The Third Surge Is Breaking Health-Care Workers
Editor’s Note: The Atlantic is making vital coverage of the coronavirus available to all readers. Find the collection here.
On Saturday morning, Megan Ranney was about to put on her scrubs when she heard that Joe Biden had won the presidential election. That day, she treated people with COVID-19 while street parties erupted around the country. She was still in the ER in the late evening when Biden and Vice President–elect Kamala Harris made their victory speeches. These days, her shifts at Rhode Island Hospital are long, and they “are not going to change in the next 73 days,” before Biden becomes president, she told me on Monday. Every time Ranney returns to the hospital, there are more COVID-19 patients.
In the months since March, many Americans have habituated to the horrors of the pandemic. They process the election’s ramifications. They plan for the holidays. But health-care workers do not have the luxury of looking away: They’re facing a third pandemic surge that is bigger and broader than the previous two. In the U.S., states now report more people in the hospital with COVID-19 than at any other point this year—and 40 percent more than just two weeks ago.
Emergency rooms are starting to fill again with COVID-19 patients. Utah, where Nathan Hatton is a pulmonary specialist at the University of Utah Hospital, is currently reporting 2,500 confirmed cases a day, roughly four times its summer peak. Hatton says that his intensive-care unit is housing twice as many patients as it normally does. His shifts usually last 12 to 24 hours, but can stretch to 36. “There are times I’ll come in in the morning, see patients, work that night, work all the next day, and then go home,” he told me. I asked him how many such shifts he has had to do. “Too many,” he said.
Hospitals have put their pandemic plans into action, adding more beds and creating makeshift COVID-19 wards. But in the hardest-hit areas, there are simply not enough doctors, nurses, and other specialists to staff those beds. Some health-care workers told me that COVID-19 patients are the sickest people they’ve ever cared for: They require twice as much attention as a typical intensive-care unit patient, for three times the normal length of stay. “It was doable over the summer, but now it’s just too much,” says Whitney Neville, a nurse based in Iowa. “Last Monday we had 25 patients waiting in the emergency department. They had been admitted but there was no one to take care of them.” I asked her how much slack the system has left. “There is none,” she said.
The entire state of Iowa is now out of staffed beds, Eli Perencevich, an infectious-disease doctor at the University of Iowa, told me. Worse is coming. Iowa is accumulating more than 3,600 confirmed cases every day; relative to its population, that’s more than twice the rate Arizona experienced during its summer peak, “when their system was near collapse,” Perencevich said. With only lax policies in place, those cases will continue to rise. Hospitalizations lag behind cases by about two weeks; by Thanksgiving, today’s soaring cases will be overwhelming hospitals that already cannot cope. “The wave hasn’t even crashed down on us yet,” Perencevich said. “It keeps rising and rising, and we’re all running on fear. The health-care system in Iowa is going to collapse, no question.”
In the imminent future, patients will start to die because there simply aren’t enough people to care for them. Doctors and nurses will burn out. The most precious resource the U.S. health-care system has in the struggle against COVID-19 isn’t some miracle drug. It’s the expertise of its health-care workers—and they are exhausted.
The struggles of the first two COVID-19 surges in the United States helped hospitals steel themselves for the third. Hardened by the crucible of March and April, New York City built up its ability to spot burgeoning hot spots, trace contacts, and offer places where infected people can isolate. “We’re seeing red flags but we’ve prepared ourselves,” says Syra Madad from NYC Health + Hospitals. Experienced health-care workers are less fearful than they were earlier this year. “We’ve been through this before and we know what we have to do,” says Uché Blackstock, an emergency physician who works in Brooklyn. And with the new generation of rapid tests, Blackstock says she can now tell patients if they have the coronavirus within minutes—a huge improvement over the spring, when tests were scarce and slow.
Smaller clinics, nursing homes, and long-term-care facilities are still struggling to provide personal protective equipment, including gloves and masks. “About a third are completely out of at least one type of PPE” despite having COVID-19 cases, says Esther Choo, a physician at Oregon Health and Science University and a founder of Get Us PPE. But larger hospitals are doing better, having built up stockpiles and backup plans in case supply chains strain again. “The hospital is probably the safest place to work in Iowa, because we actually have PPE,” Perencevich said.
Most important, COVID-19 is no longer a total mystery. Health-care workers now have a clearer idea of what the SARS-CoV-2 coronavirus is capable of. Protocols that didn’t exist in the spring have become habit. “It used to be that to do a single thing, people would start email chains and you’d be 100 emails in before we knew the answer,” Choo says. “Now we’re moving faster. It feels a lot more confident.”
