We’ve warned from early on in the Covid crisis that the driver of decisions to lock down or not would be driven by the level of distress in hospitals. While that call has been shown to be correct, officials have tended to be behind the curve on how quickly infections could accelerate and how that would in short order translate into near or actual crisis conditions in hospitals.

So here we are, in December, with the Thanksgiving infection spike proving to be generally worse than anticipated (our IM Doc reports that in his rural area, the uptick hit early and has oddly abated but his hospital is severely overloaded) and worse sure to be on the way after the Christmas-New Year holidays.

Let’s remember other boundary conditions:

Better techniques mean as of now, mortality rates for Covid are lower than in the spring wave. That will become less and less true if hospitals are choked and patients are denied care or are treated on a suboptimal timetable. Recall that at the worst of the spring wave, much of Italy was engaging in triage, with elderly patients turned away. It’s pretty much baked in that hard hit areas, the aged and others with co-morbidities, like obesity or pre-existing pulmonary conditions, will not be treated. How long this lasts in over-stretched hospitals and how many people are affected is to be determined.

And as readers know, overtaxed hospitals also mean that at-risk patients will put off all but unavoidable treatments (we’ve had cancer patients tell us they’ve been postponing visits) and in a worse-case scenario, emergency care will be compromised, as confirmed by the New Rochelle example we’ll get to soon. Recall that in the worst of the spring peak, many New York City hospitals had over 24 hour waits in ERs.

Parallel infection peaks produce system-wide overload. In the spring, regions that suffered high infection levels could still tap extra capacity elsewhere, by hiring more traveling nurses and shuttling patients to other hospitals in state. Those pressure valves are no longer available. Visiting nurses are already getting $8000 a weeks. Extra beds are scarce and becoming scarcer.

The US has only itself to blame. As the Kaiser Family Foundation reported in the spring The U.S. Has Fewer Physicians and Hospital Beds Per Capita Than Italy and Other Countries Overwhelmed by COVID-19:

Compared to Italy and Spain, two countries in which hospitals have already been overwhelmed by an influx of COVID-19 patients, the U.S. has fewer practicing physicians per capita – 2.6 per 1,000 people, compared to 4.0 in Italy and 3.9 in Spain – but more licensed nurses. While the U.S. has a higher number of total hospital employees than most comparable countries, nearly half of that workforce is comprised of non-clinical staff who are not directly involved in delivering care.

The U.S. also lags behind comparable countries in hospital beds per capita, with 2.8 hospital beds for every 1,000 people, a capacity similar to that of Canada and the United Kingdom, but less than other similarly wealthy countries. Italy, the country with the highest number of COVID-19-related deaths to date, has 3.2 hospital beds per 1,000 people – only slightly more than the U.S. South Korea, which has reportedly slowed the rate of new infection, has 12 beds per 1,000 people. Some data suggest, however, that the U.S. may have more ICU beds per person than many comparable countries.

Germany has 8 hospital beds per 1000, and even the less wealthy Czech Republic has 6.6. From the Financial Times:

“This is a bad commentary on how US hospitals are trying to manage staffing even in normal circumstances,” [University of Pennsylvania professor of nursing] Dr [Linda] Aiken said. “They’re very much in love with this idea of just-in-time staffing and just-in-time supplies. It’s a manufacturing idea that doesn’t work out in hospitals.”

Doctors and nurses are already withdrawing support due to exhaustion, health concerns, and opposition to poor patient care. We’re set to see more accounts like these in the coming months. Kaiser Health News has a story today about a Harborview Medical Center in Seattle, affiliated with the University of Washington. It has substantially reorganized its activities to combat Covid, such as offloading more non-care tasks to non-medical workers and restricting visitors to protect patients and employees, yet is contending with staff burnout due to duration of the crisis with no end in sight. Key sections:

“This is a crisis that’s been going on for almost a year — that’s not the way humans are built to work,” said Dr. John Lynch, an associate medical director at Harborview and associate professor of medicine at the University of Washington…

Until the late fall, the Seattle area had mostly kept the virus in check. But now cases are rising faster than ever, and Washington Gov. Jay Inslee has warned a “catastrophic loss of medical care” could be on the horizon….

During the spring, the hospital cleared out beds and recruited nurses from all over the nation, but that is unlikely to happen this time, with so many hospitals under pressure at once.

“All things point to what could be an onslaught of patients on top of a very tired workforce and less staff to go around,” said Nate Rozeboom, a nurse manager on one of the COVID units. “We’re all tired of this, tired of taking care of COVID patients, tired of the uncertainty.”

Already, COVID’s footprint at Harborview is expanding and bringing the hospital close to where it was at its previous peak.

“The fear I have personally is overwhelming the resources, using up all the staff — and the numbers are still going to go up,” said Scott.

And she said the realities of caring for these desperately ill patients have not changed.

“When they’re on their belly, laying down with all the tubes and drains and all these extra lines hanging off of them, it takes about four to five people to manually flip them over,” Scott said. “It feels intense every time. It doesn’t matter how many times you’ve done it.”

One positive note is that staff aren’t unduly worried about their safety; one said she felt more secure at the hospital than she did in the community.

