COLVILLE – On a Tuesday afternoon, a dozen cars snaked around the perimeter of Mount Carmel Hospital waiting for drive-thru COVID testing, as well as a potential symptom check.
Dr. Ivan Gerlitz, a family medicine resident and physician, is energetic, greeting families in cars and making them feel at ease.
“It’s been very busy the last four weeks – this has been the worst it’s been in Stevens County,” Gerlitz said, as he pulled up patient information on a laptop while wearing full PPE.
Some patients will get a routine test for exposure, others might have the on-duty physician check their vital signs and talk through symptoms. Others could be referred right around the corner to the emergency room.
“I’ve personally seen a lot of death in the last few weeks,” Gerlitz said.
Providence leaders reopened the drive-thru testing and symptom check site when case counts continued to climb in September and since then, it’s been busy.
In rural parts of Eastern Washington, where COVID was rare in early 2020 and impacted some residents last winter, the delta variant surge of the virus has completely changed the game.
Small rural ICUs are full, predominantly with COVID patients. Hospitals are boarding patients on gurneys in the hallways. Dedicated teams and well-practiced nurses are putting their skills, both learned and new, to use as they have to hold patients longer than ever before transferring them to larger hospitals.
The difference in many parts of the state where case rates are finally starting to fall is vaccination. Of the eight counties with vaccination rates of the eligible population below 50%, seven are in Eastern Washington.
Stevens County has the lowest vaccination rate in Washington state, with 37.6% of the eligible population receiving at least one dose of a vaccine.
Despite the statistics, health care teams in small rural hospitals continue to show up to work every day, stretching their limits and caring for COVID patients who are sicker and younger than ever.
Delta surge adds stress
Lynnette Bell has worked at Mount Carmel for nearly 17 years, in the emergency room and then the critical care unit.
Not all hospitals have critical care units, and Mount Carmel has the only one in Stevens County. It has four beds and, in the past two months, Bell said it was often full, predominantly with COVID patients.
Bell is an experienced CCU nurse. She first worked in Portland as a cardiac critical care nurse before coming to work in Colville.
Rural nurses are used to doing a lot with a little, with small but mighty teams, including many experienced nurses. The delta surge threw practiced rural caregivers a curve ball, however. With little room for transferring patients to larger hospitals at the height of the fifth wave, rural staff had to do even more than they normally would.
“I would be lying if I said it wasn’t more stressful, especially when people are really critically ill and, you know, you are the stopgap, and there isn’t anywhere else to go,” Bell said.
About 20 miles south, St. Joseph’s Hospital in Chewelah doesn’t have a critical care unit. Maegan George, an emergency department nurse, and her team are triaging patients, assessing what care they need and whether they need to start making phone calls to transfer them.
The emergency department has five beds – six, if you count the bed in the hallway, which has been used on more than one occasion in the latest surge.
George, who has been a nurse for 24 years, said she has never had to keep patients in the emergency room as they waited to be transferred. But with other hospitals tight on space in the past few months, it was incredibly challenging to get patients, with or without COVID, the more advanced care they needed in larger hospitals.
“We are busier in the last two months than we ever were in the pandemic, so space and staffing are our biggest things right now that we’re battling with pretty much every day,” George said.
The potential mandate impacts
This month, the governor’s vaccine mandate for health care workers could lead to some staff leaving their jobs in hospitals that already are tightly staffed.
Dr. Ed Johnson, chief medical officer of both the Providence hospitals in Stevens County, said the hospitals weren’t fully staffed before the pandemic but were at OK levels. But the pandemic meant exposures to COVID and sick calls could make those OK staffing levels plummet quickly.
Johnson said he doesn’t think the vaccine mandate will lead to a loss of doctors and nurses in the Colville hospital, but other hospital staff, like housekeeping, food services or engineering, might leave. Like many rural hospital leaders, Johnson might have to wait until Oct. 18, when the mandate goes into effect, to see what happens.
“We haven’t lost anybody to the mandate yet, but it hasn’t hit yet, so we’re still waiting on that to see where we’re going to be,” Johnson said.
The Washington State Hospital Association is collecting information from their member hospitals about how the vaccine mandate will impact staffing, and the association plans to share that with the Department of Health and the governor’s office.
WSHA already began surveying rural hospitals and found that some facilities may need to lower their number of maximum patient admissions as a result of lower staffing levels, but not necessarily close down entire service lines.
