Practicing hospital medicine in a rural setting presents many challenges on the best of days. Limitations in resources and generalist and specialist care coverage and logistics of patient transfers across large distances are daily hurdles faced, and overcome, in caring for patients in sparsely populated areas. Social inequalities are often amplified in rural settings as well, adding strain to budgets and clinicians' resilience during day-to-day care delivery.
The global pandemic of COVID-19 caused severe disruption to delivery of care in rural communities across the United States. Many rural hospitals were forced to close their doors due to loss of revenue streams from visits and procedures put on hold. Rural patients, often already burdened with significant comorbidities, are at high risk for significant morbidity and mortality from COVID-19. Despite this, many rural communities continue to distrust sound recommendations for mitigating viral spread.
It is in this climate that the critical access hospital where I practice shaped a response to the pandemic. Early on, an incident command committee was formed. Ventilators were counted, critical care algorithms were updated, testing was sought, and conversations were had about how to secure adequate PPE. We watched in subdued horror as the virus spread in Sioux Falls, South Dakota, and Waterloo, Iowa, outbreaks strongly associated with meatpacking plants. Our “turn” was only a matter of time, given the industry's status as the largest local employer.
As we feared, Buena Vista County, Iowa, made headlines in late May and early June with the dubious honor of having the highest new COVID-19 case rate in the nation. Thankfully, a combination of early planning and coordination across all hospital departments and outpatient clinics led to a robust response. We had the PPE we needed thanks in large part to a community-driven effort sewing gowns. Nursing and other clinical staff floated from idled areas such as outpatient surgery and cardiopulmonary rehab to help with emergency department triage and treatment and hospital floor coverage. Our health system provided additional ventilators and specialist support. Emerging treatments, including remdesivir and convalescent plasma, were sought and obtained. Collaboration with regional referral centers was heightened to coordinate local care and transfers when needed at an unprecedented volume.
The sheer number of patients presenting for care due to COVID-19 put an enormous strain on our small hospital, as it has across the nation and the world. Our local surge was difficult from professional, personal, and social perspectives for patients, clinicians, and the whole community. However, the great need provided a singular mission that led to a positive impact through collaboration and innovation. May this be the case for us all moving forward.