Patients moved to lower elevations
Hospitals in Colorado’s mountain communities are transporting critically ill patients — and in some cases those at risk of becoming so sick — to facilities at lower elevations, hoping the move will ease their respiratory symptoms caused by the new coronavirus.
Medical facilities in Gunnison, Pitkin and Summit counties can treat patients with the new coronavirus, but have fewer intensive care beds, doctors, nurses and other resources. So they are moving patients who are on, or likely to need, ventilators to larger facilities that can provide a higher level of care for a longer period of time.
The doctors also hope that by going to lower altitudes, their patients will need less supplemental oxygen.
“We’re doing what we can to help with preparing to care for more ICU patients in the future, in the near future,” said Dr. Jason Hogan, emergency medicine physician at Gunnison Valley Health.
Within the past week, he has started experimenting with transporting patients from
Gunnison, at an altitude of 7,700 feet, to hospitals with intensive care units in Montrose, at 5.800 feet, and Grand Junction, at 4,500 feet, as they start to require a significant amount of oxygen.
He started doing this after noticing that more than half of the people admitted eventually required ventilators, Hogan said, noting that patients start “behind the ball” on oxygen at higher altitudes.
“It mainly goes back to recognizing that we weren’t turning these patients around,” he said, adding, “It’s certainly about balancing resources, especially with a critical access hospital like ours.”
Colorado’s mountain communities have become hotspots for the new coronavirus with the first cases, and subsequent high case rates, appearing in their towns early on in the pandemic. As such, state and local health officials closed ski resorts and asked visitors to return home.
“What that did was get the tourists out of the mountain communities so that the health care really could be rationed to residents,” said Jill Hunsaker Ryan, who leads the Colorado Department of Public Health and Environment.
While the hospitals say they can handle the volume of patients arriving with COVID-19, that could soon change. The outbreak of the new coronavirus is widespread and limited testing means that the number of people with the virus is higher than the confirmed cases in Colorado — state health officials on Thursday estimated that between four times and 10 times as many people are infected as the confirmed testing indicates.
Doctors are trying to identify who needs a higher level of care, such as in an intensive care unit, as part of their preparation for a potential surge in patients in the coming weeks.
Patients with COVID-19, the respiratory disease caused by the new coronavirus, can “get very sick and very quickly.” And those who need ventilators can stay on them for at least a week to longer than three weeks, said Dr. Brad Holmes, hospitalist at Aspen Valley Hospital.
“We’re seeing more patients that are being admitted to the hospital with what looks like COVID-19,” he said. “I expect it will get worse over the next month.”
“This is all new to us”
Most people with COVID-19 have mild symptoms, such as fever, coughing and shortness of breath.
But others develop potentially deadly complications, such as pneumonia and acute respiratory distress syndrome, or ARDS.
Those most at risk for complications include individuals over 60 and people with underlying health issues, such as heart, lung or kidney disease, according to the U.S. Centers for Disease Control and Prevention.
Physicians are finding that pneumonia from the new coronavirus is affecting both lungs, which impacts how they absorb oxygen. As there are no medications to treat the disease, the best treatment doctors can provide is to give patients oxygen, Hogan said.
But Colorado’s high altitude presents a unique challenge when treating patients because while the amount of oxygen is the same as everywhere else, the barometric pressure is lower. The barometric pressure is what drives O2 into the blood, meaning patients in Colorado are already behind when it comes to oxygen saturation.
In the high country, the oxygen saturation for healthy people not sick with the new coronavirus is on average 92% to 94%. That’s already lower than the 98% oxygen saturation at sea level, according to physicians.
The oxygen saturation in patients with pneumonia from COVID-19 is dropping to the 60% to 80% ranges, said Dr. Marc Doucette, medical director of the emergency department at St. Anthony Summit Medical Center in Frisco.
“This is all new to us so we are all learning,” he said. “We have experienced that some patients that initially appear well have periodically deteriorated and get in more respiratory distress. We haven’t clearly found a pattern to predict who this will impact and when.”
Doctors say they are finding that not only do patients with COVID-19 require more oxygen than other pneumonias or viral infections, but the amount they need increases rapidly.
For example, a person with the disease will need two liters of oxygen when they first arrive at the hospital, but the next day will need five liters because their lungs are so filled with fluid and infection. Two days after that, the patient will need a ventilator, Hogan said.
“We’re seeing that they’re needing a lot of oxygen either over a short period of time or they’re sort of slowly progressing over a longer period of time,” he said.
Patients with COVID-19 report that they feel better once they have moved to a lower altitude. Others require less oxygen, but it’s unclear if they would have needed a ventilator if they had stayed at a higher elevation, Hogan said.
“The hard part to figure out is, could we have kept that person who didn’t need a ventilator longer within our facility?” he said.
“We may not have the luxury”
At Gunnison Valley Health, the goal is to transfer patients that are more likely to need a ventilator because it’s the number of people requiring ICU-level care that will strain the state’s hospitals, Hogan said.
Before the pandemic, the emergency department at the hospital had one transport ventilator for its eight emergency beds and 14 inpatient beds. Typically, it was used for treating someone injured in a traumatic incident, such as a car crash.
Two more ventilators arrived at the hospital on March 29 as part of the facility’s efforts to handle a potential increase in patients. Gunnison Valley Health has also pulled ventilators from other areas of the hospital and EMS units, but that is still fewer than 10 machines, Hogan said.
The threshold for who gets transferred to a larger facility with an ICU varies by patient and hospital.
Aspen Valley Hospital, which has four ICU beds, is sending patients who are on ventilators to Denver and Grand Junction. Dr. Barry Hammaker, chief medical officer at Vail Health, said the Eagle County hospital is moving patients to lower elevations when possible. And St. Anthony Summit Medical Center, which also has four ICU beds, is doing the same and transferring patients who need ventilators and critical care to hospitals in Denver.
“We suspect that any patient that has significant respiratory illness, from our experience, does better at a lower elevation,” Doucette said, adding, “We have kept a number of patients at this elevation that have ended up doing well.”
In Gunnison, doctors start considering transferring patients without underlying health issues once they require more than four liters of oxygen. But it’s a lower threshold, about four liters or less, for those most at risk of complications, Hogan said.
As of early last week, 10 patients had been transferred to hospitals in Montrose or Grand Junction. Of those, at least six were on ventilators.
“As all of these surrounding hospitals become more saturated with patients, we may not have the luxury to do what we’re trying to do right now,” Hogan said.