Dr. Jeff Elder was an intern at Charity Hospital when Hurricane Katrina hit New Orleans. He figured that would be the biggest emergency he’d deal with in his career.
He was wrong.
“This is a much bigger and longer health care emergency,” he said. “This is going to be a nationwide response and pandemic that I think none of our health care providers have seen in their career. And hopefully we don't see again.”
The coronavirus has upended nearly every aspect of life in Louisiana and the nation, but if the worst-case scenario projections come true, this could be the calm before the storm.
On Wednesday, Gov. John Bel Edwards said the state’s rate of growth for new positive cases leads the nation. And earlier this week, he warned that state hospitals are on track to reach their capacity by April 4. He’d already warned that the state is on a path toward a situation comparable to the one in Italy — a nation whose healthcare system has been overrun by the virus, sending hospitals into chaos and posing the threat of collapse. And so far, extreme stay-at-home measures haven’t slowed the rising number of cases.
“This is a very serious situation. We haven't flattened the curve yet," Gov. John Bel Edwards said Wednesday. “There’s nothing in today’s report that suggests our trajectory is changing. It’s more of the same and that’s disconcerting to me.”
According to a study by Harvard researchers in collaboration with ProPublica and The New York Times, in a worst-case scenario, where 60 percent of the state contracted the coronavirus over six months, New Orleans’ hospitals would need to more than double their capacity. State-wide, that capacity would need to be would need to nearly triple what it is now.
By March 25, there were 1,795 cases of COVID-19 in the state and 65 people had died by the disease — 37 of them in New Orleans. A total of 11,451 tests had been completed and reported to the state health department. Of those diagnosed with COVID-19, 491 people were hospitalized, 163 of them requiring a ventilator.
“What we’re projecting is during the first week of April, there are going to be more sick patients in the greater New Orleans region than there are hospital beds to care for them,” said Dr. Joseph Kanter, the assistant state health officer and a regional medical director for the Office of Public Health. “This is frightening. This is absolutely frightening.”
“There's a lot of work going in right now to try and prevent that,” he said. “But the clock is running out.”
The Big Challenge: Ventilator Supplies
Finding a physical building isn’t the real hurdle, Kanter said. “The limiting factor for us is going to be finding enough supplies to provide the care, enough personal protective equipment and enough ventilators. That's gonna be the choke point for us.”
The shortage of ventilators emerged as perhaps the greatest threat to the state’s ability to care for people made critically ill by the virus. In the New Orleans area, only 326 ventilators are currently available.
“In the first week in April, we run a significant risk of not having the ventilators that we need to treat the patients who will require ventilators for proper treatment in Region 1, in that area around New Orleans,” he said in a press conference.
Edwards said New Orleans-area hospitals would be receiving 100 ventilators on Wednesday and another 100 next week. He later said a total of 300 ventilators were on their way to New Orleans-area hospitals — by far the hardest hit in the state since the start of the outbreak both in terms of positive cases and deaths. But the area likely needs 600, he said.
Each ventilator costs between $40,000 to $45,000.
The state has requested about 2,000 ventilators in total, Edwards added, both from the federal government and private vendors. He also announced that Apple CEO Tim Cook is donating 100,000 masks to Louisiana. According to The Times-Picayune | The New Orleans Advocate, staff at some hospitals are being forced to use the same mask for days and preserve it in a paper bag.
Dr. Elder, now an emergency medicine physician in New Orleans, said the LCMC network hospitals have been following guidance on personal protective equipment for staff from the Centers for Disease Control and Prevention, which has changed its directives on how often to change your mask, for example, to stretch available resources.
“These guidelines are pragmatic and they're kind of the best-case scenario in a tough time,” Kanter said. “But I'll tell you, it doesn't make healthcare workers feel great to be told that what was not a recommended practice two weeks ago is now fine.”
The Other Big Challenge: Beds -- And Space For Beds
Kanter said the state has a three-pronged approach. First, use every available space in a hospital: rooms, hallways, even cafeterias. Second, utilize long-term care facilities, surgical centers and other “Tier 2” hospitals. Third, “the new frontier,” find an entirely new space for patients — the Morial Convention Center.
