Omicron is inundating a health-care system that was already buckling under the cumulative toll of every previous surge.

By Ed Yong

hen a health-care system crumbles, this is what it looks like. Much of what’s wrong happens invisibly. At first, there’s just a lot of waiting. Emergency rooms get so full that “you’ll wait hours and hours, and you may not be able to get surgery when you need it,” Megan Ranney, an emergency physician in Rhode Island, told me. When patients are seen, they might not get the tests they need, because technicians or necessary chemicals are in short supply. Then delay becomes absence. The little acts of compassion that make hospital stays tolerable disappear. Next go the acts of necessity that make stays survivable. Nurses might be so swamped that they can’t check whether a patient has their pain medications or if a ventilator is working correctly. People who would’ve been fine will get sicker. Eventually, people who would have lived will die. This is not conjecture; it is happening now, across the United States. “It’s not a dramatic Armageddon; it happens inch by inch,” Anand Swaminathan, an emergency physician in New Jersey, told me.

In this surge, COVID-19 hospitalizations rose slowly at first, from about 40,000 nationally in early November to 65,000 on Christmas. But with the super-transmissible Delta variant joined by the even-more-transmissible Omicron, the hospitalization count has shot up to 110,000 in the two weeks since then. “The volume of people presenting to our emergency rooms is unlike anything I’ve ever seen before,” Kit Delgado, an emergency physician in Pennsylvania, told me. Health-care workers in 11 different states echoed what he said: Already, this surge is pushing their hospitals to the edge. And this is just the beginning. Hospitalizations always lag behind cases by about two weeks, so we’re only starting to see the effects of daily case counts that have tripled in the past 14 days (and are almost certainly underestimates). By the end of the month, according to the CDC’s forecasts, COVID will be sending at least 24,700 and up to 53,700 Americans to the hospital every single day.

This surge is, in many ways, distinct from the ones before. About 62 percent of Americans are fully vaccinated, and are still mostly protected against the coronavirus’s worst effects. When people do become severely ill, health-care workers have a better sense of what to expect and what to do. Omicron itself seems to be less severe than previous variants, and many of the people now testing positive don’t require hospitalization. But such cases threaten to obscure this surge’s true cost.

Omicron is so contagious that it is still flooding hospitals with sick people. And America’s continued inability to control the coronavirus has deflated its health-care system, which can no longer offer the same number of patients the same level of care. Health-care workers have quit their jobs in droves; of those who have stayed, many now can’t work, because they have Omicron breakthrough infections. “In the last two years, I’ve never known as many colleagues who have COVID as I do now,” Amanda Bettencourt, the president-elect of the American Association of Critical-Care Nurses, told me. “The staffing crisis is the worst it has been through the pandemic.” This is why any comparisons between past and present hospitalization numbers are misleading: January 2021’s numbers would crush January 2022’s system because the workforce has been so diminished. Some institutions are now being overwhelmed by a fraction of their earlier patient loads. “I hope no one you know or love gets COVID or needs an emergency room right now, because there’s no room,” Janelle Thomas, an ICU nurse in Maryland, told me.

Here, then, is the most important difference about this surge: It comes on the back of all the prior ones. COVID’s burden is additive. It isn’t reflected just in the number of occupied hospital beds, but also in the faltering resolve and thinning ranks of the people who attend those beds. “This just feels like one wave too many,” Ranney said. The health-care system will continue to pay these costs long after COVID hospitalizations fall. Health-care workers will know, but most other people will be oblivious—until they need medical care and can’t get it.

The Patients
The patients now entering American hospitals are a little different from those who were hospitalized in prior surges. Studies from South Africa and the United Kingdom have confirmed what many had hoped: Omicron causes less severe disease than Delta, and it is less likely to send its hosts to the hospital. British trends support those conclusions: As the Financial Times’ John Burn-Murdoch has reported, the number of hospitalized COVID patients has risen in step with new cases, but the number needing a ventilator has barely moved. And with vaccines blunting the severity of COVID even further, we should expect the average COVID patient in 2022 to be less sick than the average patient in 2021.

In the U.S., many health-care workers told me that they’re already seeing that effect: COVID patients are being discharged more easily. Fewer are critically ill, and even those who are seem to be doing better. “It’s anecdotal, but we’re getting patients who I don’t think would have survived the original virus or Delta, and now we’re getting them through,” Milad Pooran, a critical-care physician in Maryland, told me. But others said that their experiences haven’t changed, perhaps because they serve communities that are highly unvaccinated or because they’re still dealing with a lot of Delta cases. Milder illness “is not what we’re seeing,” said Howard Jarvis, an emergency physician in Missouri. “We’re still seeing a lot of people sick enough to be in the ICU.” Thomas told me that her hospital had just seven COVID patients a month ago, and is now up to 129, who are taking up almost half of its beds. Every day, about 10 patients are waiting in the ER already hooked up to a ventilator but unable to enter the ICU, which is full.

During this surge, record numbers of children are also being hospitalized with COVID. Sarah Combs, a pediatric emergency physician in Washington, D.C., told me that during the height of Delta’s first surge, her hospital cared for 23 children with COVID; on Tuesday, it had 53. “Many of the patients I’m operating on are COVID-positive, and some days all of them are,” Chethan Sathya, a pediatric surgeon in New York, told me. “That never happened at any point in the pandemic in the past.” Children fare much better against the coronavirus than adults, and even severely ill ones have a good chance of recovery. But the number of such patients is high, and Combs and Sathya both said they worry about long COVID and other long-term complications. “I have two daughters myself, and it’s very hard to take,” Sathya said.

