ER physician describes a local COVID-19 nightmare: Not enough hospital beds, no one taking transfers, rationed health care

This public Facebook post, published a couple of hours ago by Dr. Erik Martin, Joplin, a local emergency room physician, provides a candid and frightening examination of what COVID-19 has done to our local hospitals.

The effect, as Dr. Martin explains in detail after horrifying detail, is not only on those who are unfortunate enough to contract the coronavirus, a group that is growing with each passing hour, but also with those who are unable to access the health care they need for other diseases.

Dr. Martin's post also serves as an indictment of leadership and public attitude that has placed us in this position.

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I have been working a lot recently, mostly in the ER. I’m just coming off several night shifts. I feel a little tired, I have that post-night shift fog that feels a little bit like a hangover – a slight headache, a lack of energy, my brain just doesn’t quite feel like it wants to be awake right now even though it’s mid-day, and no amount of caffeine entirely overcomes this feeling. 

People who work night shifts in the ER know what I’m talking about. It usually takes me a couple of days to get over this, to get back to feeling somewhat normal again. It’s one of the reasons that in the past I have taken time off from the ER, and one of the reasons I stopped working full-time in the ER for a couple of years, because too many night shifts can do bad things to your mind, to your body, to your soul. 

But I am working full-time in the ER again. I feel it is where I ought to be. 

It is on night shifts in the ER when you see the world as it really is. When you see the things you wish you hadn’t seen, when you have to take care of people because there is no one else to take care of them. 

Sometimes during a night shift, you can feel like you’re on an island, like there is no one else out there who can help you. It’s just me and the nurses and we’re it. It’s a lonely feeling, especially when I’m the only doctor in the hospital working, in fact in many places I’m the only doctor working in the entire county at that time.

 

There was a time in my career when this lonely feeling bothered me enough that I decided I didn’t want to work alone at night in small critical access hospitals anymore. But I have matured since then. And now, once again, I actually like it and even prefer it. It is where I feel the most needed. It is where I feel that everything that happens is my responsibility, however hard or easy it might be. It is where I feel most acutely that I am on the frontlines of medicine.

In the past two weeks I have seen and hospitalized more COVID patients in the ER that at any other time locally. 

In fact, there have been shifts I’ve had recently where I’ve seen as many COVID patients in the ER as I did in some of my shifts in New York. This is hard to believe, or perhaps it isn’t. Perhaps all along I’ve known and feared that eventually it would be like this at home too, that New York was just the harbinger of what was to come for all the rest of us. Because it is happening now. 

I’ve had the opportunity to work in a lot of different places this year. From an urban public hospital in Brooklyn, New York to a small Indian Health Service hospital in Hopi, Arizona, to several different rural ERs in Missouri, Oklahoma, and Kansas. 

Within the past month I’ve started working again at Mercy Carthage, where I have worked before several years ago so it is a familiar place with many familiar people still working there, so it doesn’t really feel like a new place at all. I liked working there then, and I like working there now.

I have had several COVID-firsts recently. I admitted my first pregnant COVID patient. She was hypoxic and requiring supplemental oxygen. She was full term and they delivered her baby and she did just fine. 

I saw my first COVID stroke. I saw my first COVID rash (strange that I hadn’t seen that yet). I’ve also seen several patients with COVID plus something else, which may or may not be related – COVID plus Strep (pretty common), COVID plus osteomyelitis (bone infection, not at all related to COVID but the guy happened to also have COVID). 

Generally, if the secondary diagnosis is caused by COVID, it has a much worse prognosis. For example, COVID plus renal failure is bad. COVID plus DKA is bad. COVID plus a stroke is bad.

I saw a man recently who came in because he wrecked his truck and was acting a little strange. He got a bunch of tests done including an MRI which showed that he’d had a stroke. So we were going to admit him to the hospital and a COVID swab was done on the patient because he was getting admitted. The COVID swab came back positive. 

