Late last month when Brian Jensen, a registered respiratory therapist at St. Peter’s Health in Helena, worked a few consecutive nights in the hospital’s emergency room, the department physician told him something concerning.
“We had ambulances coming in from all over the region with patients that didn't have COVID, but their hospitals didn't have any beds,” Jensen said. “We were the only receiving facility in the state that night.”
Cases of the coronavirus are spiking again in Montana after a relatively quiet early summer. The surge of unvaccinated patients sicker with the Delta variant mean hospitals around the state are increasingly having to make difficult decisions like diverting cases from their emergency departments, delaying elective procedures or asking for the National Guard to assist with staffing shortages.
As employees inside hospitals struggle through crisis, the buildings they’re working in can feel like a sort of reverse oasis — as severely ill people struggle to breathe on ventilators and families line up at first-floor windows for glimpses of loved ones, the communities around them have incongruently moved on from a pandemic that is still killing Montanans weekly.
Dr. Shelly Harkins, the president and chief medical officer of St. Peter’s Health, said the disconnect between what’s happening in medical units and outside the hospital walls is jarring.
“I think many people in our community have no idea that we are surging again, that we have COVID again and that our staff are suffering, having to care for these very sick patients that honestly we can do little for other than hold their hand and provide supportive treatment and hope,” Harkins said.
The state’s larger hospitals who responded to questions for this story all reported high patient volumes, several topping records. There are more strokes, heart attacks and trauma cases than in years past. And the resurging pandemic is bringing more COVID-19 patients, who consume more intensive hospital resources.
“Our COVID patients have been, in the new surge of COVID, pretty ill and ... on a typical day about 50% of our admitted hospitalized (COVID) patients are in our critical care unit,” said Dr. Kathryn Bertany, a pediatrician who is president of Bozeman Health's Deaconess Hospital and Big Sky Medical Center. “That wasn’t necessarily the case in the first surge.”
Administrators, doctors and nurses fear with lagging vaccination rates and fewer mitigation measures like mask requirements or distancing measures that were in place through parts of 2020, the sharply rising curve tallying those hospitalized with the virus will reach the highs of last November. Back then, the state had nearly 500 beds filled with COVID-19 patients for several days. On Friday the state reported 266 people hospitalized with the virus, a 29% increase over the last 14 days.
Over the last few months, Harkins said there were days when St. Peter’s could not admit a patient and had to find another hospital for the person to go to. The facility has also “boarded” patients, which means those who should really be in an inpatient room, end up waiting in the emergency department for hours or sometimes days for a bed to open.
“We actually are talking a lot here in Montana about exactly what to do when we get a call from another state looking for a bed," Harkins said. "… Typically we would say yes, but then again, we've never quite been in this situation before. Do we say yes or do we keep all of our Montana beds for Montana people? These are scarce resource conversations we've never had in health care before in the U.S. of A., in any of our lifetimes. We've never had to talk about scarce resources and who gets them and who does not.”
At Benefis Health System’s hospital in Great Falls, capacity is also pushed, sometimes over the brim.
“We are extremely busy. We are operating at greater than 100% of our typical capacity and have been very consistently for the last couple months,” said Kaci Husted, the system vice president of communications and business development.
Hospitals around the state already took steps early in the pandemic to increase the number of beds and spaces they have to treat patients. Benefis opened the eighth floor of a patient tower that typically wasn’t operational as a dedicated unit for COVID.
“We were able to close that floor this spring and have now had to re-open it,” Husted said.
Every Monday the state puts out a report of hospitalization data. Last week it showed 70% of Montana's facilities had limited bed availability or were near capacity and half had limited intensive care unit availability or were near capacity.
But hospitalization status changes hour to hour, so the information is out-of-date by the time it’s published. Counting beds also doesn’t give a great picture of what capacity is really like.
