A resource-starved rural hospital steels itself for coronavirus's arrival

"How are we on masks and protective gear?" asked Shane McGuire, the hospital's CEO. 

"Getting low," the supply manager said. "I can't buy anything. Everything's out of stock." 

"How about our staffing?" McGuire asked. "We need to make contingency plans in case some of us get exposed and need backup."

Nobody answered, and McGuire looked around the room at his pharmacy department of one, at his 70-year-old doctor, who was working alone in the emergency room, and at his lab director, who was now also in charge of infection control. Most people on his staff were already working multiple jobs to keep the hospital functioning. "I know we're stretched thin as it is," McGuire said. "We'll improvise and make it work however we can."

They had been doing exactly that for the past several years, somehow keeping the doors open even as America's rural health-care system collapsed all around them, with 125 other rural hospitals around the country closing for budget reasons and doctor shortages spreading across 85 percent of rural counties. Dayton General could no longer afford to offer obstetrics, endoscopy or surgery of any kind. Its emergency room and nursing home were both losing more than $1 million per year. But the hospital remained the final lifeline for an aging community of about 5,000 people in a rugged corner of southeast Washington state, isolated from all other medical care by 35 miles of barley and wheat. 

The employees in the meeting room took turns reviewing what they knew about the novel coronavirus. The Centers for Disease Control and Prevention said it was deadliest for the elderly, and Dayton residents were an average of 13 years older than people in the rest of the state. The virus was worse for people with underlying health issues, and, like most rural communities, Dayton had high rates of COPD, obesity, diabetes and heart disease. Experts estimated that as many as 1 million of the most vulnerable Americans might need to rely on lifesaving ventilators, and Dayton General had none.

"This is a virus that can take over and expose your weaknesses," McGuire said, and he feared that was true for both rural residents and the beleaguered hospitals left to care for them. 

The virus had just arrived in rural America, but already, small hospitals across the country had begun bumping up against the limitations of their resources. A facility in the Berkshires had lost much of its nursing staff to a 14-day quarantine. A critical access hospital in North Texas had only one face shield in storage and couldn't acquire any others. A hospital in Wisconsin was borrowing sterilized medical gowns from local dentists. And throughout the hard-hit areas of Washington state, rural hospitals with only a handful of beds had begun making plans to set up tents or rent vacant buildings in case extra space was needed.

Dayton had already closed its nursing home to visitors as a safety precaution and lined the hospital walls with its limited supply of hand-sanitizer stations. It had put signs outside the ER instructing people with flu-like symptoms to call rather than enter the building, which was what one local woman had done a few days earlier after returning from a trip abroad with a fever and a cough. Two nurses in protective gear had walked outside to the resident's car to take a sample for coronavirus testing and had sent the test kit off to a lab in North Carolina. Three days later, they were still waiting for the results.

"We should know something soon, right?" a nurse asked. 

"Yes," McGuire said. "But as far as our mentality goes, it's not a matter of if this virus comes. It's when."

"But it might not be here yet?" 

"Maybe not yet," he said.

 

- - -

If there was any source of comfort for the hospital, it could be found in the supply room. The staff had more than 40 cartons of medical gloves in storage. It had at least 50 gallons of hand sanitizer, 4,000 medical gowns, and four boxes of precious N95 respirator masks that an employee had found hidden away on the shelves of Tractor Supply and City Lumber. Under normal circumstances, Dayton General had enough supplies and enough cash on hand to operate for about two weeks, but nothing promised to be normal about the next two weeks, or the weeks after that, so supply manager Chris Davis left the meeting and went to his desk in the storage bunker to see if he could somehow bolster their reserves. 

He sat at a computer surrounded by shelves that were already starting to empty. He went online and checked the 11 orders he had resubmitted to the hospital's vendors earlier that morning. 

Antibacterial wipes, 1 carton: "Rejected."

Yellow procedure masks, 12 boxes: "Rejected."

Face shields, two cases: "Rejected."

Children's masks, 1 case: "Rejected."

 

Davis had first noticed a change in the hospital's supply chain in early January, when most retail stores sold out of respirator masks and they became increasingly difficult to find online. The hospital's vendors had begun to ration equipment according to each hospital's ordering history, which meant rural hospitals were permitted to purchase only their typically small allotment of weekly supplies, even as they prepared for the threat of a pandemic. Eventually, Dayton General's weekly purchasing allowance had been dropped to half its normal supply order, and then to a third, and lately, Davis hadn't been able to get anything at all. Vendors were running so low on protective equipment that they had begun to prioritize their biggest accounts, which meant Davis had begun looking for masks and hand sanitizer on Amazon, where he found two 12-ounce bottles selling for $80. 

He had been forced to begin his own sort of rationing, tucking away boxes of gloves and surgical masks in the hidden corners of the bunker, doling out supplies little by little to each hospital department according to need. The process of caring for just one coronavirus patient, during just one interaction, meant that each nurse and doctor would need to wear a sanitized gown, two pairs of gloves, a face shield, goggles, and a respirator mask - all of which would need to be thrown out after a single use. 

