On the Front Line

On a recent weekday afternoon, Dr. Jeffrey Tjaden sat at a narrow desk in a hospital waiting room, applied a liberal dose of hand sanitizer and swiveled into frame for a live on-camera question-and-answer session on Facebook. Dressed in shirtsleeves and a tie, a stethoscope slung around his neck, the infectious disease physician at Kalispell Regional Healthcare, and a member of the hospital’s newly minted COVID-19 incident command team, appeared at ease as he fielded questions from the community related to the coronavirus pandemic.

How quickly are COVID-19 test results returned? Is antibacterial soap any better than regular hand soap? What’s the best way to don and doff a face mask? How safe is it to eat takeout food? When will we find out how bad the spread of infection is in the Flathead?

The questions popped up in rapid succession on the live stream’s scrolling thread of comments, and Tjaden did his best to answer them. For the past three weeks, the KRH system’s daily Facebook live sessions have offered a representative snapshot of what Flathead residents are wondering and worrying about.

“We have become recurring themes on Facebook live, and we are here to answer whatever your latest questions may be,” Dr. Doug Nelson, chief medical officer at KRH, said by way of introduction during another recent forum, slathering his own hands in Purell.

Even if the rotating cast of health care professionals can’t provide definitive answers to all the questions, the daily dose of information and the high level of engagement is evidence that the community is paying attention, and it offers a lofty platform for the hosts to ask members of the public to do their part as best they can — stay home.

From their vantage on the front line of the coronavirus pandemic, nurses and doctors, medical technicians and hospital support staff, infectious disease specialists, first responders and paramedics — they’re all watching the outbreak unfold up close in real time. And although their experiences vary widely, they’re all repeating the same thing — stay home.

As the burden of social distancing and sheltering in place bears its full weight on Montanans, with many of them accustomed to occupying wide open spaces in footloose fashion, health experts continue billing the constrictive measures as the single strongest defense against the spread of a novel coronavirus, about which little is known.

In places like Flathead County, social distancing is more practical given the relatively low population density and spatial distances separating people, even if that requires additional layers of planning to purchase a gallon of milk or a carton of eggs.

“The hope is that because we started implementing a lot of these social-distancing procedures even before we had confirmed cases here in the Flathead, and because our unique geographic area means we don’t have as much close contact, and because our population density is lower, that we might not have the same heightened degree of epidemic that we’ve seen elsewhere,” Tjaden said. “Even so, we’ve been preparing for the worst-case scenario.”

That grim scenario would involve a rapid expansion of the epidemic in which lots of people are sickened at the same time, potentially overwhelming the limited resources of the health care system with a surge of critically ill patients. The preferred alternative is to “flatten the curve,” which means decrease the spread of the virus through a population so that a smaller number of people are sickened simultaneously.

Nelson said even if the same percentage of the population is sickened eventually, avoiding the spread of the illness immediately will help communities like the Flathead avoid potentially dire consequences.

“We do have the ability as a community to make this better than it would otherwise be, but it requires everyone possible doing everything possible to comply with the social-distancing and stay-at-home measures and really trying to avoid public contact because that is how the virus spreads,” Nelson said. “And if we can stop it or slow its spread, we can really change how it plays out here locally.”

One of the problems with social distancing is that health experts don’t totally know whether it’s paying off due to the limitations of testing. Not only are there not enough test kits available to test everyone who presents symptoms that align with COVID-19, but as many as half of those individuals infected with the illness don’t experience symptoms at all.

Flathead City-County Public Health Officer Hillary Hanson said she gives fairly high marks to the local efforts so far to attempt to flatten the curve and limit the damage of coronavirus in the community, but the dearth of testing is preventing a clear epidemiological picture from coming into focus.

“We would definitely like the opportunity to do more testing. I think that is kind of a sentiment statewide and a sentiment from the governor’s office,” Hanson said, explaining that about 600 tests had been completed in Flathead County. “We have had to prioritize testing and are following [Centers for Disease Control and Prevention] regulations on that piece. So unfortunately what that is not giving us is some of the data depicting the actual amount of folks in the community that may have COVID. We really aren’t getting the epidemiological data that we want around us and we are hoping that will change.”

