'Our neighbors, our family members': Small-town hospitals overwhelmed by COVID-19 deaths

In North Texas, Moore County Hospital District CEO Jeff Turner is managing more than his small rural hospital can handle.

The Dumas hospital has space and staff for 11 coronavirus patients, but only three who are really sick and need intensive care. When they need lifesaving therapies Turner's hospital can't provide, his staff tries to find open beds at larger hospitals in Amarillo, about 50 miles to the south.

When those hospitals are full, his staff scours for space, first in Midland, Wichita Falls and Lubbock, then in Dallas, Denver, Albuquerque, Oklahoma City – even Kansas City, Missouri, more than 500 miles away.

Some patients have died waiting for space at big-city hospitals. Six patients died in six days recently; two died within 24 hours last week.

“In a small town, these are our neighbors, our family members," Turner said. "That makes it tough.”

Last spring, the coronavirus attacked major metro areas like New York City and Houston. This summer, it spread to suburban communities and ravaged the Sunbelt.

The current wave, which has surpassed 2,000 deaths a day, frightens public health officials because it's tearing into the frayed health care safety net of rural America.

Small hospitals, understaffed and financially vulnerable before the pandemic, are under siege as the virus runs unchecked from North Dakota to the Texas Panhandle. Many of these hospitals are in towns where people are more likely to eschew precautions such as masks and social distancing at churches, grocery stores and other public places. 

Many of the nation’s nearly 1,800 rural hospitals lack the equipment, workforce and expertise to handle a surge of COVID-19 patients. Nurses and doctors are getting sick, leaving already short-staffed hospitals more desperate for workers.

“These rural hospitals are designed for primary care, general surgery,” said Alan Morgan, CEO of the National Rural Health Association. “They were never designed for a global pandemic response.”

'Begging them to take a patient'

At West River Health Services in Hettinger, North Dakota, CEO Matthew Shahan knows the state’s dire situation. North Dakota’s 108 deaths in the first week of November is a record. The percentage of positive COVID-19 tests in the state during the week ending Nov. 14 was, too, according to Johns Hopkins University. 

That's true from North Dakota to Oklahoma, a region with the highest per-capita infection rates in the nation. Cases, hospitalizations and deaths are on the rise.

Most people who test positive at clinics can go home, quarantine and monitor their symptoms. But those whose symptoms worsen “get incredibly sick” and need to be hospitalized, Shahan said.

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Some of them are admitted to West River’s COVID wing, which has space for four patients. Others must be sent to larger hospitals in Bismarck or Fargo, or neighboring South Dakota, Minnesota or Montana.

Before COVID-19, “I don’t think I ever made a call to another hospital, administrator to administrator, begging them to take a patient,” Shahan said. Lately his staff has had to call seven or eight hospitals to find a bed for critically ill patients.

It's not that the hospitals don't want to help. Larger metro hospitals often lack ICU beds and health care workers to take on more COVID-19 patients.

Another task Shahan couldn't have imagined just a few months ago: West River has rewritten end-of-life visitation rules so family and friends can visit dying loved ones. Visitors must sign a liability waiver and wear personal protective equipment. Those visitors risk contracting COVID-19, but nurses argued that patients deserve to be with their families in their last days. 

"We want to provide that last little comfort of a family member when somebody is at end of life," Shahan said. 

Beyond caring for patients, Shahan worries about how to keep nurses and doctors safe. An emergency order signed by North Dakota's health officer last week allows health workers who test positive for the coronavirus but show no symptoms to keep working in COVID-19 units.

Shahan said his health system rejected the idea. He doesn't want to risk spreading the virus to healthy nurses or other clinicians, which could shut down the hospital’s emergency room.

Hospital administrators are already planning for the winter, when heavy snowfall closes roads and prevents air travel. Extreme weather could halt patient transfers and make it difficult to bring in traveling nurses or state-provided health workers. If that happens, the health system will shut down clinics and “assemble all hands on deck” at the hospital, Shahan said.

“We need to be careful because we don’t have a big stable of workers available on standby,” he said.

