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Thursday Feb 25, 2021

Uncertainty and Hope: A COVID-19 Update From Rural America

Living in rural Kansas, I often feel insulated (rather than isolated) from many things. The COVID-19 pandemic was like that last spring: watching citizens of faraway places like New York City and Italy suffer greatly was heart-wrenching in the way a sad movie might be, and it didn’t always feel present or “real” to my own community. This insulation from the immediacy of COVID-19 could have led to a variety of bad outcomes for my health care community: poor preparation, lack of investment by key stakeholders or situational unawareness, for example. Fortunately, we chose a different path.

[Two doctors meeting in videoconference]

As 2020 marched on, the value of preparation became apparent. Like many rural locations across the United States, Rooks County experienced the reality of the pandemic months after the nightmare surge in the Northeast. The Pew Research Center examined COVID deaths by congressional district,(www.pewresearch.org) which nicely right-sizes the population across the country and allows for it to be categorized into urban and rural segments. Initially, urban centers were hardest hit.

However, by the summertime the urban-rural split had largely disappeared, and over the last several months, those districts with small shares of residents in densely populated places have been experiencing twice as many deaths as those in the parts of the country where all or nearly all residents live in urban neighborhoods.

Rooks County is part of “The Big First” congressional district in Kansas. Covering more than 80,000 square miles, the district stretches from the Colorado border in the west to the eastern third of Kansas across the northern two thirds of the state and from Nebraska to the Oklahoma border in the western third of the state. It is undeniably rural.(www.census.gov) About 12% of our population is 65 or older, we are 88% white and more than 60% of us were born here. From March through August 2020, The Big First averaged less than one COVID death per day.

In September, that all changed. Rooks County lost seven citizens from Sept. 25 to Oct. 4, largely due to a nursing home outbreak. By November, The Big First was averaging five to 10 deaths a day due to COVID.

I wrote about the first few weeks of preparation in my personal blog(adastrabrull.com) back in March; I remember the emotion of that time: “Last week, we did the impossible. Protocols and policies that normally would have taken weeks, or even months, to develop and coordinate were implemented overnight. Every night. I am certain I have never been through so many plan-do-study-act cycles in such a short period of time for such a critical need before in my life.”

In retrospect, we had a lot more time than we thought before COVID actually hit Rooks County, but I'm glad we didn’t wait even one minute to prepare.

We formed a team: hospital, family medicine clinics, urgent care, health department. We met every day at 5:30 p.m. for months, at first in person, then by video. When we felt most things were ready and the local number of infections were low, we had a delicious period of time with only one meeting a week. Now we are back up to twice weekly and as needed for crises. We feel comfortable voicing concerns and confident about working through the “bumps” that inevitably come up each day. We trust our core and extended team when the going gets hard and lean on each other in chaos. The relationships are just as important as the work we do.

We prepared by dealing with immediate needs and concerns and considering all worst-case scenarios and potential solutions. No testing supplies? We built new relationships with other labs to get them and prioritized patients for testing. Not enough personal protective equipment? We each found different sources, created safe protocols for re-use, pooled our resources and ensured everyone had enough. Clinics have no negative pressure spaces to see patients with COVID? The hospital “loaned” us a space for outpatient care; we built the procedure for how to use it and be good stewards. Overwhelming volume of intubated patients with COVID with nowhere to transfer? We made a plan to convert the post-anesthesia care unit to an ICU, learned about ventilator management and partnered with emergency management to obtain additional ventilators for the hospital.

We persevered — through months and months of “is it coming?” to winter, when it hit hard. We surged in December and January. Our critical-access hospital was at capacity, it frequently took several hours and many phone calls to find a tertiary hospital with an open bed to accept critical transfers (both COVID and non-COVID related), and the acuity level of inpatients we kept rose rapidly in the face of a nursing shortage. In the outpatient setting, we averaged a positivity rate of 29% late last year, with our contact tracers working overtime, weekends and holidays to ensure the community understood the importance of quarantining after exposure. It all felt overwhelming at times, and it would have been a disaster if we had not invested in preparation through the spring and summer.

There is still a lot of uncertainty. Who among my friends or family or patients will get sick next, and will they die? Will the situation locally get worse again? What will we do if the day comes when we have no beds in our own facility, a critical patient we can’t find a place to transfer, and not enough staff to care for all those folks? Those questions keep me up at night and fuel our COVID team discussions each week.

We are also asking hopeful questions. How can we partner with home health to safely discharge patients sooner and create space in our strained facility? What downstream benefits will we see from using monoclonal antibody therapy in our patient population? What impact will the vaccines have and how soon? I have begun to see the light at the end of the tunnel; we are giving vaccine every week with this same crew of volunteers giving their time and talent every Saturday to the greater good, our positivity rate has drifted down and our hospital has open beds again. I hope these days represent the beginning of the end of this pandemic.

Jennifer Brull, M.D., is a member of the AAFP Board of Directors.

Posted at 07:00AM Feb 25, 2021 by Jennifer Brull, M.D.

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