And as leaders grappled with how hospitals could treat a growing pool of COVID-19 patients, other facets of the health-care system were altered or paused.
At Kalispell Regional Medical Center in Montana, elective procedures ranging from cosmetic surgeries to routine cancer screenings were back-burnered in March, as they were at hospitals nationwide. Dr. Randall Zuckerman, chairman of Kalispell Regional's Department of Surgery and physician director of its surgical service line, said this was done primarily to conserve personal protective equipment (PPE).
"There are three major issues that impact our ability to deal with COVID and those are PPE, testing and hospital beds and the staff that manage them," Zuckerman said. "Upfront we were really worried about PPE because the global supply chain had run dry. When that happened all of the specialty societies, including the American College of Surgeons, came out with a very strong recommendation to stop elective surgery. So we stopped everything."
The decision also prompted Zuckerman and other surgeons within his unit to switch to what he called a "Team B approach." Instead of having the department's eight surgeons working at once, only two surgeons would work for a week at a time while the other six were sent home.
"There were still emergency surgeries that had to be performed. So what we were trying to avoid was all of us possibly coming down with COVID at the same time," Zuckerman explained. "At that point we didn't understand the magnitude of the virus. We didn't understand what would happen if you operated on someone who inadvertently got COVID."
The decision to halt elective procedures, which hospital leadership at the time said likely would cost Kalispell Regional millions, is just one example of how the pandemic has infiltrated nearly every arm of health care. And according to Zuckerman and other hospital leaders, one would be hard-pressed to find a piece of the industry that hasn't been impacted by the virus.
ZUCKERMAN IS one of three Kalispell Regional physicians recently interviewed by the Daily Inter Lake with the goal to better understand how COVID-19 has directly or indirectly affected day-to-day operations. Dr. Cory Short, a hospitalist trained in internal medicine and physician lead for the acute-care services line, and Dr. Adam Smith, a family medicine specialist and physician lead for the primary care service line, also were interviewed. All three physicians, who each oversee hundreds of employees within their respective service lines, said COVID-19 has been a nine-month learning curve, and it's one that has impacted each of their departments uniquely.
For example, Zuckerman said the ebb and flow of beds and PPE availability, as well as strain on staff, will be his deciding factors on whether non-emergency procedures are once again altered. He said PPE is no longer a concern at this point and his attention is now focused on hospital bed capacity and how many staff are quarantined due to symptoms or exposure.
"Just a little while ago we were running into bed troubles, and it was a function of both absolutely bed availability as well as staffing," Zuckerman said. "We were running at more than 100% capacity for a period of time and then we had a bunch of staff who were unavailable. So there was probably a three-week stretch where we thought seriously about canceling elective surgeries again."
The dedicated COVID unit at the hospital can comfortably fit around 30 patients. But for stretches in October and November, Flathead City-County Health Department data showed hospitalizations exceeded or hovered just below that number. Zuckerman added that aside from the COVID unit, he is watching emergency room capacity.
"The most unpredictable part is how many people will come through the emergency room, and that fluctuates daily. So then what we have is bodies sort of competing for the same beds." he said. " But honestly, the nurses, the CNAs and other folks over there are doing a fantastic job and are keeping the wheels spinning. To my knowledge, since starting services back up, we haven't had to cancel a surgery yet."
Zuckerman also noted there are certain routine screening procedures he would like to continue offering in-person. The reason for this is two-fold, with the first being to avoid an increase in patients exhibiting late-stage diseases — something of which he and others experienced an influx after elective services started ramping back up in May.
Zuckerman pointed to colonoscopies as one example, which often allow doctors to spot small polyps and remove them before they become cancerous. He also said the cancellations prompted some delays in chemotherapy for those who had been diagnosed with cancer.
"If you stop all screening and treatments, there are downstream, detrimental effects to that," he pointed out. "And it may take awhile to see those effects, but this concern sort of runs true across a multitude of medical problems."
The second reason for Zuckerman wanting to maintain various in-person visits is the desire to maintain better relationships with his patients. He said in the past nine months the hospital's telehealth services have been used more frequently and while that technology has its benefits, he would rather report initial test results, namely cancer diagnoses, face-to-face.
"It's tough to deliver those results when you're not in the same room," Zuckerman said. "These conversations are usually complex and can be scary and it's hard for people to hear that information on the phone or via a computer."
Some of Zuckerman's concerns align with those expressed by Smith, who works as a primary care physician in Polson and Kalispell. Smith said not being able to closely monitor patients with chronic diseases is a major worry of his.
