How Crisis Standards Of Care Puts Pressure On Idaho's Rural Hospitals
North Canyon Medical Center in Gooding opened its doors during a pandemic. It was during the 1918 Spanish flu and the rural community was ravaged. The building opened before construction was complete, just to treat the influenza patients who quickly filled the whole floor.
Now, more than a century later, North Canyon is weathering the worst wave so far of the COVID-19 pandemic.
The 18-bed hospital serving the county of 15,000 people is surrounded by farm fields. Patients often watch tractors plowing outside their windows.
The hospital can care for three COVID patients right now, said Dr. Jennifer Olsen, a hospitalist at North Canyon. They're isolated in negative pressure rooms because there’s no separate COVID wing; the hospital has one main floor for all patients.
Nurses fly in and out of the COVID rooms as they don and doff their gowns and gloves. The hospital used to have just two of these rooms, but it recently added another one. A metal box in the hallway reveals its makeshift status as it blows filtered out air into the hallway.
Olsen has been taking care of the COVID patients. They’re sicker and younger compared to last year, and they’re unvaccinated, she said. The beds have been consistently full.
“I get one COVID patient discharged from the hospital and within an hour I’ve got the ER calling to admit another COVID patient,” she said.
There’s no ICU at North Canyon. That means, even in normal times, patients are transferred out to larger hospitals if they have a heart attack or get into a bad car accident.
For COVID patients, it means if they are struggling to breathe on their own, they need to be transferred. That’s because the hospital can’t do mechanical ventilation — or intubation — when doctors put a tube through someone’s windpipe to push oxygen into the lungs.
“Those patients need to be in an ICU setting," Olsen said, "and we don't have the capabilities to take care of that level of care.”
The hospital also doesn’t have the heart and pulmonary specialists to check on those patients, or the right medications to sedate and heal them.
But with hospitals around the state full, North Canyon and other small, rural hospitals are having a much tougher time transferring patients out. And the transfers are needed more frequently — in Gooding, about once per day.
It means doctors like Olsen are taking care of sicker people with fewer resources.
“Patients who are requiring BiPAP and high-flow oxygen, I’m actually taking those patients on the floor and caring for them there, where prior to this, they would be transferred to an ICU,” Olsen said.
In an ideal situation, these patients would get one-on-one care. But that’s not possible right now. Olsen’s not an intensivist and they don’t have ICU-trained nurses.
And while the hospital is admitting sicker people than it usually takes on, that doesn't always last long. People infected with COVID can deteriorate quickly, Olsen said.
On a recent shift, a COVID patient came into the ER. Four hours later, the hospital was able to get her into one of the COVID rooms. But within an hour and a half, the patient was getting worse, and Olsen decided she needed to be intubated and sent to a larger facility.
“And we start making phone calls,” she said.
When the patient came into the ER, there were no nearby ICU beds open. But within the four hours it took for her to be admitted, one became available. The transfer was seamless, Olsen said. It doesn’t always happen that way.
Recently, a non-COVID patient waited 22 hours in the North Canyon emergency department.
“We had the nurses, the providers calling hospitals every few hours to see if any beds opened up," Olsen said.
A helicopter ended up bringing the patient to St. Luke’s in Boise. Then it came right back to Gooding for another transfer.
Patients are sometimes being treated in the hallway of North Canyon’s emergency department; some, who would normally be admitted for overnight observation, are sent home.
Though hospitals around the state are able to ration resources under crisis standards of care, as of late last week, small hospitals in the Magic Valley were not at that point yet. But they say they’re not far from it.
“That big factor for a rural hospital is when you’re no longer able to transfer a patient that you typically would or when you’re at capacity yourself,” said Ben Smalley, the administrator at Cassia Regional Hospital in Burley.
Though those situations are occurring intermittently, hospital leaders say they change by the hour. If there's a continual rush of patients needing critical care and there are consistently no beds for them, that might push a small hospital to crisis standards of care.
North Canyon has a tiered plan, said CEO J’Dee Adams.
“It could expand all the way to us setting up a medical tent,” he said.
That outdoor tent, Adams said, is still about two to three steps away. But it’s possible the hospital could blow through those phases in 24 hours.
Last week, St. Luke’s in Twin Falls, the closest regional hospital, started sending some of its patients to North Canyon straight from the emergency department.
“I think it could be upwards of 1-2 patients a day," said Adams of the St. Luke's patients coming to Gooding.
It’s a sort of trade: the sicker patients go to St. Luke's; some more manageable ones go to the critical access hospitals. Though Adams emphasized the local hospitals are all working together, he acknowledged the higher volumes could mean the Gooding hospital has to cut back further on its non-COVID care.
“I’ll be honest with you, I'm really nervous," he said.
Adams said the hospital needs the community’s help to avoid crisis standards. Dr. Olsen said they’re not getting it right now.
“We’re drowning," she said.
Having grown up in Gooding and graduated from high school there, she said it’s devastating to watch what’s happening. Only about 40% of the eligible county residents have gotten the vaccine.
“Misinformation is huge right now," she said. "And compassion fatigue is real with health care workers.”
Faced with major staff absences at Gooding schools earlier this month, the school board issued a mask mandate to try to keep kids in classrooms.
“The community was very upset about that mandate," Olsen said.
They held an emergency meeting last Tuesday that Olsen attended. She was the only one to walk up to the microphone in support of masks. The board reversed the mandate after one week.
“So I just ..." she trailed off. "I’m sorry, it’s frustrating.”
Last week, Olsen had an hour-long conversation with one of her sickest COVID patients. The patient said she’ll get the vaccine after she recovers. Olsen called it a ‘win.’ But she’s also frustrated she can’t seem to get through to people before they’re sick, in a hospital bed across from her, asking for help.
She’s hosted Q and As in local Facebook groups and has felt good about some of the answers she's been able to provide, but her outreach has also made her the target of angry messages.
"I’m trying to be positive, but it doesn’t really feel like I have a majority of allies in the community,” she said.
Still, she and Adams both emphasized the hospital staff will be there to care for the community nonetheless.
While Olsen was talking, an ambulance picked up a critical patient in the ER who needed a higher level of care. Later that night, as she was resting before her next shift, a helicopter landed in Gooding for another transfer.
Editor's Note: This post has been updated to reflect the most recent information on Gooding's vaccination rate.
Find reporter Rachel Cohen on Twitter @racheld_cohen
Copyright 2021 Boise State Public Radio