San Antonio Express-News (Sunday)
San Antonio now is paying for coronavirus indifference
Medical personnel irritated that warnings not heeded
These days, Amanda Salinas scarcely has time to catch her breath.
Six days a week, when she goes to Northeast Baptist Hospital for her nursing shift in the emergency department, she is met with the grim reality of San Antonio’s COVID-19 surge.
People on stretchers crowding the hallways. Waiting room lines longer than she ever has seen. Patients languishing in the emergency room for days, sometimes for so long that they are discharged before a bed becomes available for them upstairs. Hospital staff weary from working under arduous conditions, with little respite, for the better part of a year.
This isn’t the first surge Salinas has endured. She has worked at the hospital under a state contract since summer, when San Antonio was pummeled by its first major wave of coronavirus infections. This time, things are different. “The first one was manageable. This one is way worse,” Salinas said. “This is the worst I’ve seen.”
With about 1,400 COVID-19 patients in hospitals on any given day, San Antonio is contending with its greatest coronavirus crisis
yet.
Hospitals, health care workers and local officials are scrambling to ward off disaster.
“The boat is leaking, and so the health systems are running around trying to patch the ship, make sure it stays afloat,” said Dr. Jason Morrow, a University Hospital palliative care physician and UT Health San Antonio associate professor. “But somebody keeps pouring more and more water in.”
They are bracing for the possibility that San Antonio’s hospital systems could become overrun with patients, a worst-case scenario referred to as “Crisis Level 3” in a local emergency plan. Scarce resources would be devoted to those with the best chance of short-term survival, with the goal of saving as many people as possible.
“Once you get to Crisis Level 3, we have a very good moral, ethical framework for it,” said Dr. Ronald Stewart, a University Hospital trauma surgeon who helped develop the area’s crisis guidelines. “But to me, the most ethical and most right thing to do is to do everything possible to stay out of Crisis Level 3. That’s what we’re trying to do.”
Although hospitalizations fell slightly last week, the worst may be yet to come.
Since the beginning of the year, more than 26,000 infections have been reported among residents. More than 100 coronavirus patients are admitted to hospitals every day. Projections estimate hospitalizations could swell by several hundred patients by the end of the month — a much larger magnitude than what San Antonio faced over the summer.
Salinas expects further waves of COVID-19 patients from Christmas and New Year’s Eve to soon make their way to hospitals.
At this point, she said, it feels like “the damage is done.”
“It doesn’t matter what we do. It’s still not enough. They just keep coming,” she said. “We just have to do the best we can with limited resources, limited supplies, low morale.”
‘Did not listen’
The severity of San Antonio’s latest surge comes as no surprise.
In the fall, public health and infectious disease experts warned the winter months could create a recipe for disaster. There was a high likelihood of the virus making a resurgence, they said, as cold weather forced people indoors, and as travel and gatherings increased over the holidays.
Sure enough, transmission and hospitalizations began ticking up in San Antonio throughout November. Then they exploded.
Since Thanksgiving, Bexar County has recorded more than 65,000 infections, and COVID-19 hospitalizations have jumped nearly 160 percent.
The curve was not flattened. Now, San Antonio is paying the price.
“We’re really angry that the community did not listen to what we had to say,” said Dr. David Miramontes, medical director of the San Antonio Fire Department and an assistant clinical professor of emergency medicine at UT Health San Antonio. “The medical experts told everyone: Don’t get together for Thanksgiving. Don’t travel for Christmas.”
At Northeast Baptist, Salinas said doctors and nurses are triaging a steady flow of COVID-19 patients, on top of people with other conditions who are sicker than usual from pandemic-related disruptions to their medical care.
The hospital is in “gray status,” which triggers higher nurse-to-patient ratios and prevents staffers from taking time off. Nurses haven’t had time for lunch breaks in a month.
In the waiting room, Salinas said, tensions have grown so high at times over the long waits that security guards have had to exercise de-escalation tactics.
“I don’t think that people who aren’t in health care understand how intense it is right now,” she said.
Case managers are working with patients who aren’t sick enough to warrant a bed, in some cases sending them home with supplemental oxygen.
