Dr. Desmond Wah is used to being the only physician tending to patients during his shifts at Margaret Mary Community Hospital in Batesville, Ind., population 6,500, where at least half of the 25 beds are usually empty. But he was hardly prepared for the weeklong shift he started on March 20, when the two counties Batesville straddles became one of rural America’s worst coronavirus hot spots.
By the end of the week, most of the hospital’s beds were filled with patients who had either tested positive for or were suspected of having the virus. Six were on ventilators, two of which had been lent hastily by a local emergency medical services unit.
With limited staff, equipment and medicine, Dr. Wah and a handful of nurses and respiratory therapists had to scramble. They had only five intensive care beds, and no experience with caring for multiple patients on ventilators at once. They ran out of propofol, the drug they normally use to anesthetize patients and had to urgently consult with an anesthesia team at a big Cincinnati hospital about alternatives.
“We were trying to manage them on a ventilator with limited support, burning through our sedation protocols, having to use sedatives we never typically use,” Dr. Wah said. “We were just cobbling stuff together.”
Margaret Mary’s experience is a preview of what may be in store for more than 2,000 other small rural hospitals around the country, for which the pandemic poses a frightening set of challenges.
“We were inventing by the seat of our pants,” Dr. Wah said. “At the big hospitals in Indianapolis, a patient gets admitted and you consult all the specialists you need. If they need the I.C.U., you hand them off to an intensivist. Rural medicine is a different kind of beast.”
With older, poorer and less healthy populations than many of their urban and suburban counterparts, and far fewer specialists and financial resources, rural hospitals are potentially facing not only many more critically ill patients than they can handle, but also financial ruin because of the indefinite halt in outpatient revenue, which they rely on overwhelmingly. The $2 trillion coronavirus stimulus package that Congress approved last month includes $100 billion in emergency funds for hospitals, but those in rural areas say the formula for distributing the money favors their big urban counterparts.
“They were in a world of hurt even before this occurred,” said Jimmy Lewis, the chief executive of HomeTown Health, a group that advocates for rural hospitals in Georgia, which is home to five of the 10 rural counties with the highest infection rates in the United States, according to a New York Times analysis.
Rural hospitals lack the sophisticated equipment and even ambulance networks that those in cities take for granted. Almost two-thirds of rural hospitals have no I.C.U. beds, according to the Chartis Center for Rural Health, with Iowa, Kansas, Nebraska, Texas and North Dakota particularly short.
Margaret Mary has no “proning beds,” which rotate patients to face down periodically, a position that can help those with respiratory problems breathe better. It has no access to remdesivir, the experimental antiviral drug being given to some coronavirus patients. And if its employees fall ill, as three physicians and more than a dozen nurses and others have in recent weeks, “your bench doesn’t go very deep,” said Tim Putnam, the hospital’s chief executive.
Some rural hospitals are owned by larger systems that provide extra resources to help. That is the case in Cleburne County, Ark., which has reported 70 cases that began in a single church, and in Blaine County, Idaho, where more than 100 attendees at a ski event last month contracted the virus and which now has one of the highest per capita infection rates in the nation, with more than 450 reported cases.
There, St. Luke’s Wood River Medical Center in Ketchum, with 25 beds, temporarily lost most of its seven emergency medicine doctors to infection or exposure in recent weeks, but the St. Luke’s system sent reinforcements from Boise, more than 150 miles away. The entire hospital closed for several weeks except for the emergency department, and it is sending patients seriously ill with coronavirus to hospitals in bigger cities.
For Margaret Mary — named after a mother and daughter who helped pay for the hospital to be built in the 1930s — some of the most urgent questions are when, where and how to transfer patients too sick to handle locally.
The hospital has transferred 20 patients to Cincinnati, a 45-minute drive away, so far, but that was not without layers of complications. Some patients’ families were reluctant for them to leave their hometown hospital for the anonymity of a much bigger one, especially since nobody could accompany them.
“How do you explain it to family who can’t even be at the bedside and see how sick they are,” Dr. Wah said, “or say their goodbyes before their loved one gets shipped off to, literally, another state?”
Tom Wilson, a retired paramedic, got the news that his wife, Willa, 65, would be transferred to Christ Hospital in Cincinnati just as he was falling ill himself last month. Five weeks later she remains there on a ventilator, while Mr. Wilson, who was admitted to Margaret Mary for six days, is home alone.
“We wait on a call once a day from a doctor that tells us how she’s doing, and that’s about all the contact we have,” said Mr. Wilson, 65, who lives in tiny Metamora, Ind., 15 miles from Batesville. “It sucks.”
At Margaret Mary, he knew some of the people who cared for him and felt at home. “When my wife got transferred,” he said, “they came in and consoled me and we cried on each others’ shoulders.”
It is not yet clear why the Indiana counties that Margaret Mary serves, Franklin and Ripley, with a combined population of just over 40,000, were hit so hard by the virus, with a combined 163 cases and 10 deaths to date. An adjacent county, Decatur, has an even higher rate of infection, with 155 cases and 13 deaths.
