MICHEL MARTIN, HOST:

Cities like New York and Seattle and New Orleans have been the focus of much of our attention about the coronavirus outbreak. But we want to turn our attention now to rural areas where even before the coronavirus pandemic hit the United States, many rural hospitals were struggling to keep their doors open. And one of the states that's been struggling is Missouri. It's one of five states that has experienced the most rural hospital closures over the past 10 years.

We wanted to understand how vulnerable rural hospitals are preparing for the pandemic, so we've called Dr. Randy Tobler. He is the CEO of the Scotland County Hospital in Memphis, Mo. The pandemic has yet to hit the area, but some staff there have already been laid off and furloughed so the hospital can afford vital equipment to protect against the coronavirus. And Dr. Randy Tobler is with us now.

Thank you so much for being with us.

RANDY TOBLER: My pleasure, Michel. Great to be with you.

MARTIN: Well, first, I do want to ask how you and your staff are doing right now. How are you holding up?

TOBLER: I think we're holding up like we hold up when we see a big storm coming across the horizon. We know it's going to come - not exactly sure how, when, how heavy, how many inches of rain it'll drop. But we know it's coming, and so we're preparing. And this is on top of a fairly fragile rural health economy to begin with. And so there's just a lot of anxiety, although we're ready, and we're locked and loaded and ready to go whenever it hits.

MARTIN: I want to hear more about that, but I do want to mention that the governor of Missouri announced yesterday that a stay-at-home order would go into effect starting Monday morning. Has your hospital seen any patients with coronavirus yet?

TOBLER: They are closing in. We're getting more positives in the contiguous counties. We serve about a four-county area, and we heard east of us, there are six or seven to the south of us. So we have sent about 30 tests to date. We have 24 that are negative and six pending, so not yet. But we also know that we've probably - because of the lack of available testing, we have to ration the tests. There are probably positive people that just haven't been tested positive yet.

MARTIN: So I understand that you have only 25 beds at your hospital. So when you work in a space like that, how are you going to be able to isolate non-coronavirus patients from patients with symptoms that would warrant hospitalization?

TOBLER: Right. Well, we have - the hospital was remodeled about eight years ago, and in that process, we as built two negative-pressure isolation rooms. However, our maintenance crew and our facility ops staff have really dropped some barriers and made essentially a makeshift isolation corridor. And we've now expanded our two rooms with two beds up to eight rooms with a total of 13 beds.

And we've already had a couple of folks while we were waiting for the long turnaround testing to come back, the persons under investigation, if you will - they have occupied a couple of the rooms. We have a part of that corridor that's set aside for obstetrics. We're one of the few critical-access hospitals that does obstetrics as well. So that isolation corridor, if you will, is really segregated from the rest of the hospital for those purposes.

MARTIN: So I understand that you have now remaining - or you've got seven physicians and nine...

TOBLER: Yes.

MARTIN: ...Nurse practitioners. Is that right?

TOBLER: That's right. And we run three rural health clinics as well as the hospital.

MARTIN: So with a staff that small, I mean, you can't really afford to - if things get bad, you can't afford to have anybody get sick because then you're really in trouble. So the question, of course, then becomes - I mean, you're hearing - we've seen in New York in particular hospitals really struggling to supply staff with personal protective equipment. Do you think you have what you need right now?

TOBLER: Well, we have what we need at the current burn rate. But when we had just a few days of those isolation patients that we were, you know, waiting for those test results that were taking initially seven to eight days to get back, we were burning through the N95 masks and the disposable gowns. And it was getting really tight.

I get a daily report on our resources. And we think all we need to do is have one or two isolation rooms occupied - and remember, there's other reasons to isolate people other than, you know, coronavirus - we could be looking at less than a week in any one of those critical categories.

So we decided the other day at our regular COVID response team meeting to really gear up and buy the full face mask with respirators and the Tyvek suits so that those - the staff, whether it's nurses, doctors or respiratory therapist and others that spend any concentrated time with those patients are going to be absolutely protected. Because what we've learned as - is from the other experience that even with the allegedly great protection, N95s and goggles, health care workers are dropping like flies, you know, when it does hit the unit.

So we're going to be, I think, as protected as a staff can be because, like you say, all it takes is one or two of us to go down, and then we can't render the service to our community.

MARTIN: And what about ventilators?

TOBLER: We have three ventilators. We can borrow anesthesia ventilators if we need. We have a couple of BiPAP machines which can be used as - with some ventilation. The current state in Missouri is that the stockpile is being reserved for the hot spots - St. Louis and others - that are developing. And you have to document a coronavirus case before you can request and hopefully receive the personal protective equipment. So it's one of those Catch-22s. You have to get the disease in your facility before you can get the stockpiled equipment.

MARTIN: Wow. Well, you have excellent bedside manner. I mean, you inspire confidence. You sound very - kind of confident. But I do want to ask - what - something must be keeping you up at night. And do you mind if I ask what that is? What are you most concerned about right now?

TOBLER: Yeah. What keeps me up at night is I'm watching a staff that has already had its resilience tested because of the great financial challenges. We go through convulsive moments of wondering whether we can make a payroll up the road, one or two payrolls. That's gone on for the last year or two. And I see a staff that is just banding together and sacrificing and ready to go.

And I just wonder if we're going to have as much resilience as we're going to need depending on how steep that curve is. I hope that it's flattened so that we can cope with it. I hope that we're able to weather the storm and serve our patients before we either run out of stamina, our personal health or our money. That's what keeps me up at night.

MARTIN: That's Dr. Randy Tobler. He's CEO of Scotland County Hospital in Memphis, Mo.

Dr. Tobler, thanks so much for talking to us. And let's keep in touch. I'd love to see how things are going.

TOBLER: Look forward to that. Thanks for talking with me, Michel. Enjoyed it. Transcript provided by NPR, Copyright NPR.