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The lament of covid-19 caregivers in the nation’s safety-net hospitals: ‘What could be next?’

Chiquita Scott, senior director of pulmonary services at Touro Infirmary, figured she had seen the worst when Hurricane Katrina sundered New Orleans. Then came covid-19. (Emily Kask for The Washington Post)

Every now and then, Chiquita Scott’s mind wanders.

Sometimes, it happens in the middle of scheduling additional shifts for an already overworked staff during the coronavirus’s fourth wave of sickness and death. Other times, it is on the drive to the hospital, where some veteran respiratory therapists have seen more death these past 18 months than they have experienced in a decade on the job.

Scott works at one of the nation’s safety-net hospitals, places with a mission to provide medical care to people regardless of their ability to pay. They serve the most vulnerable — people who live in poverty or earn low incomes, those who do not speak fluent English, and people of color. The people the pandemic has hit with unequal impact. Black, Latino and Native American people die as a result of the coronavirus at twice the rate of White people.

As her brain tries to make sense of the incomprehensible nature of this pandemic, her body registers a familiar sense of disbelief. She first felt it 16 years ago working to evacuate patients during Hurricane Katrina, when floodwaters swallowed New Orleans and rushed into Tulane Hospital, where she worked at the time.

Emergency generators kept the power on until the fuel ran out. Sewage backed up. And for several days, she watched as co-workers ventilated critically ill patients by hand. The unthinkable decisions. The isolation. The anxiety. The unsatisfying answers to patients.

Katrina, she thought, was a disaster with no rival. An exception. And so, the 46-year-old said, she “put that in the space of a one-time thing. I blocked that off.”

Until Mardi Gras 2020, when her beloved city was flooded again. This time by covid-19, when feelings that were supposed to be experienced once in a lifetime bombarded her with each of the pandemic’s waves and milestones.

There was the rising death toll that surpassed 600,000 people nationwide, 877 in New Orleans alone, and that cut disproportionately deep in communities of color. A lifesaving vaccine. Then, an erosion of trust in government and in medicine — in any institution, really — slowed vaccination rates, and now respiratory therapists in Louisiana and other coronavirus hot spots across the nation are dealing with some of the worst outbreaks yet.

“Sometimes, my mind is thinking: ‘What could be next? How do you prepare for something when you have no clue what it is, what it could be?’ ” Scott, senior director of pulmonary services at Touro Infirmary, said recently by phone. “The questions are so many. Because I could not have imagined Katrina, ever, and I could not have imagined covid-19.”

The pandemic is straining the nation’s already stretched health-care system, but there are differences in the suffering.

“These are some of the hospitals that are our last line of defense and first line of care for so many communities,” said Cameron Webb, a physician and senior policy adviser for covid equity on the White House COVID-19 Response Team. “They’re standing between people and a complete lack of access to care. They’ve been hit hard by this pandemic.”

But this wave, fueled by the delta variant, said John F. Heaton, president and chief medical officer of LCMC Health in New Orleans, which includes the hospital where Scott works, “is in many ways different than the three waves we’ve experienced before.”

Not only has the virus mutated, making it more transmissible and possible for vaccinated people to infect others, but victims are younger with fewer chronic conditions, doctors and respiratory therapists say. And one of the biggest differences with this wave is the atmosphere.

A staffing shortage has left hospitals across the country with fewer respiratory therapists and nurses, and those who remain are fatigued and increasingly frustrated. Hospitals have more non-covid patients, and many medical centers have yet to reduce elective procedures and other non-urgent care, or only recently began scaling back. With no national shutdown keeping people at home and prohibiting public gatherings and crowds, the virus has greater potential to spread.

With fewer hospital workers, some patients must wait longer to get admitted, sometimes days. There are safety-net hospitals where regular inpatient and intensive care beds sit unused because of a dearth of staff. In some places, including Arkansas, makeshift ICUs have been established. Federally staffed field hospitals have opened in Mississippi hospital parking garages. And Texas is hiring out-of-state staff to meet the needs of its local hospitals.

“We are treading water,” Alan E. Jones, associate vice chancellor for clinical affairs at the University of Mississippi Medical Center, the state’s only academic hospital and a safety-net facility, said this month. “It’s kind of a day-to-day, hour-to-hour dance.”

