US hos­pi­tals are pushed to the brink as COVID-19 per­sists

- Ken All­tucker Con­tribut­ing: Mike Stucka, USA TO­DAY Health · Medicine · Society · Canada News · Georgia · California · Johns Hopkins University · Arizona · Los Angeles · U.S. Centers for Disease Control · Atlanta · United States Department of Health and Human Services · Association of American Medical Colleges · Sinclair Lewis · Los Angeles County · University of Pennsylvania · Pennsylvania · United States of America · Swainsboro, Georgia · Emanuel County · Robert Wood Johnson Foundation · Augusta University · Pennsylvania Hospital · Society of Critical Care Medicine

Damien Scott thought things couldn’t get worse than in Au­gust when a nurs­ing home coro­n­avirus out­break left his ru­ral east Ge­or­gia hospi­tal with a mass of crit­i­cally ill pa­tients.

But Emanuel Med­i­cal Cen­ter is again full with a new wave of COVID-19 pa­tients, leav­ing the Swains­boro hospi­tal ef­fec­tively full since Christ­mas with new pa­tients im­me­di­ately re­plac­ing those who are dis­charged.

As of last week, the county’s COVID-19 death toll hit 57, Scott said.

“If you are in a large city, that num­ber is not a high num­ber,” he said. “But it is a high num­ber for a com­mu­nity of 22,000.”

Hos­pi­tals from Ge­or­gia to Cal­i­for­nia are crowded with waves of coro­n­avirus pa­tients as the post-hol­i­day case spike tests the lim­its of the na­tion’s health sys­tem.

Dur­ing the past week, a record 22,676 peo­ple died from COVID-19, ac­cord­ing to fig­ures from Johns Hop­kins Uni­ver­sity. That’s more Amer­i­cans dy­ing ev­ery day than the 2,977 vic­tims on Sept. 11, 2001.

Four states with the largest share of hospi­tal beds oc­cu­pied with COVID-19 pa­tients – Cal­i­for­nia, Ari­zona, Ne­vada and Ge­or­gia – are strug­gling to keep pace with the un­prece­dented surge.

The sit­u­a­tion has be­come so dire in Cal­i­for­nia that the state re­quired hos­pi­tals to com­plete plans de­tail­ing how they will pri­or­i­tize care when they don’t have enough work­ers, space, or sup­plies.

In Los Angeles, pub­lic hos­pi­tals are pre­par­ing to shift to cri­sis mode, and the county has in­structed am­bu­lances to not send pa­tients to over­bur­dened hos­pi­tals if they can’t be re­vived in the field.

Ari­zona’s COVID-19 cases per capita over the past week through Sun­day are at the na­tion’s high­est level, ac­cord­ing to the Cen­ters for Dis­ease Con­trol and Preven­tion. Hos­pi­tals in metro At­lanta are over­flow­ing with coro­n­avirus suf­fer­ers, and more than two dozen Ge­or­gia hos­pi­tals have no avail­able beds in in­ten­sive care units, ac­cord­ing to the De­part­ment of Health and Hu­man Ser­vices.

While pub­lic health of­fi­cials are op­ti­mistic wide­spread vac­ci­na­tion will pro­vide a glim­mer of hope this spring, there’s no respite now for doc­tors and nurses.

“Ab­so­lutely, it’s what we feared,” said Ja­nis Or­lowski, As­so­ci­a­tion of Amer­i­can Med­i­cal Col­leges’ chief health care of­fi­cer.

‘No­body es­capes this’

The chal­lenges are acute at smaller hos­pi­tals that are the only op­tion for the com­mu­ni­ties they serve. The surge of coro­n­avirus cases cre­ates a cas­cad­ing ef­fect on th­ese small com­mu­ni­ties, ex­tend­ing be­yond hospi­tal walls.

Emanuel CEO Scott thought his hospi­tal reached its lim­its in Au­gust when coro­n­avirus spread through nurs­ing homes in neigh­bor­ing coun­ties and car­ing for pa­tients “felt like try­ing to scoop up wa­ter with your hands,” he said.

Cir­cum­stances are even more chal­leng­ing now. While the sum­mer peak came from nurs­ing homes, the cur­rent peak is be­cause the virus is widely cir­cu­lat­ing. The hospi­tal’s 6 ICU and 18 gen­eral med­i­cal beds are full. And with a surge of post-hol­i­day cases, more peo­ple will need care in the com­ing days as they de­velop com­pli­ca­tions.

Health data shows Emanuel County’s rates of obe­sity, smok­ing and phys­i­cal in­ac­tiv­ity all rank worse than state av­er­ages. Life ex­pectancy in Emanuel County ranks 155 out of 159 coun­ties in Ge­or­gia, ac­cord­ing to Robert Wood John­son Foun­da­tion’s county health rank­ings.

Crit­i­cal care doc­tors at Au­gusta Uni­ver­sity have trained and co­or­di­nate with Emanuel’s doc­tors to pro­vide re­mote telemedici­ne for pa­tients.

Emanuel has in­stalled neg­a­tive-pres­sure and in­stalled ion­iz­ing units in the duct­work to com­bat the air­borne spread of the virus in the hospi­tal and nurs­ing home. It plans to open an out­pa­tient clinic to ad­min­is­ter the mon­o­clonal an­ti­body bam­lanivimab to as many el­i­gi­ble pa­tients as pos­si­ble. The goal is to help peo­ple re­cover and save beds for crit­i­cally ill pa­tients un­til vac­cines are widely ad­min­is­tered.

