HETTINGER, N.D. — Over the last two weeks, the staff at Hettinger’s West River Regional Medical Center have gotten used to hearing “no.”

The 25-bed hospital in the southwestern corner of North Dakota usually refers patients with acute conditions to the medical hub of Bismarck, but the capital city’s two main facilities have recently been too full to take on transfers, said Dr. Josh Ranum, an internal medicine specialist in Hettinger.

That means staff at the rural hospital have to spend hours calling five or more medical centers to arrange for patients to be flown almost 300 miles to Fargo or taken across state lines to Sioux Falls, South Dakota, or Billings, Montana.

Finding no open beds at any of the region’s major hospitals last week, the Hettinger facility transferred a patient recovering from a heart attack by plane to Tulsa, Oklahoma, for a cardiac procedure that normally could have been performed in Bismarck.

“Our drain is plugged,” Ranum said.

Close to 200 COVID-19 patients stacked on top of an unusually high number of non-coronavirus hospitalizations have North Dakota’s understaffed medical centers “busting at the seams,” said Tim Blasl, president of the North Dakota Hospital Association.

The state’s six large referral hospitals in Fargo, Bismarck, Grand Forks and Minot had a combined eight available intensive care beds and nine regular inpatient beds as of Saturday, Oct. 9, according to a state database .

And the severe strain on capacity in the major medical hubs has put pressure on hospitals like West River Regional to do more for patients with fewer resources, beds and staff.

The Hettinger hospital’s inability to send patients to Bismarck hasn’t yet resulted in any catastrophic outcomes, but Ranum said the capacity crisis has disaster potential for patients in need of intensive care.

“We’ve been very fortunate so far, but it’s really easy to foresee a scenario where something really bad happens because there’s nothing available,” Ranum said.

'North Dakota was not an option'

Longtime Hettinger resident Billy Evenson tested positive for COVID-19 last month after working cattle with an unvaccinated person.

Though the 86-year-old was immunized, he struggled to fight off the virus even after receiving monoclonal antibody treatment.

About a week after his positive result, Evenson landed in the hospital under Ranum’s care. On Oct. 4, Evenson looked like he could be “crashing” with a bad case of pneumonia, and staff at West River Regional began searching for a major hospital to take him, Ranum said.

“We knew North Dakota was not an option, so we looked to Rapid City and they said he was 11th on their admission waitlist,” Ranum said.

Medical staff told Evenson there was nowhere in the state taking patients, which was fine with him because he wanted to stay close to home. But those caring for him worried he wouldn’t survive in the Hettinger hospital.

Evenson pulled through and is recovering nicely, but the inability to transfer him to a higher level of care is evidence that North Dakota’s hospital system is out of whack, Ranum said.

Generally, rural hospitals look to send COVID-19 patients to larger medical centers because they have space and staff designed to meet the unique challenges posed by the “high-intensity illness,” Ranum said.

Hospitals are seeing a lower volume of COVID-19 patients compared to last fall, but those with the virus still represent the “thumb on the scale” pushing the health care system to the brink, Ranum said.

The widespread unwillingness to take the vaccine in western North Dakota and South Dakota is “a major driver” of the capacity issues at the Hettinger hospital, Ranum said, echoing national health officials in noting that COVID-19 is now “a disease of the unvaccinated.”

The region surrounding Hettinger has one of the lowest vaccination rates in the country, according to the Centers for Disease Control and Prevention .

From a statewide perspective, Blasl notes that the capacity crunch at rural hospitals is worse in low-vaccination west than the more immunized east.

However, unlike last fall during North Dakota’s worst-in-the-nation outbreak , the issue of lacking hospital capacity is not as simple as COVID-19 patients overwhelming facilities.

Many residents who put off routine medical care earlier in the pandemic are now requiring hospitalization as their neglected illnesses and injuries turn into more serious maladies, Ranum said.

The combination of COVID-19 patients, hospitalizations due to delayed health care and normal admissions has added up to double the typical number of patients in West River Regional’s emergency room over the last few weeks, said hospital CEO Matt Shahan.

Also different from last year is the regionality of hospital capacity issues. When North Dakota hit its COVID-19 peak in November, other nearby states had already made it through the worst of their outbreaks, so their hospitals had room for patients from places like Hettinger.

But this time the extremely infectious delta variant of the virus has synchronized the region’s COVID-19 waves, straining hospitals from Montana to Minnesota and eliminating pressure relief valves for rural medical centers.

Ranum remembers trying to transfer a patient earlier this month when the Dickinson hospital was not accepting new ambulances, the Montana facilities were booked and the “courtesy call” to Bismarck “just to prove that they didn’t have that one magical bed” was predictably unsuccessful.

Dr. Todd Shaffer, incoming president and CEO of Sanford Bismarck, acknowledged that the hospital has been “extremely busy” of late, but he said the staff will do everything possible to keep the doors open and work with smaller facilities.

To alleviate stress on the state’s health care system, large medical centers are increasingly sending patients with less serious conditions to finish their hospital stays at smaller facilities.

West River Regional received notice on Wednesday from CHI St. Alexius that the Bismarck hospital was looking to offload 19 patients to facilities like the one in Hettinger. In normal times, West River Regional might get calls two or three times a week to take patients on the backend of their hospital stays, said nurse and discharge planner Duane Fried.

Blasl said his organization and the state Department of Health will begin holding daily calls this week with the state’s hospitals to facilitate transfers from big medical centers to smaller facilities, though he notes hospitals have been in communication about trading patients behind the scenes throughout the pandemic.

Counter to the national trend, COVID-19 cases continue to climb in North Dakota, but Blasl and other health officials hope infections will crest in the next two weeks. Until then, hospitals likely won’t see much relief, Blasl said.