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INDEPENDENCE – As a paramedic in the Emergency Department at Buchanan County Health Center (BCHC), Dan Dutler has worked with dying patients before. Never before though, he said, has he had to see a patient die without their family with them at their bedside until the coronavirus reached Buchanan County residents.

“That stuff you don’t think of until you're in that moment,” Dutler said.

Like many health care workers serving rural areas, Dutler has worn many different hats over the course of the pandemic. As BCHC’s emergency preparedness coordinator, he left his position in the ER for a month at the end of March to help the hospital prepare for COVID-19 full-time. Later, he would juggle responsibilities, shifting between preparing for new developments in the virus and how it was spread, organizing rapid testing, and tending to hospitalized patients, which only grew in number over the course of 2020.

Having kept an eye on the progression of the virus since February, Dutler said BCHC had purchased more respirators and medical supplies, including PPE, the same month. The move proved to be a vital first step in preparing for the pandemic, as PPE quickly became scarce among medical centers nationally in the early months of COVID-19.

“That probably saved us,” Dutler said.

Like many rural counties in Iowa, the first few months of the pandemic in Buchanan County were relatively quiet. The first reported positive case of COVID-19 in the county was on March 28, and the first hospitalization of a Buchanan County resident wasn’t until early May, according to the Iowa COVID-19 Tracker, which pulls daily data from the Iowa Department of Public Health’s coronavirus website.

Positive case numbers and hospitalizations began rising rapidly in the fall in a majority of rural Iowa counties, including Buchanan, which experienced a spike in the first weeks of November. Cases within the county peaked at 39 in a 24-hour period on November 12, according to the Iowa COVID-19 Tracker.

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According to Keith Mueller, head of the University of Iowa Department of Health Management and Policy and the director of the RUPRI Center for Rural Health Policy Analysis, researchers are still figuring out exactly why these fall spikes occurred as late as they did, although epidemiologists may attribute the dates to “geographic spread,” which is largely dependent on the amount of movement and travel between rural and urban communities.

Regardless of the reason, Mueller said, a virus can cause rapid widespread damage once it enters a smaller, concentrated rural community. While early “hotspots” included rural areas with meatpacking plants, multiple nursing homes, and truck stops, the pandemic is now impossible to seek refuge from in any Iowa town.

“When the pandemic hits [rural communities], the numbers may be smaller, but the percentage of the community that gets [infected] is higher,” Mueller said. “It doesn't take very many for it to have a broader community impact.”

The delay that occurred before COVID-19 began hitting rural communities hard may also have contributed to its rapid spread in the fall, as communities, understandably, he said, may have felt more insulated and protected from the virus due to their rural location.

For hospitals around the state, the fall spikes were particularly devastating. BCHC was out of beds multiple times during the surge of cases and hospitalizations in November, according to CEO Steve Slessor. One of the most distressing consequences of the spike, he said, was losing the ability to transfer patients BCHC did not have the resources to treat to other hospitals due to the statewide shortage of available space.

“Talking to my colleagues and our experience, I mean, people were transferring patients halfway across the state just trying to find any organization that had open beds,” Slessor said. “In that way, COVID wasn't just impactful for people that got COVID, COVID was impactful for people that came to emergency departments across the state with a wide array of different ailments.”

During the spike, when at most 24 Buchanan County residents were being hospitalized in a single day, Dutler said he and other health care workers found themselves “running from the time you got there till the time you left.” Dutler’s 12-hour shifts began at 6 a.m., and most days he didn’t leave until long after 6 p.m.

“When the spike came, out of your 12 hours you could spend 8 to 10 of them in a respirator, and we were having COVID patients from the start of your shift till the end,” he said.

Maintenance staff worked to set up new rooms with negative pressure to make them safe to bed COVID-19 patients. Health care workers often found themselves short-staffed because they stayed with the same patient from the moment they were checked in until they finished all of their tests, lab work, and were set up in a room to avoid wasting PPE.

Mueller said that even for rural hospitals that have beds available, the risk of becoming short-staffed due to coming into contact with COVID-19 or being infected is constant.

“The biggest problem that we're seeing nationally is the stress on the personnel,” he said. “Even when a hospital's finances are okay and its bed utilization is okay, people still end up being short on personnel to handle a tremendous surge in demand. And the stories in rural areas are the same kinds of stories you see the national media cover in places like New York. That’s true in Waverly, it’s true in Independence, it’s true in other places, too.”

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On top of the physical exhaustion that came from constantly moving around and spending a large amount of time carefully putting on and taking off PPE, Dutler said the mental exhaustion from working during the pandemic is just as fatiguing, particularly for older health care workers who risk putting themselves and their families in danger each day. 

“We have some older people that work in the ER and their spouses are not in great health, so their big worries were, ‘Oh, if I take it home, will I kill my husband, my wife?’” he said.

As of December 31, a total of 16 Buchanan County residents had died from complications with COVID-19. Fifteen of those Iowans died as a cause of underlying health conditions, according to data reported by the Iowa Department of Public Health.

For Dutler, having to resort to FaceTime at one point to allow a dying patient to safely speak to their loved ones for the last time has been “really hard to see.”

“We’ve had some of our staff that have stayed in the room with them while it happened,” he said. “You don’t want them to die alone, so we do what we can to help out. It’s definitely different than normal because you just don’t have that family interaction.”

Working in the ER, Dutler said he has seen some of the worst cases of COVID-19 in the county and wishes others could know how bad it can become.

“We see the people that are extremely sick, and in the general community, it doesn't affect a large part of our population,” he said. “But if people saw how sick some people get from it, they would have a different view of it. It is hard when you're not seeing it when you're not affected by it.”

For health care workers at BCHC, receiving the first dose of the Moderna COVID-19 vaccine has been a light in the tunnel. According to Slessor, all of BCHC’s staff and long-term care residents who want to have been able to receive the first dose of the vaccine.

Dutler said receiving the vaccine has given him and other staff members a boost of morale.

“It felt good. I was ready for it,” he said while recalling receiving his vaccination. “This is a step toward going away from the way things are right now.”

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