Carved long ago by meandering glaciers, the valley is home to bison and bald eagles, grizzly bears and gray wolves. Gibson-Snyder has seen them all. She calls it “my favorite place.”

“I know how special it is to have this in my life,” said Gibson-Snyder, an 18-year-old from Missoula, Montana, “and I don’t want it to go away.”

That concern, hypothetical not so long ago, turned tangible in June when unprecedented flooding washed out bridges, ravaged roads, forced the evacuation of thousands of tourists, and temporarily closed the park.

Although park officials described the flooding as a rare event, scientists say this type of extreme weather should be expected as the climate continues to warm.

It also illustrates why Gibson-Snyder and 15 other Montana young adults and children are suing their state.

Their lawsuit asserts that Montana — by fostering fossil fuel as its primary energy resource — is contributing to a deteriorating climate and violating the children’s guaranteed in the state’s constitution. By doing so, the lawsuit alleges, Montana is interfering with the children’s health, safety, and happiness.

“The state’s reliance on fossil fuels, its energy policy, its continued development of fossil fuel extraction has all led to exasperated effects of climate change,” Gibson-Snyder said. “It’s a betrayal by the government.”

In 2021, coal-fired power plants produced 43% of Montana’s electricity, compared with hydropower at 41% and wind power at 12%, according to

With favorable rulings from a state judge and recently the Montana Supreme Court, the children’s lawsuit is on track to become the first such climate case to go to trial in the United States. Attorneys for Gibson-Snyder and her fellow plaintiffs — ages 2-18 when the lawsuit was filed in 2020 — believe the case heralds a shift in climate-related litigation that could reverberate globally.

Already this year, children in Virginia, Utah, and Hawaii have filed similar constitutional challenges, and Our Children’s Trust, the nonprofit law firm that represents them in those actions, said other lawsuits by children in other states are likely by the end of the year.

“A win in Montana could very well have implications throughout the country and potentially even the world,” said Nate Bellinger, an attorney for Our Children’s Trust.

That children are bringing these actions, Bellinger said, should not be surprising. Our Children’s Trust, he added, routinely hears from young people interested in filing lawsuits against the states where they live.

“They have the most at stake and the most to lose and they are the least politically powerful group,” Bellinger said. “The courts offer them an opportunity to have some of that power to do something to protect their own futures.”

Claire Vlases, a plaintiff in the Montana case, noted that she was too young to vote when the lawsuit was filed.

“There are three branches of government for a reason,” said Vlases, now 19, of Bozeman, Montana. “If I’m not able to use the other two, this is my way, and it’s a way for kids, to have our voices heard.”

The cases brought by children against their states will unfold in the aftermath of a June 30 ruling from the U.S. Supreme Court to limit how the Clean Air Act — the nation’s main anti-pollution law — can be used to reduce greenhouse gas emissions from power plants. Although environmental advocates called the decision an egregious setback in the fight against climate change, attorneys for Our Children’s Trust said the ruling will not affect the youth-led constitutional lawsuits brought against state governments.

The Supreme Court decision does, however, further demonstrate “how important these children’s constitutional climate lawsuits are to address the harmful effects of our government-sanctioned fossil fuel program,” said Mat dos Santos, managing attorney at Our Children’s Trust.

Previous attempts by youngsters — or on behalf of youngsters — to force government action against climate change have been largely unsuccessful. Courts in Washington, Pennsylvania, Oregon, Florida, and, earlier this year, Alaska have dismissed those constitutional challenges.

Another case brought by Our Children’s Trust, Juliana v. the United States — the subject of a Netflix documentary — was thrown out by a federal court in 2020, although the plaintiffs are awaiting a decision on their motion to refile that lawsuit. Seventeen states, led by Alabama and including Montana, have asked to join the case and oppose its going forward.

In dismissing those cases, judges have often concluded that the remedies sought should be pursued not through the courts but through the executive and legislative branches of government.

A judge in Montana, citing the Juliana case, agreed with that reasoning when dismissing parts of the lawsuit last summer but allowed other claims to advance toward a trial. Those claims don’t assert that Montana isn’t doing enough to stop climate change. Rather, they allege, the state’s actions are causing climate change.

“These aren’t cases where governments are failing to act,” Bellinger said. “Governments are acting. They are promoting fossil fuels and permitting pipelines and power plants and extraction.”