For those who are admitted, Salinas said, “we have no place to put them.” A separate section of the ER has been designated to hold COVID-19 patients waiting for an inpatient bed to become available.
That bottleneck places far more stress on the nurses, Salinas said, forcing them to “be everything to everyone” as they juggle emergency, intensive care and bedside nursing duties.
“As ER nurses, we’re not trained to do inpatient. We have a completely different skill set than the nurses who work upstairs,” Salinas said.
Salinas’ husband, Frank, also is treating COVID-19 patients, as a critical care nurse at Christus Santa Rosa Hospital.
Across the hospital’s floors, calls for assistance from respiratory therapists and code blues — a patient in need of resuscitation — are ringing out far more often, he said. Where space allows, there are two patients to a room.
On any given day, when Salinas looks across the unit where he is working, he sees at least half the staffers are temporary employees. One day, he finished a day shift, and by the time he came back the next morning, that unit had twice the number of patients.
Frank and Amanda Salinas are among the more than 1,300 statecontracted medical personnel assisting with San Antonio’s surge. While most have come from all over the country, the couple have been able to remain in their own community. As a result, they still receive calls from friends and family who are desperately seeking information about hospitalized loved ones.
“If it gets any more full, things are going to get even worse for families when it comes to getting information and getting the care that their family member should have,” Frank Salinas said.
Amanda Salinas avoids going on social media. Posts from people flouting public health rules or claiming the pandemic is a hoax
feel to her like “a slap in the face.”
She’s resigned to the fact that she and other health care workers may emerge from the pandemic with post-traumatic stress disorder.
As much as they sought to avoid it, local health care leaders have prepared for this moment.
In the spring, when the virus began spreading in San Antonio, the Southwest Texas Regional Advisory Council, which manages emergency services for the city and the surrounding region, convened a group of physicians to develop crisis standards — a triage protocol for hospitals to follow, should they become overwhelmed.
The result was guidelines for three levels of crisis: rising transmission, expansion to surge capacity and the “worst-case scenario.”
During the first two phases, hospitals would do everything in their power to accommodate an influx of patients. Local hospitals already have taken many of those steps.
Under the third phase, they would declare an “internal disaster.” Hospitals would ration medical care to the people most likely to benefit. Doctors would assign patients a “survival score” based on their level of illness and the health of their organ systems.
Some patients would be offloaded to overflow beds at freestanding emergency centers or a field hospital at Freeman Coliseum.
Hospitals have progressed to the second crisis phase and are “flirting” with the third, Miramontes said.
“If we have to go to the crisis standards of care, it’s going to be a very sad day in this community,” he said.
Morrow, the University palliative care physician, knows crisis standards of care are controversial. During the pandemic, some localities have been sued for their plans, over allegations that they discriminate against people with disabilities or the elderly.
That’s why when he joined the group that was developing guidelines for San Antonio, he knew the guidelines would need to be grounded in equity.
The document specifies that patients with disabilities have the right to accommodations that allow them to benefit equally from care. Factors like age, race, weight or perceived quality of life should not unduly influence a patient’s access to treatment.
Medical decisions should be individualized and based on shortterm survivability, rather than assessments of how long a patient might survive after recovering from an acute illness.
On Thursday, STRAC’s crisis guidelines received the stamp of approval from the U.S. Office for Civil Rights and were praised by two advocacy groups: Disability Rights Texas and the Center for Public Representation.
When disaster strikes, Morrow said, it’s better to have a plan grounded in a strong ethical framework. Otherwise, decisions may be consciously or unconsciously influenced by doctors’ individual biases.
When doctors are under duress, they may panic and veer from common standards of care.
“What about if you have another patient and another patient and another patient, who have equal need, and you can’t save them all? That’s not a comfortable place for a physician to be in,” said Morrow, who also helps lead the ethics curriculum at UT Health San Antonio’s medical school.
The guidelines also help protect hospital staffers from the “moral injury” of being left to make life-ordeath decisions on their own, Morrow said.
Stewart still is hopeful San Antonio can avoid disaster. The city is not “helpless,” he said, and has
ways to reduce transmission — particularly if the public pitches in by wearing masks and avoiding contact with people outside their households whenever possible.