On the other side of the country, the Financial Times reports on a nurses’ strike at the Montefiore hospital in New Rochelle, New York. Even though New Rochelle is a fairly affluent suburb, this hospital takes all comeres, which means it wind up serving a high proportion of lower-income patients.

200 nurses went on a two-day strike to protest understaffing. Sadly, California is the only state to limit the ratio of patients assigned to a nurse, at 5. New York City hospitals were over that level before the pandemic. From the Financial Times:

As the number of Covid-19 patients surged, they claimed, the hospital pushed nurses to care for too many people at one time and handed out personal protective equipment that gave off a harsh chemical smell and left some staff with rashes.

“If you can safely care for one or two patients, but you’re given four or five, you have to make some decisions about who you’re going to rescue,” said Judy Sheridan-Gonzalez, president of the nurses’ union at the hospital. “That is just a horrible thing for health professionals to confront.”…

Each nurse in pre-pandemic New York City was responsible for an average of 6.5 patients, the highest anywhere in the state, according to a study by Dr Aiken published in the BMJ medical journal…. Studies have shown that patient mortality rates jump 7 per cent for each additional patient a nurse is assigned. Individual hospitals do not typically make their staffing ratios public…

This cost-cutting philosophy keeps hospitals from maintaining stockpiles of PPE beyond the 90-day supply mandated by the state or scheduling more than the minimum number of workers at a given time, Dr Aiken said.

Ms Sheridan-Gonzalez, who works a few miles south of New Rochelle in a Montefiore hospital in the Bronx, New York City’s poorest borough, said staffing shortages existed even before the pandemic. After Covid hit, she said, conditions grew worse — and some patients were left lying in their own waste until a nurse or healthcare assistant could be found to help them..

Ms [Judy] Sheridan-Gonzalez [president of the nurses’ union at the hospital] said she was reminded of a dystopian movie when she compared her emergency room with outposts of the Montefiore health system in wealthier suburbs. “It’s like you see the rich people in the sky and the poor people in the ground,” she said. “It’s two worlds.”

Sheridan-Gonzalez said some older nurses retired after two deaths among nursing staff in the spring. A 86% of the nurses polled in a national survey reported that their mental health had suffered. A reader reported that he saw an NPR interview where the head of a hospital system admitted to six suicides among her workers, presumed to have been triggered by Covid stress.

Even though striking is alien to nurses, they feel they have no other recourse, particularly since Montefiore is spending money on image-burnising rather than boosting staffing levels. Again from the pink paper:

Marcos Crespo, a Montefiore executive, said in a statement before the strike that the nurses’ union was “selfishly putting the community at risk and using Covid-19 as a political football”. He said the hospital network had offered the nurses a pay raise, fully funded health insurance, tuition reimbursement and other benefits but would not negotiate on staffing levels…

“What has Montefiore done since June?” New Rochelle nurse Maria Castillo asked in a statement released by the union on the second day of the strike. “They put a bunch of billboards up on the highway. They bought TV commercials calling us ‘heroes’. They want the community to think they appreciate us. The reality is, they would rather spend millions of dollars on their public image, instead of making sure we have enough nurses to care for everyone who is sick!”

Oddly, even though the Financial Times’ account was sympathetic to the nurses, it underplayed Montefiore doubling down on prioritizing profits over patients. The hospital retaliated by locking out striking nurses, taking the absurd position that they weren’t needed when the hospital is already short staffed. Oh, but it made that position semi-plausible by transferring some patients out. Since when is that a sound medical practice? From IoHud:

Many Montefiore New Rochelle Hospital nurses say they’re not allowed to go back to work after a two-day strike that they ended Thursday morning.

The union representing the nurses said dozens of nurses have been locked out throughout the day and they’re hearing “concerning reports,” such as COVID-19 patients and non-COVID-19 patients being mixed together on the same floor.

Montefiore leadership said in an emailed statement Thursday afternoon that the return-to-work policy was “clearly outlined in a letter delivered to MNR nurses and NYSNA leadership on Friday.”

“Once the strike has ended, nurses should anticipate returning to work immediately in those units that remained operational,” Montefiore said. “However, the return to work of nurses in those units that were decanted, may be delayed due to the lack of admitted patients. These nurses will be recalled as soon as the volume increases in their units. All nurses will be notified individually to return to work.”….

There is a full day of scheduled procedures in the operating room but without full nurse staffing in the peri-operative units,” [nurse David] Nightingale said. “I’m very concerned that the units that are opened do not have enough staff. I heard from some nurses working today that they already filed Protest of Assignment forms because they are being asked to care for an unsafe number of patients.”

Montefiore started moving patients before the strike, but since it was only a two-day protest, it looks that management decided to punish nurses rather than prioritize patient care. One assumes the hospital could have moved back surgeries to free up nurses.

The Financial Times warned that Montefiore-like conditions may be coming to you soon:

If the US does not bring the pandemic under control, Dr Aiken warned that the problems facing nurses in places like the Bronx could become more widespread. “You expect this in minority-serving hospitals,” Dr Aiken said. “What’s unexplainable is how it’s started to happen everywhere.”

If you haven’t worked it out already, a dark winter is on its way.