He was young, polite, and inconspicuous. Although he said he felt fine, he looked like he had just finished the sprints. The symptoms were there: cough, slight fever, shortness of breath. His oxygen levels were low enough that his doctor took him in. And so Oscar joined the patients at one of the country's hotspot hospitals, El Centro Regional Medical Center.
When his doctor Andrew LaFree, the center's emergency room medical director, saw him a week later, Oskar's condition had worsened. He looked scared and had difficulty breathing. He needed a machine to help him. LaFree was called from the emergency room a few days later to see the patient. He told me: “I had the surreal impression that we were under water. It occurred to me that the gradual worsening of the airways from COVID-19 was like drowning in slow motion. ”
Oscar died after several cardiac arrests. His doctor remains haunted by the fact "that his last memories of him are staring at my yellow spacesuit struggling to breathe, drifting in and out of the dark as we sedated him to sleep." But the truth is, this was the almost daily stay of doctors and nurses in this frontier town in Imperial Imperial County.
This summer, the metro area serving the El Centro Regional Medical Center (ECRMC) led the nation in cumulative COVID cases per capita for many weeks. Unlike many multi-facility counties, Imperial only has two small hospitals serving its community. El Centro Regional was overwhelmed in May and June. The first cases coincided with an outbreak in Mexicali, Baja California. LaFree said patients are often taken to the U.S.-Mexico border by ambulance, dropped off, and then taken to the nearest hospital – his hospital.
This process, which is inelegantly called border landfill, is widespread. According to Adolphe Edward, CEO of El Centro Regional, there are more than 275,000 Americans living in Mexicali, along with thousands of green card holders. Many of them cross the border to receive care in his hospital.
With 24% of Imperial County's people living in poverty, the hospital has long served a diverse patient population, including marginalized patients, with fewer resources and less access. Christian Tomaszewski, the chief medical officer of ECRMC, notes that the county has an unemployment rate of 21% and that comorbidities such as diabetes, high blood pressure and obesity are common. There is also a high percentage of elderly residents who are at higher risk for more serious outcomes with COVID.
All of these can help explain the numbers. Los Angeles Times data shows that Imperial County's cumulative COVID death rate is more than double that of any other California county and that it continues to be the number 1 state for cumulative cases per capita.
"COVID fatigue sets in’
Edward referred to the initial summer wave of cases as COVID 1.0, which he attributed mostly to patients who came from across the border. But now that the falls are popping up across the nation, El Centro is seeing its second wave. "COVID 2.0 is a little different," said Edward, with more local, community-acquired infections from superspreader events like gatherings at skate parks, restaurants, and the like. "COVID fatigue sets in," he continued. "I think our resilience is breaking down."
Imperial County's resolve has been tested several times this year. In May and June alone, 1,400 COVID-19 patients came through the emergency room, 497 of whom required admission. Twenty percent of patients were transferred outside of the county, often by helicopter, to other intensive care units across the state, including a few hundred miles away in San Francisco and Sacramento. By August, a total of nearly 500 Imperial County patients had been admitted to approximately 90 hospitals.
An aerial view of the tent structures erected by El Centro Regional Medical Center to study this year's influx of COVID-19 patients. Courtesy of ECRMC
These referrals sometimes took three to four days, according to several hospital staff I spoke to. Part of the reason for these delays, as reported by the Wall Street Journal, was that several hospitals in Southern California wrongly refused or delayed admitting COVID-19 patients based on their insurance status based on the newspaper's internal email reviews.
In our correspondence, Tomaszewski confirmed that these measures contributed to delays in transfers. He added that the state "tries to guarantee payment (to the receiving hospitals) but it doesn't always work." Several studies have since shown that the longer patients are in emergency rooms waiting to be admitted, the worse the death rate.
LaFree believes Imperial County is "back in action". The numbers rose in mid-October and rose just before Thanksgiving. According to CDC COVID Data Tracker, it increased more than 180% in a week. According to Tomaszewski, ECRMC is currently seeing 30 to 50 COVID patients per day, up from 20 to 30 per day a month ago, and 30% to 45% of those enrolled are COVID positive. In preparation, the hospital has "doubled or even tripled the capacity in the intensive care unit," he said, canceling all elective surgeries for the time being so they can switch nurses to care for COVID patients.
