Credit…Christopher Lee for The New York Times

The hospital in Starr County, Texas, had no I.C.U. at all, and only one doctor on duty for each shift. Then the coronavirus began surging through the Rio Grande Valley.

RIO GRANDE CITY, Texas — A tense rescue scene has been unfolding for weeks outside a small rural hospital on the Mexican border that has been the first line of defense against one of the most voracious coronavirus outbreaks in the country.

Nearly every day, a crew at Starr County Memorial Hospital prepares a patient whom its doctors are unable to help, loads the gurney into a helicopter and stands back as the aircraft roars into the country sky.

“Very, very unfortunately, of all of the patients we have transferred, none have come back alive,” said Dr. Jose Vazquez, the health authority in Starr County, a remote section of the Rio Grande Valley in Texas that before the coronavirus outbreak did not have a single I.C.U. bed.

There was a time not long ago when the pace was a lot less frantic at Starr County Memorial, whose 45 beds were once sufficient for the roughly 65,000 people spread out along the border near Tamaulipas, Mexico. The county is dotted with tiny villages, long stretches of open road, cattle ranches and the occasional small town.

On an average day before the outbreak, a handful of doctors and nurses treated patients at the hospital for “infections, pneumonia, heart conditions, and roughly, that’s it,” said Joseph Panlilio, one of the hospital’s head nurses.

But the new wave of coronavirus infections has been as swift as it has been merciless, with more than 2,110 cases in the county and nearly 70 deaths that are suspected of being linked to Covid-19, local officials said.

Nearby counties in the valley are also battling surges in infections, but Starr County lacks the medical staffing and facilities of its more populated neighbors. On a good day, about 12 full-time doctors serve the entire county.

“To say we are overwhelmed, it’s an understatement,” said Dr. Cruz Alberto Bernal, who until recently was the only doctor on duty during his shifts at the hospital.

Facing an overwhelming number of cases, the hospital said in July that it would convene an ethics committee to help make difficult decisions about which patients to treat, which to medevac to better-equipped hospitals, and which to send home to die.

“The time of rationing medical care is a time that we all have feared from the beginning, but it looks like we are getting to that point now,” Dr. Vazquez said last month.

Ultimately, Dr. Vazquez said in an interview later, the final decision rests with the next of kin, in a region where close-knit families may prefer to take a terminally ill patient home, rather than leave a loved one to die alone in a hospital room. “We are not deciding who lives or dies,” he said. “We are not creating death panels.”

Hospital officials said the community needed to understand that so small a facility could not treat everyone on its own.

“We were not built for a situation like this,” said Eloy Vera, the county judge.

Medical staff at Starr County Memorial move a patient to a helicopter to be transported to a larger hospital in San Antonio.
Credit…Christopher Lee for The New York Times

Starr County, one of the poorest in the nation, is not alone. A study published this week in the journal Health Affairs, warning of a stark disparity in the availability of critical care facilities in the midst of the pandemic, found that nearly half of the nation’s communities with a median income of $35,000 or less had no intensive care beds at all, compared with 3 percent of the highest-income communities.

“Unfortunately, there will be a lot of unnecessary suffering and deaths from Covid-19 because of the lack of I.C.U. capacity in these low-income areas,” said Genevieve Kanter, an assistant professor at the University of Pennsylvania Perelman School of Medicine and one of the study’s authors.

As cases climbed in Starr County and the hospital struggled, it began transporting a handful of its most severe cases by helicopter and ambulance to bigger hospitals in Lubbock, Dallas, Houston and San Antonio, and even across the state line in Oklahoma.

The Covid-19 ward at Starr County Memorial Hospital.
Credit…Christopher Lee for The New York Times

The crush shows no signs of abating. On a recent afternoon, doctors and nurses rushed in and out of the clinic’s improvised Covid-19 unit, roughly the size of one and a half tractor-trailers.

It was put together behind a makeshift wall of plywood, heavy plastic and duct tape to separate coronavirus patients from those in the rest of the hospital.

Doctors and nurses, most of them wearing several layers of protective gear, fanned themselves desperately during their rounds. Any hint of cool air sputtering from the hospital’s overburdened air-conditioning system was quickly overcome by the unforgiving Texas heat seeping through the walls.