“It is important to note that the bed capacity reported this week from the state for our hospital includes our NICU (neonatal intensive care unit), women and newborns and pediatric beds, which does not provide an accurate picture of adult bed capacity,” wrote Megan Condra, the director of marketing and community relations for Community Medical Center in Missoula, last week.
Not enough staff
Along with seemingly every other industry in the nation, another universal challenge for Montana's hospitals is an acute shortage of employees in every department from medical care providers to nutritionists and housekeeping.
The problem existed before the pandemic and is exacerbated by it. Burnout is high for people working in health care, with its grinding physical and emotional demands. COVID-19 made it worse, bringing risk to workers' own health, heartache for sick patients with long roads to recovery and even hostility from patients and their families over measures to slow the spread of the virus.
“A number of individuals have chosen to leave,” Bertany said. “ … We absolutely have experienced staffing shortages and have had times we did not have enough staff to be able to care for patients that needed beds in our facility.”
Fewer employees compounds the fatigue for those remaining.
“People are picking up extra shifts and working extra hours to help cover the needs we have,” said Rick DePaso, a nurse in the intensive care unit at St. Peter’s.
During the earlier wave of the pandemic in 2020, there was reprieve from travel nurses, but they’re not available to help with this spike since so many other hospitals across the country are in the same position.
At Bozeman Health, the facility was able to find a couple dozen contracted staff to alleviate some of the problems. Benefis in Great Falls is considering an app that allows people to order their own meals and pick them up.
“Everybody pitches in and does their best to make things work and take the best care possible of our patients, but that being said it’s gotten significantly more challenging in the last several months to do everything we need to do with staffing issues that we’ve been running into,” Husted said.
Hospitals around the state have asked for assistance from the National Guard, and last week Montana Public Radio reported the Montana Hospital Association asked for the governor to approve using federal COVID-19 aid to pay for temporary workers.
Unvaccinated, sicker with Delta
As the Delta variant proliferates though the state, making up nearly every Montana variant specimen sequenced in a report released last week, younger and previously healthy people are requiring more critical care and higher levels of ventilatory support, Bertany said. And the vast majority of those people are unvaccinated. Since Feb. 15, when the state started tracking breakthrough cases, less than 9% of new cases were among vaccinated people.
About 96% of patients who have ended up in the critical care unit in Bozeman since the vaccine became available were unvaccinated. All the current COVID-positive critical care patients on ventilators were unvaccinated, Bertany said when interviewed last week.
Roughly 90% of the COVID patients at Logan Health Medical Center in Kalispell have been unvaccinated since the recent surge started, said Dr. Corey Short, Logan Health Medical Center hospitalist and physician executive of Acute Care Services.
The hospital recently launched a status report that showed all eight patients last week in the intensive care unity were unvaccinated and all three on ventilators were also unvaccinated. Only five of the 38 hospitalized were vaccinated.
DePaso said every COVID-19 patient on a ventilator at St. Peter’s the day he was interviewed last week were unvaccinated. Over a Zoom call, still wearing his scrubs and a surgical mask, DePaso explained what struck him about helping patients battle COVID-19 now versus a year ago.
“We had no ability to prevent it and now we’re in a different situation where we do have a way to prevent it and unfortunately people aren’t utilizing it,” DePaso said. “When you come to the emergency room or get admitted to the ICU, you trust us and you listen to us to guide your course through to get better as health care professionals. And so we just plead with you: Listen to us now, before you end up in the hospital.”
Harkins stated it bluntly. Even as the Delta variant is making patients more sick and spreading more easily among the unvaccinated, the immunized aren't the problem.
“Those that are vaccinated that still get COVID are over it like a common cold. They do not use hospital resources, they do not die from COVID,” Harkins said. “Those that are in the hospital for weeks on end, those that are dying from COVID, are the unvaccinated. Those that are transmitting the virus throughout our community, are those that are unvaccinated.”
