San Francisco Chronicle - (Sunday)
ICU work grueling, ‘ but we’ve got this’
Dr. Paul Silka stood near the main entry to the emergency department at Regional Medical Center in San Jose and gazed down a row of glasswalled isolation rooms. He’d planted himself in a corner, where he could observe the scuttle of activity on a busy Tuesday morning without being in the way.
The isolation doors were closed, red signs taped to the windows warning that these were likely COVID-19 patients. Back in February, when the first coronavirus patients arrived, hospital staff had thought these four negative pressure rooms, built to prevent the spread of airborne pathogens, would be enough. They could secure COVID patients in this corridor before moving them upstairs to inpatient wards.
Silka, director of emergency medicine, laughed under his breath. “God, we were so
naive then,” he said.
All four of the isolation rooms were occupied Tuesday, along with every other room in the emergency department, and in nearly every window was the striking red sign. In one room, normally used for suturing wounds or other minor procedures, a woman with COVID19 was on a machine to help her breathe, waiting for an inpatient bed to become available.
The scene at Regional was emblematic of the increasingly dire warnings issued across the state over the past two weeks: Hospitals are overrun with COVID patients, and intensive care units are rapidly running out of space. State and local officials fear that as hospitals are pushed past capacity, patient care will suffer and people may die who would otherwise live.
The Food and Drug Administration approved the first coronavirus vaccine Friday night, and doses will arrive in California in a matter of days. But they won’t stop or even slow this current surge, and counties across the state already are running precariously low on ICU beds, along with the nurses and other health care workers to staff them.
Nearly 40 million Californians — including residents of six of the nine Bay Area counties — are under stayathome orders because of the strain on hospitals. Statewide, only about 7.9% of ICU beds were available as of Saturday.
Regional Medical Center is in East San Jose, among the hardesthit communities in the hardesthit county in the Bay Area. Santa Clara County reported on average more than 1,000 cases a day last week, and Regional’s ICU was full almost every day. On Tuesday, the hospital granted a Chronicle reporter and photographer unusual access to observe the effects of the raging pandemic. The Bay Area as a whole has fared better than much of the state, but Santa Clara County has been especially strained. Countywide, nearly 100 patients were in the ICU with COVID19 by the end of the week, twice as many as just before Thanksgiving. Three hospitals had no intensive care beds available. Public health officials expected the numbers to continue climbing over the holiday season.
“We have more than doubled ICU census in the last two weeks. Our system cannot withstand another doubling,” Dr. Ahmad Kamal, Santa Clara County’s director of health care preparedness, said at a Board of Supervisors meeting Tuesday. “This is the worst we’ve ever seen, and it is continuing to worsen.”
At Regional and other hospitals, staff say patients are being well tended to, despite the capacity crunches. Hospital staff are used to running out of beds — it happens nearly every flu season — and being creative in their care of the sickest patients. They have not yet reached a point of feeling concerned for patient safety, and they still hope to avoid that fate.
But COVID is not influenza, and this is not a typical flu season. The volume of patients and complexity of care have stressed staffing and other resources far beyond normal.
“I’m confident people aren’t going to be spilling out of the ICU. If we need more beds, we have plans for that,” said Liz Thurstone, a charge nurse on 2 East, an acutecare floor that became the COVID ward at Regional during the first surge in the spring.
What worries her is not knowing how much worse it will get. “We can maintain what we’re doing right now. It’s stressful, yes, we’re all fatigued, kind of burned out, yes. But we can take it up another level. And maybe even another level after that,” Thurstone said.
“But if it goes up indefinitely, there will be a point where ...” — she paused — “we break.”
* * *
Sabrina Medina arrived in the Regional emergency department around 6: 30 a. m. Tuesday, nauseated and dizzy, panicked that she was having a heart attack. She’d tested positive for the coronavirus the Sunday after Thanksgiving. She thinks she was infected by her boyfriend’s father — the three of them spent the holiday together, and the father started having symptoms the day after.
“I felt scared, right away,” Medina, 44, said as she sat on a cot in a private room, her breath catching behind her face mask. “I’ve been thinking since March, if I get this I’m going to die. I have diabetes, I have a heart issue, I have asthma. And I started thinking, ‘ I’m not ready to go.’ ”
In the emergency department, doctors told Medina she has pneumonia, but she was released after five hours. Despite the diagnosis, she said she was feeling less scared after a morning at the hospital and was eager to go home. “There’s people worse off than me right now,” she said. Regional had 70 COVID patients Tuesday, more than any other day in the pandemic. And that doesn’t include people like Medina who were in and out of the emergency department and never admitted.
All 35 beds in the COVID ward were occupied. The emergency department was at 110% capacity in the morning, with coronavirus patients filling up nearly every room. Patients without COVID, who don’t need to be isolated, were in beds lining the hallways. A handful of patients technically had been admitted to the hospital but didn’t yet have a room on the inpatient floors.