"There are a lot of preventative services that we offer in primary care that we certainly don't want to see delayed," Smith said. "That can be anything from colonoscopies to mammograms, which help us locate tumors before they become enlarged."
Smith also said he has lost some of his doctor-to-patient intimacy. As a primary care physician, he often has the opportunity to work with the same patients year after year, which allows him to bond with them and more deeply understand their needs. Smith said a few patients he has treated for more than a decade died from COVID-19-related complications.
"We care for people in all aspects of life, from birth to death," Smith said. "But it's certainly been hard to watch patients that you've cared for for so long be lost to this virus."
WHILE ASPECTS of the pandemic have challenged the world of primary care, a COVID-19-related shift in Smith's responsibilities has allowed him to witness health-care high points as well.
Smith has extensive experience working in rural settings and has functioned as a liaison between Kalispell Regional and critical-access hospitals in remote areas including Libby, Shelby, Polson and Ronan.
"We have really focused on how we can support these clinics, whether that's with education efforts, staffing or taking in critical patients," Smith said. "These small rural hospitals have less bench strength than we do, so situations like COVID tend to take a bigger toll on them. The teamwork I've seen has been incredible."
He highlighted one instance when a critical-access hospital had to send the vast majority of its staff home to quarantine, so Kalispell Regional helped organize and send over additional medical personnel. Smith said it has been fascinating to watch this level of teamwork play out not only at a local level, but on a global scale as well.
"The health-care industry typically has a competitive edge to it, but a lot of that has gone out the window with COVID," Smith said. "It's been interesting to watch hospitals collaborate on this and share what has worked for them and what hasn't."
Smith has also played an instrumental role in establishing Kalispell Regional's respiratory screening facilities. He said the pop-up resources, which prompted the hospital to bring on numerous additional staff members, have been vital in helping Flathead County understand its outbreak, especially after Kalispell Regional established in-house testing earlier this fall. Smith said the hospital has been regularly testing over 3,000 people per week since the testing platforms became fully operational in late October.
"Being able to identify this illness early so we can intervene sooner has really been helpful in testing and battling COVID here in Montana and it's a novelty that most of the state has not had," Smith said.
For Short, the quick turnaround in testing also has greatly benefited his emergency department's ability to organize and treat patients in a fast-moving environment. The in-house lab is able to provide results in about 48 hours, which helps Short and others not only have a better sense of how many patients are actually COVID-positive, but whether any staff members are infected as well.
WHILE SMITH and Zuckerman have dealt with various aspects of COVID-19, Short has been in the throes of treating positive patients directly since March.
He said the hospital's emergency department actually experienced a decline in patient activity at the start of the pandemic, as many other hospitals did. Short explained this was largely due to the public fearing exposure at the hospital.
"What we were seeing, for example, were patients who had actually experienced stroke symptoms several days prior to coming in and were then being admitted with advanced chest pain and heart complications after the fact," Short said. "So this started us down a major road of educating the public, telling people if they need emergency services, it's safe to come here, we have the necessary protocols in place."
Short said after the Flathead Valley experienced a dip in new cases around April and May, it didn't take long for emergency activity to pick back up. While the department typically sees around 50 to 60 patients per day, he estimated that number was closer to 70 to 80 visits over the summer and into the fall. The increase was due in part to the tourist season, but he also said the department was experiencing a noticeable bump in patients experiencing respiratory complications.
SHORT SAID the pandemic has been a marathon for both health-care workers and the community. And while he hopes the population is rounding into one of the final legs of that marathon with the upcoming shipment COVID-19 vaccine, he said it feels as though they still have a ways to go.
"We started off at a sprint and then transitioned into this marathon mode and that's really hard for everyone to sustain. The biggest challenge we face right now is endurance," Short said. "At the hospital level, we are tired. Fatigue is certainly settling in among staff. And at the community level, you know, we are all social creatures. We want to be with each other, we want to commune together and to continue having the discipline to not is really hard."
Smith and Zuckerman seconded this, saying they anticipate it will be difficult for others to continue practicing COVID-19 protocols in the coming months as Montana nears its one-year mark fighting the virus. All three physicians also agreed that they have never experienced anything like this pandemic in their lifetimes.
"I think many physicians, depending on what capacity they played in this response, would tell you this is perhaps the most challenging time of their career. I include myself in that," Short said. "It will be interesting to see how this virus has changed our society two, five or 10 years down the road. By then we will have known what worked, what didn't, and hopefully we will all come out stronger on the other side of that."
Reporter Kianna Gardner can be reached at 758-4407 or kgardner@dailyinterlake.com
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