A Blog by Jonathan Low


Dec 3, 2020

Where Do Covid Patients Go When Hospitals Are Already Over Capacity?

Temporary facilities pick up some of the load like the tent at right. Then some patients are given 'rationed care' - which means they are given less care than would normally be called for - because there are not enough beds, doctors, nurses or medicines. 

And finally, they are simply turned away. JL

Lenny Bernstein reports in the Washington Post:

With more than 91,000 covid-19 patients in their beds, U.S. hospitals are in danger of buckling beneath the pandemic and the needs of other sick people. In small- and medium-size facilities hit hardest by the outbreak’s third wave, that means finding spots in ones and twos. Covid-19 patients can linger for weeks, even a month, complicating the effort to find space for the current surge of sick people. Some doctors acknowledge they are rationing care, a euphemism for providing some patients a lower level of service. The National Guard has been dispatched to handle Covid-19 corpses, many held in refrigerated trailers. 
As the coronavirus pandemic swelled around the 160-bed Mayo Clinic hospital, the day was dawning auspiciously. Two precious beds for new patients had opened overnight. At the morning “bed meeting,” prospects for a third looked promising. 
Better yet, by midmorning, there were no patients in the Emergency Department. None. Even in normal times, a medium-size hospital like this can go many months without ever reaching zero. 
Everyone knew better than to trust this good fortune. They were right. 
From 9 a.m. to 10 a.m., seven patients arrived at the emergency room. Fourteen descended the next hour, then 10 more the hour after that. 
About a third had signs of covid-19, the illness caused by the virus, most with trouble breathing. But there was also the man who had smashed his fingers with a hammer. The unresponsive woman who had to be resuscitated. An injured elbow. Neck pain. Acute depression. 
By 12:05 p.m., Mayo had put itself on “bypass,” sending all ambulances to the two other hospitals in town, a last-resort move rarely employed. By late afternoon, the emergency room was stashing patients in four beds erected in the ambulance garage — the first time it had adopted that tactic — and holding others for hours as they waited for places in the overflowing hospital. 
With more than 91,000 covid-19 patients in their beds, U.S. hospitals are in danger of buckling beneath the weight of the pandemic and the ongoing needs of other sick people. In small- and medium-size facilities like this hit hardest by the outbreak’s third wave, that means finding spots in ones and twos, rather than adding hundreds at a time as New York hospitals did when the coronavirus swept the Northeast in the spring. 
“A bed is a gift right now,” said Jason Craig, regional chair for the Mayo Clinic Health System in northwest Wisconsin. “I’ll take all of them. 
In Utah, some doctors acknowledge they are informally rationing care, a euphemism for providing some patients a lower level of service than they should receive. In El Paso, the National Guard has been dispatched to handle the overwhelming number of covid-19 corpses, many held in 10 refrigerated trailers outside the medical examiner’s office. 
So far, such extreme measures are not widespread, but only because hospitals have spent months preparing for this catastrophe — one expected to grow worse in the weeks to come as the weather turns cold and Americans move indoors. 
More challenging still is locating doctors, nurses, respiratory technicians and other staff needed to provide care as the pandemic places unprecedented demand on the entire nation simultaneously. Even Mayo, one of the most prestigious and well-resourced systems in U.S. medicine, is supplementing its Wisconsin staff with nurses from its hospitals in Arizona, Florida and Minnesota, redeploying nurses from other parts of this hospital and hiring temporary travel nurses who sign on for short assignments. 
With nearly 300 staff infected or quarantined in northwest Wisconsin, the system has turned to technological solutions and shuttling patients between hospitals as beds open. 
“No one could have forecast what we’re dealing with right now, in regard to what the staff are having to do, what the patients are going through,” said Elysia Goettl, nurse manager of the hospital’s medical-surgical unit. 
For two days this month, Nov. 18 and 19, Mayo allowed The Washington Post to watch from inside the largest of its five northwest Wisconsin hospitals as it coped with the virus’s staggering consequences. 
On that Wednesday, the health system tallied 341 positive coronavirus tests out of 1,295 given in the main facility and four tiny hospitals in Barron, Bloomer, Menomonie and Osseo — an astonishing positivity rate of 26.3 percent. The state’s seven-day rolling average infection rate that day was even higher, at 32.5 percent. (Six days later, Mayo’s rate would fall to 17.6 percent, and later to 14 percent, though its models forecast a continuing surge of patients.) 
In contrast, New York Mayor Bill de Blasio (D) closed the nation’s largest school system the same day, when the city’s seven-day average exceeded just 3 percent. Two days earlier, California Gov. Gavin Newsom (D) imposed tough new restrictions when the state’s 14-day average positivity rate reached 4.7 percent
In the main 160-bed hospital here, there were 166 patients at 9 a.m. Wednesday, 60 of them with covid-19. At 4 p.m., after a day of transfers and discharges, there were a total of 147. By Thursday morning, as emergency room patients and others found their way into the hospital, there were 167. 
Wisconsin largely evaded the first two waves of the U.S. pandemic, which crashed through the New York area in March and April and the Sun Belt this summer. Unlike Seattle and elsewhere, Wisconsin’s younger people were infected first as the state reopened. Now, the virus is reaching into the older, more vulnerable population. 
In room 41129, on the hospital’s fourth floor, 63-year-old Mark Ahrens was beginning to recover from covid-19. Ahrens fell ill about two weeks earlier, overcome by paralyzing fatigue. His lungs clogged, leading to pneumonia. 
Three floors down, his wife, Kathryn, was undergoing surgery the same day to clear out pockets of thick fluid from severe covid-19 infection in one of her lungs. A double-leg amputee with diabetes and high blood pressure, she contracted the disease at the same time as her husband. The couple were admitted together. Ahrens hadn’t spoken to his wife in a week.“I feel real lucky that I’m still here,” Ahrens said. “Because I was in really bad shape when we came in.”


