The Covid-19 medications are supposed to keep people out of the hospital — and to infectious disease doctor Ogechika Alozie, these patients were perfect candidates.
One was a vaccinated elderly man who’d tested positive for Covid after cold-like symptoms began spreading through his family. But his family couldn’t find him an open slot for an infusion of monoclonal antibodies. His granddaughter, Krystal Tejeda, called and called. “I couldn’t get an answer from anybody. Mailbox full, mailbox full,” she said. He was sent home after his first two ER visits. On the third, he was admitted, his skin going purple.
For another patient, Alozie hoped to get a new antiviral called Paxlovid. “But nobody’s seen it,” Alozie, who treats patients at five hospitals in El Paso, Texas, said last week. “I tried to write a prescription for it and the local pharmacists have said, ‘We don’t have it. You can write all the prescriptions you want, but it doesn’t matter.’”
The scarcity of outpatient Covid treatments is just one element in a cascade inundating hospitals from Boston to El Paso, from Florida to Washington state. Some medications that could neutralize earlier iterations of the coronavirus don’t work well against Omicron, the variant now racing through the population. Hospitals were already short-staffed, the result of pandemic trauma, burnout, and the Great Resignation; now, with alarming numbers of those who remain calling in sick with Covid, there’s a whole new level of backup and strain. Beds can’t be liberated because there aren’t enough workers in rehab centers or nursing homes. In other words, a bad time to need medical care — and an awful time to be providing it.
In Boston, a well-vaccinated city with well-heeled health systems, Elizabeth Mitchell has watched her emergency department become overwhelmed in the weeks since Omicron began its rampant spread, in late December.
“It feels, actually, worse than spring of 2020 for many reasons,” said Mitchell, a clinical professor of emergency medicine at Boston University School of Medicine.
At the start of the pandemic, nobody really knew what treatments worked, or even the full scope of what Covid-19 could do to the body. But the hospital wasn’t simultaneously flooded with patients sick with other conditions, like it is now. “If the only thing we dealt with was Covid, it wouldn’t be that bad,” Mitchell said.
The emergency department at Boston Medical Center, like those at many health care facilities across the country, is full, boarding patients waiting for beds to open up on inpatient floors, and others who are homeless but can’t get into shelters because they have Covid. Many patients went to the ER for other conditions and then tested positive. “That happens all the time,” Mitchell said.
The emergency department is so swamped that antibody therapies are now administered to Covid patients elsewhere in the hospital. Boston Medical Center is able to give just eight patients a day infusions of sotrovimab, the scarce antibody treatment that works against Omicron. High-risk patients are prioritized, including those who are “severely immunocompromised, elderly and unvaccinated,” especially those with comorbidities, a spokesperson said.
Emergency room nurses and doctors who not so long ago felt comfortable wearing surgical masks around uninfected patients because of vaccines are now back to wearing the more protective N95 masks all the time, along with gowns, gloves, and eye coverings. Many staff members have gotten sick in the last two weeks, taking people out of commission as the onslaught of patients continues, Mitchell said. It is exhausting to watch the same pattern repeat itself for nearly two years, she added: “When you think things are going to get better, it gets worse.”
As Grace Meatley, a Miami ICU nurse, listened to President Biden’s news conference about the threat of Omicron on Dec. 21, she had a feeling that’s familiar to anyone living in the tropics: “It’s kinda like when you hear a hurricane may be coming,” she said — you prepare for a direct hit but hope it misses.
The Covid numbers at the time were stable in the medical ICUs at Jackson Health System, where she cares for patients who are intubated and ventilated and near death, at a hospital that treats some of Miami-Dade County’s poorest residents. She was hopeful things wouldn’t get bad again.
But by early this week, Meatley was starting to feel the storm’s outer bands. Jackson Health opened up more ICU beds and the overall patient count in the hospital was high, she told STAT. Fewer patients than in the Delta wave are so ill as to need a ventilator or high-flow oxygen. The ones that do are typically unvaccinated or immunosuppressed, she said. Many patients are arriving with a fever or shortness of breath or no symptoms at all, but testing positive before a medical procedure. What in Delta was a crush of severe illness is in Omicron a massive influx of moderately sick patients, and high rates of disease coursing through the community.
“The difference with this one is because it’s so contagious,” she said. “The last time we had a few employees, here and there, who tested positive for Covid, but certainly not as much as this time around. And we’re not just talking about nurses, we’re talking about respiratory therapists … we’re really running a skeleton staff.”
Over the last 10 days, 243 Jackson employees — 1.8% of the system’s workforce — have tested positive, including a mix of nurses, other clinical workers, and non-clinical staff, a spokesperson said. Staffing agencies, which have been a lifeline (albeit an expensive one) for hospitals during the pandemic, are also running low on nurses to deploy, Meatley said. As a result, Jackson is offering incentives — “money, money, money” — to reduce absences and to persuade exhausted but healthy employees to pick up two extra shifts during a pay period. Workers in ambulatory and primary care centers are also being temporarily moved to inpatient units or urgent care centers to manage the surge.
