Dr. Matt Hanserd of Athens-Limestone Hospital is used to dealing with death.
As a hospitalist, he routinely treats patients at the end of their lives, patients who have multiple health issues to be juggled, often patients who will not survive their stay.
It’s not the deaths caused by COVID-19 that bothers him. It’s the sheer number of patients he’s seeing laid up on hospital beds, on mechanical ventilators for weeks at a time, as more recently diagnosed patients stack up behind them.
“My job is people to take care of people with organ failure of some sort, or with severe illness from viruses,” Hanserd said. “Currently it’s just the volume of patients.”
Even as Alabama doctors are getting better at treating COVID patients, they are being slammed with record numbers of them. Hospitals large and small across Alabama are seeing new record numbers of COVID patients that are straining resources, raising alarms and crowding intensive care units.
“It’s a challenge,” said Dr. Nathan Erdmann, a physician at the University of Alabama at Birmingham Hospital who coordinates the care of the hospital’s 105 COVID patients as of Wednesday’s count.
“We’re shuffling around beds, trying to free up as much ICU space as we can. We are trying to open up additional beds as we can on the floors, but we have to have COVID staff and all the precautions that go along with that, so it continues to be a moving target, but it’s tough to accommodate.”
Dr. Ricardo Maldonado, an infectious disease specialist at East Alabama Medical Center in Opelika, said via email that COVID-19 has challenged him as no other disease has.
“In my 30 years as a physician, I have never seen anything like COVID-19,” Maldonado said. “This virus is amazingly virulent and the way it makes people sick is simply incredible.”
July surge hits hospitals
EAMC in Opelika saw a flood of COVID-19 patients early in the outbreak, with 54 hospitalizations on April 11, as the disease surged in the surrounding area before it took off in other parts of the state. The hospital broke that early record on July 20, reaching 58 cases Monday and 62 by Wednesday. Three of the 12 COVID patients who died in July at EAMC were under the age of 50.
Other Alabama hospitals are also feeling the strain. Alabama first saw more than 1,000 people hospitalized with COVID on July 6. The state has had more than 1,500 people currently hospitalized with COVID every day since July 19.
UAB hit a new peak of 106 hospitalized COVID patients on Thursday, the same day DCH Health System in Tuscaloosa reported 100 hospitalized COVID patients for the first time.
On Wednesday, the Alabama Department of Public Health announced 57 confirmed COVID deaths, the highest single-day total of the outbreak, and only a slight dip in current hospitalizations, to 1,547. Thursday, the state announced 2,283 new cases of COVID-19, another all-time high.
Erdmann said the number of patients at UAB continues to increase, even though many are seeing shorter stays.
“As we’ve gotten a little bit more comfortable with managing COVID patients, we’re discharging people faster now than we used to,” Erdmann said. “Overall, we’re turning the hospital over and yet we still have the larger capacity numbers, which is just to say that those numbers are actually under-representing where we are now compared to where we were a couple months ago.”
And doctors know that some percentage of the record number of people confirmed to have the coronavirus in July will end up in the hospital in the coming days.
Dr. Jeanne Marrazzo, an infectious disease specialist at UAB, said on the Reckon Interview podcast this week that Alabama’s hospitals were “getting close to the razor’s edge,” in terms of capacity, and that the growing number of cases puts the overall healthcare system at risk.
“About 20 to 25% of people who are sick enough to come into the hospital with COVID infection end up going into the intensive care unit,” Marrazzo said. “And a fair proportion of those, maybe about half, end up requiring mechanical ventilation or being intubated on a ventilator.”
Treatments are getting better, but issues remain
In the months since the pandemic began, doctors have discovered new ways to help COVID patients that are improving their outcomes and helping maximize the available resources.
“We understand much better now how this virus works and the mechanisms it uses to make people sick,” Maldonado said. “It is an incredible virus.”
One of the best weapons so far is remdesivir, a drug tested at UAB and granted an emergency authorization to fight the virus.
“It’s really the only COVID-specific treatment we have,” Erdmann said. “There are other interventions that are starting to come online that are going to be very important and beneficial, but remdesivir is the one that we know directly disrupts the COVID virus itself.”
There are significant supply chain issues with Remdesivir, however, as the virus surges across the country. Hanserd said his hospital, Athens-Limestone, briefly ran out of the drug last week before receiving another shipment.
Even at UAB, a much larger hospital, supplies are limited. Erdmann said UAB uses “an algorithmic approach,” to evaluating patients and trying to ensure that the drug is available for those who need it most.
Erdmann said the use of steroids and anti-inflammatories to stifle the body’s immune system response to the virus also seems to provide benefits for COVID patients, but should be approached with caution because those drugs stifle the immune system.
“It’s a messy intervention,” Erdmann said. “I think it’s clearly beneficial for a subset [of patients]. We’re still trying to figure out how best to leverage that so that we get the most benefit and try to limit some of the harm. We use steroids a lot, but they have their own problems as well.”
Maldonado said EAMC is using anti-inflammatories like tocilizumab, sarilumab and anakinra on COVID patients, but that those drugs have to be used carefully.
