With Covid-19 hospitalizations steadily approaching a record high in the US, states like Arizona have activated emergency plans and requested refrigerated trucks to prepare for overflow at morgues. Doctors there say packed emergency rooms and ICUs are forcing them to prioritize the sickest patients, leaving other ill patients to deteriorate while waiting for care they’d ordinarily receive right away.
Hospitals in hot spots across the country are expanding and even maxing out their staff, equipment, and beds, with doctors warning that the worst-case scenario of hospital resources being overwhelmed is on the horizon if their states don’t get better control of the coronavirus.
“With Covid, a lot of times people who aren’t sick enough yet get pushed to the back, and then they can become really, really sick unfortunately because we were focusing our efforts on the people who are on the brink of death,” an emergency room doctor at the Banner Health system in the Phoenix metro area, who asked to go unnamed fearing retaliation from his employer, told Vox.
Other doctors in Arizona, where 90 percent of hospital beds statewide were in use Tuesday, say the scarcity of resources means they’ll soon be rationing medical care, as doctors in Italy were forced to do.
“The fear is we are going to have to start sharing ventilators, or we’re gonna have to start saying, ‘You get a vent, you don’t.’ I’d be really surprised if in a couple weeks we didn’t have to do that,” says Murtaza Akhter, an emergency medicine physician at Valleywise Health Medical Center in Phoenix.
It’s not just Arizona. Doctors and hospital experts in Texas and Southern California say capacity is a major concern for them as well, particularly if new daily cases keep rising. Several counties in California are facing major outbreaks of the virus, with hospital resources stretched thin to care for the sickest patients.
States have started to roll back their reopenings in recognition of the intensity of current transmission. California Gov. Gavin Newsom announced Monday he would order some businesses to close again. Texas Gov. Greg Abbott has finally issued a statewide mask mandate and closed certain establishments. Arizona Gov. Doug Ducey also reimposed some restrictions, though has refused to require residents to wear masks in public spaces, instead asking for voluntary compliance with public health experts’ advice.
The question is, will it be enough?
“If things continue to get worse,” John Swartzberg, a clinical professor emeritus at UC Berkeley’s School of Public Health, says, medical care for Covid-19 patients “will get much more draconian.”
When New York and New Jersey raced to expand hospital capacity in April to handle the crush of Covid-19 patients, Sunbelt states largely avoided the big spring wave. But after their governors moved forward with reopening in May even though they didn’t meet the public health criteria set by the federal government to stay safe, three states in particular — Arizona, Texas, and Florida — saw significant increases in new cases.
Experts say these outbreaks are largely driven by people flocking to newly reopened restaurants, bars, gyms, and other high-risk indoor spaces, as well as weakly enforced or nonexistent face mask mandates. Now, with new cases and hospitalizations rising in 44 US states and territories, many fear some hot spots may be faced with even bigger surges, with less ability to expand capacity than hospital-dense New York City.
Hospitalizations nationwide are now quickly on their way to exceeding the peak of 59,539 on April 15, hitting 56,147 on Wednesday, according to the Covid Tracking Project.
Hospital organizations in Florida say facilities there can still expand capacity if needed. But they, like other hot spot hospitals, are starting to cut back on elective surgeries and procedures — leading them to furlough staff in some cases to compensate for massive losses in revenue — to accommodate the rising tide of Covid-19 patients.
And most worrying for the states now battling major outbreaks is that, unlike in April, when most of the country was in lockdown, there’s no clear sense of when the current outbreaks will peak or decline. With only partial social distancing measures in place and inconsistent mask use, the virus may continue to spread, leading to an unabated wave of severe illness requiring hospitalization, more deaths, and more long-term complications requiring medical care.
Here’s a closer look at how some hospitals in Arizona, Florida, Texas, and Southern California are handling the pressures of the latest surge of Covid-19 patients, and why it may get worse in the coming weeks.
Arizona doctors say the surge is forcing them to make brutal decisions in patient care. Meanwhile, morale is dangerously low.
As Vox’s German Lopez has reported, Arizona’s Covid-19 outbreak has lately been the worst in the country, with the highest test positivity rate of all the states: 24.7 percent of tests coming back positive (nearly five times the recommended maximum of 5 percent), compared with 18.7 percent in Florida and 17 percent in Texas, according to Johns Hopkins.
It also, until very recently, had the highest number of daily cases per 100,000 people. (As of Wednesday, Florida was in the lead, with 54 new cases per day per 100,000 people, compared with Arizona’s 48, according to data compiled by the Washington Post.)
Whichever metric you’re looking at, the implication is the same: The virus continues to spread rapidly in the state, despite the governor’s (relatively weak) efforts to discourage indoor gatherings and ensure widespread face mask use since reopening. Meanwhile, hospitalizations are rising steeply following the upward trend in new cases. The heat wave underway, which is forcing more people indoors, isn’t helping, either.
