Los Angeles Times - 04.04.2020

A12 SATURDAY, APRIL 4, 2020 LATIMES.COM

space for makeshift inten-
sive care zones and even
train staffers who may be
called on to perform tasks
that are only distant memo-
ries from their days in
school.
There is also growing
concern from some frontline
workers that not enough is
being done to protect them
and suspicion that their in-
stitutions may not be telling
them the truth about how ef-
fective work-around safety
measures are.
At St. Francis Medical
Center in Lynwood, the
emergency room has not
been as crowded as it nor-
mally is, according to a nurse
there, yet the scramble for
gear is already on.
“It’s very scary inside the
hospital,” said the nurse,
who, like some of those inter-
viewed, requested anonym-
ity because he was not au-
thorized to speak publicly.
“Everyone is looking at each
other, we’re just waiting.”
The nurse said he has
heard from friends in the
profession elsewhere that a
surge can come in a matter of
hours, a crush of patients
can engulf the hospital in an
instant.
“I don’t know what’s go-
ing to be the straw that
breaks the camel’s back
when we get down to it,” he
said. “Every place becomes
an ICU, that’s what we’re
waiting for, that’s what ev-
eryone is anticipating.”
A hospital administrator
in the San Fernando Valley
said she begins each day by
looking over the updated ac-
counting of what is left of
their COVID resources —
face shields, intensive care
unit beds, isolation gowns,
ventilators — and then goes
department to department
to buck up the exhausted
and fearful staff.
“When you walk around
on the floors of the hospitals,
it is the most eerie sense of
what is to come,” she said. “It
is just palpable.”
On the COVID-19 wards,
the nurses are busy and pro-
fessional, she said, but “if
they get a moment to sit
down, to grab coffee, they
just crumble.”
She said that for now she
tells them the hospital has
what it needs. She doesn’t
tell them she thinks it’s pos-
sible, even likely, that they
will run out of N95 masks in
the near future or that she
worries “every night, every
day, every hour” about what
that will mean.
“It’s like sending your sol-
diers into battle without
weapons,” the administra-
tor said. “How do you pre-
pare people for something

like that?”

Nurses who’ve been ex-

posed to the virus ask to be

tested, but “we simply don’t

have enough tests,” the ad-

ministrator said.

So they keep working,

and she fears that they may

be infecting other patients.

She said she has decided

that she will not force any-

one to work without protec-

tion if they do run out, but

she will remind them of their

duty to the public.

“I will explain what’s be-

fore us and see who is willing

to step up,” she said.

Dr. James Keany, an

emergency room physician

at Providence Mission Hos-

pital in Mission Viejo, said

his facility is in a similar

holding pattern. They have

COVID-19 patients, includ-

ing some in the ICU and on

ventilators, but not many.

“I feel like we’re not any-

where near capacity right

now,” he said. “But the

COVID patients are defi-

nitely on the increase and it’s

increasing daily.”

Some staff members are

anxious and want to wear

N95 masks whenever treat-

ing COVID-19 patients, but

the hospital is recom-

mending their use only for

high-risk situations.

He said they are now

weighing whether it is better

to have the staff wear N95s

more often and reuse them

or to try to stick to the policy

of wearing a surgical mask

with a face shield. He prefers

the latter, saving the coveted

filtered mask for when it

might really matter.

“People don’t want to

hear that,” he said. “There

will be anxiety among the

staff. ... Emotionally, I think

the [N95] mask feels better.”

A nurse at UC Davis Med-

ical Center in Sacramento

said he feels discouraged for

the first time in his career by

the lack of protective gear.

The nurse, who was not au-

thorized by his institution to

speak to the media, said he

has been punched, kicked,

scratched and bitten by pa-

tients and even faced down

weapons during his years on

the job. But this is worse.

“One thing I never signed

up for was bringing some-

thing home that could kill

my family,” he said. “Health-

care workers [are] without

adequate [personal protec-

tive equipment] and their

families are going to pay the

price.”