There are still no cures, and the best drug on offer—the steroid dexamethasone—reduces the odds of dying from COVID-19 by at most 12 percent. But doctors know how to triage patients, which tests to order, and which treatments to use. They know that ventilators can sometimes hurt patients, and that “proning”—flipping patients onto their stomach—can help. They know about the blood clots and kidney problems. They know that hydroxychloroquine doesn’t work. This cumulative knowledge means that death rates from COVID-19 are much lower now than they were in the spring. Flattening the curve worked as intended, giving health-care workers some breathing room to learn how to handle a disease that didn’t even exist this time last year.
But these hard-earned successes are brittle. If death rates have fallen thanks to increasing medical savvy, they might rise again as nurses and doctors burn out. “If we can get patients into staffed beds, I feel like they’re doing better,” Perencevich said. “But that requires a functional health-care system, and we’re at the point where we aren’t going to have that.”
Intensive-care units are called that for a reason. A typical patient with a severe case of COVID-19 will have a tube connecting their airways to a ventilator, which must be monitored by a respiratory therapist. If their kidneys shut down, they might be on 24-hour dialysis. Every day, they’ll need to be flipped onto their stomach, and then onto their back again—a process that requires six or seven people. They’ll have several tubes going into their heart and blood vessels, administering eight to 12 drugs—sedatives, pain medications, blood thinners, antibiotics, and more. All of these must be carefully adjusted, sometimes minute to minute, by an ICU nurse. None of these drugs is for treating COVID-19 itself. “That’s just to keep them alive,” Neville, the Iowa nurse, said. An ICU nurse can typically care for two people at a time, but a single COVID-19 patient can consume their full attention. Those patients remain in the ICU for three times the length of the usual stay.
Nurses and doctors are also falling sick themselves. “The winter is traditionally a very stressful time in health care, and everyone gets taken down at some point,” says Saskia Popescu, an infection preventionist at the University of Arizona. The third COVID-19 surge has intensified this seasonal cycle, as health-care workers catch the virus, often from outside the hospital. “Our unplanned time off is double what it was last October,” says Allison Suttle of Sanford Health, a health system operating in South Dakota, North Dakota, and Minnesota. Many hospitals have staff on triple backup: While off their shifts, they should expect to get called in if a colleague and their first substitute and the substitute’s substitute are all sick. At least 1,375 U.S. health-care workers have died from COVID-19.
The first two surges were concentrated in specific parts of the country, so beleaguered hospitals could call for help from states that weren’t besieged. “People were coming to us in our hour of need,” says Madad, from NYC Health + Hospitals, “but now the entire nation is on fire.” No one has reinforcements to send. There are travel nurses who aren’t tied to specific health systems, but the hardest-hit rural hospitals are struggling to attract them away from wealthier, urban centers. “Everyone is tapping into the same pool, and people don’t want to work in Fargo, North Dakota, for the holidays,” Suttle says. North Dakota Governor Doug Burgum recently said that nurses who are positive for COVID-19 but symptom-free can return to work in COVID-19 units. “That’s just a big red flag of just how serious it is,” Suttle says. (The North Dakota Nurses Association has rejected the policy.)
Short-staffed hospitals could transfer their patients—but to where? “A lot of smaller hospitals don’t have ventilators or staff trained to take care of someone in critical condition,” says Renae Moch, the director of Bismarck-Burleigh Public Health, North Dakota. “They’re looking to larger hospitals,” but those are also full.
Making matters worse, patients with other medical problems are sicker than usual, several doctors told me. During the earlier surges, hospitals canceled elective surgeries and pulled in doctors from outpatient clinics. People with heart problems, cancers, strokes, and other diseases found it harder to get medical help, and some sat on their illness for fear of contracting COVID-19 at the hospital. Now health-care workers are facing an influx of unusually sick people at a time when COVID-19 has consumed their attention and their facilities. “We’re still catching up on all of that,” says Choo, the Oregon physician. “Even the simplest patients aren’t simple.”
For many health-care workers, the toll of the pandemic goes beyond physical exhaustion. COVID-19 has eaten away at the emotional core of their work. “To be a nurse, you really have to care about people,” Neville said. But when an ICU is packed with COVID-19 patients, most of whom are likely to die, “to protect yourself, you just shut down. You get to the point when you realize that you’ve become a machine. There’s only so many bags you can zip.”
