Billings Clinic Cancer Center. Credit: Photo courtesy Billings Clinic

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When Dr. Kristin Spanjian came out of retirement earlier this year and volunteered to help treat COVID-19 patients in an overwhelmed New York City hospital system, she saw doctors and nurses stretched thin, low supplies, limited access to medication and diminished care for non-COVID-19 patients.  

Now, back in Billings, as new cases and hospitalizations spike around Montana, she’s been pressed into service again — this time in the state where she practiced medicine for more than 30 years. While health providers have learned a lot about COVID-19 since the early days of the pandemic, she’s worried that Montana’s health care system will face the same challenges she saw in New York City if the local situation doesn’t improve. 

“We’re right on the edge,” she said. “I’m afraid that we’re going to end up having some of the same problems, where we’re going to end up not being able to actually treat patients the way we should, running out of supplies, etcetera.”

Spanjian retired as an intensive care physician in 2017, but is now back to work at Billings’ St. Vincent Hospital ICU. She’s working in a state where officials and health care workers have warned for weeks of an overloaded health care system, pleading with the public to follow public health recommendations and a statewide mask mandate as COVID-19 cases rise sharply. On Friday, the state reported 863 new cases, one day after a daily-record-breaking 932 new cases

In Billings, the stress on Montana’s health care system is apparent and acute. As of Friday, Yellowstone County has the most active cases in the state at nearly 2,000. Yellowstone County is also home to the state’s largest and third-largest hospital. The two hospitals serve as a medical hub for much of eastern Montana, northern Wyoming and the western Dakotas, serving patients who need a higher level of care than they can access at the smaller “critical access” hospitals in their local communities.

On Thursday, Yellowstone County’s infection rate per 100,000 people was 76.3. At its peak, New York City’s seven-day average infection rate per 100,000 was just over 60

Billings Clinic, Montana’s largest hospital, reported Friday that the hospital’s ICU was full — and that’s after a recent expansion of its ICU capacity. At nearby St. Vincent Healthcare, one ICU bed remained open on Friday morning, according to a daily state report on hospital capacity. Combined, the two hospitals have 68 ICU beds. Overall, 88% of the county’s hospital beds are occupied. 

Some of the state’s eight other large hospitals, like the Kalispell Regional Medical Center, are in better shape. Kalispell Regional reported that more than half of its 48 ICU beds were open, according to state data. Others, like St. Peter’s Health in Helena, reported a full ICU. Benefis Health Center in Great Falls had one ICU bed available on Friday. And many of Montana’s smaller critical access hospitals are dealing with their own challenges, including lack of staff to care for COVID-19 patients, Montana Public Radio reported on Thursday.

“Our teams are working incredibly hard. They are providing excellent care, but they are stretched — we’re tired. We’re here for the community and our patients, but we definitely need for the community to be acutely aware of the situation.”

Bililings Clinic Chief Nursing Officer Laurie Smith

“We’re very concerned about the hospital situation,” said Dr. Greg Holzman, the state’s medical officer, during a Thursday press conference. “A lot of the hospitals are more stressed than they usually are at this time of the year, and that puts more panic into us knowing that we’re now going into cold and flu season, which is the typical time of year that hospitals see more people coming through.”

The increase in COVID-19 patients at Billings’ two hospitals has led to the implementation of surge plans to deal with the demand. 

At Billings Clinic, that’s meant finding hospital space to convert from other uses to ICU rooms and, in some cases, housing two patients in one ICU room, said Chief Nursing Officer Laurie Smith. The hospital also has a contract for a portable cooling unit to hold bodies of deceased patients, though it hasn’t been used yet, she said. 

St. Vincent also has been finding space to add ICU beds, and in some cases has had to send patients warranting ICU-level care to other hospital departments to be treated by staff with less experience treating such patients, Spanjian said. 

For example, St. Vincent spokeswoman Angela Babcock said, the hospital has turned its sleep medicine unit into an area for COVID-19 patients. Its post-operation recovery unit is also being used to house non-COVID ICU patients. 

So far though, both hospitals say they haven’t had to turn patients away. While it may feel as if the hospital is operating in crisis mode, “because we are all so exhausted, and just working as hard as we can to take care of every possible patient that we can,” Smith said Billings Clinic is operating at a “contingency” plan level.

“If we continue as a state to escalate with the number of cases that we are seeing, my fear is that we could enter a crisis state,” she said. “We are doing everything that we can to prevent that, and we are not there right now.”

While both Billings hospitals say they’re currently able to meet demand, stay supplied and take on new patients, medical staff are beginning to feel overwhelmed, a feeling exacerbated by high numbers of staff members testing positive themselves or having to quarantine because of exposure elsewhere. 

“Our teams are working incredibly hard. They are providing excellent care, but they are stretched — we’re tired,” Smith said. “We’re here for the community and our patients, but we definitely need for the community to be acutely aware of the situation.”

The hospital is also seeing burnout and high rates of absenteeism among staff members, Smith said. To ease the stress, the Billings Clinic this week has brought in 54 travel nurses from across the country as temporary workers.

If the situation doesn’t improve, Spanjian and Smith said, patients, staff members and the community could begin to see impacts on quality of care, such as limited access to personal protective equipment and dwindling stocks of supplies and medicine. Spanjian said patients seeking advanced care in Billings may have to be turned away and redirected to hospitals as far away as Denver. Family may also be further prohibited from visiting critically ill or dying patients if the situation doesn’t improve, Spanjian said. 

Individual hospitals are in charge of developing and implementing their own plans for dealing with the increase in COVID-19 patients, but the state has its own surge plan, which includes temporary overflow sites to help treat patients, Holzman said Thursday. He added that the state is considering revisions to that plan. Gov. Steve Bullock has also called for additional nursing help from out of state and assistance from the National Guard to ease the burden on health care workers.

“We’re kind of going back and looking at that and bringing players in to review and figure out what are some of the best ways to move forward,” Holzman said.

He said the state meets with the state’s large hospitals daily during the week to discuss their current situations and to see how the state or other hospitals can help one another and “balance the load,” adding that hospital leaders have worked well together to ensure they can meet patient needs. 

Hospitals statewide are feeling the strain but, so far, aren’t at a crisis point, Holzman said. Still, the timing of the new case spike in Montana and resulting hospitalizations isn’t ideal with flu season approaching. 

“This is very, very different from the flu,” Smith said. “We have never had to expand our ICU capabilities to the extent that we are currently.”

Despite some similarities between the New York City hospital she volunteered at earlier this year and Montana’s current situation, Spanjian said hospitals and health care workers have learned a lot since the early days of the pandemic.

“I was happy to be able to help out. Some of those doctors and nurses there were so exhausted, they really did need a break,” she said. “It was something that none of us had ever seen before — the severity of the illness — in my over 30 years of practicing.”

But for hospitals to keep from reaching a crisis point, Spanjian said, the public needs to respect the recommendations of state leaders and health care workers regarding the seriousness of the virus and the importance of practicing social distancing following mask directives. 

“If we’re going to keep our schools open, our businesses open, our hospitals open and functioning, the public has to start following the guidelines,” she said.

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Chris Aadland covers tribal affairs in Montana as a Report for America corps member based in Billings. Before moving to Montana he covered the Wind River Reservation in Wyoming for the Casper Star-Tribune, and has also reported for the Wisconsin State Journal. Contact Chris at caadland@montanafreepress.org and follow @cjaadland on Twitter.