The folding chairs outside the windows appeared late last month, after the maintenance staff at St James parish hospital labeled each window with patient numbers so families and friends could at least see their loved ones battling Covid-19.

Yet even this small solace the Louisiana rural hospital can offer is tainted for Leslie Fisher, a clinical nurse educator. She has to remind the family members to take shifts to properly physically distance from each other – even when their loved ones could quite possibly be in their final moments.

The difficult conversations feel unceasingly cruel, she said, but she feels she has an obligation to protect these people, too. All she can do is look them in the eyes and say: “I’m so, so sorry.”

Folding chairs outside the hospital’s windows allow families and friends to see their loved ones battling Covid-19. Photograph: Courtesy of St James parish hospital

This is the new normal for St James parish hospital, a 25-bed rural hospital located about 45 minutes from New Orleans, a pandemic hotspot. Its county – or parish, as they call them in Louisiana – of 22,000 residents already has confirmed more than 175 cases and six deaths as of Tuesday. That earns it the horror of being one of the hardest-hit counties nationwide for cases per capita, placing its rural hospital that sits just blocks off the east bank of the Mississippi River on to the frontlines with a continuous swell of patients.

Previously battered by hurricanes and a flood, the hospital is used to more than its fair share of disasters. But in the aftermath, it has usually been able to rally help from around the country, CEO Mary Ellen Pratt said by phone.

Now, communities nationwide have to fight their own battles, leaving St James parish hospital to make do with limited staffing, testing, personal protective gear and mechanical equipment. Although working with limited resources is something rural hospitals know how to do well, Pratt said, this is something entirely different.

‘I want to ventilate everyone. I want everyone to live’

Before the pandemic, the hospital housed about eight inpatients a day. Almost overnight, it’s up to 20 inpatients some days, the majority of them with suspected Covid-19. Dozens of positive cases, with many more suspected, have passed through its doors.

To add to the challenge of the crush, the severity of the patients’ conditions is much worse than those of its typical patients, especially for a hospital without an official intensive care unit.

Jared Olivier, an MRI technician, drove six hours roundtrip to pick up a ventilator from another rural Louisiana hospital. Photograph: Courtesy of St James parish hospital

While the hospital has had two ventilators staff can use before transferring patients to more advanced facilities, the wait times to transfer patients to other hospitals have continued to lengthen. Pratt said she has been dismayed at how often she’s had to use the ventilators so far.

“We’re intubating every single day, several patients a day, when we maybe do it on a monthly basis,” she said. “It’s crazy.”

The hospital is planning to bring five more ventilators online in the next few days – three are rentals, one is a converted anesthesia machine, and a staff member drove six hours round-trip to pick up the final one from another rural Louisiana hospital.

The bigger surrounding hospitals 45 minutes away continue to be packed with their own Covid-19 patients. If the other hospitals begin to deny transfer requests, Pratt and her staff may be forced to make unthinkable decisions about rationing care.

Fisher can hardly speak of the possibility.

“My biggest fear and the fear of the entire hospital is that we’re going to have to end up choosing who we are going to ventilate,” she said. “I want to ventilate everyone. I want everyone to live.”

‘When it starts getting into your local hospital, it becomes real’

Maitland John Faucheux III – who goes by Spuddy – didn’t think there was much to this whole coronavirus thing back at the beginning of March, which feels like an eternity ago now. The 62-year-old owner of Spuddy’s Cajun Cooking, which is about 18 minutes from the hospital, added that in retrospect, he had been a bit hard-headed about the whole thing.

But then the Rev Leon Franklin, a 60-year-old Baptist pastor in St James and a “jolly” customer for years, died at St James parish hospital of Covid-19 in the middle of March.

“When it starts getting into your local hospital, it becomes real,” Faucheux said.

The hospital, on the other hand, had been preparing since January. As soon as it had its first suspected case, a patient who arrived on 13 March, it activated its emergency operations. As more people of all ages came in complaining of a fever, cough and respiratory symptoms, Pratt ratcheted down the hospital’s five entrances to three. Anyone who enters is checked for fever. Hospital staff also redesigned the internal layout to offer more separation from Covid-19 cases.

Using Facebook, a county resident raised thousands of dollars to buy the staff food and snacks. Photograph: Courtesy of St James Parish hospital

Elective surgeries, therapies, tests and labs – which provided about 80% of the hospital’s revenue – were canceled. Pratt said she’s been too busy dealing with the crush of patients to even think about the implications for the hospital’s bottom line. That’s a real concern because even before the virus struck, many rural hospitals nationwide limped along financially, with more than 120 closing in the past decade.

Typical days in the emergency room start off by triaging the potential coronavirus patients by the oxygen saturation of the patient’s blood, the emergency room medical director, Dr Will Freeman, said. For those who are in better shape, hospital staff must spend a fair amount of time convincing them it’s safer to be at home.

Top of mind is how to manage the diminishing amounts of personal protective equipment: nurses are each given one N95 mask a day and put a protective mask on top of it.

Testing has been another frustration.

“We’re still limited,” Freeman said. “Not every person is getting tested, for darned sure.”

Freeman urged other rural hospitals nationwide to start planning today.

“If you’re one of the fortunate areas that doesn’t have many cases – that doesn’t think it’s coming – it’s going to come,” he said. “One day, it’s going to be there.”

‘I’m completely terrified of what I’m bringing to my children’

The surrounding community has stepped up – sewing cloth mask protectors and making a big sign outside the hospital that says “HEROES WORK HERE”. Using Facebook, a resident raised thousands of dollars to buy the staff food and snacks.

But the personal toll and sacrifice have been heavy for staff. They’re working all hours of the day, in enhanced roles – techs who normally assist with surgery are working as bedside aides in the Covid-19 unit, Pratt said. Employees are being repurposed to clean rooms for infection control.

Fisher’s face is another marker – she has a bandage across her nose from the constant digging of her goggles into her skin.

Every day, it seems, someone else’s family member or a member of the community needs treatment, Freeman said.

A sign decorates the lawn of St James parish hospital. Photograph: Courtesy of St James parish hospital

“We take care of all of our patients like they’re our family, because they are our family,” he said.

Which is one of the staff’s greatest concerns: what they’re bringing home. Fisher sent her kids, ages seven and 11, away to her parents’ house and now FaceTimes her girls each night, which she said was incredibly difficult.

“My child asked me the other day why am I a nurse,” she said. “And my answer was God called me to be one.”

Laurie Webb, the hospital’s cardiopulmonary director and a registered respiratory therapist, started sobbing when talking about her own four-year-old and nine-month-old. She isn’t able to send them away because of their ages. Her nightly routine involves stripping naked in front of her patio – “it’s pretty humiliating” – putting her clothes in a bag, Lysol-ing her shoes and heading straight for the bathroom.

“I’m completely terrified of what I’m bringing to my children and husband, but I can’t stay away from my family,” she said through tears.

As of Tuesday, at least 16 of the over 200 employees had tested positive for coronavirus.

During one call with KHN, Pratt, the CEO, coughed.

“I am feeling OK,” she said. “I’m just tired.”

On her mind, always, is what happens if more and more and more patients keep coming – and the hospital runs out of ventilators.

“I can’t imagine, I don’t want to think about it,” she said. “I pray that we don’t get there.”

Kaiser Health News (KHN) is a non-profit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente