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Editor’s note: KHN wrote about St. James Parish Hospital in April, when it was experiencing its first surge of covid-19 patients. Ten months later, we checked in to see how the hospital and its staff were faring.

The “heroes work here” sign in front of St. James Parish Hospital has been long gone, along with open intensive care unit beds in the state of Louisiana.

Staffers at the rural hospital spent hours each day in January calling larger hospitals in search of the elusive beds for covid-19 patients. They leveraged personal connections and begged nurses elsewhere to take patients they know are beyond their hospital’s care level.

But as patients have waited to be transferred out of the hospital, which is about 45 minutes outside New Orleans, doctors such as Landon Roussel are forced to make unthinkable choices. As recently as Jan. 29, he had to decide between two patients: Which one should get the sole available BiPAP machine to push oxygen into their lungs?

That’s like a “war situation, which is not a situation that I want to be in — in the United States,” he said.

As the nation’s attention shifts to the vaccine rollout, rural hospitals such as St. James Parish Hospital have struggled to handle their communities’ sick following the holiday surge of covid patients.

“We knew it was coming. We saw it coming,” Mary Ellen Pratt, St. James Parish Hospital’s CEO, said by phone. “It really has to happen to their family for them to really go, ‘OK, wow.’”

And even though the vaccines have arrived and caseloads continue to improve after the holiday surge, only about 30% of staffers have opted to get their shots. Disparities in the broader community persist: In the initial rollout, only 9% of those vaccinated were Black in a parish — the Louisiana equivalent of a county — that is nearly 49% Black.

Staff members are burned out from months of handling never-ending covid crises.

“They had been giving 150%, and they’re just getting really tired,” Pratt said. “It’s just exhausting.”

‘Sometimes, Your Best Isn’t Enough’

In mid-January, the closest intensive care bed the staff could find was some 600 miles away in Brownsville, Texas — so far that a plane would have been necessary to transport a patient. After three days, a closer bed was found at a Veterans Affairs hospital about 45 miles away.

Staffers have tried Mississippi and Alabama with mixed luck. One patient they tried to transfer four hours away couldn’t go because the ambulance didn’t have enough oxygen to make it that far. A hospital in Florida even called them looking for ICU beds at St. James Parish Hospital, which has never had any.

More than half of U.S. counties are like St. James Parish and have no intensive care beds, full or empty. Rural hospitals in those communities are designed for step-down care: They often serve as a stopping point to stabilize people before they can be sent to larger hospitals with more specialized staff and equipment.

Across the country, has been consistently higher than that of urban residents since August, according to the Rural Policy Research Institute Center for Rural Health Policy Analysis. That has occurred even though covid incidence has been lower among rural populations than urban ones since the middle of December, said , who runs the health policy department at the University of Iowa’s College of Public Health and co-authored the study.

But, he said, rural populations are typically older, sicker and poorer than urban populations. And the nation has lost at least over the past 17 years.

“This crisis is just magnifying existing access issues in a rural context,” said Alan Morgan, the head of the National Rural Health Association. “If you don’t have a local hospital, that impacts the diagnosis, the initial treatment, the complex treatment. It has multiple impacts, all leading to what we’re seeing: higher mortality.”

And at the hospitals that remain, such as St. James Parish Hospital, the stress level is palpable, because the level of care needed for such sick patients is higher than what staffers normally handle, said Karley Babin, the hospital’s acute nurse manager.

“It’s just an uncomfortable spot,” she said. “You know you’re doing everything you can and that patient just needs more.”

That’s led to many sleepless nights for Pratt.

“Sometimes your best isn’t enough if you don’t have the right resources,” she said.

‘We Know All These People’

Radiology technologist Brooke Michel lives seven minutes from the hospital, where she works with her husband and five other relatives. Her grandfather, grandmother and aunt were hospitalized there in December with covid.

Her family brought folding chairs to sit outside her 83-year-old grandfather’s hospital window each day, keeping vigil through the glass on Christmas Eve. He died Jan. 3 while family members stood outside, taking turns looking in and praying.

“It gave us a sense of closure,” Michel said. “We were all together. We were with him. We would never have gotten that at a bigger hospital.”

Seeing multiple family members hospitalized at the same time is tough on the staff, said Scott Dantonio, the hospital’s pharmacy director. “We know all these people,” he said.

Dozens of hospital staffers also have battled covid, and three have been hospitalized. A nurse’s aide died last summer after contracting it. One staffer, who was particularly close to that aide, now has a hard time treating covid patients, said Rhonda Zeringue, chief nursing officer.

“It’s a reminder: ‘You took my person,’” she said.

‘It’s Just Exhausting’

St. James Parish Hospital has been running short-staffed, because they haven’t been able to hire more nurses or pay traveling nurses — they’re just too expensive. Amid the pandemic, traveling nurses can command more than double what the staff nurses make.

So Babin’s kids ask often why she works all the time.

Community praise has died down, she said. People aren’t thanking them in grocery stores anymore. One upside? Pratt is happy to have finally lost the “covid 19” — the weight she put on from the community bringing food to the hospital back in the spring.

Pratt and Zeringue have offered staff members counseling, massage sessions, coffee and doughnuts. But it’s not enough.

Zeringue said the stress has gone through the staff in waves: First they were scared to death of being the front line in the spring. Now she sees burnout and sheer exhaustion.

The vaccines were supposed to offer hope. But when Pratt heard they would be distributed through CVS and Walgreens, she knew immediately the logistics of getting the ultra-cold Pfizer vaccine from its cooler into residents’ arms would fall to them. She said the community has no chain pharmacies nearby and the local health department is overloaded.

“We get an email at, like, 4:30 on Friday which says, ‘We’re going to send you another 350 vaccines on Wednesday and you have to respond in the next 10 minutes,’” Pratt said. “There’s not enough planning or time to do it.”

Staff members, who are juggling monoclonal antibody infusions and elective surgeries to deal with the backlog from the spring on top of the surge, must also call members of the community to let them know they have the vaccine available. And then the problems begin.

“People don’t answer the phone or they’re not available,” Dantonio said. “Or they can’t come at that time or they scheduled somewhere else.”

Most of the people coming in following the hospital’s advertising online and on Facebook have been white. So Pratt called on the people she had relied on during the rollout of the Affordable Care Act: Black preachers and well-respected Black local leaders such as Democratic state Rep. . After word from the pulpit spread and Brass’ team staffed a phone line, the vaccine distribution the next week jumped to 30% Black residents from the prior week’s 9%.

Even some among the St. James Parish Hospital staff have been reluctant. Many have told Zeringue they’re worried about their fertility. Others just don’t want to be first. So the hospital's line of defense has many holes.

And the covid patients keep coming.

“This is a nightmare,” said Kassie Roussel, the hospital’s marketing director. “It’s crazy because it’s at the same time we marketed the beginning of the end.”

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