Expertise, equipment lacking

Most of the nation’s rural hospitals are called critical-access hospitals, and they're licensed for up to 25 beds. Each has an average of one or two ventilators, and most don’t have ICU beds, said Morgan, of the National Rural Health Association.

It's especially difficult to manage an emerging threat like COVID-19 as doctors around the world learn how to treat it and protocols shift. Large hospitals have teams of specialists such as infectious disease doctors, respiratory specialists and critical care doctors. Rural hospitals usually don't.

And they may not have access to cutting-edge therapies and treatments that have helped COVID-19 patients recover at academic medical centers and suburban community hospitals.

“These are often family doctors taking care of these patients,” said Dr. William Schaffner, a Vanderbilt University School of Medicine professor of preventive medicine and an infectious disease specialist. They frequently “can’t transfer their patients to the major medical center because the major medical center is all jammed up.”

Rural hospitals long have sought to address shortages of doctors, nurses and other health care workers. These hospitals struggle financially – 17 rural hospitals have closed in 2020 and 136 over the past decade, according to the National Rural Health Association.

During the pandemic, hospitals' finances took a hit after they cut off non-emergency operations to make room for COVID-19 patients.

Communities resist wearing masks

It's also challenging because these hospitals are in communities that have been more likely to eschew masks and social distancing.  

In Tennessee, a state health officer visited rural communities to discuss how the coronavirus vaccine will be distributed when it’s expected to be available next year. Most residents didn’t wear masks at the indoor meetings, Schaffner said.

“The more rural you get, the more disdainful people are, the more doubting and skeptical they are about the whole COVID story,” Schaffner said.

Mask wearing has been inconsistent nationwide. President Donald Trump rarely wears a mask in public and has ridiculed his rival, Joe Biden, for being so diligent.  

The surge in cases after the election might be an opportunity for Democrats and Republicans alike to stress the importance of wearing masks, Schaffner said.

"We have to give everyone an off-ramp," he said. "It’s not that they were wrong in the past. It’s that circumstances have changed. They’re now much more dire."

For the first time last week, the federal Centers for Disease Control and Prevention said masks protect the person wearing it; prior guidance said they protected others from the masked person. 

Experts warn the nation is embarking on the most difficult phase of the pandemic. Holiday celebrations over the summer spurred large gatherings across the country that were blamed for the summer spike. Gatherings at Thanksgiving could fuel even more spread, especially as it gets colder and people spend more time indoors.

“The situation in the next two to four weeks is going to be grim,” said Andrew Pavia, chief of pediatric infectious diseases at the University of Utah School of Medicine. “If Thanksgiving does to us the same things that Memorial Day and Labor Day (did), and people gather as we all want to do without taking precautions, we can see another acceleration going into Christmas.”

Momentum is growing in several parts of the country for tighter restrictions on gatherings and masks. Republican governors in Iowa, Ohio and Utah have issued new mask mandates. 

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The city of Fargo, North Dakota, has ordered that masks be worn in public. But the city council in Sioux Falls, South Dakota, rejected a mask ordinance last week.

Shahan said people wore masks in North Dakota in the early days of the pandemic when lockdowns were in place. As restrictions loosened, the state didn't see an immediate jump in cases, and residents "just got fatigued."

He said he has seen more people wearing masks in recent weeks, particularly friends and family of those who've gotten sick.

"It’s going to take a lot of communication from everyone at all levels of the state to get this done," he said.

In Dumas, Texas, few people wore masks during the summer, Turner said. Kids are attending schools and few have gotten sick. But that might be because "we're not testing the kids."

Cases in surrounding Moore County continue to climb, with about 7% of residents testing positive, according to figures from the Texas Department of State Health Services. 

The World Health Organization recommends testing enough people that the positive rate is 5% or lower. If it's higher, it could mean a region is missing cases. 

Turner has noticed more masks around town, too. The mother of one of his employees became ill. So did a neighbor's family member and local police officers. 

"It’s people you know," Turner said. "It gets up close and personal in a small town."

Ken Alltucker is on Twitter as @kalltucker or can be emailed at alltuck@usatoday.com