Pamela Wu, spokeswom-

an for UC Davis Medical

Center, said in an email Fri-

day that the facility “cur-

rently has sufficient supplies

of personal protective equip-

ment (PPE),” but has “revis-

ited our storage of PPE, spe-

cifically masks, after some

instances of theft, so they

are now kept more securely.”

As administrators, doc-

tors and staff navigate the

shortages, trust and pa-

tience are also drying up.

UCLA emergency room

nurse Marcia Santini said

she and other nursing staff

recently received an email

from UCLA that their N

masks will be sterilized us-

ing ultraviolet irradiation.

Each nurse will label her

mask, place it in a paper bag

and it will be put in a mach-

ine for ultraviolet germicidal

irradiation, according to the

email.

“The nurses are very, very

concerned about that,” she

said. “Does it get all the

nooks and crannies? Will the

integrity of the mask hold

up? Will it still fit your face

the same way?”

UCLA confirmed in a

statement that it was using

UV light to disinfect N

masks.

“This is a validated proc-

ess to kill viruses,” the state-

ment read, adding that it is

one of the first healthcare

systems in the nation to use

the method.

A nurse who works at

USC’s Keck Hospital said

her facility is changing “how

we are using our PPE on a

daily basis.”

That, she said, has led to

“a lot of anxiety, and I think a

lot of anger.”

The nurse said it had

been long-standing custom

to dispose of an N95 mask af-

ter treating a patient with an

infectious disease. Now, the

rules keep shifting. First,

nurses were told to wear the

mask for four hours, then

eight hours. Then the hospi-

tal started instructing

nurses to put their N

masks in a UV light box and

zap the bacteria off, a proc-

ess that took about 60 sec-

onds.

“We said OK, but the

masks smelled like they were

burning,” she said.

After nurses questioned

whether the UV light was

frying the filter and compro-

mising the efficacy of the

mask, the hospital rolled out

a new policy, she said.

Masks are put in a brown

paper bag after each use and

picked up by housekeeping,

she said. The next day, a

nurse returns to find a white

paper bag with their name

on it, and the cleaned mask

inside.

“It feels like they are mak-

ing it up as they go,” she said.

In a statement, Keck

Medicine of USC did not dis-

pute the account and said it

was following guidelines set

by the University of Ne-

braska Medical Center for

extending the use of N

masks. The masks were be-

ing disinfected with UV light

from Xenex robots.

“As we believe that Los

Angeles has not yet peaked

in COVID-19 case volume, we

are therefore continuously

assessing our PPE re-

sources, while ensuring the

health and safety of our

health care providers,” Keck

said in the statement.

Other nurses are frus-

trated by being asked to do

jobs they aren’t comfortable

with. One nurse without ex-

perience in intensive care

said that with elective sur-

geries canceled and his nor-

mal work dwindling, he’s

now being pushed to handle

serious cases of COVID-19.

“I’ve never done ICU,” he

said. “I’ve never wanted to.”

Anurse at Cedars-Sinai

Medical Center, where there

are a few dozen COVID-

patients, complained that

doctors there have had more

consistent access to N

masks and other more so-

phisticated protection gear

while nurses caring for such

patients often are told to

wear simple surgical masks.

It seemed wrong to her,

she said, because nurses

spent more time in the pa-

tients’ rooms.

“We are the ones face-to-

face with these people,” she

said.

She said nurses are told

to clean and reuse some face

shields, and that the protec-

tive sheets become dimpled

upon repeated washing,

leaving her wondering if it’s

working.

“By the end of the day, I

can smell medicines

through the [shield],” she

said.

Cedars-Sinai said in a

statement that it offers “a

single standard of protec-

tion for doctors, nurses, res-

piratory therapists, environ-

mental health personnel,

chaplains and other staff

who work in patient areas”

and that its procedures are

“consistent with guidance

from national, state and lo-

cal public health author-

ities.”

Despite the doubts and

creeping trepidation, medi-

cal providers who spoke to

The Times shared one re-

solve: to remain on the job,

providing care, even as the

risks mount.