Rural hospitals are normally nimble with staffing and shifting resources.
At Newport Hospital and Health, COVID inpatients remain high, with about six to seven COVID patients being treated there at one time recently.
Jenny Smith, COVID-19 incident commander at the hospital, said the hospital occasionally has to close the floor to new admissions depending on staffing, but remaining open for care to the community is always the priority.
“When you work in rural hospitals you’re used to shifting resources wherever the need is greatest, so if we have to shut down procedures and shift those nurses, we do that,” Smith said. “If ancillary services are short-staffed, we might have to cancel routine appointments.”
This shuffle has become almost routine for hospitals, where it’s common for nurses and other staff members to take on extra shifts when things get busy.
The vaccine mandate will impact staffing at Newport Hospital to some degree, even with 80% of the staff fully vaccinated. Hospital administrators granted 26 accommodations for religious or medical reasons so far, and seven employees resigned over the mandate.
And while hospitals can reach out to agencies for health care staff, it is extremely expensive, Smith said, especially for a public hospital district.
Education, not shame
It’s unclear what the winter will bring for rural hospitals in counties with low vaccination rates. As other parts of Washington state begin to see declines in COVID hospitalizations, it has gotten slightly easier for rural hospitals to transfer patients.
That said, even in the last days of September, Stevens County hospitals remained quite busy, albeit with a bit more wiggle room.
“We canceled all our procedures a couple weeks ago, and we scaled those back up slowly,” Johnson said.
Case rates in the Northeast Tri-County region haven’t begun to decline, and COVID hospitalizations in some rural hospitals in the region are still quite high.
“We think we have weeks ahead of us before we see some type of substantive decrease within those case rates,” Northeast Tri-County Health District Administrator Matt Schanz told reporters Oct. 1.
The Northeast Tri-County region isn’t the only part of the state where vaccination rates remain low.
In Whitman County, just 45% of eligible residents have received one dose of a COVID-19 vaccine. The WSU-Pullman campus has the majority of students vaccinated, but the rest of the county lags.
In late September, providers from clinics around the county and the hospital asked residents to get vaccinated to help ease the immense stress on the health care system there.
The emergency department at Pullman Regional Hospital is still stressed, and just like in other parts of the state, care is being delayed that is not urgent or an emergency.
Whitman County providers described having one-on-one conversations with patients about the vaccine, and have asked residents to seek advice from physicians.
“Nobody wants to be told what to do – that’s a part of it,” Dr. Peter Mikkelsen, medical director of the emergency department at Pullman Regional, told reporters on Sept. 28.
Providers also said that trusted people, like family members or friends, can be sources of misinformation when it comes to the vaccine.
“Sometimes trusted people in your life aren’t using good resources, so please check with a physician,” said Dr. Sunday Henry at Cougar Health Services.
George, the Chewelah emergency department nurse, views it as a part of her role as a health care provider to offer information and resources to family, friends and acquaintances when they ask her. She’s not interested in debates or confrontation, she said, but she does make sure she has good information for when she’s asked questions.
“I make sure to have that good information to give people if they ask, because they trust what we’re saying, and we want to be able to be the most knowledgeable we can,” George said.
Gerlitz said he wished more people were vaccinated, but he also said a respectful discourse is important.
“I think the way to do it is not to vilify people; I don’t think shaming is going to be effective,” he said.
Bell said she believes everyone has the right to make choices about the vaccine for themselves, but regardless of that choice, she said masking, distancing and other public health measures are vital.
“It’s unfortunate that people on a daily basis are contracting COVID and some of them are going to die, and that’s a reality we deal with,” Bell said. “So I hope that, for health care and for our community, that we don’t have to watch our community suffer when we can do simple things like mask-wearing that can contain it.”
The teamwork and trust among rural health care teams is part of what is keeping them going. If the team is swamped, both Bell and George said they’ve come in on their days off. They also keep their own limits in mind, knowing they don’t want to burn out.
George thinks of her energy reserve as a cup that needs to be refilled when she’s off the clock.
“On my days off, I fill my cup with things that matter to me and things that make me feel like I can do a good job when I come back, because when I leave after my shifts, my cup is empty,” George said. “I’ve been talking to some of our team staff members about that: when you’re off, make sure you’re off and take that time to really fill that cup, because you can’t come in with a quarter cup, because it will be 12 hours of a rough time.”