"We could burn through some of these supplies in days," Davis said, so management at Dayton General had called the governor's office to request 3,500 masks that had yet to emerge from a state stockpile, and Davis had continued placing and checking his daily orders even as the quest began to seem increasingly futile. 

Surgical masks: "Rejected."

Sanitary hats: Backordered and scheduled to arrive April 8. 

Hand sanitizer: Backordered and scheduled to arrive April 11.

"That's almost a month," Davis said, and he got up from his desk to sort through boxes of supplies, trying not to think about what might happen before the next delivery came.

 

- - -

One doctor at the hospital had spent his professional life anticipating and confronting worst-case scenarios, and now Lewis Neace finished treating a patient for stomach pain and toured his empty ER with another doctor as they tried to envision what it might look like during an outbreak. Neace had only three examination bays where he could treat patients. He had only two rooms with negative airflow that could be used in the case of an infectious disease. He had an average of only one nurse and one nursing assistant to accompany him during each shift, and his ER had no intensive-care capabilities. 

"What if people start to crash?" his colleague asked.

"We'll transfer them," Neace said. "Spokane. Walla Walla."

"And if those trauma centers are full?"

Neace thought for a moment. He knew it was a possibility, and he'd imagined creating more ER space in the event of a surge by adding tents or cots in the hallways for patients. But who would care for those patients? And how much intensive care could the hospital provide without ventilators? 

"The path of this disease is something we can't fully travel," Neace said. 

He'd spent more than 45 years practicing the most intense versions of emergency medicine as a doctor in a busy urban ER and also as an Air Force flight surgeon on missions in Afghanistan and Iraq. He'd served as a helicopter medic during Hurricane Andrew and performed rescue missions around the world by parachuting and by scuba diving. And then, in 2015, he'd moved back with his wife to their tiny hometown nine miles down the road from Dayton, planning to retire. But the hospital needed another doctor to staff the ER, so he'd agreed to work one day a week, which had become three days a week, which had turned into a full-time job as ER director. 

"I failed at retirement," Neace liked to say, but the hospital needed him, and he loved the work. Dayton General was considered one of the best-run rural hospitals in the state, with an innovative program for telemedicine and stellar ratings from its patients. Most of them were on Medicaid or Medicare with limited income, but they had voted to increase their own taxes to expand the hospital's nursing home and keep the ER afloat. Occasionally, Neace treated traumatic injuries coming off the adjacent highway, or the nearby ski area, or the Snake River, but his job mostly consisted of caring for patients who were dealing with the gradual impacts of getting older. Many left their trucks running in the parking lot and greeted him by name.

Only during the past few weeks had it occurred to Neace that it could be here in this troubled hospital that he might confront one of the largest global emergencies of his career. 

A nurse knocked on his office door and held out a piece of paper. "The results finally came back," she said, and Neace took the single-spaced lab report from her hand and started to scan it, until after a few seconds he noticed a line that read, "Reference Range: Not Detected." 

"Not detected," he said, sounding relieved, and he kept looking at the lab report until he saw a section labeled "COVID-19," where a single word was printed on its own line. "Detected," it read.

"Oh," Neace said, wincing, setting the paper down on his desk. "Detected."

 

- - -

Within a few minutes, the news began to travel out of the ER and through the building, spreading from one person to the next until it reached the main nursing station, where Angie Moore was holding an evening meeting for her staff. 

"In case you didn't know yet, we got a positive result," she told them. A few of the nurses started to stay something and Moore held up a hand. She had been born at Dayton General, and now both of her daughters were also on the nursing team. Nobody knew the hospital better, which made her a trusted authority among her staff. "Now, there's also good news," she said. "It's one person that tested positive. That one person was traveling overseas. That one person was tested in the car and never came into the hospital. From what I understand, that one person has been quarantined at home ever since she took the test, which is exactly how this is supposed to go."

"But what about before she took the test?" one of the nurses asked.

"How about her family?" asked another. "Have they been quarantined, too?"

"Everything spreads in this town," another nurse said. "If any of them even stopped at the gas station at some point, that could be all it takes." 

"Or went to church, or the grocery store -" 

"OK. Yes. That's the reality," Moore said, hoping to end the conversation, because despite all the variables her nurses couldn't control, there were still some things they could. She led her staff toward the two rooms of the hospital that had negative airflow to prevent the spread of infectious disease. The rooms had been sealed off with two clear plastic sheets, with just enough room between the plastic sheets for a few nurses to change into protective gear. 

Moore explained that the hallway had been divided into three zones: "COLD" for the regular part of the hospital; "WARM" for the area between the plastic sheets where the medical staff would change into protective equipment; and "HOT" for the two negative-airflow rooms where they would treat patients who had the novel coronavirus. She handed each nurse two pairs of gloves, a gown, a sanitary hat, a respirator mask and a face shield. She reminded them to save their equipment, since it didn't need to be thrown out until they treated a patient. 

"It's time to practice a full dress rehearsal," Moore told them. 

One by one, the nurses moved through the stations, traveling from cold to warm to hot, until after a few minutes the medical staff at Dayton General was crowded into the secure area. They stood in full protective gear and rubbed hand sanitizer onto their gloves, waiting for the virus they knew had arrived.