“We thought we may get some bed relief, and then, of course, the law of health care kicks in,” Craig said. 
A careful mask-wearer outside the home, Ahrens believes he and his wife, who is 57, were infected by Kathryn’s grandchildren, who visited the couple’s home for a week. Kathryn’s daughter, Sandy Kassa, assumes her children picked up the virus during an outbreak at their day-care center, then passed it on to her and the couple. 
“I thought I had the flu,” Kassa said. She suffered from fever, chills and difficulty breathing, which has lingered for weeks, though she has recovered. “Somebody was reaching up inside my rib cage and squeezing my lungs.” 
Small family gatherings are thought to be a significant avenue of virus transmission in the current surge. But Kassa didn’t heed the public health warnings until the virus struck three generations of her family. 
“I honestly thought before I became sick that people were just being dramatic,” she said. “Now that I’ve experienced it myself, I just know that it’s real. 
“I shouldn’t have had my kids over there.” 
Ahrens is incredulous at how casually some people are still treating the virus. 
“People were … saying it was fake news and stuff. They’ll probably realize in a year from now, when they lose somebody. If they would listen now, they would be here for the next holidays,” he said. 
In the room next to Ahrens, 72-year-old Donna Keller said she fought diarrhea, vomiting and dehydration from covid-19 before she was finally hospitalized. “I thought I could whip it,” she said. 
Keller said she, too, was careful to safeguard herself against the virus and is unsure how she became infected. But she doesn’t like what she sees on the street. 
“The younger kids, I think, feel they can fight this and it doesn’t affect them,” she said. “But they don’t realize that they pass it on to the older people that have a harder time fighting it.” 
Ahrens and Keller were discharged Nov. 20, Ahrens to the small Mayo hospital in Bloomer, where he began rehab, and Keller to her home. On Friday, Ahrens’s wife joined him at the hospital in Bloomer. 
Until the surge, the floor where they convalesced was reserved for all kinds of medical and surgical patients. On Nov. 18, 38 of its 40 beds were occupied by covid-19 patients, and the hospital was seeking staff so it could fill the last two. More covid-19 patients spill onto the third and fifth floors and into the intensive care unit. 
In normal times, Mayo is nearly this full, said Richard A. Helmers, a pulmonologist and vice president for the region’s hospitals. Mayo does brisk business in high-end care, including cardiac surgery and neurosurgery. 
But those patients generally follow a predictable course. Doctors and administrators know when they’ll leave, when the next bed will open. Covid-19 patients can linger for weeks, even a month or more, complicating the effort to find space for the current endless surge of sick people. 
Despite the overcrowding, officials stress that the hospital is still open to anyone who needs its care. 
A glimpse inside the hospital’s sandstone walls reveals little of the stress it is under. The corridors are clean and quiet. Little equipment is visible. Few people scurry through public areas or cluster in conversation. The hospital was designed this way 10 years ago. If necessary, Mayo could close off the covid unit and create one giant negative-pressure system in an attempt to keep the airborne virus contained. 
On Ahrens’s floor, nurses attend to covid-19 patients at least once an hour, and each nurse typically is responsible for at least three patients. In an eight-hour shift, nurses must don gowns, gloves, N95 masks and face shields a minimum of 24 times, checking to ensure they are protected against the virus. After each visit, they carefully strip off the protection and dispose of it. 
