It's a new procedure, one of several routines that Gila Valley Clinic in Safford, Arizona, has implemented since Graham County's first coronavirus patient walked through its doors last week. The patient, an elementary school teacher, tested positive for the virus on Friday.
The positive case jolted the health care community in Safford, as well as the surrounding towns that make up a mining and ranch community in southeast Arizona. Clinics are rationing masks, public health officials are dissuading residents from overwhelming the strained health system, and the sole hospital in the region is grappling with the possibility that it may no longer have the option to airlift seriously ill patients to big cities.
While the largest known coronavirus outbreaks in the United States so far have occurred in densely packed cities — such as Seattle and New York — the case in Graham County highlights the risks of the global pandemic in rural communities.
Safford sits along a cluster of small towns near U.S. Route 70 in southeast Arizona, including Pima, Central, Thatcher, and Solomon. Mt. Graham Regional Medical Center — the only hospital in the Safford area — serves a population of about 40,000 people.
It's a tight-knit community that comes with its own problems when dealing with a virus that spreads via shared surfaces and respiratory droplets."We’re being encouraged to get takeout stuff, but what if one of those kids from Pima works at the Dairy Queen?" — Dr. Gail Guerrero-Tucker
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Town residents shop at the same Walmart, grab last-minute meals at the same fast food joints, and watch movies in one of two Safford theaters.
"We’re being encouraged to get takeout stuff, but what if one of those kids from Pima works at the Dairy Queen?" Guerrero-Tucker said. "You’re almost afraid because there is no anonymity and nobody knows what to do."
Most families in the area likely know someone who attends Pima Elementary School, the center of the Graham County outbreak. Authorities asked 166 students and five staff members who may have been exposed to voluntarily self-quarantine, but health officials did not expect everyone to follow the order.
"I am not expecting that we would be able to contain this exposure. We’re planning for that unfortunate end," said Matt Bolinger, infectious disease epidemiologist for Greenlee and Graham counties.
At Gila Valley Clinic, the staff of five physicians and four nurse practitioners have been taking unprecedented steps to prevent coronavirus spread. They're separating patients with upper respiratory symptoms. They're dividing the day into two shifts: One for "well patients" without illnesses, and one for sick patients. They made a mother wait in her car during her child's appointment after finding out she was exposed to the virus.
And they're rationing N95 respirator masks, which are critical to protecting health workers from coronavirus. Guerrero-Tucker said staff found a few in storage units, and the county health department delivered a handful of "duck bill" masks, which are not quite as protective.
"But honestly if we have a big outbreak here, we’ll run out of masks within a week," Guerrero-Tucker said.
Pulling Together
Down the street from Gila Valley Clinic, Mt. Graham Regional Medical center is making its own preparations.Arizona as a whole faces a potential statewide shortage of hospital beds in case of a large coronavirus outbreak. The problem could be even more acute at rural hospitals, which are not as well equipped to handle severe trauma and illnesses.
Mt. Graham Regional Medical Center has licensed 49 beds, according to CEO Roland Knox. With state restrictions waived, the hospital could convert rooms and have "probably closer to 80."
That would not be enough to handle a worst-case scenario in Safford, where hundreds or even thousands of patients could require hospitalization for coronavirus.
The hospital owns 10 ventilators that potentially could be used to keep seriously ill patients alive, including six that would have to be borrowed from operating rooms. That's not all the ventilators Mt. Graham has access to. The Graham County Health Department lent the hospital three ventilators and a private ambulatory company in town spared two of its own, bringing the total at the facility to 15, a relatively large inventory for a hospital of Mt. Graham's size.
"It’s just amazing how everybody pulled together," Knox said.
One of the starkest challenges that Mt. Graham could face is keeping the hospital staffed amid a large-scale outbreak. On Monday, the hospital held a meeting with local clinicians, including Guerrero-Tucker, to get a sense of who might be available to staff the hospital in case any doctors there become exposed. Everyone in the room said they could fill in if necessary.
"We’re trying to preserve, so to speak, our staff," Knox said. "If you had 60 patients in the building that can normally handle 49, soon it becomes very difficult to keep all of the staff safe and well rested and well nourished."
When the coronavirus outbreak occurred, Mt. Graham Regional Medical Center had been working on qualifying as a Critical Access Hospital, a federal designation for rural hospitals with fewer than 25 beds that are within 35 miles from another hospital facility, that have a 24/7 emergency department, and have an average length of stay of less than 96 hours.
Arizona's 15 critical access hospitals are mostly Level IV or Level II trauma centers, meaning they don't typically have the equipment or staff to stabilize patients for long periods of time, according to Dr. Daniel Derksen, director of the University of Arizona's Arizona Center for Rural Health. In cases that require long-term stabilization, these hospitals transport patients to Level I trauma centers, which are almost always located in urban areas.
Rural hospitals will have to contend with the possibility that they may no longer have the option to transport patients to big cities.
"If this is widespread all over the state, we’re going to have to care for our own folks here," said Bolinger, the
county epidemiologist. "We may not have the option of shipping them out to Tucson or Phoenix."
Up until about a month ago, Bolinger said, he had been telling people that asked about the coronavirus that they had a better chance of dying from the flu.
Now Bolinger stresses the importance of everyone staying home ("do puzzles, watch Netflix, whatever") to prevent coronavirus spread and keep the health care system from becoming overwhelmed. Otherwise Graham County, just like anywhere else in the world, could become the next coronavirus disaster zone.
"Where are we going to get the oxygen for all these people?" he said. "It’s an apocalyptic subject to me."
