Hospitals still waiting for the surge; is it coming?

2020-04-12 | The San Diego Union-Tribune

April 12--They've built special wards, literally punching holes in their walls and snaking ventilation pipes through their halls to make their rooms ready to receive COVID-19 patients.

They've conserved personal protective equipment, and they've canceled most elective procedures, inconveniencing their own patients in ways that will surely take months to untangle.

But, as Easter arrives, the expected surge of patients with novel coronavirus infections still has not swamped local emergency rooms and intensive care units across San Diego County though news came this weekend that many hospitals in Baja California now have more patients than they can handle.

As of Saturday afternoon, the county public health department has tallied just 396 total hospitalizations since Feb. 14, nowhere near the number that would be needed to inundate the combined capacity of the region's 21 acute care hospitals which, taken together, exceeds 7,000 beds.

But that does not mean that the burden has fallen evenly on San Diego's houses of healing. Hospitals in Escondido, San Diego and Chula Vista, visited Friday, had similar but distinct COVID experiences.

Up north, a large emergency medicine unit at Palomar Medical Center Escondido was ready, primed for a large wave of patients, but largely empty.

Dr. Brian Grennan, nursing manager of the facility, said it's not that there haven't been any COVID patients. Several patients with confirmed infections were fighting for their lives in Palomar's intensive care unit at that very moment. But the numbers coming through the doors just haven't had that alarming spike that everyone fears just around the corner.

"We've seen a day or two where the numbers have had bumped up a bit, but overall it has been flat," Grennan said, adding that with the hospital's emergency volume 70 percent below normal, he worries that some patients with chest pain and other emergencies are staying home when they shouldn't.

Moving south to Sharp Memorial Hospital in Kearny Mesa, a larger number of suspected COVID patients was present Friday, but the number was well within what those in the facility's COVID emergency unit could manage. Physicians and managers had time to go more slowly than they would if they were working in, say, New York with team members helping wipe each other down, sanitizing reusable gear the moment it left a patient room.

It's not necessarily the vibe that everybody expected, said Joshua McCabe, Memorial's EMS director.

"Two weeks ago, you know, it felt like we saw the tide go out, and now we don't know if what's coming is going to be a tsunami or is it just going to be a series of waves that slowly builds," McCabe said.

It's important, he added, to understand that even if every bed is not currently full, COVID precautions are still making it take much, much, longer to handle the simplest needs of patients. Now, everybody with a cough gets treated by workers in protective gear that has to be methodically donned and doffed, putting emergency workers used to operating fast on a slow burn.

"Our sense now is that what we're dealing with is longer, slower and, in some ways, deeper," McCabe said.

Recent uptickThough the careful pace of care is the same, COVID activity seemed to be growing more quickly 15 miles south at Sharp Chula Vista Medical Center.

Friday evening, an ambulance pulled up to the patient delivery door at the hospital's emergency department, paramedics quickly unloading a patient on a gurney covered by a yellow plastic sheet to deflect the pounding rain.

Soon uncovered, his temperature taken, patient Michael Weiss, a software developer from Chula Vista, moved to a bed in a section of the hospital's emergency department set aside for those with relatively minor symptoms.

Weiss, 54, said he came in because symptoms that he and his wife had been tending at home with the help of over-the-counter medications had moved beyond cough, fever and "tremendous body aches" to breathing difficulty that had caused his blood oxygen level to plummet to 70 percent.

Breathing more easily under supplemental oxygen, he said it just became too difficult, too scary, to keep staying home.

"I started to cough, and my chest would get really tight, and it would just make me cough even more," Weiss said.

Sharp Chula Vista's ER is starting to attract a greater number of patients like Weiss who have been fighting it out and now must come in for professional help.

Registered nurse and infection prevention specialist Cindy Stuart said that it's difficult to know whether this is the start of a surge.

"I think it's still too early for us to tell," Stuart said.

Fellow infection preventionist Myra Laurino said it definitely felt like the situation is getting more intense recently.

"It seems like what we've seen the last couple of days we've gone from not having that many ventilated patient to having a lot more on ventilators in critical care," Laurino said.

Intensive careThat's what was going on upstairs, where 32 patients were admitted at Sharp Chula Vista as of Saturday afternoon.

The hospital has worked in recent weeks to convert an entire floor to a COVID unit, adding temporary anterooms that function like air locks and bringing in large ventilation pipes to keep the air inside each patient space from leaking out into the hallways. The hum of air-purifying equipment is now constant as nurses peer at their patients through windows, checking the conditions of those who are sedated as mechanical ventilators pump oxygen-rich air into lungs inflamed by coronavirus infection.