When Dr. Amit Gohil, a

pulmonary critical care doc-

tor at Santa Clara Valley

Medical Center, dons his full

protective gear to enter a

COVID-19 patient’s room, it

is quiet and still, with only

the sound of a ventilator.

His county has been one

of the hardest hit so far with

more than 1,000 positive

cases as of Friday, with 245

patients in hospitals and 92

in intensive care.

At those bedsides, Gohil

finds calm and purpose.

“Even if people are dying,

you really feel like you can

care for them,” Gohil said.

“Your whole life has come to

this pinnacle.”

Times staff writers Paul

Pringle and Phil Willon

contributed to this report.

On edge and bracing for a deluge

[Hospitals,from A1]

THERE ISalso growing concern from some frontline workers that not enough is being done to protect them

and suspicion that institutions may not be telling them the truth. Above, Eisenberg Village in Reseda, Calif.

Jason ArmondLos Angeles Times

WASHINGTON —Rural
hospitals nationwide are
bracing for a wave of high-
risk coronavirus patients
that could break an already
fragile healthcare system,
one facing shortages of sup-
plies and a scarcity of doc-
tors so dire that some cen-
ters might have to shut down
if a single physician con-
tracts the disease.
“There is literally no
room for error here,” said
Alan Morgan, chief execu-
tive of the National Rural
Health Assn., which repre-
sents 21,000 healthcare pro-
viders and hospitals. “Rural
America is a tinderbox of a
healthcare crisis for those
most in need.”
About 2,000 hospitals
serve more than 60 million
people in rural areas, about
a fifth of the U.S. population,
and experts say they are
simply not equipped to han-
dle a pandemic that has
claimed more than 7,
lives and infected more than
275,000 people in the U.S. as
it spread from China and
around the globe. Dense ur-
ban areas have been the
hardest-hit so far — New
York City has recorded
about 1,500 deaths, making
it the epicenter of the out-
break in the U.S. But it’s ex-
pected to be only a matter of
time before the virus strikes
rural America.
Doctors at rural hospi-
tals say they are getting
ready, if belatedly, and brac-
ing for the impact.
Dr. Gregory Byrd, vice
president of medical affairs

for the 25-bed Shenandoah

Memorial Hospital in Wood-

stock, Va., said his staff is im-

provising on the fly.

It has started using video

and telephone conferences

to reach patients before they

get to the hospital, prescribe

them medications or refer

them to offices dedicated to

the coronavirus. Those who

show up at the hospital must

first enter a tent erected out-

side the emergency room, he

said.

Patients deemed likely to

have the illness are sent to a

“hot zone” at the hospital.

The rest are treated in an-

other area. In recent weeks,

the hospital has sent several

patients sick with the virus

to a sophisticated medical

center in Winchester, Va.,

about 45 minutes away.

“This has been the crazi-

est two weeks of my career,”

Byrd said. “We are trying to

plan for something we had

theoretical knowledge

would happen one day, but

we just weren’t prepared. We

were all caught with our

pants down.”

The coronavirus could in-

flict disproportionate dam-

age on the American

countryside for a variety of

reasons. Its population is

generally older, heavier and

has more underlying health

conditions than city and

suburban dwellers. Such pa-

tients are more likely to need

risky invasive care.

Yet its healthcare system

is ill-prepared for the need. It

has been hard-hit by social

and economic forces, op-

erating mostly in areas that

have lost population and

serving a disproportionate

number of patients whose

age and condition make

them among the most ex-

pensive to treat. Rural hos-

pitals rely on government

payments, but many are in

Republican-led states that

have resisted expanding

Medicaid to more low-in-

come adults and children.

Nearly half of rural hospitals

lost money last year. In the

last decade, more than 100

rural hospitals have closed,

eight of them since January.

The pandemic is likely to

exacerbate those trends. To

keep hospitals afloat, ad-

ministrators have focused

intensely on the bottom line,

boosting outpatient and

elective procedures and cut-

ting back on costs such as

stockpiling protective gear.

Yet the virus has forced hos-

pitals to halt most elective

surgeries, both to preserve

stores of masks, gloves and

scrubs and to reduce

chances of spreading infec-

tion, thus eliminating a ma-

jor source of revenue.

