Lisa Swanson assumed she was probably sick with COVID when, in late October, she was congested and coughing with aches through her whole body. Then, finally, came the positive test, and the readout on an oximeter her friend had given her: 83.

That number measures oxygen levels in the blood, and it’s dangerously low for a reading that usually hovers above 95 in healthy adults. Swanson, 54, waited a day. She said she wasn’t really thinking of how bad it was, her mind fogged by illness.

The next day, Oct. 31, she was at RiverView Health in Crookston, hooked to a heart monitor and oxygen, undergoing X-rays and blood work. She was hit with a severe case of the virus, but considers herself lucky.

“The doctor had come in and said, ‘There’s no way you can go home. You’re being admitted,’” Swanson said this week. “And he had called, and both Fargo and Altru (hospitals) were full, and that I was getting the last COVID bed at RiverView.”

Carrie Michalski, the president and CEO of RiverView Health, acknowledged hospital resources have been tight.

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“Yesterday we had more patients in our care than we have had in the previous 30 days, both COVID care and other acute care patients,” she wrote in a Friday email to the Herald. “We have said often, our nurses and doctors have been battling since March on the frontlines, (but) really we have been battling at the last line of defense.

“We are battling when other systems to contain and prevent spread have failed. What we need every community member to realize is hospitals are not the frontline, citizens are the frontline,” she added. “The choices the community makes on the frontline to mask or not mask, to use good hand hygiene or not, to stay home when ill or not, to congregate in large groups or not, that is the frontline.”

And there are plenty of hospitals where leaders say they’re running out of space and burning out staff — whether that’s in rural counties or in Grand Forks, where officials say beds are tight and staffing is growing stretched as well.

“You're at the point where the balloon's going to pop,” said Pete Antonson, CEO of Northwood Deaconess Health Center, a rural hospital in Grand Forks County. He said he’s reluctant to make doom-and-gloom predictions, but he wonders how far away the system is from triaging patients, or from some people going without care.

“We hope that we're not going to get to that,” he said. “North Dakota takes care of its people, and they seem to have ways to figure things out. But at some point, when does too much become too much?"

Eight long months ago, when the pandemic began, the mantra to “flatten the curve” — and keep infection rates from spiking — was really about keeping the health care system working. If citizens stayed safe and distanced, the logic went, patients who needed medical care would get it. They wouldn’t be crowded out by the overwhelming demands of the pandemic.

But resources are getting thin, and Swanson’s brush with the limits of the health care system is increasingly common in the Grand Forks region. COVID and a surge in deferred medical needs are combining to fill hospitals, run nurses ragged and raise serious concerns about what the next few months will bring.

Antonson said a heart attack and a hip fracture patient both took hours to be transferred to a bigger facility — waiting until there was a space available to take them. Nursing staff are under a deluge of work, but they can only be in so many places at once, and can only sustain so much effort before burning out.

“Beds are very tight,” said Janice Hamscher, chief nursing officer at Altru Health System. But she pointed out that the limitations of local health care aren’t always rooted in beds, but in the number of nurses that can tend to them, now thinned by COVID absences. “What you have to understand is, you know, there’s a physical bed, and then we have to have the staff to go along with that. So that has been a challenge for us.”

Altru officials stress that people who need it should still seek medical care, especially in emergency situations. But it’s also true that resources are getting thinner; Annie Bonzer, an Altru spokeswoman, said that Altru will receive nursing support staff from the U.S. Air Force — part of a contingent of military nurses that were reported on Thursday night to be headed to North Dakota. But on Friday morning, Bonzer said further details on their arrival weren’t available.

Bonzer shared a look at some of the hospital’s internal numbers, though. She said that, out of 23 ICU beds at Altru, 20 are full — and four of them are occupied by COVID patients. For general inpatient staffed beds — not including ICU — there are 117 out of 147 currently occupied, with 29 of them assigned to COVID patients (Bonzer stressed these numbers are in constant flux as patients’ status change and as new patients are admitted).

For the better part of a year, regional hospitals have managed to push through the pandemic. But for months, a new surge in cases has strained their resources like never before. North Dakota has led the nation in new cases per capita for weeks, according to a New York Times database, and state data shows Grand Forks County’s COVID hospitalizations have risen explosively since October.

The proverbial curve is anything but flat, and the health care system is getting closer all the time to a tipping point. Thanksgiving is coming, and families will likely gather in dangerously large groups indoors. The onset of winter’s coldest months will mean the same, and COVID cases look set to rise even more.

Finding beds

Grafton’s Unity Medical Center is eight months and counting into the pandemic, and space is at a premium. The small, rural hospital serving Walsh County, North Dakota, is licensed for 14 beds, but it isn’t really built for that many.

So, under an influx of patients, the staff is doing what they can. CEO Alan O’Neil says a waiting room has been turned into an overflow area. There is a bed in the hospital chapel. At times, surgical staff have been asked to help on the hospital floor.

“We have nowhere to transfer them to,” O’Neil said. “For the most part, (hospitals in Grand Forks and Fargo) are doing their best. But they’re full, too. So we have to make it work here.”

Matthew Viscito, the hospital’s chief medical officer, said the same. When patients walk in the door who simply can’t be kept in Grafton, he said, they’ll be sent wherever there’s a bed — even if that means an urban hospital in Minnesota.

“There are beds out there,” he said. “We’re just going to have to put (patients) in an aircraft to find them one.”

Bill McKinnon is Altru’s medical director of regional operations, and deals with precisely that kind of logistical pressure: where to put incoming patients from clinics and critical access hospitals. He said Altru is getting up to five times the usual rate of requests for transfers.

“And this is typical throughout the state at this point,” McKinnon said. “It’s not unique to Altru at all. Every larger institution in the state is experiencing the same problem.”

One of the consequences of a health care system filled to the brim is obvious: patients could have to travel extraordinary distances to get a hospital bed as the system fills and, in Antonson’s words, the balloon pops. Other consequences are more long-lasting.

“The labor force in general, I do think that we're completely going to lose nurses to practice in general,” said Tessa Johnson, president of the North Dakota Nurses Association. She’s worried about the strains put on health professionals now and across the coming winter. For example, how can nurses be retained in North Dakota in light of all those demands and burnout?

And there’s a big question, far in the future, of money. Health care workers are often racking up 60- to 80-hour weeks at steep overtime pay. Many hospitals say things are fine for now, but how much more financial aid — especially in rural areas — will hospitals need?

“How much water are you going to need to carry when you cross the desert on foot?” O’Neil asked. Though things look steady for now, he said, it’s hard to say what the far future looks like. “You don't really know. The more you can carry, the more you have in reserve.”

McKinnon says he has “guarded optimism” about where the next few months take the region. Yes, Thanksgiving is coming; yes, the winter will drive the region’s residents indoors. But he’s heartened by new masking orders — statewide and local — and by new treatments for the virus. And he said he’s hopeful that Americans make smart decisions to stay distant and keep the virus under control.

“That’s been proven everywhere — that once people make up their mind and have a social conscience … it makes a difference,” he said. “That’s probably the biggest reason I feel optimistic.”