No Air

Buckle up.  This is gonna be a long ride with no potty breaks.

I started writing this on the kind of crisp, sunny fall day that only Minnesota can properly serve up.  The leaves abruptly changed color two days ago and now are headed for spectacular.  Cheering and singing wafted through my windows from spectators at the Twin Cities Marathon.

Things seemed normal.

The lead article for the Star Tribune discussed how supply chain issues may impact holiday shopping habits.  So sad.  In the past several months, I’ve seen only a couple articles that hint at the real impending crisis: our teetering health care system.

I am a family doctor, trained in Minneapolis in one of the largest health care systems in the state.  I’m retired from clinical practice.  For simplicity, I will use the term “doctor” to refer to physicians, nurse practitioners, and physician assistants.  (I retch when I hear “health care provider.”)  If I were a nurse practitioner, I’d use “nurse practitioner” to refer to nurse practitioners, physician assistants, and doctors.  My comments relate primarily to the situation in Minnesota.

What does it mean when the occasional article mentions a shortage of hospital beds?  Before COVID, hospitals developed their own natural rhythms, with predictable supply and demand variables.  In the summer, expect more near-drowning incidents and boating accidents with orthopedic injury.  Dr. Abc performs an average of X transplants per year, but the doctor takes a two-week vacation every December.  Hospitals are staffed according to predicted need.  If a floor (regular medical unit) nurse takes care of five patients and average hospital census for medical beds at this time of year is 15, the charge nurse will schedule three nurses.  Pre-COVID, “we don’t have a bed” usually meant “we don’t have a nurse” to take care of the patient.  Doctors are another matter, with less regulation of provider to patient ratios.  Doctors will basically keep admitting people to the hospital until they fall over.  If you say, “No, I literally cannot care for one more person,” you look weak and you’re losing revenue for the hospital.

Patients frequently arrive in regional or rural emergency rooms and need to be transferred.  Folks having heart attacks might need a cath lab and an interventional cardiologist.  ATV accident victims are sent to trauma centers like HCMC or Regions.  The greater system had predictable rhythms as well.

In the COVID era, “no beds” means either there isn’t a nurse (and no one can come in from home or from retirement) OR there is no physical space to put the patient OR there is no doctor who can accept the patient.  Doctors and nurses are conditioned to be tough and resilient.  They work when they’re sick.  They know any unexpected absence has a ripple of negative consequences for colleagues.  You can’t reschedule Ms. Meyer’s cerebral aneurysm rupture for another day.  COVID quarantine requirements meant that, perhaps for the first time in their careers, doctors and nurses couldn’t work while ill.  And in the very beginning of the pandemic, they couldn’t work if exposed.  You can imagine the staffing nightmare.

Now, when a patient needs to be admitted to the hospital, a very dangerous dance commences.  If enough people have been discharged to home that day and staffing is adequate, the fortunate patient can be admitted to the facility at which they presented.  A patient might be held in the ER in the hopes of a bed opening up.  Some ERs are even “boarding” patients, continuing to care for them as if they are admitted to the hospital.  People who need cath labs or ICU doctors or trauma surgeons are unable to transfer for specialized care because there are “no beds.”  A nursing supervisor or doctor might spend hours calling hospitals, looking for a bed for a patient.  There is no reliable centralized coordination.

The Minnesota Hospital Association and the MN Department of Health launched the Critical Care Coordination Center (The C4) about a year ago in order “to create and enhance visibility and coordination for patient placement from ED to ICU or ICU to ICU to available staffed ICU beds with ventilators if necessary across Minnesota during the COVID-19 surge…”  The C4 is great in theory, clunky in practice.  Theoretically, a doctor can call The C4 and the cheerful C4 staffer will find an ICU bed for the doctor’s patient.  The bed might be in Hibbing.  In three days.  And you have to call back every couple hours to check while your patient “boards” in the ER.  The C4 doesn’t appear to maintain an ordered list of patients needing ICU care; they merely provide in-the-moment availability.

Some Minnesota hospital systems have started maintaining their own ordered lists.  Finally.  It’s in Fairview’s best interest to keep Fairview patients within the system.  Same for Mayo, Health Partners, Essentia, etc.  So if a patient presents to the emergency room at Regina Hospital in Hastings, MN, and their medical needs cannot be met, that patient should have “dibs” on available beds within the Allina healthcare system.  Which screws up the C4 system since C4 assumes any patient can be dumped on transferred to any facility.

Why don’t hospitals cancel elective surgeries to free up more beds and staff?  Surgeries are lucrative.  COVID reimbursement isn’t.  And empty beds could immediately be filled with patients from other full hospital systems that haven’t cancelled surgeries.  The right thing to do isn’t the economically attractive thing to do.