The young plaintiffs in Montana maintain they are harmed by a state energy policy that favors fossil fuels and a law that prohibits environmental reviews by the state from considering the effects of policies outside Montana, which they contend doesn’t allow a proper examination of the effects of climate change.

Those actions affect the environment and their health, the lawsuit claims. The children report experiencing, among other medical issues, aggravated asthma, headaches, and throat and eye irritation, mostly brought on by pollution from intense fire seasons in Montana.

The threat of a worsening climate, too, has emotional effects, the lawsuit maintains. Gibson-Snyder, for instance, said she worries about the welfare of any future children of her own.

“At best, they will grow up in an environment different than mine and with the same guilt and fear that I have about this issue,” she said. “At worst, they will suffer directly from the fires and the floods and the famines. I think a lot of my peers are going through very similar things.”

Aiding the children’s case in Montana is the specific constitutional right to “a clean and healthful environment,” considered among the nation’s strongest environmental protections.

“Our constitution does not require that dead fish float on the surface of our state’s rivers and streams before its farsighted environmental protections can be invoked,” the Montana Supreme Court concluded in a 1999 case that fortified a clean and healthful environment as a “fundamental right.”

On June 10, Montana Attorney General Austin Knudsen filed an emergency motion asking the state Supreme Court to overrule the lower court and dismiss the children’s case, which he described as “a climate crusade” and “a scheme” seeking the “radical overhaul of Montana’s environmental policy.”

“This lawsuit features a special interest group seeking to circumvent Montana’s political processes and impose — by judicial fiat — its preferred climate change policies on the people of the state,” the motion said.

Four days later, the Montana Supreme Court denied the request. At the request of the attorney general who wanted more time to prepare, the state judge did postpone the trial originally set for next February. A new date hasn’t been scheduled, although Bellinger expects the case will go to trial in summer 2023.

Gibson-Snyder said she is frustrated by her government’s continued opposition to helping end the climate crisis.

“It’s weird to be relied upon to solve an international emergency while also being dismissed by some of the same people who have that responsibility,” she said. “I keep holding out hope that the state is going to come around and help its citizens.”

Vlases agreed, saying she doesn’t understand the resistance to change when there is consensus that Montana’s landscape is worth protecting. The inaction of today’s leaders, she said, is an existential threat to her and her peers.

“It feels like we are wearing the hand-me-downs of the past generation,” she said.

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In states where courts have ruled that their constitutions’ explicit privacy rights extend to the right of a woman to have an abortion, the procedure would continue to be legal even if the Supreme Court’s 1973 ruling is overturned, legal scholars and abortion-rights advocates said.

In Montana, the issue is playing out in the courts, where a state judge temporarily blocked three new anti-abortion laws. The state’s Republican attorney general appealed to the state Supreme Court, asking the justices to overturn a 23-year-old ruling that extended the state’s constitutional right to privacy to the right to have an abortion.

If that effort fails and if Roe v. Wade is overturned, conservative Montana could find itself a sanctuary for women seeking abortions from neighboring Wyoming, Idaho, North Dakota, and South Dakota, states where access is more tenuous, said an analyst for a research organization that supports abortion rights. 

“If half the states ban abortion, you are talking about people, if they can, traveling vast distances to get that right to care,” said Elizabeth Nash, a policy analyst at the Guttmacher Institute. “And if access remains protected in Montana, then Montana will be a place where people seek that care.”

In the coming months, the U.S. Supreme Court is expected to rule in a case challenging a Mississippi law that bans most abortions after 15 weeks of pregnancy. The court recently let stand a Texas law that bans most abortions after six weeks and turns enforcement over to citizens who can file lawsuits against people who aid in the abortion.

The ruling in the Mississippi case, legal experts speculate, could upend the Roe decision that guaranteed abortion rights around the country and allow individual states to set their own laws. In that scenario, the Guttmacher Institute predicts, abortion is certain or likely to be banned in 26 states.

Meanwhile, lawmakers and citizens in other states — including New Jersey, New York, and Colorado — are working to protect or expand abortion rights.

The original Roe v. Wade ruling was largely based on protecting the right to privacy under the due process clause of the 14th Amendment. But the words “right to privacy” aren’t actually written in the U.S. Constitution, a point frequently raised by abortion opponents.

Those words are, however, written into , adding an unexpected twist to sorting out a post-Roe legal landscape.

