Front lines brace for onslaught

But health care workers have more knowledge, options for treating COVID-19 than they did in spring wave

On Friday afternoon, there was a feeling of weary inevitability among those walking the halls of Sharp Memorial Hospital in San Diego.

As a dwindling supply of intensive care beds triggered a fresh round of community restrictions from the state, a certain level of fatigue was visible in many eyes, whether peering through face shields or squinting through windows into rooms where a growing number of beds are being filled with newly admitted COVID-19 patients.

Things are not yet bad enough where entire medical staffs must work seven days a week, but many know that could come soon if beds keep filling at the rate they have in recent weeks.

The problem, noted critical care nurse Megan Weske, is that the coming wave lands after more than nine months spent tediously putting on and taking off personal protective equipment, conjuring the kind of hypervigilance needed to make sure that masks and shields and gowns and gloves are put on and taken off in the proper order and with the proper technique to avoid getting sick or, even worse, taking something home to family members.

Add in the need to serve as a constant informational and emotional conduit to the bedside for family members kept away by strict visitation restrictions, and the result is a kind of health care pressure cooker that makes it difficult to ever feel truly at rest.

“That adrenaline wears off after a little while and we feel more tired and we feel more worn out and more burnt out,” Weske said. “You’re trying your best to give everything to these patients, but it wears on you.

“It wears on your soul, too, to

see this.”

Nothing can truly alleviate that pressure that frontline workers are feeling in this particular moment of pandemic panic, but there have been some gains that will help them navigate what is likely to be the most difficult holiday season of their lives.

Nearly 10 months of experience has helped the medical community figure out how to treat COVID-19 patients more effectively than they were able to in March and April when the threat was still brand new and barely understood.

Medications and methods honed in recent months have produced tangible reductions to the amount of time that patients spend in hospitals when they do get admitted.

Sharp reports that its average length of stay for COVID-19 patients has dropped from 12 days to six in recent months, a significant gain at a time when the number of county residents requiring hospitalization is increasing rapidly and is expected to continue to rise for weeks or months to come.

Dimitrios Alexiou, president of the Hospital Association of San Diego and Imperial Counties, said the trend goes beyond Sharp hospitals, though broader statistics encompassing the entire region were not immediately available.

Generally, though, there are a few main reasons why the small percentage of coronavirus patients who end up hospitalized are spending less time convalescing than they did in the spring and early summer.

“The patient population is different than the initial wave earlier in the year. It’s a younger population than the initial wave,” Alexiou said in an email. “The other factor is that clinicians have better recognition of COVID-19 cases and better treatments than we did early on.”

It is clear that there has been a significant age shift toward younger patients as the pandemic has proceeded. Data examining the 81,084 cases in San Diego County confirmed through Dec. 1 shows that the risk of dying after becoming infected with the novel coronavirus has remained near zero through age 49, increasing a bit among patients in their 50s and then more sharply still for those age 60 and older.

County data shows that, through May 31, the age split was relatively even with 41 percent age 50 or older and 58 percent age 49 or younger. Today, the overall age breakdown has shifted considerably, with 71 percent having not yet celebrated their 50th birthdays.

More younger people getting infected translates to fewer severe complications, such as respiratory or cardiovascular distress, which can often be the factors that send a person to a hospital for help rather than continuing to fight the virus at home.

For those who do end up coming in, there are treatment options available that simply weren’t on hand in the first few months of fighting the disease.

Standing in the busy intensive care unit at Sharp Memorial Hospital, Dr. Tom Lawrie, the facility’s chief medical officer, said three drug categories, anti-virals, steroids and anticoagulants, have been shown to help keep moderate cases from growing in severity. Remdesivir is the anti-viral of choice, alongside the powerful steroid dexamethasone and anticoagulation medications such as enoxaparin and heparin.

“What’s different now, and what’s really helping drive down the amount of time that many patients are spending in the hospital, is that we’re able to provide help through multiple different channels,” Lawrie said. “Remdesivir helps the body fight the virus itself; dexamethasone helps a little more indirectly by inhibiting some of that inflammatory cascade that can cause more severe respiratory problems, and the anticoagulation meds help prevent some of the more severe cardiovascular issues like clots and stroke.”

There are also changes to process.

In the early going, there was a tendency to put patients on breathing machines relatively soon after their blood oxygen levels started to drop. The thought was that it would be easier to carefully sedate patients, and insert breathing tubes, if those steps were not being taken in emergency situations more likely to make highly infectious respiratory droplets airborne.

That concern has largely waned, with patients now much more likely to be put on robust oxygen supplies before a breathing machine is deemed necessary.

“Now we know that, with this progression, we can delay intubating them altogether,” Lawrie said.

Proning, the act of turning patients experiencing extreme respiratory distress onto their fronts and then onto their backs to increase oxygen f low in their inf lamed lungs, has also become standard practice. First used mainly with patients on breathing machines, the practice is now common with patients much earlier in their courses of illness.

But using the knowledge and drugs to cut the average amount of time that COVID-19 patients spend in hospital beds has not been able to keep numbers from rising as infection rates, driven by an overall level of “COVID fatigue” in the community, from increasing rapidly.

For those who just don’t want to wear their masks anymore, Weske has a simple reality check.

“I get it, people want their normal life back, but life isn’t normal right now,” she said. “Our life isn’t normal. These poor patients’ lives aren’t normal. We’re just not there yet.”

NELVIN C. CEPEDA U-T Taylor May checks on her patient Cynthia Powers, diagnosed with COVID-19, at Sharp Memorial Hospital on Friday. After nearly 10 months of learning about the coronavirus, the medical community has learned more effective ways to treat it.

NELVIN C. CEPEDA U-T Medical staff at facilities such as Sharp Memorial Hospital are gearing up for a difficult holiday season as cases surge and they deal with the fatigue of the past months.