At the University of Arkansas for Medical Sciences Medical Center, the safety-net hospital is full of covid and non-covid patients, but the staff has dwindled because of the danger, frustration and fatigue, said Rawle A. Seupaul, chair of emergency medicine.

During a recent Friday shift, Seupaul said, most of the 30 patients he saw had not come there because they thought they might have covid. Instead, he said, they were there for things such as chest pain.

“But anyone that needs to be admitted is getting tested. And lo and behold, they’re coming back positive,” Seupaul said. “That’s how prevalent the disease is today.”

To make space, the hospital has commandeered areas that traditionally would not be used to care for critically ill patients. But those nooks of the hospital lack windows or entertainment.

“That might sound trivial, but we had a patient that experienced delirium because of the environment,” Seupaul said. “The environment is very important to the care of critically ill patients. We were able to mitigate that person’s delirium, but these are the things that happen when you run out of space.”

So staff members, he said, are overwhelmed and struggling. ICU nurses and respiratory therapists provide bedside care to coughing and wheezing patients as well as to those who need machines to help them breathe. “They’re placed at risk,” Seupaul said. “Now, that risk seems even more unnecessary because people are not responsibly getting vaccinated.”

During what Scott calls “the pre-vaccine waves,” when illness surged before the arrival of coronavirus vaccines, it “felt like we were in the fight together,” she said, “like we all were doing what we had to do until we had a light at the end of the tunnel.”

Her staff of 29 respiratory therapists at New Orleans’s Touro Infirmary has been inundated. In normal times, they operate about eight ventilators. At one point during the pandemic, they were up to 30 covid patients on ventilators, with at least two people dying every day.

The deaths have slowed — but not stopped. There are still too many sick patients in need of care, and Scott has four vacancies in her department.

On Aug. 9, about 20 people — five covid and 15 non-covid — were on ventilators. Within 12 days, the staff was caring for 28 covid patients, five on ventilators and two on BiPAP machines, which push air into the lungs without intubation.

A co-worker’s father was transferred from a rural hospital on a ventilator. During the pandemic’s previous waves, Scott’s staff had been fortunate not to have to care for one of their own or for a colleague’s relative.

“We’re walking through it as best we can,” she said.

The unfilled jobs at Touro mean respiratory therapists work a minimum of four 12-hour shifts a week instead of their typical three. And the hospital has nearly doubled the number of therapists on shift, going up to eight or nine to divide staff between covid and non-covid patients.

Vaccines were supposed to be a beacon signaling the end of this.

The states being hit hardest by this latest blast of covid cases have the lowest vaccination rates — Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, South Carolina and Tennessee.

“It’s very frustrating to work so hard and take care of patients and yet hear in the community, ‘this is not real.’ Just conspiracy theories and thoughts,” Scott said. “It’s hard to explain watching a patient go from having difficulty breathing to basically dying. It’s an overwhelming feeling.”

Now, she said, there is an added layer of watching patients cut down in the prime of life, wondering if their outcome would have been better had they been vaccinated, and listening to them ask, “Is it too late for me to take the vaccine?”

“Yes, it’s too late right now,” she said. “You just can’t make people understand that. It’s mentally draining.”

It fills Julie Eason with rage.

“If we would have snuffed things out when we had opportunities, the delta variant should have never come into existence,” said Eason, director of respiratory therapy at University Hospital of Brooklyn at SUNY Downstate Health Sciences University.

During the initial wave of the pandemic, when New York was the epicenter, Eason’s hospital was designated a covid-only facility.

“We lost too many friends and colleagues, and it feels like it was in vain,” she said. “We lost a physician here who should have been retired, and yet he stayed. We shouldn’t still be doing this.”

Death is part of the regular rhythm of the job. Respiratory therapists see every patient in the hospital with breathing trouble, attend every code, respond to every emergency. They run the ventilators, make sure blood oxygen levels are where they should be and insert breathing tubes. But rarely is death experienced multiple times a day.

Covid changed that.

“If you were in an underserved community like this one, we had massive amounts of death,” Eason said. “You just couldn’t be prepared for it.”

In spring 2020, the hospital’s morgue, which has space for about a dozen bodies, was so overwhelmed that three refrigerated tractor-trailers were brought in to accommodate the dead. University Hospital of Brooklyn is in a 55-year-old building with outdated facilities that sits in a heavily Black and Latino borough, where a quarter of the residents live in poverty.