It’s not an issue for left-leaning states like California, which passed a 2002 law protecting abortion rights that cited its constitutional right to privacy for personal reproductive decisions. In that state, leaders are preparing for a potential rush of women from other states in search of medical care if the Supreme Court weakens or throws out its Roe »å±ð³¦¾±²õ¾±´Ç²Ô.Ìý

But in conservative Alaska, say the constitutional right to privacy will protect a woman’s option there regardless of what the U.S. Supreme Court does. Voters will decide in November whether to call a constitutional convention, which abortion opponents see as an opportunity to amend the constitution to ban abortions.

In Florida, the state constitution says that “every natural person has the right to be let alone and free from governmental intrusion into the person’s private life.” In 1989, that the provision protects the right to an abortion.

Louisiana’s state constitution protects its citizens against invasions of privacy, but voters in 2020, inserting that “nothing in this constitution shall be construed to secure or protect a right to abortion or require the funding of abortion.”

Right-to-privacy provisions are also found in the constitutions of Arizona, Hawaii, Illinois, Montana, New Hampshire, South Carolina, and Washington.

Montana’s constitution says, “The right of individual privacy is essential to the well-being of a free society and shall not be infringed without the showing of a compelling state interest.” 

In 1999, the that includes the right of citizens to make their own medical decisions. “We held that this right protected a woman’s right to procreative autonomy and her ability to seek and obtain a lawful medical procedure, which abortions were and are, free from interference from the government,” retired Montana Supreme Court Justice James Nelson, who wrote the court’s unanimous opinion, said in a recent interview.

Caitlin Borgmann, the executive director of the Montana ACLU, succinctly described the importance of the ruling. “It is essentially Montana’s Roe v. Wade,” she said.

The Republican-controlled Montana Legislature, buoyed by the state’s first Republican governor in 16 years, passed a slate of anti-abortion bills last year. They included a ban on most abortions after 20 weeks of pregnancy, the requirement that providers give a woman the opportunity to view an ultrasound before an abortion, and constraints on the use of abortion pills, ​​including that an authorized abortion provider first examine and then give the woman the drug in person, an added obstacle in a rural state like Montana.

Planned Parenthood of Montana filed a lawsuit that said those bills violate the state’s constitutional right to privacy, along with rights to equal protection, safety, health and happiness, individual dignity, free speech, and due process. Billings Judge Michael Moses in October granted a preliminary injunction to block the laws from taking effect.

That ruling prompted one Republican lawmaker, Rep. Derek Skees, to call for throwing out “Montana’s socialist rag of a constitution,” . “There’s no basis in our constitution to use the right to privacy to murder a baby,” he told the newspaper.

Attorney General Austin Knudsen to overturn Moses’ injunction and nullify the 1999 ruling that linked privacy rights to medical decisions. Knudsen said the court’s seven members have a chance to correct what he called “unrestrained judicial activism,” according to legal filings.

David Dewhirst, Montana’s solicitor general under Knudsen, called the 1999 decision “sloppy” and “a mess.”

“This is not some sort of political stunt,” Dewhirst said. “The case is wrongly decided.”

Martha Fuller, president and CEO of Planned Parenthood of Montana, said she believes Knudsen’s attempt to overturn the state court’s 1999 privacy ruling echoes the larger national debate over court precedents in abortion law. “The law is the law and not based on, ‘This judge said this, and this other judge said that,’” Fuller said. “That’s not where the integrity of our legal system comes from.” 

If the state’s high court rules against Knudsen, abortion advocates anticipate that lawmakers will ask voters to alter the state’s constitution, either through an amendment or by initiating a constitutional convention, which would be Montana’s first in more than five decades.

Changing the state’s constitution, however, is purposefully difficult, said Anthony Johnstone, who teaches constitutional law at the University of Montana. Just to ask voters to consider an amendment or a convention requires 100 votes in the state’s 150-seat legislature.

“Montanans always have the last word in amending our constitution,” Johnstone said.

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Venus has been in Billings since mid-November, working in a surgical recovery unit at Billings Clinic, Montana’s largest hospital in its most populous city. She and her husband moved into an apartment, bought a car and are settling in. They recently celebrated their first wedding anniversary. Maybe, she mused, this could be a “forever home.”

“I am hoping to stay here,” Venus said. “So far, so good. It’s not easy, though. For me, it’s like living on another planet.”

