by Kellen Squire
Like any tsunami, the wave started innocuously enough. Even disconcertingly calmly.
Elective surgeries weren’t scheduled over the Thanksgiving holiday anyway, and the glut of open beds meant that the emergency department, for once, had a manageable caseload. Of course, this was all relative – a half dozen nurses and technicians were out with COVID, because a patient came in with a fractured shoulder (and no other symptoms). When the x-rays came back, boom – it showed the telltale sign of a COVID infection: hazy “ground glass” infiltrates in the lungs. An asymptomatic superspreader, who would never have known they had COVID if they hadn’t fallen off a ladder putting up Christmas decorations.
Beyond that, though, the department has been running on half staff for months now. The ten-year retention rate for ER nurses and technicians is around 5%, even when there isn’t a global pandemic, and the hospital’s inability to hire more in the interim – a combination of budget constraints and lack of providers who want to take jobs on the very the bleeding edge of the COVID crisis – hasn’t helped any. But at least the staffing levels were merely woeful, instead of critical.
Over the next few days, however, things began to turn rapidly. The phones began ringing off the hook – “I think I was exposed to COVID-19, and I am having some mild symptoms, can I come in for a test?” Apologies are made, as no COVID testing can be done without being fully screened by an ER physician. Left unsaid is that, thanks to federal mismanagement, the hospital is so limited in its testing capacity that, for a while, if you wanted to run a rapid COVID test, you had to have the personal approval of the head physician of the hospital. Things aren’t quite that bad now, but unless you are being intubated or needed emergency surgery, you’d be relegated to getting the results in 3-5 days, just like if you’d gone to CVS or your primary care provider.
Three dialysis patients are brought via ambulance within an hour of one another. There was an outbreak of COVID amongst the staff at the dialysis center, and these patients were unable to receive their normal treatments. Even worse, one of them turns out to be COVID positive themselves. The same happens with an infusion center patient who arrives in dire need of a blood transfusion. An elderly Alzheimer’s patient, whose daughter caught COVID and, as the sole caregiver to her ailing father, gave it to him, is brought in with extreme delirium, an underappreciated consequence of COVID infections. His vital signs are stable, but he yells. Screams. Refuses to wear a mask. Kicks and bucks at the staff.
A classic COVID patient, on day 9 of their symptoms, arrives in triage. Their blood oxygen level is 60%, and while able to talk, are quickly worsening. It’s quickly determined that they will need to be intubated. Except the hospital’s ICU is full, so calls are desperately made to other nearby hospitals, attempting to find an ICU willing to accept them. While half of the ER staff is assisting with the intubated patient and covering that nurses’ other patients, the COVID Alzheimer’s patient rips his IVs out and gets out of bed, wandering maskless and infectious down the hallway, trailing blood, opening the doors to other patients’ rooms. A scream brings the attention of a CNA who is “sitting” outside the door of a room with a 1:1 suicidal patient, who has been waiting four days for a bed placement; she and an x-ray technician, both only wearing surgical masks due to a critical shortage of N95 masks that hasn’t improved since the pandemic started, call for help and attempt to corral the patient.
In triage, the wait time has grown to a minimum of six hours, perhaps double that for “less acute” patients. Large, white surge tents are setup in the triage parking garage, but even that extra space cannot decompress the waiting area fully. The sardonic joke of flu seasons in the past of, “if you don’t have the flu when you go to the ER, you will by the time you leave” takes on new meaning. Unlike during the summer, when patients and visitors could wait on a bench outside, it is now almost winter. The temperature at night drops below freezing. Environmental engineers have given it their all, having received the greenlight from administration to do whatever is necessary to increase patient and staff safety. Eventually, they jury-rig the ventilation system to pull in fresh air instead of recirculating it, and make the entire unit as “negative pressure” as possible, to keep COVID particles from aggregating dangerously. But without shutting down the hospital and conducting a wholesale gut of the building’s HVAC system, no permanent solutions will be found in time for this pandemic.
The ER charge nurse gets a call from the nursing supervisor – the neighboring level-one trauma center is going on “divert,” meaning that they have decided their emergency department is too busy to manage any more patients. If an ambulance tries to bring a patient to the level-one, they’ll be instructed to take that patient elsewhere… and this is the only other emergency department within fifty miles. Indeed, within minutes of that notice, five ambulances have called in, saying they were re-routed and will be arriving momentarily.
Except there are no beds to be had. Two of the patients are jammed into hallway beds in the back of the department. The other three are sent to triage, including a patient who is extremely intoxicated and seeking “detox” before they go into withdrawal; another, bruised and bandaged, wearing a cervical collar after having crashed his motorcycle; an elderly woman who is helped into a wheelchair, crying, who will eventually be diagnosed with a fractured hip and pelvis. But that will be hours and hours from now.