COVID can cause blood clots and I’ve seen that several times, it can also cause heart attacks and strokes, but I had not seen that yet. The patient was pretty confused and couldn’t really give me a good story. So I called his wife and talked to her, he lived out of state and was only passing through because he was a truck driver. She wasn’t too surprised by the COVID result because she said she was starting to have symptoms herself – fever, cough, etc. His only symptoms had been fatigue and dizziness. 

She was grateful that I called to update her, because of course she couldn’t visit him. Not only was she out of state, but her husband had COVID, and she had it too.

So this patient clearly needed to be hospitalized. He wasn’t having any respiratory symptoms, just the stroke symptoms, but he needed a COVID unit bed and because he was an acute stroke he needed a COVID ICU bed. So between myself, the unit clerk, and the nurse, we spend the next several hours calling multiple hospitals trying to find a COVID ICU bed for this patient. 

I really lost track of how many we called because we called so many, but I would guess it was somewhere around 15-20 hospitals. We called Joplin, Springfield, Tulsa, Oklahoma City, Rogers, Pittsburg, Wichita, and Branson. I might have missed a city or two. Every hospital in all of those cities was on divert, was not accepting transfers, did not have COVID beds, did not have ICU beds. 

I was beginning to think we wouldn’t find a bed for him and we would just have to keep him in the ER.

Finally, we found an open ICU bed in Northwest Arkansas and that’s where he went.

I had a similar experience just a few days before. An elderly man had caught COVID about a week before, it had progressed to COVID pneumonia and he was now hypoxic. So he was requiring oxygen, but with oxygen he looked ok and was doing fine. 

I ordered his first dose of Dexamethasone, which we give to patients with COVID requiring oxygen. He just needed to be admitted to the hospital. He didn’t need an ICU bed, just a regular hospital bed which because he has COVID needs to be a negative pressure room. We didn’t have enough staff to admit him, so I called Freeman and Mercy Joplin and both were full and couldn’t accept any patients. So were several other hospitals nearby. 

Mercy Springfield said they would put him on the list and when they had a bed available they would call us back. So I left at the end of my shift and assumed that he would go to Springfield sometime that evening. He didn’t. He was still there the next day when I came back to work. 

In fact he was there long enough that I ordered his second dose of Dexamethasone (it’s given every 24 hours). Finally, after more phone calls I found a bed for him in Kansas City. He was in the ER for about 30 hours. 

Multiple studies have shown that the longer patients stay in the ER waiting for an inpatient bed, the worse their outcome is. 

There are many reasons for this, but the primary reason is because we are not trained and experienced at delivering inpatient medical care in the ER. Hospitalists, Intensivists, Med-Surg nurses and ICU nurses are trained and experienced at taking care of inpatients. It’s what they do every day, and generally they are very good at it. 

In the ER, we are very good at providing acute care. It’s what we are trained to do. We do it better than anyone. But because of the lack of bed capacity that is happening across the region right now due to COVID, many ERs are now providing inpatient care for an extended period of time for their patients waiting for a hospital bed. 

This is not ideal for the boarding patient, and it is also not ideal for other patients in the ER. It takes away the nurse and staff from caring for other ER patients. It also ties up an ER bed, and the result especially in the bigger hospitals that are boarding a lot of ER patients recently is that wait times increase dramatically. None of this is good for patient care.

I have advocated all along since I returned home from New York, that all local hospitals need to be prepared to take care of COVID patients. Some local hospitals have done an excellent job preparing and have handled the surge of COVID patients well. Cox South in Springfield is probably the best example of this. Via Christi in Pittsburg also seems to have done well from the beginning. 

Mercy and Freeman have not been as proactive. 

Early in the summer, it was common for COVID patients to be transferred from Joplin to Springfield because neither hospital had enough COVID unit beds. Mercy as a system furloughed a lot of workers during the slowdown and this summer had a difficult time finding enough staff to take care of all the patients at Mercy Springfield. 

Staffing has improved somewhat since then, but still overall we do not have enough nurses and staff to take care of all the additional COVID patients that we have right now.

Not everyone that I have hospitalized recently has been elderly, although still the majority of hospitalized COVID patients are over the age of 60. The pregnant patient was in her 20s. Just this past week I had two patients in their 50s who were pretty sick. One of them was otherwise in very good health, he had no underlying medical problems, he was not obese, but he had a bad COVID pneumonia and was requiring a fair amount of oxygen. He had to be transferred to an ICU. 