Administrators at Billings Clinic hope she stays, too. The hospital has contracts with two dozen nurses from the Philippines, Thailand, Kenya, Ghana and Nigeria, all set to arrive in Montana by summer. More nurses from far-off places are likely.

Billings Clinic is just one of the scores of hospitals across the U.S. looking abroad to ease a shortage of nurses worsened by the pandemic. The national demand is so great that it’s created a backlog of health care professionals awaiting clearance to work in the U.S. More than 5,000 international nurses are awaiting final visa approval, the American Association of International Healthcare Recruitment reported in September.

“We are seeing an absolute boom in requests for international nurses,” said Lesley Hamilton-Powers, a board member of AAIHR and a vice president for Avant Healthcare Professionals in Florida.

Avant recruits nurses from other countries and then works to place them in U.S. hospitals, including Billings Clinic. Before the pandemic, Avant would typically have orders from hospitals for 800 nurses. It currently has more than 4,000 such requests, Hamilton-Powers said.

“And that’s just us, a single organization,” added Hamilton-Powers. “Hospitals all over the country are stretched and looking for alternatives to fill nursing vacancies.”

Foreign-born workers make up about a sixth of the U.S. nursing workforce, and the need is increasing, nursing associations and staffing agencies report, as nurses increasingly leave the profession. Nursing schools have seen an increase in enrollment since the pandemic, but that staffing pipeline has done little to offset today’s demand.

In fact, the American Nurses Association in September urged the U.S. Department of Health and Human Services to declare the shortage of nurses a national crisis.

CGFNS International, which certifies the credentials of foreign-born health care workers to work in America, is the only such organization authorized by the federal government. Its president, Dr. Franklin Shaffer, said more hospitals are looking abroad to fill their staffing voids.

“We have a huge demand, a huge shortage,” he said.

Billings Clinic would hire 120 more nurses today if it could, hospital officials said. The staffing shortage was significant before the pandemic. The added demands and stress of covid have made it untenable.

Greg Titensor, a registered nurse and the vice president of operations at Billings Clinic, noted that three of the hospital’s most experienced nurses, all in the intensive care unit with at least 20 years of experience, recently announced their retirements.

“They are getting tired, and they are leaving,” Titensor said.

Last fall’s surge of covid cases resulted in Montana having the highest rate in the nation for a time, and Billings Clinics’ ICU was bursting with patients. Republican Gov. Greg Gianforte sent the National Guard to Billings Clinic and other Montana hospitals; the federal government sent pharmacists and a naval medical team.

While the surge in Montana has subsided, active case numbers in Yellowstone County — home to the hospital — are among the state’s highest. The Billings Clinic ICU still overflows, mostly with covid patients, and signs still warn visitors that “aggressive behavior will not be tolerated,” a reminder of the threat of violence and abuse health care workers endure as the pandemic grinds on.

Like most hospitals, Billings Clinic has sought to abate its staffing shortage with traveling nurses — contract workers who typically go where the pandemic demands. The clinic has paid up to $200 an hour for their services, and, at last fall’s peak, had as many as 200 traveling nurses as part of its workforce.

The scarcity of nurses nationally has driven those steep payments, prompting members of Congress to ask the Biden administration to investigate reported gouging by unscrupulous staffing agencies.

Whatever the cause, satisfying the hospital’s personnel shortage with traveling nurses is not sustainable, said Priscilla Needham, Billings Clinic’s chief financial officer. Medicare, she noted, doesn’t pay the hospital more if it needs to hire more expensive nurses, nor does it pay enough when a covid patient needs to stay in the hospital longer than a typical covid patient.

From July to October, the hospital’s nursing costs increased by $6 million, Needham said. Money from the Federal Emergency Management Agency and the CARES Act has helped, but she anticipated November and December would further drive up costs.

Dozens of agencies place international nurses in U.S. hospitals. The firm that Billings Clinic chose, Avant, first puts the nurses through instruction in Florida in hopes of easing their transition to the U.S., said Brian Hudson, a company senior vice president.

Venus, with nine years of experience as a nurse, said her stateside training included clearing cultural hurdles like how to do her taxes and obtain car insurance.

“Nursing is the same all over the world,” Venus said, “but the culture is very different.”

Shaffer, of CGFNS International, said foreign-born nurses are interested in the U.S. for a variety of reasons, including the opportunity to advance their education and careers, earn more money or perhaps get married. For some, said Avant’s Hudson, the idea of living “the American dream” predominates.