"We are on the advance," said Tomaszewski. "It's going to be really bad starting the week after Thanksgiving, I'm sure of it."
In a facility as small as El Centro, the scales of equilibrium can tip quickly. In one day last week, a single doctor ran four different code blues from pulseless COVID-19 patients, LaFree told me. As emergency doctors, we sometimes don't have a single patient code for a week or two. Are these vendors and caretakers superheroes? I think we have our answer.
"The hell a lot better prepared"
El Centro Regional is not a tertiary or quaternary care center, which means it is not a full-service or comprehensive care hospital. In the past, the hospital only had six to eight intensive care beds. Now, Edward said, the center has increased capacity to 20 ICU beds and hired ICU specialists from a nearby hospital to treat all critically ill patients. Edward said it was planned to have 32 or even 42 beds in the intensive care unit soon. The main limitation at present is a nationwide shortage of ICU staff.
With all of this planning and preparation, "we're not going to the same place this time," said Edward. "We have Regeneron's antibody cocktail, monoclonal antibodies, and other sophisticated treatments to help patients recover faster." I think the clinical lessons learned earlier are very important to us as we are in a much better place when it comes to treating the disease. "Tomaszewski added," We took this opportunity to become an intensive care hospital that offers high-quality care. "
In the time of COVID, preparation is everything. Venktesh Ramnath, medical director of intensive care and telemedicine at UC San Diego Health, helped set up the expanded intensive care program at El Centro. "I think we are much better prepared than on the first climb," said Ramnath. “Now the engine is working in a real, modern type of intensive care. We are much better staffed, we have made improvements in results … Now some patients are actually coming off the ventilators. You actually get better. "
Since the pandemic, El Centro Regional has set up nine tent structures in its parking lot. Edward, who himself retired from the Air Force, noted that the military department has a saying, "Flexibility is the key to power." In March, Edward realized he needed to build capacity to meet his county's needs, and the COVID tent has treated an average of about 25 patients a day for the past week alone.
The ECRMC tents from the ground. Courtesy of ECRMC
Another tent is dedicated solely to infusions of bamlanivimab, a new monoclonal antibody that recently received emergency approval from the Food and Drug Administration. LaFree said that in a matter of days, El Centro "burned out" the 26 cans the state gave him last week.
Edward has been seeing projections from now through March 2021, and they are troubling again. With his hospital already full for most of the last month, his team has just erected a new large tent, a 50 bed medical / surgical unit that treats non-COVID patients to aid in decompressing the hospital bed space.
The transfer of COVID patients is likely to continue with the ICU and hospital at full capacity. Last week, LaFree said, he was only able to offer one of his COVID patients a transfer to a hospital in Modesto, 520 miles away. His patient refused and went home, only to return "much, much sicker" 24 hours later.
El Centro is a hotspot again and is ready, but constantly on the verge of being overwhelmed. "What's scary this time around is that it looks like the numbers are exploding across California," LaFree said. "I fear that we will hit a wall that will get patients out of this group because other institutions will only have limited capacities." LaFree is also concerned about the lack of available critical care units and the acceleration of cases that many predict after holiday gatherings.
Ramnath tried to think outside the box. When staffing issues become a bottleneck, he thinks it might be possible to deploy an augmented reality platform (similar to the one used by the Navy) for the ICU. "You may have a less skilled nurse or doctor caring for the patient, but someone remotely coaches you in real time," Ramnath said.
It may sound extreme. However, in this pandemic, at least one such solution should be considered. Clearly, a vaccine can't come soon enough. Meanwhile, Edward and his team soldier are treating patients from both sides of the border as COVID 2.0 strikes in full force. Tomaszewski has described El Centro Regional as "The little hospital that could". Once again, its ability to deliver will reach its limits.
Carolyn Barber, MD, has been an emergency room doctor for 25 years. She is the co-founder of the homeless work program Wheels of Change and the author of Runaway Medicine: What You Don't Know Can Kill You.
More Health Care and Big Pharma Coverage from capital::
- It may be weeks, not months, before Americans can get COVID vaccines
- As hospitals keep getting crowded, Americans cannot receive critical medical treatments
- DeepMind's New Protein Folding A.I. is already helping in the fight against COVID-19
- According to researchers, coverage of COVID in the US has been more negative than in other countries
- Can Your Boss Get You To Get A COVID Vaccine? Probably