Fortunately, that day Springfield had a COVID ICU bed available. Another man in his 50s that I saw, and this was perhaps a day or two later, also had a bad COVID pneumonia. He had some underlying heart problems. He had an abnormal heart rhythm, was in acute renal failure, and was on high-flow oxygen. He also needed an ICU bed. But it was much harder to find him one. Springfield, Joplin, Tulsa, Northwest Arkansas, and Pittsburg all didn’t have COVID ICU beds. We called 15 hospitals before we finally found an ICU bed for him in Kansas City.

One thing I have noticed recently is that fewer people know how they caught COVID. Many of them have no idea. Some still do and know of a relative or a friend or a coworker who they think they caught it from. But the majority of my patients recently do not know where they caught it. This is an indicator of just how widespread the prevalence of the virus is in the local community.

I have felt all along that the last demographic to see widespread community spread would be older retired people who live independently – that is, they are not nursing home patients. People like my parents, who still live at home and are retired. They no longer work, they don’t go out to bars and restaurants like young people do, they live pretty socially distanced lives under normal circumstances, so their risk of catching COVID is less on average than younger people. 

I thought that this demographic would not really see a big spike in cases until after the holidays, after Thanksgiving and Christmas when family gatherings will occur all over the country. But I think I was wrong. It is happening sooner than that. 

It is happening now. 

I have seen multiple elderly patients just in the past week or two with COVID, and most of them don’t know where they caught it. Many of them have no idea at all, although some have suspected church or family gatherings, a wedding perhaps, I saw one woman who was pretty sure she caught it from her best friend who was about her same age – thus community spread occurring between elderly people. This is bad indeed if it is happening broadly and will surely tax our healthcare system even more because elderly people with COVID are much more likely to need to be hospitalized.

I continue to be discouraged by the leadership vacuum locally, regionally, and nationally. On every level, but particularly the local level, the response has largely been reactive and delayed and piecemeal rather than proactive and coordinated. 

A perfect example is our current predicament with lack of beds. In order to try to find a bed for a patient, each hospital ER has to call dozens of other hospitals to try to find a bed. This takes a lot of time, sometimes hours. 

Bigger hospitals might have a case manager who can help do this, in smaller hospitals it might be the unit secretary, but in most cases it is either the nurse or the doctor who has do it. Phone call after phone call. ‘Hello this is Dr. Martin, I have a patient who needs to be transferred, do you have any COVID beds available?’ 

And I’m not the only doctor having to do this. It is happening across the state, across the region, across the country. One thing that would help would be if there was a centralized hotline that we could call that would help to coordinate open beds in the state and help to arrange transfers. 

Arizona set up something like this for COVID transfers. There is a toll-free number any hospital in the state can call if they have a COVID patient they need to transfer. Oklahoma has a hotline for trauma transfers which works pretty well, and I would think it wouldn’t be too difficult to transition that system to COVID as well. We have nothing like that in Missouri and I doubt we will, because there seems to be no one in leadership who will advocate for something like that.

Another simple measure which would help a lot with the regional surge of patients we are having to deal with now - and which might surprise some non-medical people reading this - is that every hospital should admit COVID patients. Because some hospitals have tried very hard to avoid admitting them. This has never made sense to me. I think in some cases, local hospital leaders were COVID-skeptics. They didn’t believe it was real and they acted accordingly. 

Later, when it became impossible to disbelieve in the virus, they tried to pretend it just wasn’t that bad. 

Maybe some people were just afraid of it and didn’t want it in their hospitals. Maybe it was primarily financial, trying to prioritize elective surgical cases which generate a lot of revenue and trying to keep their hospital ‘clean’. Maybe it was just poor decision making. 

Whatever the reason, some hospitals have avoided admitting COVID patients for as long as possible. It has only been in the past week, for example, that Mercy Carthage has started admitting COVID patients. Even Cox Branson, which is a pretty big hospital, avoided admitting COVID patients for quite a long time (they are admitting them now). 