“These medications can save lives when used at the right time,” he said. “We cannot use them too early or too late. It’s all about timing with these medications.”
Hospitals also use convalescent plasma from people who have recovered from COVID in hopes of boosting the current patient’s immune response.
There are also non-pharmaceutical techniques like proning — rolling patients over on their stomachs to help breathing – that can help patients breathe better, but can be very labor intensive.
“Proning isn’t some sort of magic fix,” Erdmann said. “It just kind of opens up some lung capacity that would otherwise be difficult to do when someone’s lying on their back. That’s not unheard of to do in the hospital, and we know it has benefits for oxygenation, but it presents all sorts of logistical challenges.
“You can only imagine someone who has multiple IVs and an airway and a catheter in and you have a bunch of nurses in there that are literally trying to flip this person over, and not disconnect anything that doesn’t need to be disconnected. And they do it extraordinarily well, but it’s quite the adventure each time.”
Hanserd in Athens said that conventional wisdom early on was to put patients on ventilators early, but with limited supplies and some patients remaining intubated for weeks at a time, they are having better results now trying other therapies to prevent the patient from needing mechanical ventilation.
“What we were told from when it was on the other side of Earth, was to intubate patients early, put them on a ventilator early, because they’re not going to get better, and they’re going to tire out and you’re going to have to do it eventually anyway,” he said.
That thinking has changed, Hanserd said, and the hospital now has better outcomes keeping patients off ventilators as long as they can with remdesivir and other drug therapies where they can.
Disease comes in waves
Maldonado, who estimated he’s supervised treatment for about 300 COVID-19 patients at East Alabama Medical Center, said the disease often presents in phases.
“Typically, the young and healthy will have a ‘flu-like’ illness or sometimes no symptoms at all or very mild,” Maldonado said. “They tend to only have to endure one phase that could last 7 to 10 days; and they recover, except for symptomatic treatment, so no other specific treatment is needed.”
Others may experience more severe symptoms and require additional oxygen or drug treatments, but not need mechanical ventilation.
The most severely affected patients do need mechanical ventilation, and those often need it for a long time.
“Once the [COVID] patient goes on the ventilator, our average at our facility is 21 days on the ventilator, so that’s a considerable amount of time,” Hanserd said.
Hanserd said in the pre-COVID world, his patients at Athens—Limestone who needed ventilators due to pneumonia for example, would need the ventilator for three to five days at most.
Erdmann at UAB said one patient there has been on a ventilator for eight weeks.
“There are few things more physically disconcerting than being on mechanical ventilator,” Erdmann said. “This is a large piece of plastic that is literally jammed in your airway, and everything in your body tells you that should not be there.”
Erdmann said patients on ventilators are often given sedatives so they don’t try to fight the machine that’s breathing for them.
“Once we intubate someone, we very quickly have to try to overcome the body’s response to not wanting that to be there,” Erdmann said. “Generally, we’ll do that with a variety of medicines trying to get the person to calm down. But, at least early on, very rarely does the patient really have an understanding what’s going on. They’re usually kind of medically sedated because we’re trying to keep them from fighting the ventilator as best we can.”
Because the virus is so contagious, visitors for COVID patients are still restricted, forcing patients and their families to endure the illness apart.
“We would do what we could to try to allow you to communicate [if your family member was hospitalized],” Erdmann said. “We would try to pass information along as best we could. But your opportunity to actually go in and be in the room would be very, very limited, if at all.”
COVID’s toll on healthcare workers
Marrazzo said hospital capacity isn’t just limited by the number of beds or the physical space, or personal protective equipment, but by the number of health care workers available to treat those patients.
“Our healthcare workforce is not inexhaustible,” Marrazzo said. “It’s a really intensive physical ask, and it’s also a big emotional ask because you’re having people in the trenches being exposed every day. Remember, patients can’t see family, they can’t see friends because of the rules of trying to keep everybody safe, so the emotional burden on care providers in those settings is huge.
“We’re really worried about that.”
Hanserd, a father of four who spoke with AL.com on a rare day off after working 12 straight, said the potential consequences weighed heavy, particularly early in the outbreak.
“It’s bad enough, I know a pandemic is coming,” he said. “I don’t know how sick it really makes people until it gets here. I could get infected with it and bring it to my family. I’m working more hours. And then on top of that, I’m having to take care of other people that work with me who have got it and are extremely sick. So that can, you know, obviously that can kind of mess with your psyche.”
Erdmann, who has two school-age children, said he hasn’t had a full day off since March, and expects the situation to continue for more months.
“Looking at the landscape, it’s hard to think why things should be significantly better anytime soon,” he said. “I think we’re settling into a pattern where we have weeks but more likely months of this and the ability to sustain this response is problematic.”
Maldonado in Opelika said there are times he has cried and prayed for his patients.
“Crying and being sad does not bother me,” he said. “The day I do not feel emotional about people dying, I should quit medicine. But I know that will never happen because I am an emotional person. Sadness and stress are part of my job.”