The unchecked transmission of the virus in the state and resulting pressure on hospitals are particularly infuriating to some emergency room and ICU staff, who say they are losing hope that they will get any relief from the surge of severely ill Covid-19 patients anytime soon. And they’re having to make decisions on the fly that they’re uncomfortable making.
“Sending people with Covid home with oxygen tanks because we don’t have the resources for them? This is something I’ve never done in my life before,” says Akhter of Valleywise Health. “This is crazy. And this is gonna be even worse in a couple of weeks. So far we’re trying to hold steady, but how long will that last?”
The psychological toll, he says, is serious too.
“To come off a shift and be like, ‘I’m losing hope’ — that’s a dangerous place to be in,” he says. “I don’t want to feel that way. And that’s because despite the horrible numbers, despite the fact I’m still getting the Covid cases [in the ER], despite what we’ve been saying to the media from the front line, I drive home from work and I literally see lots of people congregating together closely and in the grocery store not wearing masks.”
Another ICU doctor in Phoenix, who spoke on the condition of anonymity because his employer has forbidden staff to speak to the media, described increasingly low morale among health care workers in the state.
“I think a lot of us feel as if our community has abandoned us almost, because there’s a lot of fake news about how masks are not helping the spread,” he says. “I think there’s just a sense of abandonment almost where we feel like we don’t have the support of our community; this individual selfishness that we’re seeing in society is really upsetting. And I think psychologically it’s really affecting a lot of my nurses and staff.” Some of them, he says, are so frustrated and worried about getting sick themselves that they’re not coming to work as much, calling in sick, or just cutting their hours.
Akhter thinks there are a lot of people in Arizona who still don’t believe Covid-19 is bad. “If their mother gets sick, even with non-Covid, with appendicitis, for example, what do they think is going to happen if there are no hospital beds? I don’t know what else to say other than, like, ‘What if your loved one gets sick, where do you think she’s gonna go?’”
Some of his colleagues in emergency and critical care medicine say they are already running out of ICU beds. “We have patients who are admitted to the ICU, but there isn’t a physical ICU bed for them,” says the ER doctor at Banner Health who asked not to be named. “So they physically stay in the ER. And they have been staying in the ER for over 24 hours because there is nowhere else for these patients to go. And then we’re using ventilators that have previously been retired, that are more likely to cause lung injury on patients, because, again, there’s no other option, no other way.”
The crunch on beds is getting so tight that Tucson Mayor Regina Romero recently told CNN that Pima County might have to send patients to other states for care. “Any day, we’re going to have to be sending patients to other states because of our lack of capacity,” she says.
Banner Health system, the largest hospital network in the state, says it has been able to expand capacity so far to keep up with the heightened demand from Covid-19 patients, moving them and resources between hospitals to keep volumes balanced and manageable. In recent weeks, it has also brought in about 400 travel nurses and respiratory therapists from out of state, spokesperson Becky Armendariz told Vox over email. But she didn’t rule out the possibility of exceeding capacity. “It is certainly possible for us to reach max capacity if the trend in cases continues.”
The only way to avoid that at this point, the doctors say, is for more people to start wearing face masks and for officials to enforce mandates at the city level.
“If Arizona does not mask up, we are in big, big trouble,” says the ICU doctor. “That’s the ground reality of the situation.”
Florida hospitals are walking a path “with a precipice on either side”
In terms of sheer numbers of new cases, Florida — the third most populous state in the country — has consistently been in the lead this summer, with a record high of 15,300 new daily cases on Saturday. (On Tuesday, the number of new daily cases fell to 10,101.) More than 4,400 Floridians have died due to the virus, with an average of 81 deaths per day in recent weeks.
According to Justin Senior — CEO of the Safety Net Hospital Alliance of Florida, which advocates on behalf of 14 hospitals in the state that provide care regardless of patients’ ability to pay — the state’s hospital capacity has not been reached yet and there will still be many hospital and ICU beds available if hospitalizations continue to rise rapidly.
Even so, Senior says hospitals are in a precarious place, “with a precipice on either side” as they try to juggle the needs of non-Covid-19 patients with the rising number of Covid-19 patients. If they postpone elective procedures, like certain surgeries, they lose revenue at a time when they’re still reeling from losing, by his estimate, $5 billion to $6 billion overall from March to May when the state shut down. If they don’t postpone those procedures, it’s harder to care for patients in a Covid-19 surge, he says.
“This is the path that the hospitals are trying to walk, because you don’t want another shutdown completely when there aren’t enough patients to avoid layoffs and avoid a really bad financial situation on one side, and of course, overcapacity and overtaxing of resources with too many Covid patients on the other side,” he says.
