BISMARCK, N.D. — When Tammy Gimbel called to check on her 86-year-old father two weeks ago, he sounded weak. He was rushed to Sanford Medical Center in North Dakota’s capital, where doctors said he had the coronavirus. But all the hospital beds in Bismarck were full, his relatives were told, and the only options were to send him to a hospital hours away in Fargo, or to release him to be monitored by his daughter, who was herself sick with the virus.
Ms. Gimbel and her father hunkered down in a 40-foot camping trailer in her backyard to try to recover. He only got worse.
“There I sat in my camper, watching my dad shake profusely, have a 102 temperature with an oxygen level of 86,” Ms. Gimbel recalled. “I am sicker than I had been the whole time, and I wanted to cry. What was I going to do? Was I going to watch my dad die?”
As President Trump returned from the hospital, still telling Americans not to be afraid of Covid-19, the coronavirus has exploded in North Dakota. In the past week, North Dakota reported more new cases per capita than any other state. Hospitalizations for the virus have risen abruptly, forcing health care officials in some towns to send people to faraway hospitals, even across state lines to Montana and South Dakota.
Officials have huddled with hospital leaders in recent days to contemplate ways to free up more hospital beds even as they contend with broader turmoil over virus policy in a state that has seen resignations of three state health officers since the pandemic’s start.
The rise in cases and deaths — September was by far the deadliest month for North Dakota since the start of the pandemic — reflects a new phase of the virus in the United States. From Wisconsin to Montana, states in the Midwest and Great Plains, many of which had avoided large outbreaks in earlier months when coastal cities were hard hit, are seeing the brunt. And in rural portions of the states now reeling, medical resources are quickly stretched thin for residents who can live hours from large hospitals.
Still, partly because these outbreaks were slow in coming, public health officials say they have struggled to convince the public that the situation is urgent or that limits like mask rules make sense. North Dakota is one of fewer than 20 states with no statewide mask mandate and many counties have resisted restrictions. But as the state reaches a boiling point, health officials say they hope people now will start to take the virus more seriously.
“If there’s anything that should get our population’s attention, it’s this: how perilously close we are to the edge,” Vern Dosch, who leads contact tracing efforts for North Dakota, said last week.
Compared to many states, North Dakota has seen a tiny number of cases. More than 24,000 people have been reported as having the virus, and, as of Tuesday, 284 have died. But North Dakota is one of the least populous states in the country, with 762,000 residents spread across vast stretches, from a handful of cities like Bismarck to farms, oil fields and towns separated by hundreds of miles. So the growing outbreak is testing the hospital systems, health officials said, pushing them near their limits.
On Monday, hospitals in Bismarck reported that only six inpatient beds were open and just one intensive care unit bed. Across the entire state, 39 staffed I.C.U. beds were available.
“I think the numbers speak for themselves,” said Dr. Amesh Adalja, an infectious-disease expert and senior scholar at the Johns Hopkins Center for Health Security. “There are other conditions — diabetic emergencies, cardiac emergencies, other types of infectious diseases that require I.C.U. space, and there’s not a lot of slack if you only have that many intensive care unit beds.”
Gov. Doug Burgum, a Republican who is widely favored to win re-election next month, has maintained that a “light touch of government” is the best way to handle the coronavirus in North Dakota, and that it has helped the state keep its unemployment rates low and reopen ahead of many others. He has said the hospitals have enough space to handle the situation.
“It is an accurate statement that capacity to date has not been a problem in the state of North Dakota,” he said this month.
The state’s response to the virus since the start of the pandemic has been complicated and tense as new plans and restrictions emerged. Even its public health office has been in tumult, with Dr. Paul Mariani, an infectious-disease specialist, resigning last month after just two weeks on the job.
Dr. Mariani instituted an order requiring close contacts of those with the virus to quarantine or risk a misdemeanor charge, but the governor quickly overturned it after Republican legislators and residents voiced outrage. Dr. Mariani resigned because he did not want his signature on an order he felt went against public health guidelines, Mr. Burgum explained in a news briefing. Dr. Mariani declined to be interviewed.
Around Bismarck, there is a range of responses to the virus; but people are generally left to make their own choices about the potential risks. Some cafes are bursting with maskless patrons and workers. Other businesses have limited their capacities. Around half of the customers in Al’s Barber Shop, near one of the city’s hospitals, wear a mask, Travis Zenker, the owner, said.
All of it should be a personal choice, said Wanda Serr, owner of Little Cottage Cafe, a popular diner where workers do not wear masks.
“If you feel safe, go out and do what you do; if you don’t feel safe, it’s your right to stay home,” she said.
As cases have risen, some officials have tried to press for county-level mask requirements.
“I feel like I’m powerless,” said Renae Moch, public health director for Bismarck-Burleigh Public Health, who said she received insulting and threatening emails and Facebook messages for suggesting that the county set a mandate.
Miles from Bismarck, smaller communities have long turned to city hospitals to handle cases they do not have capacity to manage, but that is shifting.
“In the past two weeks, my ability to send people to Fargo or to Bismarck has been nonexistent,” Dr. Sarah Newton of Linton Hospital, a facility in Emmons County, told her City Council last week.
Emmons County is dealing with the state’s worst level of infections per capita, and Linton Hospital has been completely full. Dr. Newton described spending hours calling around the state for a patient who needed emergency heart surgery. A bed finally opened in Fargo.
“We’ve had to scramble, and I think a lot of the other hospitals have had to scramble as well,” Robert Black, the chief executive of Linton Hospital, said.
Because of the growing concerns, Sanford Medical Center in Bismarck added 14 new beds last week. Even before the pandemic, the more than 200-bed hospital occasionally had patients waiting overnight in the emergency room for an inpatient bed to open up, said Dr. David Field, a family physician. But lately, he said, the number of people waiting has jumped to at least nine.
Still, Todd Schaffer, vice president of the clinic at Sanford Medical Center, said he believed that hospital officials felt “very, very comfortable with taking care of them with what we have within our four walls, and not having to go outside of our building.”
In earlier months, some nursing homes with outbreaks had often sent residents with Covid-19 to a hospital for treatment and to help slow the spread of the virus inside the nursing home, according to Sandy Gerving, an administrator at Marian Manor Healthcare Center, a nursing facility an hour west of Bismarck. In the past month, though, she said, nursing homes have been turned away from some hospitals.
When Marian Manor had an outbreak in August, Marie Halstead’s husband was one of the residents who tested positive for the virus and grew ill enough to be hospitalized. There was no room in Bismarck, though, so workers found him a spot in a rural community hospital 100 miles away. Ms. Halstead said her husband received excellent care, but said she was surprised to know there was a shortage.
“We had been told by our governor that there was no problem with bed availability,” she said.
Marian Manor has since experienced several more waves of cases.
“We got to the point where we knew there was no one that would take them,” Ms. Gerving said of patients who were sick but not critically ill. “So then we started keeping them in our building. And then we started having an outbreak internally.”
Back in Bismarck, Ms. Gimbel was still reeling from her own experience with the virus — and with her father’s. Officials at Sanford Medical Center, where her father was first taken, said that they could not discuss a particular person’s medical case but that they would never turn away a patient with emergency medical needs.
Ms. Gimbel’s relatives said that after several trips to the hospital, her father was admitted to another hospital in Bismarck, where he stayed for five days and has since recovered.
Ms. Gimbel said she did not blame any hospital for being overwhelmed.
“What frustrated me is based on everything I’ve been hearing, at no point was I educated through the governor or anybody that we were this bad,” she said. “The bottom line is my dad needed care, and I couldn’t give it to him.”