The hitch so far has been getting the nurses into the country fast enough. After jobs are offered and accepted, foreign-born nurses require a final interview to obtain a visa from the State Department, and there is a backlog for those interviews. Powers explained that, because of the pandemic, many of the U.S. embassies where those interviews take place remain closed or are operating for fewer hours than usual.

While the backlog has receded in recent weeks, Powers described the delays as challenging. The nurses waiting in their home countries, she stressed, have passed all their necessary exams to work in the U.S.

“It’s been very frustrating to have nurses poised to arrive, and we just can’t bring them in,” Powers said.

Once they arrive, the international nurses in Billings will remain employees of Avant, although after three years the clinic can offer them permanent positions. Clinic administrators stressed that the nurses are paid the same as its local nurses with equivalent experience. On top of that, the hospital pays a fee to Avant.

More than 90% of Avant’s international nurses choose to stay in their new communities, Hudson said, but Billings Clinic hopes to better that mark. Welcoming them to the city will be critical, said Sara Agostinelli, the clinic’s director of diversity, equity, inclusion and belonging. She has even offered winter driving lessons.

The added diversity will benefit the city, Agostinelli said. Some nurses will bring their spouses; some will bring their children.

“We will help encourage what Billings looks like and who Billings is,” she said.

Pae Junthanam, a nurse from Thailand, said he was initially worried about coming to Billings after learning that Montana’s population is nearly 90% white and less than 1% Asian. The chance to advance his career, however, outweighed the concerns of moving. He also hopes his partner of 10 years will soon be able to join him.

Since his arrival in November, Junthanam said, his neighbors have greeted him warmly, and one shop owner, after learning he was a nurse newly arrived from Thailand, thanked him for his service.

“I am far from home, but I feel like this is like another home for me,” he said.

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Just a few months into her new job as public health director for Madison County, she had hoped that those local connections might make a difference, that the fewer than 10,000 residents spread out across this agricultural region would see her familiar face and support her efforts to curtail the covid-19 pandemic raging here.

That largely hasn’t happened. School boards have rebuffed even minor measures to prevent outbreaks, vaccination rates languish and the Centers for Disease Control and Prevention categorizes infection levels in the rural county as high. Parents, Sayler said, are sending sick kids to school.

On top of that, a resident phoned her office and told a member of her staff, “I wish that you would get covid and die.”

“People have used the term ‘free-for-all,’ and I really hate to admit that that’s what it kind of feels like,” Sayler said.

Nationally, KHN and The Associated Press have documented that more than 300 public health leaders, weary of abuse and of their expertise being questioned, have resigned or retired as the country struggles to recover from the worst pandemic in a century. They have been replaced by people like Sayler, often inexperienced yet tasked with repairing the trust of a polarized and fatigued public.

At least 26 states have passed laws or regulations limiting the powers of public health officers this year, meaning these replacements have fewer tools and less authority than their predecessors to enforce their orders and recommendations.

Montana passed laws considered some of the most restrictive. This year, the state legislature curbed the powers of health officers to, among other things, quarantine infected citizens or isolate those in close contact with them. Lawmakers also prevented public and private employers from requiring workers to be vaccinated and gave local elected officials the ability to overturn public health orders.

Now Montana is at or near the bottom of many national statistics charting the covid surge — — that is happening in counties big and small.

Lori Christenson is the new health officer for Gallatin County, Madison County’s neighbor to the east and home of the city of Bozeman and Montana State University. In June, she replaced Matt Kelley, who before resigning had become a political punching bag as the county mandated masks in public places and restricted business hours and the size of crowds. Protesters on social media demanded his ouster; a few picketed outside his home. Christenson had served in the health department for seven years before her promotion and worked closely with Kelley.

While her office still hears daily from frustrated citizens “on both sides,” she said the vitriol is not quite as malicious as in the past. That’s in large part, she believes, because the new laws that gutted her department’s power shifted criticism to other entities like local school boards that still have the authority to mandate measures such as wearing masks.

“Sometimes it can be pretty frustrating not having the ability to make some immediate changes that previously helped to slow transmission,” Christenson said. “We just don’t have the tools at our disposal in the same way that we did before.”

That reality, she said, has been “morally challenging.”

“I have a duty to protect the community. You want to do what is right, but you also want to do what is lawful. In this situation, it didn’t mesh.”

