On the day after rural Bibb County got its first confirmed coronavirus case, nurses and staff at a small testing clinic in Centreville gathered at a few outdoor wooden picnic tables for a socially-distanced lunch break in the fresh air.

It’s the only part of the workday they get to take off the face masks and gowns and bulky plastic face shields that are now their daily uniform.

“You have to work at keeping your mind in the right place,” said Amanda Wiggins, 40, a licensed practical nurse and Bibb County native. Her mother is a resident at a nearby nursing home, and she worries about her. She’s glad schools and other businesses closed to prevent the spread of the virus, even though it meant her daughter, a high school senior, wouldn’t get to attend prom or graduation.

She tries not to worry much about herself.

“Nursing is a calling,” she said. “This is what we’re supposed to do. We’re the front lines.”

Wiggins and the others work at Cahaba Medical Care’s Respiratory Evaluation Clinic, located inside a tiny converted community center surrounded by fields. The 35-bed Bibb Medical Center is a five-minute walk in one direction and the highway a five-minute walk in the other.

Since March 16, Cahaba consolidated its COVID-19 testing to three clinics: one in Birmingham’s West End neighborhood, and one each in rural Bibb and Perry Counties.

That was done by design, to conserve precious protective gear and testing supplies.

“We thought this would be the way to maximize the number of patients we’re serving,” said Dr. John Waits, “without blowing through PPE (personal protective equipment) for every provider and nurse we have, on every patient.”

Waits is CEO for Cahaba Medical Care, a community health center that operates 16 clinics in Bibb, Perry, Chilton, Dallas, Autauga and Jefferson Counties. The clinics serve patients regardless of their insurance status or ability to pay.

Staff at Cahaba Medical Care in Centreville, Ala. opened a Respiratory Evaluation Clinic in March to screen and test for COVID-19 in rural Bibb County.

And because Cahaba already has sliding fees for patients based on what they’re able to pay, it’s a place where uninsured and underinsured people can be screened and tested without having to go to local emergency rooms.

Recently, Waits, said, he’s been fielding calls from hospital administrators asking if he could open another testing site. The clinics have opened temporary drive-thru sites on certain days, particularly in Jefferson County.

“When (coronavirus) first hit, it seemed like everybody was trying to have their own testing sites,” said Waits. “But now that people are getting sick and ending up in hospitals, the hospitals are trying to preserve their tests for their in-patients.

“The last place we want someone who may not have COVID is to be in the hospitals that are starting to get the sickest COVID patients.”

Nurse practitioner Andria Knighten, left, and licensed practical nurse Amanda Wiggins don protective gear before an afternoon shift at the clinic. Staff at Cahaba Medical Care in Centreville, Ala. opened a Respiratory Evaluation Clinic in March to screen and test for COVID-19 in rural Bibb County.

Bibb County

Wiggins shares the picnic table with Andria Knighten, a nurse practitioner. Until three weeks ago, the pair worked in Bibb County Schools as part of Cahaba’s school-based clinic program.

When the schools shut down, they were reenlisted to work at the evaluation clinic in Centreville, screening and testing patients for COVID away from Cahaba’s main clinic down the road. The clinic tests 20-40 patients per day for COVID-19. They’ve had at least one test positive so far.

The spectre of an overwhelmed hospital and healthcare system looms large, particularly in a rural setting. Waits said local hospital and clinic leaders have been meeting to map out contingency plans if COVID-19 slams their community and their hospital. He and Cahaba Chief Operations Officer Dr. Lacy Smith have held several virtual town hall meetings with their staff to keep them updated on what’s happening and what they could expect.

Knighten said she felt reassured when Waits and Smith told the staff, weeks ago, that Bibb County would certainly have a positive case and that they’d soon see infection numbers rise around the state.

“Instead of freaking out when it happened,” she said, “we knew about it beforehand and it wasn’t as much of a shock.”

Medical assistant Kenya Abner, right, checks the temperature of everyone who enters. Staff at Cahaba Medical Care's West End neighborhood of Birmingham opened a Respiratory Evaluation Clinic to screen and test for coronavirus. The clinic sees patients regardless of their ability to pay.

West End, Birmingham

Kenya Abner waits outside the front door of Cahaba’s West End Clinic in Birmingham with a thermometer, checking the temperature of everyone who enters. It’s a busy morning, the parking lot at least half-full. The front doors of the clinic are propped open to the breezy, 70-degree day, welcoming a steady stream of patients. Some wear masks.