Some nurses are working 12-hour shifts and overtime in a job in which they are holding patients’ hands as they die and helping others grieve over lost loved ones. 
Marybeth Pichler was filling in on the floor recently when another nurse asked her to sit with a dying covid-19 patient. He had perhaps an hour to live. He had been given morphine to ease his discomfort. 
“I just sat down, and he just talked,” she said. “He talked about how he used to farm and how he had dairy cows and after he sold the dairy cows, he had Black Angus.” After about 25 minutes, the patient took off the mask that provided him high-flow oxygen and soon passed away. 
With no visitors allowed, Pichler said she “felt it was an honor to be able to sit with him and hear about his life. Otherwise … he would have been alone when he died." 
“I knew when I volunteered what I was volunteering for,” she added. “When I’m going to work in the morning, I actually pray to be a blessing to someone or to be there for someone.” 
For hospital personnel everywhere, the early part of the pandemic meant confronting a new, lethal and unpredictable virus. Now, the dominant theme is burnout from responding all year with no end in sight, coupled with the complications of home life. 
“They’re struggling — emotionally, physically. They’re exhausted,” Goettl, the nurse manager of the medical-surgical unit, said. “And they have given 120 percent on their shift, and they walk out exhausted. They go home to a family where they have to give another 120 percent. We do that day in and day out.” 
Sara Annis, who supervises the medical-surgical nurses, works long hours at the hospital while her husband puts in 60 to 80 hours a week trying to keep the couple’s brewpub alive. When neither can be home, they leave their children, ages 9 and 12, there alone to attend school online. Neighbors check up on them. 
“It’s a huge, huge struggle just to try to balance work and family life right now,” she said. 
Mayo is exploring technology to help with the crisis. Before the pandemic, its advanced care at home program was designed as an experiment to determine whether patients who should be hospitalized could be treated in their own homes. They are provided hospital equipment, full-time monitoring from a central control room and visits by paramedics, nurses or nurse practitioners. 
But when the virus struck, the program was pressed into service to help ease crowding. Mayo is now caring for five people at home, including covid-19 patient Rita Huebner. 
A Mayo paramedic visited Huebner’s small apartment before she arrived, making room for the hospital equipment she would need. Then he and two others delivered her there late that afternoon. 
Huebner, 83, said she may have to rehab in a nursing home but for now accepts recuperating at home. “I’m doing pretty good, but not good enough,” she said. “I’m so damn weak.” 
Patients trade the security of having trained caregivers at their bedside for the advantages of staying in their own beds, at times with family around them, said Margaret Paulson, chief clinical officer for the at-home program. Remote monitoring can be done at long distances, including from Mayo’s main headquarters in Minnesota. 
On Wednesday, the federal Centers for Medicare and Medicaid Services announced new measures to encourage more hospitals to adopt telehealth programs that could ease the strain of the pandemic. 
Until the surge eases, there is only one glimmer of light at the end of this crisis. On Nov. 19, Mayo was notified that its first shipment of the coronavirus vaccine would arrive in early January. A team already is devising a distribution plan. 
“We need hope right now,” Craig said. “Hope is what’s going to get us through the winter.”


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