COVID-19

Holy Cross: A rural hospital braced for onslaught

Lack of ventilators, postponing nonemergency treatments, enlisting labor pool

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Hospitals around the country are mobilizing to adapt to the national surge of patients infected with the novel coronavirus, or SARS-CoV-2, that causes the respiratory illness called COVID-19.

In urban areas hit first with the coronavirus outbreak, the volume of patients with COVID-19 currently flooding emergency rooms and intensive care units is unlike anything health professionals have seen before. In an attempt to respond, medical institutions are searching for solutions.

Hospitals are converting medical and surgical units into specialized COVID-19 units, scrambling to find additional ventilators and personal protective equipment and reaching out to surrounding communities for help with supplemental staffing.

Holy Cross Medical Center in Taos, a 25-bed Critical Access Hospital that serves a population of 37,000 in Taos County and surrounding areas, has been in preparation for the oncoming pandemic since mid-January.

"We're stacking up backup plans," said David Elliot, the hospital's emergency manager. However, the capacity of a small community hospital like Holy Cross to manage the kinds of surges occurring in other parts of the country is limited.

"We are going to do everything in our power to treat as many people as we can with the highest quality care possible," Elliot continued. "At some point, we can't just take infinite patients--at some point, we have to start triaging patients for potential success given the available interventions."

Preparing for the worst

In its steady state, Holy Cross has six ICU beds and four ventilators. In preparation for potential community spread of coronavirus in Taos, the emergency management is now working to at least double ICU capacity by adding more beds and purchasing a number of alternative oxygen delivery devices.

Even with these measures, however, Taos' curve of coronavirus infections will have to be different from that of America's early outbreaks for the local facility's resources to be enough once Taos hits the peak of positive cases.

In severe cases, COVID-19 is characterized by the dangerous and potentially fatal pneumonia that cripples the lung's function, leading to acute respiratory distress syndrome or ARDS. For patients who get to this critical stage, a ventilator can be the difference between life and death.

In New York City, home of some of the best-equipped hospitals in the country, medical professionals are seeing a catastrophic inundation of their institutions and resources. Hospitals throughout the city are reporting that ICUs are completely at capacity and do not have enough ventilators to intubate the number of patients that are arriving in respiratory distress.

In rural hospitals around the United States, the supply of ventilators and sedation medications needed for intubation is alarmingly low.

"We have gotten very little support from the national stockpile," said Elliot. "As the emergency manager of the hospital, I don't feel like we should be planning on getting help from the state to do anything other than getting us information. I don't think we're going to get 'stuff,' especially when we can see community spread in Albuquerque and Santa Fe with much larger populations. I don't think we're going to get vents from anybody.

"Also," he added, "if someone gave us 100 ventilators, it doesn't mean we can staff 100 ventilators. That's a very unique skill set."

Intubation as last resort

Without the prospect of receiving additional ventilators from the federal government and lacking access to a supplementary pool of skilled personnel needed for intubation procedures, Holy Cross is actively searching for other options.

Though COVID-19 can lead to severe inflammation of the lungs and trouble breathing in some patients, the Holy Cross emergency management asserts that not everyone who comes in their doors suffering from coronavirus will need mechanical ventilation support - and the hospital administration is hopeful that solutions such as high flow oxygen helmets and high flow nasal cannulas could help a percentage of patients.

Elliot emphasizes that because of Holy Cross' limited ICU capacity and the nature of the hospital's alternative respiratory support options, "People need to come in before they can't breathe. If you're maintaining a temperature that's over 100 for a long time, go to the doctor so we can give you interventions as opposed to having you wait until much later and occupy an ICU bed when we have such a limited capacity."

In the face of the hospital's limited resources, Gayle Martinez, the marketing and communications manager at Holy Cross, encourages the Taos community to continue with its rigid adherence to social distancing and staying at home.

"We have worked with federal and state numbers on running projections," Martinez said, "Taos scoring an A-minus on social distancing -- that helps us, that helps change the numbers, so we don't have everyone needing everything at once at a higher level of care. So, we're doing something really, really good, and we need to keep doing it."

Pushing off treatment

And it's not just the patients with COVID-19 who are affected by the overcrowding -- another frightening repercussion of the COVID-19 surge in first-hit populations is that patients with other treatable emergency conditions who would have normally received immediate care are getting lost in the flooding of the medical system.

With the novel coronavirus exponentially increasing hospitalizations throughout U.S. cities, this is becoming a crisis not only for coronavirus patients, but also for other emergency patients and patients with chronic conditions who need ongoing monitoring and care to remain healthy, and, in many cases, alive.

Holy Cross Medical Center is already restricting its surgery area to emergency cases only and encouraging patients with chronic conditions to choose telehealth options. In March, the hospital postponed all elective surgeries.

According to Tim Moore, chief of staff at Holy Cross, "The hospital usually does 240 surgeries per month, or 60 per week. We've currently cut about 80 percent of those."

Enlisting labor pool for help

In addition to these measures, Holy Cross is asking the surrounding community to help them with managing the crisis to avoid their equipment and staff from becoming stretched too thin.

Holy Cross is gathering a labor pool of paramedics, doctors and nurses from around the community to be part of the effort. Communication with Taos Ski Valley Ski Patrol paramedics, alongside community endeavors with 3D printing of supplemental masks, and efforts of the University of New Mexico Taos Nursing School to bring in additional patient beds and equipment are all pieces of the puzzle as the peak of the coronavirus curve approaches the Taos community.

However, even with the greatest possible collective push, what is most clear at this juncture is this: with the limited resources and capacity of the only hospital in Taos County, the community's success in social distancing and staying at home will be the key factor in the medical facility's success in the COVID-19 crisis.

Elliot remains hopeful. "If the numbers that we're looking at -- even at the upper limits -- hold, and if the community support and social distancing continue, we're getting closer to being able to get through this thing."

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