The local community suffers because of these poor decisions. Most local people want to be hospitalized in the community where they live. They understand if they need some specialty care that they will have to be transferred elsewhere, for example if they need a Cardiologist or a Neurosurgeon, then of course they need to be transferred. But most hospitalized COVID patients just need a little oxygen, steroids, and time. 

Every hospital can provide those treatments, even the smallest rural critical access facility. Some rural hospitals have done a great job taking care of local COVID patients from the very beginning. 

Parsons, Pittsburg, Lebanon, and McAlester all have done this. I saw recently that Cox Monett has converted its ICU to a COVID ICU and is taking care of patients. I’m not surprised at all that Monett is doing this, I enjoyed my time working there and the nurses and staff are great and so is the hospital leadership. 

So every hospital needs to do its part to bear the burden of caring for all of these COVID patients. We cannot depend on the larger hospitals in Springfield and Kansas City to take care of everyone because they simply can’t. 

The most basic function of a hospital is to care for the sick people in their local community, and COVID is no exception. To refuse to care for someone because they have COVID is to violate our solemn and sacred duty to care for the sick. I feel this very strongly. Every hospital therefore should care for COVID patients. And as beds become increasingly scarce, they are going to have to care for sicker COVID patients as well.

The lack of bed capacity across the region will result in worse outcomes for patients, and not simply for COVID patients but for non-COVID patients as well. Because it is taking just as long to find beds for non-COVID patients too. 

I had a patient recently who had an abnormal heart rhythm. He needed to be hospitalized. The medication that we usually give to control this heart rhythm wasn’t working, so he really needed to be hospitalized because standard therapy was failing. He needed to see a cardiologist. He needed to be admitted to an ICU, on a drip, he needed an echocardiogram and anticoagulation and likely an electrical cardioversion. This was a couple of weeks ago when it wasn’t quite as hard to find a bed as now, but still I knew I was going to have to make a few phone calls and would have to transfer him somewhere else. 

The patient refused. He didn’t want to go somewhere else. He didn’t want to be transferred. I explained all the risks and benefits and tried to reason with him but still he didn’t want to go. He said he had things he needed to take care of at home, and mostly he was worried about his pets (this is actually a pretty common reason that people don’t want to be hospitalized). 

So I called his primary care physician, explained what was going on, and his doctor said he would try to make some arrangements. And the patient signed out AMA (against medical advice).

In this patient’s case, he was probably going to leave against medical advice regardless of whether there was a bed nearby or not. But on several occasions recently, I have had patients refuse to be transferred somewhere far away. They didn’t want to go to Kansas City or Columbia or wherever else that might have had a bed. So they either stayed in the ER, or simply left and went home.

Some COVID patients, when faced with the prospect of boarding in an ER for several days or being transferred 200 miles or more away from home, are choosing instead to go home. We send them home with an oxygen tank and a script for a few days of steroids and we hope for the best. It doesn’t feel like the right thing to do. It is not ideal care at all. 

These are patients with an acute illness that is attacking their lungs and causing them to not be able to get enough oxygen. I feel strongly that they should be in the hospital. And most doctors agree. But we have so many COVID patients in the hospital now, we don’t have enough hospital bed capacity, that some COVID patients are being sent home on oxygen. 

In many cases these patients will be fine – they will take their steroids and use oxygen for a few days and they will get better. But many of them will not be fine – they have complications and further problems and will end up back in the hospital. I have seen this already several times.

Ideally, they would all be hospitalized for their acute illness until they get better, if needing oxygen or some other supportive care. But because we have limited resources, because we have too many COVID patients needing hospital-level care right now, we are exceeding our ability to provide this highest level of care for everyone. 

This has happened in various places in America throughout the pandemic, and it is happening on a broad scale right now. It is happening locally too. It will only get worse.

I think everyone should understand clearly what all this means – we are being forced to ration healthcare. This is the end-result of our laissez-faire approach to the containment of COVID in America. 

It the logical conclusion of what happens in a leadership vacuum. 