In Florida, Senior says, staff is the biggest concern for hospitals at the moment — in particular making sure that they don’t burn out and have enough PPE to stay protected from the coronavirus. “This is a really stressful situation, and there’s a real recognition of that.”
According to CBS Local in Miami, Florida Gov. Ron DeSantis has requested that the Federal Emergency Management Agency (FEMA) send 1,500 nurses to the state to relieve the pressure on overworked hospital staff. “As of Monday morning, FEMA had not approved the request,” CBS reports. “DeSantis, meanwhile, said he is sending 100 nurses under contract with the state to Miami-Dade County.”
Some hospitals, particularly in Miami-Dade County, are already dialing back on some elective procedures to lessen the strain on staff and other resources. “The next step would be to declare surge capacity — this actually creates additional capacity by allowing a hospital to temporarily deal with an emergency by doubling up patient rooms and relaxing staffing ratios to exceed the hospital’s normal bed count,” he says. “You can’t keep that up for long. A final step would be to bring in field hospitals and significant outside resources.”
On Monday, Senior warned Vox that he was worried about hospitalizations exceeding 500 per day. “If daily hospitalizations shoot up over 500 a day, there will be serious stress ahead,” he says. “800 or 1,000 and it will be a wild ride.”
Unfortunately, the state is heading in that direction. On Tuesday, Florida hit 533 hospitalizations:
“If it grows exponentially from here, there’s no denying, you know, we’re gonna have to relook at everything at the beginning of August,” Senior notes.
Texas hospitals warn they are running out of staff, PPE, drugs, and other supplies
Texas hospitals thought they had already seen the worst of Covid-19 in the spring. This latest surge has surpassed that first surge several times over.
During the first wave, from late February to early May, Houston Methodist Hospital peaked with about 250 coronavirus patients. Today, they have nearly 700. “There are too many Covid patients, full stop,” Roberta Schwartz, executive vice president at Houston Methodist, told me. “We ran full before, we’re running full-plus now.”
Their experience mirrors the statewide trends: Hospitalizations in Texas had topped out at about 1,800 in early May, but now, after cases began to accelerate dramatically, they’ve surpassed 10,000.
“Every day, or every other day, we’re turning another unit of this hospital into Covid units,” Schwartz says. “It’s slowly starving out the other services that we offer.”
She ticked through the list: Half a dozen of the hospitals’ medical surgical units are now being used to house Covid-19. An orthopedics unit has been shut down and flipped for patients who require high-oxygen flow. Cardiology units have also shortened their surgery schedules so that their space can be used for the coronavirus surge.
Schwartz and John Henderson, president and CEO of the Texas Organization of Rural and Community Hospitals, say their hospitals are in better shape now with personal protective equipment than they were in March and April.
But that could change as the crisis gets worse. Schwartz says her facilities have sometimes had trouble getting gowns and disinfectant wipes. Henderson says he “got a couple of SOS calls this week.”
Staffing is a universal problem. Houston Methodist has already brought in out-of-state nurses and asked its administrative staff with nursing certifications to start doing medical work again. Nurses are also being asked to work longer and overnight shifts.
Rural hospitals in Texas aren’t running out of beds yet, but they are running into a staffing shortage. These facilities might typically have five patients in a given unit, and the hospitals have staffed them accordingly. But now, there might be as many as 20 patients.
“You’re working every nurse as much as you can work them and still not meeting the need,” Henderson says.
It’s not clear where more staff could come from. The state has already sent about 2,300 volunteers to the Rio Grande Valley, one of the hardest-hit areas in the state.
“Other areas are requesting that workforce support,” Henderson says. “But there’s not much more in terms of resources to be sent.”
Another concern is ventilators. Rural hospitals in Texas would ordinarily transfer their patients in serious condition, the kind who might be on a ventilator for days, to a larger hospital in the city. But because urban hospitals are already overrun with Covid-19 patients themselves, there is nowhere for the rural hospitals to send their patients. Instead, they are forced to keep those patients, causing their beds to fill up even more quickly.
And while the current coronavirus patients are younger than those seen in the spring, Henderson says his hospitals don’t have enough of the nasal oxygen hookups that are used to help those patients breathe on their own and prevent them from being put on a ventilator.
“They’ve shown to be effective but everybody’s trying to get them,” he says.
Hospitals are putting lessons from the early weeks of the crisis to use. Remdesivir, an antiviral treatment prescribed to Covid-19 patients with low blood oxygen or who need breathing assistance from a mechanical ventilator, is protocol now. The University Health System in San Antonio, which got firsthand experience in the initial wave when it was asked to treat some of the first patients from Wuhan and the Diamond Princess cruise ship, has adapted its standard of care to include remdesivir, anti-inflammatory drugs, and putting patients on their stomachs to help them breathe. They have also reduced their use of ventilators, only using them when absolutely necessary.