Many of these patients need to be turned regularly to help prevent further lung damage, and on Friday evening it was ICU nurse Linda Isidienu pushing through the doors to start the process for a man laying on his front, ventilator tubes protruding from his mouth.

After she checked the man's condition, and his ventilator connections, the nurse beckoned one, and then another, of her coworkers to join her. The trio then began a truly intricate collaboration, gently lifting the man's torso and turning him from his left to his right side. Carefully lifting the tubes out of the way and moving his head, the team looked like they were moving a newborn baby or maybe a Faberge egg.

After completing the maneuver, Isidienu pushed back through the doors, her hands held up to avoid contact with shared surfaces. She carefully moved to the nursing station, calling out that she was coming, her co-workers sliding out of her way as she washed up and began cleaning her reusable face shield, stowing her respirator in a plastic bag for re-use.

Smiling, she said she has learned the specific dance steps necessary to stay safe in her environment and has been forced to think about the logistical nature of her job more than ever before.

"When you go in, you need to make sure you have everything you need. You don't want to go in and have to go right back out again," Isidienu said.

Often hidden behind layers of protective gear, her smile seemed omnipresent when not hidden away, and she said, that's just her approach, despite the serious nature of her present assignment and her need to scrub herself and the inside of her car down after every shift before reconnecting with her family.

"It helps to be positive. You have to get through the day, you know," she said.

Sending 'em homeThough the daily focus in San Diego County and worldwide has been on the number of newly-reported cases and deaths, victories quietly occur in intensive care units daily. The county estimated Saturday that based on the assumption that it takes about two weeks to recover from COVID-19, about 443 of 1,761 local patients with confirmed infections have already gotten well.

A survey of local hospital systems late last week found that that more than 159 patients have already been discharged home after having it out with coronavirus in a hospital bed. That figure surely under-represents the true total as Kaiser Permanente, Alvarado Hospital and Paradise Valley hospital did not provide their discharge totals upon request.

One of the 59 discharged so far at Sharp HealthCare was under the care of registered nurse Tom Roschek for nearly two weeks. The tall intensive care specialist with black-rimmed glasses said the patient was in very rough shape even though they did not have any complicating health factors and were middle aged.

Sending this one home, he said, felt like a victory for the whole hospital.

"We were very pleasantly surprised when they left the ICU," he said.

Roughly a month into treating the deadly effects of novel coronavirus infection, Roschek said, he and his colleagues have gradually learned to modify how they work.

Sometimes, he said, the decision to insert a breathing tube, which is necessary to hook a patient up to a ventilator, comes relatively quickly after patients begin needing greater and greater levels of supplemental oxygen. The idea is to avoid emergency intubation, because that can give the entire medical team less time to put on their protective gear.

"When you're forced to rush, that just makes it less safe for everyone," Roschek said.

So many hours spent taking care of COVID patients and also absorbing what's happening in places where hospitals are inundated, Roschek said, does weigh on the mind, even for intensive care workers who are used to working with infectious diseases of all kinds.

"We read and follow what the CDC says we need to do to stay safe but, every once in a while, you get a little tickle in your throat, and you go, 'oh no, what's going on?'" he said.

Where it's headingModeling released this week by the Seattle-based Institute for Health Metrics and Evaluation predicts that the peak of the surge in California will put about 5,100 COVID patients in hospital beds, which the organization finds will likely come early next week.

Even in the model's worst-case scenario, peak bed use would be about 14,000 which would be far below the max capacity of 26,654. It's the same thing for intensive care beds, with the peak projected to use about half of the state's 2,000-bed capacity and to max out ICU capacity in the worst-case scenario.

Dr. Theo Vos, a senior faculty member at the institute, said Friday that California's early action on social-distancing measures clearly has delivered this result.

But he cautioned those in the Golden State not to get cocky.

Relaxing social-distancing requirements, he said, will definitely come with second and third waves of infection that could be worse than the first. Preventing that scenario, Vos said, will require public health departments to commit to aggressive detection of new cases, making sure that everyone with even the mildest symptom gets tested and isolated immediately and that health investigators are able to find and test all close contacts of positive cases with lightning speed.

"That requires a very large workforce, much larger than public health agencies currently have available, and we really need to start preparing for that now," Vos said. "But that challenge shouldn't prevent us from getting ready for the next wave in as proactive a manner as we can."