The bottom line = people are dying.  In a system over capacity, there is a deadly mismatch of patients with facilities and resources.  We can’t magically reshuffle everyone to the exact right place with the right doctors and operating rooms and nurses.  Regional hospitals are caring for patients that are beyond their capability, hoping that COVID patient Y doesn’t go down the tubes and require ventilation.  Emergency room doctors are taking care of “boarding” patients for days instead of the typical hours.  For many ER docs, care of the hospitalized patient wasn’t part of their training.  Patients aren’t getting timely vascular intervention or cancer surgery or the routine primary care screening that can prevent medical catastrophe.

Additionally, we’re unintentionally exploring the ethics of resource allocation, health disparities, and medical futility and not in a planful way.  Early in the pandemic, doctors at long-term care facilities were warned that they might have to inform patients and their families that they would be “dying in place.”  In other words, nursing home patients would not be offered hospital admission.  Every day, doctors and nursing supervisors are deciding who gets a bed, who gets surgery, who gets transferred, who has the best chance.  A man with a ruptured abdominal aortic aneurysm is kept alive in the ER with fluids and pressors while staff frantically try to get a vascular surgeon on the phone.  When they finally find one, there is no way to unite surgeon, patient, and OR in a timely manner.  The man bleeds out.  Pre-COVID, he might’ve died anyhow, but the surgeon would have had an opportunity to do their best.

The long-term ramifications of the above morass are multitudinous, and include:

1)    Serious ongoing staffing problems: doctors and nurses are retiring, leaving the profession (burning out), and dying of COVID/suicide/stress-related health issues.

2)    Health decline (body and brain) in nurses and doctors due to ongoing extreme stress.  Anticipate higher rates of depression, anxiety, PTSD, heart disease, and hypertension.  Moral injury – how can a doctor trust the system that put them in such an impossible position?

3)    Potential failure of the healthcare system.  What would that even look like?  Italy?  NYC?  Will our Mississippi River become India’s Ganges, with bodies of COVID victims floating down, down to the sea?

4)    Financial fallout: individual bankruptcy, rising insurance premiums, bankruptcy of health systems or insurance companies.

5)    No more Dr. Nice Gal:  Will doctors finally unionize?  Will they demand better working conditions?  Will they refuse to admit COVID patients who declined vaccination due to Freedom Infringement?  We are trained to deliver compassionate, competent care to whomever is in front of us, be they fascist, serial killer, or pedophile.  The critical difference with the delta variant surge is that doctors have to care for patients who refused vaccination and are now consuming finite medical resources and imperiling staff and other patients.

6)    Cultural schism: A doctor told me recently of an unvaccinated patient who refused to believe they had COVID, got admitted, tested positive, still denied having COVID, wound up ventilated, and died.  Anti-mask, anti-vax, anti-mandate.  Will e pluribus unum shift to non obstante multis, unum solum?  Despite many, only one.  ME!  ME!  ME!

You might be wondering what you can do.  Here are some ideas:

1)    Wear a mask.  I’ve heard estimates ranging from 10-25% of patients hospitalized with COVID were fully vaccinated prior to admission.  That’s not zero.

2)    Put masks on your kids.  Even if the school doesn’t require them.  Terrible is being born into slavery.  Terrible is growing up in an internment camp.  Terrible is being ripped away from your parents at the US border when you’re seeking asylum.  Terrible is NOT having to wear a mask while you learn to take care of your community.

3)    Know your boundaries.  Keep your boundaries.  Be unapologetic about your boundaries.  I won’t be eating indoors at restaurants until this surge ends and I get a booster.

4)    If you are fully vaccinated for COVID, thank you.  And please go get your flu shot.  We’re already seeing cases of flu in Minnesota.

5)    If you are not fully vaccinated, please do it.  You might be a lovely specimen of health, but you are putting other people at risk.

6)    If you won’t get vaccinated because of Freedom Infringement, please do not seek medical care.  Tend your broken bones at home.  Treat your MI at home.  DIY a ventilator and show your dog how to run it in case you are incapacitated.

7)    This is not a good time to have a stroke or diabetic ketoacidosis or appendicitis.  Plan accordingly.

8)    It’s also a bad time to take up ski jumping, rock climbing, and slacklining.

9)    Think about supporting a single-payer, universal health care system.  Un-link insurance and employment.

10) Do you want to be seen by a dentist, chiropractor, doctor, hairdresser, or aesthetician who isn’t vaccinated?  If not, ask their status.

11) In the middle of a pandemic, there is no “it’s just a cold.”  Assume any new symptoms are COVID until you test negative.

I’m wrapping this up the day after the Twin Cities Marathon.  From the Star Tribune page A3 today (reprinted from the New York Times): “Virus outbreak forces grim choices in Alaska.”  The grim choices are local as well.  They just aren’t in the news yet.

Musical Moment