What health experts do know about the confirmed cases of COVID-19 in Flathead County is that six of those individuals were not exposed while traveling out of state or internationally, or as a result of coming into contact with someone who had traveled out of state, marking the first evidence of community transmission locally. Prior to April 6, the lack of community spread set Flathead County apart from places like Missoula, Yellowstone and Gallatin counties, but Hanson said that is no longer the case.

Additional testing will likely turn up even more cases of community spread, health experts said, particularly as residents settle into a prolonged period of sheltering in place during which most travel has been stymied.

The availability of more test kits may soon arrive, however, and the longer the Flathead Valley delays its period of “peak illness” — in other words, the more its residents do to flatten the curve — the more time health care professionals have to shore up resources.

“If the world was our oyster, if we could choose whatever tool we wanted, I would want more testing,” Nelson said. “If we had unlimited testing we would just test everyone to understand how widespread it is in the community, and we could improve our ability to do contact tracing.”

According to Tjaden, as companies manufacturing the test kits increase their inventory and improve the technology allowing for more rapid results, the better the outlook for the Flathead.

“If we can delay our peak or delay the number of cases from spiking even by a few weeks, we could start to see a lot more test kits available,” he said.

Weeks before the first case of COVID-19 was detected in the Flathead, the leadership team at KRH began meeting on a regular basis with state and local health officials to discuss their level of preparedness and take stock of critical resources.

The hospital also began limiting non-essential hospitalizations, in large part by limiting elective surgeries — operations that a patient needs to have but that are not time sensitive or critical.

“We currently have plenty of bed capacity, and we are doing everything we can to free up additional space,” Nelson said, explaining that KRH has 18 adult intensive-care unit beds, as well as 12 intensive-care beds that it can make available in the old intensive-care unit.

“We have made specific plans for the use of those facilities for the sickest of the sick, or basically those who need ventilators,” Nelson said.

The organization has additional capacity at North Valley Hospital and at the Montana Children’s medical center, while operating rooms are equipped with anesthesia ventilators. Nelson said he remains hopeful that the measures to expand the hospital’s capacity will allow the facility to provide care for all patients and perform lifesaving functions by artificially ventilating patients who experience acute breathing difficulties.

The biggest strain on resources has been to KRH’s dwindling supply of personal protective equipment — masks, respirators, gloves, gowns, goggles, and other supplies that are in high demand as staff cycles through the gear more quickly to interact with potential COVID-19 patients.

“That equipment is highly dependent on the supply chain, so if we did have a sudden outbreak our inventory could be depleted pretty quickly,” Nelson said.

To help gird against that scenario, KRH launched Project PPE, soliciting donations of protective equipment from members of the community and local businesses, the results of which have been uplifting, Nelson said.

“We are so incredibly grateful for the ways in which the community has stepped up to help,” Nelson said.

KRH set a goal of amassing 10,000 masks or respirators, and had a total of about 4,000 masks as of April 6, including sewn cloth masks, 3D-printed masks, N-95 masks, surgical masks, and face shields.

“It sounds like a lot, but it’s not that many,” Nelson said.

The drop-off site for donations is located at the north entrance of the Summit Medical Fitness Center Monday through Saturday from 9 a.m. to 3 p.m. Visit krh.org/projectppe for mask patterns and tutorials.

On March 26, Montana Gov. Steve Bullock issued a stay-at-home directive through April 10, marking his most dramatic measure to curb the spread of coronavirus, and he was expected to extend the order by at least two weeks.

According to Nelson, the projection models vary widely, but the data he’s been assessing show COVID-19 cases peaking in Montana later this month or in early May.

“The model I have looked at most predicts a peak of cases in Montana in late April and early May, but that is dependent on lots of different factors, including what we do now in terms of self-isolation and social distancing,” Nelson said.

That may seem like a tall order for people stuck at home, but the alternative, he said, is much starker.

“Maybe I am naïve, but I am still hoping that this is a very controllable thing and we can have a relatively mild epidemic here,” Nelson said. “But we are still making preparations for the worst-case scenario, and whether that occurs is largely based on our actions now.”