“We have many contingencies in place, so we’re not dead in the water. But we’re above capacity. Things are moving a little less efficiently with all the demand,” said Silka, as he threaded his way between beds and rushing staff on his way around the emergency department. “It’s not highly unusual for us to have patients in the hallway, but we have every hallway filled. That burden is very, very stressful on the staff and the patients.” He nodded down a corridor toward a gurney, where a woman recently arrived by ambulance was being treated for a stroke. Though the hospital had stopped performing most elective surgeries Monday to preserve beds and staff, it can’t turn away people who need urgent care.
“We have no room for this stroke patient right now, but what are they going to do if we don’t squeeze them in?” Silka said.
In the ICU, Bhargavi Simhadri, a registered nurse and director of intensive care, was trying to figure out how to move two more patients to the floor. All 37 beds were occupied, 14 with COVID patients. She’d manage it, she said. She could safely move two people who didn’t need this level of care to another ward.
Downgrading patients and moving them to lesscritical floors happens every day in every hospital. What’s different now is the urgency: Nurses in the ICU are constantly assessing patients with an eye for who can be safely transferred. On Tuesday, they huddled over a handwritten list of names, discussing who didn’t quite need intensive care.
But the constant strategizing, moving patients around like chess pieces, is draining. And these COVID patients probably were just the tip of the postThanksgiving crush.
“I’m dreading Christmas,” Simhadri said with a sigh.
* * *
Tomi Ryba, president and chief executive of Regional Medical Center, has a handwritten list on her desk, too, of patients who could be transferred to other hospitals in the Bay Area. With ICU capacity so low across the region, finding beds for all the patients who need them is a team effort, and not just within her hospital.
Ryba talks daily, usually more than once a day, to her colleagues at the other Santa Clara County hospitals, as well as public health officials who are trying to help coordinate ICU care. Every patient who comes to the Regional emergency department is assessed for possible transfer, Ryba said.
But with so many hospitals running out of space, those transfers become more difficult.
“Transferring patients is something we do every single day. But when it’s not COVID and you’re not overly impacted and you don’t have 20 to 30 patients waiting in the ( emergency department) for admission, it’s different,” she said.
“We have to always prepare for the possibility of catastrophe — that would be the entire region is impacted and every single bed is full,” Ryba said. “There’s a whole plan, a robust plan, for that. And that’s what we’re trying to prevent and preempt, of course.”
There are layers upon layers of contingencies. Regional could add a few more ICU beds and expand the COVID ward. Nurses and doctors trained to treat trauma patients could back up their colleagues in intensive care. The hospital could cancel more elective procedures. The county could open alternative sites that already are built up and just need to be activated.
“Honestly, if all hell breaks loose, California National Guard can come and set up tents,” Thurstone said.
* * *
The secondfloor COVID ward was quiet Tuesday afternoon, the windowless doors closed to prevent the virus from spreading. Stacked against the walls were stations marked “clean” and “dirty”: clean for donning N95 masks, face shields, gloves and gowns before entering a patient room, dirty for discarding or sanitizing the gear after leaving.
Nurses rolled tablet devices mounted on wheeled poles from room to room, so patients could have video chats with friends and family who aren’t allowed to visit. Staff also use the tablets to reach virtual interpreters to help them communicate with patients, most of whom don’t speak English as their first language — a reflection of the diverse community the hospital serves. Thurstone was on the team that treated the hospital’s first COVID patient, back in February. “That feels like a hundred years ago,” she said.
She recalled she wasn’t quite scared at the time, just uncertain. The most stressful part of those early months was not knowing how best to treat patients with a virus never before seen in humans. They’ve learned so much since then, she said.
They know it’s best to keep patients off ventilators as long as possible, even if their oxygen levels seem dangerously low. They’ve learned that simply “proning” patients — carefully flipping them to improve air circulation in the lungs — can be lifesaving. They have therapies that seem to be effective: the antiviral remdesivir, the steroid dexamethasone, convalescent plasma.
All of that builds confidence, and in many ways it makes this current surge less stressful than earlier waves of the pandemic, Thurstone said. Still, “we’re not robots. We have mental, emotional, physical limits,” she said. They watch the hospital census. They’ve seen the patient load climb every day for the past two weeks, and they know it’s likely to get worse before it gets better.
“We’ve already been running at breakneck speed, and nobody can sprint indefinitely,” she said.
She sat in the cafeteria at Regional, sunlight flooding the wide open space where a handful of doctors and nurses sat alone at tables, eating or sipping coffee. The case counts are horrifying and the reports of hospitals running out of beds are appropriately grim, Thurstone said.
But she wanted people to know that Regional is in good shape for now.
“It’s stressful. It’s a lot,” she said. “But we’ve got this.”