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Opinion: Coronavirus could swamp small hospitals, endanger rural America

Rob Davidson

For 20 years, I’ve served as an emergency physician at a rural hospital in Michigan. Each year, our emergency department sees 30,000 patients in a county of 48,000 residents. With coronavirus now reported in Michigan, we must brace for one of my nightmare scenarios, which goes something like this:

Near our hospital are three skilled-nursing and two assisted-living facilities. On most days, several ambulances may come from these facilities, transporting patients with hip fractures, breathing difficulties, chest pain or stroke symptoms. Because these patients are older, they make up a disproportionate number of admissions into our hospital. 

Should one of the nursing facilities near my hospital become a COVID-19 hotspot, the morbidity and mortality to residents of these facilities would be devastating. For small hospitals like mine, such an incident could potentially cripple our ability to provide essential services.

A mask-wearing paramedic leaves a tent set up by the Italian Civil Protection outside the emergency ward of the Piacenza hospital, in northern Italy, Thursday, Feb. 27, 2020.

As a critical access hospital, we have a small number of beds which are often filled, and patients who should be admitted must be transferred to tertiary hospitals over 30 miles away. With three ambulances serving our county, patient transfers can become overwhelming as those ambulances must also attend to 911 calls.

I’ve been thinking about the health care infrastructure in communities like mine since the novel coronavirus began spreading across the United States. My hospital is one of 37 critical access hospitals in Michigan. We have 24/7 emergency departments, yet our hospitals have no more than 25 beds. We’re in rural, underserved and older communities, miles away from larger hospitals and at the tail end of the supply chain, where we’re often the last ones to get resources such as test kits and protective supplies.

If an outwardly healthy nursing facility worker gets coronavirus, they may not be tested if they don’t show symptoms, a criteria for testing as determined by the Centers for Disease Control and Prevention. Another is travel to hotspot countries such as China, Italy and Iran, which is unlikely among nursing care workers in a rural community.

Untested, they’ll continue working, interacting with the most at-risk individuals in our community. The mortality rate in people older than 80 is 15% — many times deadlier than influenza.

Based on cases thus far, we know that older patients get much sicker than younger patients regardless of underlying conditions. Many need to be hospitalized, with oxygen support for up to five weeks.

My hospital’s four negative-pressure rooms would quickly be filled. Our limited supply of personal protective equipment would be depleted. Testing capacity remains limited. My hospital alone employs almost 700 people — not just nurses and doctors, but dietitians, social workers, cleaning staff, patient access and dozens of people who circulate throughout our hospital without personal protective equipment.

The failure to test means we don’t know who has COVID-19. Because many of our patients are low-income, they’re highly unlikely to have left the country for high-risk nations like China or Italy. Patients who come in with fever, coughs and difficulty breathing will most likely have their illness attributed to pneumonia: Their chest X-rays will show infiltrate-looking lesions, and they’ll be put on antibiotics. They’ll only get tested for COVID-19 when they fail to respond to antibiotics or when more tests become available. By then, multiple shifts of nurses, certified nurse assistants, lab and radiology techs would have been exposed. 

This cascade of events could unfold within a week, maybe less. Small hospitals like ours will soon be running on skeleton crews of overworked staff. Emergency medical services will be depleted. Local healthcare infrastructures will reach capacity quickly.

With 1,350 critical access hospitals across the United States, this scenario could play out in many locations. 

COVID-19 patients recuperate in a temporary hospital converted from an exhibition center Feb. 18 in Wuhan in central China's Hubei province.

Meanwhile, people will still have heart attacks, broken bones and babies. They’ll need medical care. None of them may have coronavirus, yet unless we address how coronavirus will strain our health care infrastructure, we will be exposing people to a virus that’s more lethal than the flu.

To help small communities better brace for the outbreak, we need to increase testing aggressively for the public and for healthcare workers so we get a true picture of the scale of the outbreak. 

And we need to let health experts drive the national coronavirus response, not President Trump, Vice President Pence and other politicians, many of whom have allowed politics to overshadow science and facts. 

Trump can make this happen, if he chooses to.

Rob Davidson, M.D., is the executive director of the Committee to Protect Medicare.