COVID-19 cases are surging in rural places across the Mountain States and Midwest, and when it hits healthcare workers, ready reinforcements aren't easy to find.
In Montana, pandemic-induced staffing shortages have shuttered a clinic in the state's capital, led a northwestern regional hospital to ask employees exposed to COVID-19 to continue to work and emptied a health department 400 miles to the east.
"Just one more person out and we wouldn't be able to keep the surgeries going," said Dr. Shelly Harkins, chief medical officer of St. Peter's Health in Helena, a city of roughly 32,000 where cases continue to spread. "When the virus is just all around you, it's almost impossible to not be deemed a contact at some point. One case can take out a whole team of people in a blink of an eye."
In North Dakota, where cases per resident are growing faster than any other state, hospitals may once again curtail elective surgeries and possibly seek government aid to hire more nurses if the situation gets worse, North Dakota Hospital Association President Tim Blasl said.
"How long can we run at this rate with the workforce that we have?" Blasl said. "You can have all the licensed beds you want, but if you don't have anybody to staff those beds, it doesn't do you any good."
The northern Rocky Mountains, Great Plains and Upper Midwest are seeing the highest surge of COVID-19 cases in the nation, as some residents have ignored recommendations for curtailing the virus, such as wearing masks and avoiding large gatherings. Montana, Idaho, Utah, Wyoming, North Dakota, South Dakota, Nebraska, Iowa and Wisconsin have recently ranked among the top 10 U.S. states in confirmed cases per 100,000 residents over a seven-day period, according to an analysis by The New York Times.
Such coronavirus infections — and the quarantines that occur because of them — are exacerbating the healthcare worker shortage that existed in these states well before the pandemic. Unlike in the nation's metropolitan hubs, these outbreaks are scattered across hundreds of miles. And even in these states' biggest cities, the ranks of medical professionals are in short supply. Specialists and registered nurses are sometimes harder to track down than ventilators, N95 masks or hospital beds. Without enough care providers, patients may not be able to get the medical attention they need.
Hospitals have asked staffers to cover extra shifts and learn new skills. They have brought in temporary workers from other parts of the country and transferred some patients to less-crowded hospitals. But, at St. Peter's Health, if the hospital's one kidney doctor gets sick or is told to quarantine, Harkins doesn't expect to find a backup.
"We make a point to not have excessive staff because we have an obligation to keep the cost of healthcare down for a community — we just don't have a lot of slack in our rope," Harkins said. "What we don't account for is a mass exodus of staff for 14 days."
Some hospitals are already at patient capacity or are nearly there. That's not just because of the growing number of COVID-19 patients. Elective surgeries have resumed, and medical emergencies don't pause for a pandemic.
Some Montana hospitals formed agreements with local affiliates early in the pandemic to share staff if one came up short. But now that the disease is spreading fast — and widely — the hope is that their needs don't peak all at once.
Montana state officials keep a list of primarily in-state volunteer workers ready to travel to towns with shortages of contact tracers, nurses and more. But during a press conference on Oct. 15, Democratic Gov. Steve Bullock said the state had exhausted that database, and its nationwide request for National Guard medical staffing hadn't brought in new workers.
"If you are a registered nurse, licensed practical nurse, paramedic, EMT, CNA or contact tracer, and are able to join our workforce, please do consider joining our team," Bullock said.
This month, Kalispell Regional Medical Center in northwestern Montana even stopped quarantining COVID-exposed staff who remain asymptomatic, a change allowed by Centers for Disease Control and Prevention guidelines for health facilities facing staffing shortages.
"That's very telling for what staffing is going through right now," said Andrea Lueck, a registered nurse at the center. "We're so tight that employees are called off of quarantine."
Financial pressure early in the pandemic led the hospital to furlough staff, but it had to bring most of them back to work because it needs those bodies more than ever. The regional hub is based in Flathead County, which has recorded the state's second-highest number of active COVID-19 cases.
Mellody Sharpton, a hospital spokesperson, said hospital workers who are exposed to someone infected with the virus are tested within three to five days and monitored for symptoms. The hospital is also pulling in new workers, with 25 traveling health professionals on hand and another 25 temporary ones on the way.
But Sharpton said the best way to conserve the hospital's workforce is to stop the disease surge in the community.
Earlier in the pandemic, Central Montana Medical Center in Lewistown, a town of fewer than 6,000, experienced an exodus of part-time workers or those close to retirement who decided their jobs weren't worth the risk. The facility recently secured two traveling workers, but both backed out because they couldn't find housing. And, so far, roughly 40 of the hospital's 322 employees have missed work for reasons connected to COVID-19.
"We're at a critical staffing shortage and have been since the beginning of COVID," said Joanie Slaybaugh, Central Montana Medical Center's director of human resources. "We're small enough, everybody feels an obligation to protect themselves and to protect each other. But it doesn't take much to take out our staff."
Roosevelt County, where roughly 11,000 live on the northeastern edge of Montana, had one of the nation's highest rates of new cases as of Oct. 15. But by the end of the month, the county health department will lose half of its registered nurses as one person is about to retire and another was hired through a grant that's ending. That leaves only one registered nurse aside from its director, Patty Presser. The health department already had to close earlier during the pandemic because of COVID exposure and not enough staffers to cover the gap. Now, if Presser can't find nurse replacements in time, she hopes volunteers will step in, though she added they typically stay for only a few weeks.
"I need someone to do immunizations for my community, and you don't become an immunization nurse in 14 days," Presser said. "We don't have the workforce here to deal with this virus, not even right now, and then I'm going to have my best two people go."
Back in Helena, Harkins said St. Peter's Health had to close a specialty outpatient clinic that treats chronic diseases for two weeks at the end of September because the entire staff had to quarantine.
Now the hospital is considering having doctors take turns spending a week working from home, so that if another wave of quarantines hits in the hospital, at least one untainted person can be brought back to work. But that won't help for some specialties, like the hospital's sole kidney doctor.
Every time Harkins' phone rings, she said, she takes a breath and hopes it's not another case that will force a whole division to close.
"Because I think immediately of the hundreds of people that need that service and won't have it for 14 days," she said.
Mountain States editor Matt Volz contributed to this story.
Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.