“The hospital where I am is in a predominantly Afro-Caribbean, African American population, working-class populations that have high incidence and prevalence of covid,” said Wayne J. Riley, president of SUNY Downstate. “They’re the people who get up and do the work of the world. They get up and drive the buses. They deliver the mail. They wait on us in the grocery stores. They take care of our children. And they need to feel that they can get the same level of care … and have similar resources.”

But there are not enough doctors or hospital beds — fewer still if you are a patient insured through Medicaid — to care for Brooklyn’s 2.6 million residents. The borough has a shortage of primary-care providers willing to accept patients whose care is subsidized by the federal government at pennies on the dollar compared with private insurance.

About 80 percent of the hospital’s patients are insured through Medicaid.

“We maintain at least two very different health and health-care systems in this country,” said Bruce Siegel, president of America’s Essential Hospitals, a coalition of safety-net hospitals. “You can draw a straight line from segregated communities and redlining to Medicaid policy, which says we’re going to pay less for the same service.”

More health-care dollars are spent on White people than Americans of other races and ethnicities, according to a study published Aug. 17 in the medical journal JAMA. Researchers found that in 2016, $8,141 was spent per White patient compared with $7,649 to care for Native American and Alaska Native patients, $7,361 for Black patients, $6,025 on Hispanic patients, and $4,692 on patients who are Asian, Pacific Islander or Native Hawaiian.

The study, which analyzed trillions of dollars spent over 14 years, also found that a higher than average amount went to outpatient care for White patients while Black patients saw less spent on outpatient care and more on emergency room visits and hospital stays. That means Black patients do not have access to care earlier in their illness, which worsens and ends up requiring hospitalization.

Riley said his hospital is not as “resource blessed” as many others.

“It’s not uncommon for a nurse, particularly over the last six to seven months, to walk in and say, ‘Hey, you know, I love working here, but I’m going to become a traveling nurse,’” he said. They’re being offered $10,000 and $15,000 signing bonuses by agencies, contributing to the hospital’s 25 percent nursing vacancy rate. “We can’t match that,” he said.

The Brooklyn hospital has not experienced anything in this surge close to the level of hospitalization and mortality endured during the early months of the pandemic, though infection rates are up. About half of the 11 covid patients Eason’s team was caring for on Thursday were on high-flow oxygen, and one person was on a ventilator. Two people in the emergency department were on machines to help them breathe while awaiting coronavirus test results. There was talk of transferring in covid patients, including three children who were intubated, from a nearby hospital. And three people had died.

It has been more than a year since covid patients filled Eason’s hospital, yet the trauma remains fresh to her staff of 25. There are seven vacancies.

Typically, she is able to fill openings with no trouble, hiring new graduates with ease. Not this year.

“How do I pay somebody $41 an hour when they can get $100, $120 an hour?” she asked. “A lot of contracts are for Manhattan hospitals, so it’s local. Staff get text messages on their phone, ‘Hey, come join this agency. You don’t even have to travel. You can stay right in your own home and make $120 an hour.’ ”

Eason has resorted to begging her staff for more hours, more time, a request that seems almost cruel. They have shared their concerns with her: I didn’t get sick last time. Am I going to get that lucky again? Will I live through this again?

“We’re all living with that fear,” she said. “None of us will ever be completely the same.”

Coronavirus: What you need to know

Vaccines: The CDC recommends that everyone age 5 and older get an updated covid booster shot. New federal data shows adults who received the updated shots cut their risk of being hospitalized with covid-19 by 50 percent. Here’s guidance on when you should get the omicron booster and how vaccine efficacy could be affected by your prior infections.

New covid variant: The XBB.1.5 variant is a highly transmissible descendant of omicron that is now estimated to cause about half of new infections in the country. We answered some frequently asked questions about the bivalent booster shots.

Guidance: CDC guidelines have been confusing — if you get covid, here’s how to tell when you’re no longer contagious. We’ve also created a guide to help you decide when to keep wearing face coverings.

Where do things stand? See the latest coronavirus numbers in the U.S. and across the world. In the U.S., pandemic trends have shifted and now White people are more likely to die from covid than Black people. Nearly nine out of 10 covid deaths are people over the age 65.

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