Joe Russell does not envy health officers new to their positions. He retired as head of the Flathead City-County Health Department in 2017 but returned in December after the interim director resigned over what she called a “toxic environment” inflamed by the “ideological biases” of local politicians.

“Think about going into a brand-new profession, in a leadership role that you’ve never held, in a crisis like covid-19,” Russell said. “It would be miserable.”

He said his experience — 30 years in the Flathead health department, including 20 as its leader — has eased navigating through the pandemic in one of the state’s most populous and conservative counties, although the rate of cases there remains high and its vaccination rate low.

His tenure, he said, has given him the credibility to confront officials who question the seriousness of covid or the safety and effectiveness of vaccines.

“When someone spouts this nonsense, who better to stand up and give them the science-based evidence and tell them that they are full of crap?” Russell said. “I love it when that happens at a public meeting.”

Although Montana laws essentially prevent public health officials from following many CDC guidelines, Christenson said they still have useful tools available to combat the virus: testing, contact tracing, vaccination, communicating with the public.

“That is what I focus on,” she said. “That is what we can do.”

Christenson believes she has the community’s support. She noted that while a few people protested outside of Kelley’s home, crowds countered that criticism by lining Bozeman’s Main Street, offering cheers of support on his drive home.

“Not to say that every day is rosy,” she said. “That would be naive. But you can feel the staff here continue to try to move forward, and that to me is a success.”

In Madison County, Sayler said she is taking an “olive branch” approach to turning things around, advancing recommendations rather than orders, as her staff works to nudge vaccination rates up from the current 48%. She’s doubtful that will quickly reduce covid.

In September, the county saw approximately 200 new cases — roughly 20% of all its infections since the pandemic began — and had more residents hospitalized with the virus than ever before.

While the pandemic has filled Sayler’s first months on the job, she said she looks forward to focusing on other ways the health department can restore the public’s faith and help Madison County, such as offering car seats for babies or nutrition advice for expectant mothers.

“There is a lot of rebuilding to do here, because this whole office has been consumed by covid for so long,” she said. “I can still see long-term goals for us and what we can do for this community. That’s not just a goal. That’s a need.”

Her office has on occasion persuaded those sick with covid, even those who insisted the virus is not serious, to seek medical help. “Tell your story,” Sayler said she advises those covid survivors. “Make sure everybody knows how sick you were.”

But then there are more difficult encounters, such as when a mother cursed her out over the phone about the recommendation that her child be quarantined. A week later, she saw the woman at her daughter’s volleyball game.

“She was sitting there and looked directly at me and then looked away,” Sayler said. “That made me feel better. You truly don’t feel that way. You were just expressing frustration in that moment.”

That experience left her with cautious optimism about the difficult task she has ahead with the pandemic set to enter its second winter.

“It is reassuring that there is potential here. We can still work with these people,” she said. “We just really don’t want to be a punching bag, either.”

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Lying on his stomach all those hours has produced sores on his face, and one nurse dabs at the wounds. The dark lesions are insignificant given his current state, but she continues just the same, gently, soothingly, appearing to whisper to him as she works.

The man has been a patient at Billings Clinic for nearly a month, most of that time in the hospital’s intensive care unit. He is among other patients, room after room of them, with the same grim tubes inserted down their throats. They have covid-19 — the vast majority unvaccinated against the virus, the hospital says. Visitors generally aren’t permitted in these rooms, but the man’s mother comes most days to gaze through a glass window for the allowed 15 minutes.

This all happened Friday. He was dead, at age 24, by Sunday morning.

The hospital’s morgue cart arrived at the ICU — as it frequently has these days — then the room was sterilized, another patient took the man’s place, and the cycle began again. In the past week, 14 people have died of covid here, the state’s largest hospital.

“I do feel a little hopeless,” said Christy Baxter, the hospital’s director of critical care.

The situation has played out in hospitals around the nation since 2020. But now Montana is a national hot spot for covid infections, recording the highest percentage increase in new cases over the past seven days. The state announced 1,209 new cases on Friday, and Yellowstone County, home to Billings Clinic, is seeing the worst of it. Last week, the county had 2,329 active cases, more than the next two counties combined.

What’s different from the early scenes of the pandemic is the public’s response. Not so long ago, the cheers of community support could be heard from the hospital parking lot. Now, tensions are so strained that Billings Clinic is printing signs for its hallways, asking that the staff members not be mistreated.

