October 2020, Volume XXXIV, Number 7

rural health

COVID on the North Shore

Establishing trust to meet the challenge

s we in medicine face this pandemic of COVID-19, we face a reality where therapeutic medical approaches and public health measures start to become one and the same.  In a disease where treatment is largely supportive even in the most advanced tertiary care hospitals, we have been repeatedly humbled and brought to the realization that what answers we have, lay largely outside clinic and hospital walls.

I practice family medicine in the far reaches of the Arrowhead in Grand Marais, MN.  Many readers will associate this area as a popular outdoor tourist area and have likely visited themselves.  The Sawtooth Mountain Clinic where I work is a Federally Funded Qualified Health Center and the only outpatient clinic in our county of 5000 people.  Likewise, the attached county hospital, North Shore Health, is the only hospital in the county where we as family medicine providers also staff the inpatient service.  We have 16 beds, no ICU capacity, and no specialty physician presence other than infrequent orthopedic follow up.  The nearest ICU is over 100 miles away in Duluth, Minnesota.  When the COVID-19 pandemic became a stark reality, our local public health department had a sum total of one staff person covering the entire county.  Our remote location and small scale immediately pose significant obstacles when it comes to providing care for an illness that causes rapid deterioration and too often requires highly specialized care, not to mention that our age demographic is heavily weighted to those most at risk of complications.  Those same obstacles, however, also have proven to be assets.  At the time of this writing, our county has the lowest case count both in absolute numbers and per capita across the state.  I readily admit that much of our success can be attributed to factors out of our hands.  We have a low population density, only one long-term care facility, no meat packing plants, a nearly nonexistent homeless population, and nearly everyone speaks English as a primary language.   I also readily admit that our situation can change in an instant.  That being said, we have clear examples of the success of our local efforts and I hope that it can be of help to others.

our age demographic is heavily weighted to those most at risk of complications

If I could name the most important strategies that have had the biggest effect in keeping our numbers down, it would be the collaboration across public entities and our investment in public health.  Early on in the pandemic, it was clear that we could not place our hope in a readily accessible cure for this disease.  COVID-19 was humbling advanced hospital systems across the world.  Our clinic and hospital recognized that our best chance to avoid becoming overwhelmed was to do our part to promote the public health measures shown to reduce the burden of this disease on healthcare.  Already some of our staff was funded in part by public health funds through the County.  These team members quickly shifted gears to support public health messaging and outreach to local businesses.  We also immediately brought our local public health coordinator into the incident command meetings at the hospital so that she was aware of the capabilities and challenges of our remote healthcare system and vice versa.  From those regular communications we coordinated with the popular local radio station that graciously offered regular airtime three times per week where representatives from public health, the clinic, and the hospital could keep the public informed on the latest COVID-19 information.  A lot of time was spent making sure that our messaging was consistent and accurate.  I don’t think I can emphasize how important that consistent messaging has been in establishing trust with our community.  From a foundation of trust with the community, we have been able have some impact on how this virus spreads.

One of the most immediate obstacles we faced was the fact that over 80% of our economy is tourist based.  This seemed to be a major liability realizing that with tourism would inevitably come the virus.  We made statewide headlines highlighting tensions between locals and visitors, most notably when a large tree was cut over the highway in an effort to keep tourists and COVID-19 out.  Despite objection from some locals, however, it was readily apparent that tourism was coming whether we wanted it or not, and that the implications of trying to shut down 80% of our economy would have far reaching effects on the overall health of our communities.  Our response was to bring together representatives from the local Chamber of Commerce, the clinic, hospital, and not least public health.  National headlines were pitting public health and the economy against each other, but our local group managed to make headway with a best practice guide for local businesses, support for creating business preparedness plans, and on-site visits by public health to help businesses address concerns and strengthen their implementation of best practices like physical distancing and masking.  The key to this business-public health partnership was that it was not a punitive process, the businesses were requesting the visits. The work of the Chamber of Commerce was critical to establishing that trust and businesses rose to the challenge.  The clinic and hospital’s role was to consistently emphasize the importance of these interventions to those in the business community.  The summer of 2020 ultimately proved to be busier than ever with more visitors to our area than most other years.  A recent poll showed that around 40% of businesses reported revenues at or above an average year.  Most notable is that at the end of this summer tourist season, there was no evidence of transmission from a tourist to a local resident.

Our best chance to avoid becoming overwhelmed was to do our part to promote the public health measures

The largest initiative, and potentially the most important has been establishing our own local contact tracing.  Our clinic triage nurses have been inundated throughout the last six months with questions regarding what to do when local businesses and community members were told that they were in contact with COVID-19.  Our nurses did not have the training, nor the time to adequately address these concerns.  It was also apparent that local residents and businesses that were involved with the statewide contact tracing process continued to have questions.   We coordinated with public health to directly route those calls to their newly formed public health team who has the training and resources to clarify community questions.  Additionally, in collaboration with the clinic, and hospital, and nearby Grand Portage Band of Lake Superior, our local public health coordinator realized that our local resources have innate advantages over the statewide contact tracing system.  Through CARES Act funding that was graciously offered by the local county system, public health expanded their workforce and is assuming contact tracing for our region in collaboration with the Minnesota Department of Health, Grand Portage Band of Lake Superior, and the neighboring Lake County public health.  By creating a local contact tracing program, we now have people who live and work in this community providing our contact tracing.  This allows them to avoid some of the mistrust that limits the effectiveness of other programs.  Our local tracers know the connections within the community, they are often familiar voices to those they are calling, and are highly motivated in their work, because it directly impacts the community in which they live. 

The local contact tracing program also addressed the inherent delays in the statewide system.  It was immediately clear with our first cases that there could be a delay of several days between our lab getting a positive result and the initiation of contact tracing in the statewide contact tracing system.  In the case of a virus that transmits up to two days before symptom onset, this delay risked any benefit that contact tracing could have.  We now have direct communication from the lab to our local public health team.  Almost as soon as the patient’s provider knows of a positive case, a contact tracer is notified and ready to begin that process. In one case this allowed us to isolate an asymptomatic adolescent contact at high risk of spreading COVID-19, and in another prevented over 20 high risk contacts from going back to the local school for what could have been days prior to the initiation of contact tracing.

As with every other health system, we have put in an enormous amount of work preparing to safely care for patients with COVID-19 both at the clinic and hospital, but I cannot yet speak to rural care of a hospitalized COVID-19 patient.  As of the writing of this article, no local residents have needed hospitalization for COVID-19.  And that is my point. There are ways to slow the spread of this virus.  At their core they are not complicated.  The essence of what we have done here can be done elsewhere.  My sincere hope is that our small community can be an example of how we can come together and make a difference in this pandemic.

Kurt Farchmin, MD, is a board-certified family physician practicing in Northeast MN.  He specializes in full scope family practice medicine, including treatment for opioid use disorder. 

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Kurt Farchmin, MD, is a board-certified family physician practicing in Northeast MN.  He specializes in full scope family practice medicine, including treatment for opioid use disorder.