Be­yond the crowd of hospi­tal pa­tients, Emanuel County Coroner Jef­frey Pee­bles has an­other worry – a po­ten­tial short­age of morgue space.

His of­fice has pur­chased a re­frig­er­ated morgue with space for up to 10 bod­ies that will be placed in­side the hospi­tal when it ar­rives.

Ar­range­ments have been de­layed when rel­a­tives of peo­ple who died from COVID-19 must iso­late be­cause they have the virus.

So far, be­tween the county’s fu­neral homes, there has been no short­age of ca­pac­ity. Pee­bles said he hopes the new morgue unit ar­rives in time so they don’t run out of space.

“It’s been stress­ful on a lot of folks,” Pee­bles said. “We’re a tight-knit com­mu­nity so you know every­body when some­thing hap­pens … No­body es­capes this.”

Jimmy Lewis, founder and CEO of the Ge­or­gia-based ru­ral hospi­tal group Home­town Health, said ru­ral hos­pi­tals are strained as they han­dle this “surge on a surge, on a surge.”

Be­yond tak­ing care of peo­ple in emer­gency rooms, th­ese small hos­pi­tals also must ex­e­cute plans to dis­trib­ute vac­cines, a process that re­quires mak­ing “field grade gen­eral out of hospi­tal ad­min­is­tra­tors,” Lewis said.

“We’re hav­ing to learn to do all this jug­gling and lo­gis­tics on the fly,” Lewis said. “It’s a night­mare be­cause every­body is worn out.

‘Dark days of win­ter’

When things get crowded or be­yond the ex­per­tise of smaller hos­pi­tals, they send pa­tients to larger ur­ban hos­pi­tals.

It’s those hos­pi­tals now in big cities such as Los Angeles and At­lanta that are get­ting more pa­tients than they can han­dle.

The Los Angeles County De­part­ment of Health Ser­vices last week is­sued guid­ance on how hos­pi­tals should al­lo­cate scarce re­sources. The doc­u­ment de­tails de­ci­sions hos­pi­tals must make when de­mand for crit­i­cal care ser­vice, staffing, space, or life sav­ing equip­ment out­strips what the hospi­tal is able to pro­vide.

Such wrench­ing de­ci­sions might in­clude “which pa­tients get which re­source, and in some cir­cum­stances, may in­volve de­ci­sions to take scarce re­sources from one pa­tient and give them to an­other who is more likely to ben­e­fit from them,” the doc­u­ment states.

Hos­pi­tals al­ready are pre­par­ing staff and no­ti­fy­ing the com­mu­nity of plans to shift to such cri­sis-care mode.

When hos­pi­tals must im­ple­ment such cri­sis stan­dards, they of­ten rely on hospi­tal com­mit­tees and poli­cies rather than doc­tors and nurses mak­ing eth­i­cally fraught de­ci­sions about care for their pa­tients, said Dr. Lewis Ka­plan, pro­fes­sor of surgery at Uni­ver­sity of Penn­syl­va­nia Hospi­tal.

“That is a very dif­fi­cult place to look in some­one’s eyes, hav­ing held their hand and hav­ing shared what you now know about them, and say, ‘I’m go­ing to de­cide not to pro­vide you with this,’” said Ka­plan, pres­i­dent of the So­ci­ety of Crit­i­cal Care Medicine.

In­stead, triage com­mit­tees gather in­for­ma­tion about a par­tic­u­lar case and as­sign a score to in­di­vid­ual pa­tients.

Or­lowski, of the As­so­ci­a­tion of Amer­i­can Med­i­cal Col­leges, said hos­pi­tals are es­pe­cially stressed be­cause the post-hol­i­day surge comes dur­ing cold and flu sea­son.

“We are in the dark days of win­ter in re­gards to this COVID pan­demic,” Or­lowski said.

Or­lowski re­calls see­ing fed­eral es­ti­mates in March pre­dict­ing 20 to 30 mil­lion cases and 400,000 deaths in the United States. Dur­ing the early days of the pan­demic, Or­lowski said she thought such es­ti­mates were “un­fath­omable to think there would be 400,000 deaths in the United States – just un­be­liev­able.”

As of Tues­day, 22,663,962 Amer­i­cans have been in­fected and 377,827 died, ac­cord­ing to Johns Hop­kins.

She said those March es­ti­mates rep­re­sented a worstcase sce­nario “if we don’t flat­ten the curve and re­ally take care of this.”

“And in­deed,” Or­lowski said, “that is what we’re look­ing at right now.”

 ?? GETTY IMAGES ?? A clin­i­cian cares for a COVID-19 pa­tient at Prov­i­dence St. Mary Med­i­cal Cen­ter in Ap­ple Val­ley, Calif., amid a surge in COVID-19 pa­tients.
GETTY IMAGES A clin­i­cian cares for a COVID-19 pa­tient at Prov­i­dence St. Mary Med­i­cal Cen­ter in Ap­ple Val­ley, Calif., amid a surge in COVID-19 pa­tients.

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