Unlike rural hot spots in Idaho, Utah and Colorado, which have large ski resorts that draw visitors from all over, the region has little tourism. Batesville is, however, just off busy Interstate 74, between Cincinnati and Indianapolis. And it has two large manufacturers, a casket company that has been there for more than a century and a medical supplier that makes hospital beds, which draw workers and visitors from outside the immediate area, including China, where the virus originated.
“I’ll let the epidemiologists tell me afterward why we’re such a hot spot,” Mr. Putnam said, “but we really saw a lot of sick folks early.”
Among the coronavirus patients filling the emergency department at Margaret Mary the week of March 20 was Dr. Jeffrey Hatcher, an obstetrician who has delivered babies at the hospital since 1997. He started feeling sick in mid-March and fought the virus at home, alone with his dogs, until his oxygen saturation levels dropped low enough to frighten him.
A chest X-ray and blood tests determined he did not need to be admitted, and he is now preparing to return to work.
“The beauty of our town is that you can pick up the phone, talk to our E.R. doc, he says he’s got a spot for you, come on in,” Dr. Hatcher said. “Most people at the hospital are going to know you, whether you’re their neighbor, somebody’s relative, somebody’s friend.”
While hospitalists like Dr. Wah have handled coronavirus patients sick enough to be admitted to Margaret Mary, family doctors like Dr. Michelle Shorten have been trying to keep tabs on their chronically ill patients — those with diabetes, high blood pressure, severe asthma and other such conditions — via phone or video appointments, to ensure they, too, don’t end up needing one of the hospital’s scarce beds.
Dr. Shorten has also been developing a “surge plan” in case the hospital gets an even bigger influx of coronavirus patients. She said the hospital could take as many as 66 inpatients — almost three times its normal capacity — with each room holding two patients and the labor and delivery department moving to a wing of the hospital normally used for same-day surgeries.
Under that scenario, Dr. Wah and other hospitalists would be joined on the inpatient floors by primary care physicians like Dr. Shorten, a prospect she has been preparing for by reading treatment protocols for Covid-19 on her laptop every night while her son watches YouTube on his.
“I can manage high volume/low acuity,” Dr. Shorten said, “but if you start adding that high acuity, that’s where it starts to get complicated really quickly.”
Other doctors who do not typically treat inpatients have volunteered to help, too. “I even have a psychiatrist who informed me last week that he has pretty good experience working in an I.C.U. and if we need him, he will step up,” Mr. Putnam, the hospital’s chief executive officer, said.
Even in good times, financially, rural hospitals like Margaret Mary have a much harder time staying afloat than larger, busier institutions. Forty-four percent of rural hospitals operate in the red, according to the Chartis Center for Rural Health, an advisory and analytics firm based in Maine, which also estimates that about 450 rural hospitals are at risk of having to close, as many already have. For most, the bulk of their revenue comes from run-of-the-mill medical appointments, tests, scans and other procedures done on an outpatient basis. With those canceled indefinitely, the cash that these hospitals have on hand has plummeted.
Margaret Mary, which employs 40 doctors and 815 people over all, is in a better position than many: Indiana is among the 36 states that have expanded Medicaid under the Affordable Care Act, so relatively few of its patients are uninsured. The hospital has invested wisely over the decades and has built up cash reserves. Still, its daily revenues have plummeted to less than 40 percent of what they normally are, Mr. Putnam said.
Maggie Elehwany, vice president of government affairs and policy at the National Rural Hospital Association, said that bigger health systems and academic medical centers would have an easier time getting shares of $100 billion in stimulus funds. Another stimulus program that makes small business loans available to rural health providers excludes publicly owned facilities, which about a third of rural hospitals are.
“We are concerned that the few rural-specific provisions in the stimulus bill will be too little and too late for many rural hospitals,” Ms. Elehwany said. “Some of these hospitals aren’t going to be there by the time the surge hits them.”
Although Batesville got hit early and most rural counties have now confirmed at least one case, many rural hospitals predict they will not see a surge of coronavirus patients until next month or even June. Dr. Wah said they should be preparing scrupulously.
“Everyone wants to keep the business local, but you have to be aware of your limitations,” he said. “If your E.R. cannot handle it, don’t try to be gung ho.”
Margaret Mary’s inpatient population peaked at 30 around March 30 and has dropped back to normal since then. If another surge should come, Dr. Wah dreads two things in particular. One is not having time to get to know each patient, as doctors in a slower rural environment are usually able to do.
“People were deteriorating so quickly that I had to be like, ‘Sorry, I can’t talk to you anymore just in case you crash and burn,’” he recalled.
Even worse is the prospect of having to rush when informing a family member that someone has died from the virus, as two of the hospital’s coronavirus patients have so far.
“I said, ‘I’m so, so sorry for your loss, but I unfortunately cannot stay on the phone,’” he said, softly recounting one such case. “I had another crashing patient.”
Robert Gebeloff contributed reporting.