But those improvements in treatment require adequate staffing and supplies to implement them. And as the crisis grows, supples are starting to run low.
“We still don’t have a steady stream of enough remdesivir,” Schwartz at Houston Methodist says.
That is the situation on the ground as of early July. Cases are continuing to climb in Texas, and more people are expected to end up in the hospital as a result. The emergency plan to set up temporary facilities in convention centers or sports venues is suddenly on the table.
Hospitals like Memorial Hermann in Houston have already activated their surge capacity plans, but that might not be enough if current trends continue.
“We remain concerned about the current growth rate in new cases and the demand for hospitalization, as we could reach the limit of our surge expansion plans if the current trends do not reverse,” Drew Munhausen, a spokesperson for the hospital, says in an email.
The hope is that new cases will start to level off soon, now that Gov. Abbott has reimposed some social distancing restrictions and established a statewide mask mandate. But for now, Texas hospitals are just waiting and hoping and preparing.
“If you’re counting hospital admissions and ICU patients on vents, you’re weeks behind. We’re chasing it right now,” Henderson says. “There’s no optimism today for what the rest of July looks like.”
The worst-case scenario, in these moments, is that people will die who otherwise wouldn’t have because the shortage of beds or supplies or staff will lead to suboptimal care.
Even fear itself can be devastating to public health. As ProPublica and NBC News reported, the number of Houstonians dying at home has spiked in recent weeks, suggesting people who either had Covid-19 or another life-threatening condition didn’t make it to the hospital in time.
“When you are unable to take care of patients in the optimal circumstances, you do worry that you are not able to do as good of a job in not-optimal circumstances,” Schwartz says. “And we are about to get into not-optimal circumstances.”
It could be a difficult few weeks ahead. Youyang Gu’s Covid-19 Projections currently expects cases in Texas to peak at the beginning of August and deaths to peak in mid-August.
In Imperial County, California, a run on ventilators
El Centro Regional Medical Center in Imperial County, one of California’s biggest Covid-19 hot spots right now, has already brushed up against its worst-case scenario.
About 60 percent of the patients in the medical center were infected with the coronavirus as of last week, and there aren’t enough ventilators, Adolphe Edward, the hospital’s CEO, told Vox. The medical center serves a largely Hispanic community, with many patients who have diabetes or other preexisting conditions that make them more vulnerable to the virus and who require mechanical ventilator support for their breathing when the disease takes a turn for the worse.
The hospital recently saw its available ventilators dwindle to one. Edward convened an impromptu committee to evaluate the patients currently on ventilators so they could prioritize if another patient who needed one came through their door. They checked their lung capacity and considered whether they could risk taking one or two of the patients off the ventilator if the need arose.
Luckily, Edward figured out a workaround. He called another nearby hospital and asked if they had any ventilators available. They had two, which they shipped over to El Centro. For now, the machines are still there, though Edward says he and the other hospital have stayed in constant contact in case the ventilators need to be transferred again.
Edward sounds exasperated describing that makeshift solution and he wonders why the federal government hasn’t started manufacturing “half a million or a million” ventilators to meet the need that hospitals like his have.
“Somebody’s gotta figure that out,” he says. (The Trump administration signed contracts in April under the Defense Production Act that are supposed to yield a little fewer than 150,000 ventilators by the end of 2020.)
Statewide, only about 30 percent of all available units are currently in use, according to NPR. But there have been surges of patients in some regions like Imperial County that have nearly overwhelmed local hospitals. About 30 percent of ICU beds are still open statewide as well, but those numbers could start shrinking as the state outbreak shifts from the younger cohort less prone to serious complications to older people who are more likely to require hospitalization and ventilation.
A California plan to stockpile ventilators never materialized, and the available capacity could be stretched with the hardest-hit areas exporting their patients to facilities in other parts of the state.
El Centro Regional Medical Center is moving patients out of its building at a rate Edward would ordinarily have found unfathomable. During normal times, the hospital might send out one or two patients a day, he says. Nowadays, they’re averaging between six and eight.
“If you had told me at the beginning we’d be transferring that many patients, I would have told you: I don’t know what you’re drinking,” Edward says.
For the time being, hospitals elsewhere in the state have the extra space to accommodate them. But the worry is if the outbreak keeps spreading, that excess capacity will evaporate very quickly.
New Covid-19 cases and deaths in California are currently expected to peak by August or early September, according to Youyang Gu’s Covid-19 Projections, meaning the new surge has not peaked yet.
More hospitals could be faced with the kind of difficult decisions that Edward and his team were nearly forced to make.