Illustrating the resources it takes to treat very sick COVID-19 patients, Jensen explains what it takes to perform a procedure called "proning" to alleviate fluid buildup.
The process involves taking a patient and flipping them over on their stomach to aid in breathing. It’s not an easy process, given the number of IVs a COVID patient is generally on, not to mention a possible ventilator.
“It easily takes five strong people to carefully maneuver someone without pulling a line, removing an ET tube or at the same moment causing pressure sores,” Jensen said.
The hospital has been so short-staffed it’s had to pull over the ambulance crew at night to help with the process or nurses off other floors. Depending on the size of the patient, it might take even more to do the procedure safely.
Treating people who are so sick exacts an emotional toll. It’s matter of weeks, not days, receiving critical care for those who are the most ill but still recover. No matter how someone lands in the intensive care unit or their vaccination status, DePaso said nurses provide care to their full ability, which can be incredibly draining.
“It's hard emotionally to watch these families of people ... struggle with the fact that their loved ones are in the ICU for 20 days or longer, in isolation, where they can't come visit and and see their loved one except for the occasional Zoom call or looking through the window because we happen to be on the first floor of the hospital,” DePaso said.
Kallie Kujawa, who leads the incident command team for Bozeman Health, said employees are also experiencing “compassion fatigue,” fueled by adversarial interactions with patients and their family members.
“They’re trying to do their best, they’re working extra shifts and with decreased support staff and then on top of that they are having confrontational situations with patients and their family members about things such as wearing a mask in our facility and having limited visitors for patients to decrease the viral load in our building,” Kujawa said.
It’s critical for the hospital to help employees avoid exposure to COVID-19 because if they get sick, the facility is at risk of not having enough staff to care for patients.
Last week in a letter to colleges, administrators at St. Patrick Hospital in Missoula halted scheduling new non-emergency and inpatient procedures because of capacity issues, citing the COVID spike. Billings Clinic CEO Dr. Scott Ellner said his facility is still doing “medically necessary procedures” to prevent conditions from worsening, but others are being postponed in order to maintain resources and avoid further burnout in nurses.
Bozeman Health hasn’t had to limit elective procedures, but “there was a day we were talking about it” recently, Bertany said. St. Peter’s looks at its operating room schedule daily to determine if it has enough beds to do surgeries that require patients to stay in the hospital overnight or longer.
“It’s touch-and-go and every day we take a look to see if we need to cancel and we have had to cancel a few this summer,” Harkins said.
Last year St. Peter’s “learned our lesson” when it canceled elective surgeries, Harkins added.
“It took us well over a year to catch up,” Harkins said. “People got really sick and their pain levels increased. Elective doesn’t mean unnecessary.”
Eyeing the steeping curve in new COVID-19 cases, schools opening with limited mitigation measures in place in some parts of the state and colder weather pushing people indoors, it's hard to look ahead and be hopeful.
“I think it’s very realistic for us to expect this fall and winter season to be really hard for us,” Bertany said. “We don’t really know what the flu season is going to like this year, especially with the lax compliance with masking in our community.”
Hospitals are begging, pushing and pleading with their communities to get vaccinated, use face coverings and avoid large crowds. St. Peter’s posted what the hospital called the “Longest Facebook Post of All Time” last week asking for help from the community. The letter was signed by more than 500 hospital employees and implored Helena to get vaccinated, ending with a message of unity: “As always, we’re in this together and together we’ll get through this.”
But it doesn’t always feel that way.
“You walk down the halls of the hospital and (it) feels like we step back in time to January again,” DePaso said. “The weirdest juxtaposition of that is when you leave the hospital, it feels like nothing ever changed, whereas when you left the hospital in the winter of last year, you knew we were in a pandemic because … the grocery stores weren't as busy, people were wearing masks constantly. … The weirdest thing now is is that when you leave work, nothing is different and it's business as usual.”
— Billings Gazette reporter Emily Schabacker contributed to this story.