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