San Francisco Chronicle - (Sunday)
Hospitals may be pushed past breaking point
Dr. Sara Cody gave her last COVID19 update of the year to the Santa Clara County Board of Supervisors on Tuesday — a momentous day, with the first coronavirus vaccines having arrived that morning.
But Cody, the county health officer, was subdued. This year, she told the board during its virtual meeting, her disembodied voice echoing slightly, “started so unremarkably, but has become one of the most difficult years of the last 100.”
The county is reporting on average 1,000 new cases a day and intensive care units at all of the hospitals are running out of beds, she said, “And today we are reporting 24 new deaths.”
Cody broke off then, her
silence heavy. One of the supervisors told her to take her time. When Cody next spoke, her voice wavered with tears. “We have lost 553 people in our county” since the pandemic began, she said, and paused again to collect herself.
These are dark days in the pandemic, and Cody is not the only California health officer to have publicly lost her composure recently. For all the exhilaration and hope that comes with the arrival of vaccines, everyone is exhausted too, and sad and frustrated to still be facing such incredible devastation after nearly a year of battling this pandemic.
California is now among a handful of states driving the national surge, averaging well over 40,000 cases — and nearly 300 deaths — a day over the past five days. That’s four times the cases of just a month ago, and the numbers rise nearly every day. The state has among the highest new case rates — on average 96 cases a day per 100,000 residents in the seven days ending Friday.
On Friday, intensive care capacity had bottomed out for the greater part of the state, with all of Southern California and the San Joaquin Valley reporting no ICU beds available. Earlier in the week, intensive care availability in the Bay Area fell to less than 15% and the entire region was required to comply with the state’s stayathome order, though most counties already had adopted it preemptively.
The situation is dire, and if the surge gets much worse — as many expect it will after Christmas and New Year’s — then hospitals will face intolerable conditions, public health experts say. It’s possible patient care already has been compromised by bed and staffing shortages. It may not be long before people begin to die who otherwise could have been saved.
The Bay Area is faring better than other parts of the state, and the region may skate through this surge without the needless loss of life that seems almost inevitable elsewhere. But “my sense is that we’re whistling past the graveyard,” said Dr. George Rutherford, a UCSF infectious disease expert.
“This is dangerous times. We’re juggling chain saws and machetes right now.”
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It’s not news to anyone paying attention that the next few weeks in the pandemic are critical. The tens of thousands of cases reported daily in California won’t translate into patients needing hospitalization for another week or two, and intensive care a week or so after that.
If the cases climb again after Christmas, the “surge upon a surge,” as many public health experts have framed it, will be disastrous. Gov. Gavin Newsom said last week that he’d ordered 5,000 extra body bags delivered to morgues in Southern California. Hospitals in Southern California and the San Joaquin Valley already are tapped into their surge plans to expand beds and staffing and try to keep up with health care demands.
They’re opening field hospitals and treating COVID19 patients in tents or parking lots. They’re training nurses and other staff to provide care outside their usual area of expertise. They’re canceling elective surgeries and advising patients to stay home instead of coming to emergency rooms unless their need is truly urgent.
“I never thought I’d see anything like this in the United States, much less in California,” said John Swartzberg, an infectious disease expert at UC Berkeley. “People are starting to get their care rationed. And these are the people who can get into the hospitals. We’re getting close to the point where there won’t be hospital beds for them.”
When hospitals are pushed past capacity for too long, especially when staffing is stretched thin and the people providing care are exhausted, the immediate concern isn’t that patients won’t have a bed. It’s that the caregivers will have to make tough decisions to preserve space.
That could mean sending a patient home a little earlier than they would have a month ago, or telling someone with low oxygen that she doesn’t need to be admitted. It could mean placing someone on a floor for postsurgery patients instead of an intensive care unit. “It means you probably make slightly different decisions on the margins,” said Dr. Kirsten BibbinsDomingo, vice dean for Population Health and Health Equity at UCSF. “Whether that has real consequences in terms of bad outcomes, that’s the thing we don’t really know.” The Bay Area isn’t under quite the same level of stress as Southern California or the San Joaquin Valley, but some counties aren’t that far off. Napa and Marin counties are both at or close to capacity. The Marin County health officer said last week that he’d turned down requests to accept patients from other parts of the state because his hospitals were too close to being overwhelmed. In Santa Clara County, several hospitals have been over capacity for most of December. Regional Medical Center in San Jose was full on Dec. 11, with 70 COVID19
patients. A week later, it had nearly 100 COVID19 patients. ICU beds had been opened in the emergency department, and the COVID ward was being expanded.
“The hospitals will expand and expand to deal with patients. That’s what they do, that’s in their DNA,” Dr. Ahmad Kamal, director of health system preparedness for Santa Clara County, said at the Board of Supervisors meeting last Tuesday.
But their ability to expand is not limitless. Hospitals are like a water balloon, he said, “and like a water balloon, when they explode, it’s not subtle.”
Dr. Karen Relucio, the Napa County health officer, was harried during a brief phone interview Friday. The county reported on average 137 cases a day last week, nearly four times as many as a month ago. The daily case rate — 64 cases per 100,000 residents — was the same as hardhit Santa Clara County.
Napa County’s two hospitals had one to three ICU beds available between them on any given day the past week, she said. And though that’s not so unusual for this time of year, when the flu often fills up local intensive care wards, it doesn’t happen everywhere in the state at once, and for days or weeks on end.
The county can usually rely on neighbors for help, in terms of transferring patients or borrowing staff. Now, everywhere is stretched near to breaking.
“This has been the most brutal moment of the pandemic,” Relucio said, letting out a punchdrunk laugh.
Relucio and her neighboring health officers in Solano and San Mateo counties had held out on joining the Bay Area’s preemptive stayhome order earlier in the month. None of them was convinced that such a mandate was going to make people stop gathering together, a behavior that’s been driving local disease transmission since the spring. When the Bay Area region fell to 13% ICU availability Wednesday, the holdout counties were forced under the state order. Relucio said it may help, though she didn’t sound all that confident. “We’re hoping it’s effective, or else we’re going to be at the point where we have to ration medical care,” she said.
Dr. Bela Matyas, the Solano County health officer, was similarly less than optimistic. “I think we are looking at a fourweek continuation of this surge before it starts to abate,” he said. “Look at the calendar: The last holiday with gatherings is likely New Year’s Day, and two weeks after that we start to see the decline.
“Things will get worse. I think we will find ourselves with spot situations where people are not getting optimum care,” he said. “I do believe we will see a bump in fatalities accompanying this as well. I don’t see any way around it.”
Cody, at least, remains hopeful that there’s still time to push through this surge — and the next one, however the coming few weeks play
out — and avoid the nightmare of hospitals unable to keep up with demand, and people dying who could have lived.
The health care system in Santa Clara County is stretched thin, but “not yet to the breaking point,” she told the Board of Supervisors. If people can hunker down and wear their masks, if they can forego the traditional holiday gatherings, they can make it safely to 2021 and the
promise of vaccines and an end to the pandemic.
“We are truly, truly in the worst place we’ve ever been in this pandemic,” she said. “Everyone is quite tired. And this is scary. And people feel sad. But we have to just continue to soldier forward, because there isn’t anything else to do.”