Our healthcare system is now rationing care. This is not happening in any coordinated manner, because nothing at all has been dealt with on a coordinated nationwide level throughout the pandemic. Rather it is happening locally, piecemeal, one patient at a time. 

The general public knows that right now you might have to wait 6 to 8 hours at certain ERs before being seen, so some of them give up and go home or just stay home. People have heard that the hospitals are full so they stay home. 

Primary care doctors are ordering oxygen and steroids for some pretty sick patients who really ought to be in the hospital, but they either don’t want to go or don’t want to be transferred somewhere else. And sometimes in the ER we are faced with either boarding patients for days or sending them home with oxygen.

Another way in which rationing of healthcare occurs is that elective surgical cases sometimes are postponed. This has happened locally on a limited scale recently, and throughout the pandemic has happened in various parts of the country which have seen a surge of COVID cases. 

Occasionally a hospital will announce this to the public and you will see it in the media, but often it is done in the background without the public even hearing about it. 

Many of these surgeries are elective only in the sense that they can be delayed for a bit longer. But people still need their gallbladders removed, they need new hips, they need dental procedures done, they need tumors resected. These things might be able to wait a week or so, but they can’t wait forever. 

We may be forced to cancel even more surgeries again locally to free up staffing and bed capacity for COVID patients.

This rationing of healthcare, in particular inpatient beds, will result in worse outcomes across the spectrum, not just for COVID but for other diseases as well. These poorer outcomes will be reflected in excess mortality figures that we have already seen, excess deaths that are occurring not directly due to COVID but nevertheless are happening more because of a strained healthcare system. 

A colleague of mine had a patient with a heart attack in the ER. The patient was improving and was no longer having chest pain, but the standard of care for this patient would be admission to the hospital and an angiogram (heart cath) to see if there were any blockages. But because there weren’t going to be any beds at the larger hospital any time soon, the cardiologist suggested that my colleague to just send the patient home to follow up with him later. My colleague refused to do this. He kept him in the ER and eventually found a way to get him transferred, which was the right thing to do. So you see the decisions we are faced with now in the COVID era. 

So that’s what it is like on the frontlines right now. I’m seeing more COVID in the ER than I have at any time since I left New York. 

We are routinely boarding admitted patients for both COVID and non-COVID related problems in the ER for hours and sometimes days waiting for beds. Patients are being sent home from the hospital and sometimes from the ER with oxygen who really ought to stay in the hospital. 

Some patients are making the decision to forego long wait and long transport times themselves. I do not see any of this improving in the short-term. We are still a long way from herd immunity, and it seems that more of the herd gets sick every day. 

It would help if we had a centralized transfer hotline to better coordinate available beds throughout the state and the region. It would help if every single hospital including small rural critical access hospitals did their part to admit COVID patients from their communities. It would help if there was a statewide mask mandate, but I don’t see that happening. 

It would help if people participating in large group activities like attending church and meetings and watching youth sports would all wear a mask. But it might be too little too late for any of these measures to really help. So much community spread is happening in small groups of family and friends now. Maybe it is just inevitable and I’m silly to even try to change that. Still, I feel like it is my duty to try.

I still feel that the worst is yet to come. I think it will be after the holidays, in January and February. 

Every ER across the region will become a COVID unit as the system will be in utter gridlock. We are getting close to this now. Maybe I’m wrong and it will happen sooner than I thought. We’ll see.

Sorry if this is pessimistic. Sorry for another long post. I’m being as realistic as I can. 

The sky isn’t falling, and life will go on for most of us, and indeed many people who are quite sick are surviving COVID now as a result of improvements in care. We are getting better at treating this. Pandemics don’t last forever. 

Rationally I know all of this, but still it feels like we have a long way to go. Being on the frontlines has changed. It’s gone from what felt like a heroic life-and-death struggle to save people’s lives, to now spending hours calling hospitals all over four different states asking, ‘do you have any beds?’

I am reminded of the closing lines of the poem The Hollow Men by TS Elliot: ‘This is the way the world ends, Not with a bang but a whimper’.

That’s what it feels like right now.