compensation and the injured employee has already reported it to his employer and safety officer. So everybody is coming in on the same page. Everybody is all informed. There's been implicit informed consent between the patient, his company and the safety officer. And in a lot of cases, there's a signed document already between the patient and the safety officer.

So HIPAA really doesn't apply in that regard. If there is something that I discover in the lines of what I'm doing with the patient that is unrelated to that, certainly HIPAA would apply. But in terms of what I'm doing with the patient, the patient has already tacitly implied that the safety officer can be informed of what's going on. And generally speaking, the safety officer is there with the patient, everything is discussed between the three of us, and there is nothing that's discussed out of school.

Has the company ever had doctors call you, their own doctors?


But why do they do that?       

Some of the large companies have doctors that are employed that are basically statisticians and are looking at oil field accidents, and they are documenting as to what is happening. And how they're happening. And I will get a call from them, and they will ask me basically what the parameters of the accident were. And they've already had a release from the patient who is, who I've already seen. And so I will discuss the case with the physicians for that company. At the patient's permission. And then they in turn are working to make things better in the company. And you know they are looking at safety issues. And they're trying to improve. Because there is always room for improvement here with the accidents.

Do they ever have their own opinion about the way something should be treated, or what's wrong?

I haven't had that experience. I haven't had anybody phone me up and say you know you need to do this and this and you need to prescribe this and this. I think there's a professional, collegial relationship between myself and the other doctors, the safety officers. That we all work together. And we're actually trying to do the best thing that we can. You know, we're trying to do the best by the patient and we're trying to make the oil field safer as well.

So when you have that kind of increase in patients, I'm sure a lot of them have insurance. And then some don't. What happens to that increased uncompensated care bill at this hospital? Who is carrying the weight of that?

We as a community are. Our hospital is a community-owned facility. When people come to work here, there's usually a waiting period before their insurance kicks in. And so there's a fairly significant amount of people in the oil field who are underinsured or completely uninsured. The way it's set up now is that the clinics have a co-pay. So if someone is destitute and they don't have any money and they can't afford to go the clinic, they come to the emergency room.

The emergency room sort of doubles as a family practice. We lost $1.5 million in unpaid bills last year.

To be carried by the town?

The hospital society. We're a non-profit organization, but ultimately we're a community hospital. It's carried by the hospital. We have various organizations that raise money. We have a foundation that raises money. We have our administrative group. They have ways of recouping money. We applied for grants. We make ends meet. There's lots of ways to make ends meet.

There’s a direct correlation though to the oil industry being here and you having those costs and that debt. Why doesn't the oil industry pay?

They are beginning to come around. We're building a new $60 million hospital. The breaking ground is in the spring of next year. We've actually broken ground now, but we're starting the actual construction in the spring of 2015. And we are having oil companies kick in. They are giving us large checks to build that hospital. So they are helping in that regard.

And I think everybody is starting to understand that this is an oil boom that's going to last for a while. It's not a short-lived phenomenon. And once everybody starts to settle down and starts to build houses here and move in and bring their families, everybody will realize they have to participate in the community. And if they are going to participate in the community, then they have to participate financially, as well.

In "Death on the Bakken Shale," Fault Lines investigates why the oil boom in North Dakota has brought with it the highest worker fatality rates in the country—and who should be held responsible. The film airs on Al Jazeera America Monday, January 12, at 9 p.m. Eastern time. It will air again that evening at 9 p.m. Pacific time.   

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