Anyone in South Dakota right now can visit Mount Rushmore, take in an auto race or eat at a restaurant. All over the state, people are going about their lives — to the store, to bars — maybe half of them wearing masks, the only sign that anything is amiss. As a doctor in the state, I’m terrified we aren’t ready for the pandemic to spread here.

It has already arrived, as the recent outbreak centered on a pork processing plant in Sioux Falls showed. The question is: How bad it will get?

South Dakotans aren’t required to stay at home during this pandemic, a measure recommended by epidemiologists, not politicians, who warn that preventable infections and deaths may skyrocket without such an order. The South Dakota State Medical Association has taken the lead in asking our state and local governments for a stay-at-home order. Some cities have passed ordinances to restrict customers to no more than 10 people inside businesses, but I worry that won’t be enough. As the rest of the country begins debating how and when to reopen safely, South Dakota never officially closed. Doctors like me have asked Gov. Kristi L. Noem (R) to take stronger action, which would give our health professionals the necessary time and resources to manage the coronavirus outbreak. We may soon be facing the challenges and hardships already seen in New York and other cities if a statewide order is not issued immediately.

I’m a physician in the town of Yankton, located near the amazing Lewis and Clark Lake, on the Missouri River. My health system has been working tirelessly to get us information about best practices during the pandemic, and I receive daily updates. We have begun to wear masks and eye shields during all times when in patient-care areas. Even that soft cotton starts to break down the skin. I’ve shaved my head to keep the mask from pulling at my hair, and my wife and I are trying to decide whether I should stay away from the family to avoid getting them sick.

I took care of a patient last week who had chronic lung disease. She looked well when she arrived to the ER, and I thought she would be going home after a few tests, but I was wrong. For good reasons, she couldn’t have visitors because of our hospital’s new policy. She got worse — fast. Her breathing became labored, and she would need to stay in the hospital. We tested her for the coronavirus, but we knew it might take days to get results.

We took care to protect ourselves, wearing personal protective equipment at all times. We worried that she was infected with the virus and that, if so, our normal treatments for lung disease would put the virus into the air, potentially infecting other patients and staff. The only treatment would be to put her on a ventilator, but we knew from New York and elsewhere that her survival chances would be grim no matter what. She agreed — and she did not want to be on a ventilator. She understood that with her bad lungs, it was only going to get worse. She refused the ventilator, knowing that she would die.

In this situation, we allowed her daughter to visit. To our hospital’s credit, her daughter was issued her own personal protective equipment from our limited supply for the visit and entered a room sanitized of any item of comfort that could harbor the virus and infect others. We gave medication to calm the mother, and, in front of five people in masks, gloves and goggles, she died. The chaplain was present and said a prayer. It was moving and horrible, and I can only wonder how many more times it will happen again.

Later, I spoke with her daughter and got permission to write about it. She was thankful for our efforts and said she could tell how much our staff struggled to make it better for our patients despite the reality of the coronavirus.

Would our patient have accepted a ventilator if it weren’t during a pandemic? I wonder whether she gave her life because she wanted to save that precious equipment for someone else. Four days later, I found out her test was negative (which, because there are a lot of false negatives, might not have meant she didn’t have covid-19, the disease caused by the virus). That’s the kind of decision that physicians are being forced to make.

Healthy, young people might not worry about getting sick because they know their fatality rate is so low. They don’t realize that they are the most mobile, active members of the public, and so they’re more likely to be healthy enough to spread the infection to others who are much more vulnerable. These are the people going to the bars, restaurants and auto races without an order not to do so. Even if these are only young, healthy people, they risk going home and to work and infecting those more vulnerable. The vulnerable then seek the hospital for care, and if enough of them do so, our rural facilities will be overwhelmed.

We have only 11 state-licensed hospitals, with a total capacity of about 2,000 beds. An additional 38 critical-access hospitals serve rural areas, with about 700 beds. As of a couple of years ago, there were only 152 intensive care unit beds in the whole state, which has nearly 900,000 residents. If large numbers of people get sick, we won’t be able to take care of everyone, and more will die.

South Dakotans live in a state with more cattle than people. But wherever people come together poses a risk of transmission, as the spike of covid-19 cases in the meat-processing plant shows. Like a lot of South Dakotans, I have strong views about personal liberty. I detest government mandates, and I want the economy to boom. But, like many of my colleagues on the front lines of this quiet war, when I weigh that against the lives of our patients, I don’t see a choice.

It’s not just physicians, either. Paramedics, nurses, peace officers, firefighters and everyone else who is risking their lives quietly and tirelessly to protect others are wondering when the tidal wave will come or whether it can still be prevented. The decisions made today will reverberate for years to come. We are thankful for the conservation of PPE. We are thankful for homemade masks, ventilators, hopes and prayers. Under the watchful eyes of our forefathers set in stone, we will stay at work. All you need to do is stay at home.

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