Rural hospitals will face

trouble boosting those

stockpiles. They don’t have

the political sway or buying

power to obtain such sup-

plies in a chaotic open mar-

ket dominated by larger hos-

pitals and their networks.

Also, they were not built

to treat people with conta-

gious pathogens. Many lack

the space to put up infec-

tious disease wards. And

whereas major medical cen-

ters have specialists direct-

ing patient care, rural hospi-

tals rely on generalists who

may not have access to the

most up-to-date medicine.

They have evolved in re-

cent decades from full-serv-

ice medical centers into

army-style “field hospitals”

that often triage and stabi-

lize patients before sending

them to more sophisticated

facilities. While that system

is adequate for car-crash vic-

tims and those with minor

illnesses and injuries, it is

not equipped for a wave of

coronavirus patients.

But if larger regional cen-

ters become overwhelmed,

rural hospitals will have no

place to send their sickest

patients. Most rural hospi-

tals have only one or two ven-

tilators, administrators say,

and their doctors and nurses

have little experience keep-

ing people alive on such de-

vices for days on end, a rou-

tine outcome for critically ill

coronavirus patients.

“Managing patients over

time will be a big problem,”

said Dr. David Wallace, an

assistant professor of criti-

cal care medicine at the Uni-

versity of Pittsburgh. “Rural

areas are just not set up with

the same infrastructure to

handle a large surge of pa-

tients.”

Politics also could be at

play. As President Trump

often notes, rural America

backed him by a wide mar-

gin, and it remains loyal.

Hospital administrators

said they were concerned

that residents in their re-

gions had not taken the

threat as seriously as they

should have because, until

recently, Trump and his al-

lies at right-wing media out-

lets for months downplayed

it. Trump supporters dis-

trust the mainstream media

and many believed news

outlets over-hyped the virus’

dangers, they said.

Rural areas “won’t be

spared. In fact, we could get

walloped because of where

we get our news, and the per-

ception that urban prob-

lems are not necessarily ru-

ral problems,” said an execu-

tive of a state hospital asso-

ciation, who requested

anonymity. “There is no

doubt the president’s early

skepticism is playing a role

in this. And then his people

were skeptical about it.”

But now, the executive

added, “the president seems

to be taking it more seri-

ously, and rural America will

likely follow his lead.”

Administrators of rural

hospitals say they have so

far seen only a trickle of co-

ronavirus patients. Those

without COVID-19 symp-

toms or with minor illness

are being sent home to rest,

and patients in need of more

acute care are being di-

verted to regional centers.

Teresa Grimes, chief exe-

cutive of the Washington

County Hospital and Nurs-

ing Home in Chatom, Ala.,

said her facility was taking

steps to reduce the chances

for transmission and to bet-

ter treat those with the dis-

ease. It has enhanced its

screening of employees, visi-

tors and patients, and is

beefing up disinfection of

high-touch areas. A resident

physician, who recently

spent time in a critical care

ward of another hospital,

has been training nurses

and doctors on how to best

use the hospital’s two venti-

lators, Grimes said.

“We are as prepared as we

can be,” Grimes said. “Two

weeks ago, I got a call from a

hospital in north Alabama

that needed ventilators. I

told them if nobody else

could help them to call me

back and I would see what I

could do. But I only have

two, and there may come a

time when we need them

here.”

One thing that might

work in rural America’s fa-

vor, doctors said, is that the

virus may not spread as

quickly or deeply in sparsely

populated areas as it does in

densely populated places

like New York City, Detroit

or New Orleans.

Said Lorenzo Serrano,

chief executive of a 19-bed

Winkler County Memorial

Hospital in west Texas: “It is

easier to social distance in

rural America.”

Virus could overwhelm struggling rural hospitals

DR. GREGORY BYRD, an executive with Shenan-

doah Memorial Hospital in Woodstock, Va., stands by

a tent where patients are evaluated for coronavirus.

Tammy Gasper

Many facilities lack

the budget and staff to

confront COVID-19.

By Del Quentin Wilber