If a patient is there for a regular appointment, Abner sends them into the main waiting room.

But if they’ve got an appointment for a COVID-19 test, she hands them a blue hospital mask and directs them to a separate waiting room to the right. They’ll wait, masked, for their turn to be screened and tested.

Birmingham is the epicenter of Alabama’s COVID-19 outbreak, with hundreds of confirmed cases as of Sunday morning and at least four related deaths.

“It feels like here, we’re stuck on the tracks and there’s this slow-moving train coming in our direction,” said Dr. Jeremy Crider, who works at the clinic. In the past three weeks, the West End clinic has evaluated 454 people and tested 157. Four were positive for COVID-19.

“We’re all waiting for things to get bad,” he said. “It can be nerve-wracking.”

Staff at Cahaba Medical Care's West End neighborhood of Birmingham opened a Respiratory Evaluation Clinic to screen and test for coronavirus. The clinic sees patients regardless of their ability to pay.

On the testing side of the clinic, staff wear head-to-toe protective garb. Once they’re suited up, they’ll stay that way until lunch, and then again until the office closes.

“The more you take (the protective gear) off and on, the more chances you have to contaminate,” said Veronica McDonald, office manager and registered nurse.

“Who needs to use the restroom these days?” she joked. “So overrated.”

An older woman approaches the front door, saying she heard on the news that the clinic offered coronavirus tests. She didn’t have an appointment, but she was fearful about symptoms she’d been having. Abner took her aside, talked with her about her symptoms and made her an appointment.

McDonald, watching the exchange, said the most important thing the doctors and nurses at Cahaba West End can do is to keep the clinic open. Cahaba offers telemedicine visits and is working to educate patients on how to do that. But some low-income families still face barriers to internet access and in some cases don’t have reliable phones.

“We have a lot of people who are not going to hop on a smartphone or computer and do a telemedicine visit,” said McDonald. “They go to the library for internet and the library’s closed, so they have no internet access. We have to be open to provide any measure of healthcare.”

It’s not easy. Cahaba has seen a 40% decrease in regular patient visits as coronavirus has taken hold in Alabama. That kind of financial hit poses a real threat to clinics working to remain open. And it means patients aren’t coming in for treatment of chronic issues that threaten their health.

McDonald said she’s worked with patients to ease their fears about COVID-19 and help them sort through what they’ve heard or read about in the news.

Dr. Jeremy Crider, left, and office manager Veronica McDonald stand outside of Cahaba Medical Care's clinic in the West End neighborhood of Birmingham. They opened a Respiratory Evaluation Clinic to screen and test for coronavirus. The clinic sees patients regardless of their ability to pay.

Many of Cahaba’s patients are using social services now more than ever, McDonald said.

“We’re still helping with things like transportation, making sure they have a gas card if they need it, or bus tokens, and the food pantry is open,” she said. “We’ve definitely seen a spike in people accessing the food pantry.”

At the end of the day, McDonald and the other staff go home and shed their clothes in their garages, scrub down in showers, anything to avoid bringing the virus home.

“Prayer’s always been a part of it, but we’ve been praying more,” said McDonald. “And really just trying to be smart.”

Back in Bibb

The first patients of the afternoon begin arriving as the lunch break winds down. Wiggins, Knighten and the other staff head back inside and help each other suit up, tying the strings on their gowns and adjusting head coverings.

Staff at Cahaba Medical Care in Centreville, Ala. opened a Respiratory Evaluation Clinic in March to screen and test for COVID-19 in rural Bibb County.

Wiggins worries about what might happen if the clinic runs out of protective equipment just as Alabama’s COVID cases begin skyrocketing. Waits and Smith have tried to be creative about finding more gowns and masks, but it’s been difficult.

“It’s on our minds every day,” Wiggins said. “We do what we can to conserve.”

Her main focus, she said, is trying to help patients feel comfortable. Peace of mind doesn’t just come through a test. Sometimes it’s as simple as having someone you trust answer the questions behind your worries.

Cahaba staff recently created videos for patients, to answer their questions about COVID-19 and to explain how to access telemedicine visits.

Wiggins said it helps patients to see a familiar face explaining what’s going on.

“They don’t know people at the CDC so they don’t trust them,” she said. “To hear somebody who’s been working in the community go out there and talk about it and give them updates, it makes a big difference.”

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