Alabama hospitals are out of ICU beds, Montgomery's mayor says. That 'dire' situation could crop up across rural America as states reopen.

• Montgomery, Alabama is "down to just a handful of ICU beds," according to Mayor Steven Reed, and the city has begun transferring critical patients to Birmingham.
• As states reopen and the coronavirus spreads through rural America, small-town and rural-adjacent hospitals could face overwhelming waves of COVID-19 patients.
• Experts told Business Insider they feared what fast upticks in coronavirus cases could mean for rural facilities that don't have the staff or resources to handle the influx.

As the state of Alabama lifts coronavirus restrictions, hospital intensive care units in its capital are running out of beds.

Montgomery hospitals are "down to just a handful of ICU beds," Mayor Steven Reed told Business Insider on Thursday. Many of the incoming patients are from surrounding rural counties which don't have ICUs.

Unable to take in new patients who are in need of immediate attention, Montgomery hospitals are transferring them 90 miles away to Birmingham, Reed said. It's the first time they've had to make such transfers since the pandemic began.

"That's very serious," Reed said in a Wednesday press conference. "Right now, if you're from Montgomery, and you need an ICU bed, you're in trouble. If you're from Central Alabama, and you need an ICU bed, you may not be able to get one because our health care system has been maxed out."

On Thursday, Gov. Kay Ivey announced that Alabama would allow theaters, bowling alleys, childcare facilities, and summer camps to reopen.

Other small cities and towns surrounded by rural counties could soon face similar influxes of coronavirus patients, as businesses reopen and new outbreaks spread through remote areas with little critical care capacity.

"[States] are starting to think about reopening at the very same time that this crisis is spreading across rural places," Carrie Henning-Smith, Deputy Director of the University of Minnesota Rural Health Research Center, told Business Insider in early May. "Given the fact that we're seeing these high increases, these fast increases, in rural areas, I worry about what that means for rural facilities and their ability to keep up and keep up safely."

'Rural hospitals are not built for pandemic surge capacity'

As the coronavirus hits rural America, several weeks after it made its first surge through larger cities, some of the country's most underresourced healthcare systems are overflowing with new patients.

There are roughly 2,000 rural hospitals across the US. Many have few inpatient beds and just one or two ventilators. More than half of US counties have no ICU beds, according to an analysis by Kaiser Health News.

"They are built for primary care and general surgery. These rural hospitals are not built for pandemic surge capacity," Alan Morgan, CEO of the National Rural Health Association, told Business Insider.

In addition, rural facilities are often notoriously understaffed. If one doctor or a couple nurses contract the virus, "you've got a real problem," Morgan said.

When the rural hospitals become overwhelmed, they send patients to larger facilities in nearby cities. That can lead to situations like the one in Montgomery, which now has its own overflow patients to send to Birmingham. Those transfers in themselves take up valuable resources.

"Some rural hospitals may only have one ambulance, and if you're using that ambulance to transport someone who has COVID to an urban facility, what does that mean if someone else in town has an emergency?" Henning-Smith said.

She expects that many rural hospitals will shut down during the coronavirus crisis, especially after months of lost income from canceling non-essential surgeries. That will only make matters worse in some places, condensing more COVID-19 patients into fewer hospitals.

Both Morgan and Henning-Smith said that states reopening their economies could make the rural crisis worse and allow the virus to spread faster.

"I would have preferred a slower reopening, a more cautious reopening," Reed told Business Insider.

'We are still in a place were we could go either way'

In Alabama, daily hospitalizations from COVID-19 appeared to plateau in mid-April, but have since been on the rise.

The state of Alabama reported 13,938 cases of COVID-19 as of Saturday, with more than 4,200 of them being identified in the last 14 days. Montgomery County has 1,126 cases — nearly half of them in the last 14 days — and more than 1,500 hospitalizations.

"I don't come before you every day to talk about how dreary the circumstances are, but I come before you this day to tell you that the circumstances are certainly dire," Reed said Wednesday. "We have to make sure that we don't get into a hole that we cannot get ourselves out of."

He pleaded with citizens to continue practicing social distancing and to stay home as often as possible.

"While I know people are ready to enjoy this Memorial Day weekend and are fatigued by all of this, I just want to reiterate: We are not there yet," Reed said. "We are still in a place were we could go either way, and we don't want to slip and fall off a cliff."