The triage nurse is overwhelmed. She has no help, and is now expected to watch over thirty patients, deciding who needs to go back first. Every time a bed opens in the back, instead of moving the waiting line forward, another ambulance comes in and takes it – a nursing home patient who is septic from an infected indwelling Foley catheter, an actively seizing epileptic – requiring her to start her priority list over from scratch. While the triage nurse scrutinizes her patient board again, checking the vital signs on a emotionally stricken woman who is suffering a miscarriage, she is accosted by another patient, demanding to know why they’ve been made to wait for hours to get stitches put in. She tries to politely apologize, but is interrupted by the patient spewing a litany of insults, who tells her she must not know how to do her job and that her hospital is the worst they’ve ever been to.
Meanwhile, in the main ER, a facility across the state finally agrees to take the intubated COVID patient – but only if they are transported by air. If the patient survives their ICU stay, they’ll find a $25,000 helicopter bill awaiting them, along with an ICU bill that will easily be in the six digits. It’s unlikely they’ll be able to pay that, even if they do have health insurance, which means that cost will get spread out amongst everyone else, in a sort-of “stupid single payer.” Socialize the losses, privatize the gains, bankrupt the patient – basically, make sure to cost society the highest possible amount in the least efficient way possible.
Right now, it’s an all-hands-on-deck evolution to try and make space somewhere, anywhere, in the hospital. But with all inpatient units already full, the ER charge nurse is told some of the patients there will have to wait for tomorrow – if not beyond – at the earliest for beds. By the end of the day, the emergency department will be down to a mere three rooms (out of the original 35) within which patients can actually be seen by ER physicians. All the other beds will be taken up by “boarders” waiting for a room. Administration attempts to open a makeshift unit to house these patients, using admit-recovery and PACU rooms to take some stress off the ER, but new patients simply fill those spots as soon as they open, and no headway is made whatsoever.
A half a dozen people leave the triage waiting room. The patient needing stitches angrily screams they will be going to another hospital; unfortunately, there are no hospitals in the area in better shape, meaning they will arrive elsewhere only to find themselves at the back of a ten-hour wait to be seen. Another patient who suspects they have had COVID for a few days, but with only mild symptoms, looking for a prescription for an inhaler, will leave… only to return by ambulance in the middle of the night, in cardiac arrest. It turns out COVID had given them a constellation of massive pulmonary embolisms – blood clots in their lungs. Before acute intervention can be done, they go into cardiac arrest. While the harried emergency department team is able to resuscitate the patient, they will eventually be discharged to a nursing home, requiring full-time care for the rest of their lives from the anoxic brain injury they suffered while arresting.
This goes on all night. Administration offers unlimited overtime, time and a half, even double-time pay for anyone who will pick up a shift anywhere in the hospital. COVID-positive staff are allowed to work, even if ill, as long as they are able to stand and walk. Maximum shift lengths rules are ignored, as are the number of consecutive days one is allowed to work without a break. Every manager is in the building, told they will not be allowed to leave until the hospital decompresses, and they are on the “other side” of this surge.
Dawn breaks. It is Thursday, December 3rd, 2020. COVID takes 2-5 days to manifest symptoms, and the window for acute symptoms requiring hospitalization is between days 8 and 10 after symptoms start. Which means there is another five to seven days to go before the people who became infected on Thanksgiving day will be showing up to the ER, critically ill.
Today was only the beginning.
This emergency department will fail. Patients will die that, a year before, would never have been in any jeopardy whatsoever. Others will survive with chronic, lifetime health problems that will make them “frequent fliers” to the ER and other health services for the rest of their lives, dramatically impacting their quality of life and incurring an incalculable toll on themselves, their family, and society as a whole.
The emergency department staff will absolutely wreck themselves trying to hold the line. Of all the tragedies that will come, the cost to the frontline staff will have one of the biggest impacts. Because these emergency services providers will carry every failure with them for the rest of their lives. And it’s not their fault; they will do everything they can. They will wreck themselves trying to hold the line. A third of the staff that make it through the pandemic will leave nursing altogether once on the other side of the crisis. Marriages and relationships will be destroyed; substance abuse problems will become manifest; compassion fatigue almost universal.
None of them will ever be the same.
And it’s not fair. They will internalize every failure, every patient who suffered or died, and say, that was my fault. What should I have done to save this person? The truth, of course, is that the problem was always beyond their capacity to solve alone. That effort needed to be led and managed at the federal level. No emergency department anywhere was designed to be able to handle a mass casualty event lasting for days, weeks.
Effective intervention was needed from the get-go. A coordinated message to push for masking. Using the Defense Production Act to make sure there was enough PPE to go around. Onshoring critical national security supply lines. Keeping schools and teachers safe. Not forcing working-class folks and small business owners to choose between paying bills and getting sick or dying.
While these frontline providers may recognize that logically, their conscience will never allow them to believe that.
This story is not hyperbole. It will happen – it has already happened – in the United States of America. Some places won’t be as bad as what is described here; some will be worse. Regardless, we had a chance to avoid it; we could have done so with a modicum of national effort and competency.
But that chance is gone.
And the price will be paid in blood.
The only question now is how much.