On Wednesday, New Orleans Mayor LaToya Cantrell announced that the convention center will be used to house up to 3,000 COVID-19 patients, ideally those recovering from stays at local hospitals. The goal is to free up hospital space for incoming severe cases. A state contract has been activated to bring in health care workers from across the nation to staff the facility. Cantrell said ventilators aren’t expected to be used at the site.
“The Louisiana National Guard, engineers, architects and logisticians” had been touring sites in the New Orleans area “where it would be appropriate to build out very large spaces to care for patients,” Kanter said.
They had looked at school dormitories, hotels and arenas, he said. The convention center is being dubbed a surge hospital, and it will be used for patients who need some, but minimal care — those that might normally stay in the hospital for a daily nursing visit, but could be moved to a different location to make space for COVID-19 patients in hospitals.
Space is also needed to quarantine people who test positive for the coronavirus but who can’t safely self-isolate at home — people who are homeless or those sharing a small home. Already, the state has designated Chicot State Park as an "overflow" location for patients who need to be quarantined, but can’t return to their homes or residential facilities.
The Human Challenge: Keeping Hospitals Staffed, And Keeping Staff Healthy
Edwards warned Wednesday that staffing this new surge hospital could be a struggle.
“When you create what is essentially a hospital, but it is not connected to an existing hospital, the staffing becomes a real challenge,” he said.
Edler is among the senior staff leading the response at University Medical Center New Orleans hospital and the LCMC Health network, which includes three other adult hospitals across the New Orleans area: Touro, New Orleans East Hospital and West Jefferson Medical Center. He said hospitals have seen COVID-19 patients take up increasing space. First, there maybe have been just a few patients. Now, COVID-19-positive patients can take up a whole unit.
“We're looking at bringing on an additional 75 ICU-level beds throughout multiple hospitals, to increase that ICU level capacity,” Elder said. “We're also just looking all throughout all facilities. If there are places or units that aren't being utilized currently, can we create negative pressure there? Can we put patients in those areas, and then work on the staffing plan?”
COVID-19 patients are being kept together and treated by a dedicated group of staff, he said, to keep expertise on the disease in one place.
“Every day, multiple times a day, we're looking at our kind of inpatient capacity and the capacity of our emergency departments,” he said. “Our numbers are high at some of our hospitals.
“We are constantly working on surge capacity. so that's really been a big push. We're really looking at how we can expand capacity if it's needed in the upcoming couple weeks and beyond.”
LCMC officials and hospitals across the state have been working with the governor’s office and the Louisiana Hospital Association to coordinate regional planning, he added.
“We're feeding data to them that looks at inpatient census and ICU beds, versus medical surge beds, versus ED beds.”
Intensive care unit beds are for the most severely impacted patients, surge beds are the typical hospital beds, and emergency department beds handle the flux of incoming and outgoing patients in an emergency room. It’s the ICU beds that could become the most needed in the state. The problem isn’t just the number of COVID-19 patients, but their severity. Covid cases have a higher percentage of ICU patients on ventilators, and they stay longer, than the patients hospitals typically get, Ochsner Health officials said Wednesday.
In a briefing with the media, the officials said Oschner hospitals are being filled with coronavirus patients despite the fact that admissions for other reasons have actually gone down. As a result, staff are being redeployed to care for COVID-19 patients.
Ochner is opening 96 new ICU beds at Ochsner Medical Center on Jefferson Highway and 12 new ICU beds at Ochsner Medical Center in Kenner. It’s also relocating medical-surgical patients in it’s Jefferson Highway hospital to an orthopedic hospital in the Clearview Parkway area to make space for more COVID-19 patients.
The Tulane Medical Center campus is also fielding an influx of patients with COVID-19, according to a statement released by the hospital.
“While we have the bed capacity, staffing and supplies we need at this time, we are working very hard and accessing resources, support and best practices we have access to as part of HCA Healthcare to help ensure we remain able to meet the needs of the communities we serve as the situation continues to evolve,” the statement continued.
The stress — and risk — for health care workers is enormous, “Not only the short term of what happens today on your shift,” Elder said, “but what's going to happen, you know, two weeks from now. Two months from now.”
This is a lot to keep up with
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