Fifty years in farming had given Tom Soukup a few brushes with his own mortality, but after a cow pinned him against a wall, death felt closer than ever. He lay on the muddy ground and began to pray, every gasp feeling like a stab to the chest.
Although the nearest clinic was just a 10-minute drive from Soukup's South Dakota ranch, the doctor on duty did not have much experience treating such injuries. He had rarely inserted chest tubes and wanted guidance from another physician without having to consult a medical reference book.
So the clinic in tiny Wagner connected by video to doctors in Sioux Falls, who talked him through the steps to stop the bleeding and drain the blood collecting inside the 72-year-old man back in March 2010.
It's a system that's gaining wider use across the rural U.S., where there are often few primary care doctors and even fewer emergency rooms. Although so-called telemedicine has been around for at least two decades, the practice is fast becoming a standard feature in many small communities, even as other public services such as police and fire protection decline.
Soukup watched the monitor on the wall as the "doctor in Sioux Falls was telling the doctor down here how to do that procedure."
A growing number of South Dakota health care providers are being assisted by a 24-hour emergency medicine hub based in Sioux Falls that uses two-way audio and video feeds.
The operator, Avera Health, has a telemedicine network that includes 86 hospitals in seven states in the West and Midwest. It expects to have contracts with 100 facilities by the end of the year.
The rapid expansion in telemedicine has led facilities to link up with providers well beyond their immediate region.
"The fact that they are going across state lines was almost unheard of 10 years ago," said Jonathan Linkous, chief executive of the American Telemedicine Association.
Since the first hospitals were connected in 2008, Avera's system has hosted more than 9,500 video encounters - about 4,000 within the last 12 months.
Not all of the hospitals connected to the network are part of Avera Health, and they must pay for the equipment and a yearly rate for the service.
The operator declined to provide the average cost of the service, citing competitive reasons. But Avera's senior vice president of quality initiatives, Deanna Larson, said the amount each hospital pays is less than the average salary of an emergency physician, which is about $270,000, according to industry estimates.
North Dakota has 29 facilities connected to the network, the largest number of any state. South Dakota has 23 connections, and Minnesota has 18.
When Soukup arrived at the clinic, nurses and the doctor on call quickly concluded that the 1,400-pound cow had punctured one of his lungs. Within seconds, they connected with the e-Emergency service with the push of a button on a wall.
The Sioux Falls staff guided Soukup's physician as he made a 1-inch incision between the ribs, pushed a finger through muscles and cleared the way for a tube.
At the same time, nurses in Sioux Falls charted all medications administered to Soukup, allowing the Wagner nurses to keep their hands on the patient instead of jotting down notes. A Sioux Falls physician located a helicopter to pick up the patient and transferred his record to the receiving hospital, expediting the transport and avoiding duplication of tests.
That kind of organization is especially helpful when multiple victims arrive at a rural facility, said Dr. Timothy Taylor, a doctor at a clinic in Spirit Lake, Iowa.
Because the clinic is in an isolated resort area, "we can be overwhelmed in an instant," Taylor said, explaining that the e-services allow the staff to coordinate patient care with a nurse if Taylor is tied up with another patient.
Wagner, a one-stoplight town with a handful of gas stations, one pharmacy and a phonebook dominated by a few last names, is 110 miles from Sioux Falls, home to the nearest trauma center.
For Bryan Slaba, CEO of the Wagner hospital, Avera's telemedicine service has helped him recruit and retain medical residents and physicians.
"The younger docs embraced it because they have all the support mechanism around them when they're going through residency," said Slaba, whose hospital joined the network in 2008 with the help of a federal grant. "They get out in this rural community, and they look around and there's nobody around for 60 miles."
Soukup made a full recovery but now leaves most of the farmwork to his son-in-law so he can spend winters in Arizona with his wife, Linda.
"Fifteen years ago," Linda Soukup said, "this probably would have had a different outcome."