The ICU here has space for 28 patients but last Friday was operating at 160% capacity, Baxter said. To handle the overflow, nurses elsewhere provide care beyond their training as covid patients fill other parts of the hospital. In the lobby of the emergency department, rooms roughly 6 feet by 6 feet have been fashioned with makeshift plastic walls. Ten members of the Montana Army National Guard arrived last week to help however they can. Hospital staffers volunteer to sit with dying patients. Beds line hallways.

“The problem is,” said Brad Von Bergen, the hospital’s ER manager, “we are running out of hallways.”

The hospital announced it may soon implement “crisis standards of care,” which basically means it will ration its equipment, staff and medicine, giving preference to those it can most likely save, regardless of vaccination status. It’s an ugly system, abhorred by those who will wield it, with tiebreakers in place to decide who potentially lives and dies. Other hospitals in Montana have taken similar steps.

An overcrowded hospital also means that a person ― say, one injured in a car crash in rural eastern Montana and needing advanced hospitalization ― won’t be able to get that care at Billings Clinic.

“We are at the point where we are not confident going forward that we can continue to meet all patients’ needs,” said Dr. , the medical ethicist for Billings Clinic and its department chair for emergency medicine. “And that’s heartbreaking.”

“Nobody wants to be in a position where we may have to ration health care and potentially remove a ventilator from one patient who would likely die and give it to another,” said Dr. Scott Ellner, the hospital’s CEO. “Are we there? I would say we are very close.”

To some extent, that rationing is already happening. A patient still hospitalized here with covid might have benefited from a machine, known as an ECMO machine, needed to keep his heart and lungs functioning. Operating that machine, though, requires at least one nurse, 24 hours a day, usually for two to three weeks. Typically, it would be a last-ditch effort for the most critical of patients. Even with that care, the prognosis for the middle-aged man would be poor. Without it, Baxter said, he will assuredly die.

“The reality is I can’t staff that,” Baxter said. “Do you give that optimal care to one patient or do you give great care to five?”

Billings Clinic would hire more than 100 additional nurses if it could. The staffing shortage is not unique to this hospital; it’s nationwide, meaning the needed help isn’t arriving anytime soon. Baxter tells the story of a young nurse who quit, saying he had grown tired of lying to patients he knew would die.

“The patients look at you with that fear in their eyes and say, ‘Am I going to make it?’” Baxter said. “You want to encourage them to not give up hope, but you also know the chances of survival are going to be slim.”

Recently, a patient’s dying wish was to have their preschool-age child come and sit with them, to see them one last time. That typically wouldn’t be allowed, but an exception was made, with staffers at the hospital draping the child in oversized protective clothing, goggles and an N95 mask. Afterward, the nurse and doctor sobbed with the patient.

“The moral distress of working in health care is for many, many people extremely high right now,” said Allen.

Intensifying that, he said, are patients or their loved ones mistreating doctors and nurses. Threats have on occasion required a police response. Screaming, profanity-laden insults are a daily occurrence. One patient threw his own feces at a doctor. Some, even in the face of an intubation tube, question the need to be vaccinated or the effectiveness of the medicine being prescribed.

Dr. Sara Nyquist, an emergency medicine physician, said she has been asked by a patient if she is a Republican or a Democrat.

“I said, ‘I am your doctor,’” she recalled. “You do wonder how we got here.”

Ellner, the clinic’s CEO, said he doesn’t understand what happened to civility. “There is a part of the society that wants to pretend that the covid surge isn’t really happening,” he said. “But this is our reality every single day.”

Jennifer Tafelmeyer, a nurse in the hospital’s cardiovascular unit, said the best part of her job before the pandemic was helping patients improve, walking them down hallways, talking about diet and exercise, and eventually escorting them to the front door. That hasn’t happened in a long time.

“We just don’t get the wins,” she said.

As she told the story, she stopped to wipe a tear. Moments before, she had learned that one of the patients on this floor was not expected to survive the night.

Allen predicted Billings Clinic hasn’t yet seen the worst of the recent surge in infections.

“We are still seeing growing numbers in community cases,” he said. “And we know hospitalizations lag behind new diagnoses. Unfortunately, it can absolutely get worse than where it is at.”

In the meantime, he said, he expects the doctors and nurses here will rally as they have, taking comfort from words of thanks from many patients and gestures like a father bringing pizza to the emergency department as a show of appreciation for the care given his child.

“The most difficult things have been the big things,” Allen said, “and the most inspiring things have been the little things.”

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