Shame and blame have not proved effective in altering people’s behavior during the pandemic, he said. So his appeal to the public is simple: help save more lives.
“I would ask my friends, my neighbors, the people in our community, to double down and really work to improve adherence to those public health measures, because it is a strategy that’s been shown to work,” he said. “This is not political. This is medical.”
‘Where did we really get it?’
As bad as this surge has been, medical providers have the benefit of experience this time around, said Dr. Minh-Phuong Le, a UT Health San Antonio clinical hospitalist who practices at University.
Coronavirus hospitalizations have risen more gradually than they did over the summer, giving hospitals more time to expand beds and staffing. Testing has expanded significantly, leading to earlier diagnoses and treatment. Doctors and nurses now are intimately familiar with the progression of COVID-19 and what drugs work against it.
“It’s still hard,” Le said, but “this time it feels more standardized.”
And patients with underlying health conditions now have more treatment options.
At Freeman, an exposition hall has been converted into an ad hoc COVID-19 treatment area. In the “hot zone,” medical workers swathed in personal protective equipment bustle past lines of white tents, which each can house a coronavirus patient undergoing a monoclonal antibody infusion. Clinical trials have indicated the outpatient treatment can reduce people’s chances of being hospitalized.
The state-supported operation recently transitioned from the purview of the Fire Department to BCFS Emergency Management Division, a local contractor. It can schedule about 90 patients a day, who are infused for an hour.
Miramontes said the infusion center aims to reduce the burden on hospitals by targeting patients who are at a high risk of COVID-19 complications but aren’t seriously ill.
On Friday morning, that included Jan Hartl and her husband, Herman, who underwent their infusions in adjoining tents after testing positive Wednesday.
Hartl, 66, was shocked by their results. She had been assiduous throughout the pandemic, wearing a mask and avoiding grocery stores. Her only outings were to her job as Wilson County’s treasurer.
As a diabetic, she had worried she wouldn’t survive if she contracted the virus. Knowing she finally caught it filled her with anxiety and fear.
“I was so careful,” she said. “Our biggest concern is, where did we
really get it?”
Across the area, Roger Machin, 54, reclined in a chair as the drugs flowed into his arm. Two days after returning from yachting in Miami with friends, he learned someone on the boat had contracted the virus. Machin initially was asymptomatic but started developing symptoms after receiving his own positive results Jan. 7.
His chief concern is being away from work, which is busier than ever as the virus rages across Texas. His company, which operates in San Antonio, Corpus Christi and McAllen, has created a COVID-19 team to safely allow infected patients to die at home, surrounded by family.
“It’s a huge need in the community,” he said. “Having to be home is more upsetting to me, to be honest with you, than being out (in) the field, helping others.”
At University, coronavirus patients now are spread across three floors. Earlier this month, Morrow was working with the hospital’s COVID-19 palliative care team, which helps call family members to provide patient updates and emotional support.
From Monday to Sunday, he lost six COVID-19 patients. As the next week began, another four people he had cared for succumbed to the virus.
When he drives home from the hospital, he passes packed restaurant parking lots.
Over the summer, he said, the state’s mask mandate and order to shut down bars helped bring the first surge to heel. The virus once again is rampaging, but urgency is lacking this time. Many members of the public are going about their daily lives. State officials repeatedly have blocked localities’ efforts to reduce transmission.
While the arrival of vaccines is a welcome development, Morrow said, it doesn’t negate the need to control the spread of the virus. Reaching herd immunity is a months-long process; inoculation won’t solve the immediacy of San Antonio’s crisis.
“How can we keep doing what we’re doing, when the deaths keep piling up?” Morrow said. “If we don’t do something different, then the medically at risk in our community will die. I’m watching it every day.”
Le has been witnessing her share of tragedy, too.
She has watched colleagues work for weeks on end, seen the virus ravage entire families, watched patients younger than her die. She and other health care workers understand they will have to put their own needs, and that of their families, aside as they respond to the crisis.
During one shift in December, Le spotted an ICU patient taking tentative steps with the help of physical therapists.
The woman fell ill during the first surge and has been hospitalized for COVID-19 since June. She had to relearn how to walk, talk and eat.
Yet another surge was underway, and she still was there.