Health officials in rural communities are worried that Thanksgiving gatherings could take things from bad to worse and, in some places, overwhelm already strained health systems.

The small towns surrounding Spokane County have experienced a surge in cases in recent weeks, mirroring trends seen statewide.

In the past two weeks, the Northeast Tri County Health District, which covers Ferry, Stevens and Pend Oreille counties, reported 303 new COVID-19 cases, a record number accounting for a third of their total cases confirmed thus far in the pandemic.

Similarly, Lincoln County has seen more than 50 cases in the past few weeks, which account for a third of the total cases recorded in the county.

In some ways, the spread in rural areas is a reflection of how the disease travels from the city to the countryside.

“What we’re finding is a lot of our cases that we’ve identified here, we can track back to people in Spokane,” said Ed Dzedzy, public health administrator in Lincoln County. “It’s just the nature of the beast, and it’s not pointing a finger at anybody, but the virus is going to do what it does; People move from rural to urban to buy goods and go to work.”

Lincoln County experienced a few larger outbreaks this month in long-term care settings and one larger family cluster. In the three counties north of Spokane County, outbreaks at social gatherings, workplaces, restaurants, bars and churches have led to a surge in cases.

The Northeast Tri County Health District had to stop contact tracing last week due to so many cases, particularly in Stevens County, which is seeing the highest increase of cases it’s had in all the pandemic. The district is focusing its resources on doing case investigations, reaching out to all people confirmed to have COVID-19, and asking them to reach out to their close contacts.

“We were contacting all those close contacts and letting them know what requirements are,” Matt Schanz, administrator at the Northeast Tri County Health District, told reporters last week. “That became something that’s not sustainable for us and had limitations on its effectiveness as well.”

The Washington Department of Health announced this week that it’s hiring 350 more contact tracers and investigators to support local health jurisdictions by mid-December, which could help smaller health departments meet the challenge of tracing all contacts with cases surging.

“We expect two weeks after Thanksgiving to see a case increase and three weeks after Thanksgiving to see our already critical hospitalization levels get higher,” Northeast Tri County Public Health Officer Sam Artzis told reporters last week.

Hospitalizations due to COVID-19 in critical access hospitals present unusual challenges for health care systems already limited in beds. Critical access hospitals are licensed for 25 beds, but this doesn’t necessarily mean they have the staff to take care of that many patients, especially COVID-19 patients, who often require multiple care providers and more attentive staffing.

That’s not to say that rural hospitals cannot care for COVID-19 patients, however. All hospitals in Washington, including those in rural communities, have access to the latest drugs and treatments for COVID-19, but not all critical access hospitals have intensive care units.

“Every hospital in the state has the ability to care for COVID patients; that’s not to say that every hospital can care for the worse-off patients. Not every rural hospital has an ICU, so if somebody is really looking like they will have a high-acuity case, a hospital will need to judge whether or not they can care for that,” said Jacqueline Barton True, vice president for rural health programs at the Washington State Hospital Association.

“But if someone has a lower-acuity case, maybe they just need some oxygen or they need some therapeutics, our rural hospitals had the summer to prepare.”

While there is capacity at rural hospitals, many administrators are expecting a coming surge and are well aware that too many COVID patients could overwhelm them, largely due to staff shortages, not for lack of space or beds.

Recruiting nurses to rural hospitals was a challenge before the pandemic, and the shortage could be worsened if more people in these regions continue to gather and transmit the virus to one another.

At Lincoln Hospital, staffing challenges have impacted the Davenport-based critical access facility throughout the pandemic, said Tyson Lacy, chief executive officer.

“It’s not due to staff being COVID-positive or quarantining, it’s just finding staff consistently that can do this,” Lacy said.

Rural hospitals are caring for COVID patients in addition to other patients, but when outbreaks in long-term care facilities lead to a demand for hospital care, they can quickly find themselves at capacity.

In October, Pullman Regional Hospital was at or near capacity due to the increase in cases and severity of the cases, primarily in older residents there.

“October was a difficult month with outbreaks in long-term care facilities, which led to deaths and hospitalizations, and led to the regional trend of full hospitals,” said Ben Stone, public information officer at Whitman County Public Health.

While case counts have calmed in Whitman County since students returning to Pullman drove them in August and the October surge, health officials there confirmed 130 new cases in the past five days. Currently, there are six residents hospitalized with the virus.

Now, Pullman Regional Hospital is back to about 50% capacity, but like other regions, is preparing for surges in the coming weeks and months.

At Newport Hospital in Pend Oreille County, just four COVID patients being hospitalized could force hospital leaders to begin to make difficult decisions about elective procedures, said Jenny Smith, incident commander and public information officer. And while they have the beds and ventilators to treat more COVID-19 patients, Smith said finding staff to care for patients is challenging.

Drawing the connection between community members’ behavior and hospitalizations is vital for rural public health and hospital officials.

More COVID patients needing treatment in hospitals takes up precious staff resources that might be needed for other emergent or urgent procedures.

“We are concerned that if we have local patients that need that critical care, that there isn’t going to be any place for them to go,” Smith said.

In other words, bed counts do not tell the full story, especially with vital resources strained regionally, like traveling nurses or transfer capabilities to larger facilities. Too many COVID patients in a local hospital can lead to challenges in caring for all of a community’s needs – including those more urgent than elective surgeries.

“If you have a car accident or heart attack and you need to go to your local critical access hospital and possibly be transferred to another tertiary hospital, there isn’t going to be space,” Smith said.

Keeping local rural health systems afloat is top of mind for health officials, and they pleaded with residents to heed the governor’s guidance to not gather for Thanksgiving.

“Hopefully a lot of individuals take this to heart and take a lot of responsibility for loved ones that are at risk,” Stone, with Whitman County Public Health, said.

“Then also, Thanksgiving is one of those holidays centered around multigenerational families, so it could bring a lot of cases in higher-risk demographics.”

The coming weeks will show how detrimental or potentially curve-bending the Thanksgiving holiday is for rural communities.

“It’s going to be critically important,” Artzis said of following the guidance to not gather outside of their immediate households.

“We talk about ‘If and when,’ but we’re currently in the ‘Now’ of this crisis.”