That domino effect is clattering in every part of hospitals. “We were already very leanly staffed, just because we’re still dealing with, you know, the Great Resignation and people not really being interested in working in a hospital pharmacy,” said Mark Sullivan, associate chief pharmacy officer at Vanderbilt University Medical Center in Nashville, Tenn. Subtract the employees who are infected with Covid and everyone has to scramble to patch holes, pharmacists filling in for technicians, managers taking shifts for which they have no available workers.
Those who’d normally monitor and replenish the stocks of everyday meds on patient floors are busy doing someone else’s job. That sometimes means hand-delivering doses that would, in normal, well-oiled-machine times, simply have been there for the nurses when they needed them. The added tasks and inefficiencies only increase everyone’s burnout. “The pharmacy technicians, it’s a group that is really struggling,” Sullivan said.
The same is true of just about everyone they work with. As Todd Karpinski, chief pharmacy officer at West Virginia University Medicine, put it, “The virus is not selective. So our shortages are really across the board, from our non-clinical staff that may be doing housekeeping, janitorial services. It’s impacting our nurses. We have physicians that are out. It really is across the gamut.”
Similar issues outside of hospitals end up worsening what’s going on inside. Backups in testing capacity might mean patients miss the window for drugs that could allow them to stay home. In some cases, a drug is authorized to be given to a Covid patient 10 days after the onset of symptoms, but the wait for an infusion might be as long as a week. If the person took a few days to realize what they had might be Covid, their chances of getting monoclonal antibodies may already be eclipsed.
That can influence which patients arrive at the hospital; there’s a similar issue on the other end of their stay. “We and many other hospitals have increasing numbers of patients who occupy an inpatient bed, who no longer have a medical condition that warrants continued inpatient care, but we’re unable to find post-acute care facilities that are able or willing to take them,” said James Cook, chief medical officer at Providence Regional Medical Center, in Everett, Wash. “We have over 100 of such patients” — all of them still requiring care that might be better provided by, say, nursing facilities or rehab centers, which are also at or above capacity and short-staffed.
For health care workers, it creates a kind of whiplash. “You live in two different worlds,” said Inga Lennes, senior vice president of ambulatory care and patient experience at Massachusetts General Hospital. On the one hand, there’s the world of the hospital, which is in crisis, where surgeries are being canceled, where thousands of employees are sick, so many that some are having trouble getting tested. On the other, there’s the Facebook parenting group Lennes is in where someone just asked where she might be able to rent a table for 20.
One of the hardest elements is being unable to provide all the care that’s needed — the cancer treatments, the surgeries that would ease people’s chronic pain. “I don’t use the word traumatizing lightly. You know, it’s something used very commonly now by lots of people — there’s a lot of things that are described as trauma that may not be,” Lennes said. “But this is morally injurious. Because you can’t do the thing that you always trained to do.”
In El Paso, Tejeda, who tried to get monoclonal antibodies for her grandfather, has a lot of empathy for health care workers: She’s one herself, working as the surgical coordinator for an ophthalmologist. She also knows firsthand that a terrible time for health care workers can translate into a terrible time for patients.
She wishes the hospital had been in a better state for her grandfather’s last days. His name was Fernando Ramirez, and he was a force of nature, a restaurateur in Ciudad Juarez, in Mexico, who then moved across the Rio Grande to El Paso and became a U.S. citizen, working first as a gas station attendant and then as an optician. He loved to sing — operatic arias, mariachi songs, the American national anthem, whatever happened to pop into his head. Even into his 90s, he refused a cane or a walker. He couldn’t exactly run around with his great-grandkids, but he still liked being on the basketball court. “He would stand up and he would shoot hoops from the free throw line,” Tejeda said.
Usually, he refused medication — “his cure for everything was just a shot of tequila” — but he made an exception for Covid. In early January, he’d called Tejeda, gasping between words, asking to go back to the emergency room for the third time. His hospital stay was rough. Tejeda was grateful that Alozie, a medical consultant who doesn’t work for the hospital itself, could take the time to sit with them and explain what was going on.
Nurses didn’t have that luxury. Tejeda said that even the most basic care was falling through the cracks. “I said, ‘My grandfather was supposed to have an IV since last night. … They took it out and they haven’t put one back in. He’s severely dehydrated. Where’s the IV?’” But nothing changed. “And when the doctor came in, he was like, ‘No, he should be on an IV. Why is he not an IV?’”
He died on Sunday, in the afternoon. “At least he’s better now, he’s not suffering here,” Tejeda said the next day. Her sentences kept jumping from one point of view to another, from the overworked nurses’ back to her own. It was injurious for everybody. “I 100% understand — that there’s no staff,” she said. “There’s nobody to help.”
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