“The A.C. is working,” Dr. Bernal said. “It’s overworked, just like us.”

Most of the patients in the Covid-19 unit were older, and were grappling with pre-existing conditions including obesity, hypertension and heart conditions.

Roger Garcia, 38, said his mother, Martha Ramos de Garcia, 65, had contracted the virus in late July while she was undergoing chemotherapy for breast cancer.

For a while, the family held off sending her to Starr County Memorial, he said. “We knew it was a small hospital. They don’t have enough of everything.”

But one blistering day, she was unable to breathe on her own, and a responding paramedic only needed a quick look. “Se ve malita” — she looks a bit sick, he told Mr. Garcia, his words minimizing what they all knew was a grave situation. His mother died a few days later in the makeshift Covid-19 unit.

“They tried, but couldn’t save her,” Mr. Garcia said. “It feels like a horror movie. People are dying everywhere.”

Staff in the COVID-19 ward move equipment.
Credit…Christopher Lee for The New York Times

Residents are still trying to understand how the situation became so serious as suddenly as it did.

The surge was slow to arrive. After neighboring counties began reporting an explosion of infections in the spring, 21 days passed before a single case was detected in Starr County, Dr. Vazquez said.

Dr. Cruz Bernal said he never expected the pace at Starr County Memorial Hospital to become as busy and harried as it has during the pandemic.
Credit…Christopher Lee for The New York Times

But when the state reopened its economy in May, the virus began spreading rapidly through nearby Hidalgo and Cameron Counties, fueled by poverty and chronic disease. Large family outbreaks occurred as soon as people were allowed to leave their homes freely, health officials said.

Starr County Memorial Hospital serves an area of rural Texas near the Mexican border.
Credit…Christopher Lee for The New York Times

Fear spread through the communities along the border. “We’re in a crisis,” said Roel Ruiz, 57, a construction worker who was strolling along the river last week wearing an N-95 face mask in the sweltering heat.

“I’m not sick. Neither is my family. But I’m afraid it’s a matter of time.”

An improvised partition isolates the Covid-19 unit from the rest of the hospital.
Credit…Christopher Lee for The New York Times

Aid from the state and from the Navy has staved off some of the casualties that might otherwise have occurred, hospital officials said. Medical specialists and much-needed medical supplies and equipment — including ventilators, oxygen support and IV pumps — were welcomed with a huge sense of relief by the small hospital staff.

“We can use any help we can get,” Mr. Vera said.

As is the case at most hospitals during a pandemic, visitors are not allowed. But that did not stop dozens of local residents from flocking to the hospital grounds last week, peering in at patients through the windows. They resembled Victorian suitors defying orders to stay away from a forbidden love, throwing air kisses and heart hand signs their way.

Inside, the doctors made their way among the roughly 30 patients in the ward — it was filled to capacity — walking in and out of quaint rooms adorned with country flowered curtains.

Dr. Bernal, who graduated from medical school three years ago, said that when he took the job at the rural hospital, he never thought he would be facing the pace of a big-city facility.

“Before the pandemic, I was signing three to four death certificates a year,” he said. “These days I have been signing at least six a week. And that’s just me.”

A nurse wearing a face shield delivered news that the doctor had dreaded but expected — a 72-year-old woman, already suffering from severe obesity, had succumbed to the virus moments earlier.

Medical workers confer in the Covid-19 ward. 
Credit…Christopher Lee for The New York Times

Not far away, his colleagues were trying to save the lives of several other patients who were fading fast.

Mr. Panlilio, the nurse in charge, watched closely as three other nurses wrapped bandages around the knees of a woman in her 60s who was connected to a ventilator. Her treatment at the hospital, he said, had run its course.

“She needs a higher level of care than we can provide,” he said. “We need to open her throat and clear her airways. We simply don’t have the necessary tools to do that here.”

He ordered an air transfer to a bigger hospital in another city —  anywhere that would take her, he said.

Wasting no time, another nurse stabbed a phone’s keypad with her finger. “We are trying to make it happen as soon as possible,” Mr. Panlilio said.

But there was no answer.

Mr. Panlilio stood and watched as his colleague tried another phone number, and another, and another.

New York Times