These numbers reflect the wild spread of COVID right now. The youngest patients are not necessarily being hospitalized for the disease—Sathya said that most of the kids he sees come to the hospital for other problems—but many of them are: Combs told me that 94 percent of her patients are hospitalized for respiratory symptoms. Among adults, the picture is even clearer: Every nurse and doctor I asked said that the majority of their COVID patients were admitted because of COVID, not simply with COVID. Many have classic advanced symptoms, such as pneumonia and blood clots. Others, including some vaccinated people, are there because milder COVID symptoms exacerbated their chronic health conditions to a dangerous degree. “We have a lot of chronically ill people in the U.S., and it’s like all of those people are now coming into the hospital at the same time,” said Vineet Arora, a hospitalist in Illinois. “Some of it is for COVID, and some is with COVID, but it’s all COVID. At the end of the day, it doesn’t really matter.” (COVID patients also need to be isolated, which increases the burden on hospitals regardless of the severity of patients’ symptoms.)

Omicron’s main threat is its extreme contagiousness. It is infecting so many people that even if a smaller proportion need hospital care, the absolute numbers are still enough to saturate the system. It might be less of a threat to individual people, but it’s disastrous for the health-care system that those individuals will ultimately need.

Other countries have had easier experiences with Omicron. But with America’s population being older than South Africa’s, and less vaccinated or boosted than the U.K.’s or Denmark’s, “it’s a mistake to think that we’ll see the same degree of decoupling between cases and hospitalizations that they did,” James Lawler, an infectious-disease physician in Nebraska, told me. “I’d have thought we’d have learned that lesson with Delta,” which sent hospitalizations through the roof in the U.S. but not in the U.K. Now, as then, hospitalizations are already spiking, and they will likely continue to do so as Omicron moves from the younger people it first infected into older groups, and from heavily vaccinated coastal cities into poorly vaccinated rural, southern, and midwestern regions. “We have plenty of vulnerable people who will fill up hospital beds pretty quickly,” Lawler said. And just as demand for the health-care system is rising, supply is plummeting.

The Workers
The health-care workforce, which was short-staffed before the pandemic, has been decimated over the past two years. As I reported in November, waves of health-care workers have quit their jobs (or their entire profession) because of moral distress, exhaustion, poor treatment by their hospitals or patients, or some combination of those. These losses leave the remaining health-care workers with fewer trusted colleagues who speak in the same shorthand, less expertise to draw from, and more work. “Before, the sickest ICU patient would get two nurses, and now there’s four patients for every nurse,” Megan Brunson, an ICU nurse in Texas, told me. “It makes it impossible to do everything you need to do.”

Omicron has turned this bad situation into a dire one. Its ability to infect even vaccinated people means that “the numbers of staff who are sick are astronomical compared to previous surges,” Joseph Falise, a nurse manager in Miami, told me. Even though vaccinated health-care workers are mostly protected from severe symptoms, they still can’t work lest they pass the virus to more vulnerable patients. “There are evenings where we have whole sections of beds that are closed because we don’t have staff,” said Ranney, the Rhode Island emergency physician.

Every part of the health-care system has been affected, diminishing the quality of care for all patients. A lack of pharmacists and outpatient clinicians makes it harder for people to get tests, vaccines, and even medications; as a result, more patients are ending up in the hospital with chronic-disease flare-ups. There aren’t enough paramedics, making it more difficult for people to get to the hospital at all. Lab technicians are falling ill, which means that COVID-test results (and medical-test results in general) are taking longer to come back. Respiratory therapists are in short supply, making it harder to ventilate patients who need oxygen. Facilities that provide post-acute care are being hammered, which means that many groups of patients—those who need long-term care, dialysis, or care for addiction or mental-health problems—cannot be discharged from hospitals, because there’s nowhere to send them.

These conditions are deepening the already profound exhaustion that health-care workers are feeling. “We’re still speaking of surges, but for me it’s been a constant riptide, pulling us under,” Brunson said. “Our reserves aren’t there. We feel like we’re tapped out, and that person who is going to come in to help you isn’t going to, because they’re also tapped out … or they’ve tested positive.”

Public support is also faltering. “We once had parades and people hanging up signs; professional sports teams used to do Zooms with us and send us lunches,” Falise told me. “The pandemic hasn’t really become any different, but those things are gone.” Health-care workers now experience indifference at best or antagonism at worst. And more than ever, they are struggling with the jarring disconnect between their jobs and their communities. At work, they see the inescapable reality of the pandemic. Everywhere else—on TV and social media, during commutes and grocery runs—they see people living the fantasy that it is over. The rest of the country seems hell-bent on returning to normal, but their choices mean that health-care workers cannot.

As a result, “there’s an enormous loss of empathy among health-care workers,” Swaminathan said. “People have hit a tipping point,” and the number of colleagues who’ve talked about retiring or switching careers “has grown dramatically in the last couple of months.” Medicine runs on an unspoken social contract in which medical professionals expect themselves to sacrifice their own well-being for their patients. But the pandemic has exposed how fragile that contract is, said Arora, the Illinois hospitalist. “Society has decided to move on with their lives, and it’s hard to blame health-care workers for doing the same,” she said.

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