As the pandemic moved out of big coastal cities and into rural communities, health-care workers were more likely to treat people they knew personally—relatives, hospital colleagues, the bus driver who drove their kids to school. And across the country, doctors and nurses have struggled with the same anxieties as everyone else—loneliness, extra child-care burdens, the stress of a tumultuous year, fear. “The lines between our personal lives and our careers have completely gone,” says Laolu Fayanju of Oak Street Health, a network of primary-care centers in Ohio. “We’re often thinking about how we protect ourselves, our families, and our neighborhoods” from the pandemic.
After SARS hit Toronto in 2003, health-care workers at hospitals that treated SARS patients showed higher levels of burnout and posttraumatic stress up to two years later, compared with those at hospitals in nearby cities that didn’t see the disease. That outbreak lasted just four months. The COVID-19 pandemic is now in its tenth month. “I’ve had conversations with people who’ve been nurses for 25 years, and all of them say the same thing: ‘We’ve never worked in this environment before,’” says Jennifer Gil from Thomas Jefferson University Hospital in Philadelphia, who contracted COVID-19 herself in March. “How much can meditation or mental-health resources help when we’re doing this every day?”
Even after cases stop climbing, health-care workers will have to catch up on a new round of procedures that didn’t happen because of COVID-19—but without the adrenaline that a packed hospital brings. “Everyone talks about fatigue during the surge, but one of the hardest things is coming down from it,” Popescu says. “You’re exhausted but you still don’t get that mental break.”
As hard as the work fatigue is, the “societal fatigue” is harder, said Hatton, the Utah pulmonary specialist. He is tired of walking out of an ICU where COVID-19 has killed another patient, and walking into a grocery store where he hears people saying it doesn’t exist. Health-care workers and public-health officials have received threats and abusive messages accusing them of fearmongering. They’ve watched as friends have adopted Donald Trump’s lies about doctors juking the hospitalization numbers to get more money. They’ve pleaded with family members to wear masks and physically distance, lest they end up competing for ICU beds that no longer exist. “Nurses have been the most trusted profession for 18 years in a row, which is now bullshit because no one is listening to us,” Neville said.
Trump is still falsely claiming victory over the virus that ran amok because of his incompetence, and he is unlikely to do anything more to control it during the dusk of his presidency. Neither a vaccine nor a Biden administration will arrive quickly enough to turn the current surge around. The next months will be bleak. But Biden’s election “has given me a second wind,” Fayanju says.
Biden openly wears a mask, and has urged Americans to do the same. He has released a sound COVID-19 plan that, he said during his acceptance speech, is “built on a bedrock of science.” He has assembled a coronavirus task force composed of 13 people with medical expertise. He has committed to rejoining the World Health Organization. His presidency, many health-care workers hope, will mark a newfound commitment to stopping the pandemic, restoring the humbled Centers for Disease Control and Prevention, and ending a steady stream of gaslighting and misinformation from the federal government itself. “I slept this weekend like I haven’t slept since February—without the same demons,” Choo says. “I woke up doped up on sleep.”
Choo also studies the impacts of health-care policy, and has found that health-care systems sometimes react to imminent policies months before they are actually come into force. Could that happen with Biden’s pandemic plan? “It absolutely could, and there’s precedent for it,” she says. She expects that state leaders will start to coalesce around his plan and consult with his task force.
Still, “you can’t just fix a pandemic this far down the rabbit hole,” Popescu says. “I’m hopeful, but I don’t expect this to suddenly turn itself around overnight.” Biden will inherit a health-care system that is battered at best and broken at worst, a polarized electorate, and many local leaders who are doubling down on bad policies. Trump won Iowa by eight points, which Governor Kim Reynolds took as validation of the state’s COVID-19 response thus far. Bars, restaurants, and schools in Iowa are still fully open, and a recently announced mask mandate applies only for gatherings of 25 people or more. “That takes away my hope,” Perencevich said.
“We can’t just sit on our hands and wait for Jan. 20 to come,” said Megan Ranney, the Rhode Island physician. Several health-care workers I spoke with are trying to keep mild cases of COVID-19 from becoming severe enough to warrant an ICU bed. In Ohio, Fayanju’s primary-care centers deliver fluids, pulse oximeters, and smart tablets to the homes of newly diagnosed COVID-19 patients, so doctors can check on their symptoms virtually. In North Dakota, South Dakota, and Minnesota, the Sanford Health network has set up outpatient “infusion centers” where elderly COVID-19 patients or those with chronic illnesses can get drugs that might slow the progression of their disease. These drugs will include the antibody therapy bamlanivimab, which received an emergency-use authorization from the FDA on Monday, Suttle told me.
But the best strategy remains the obvious one: Keep people from getting infected at all. Once again, the fate of the U.S. health-care system depends on the collective action of its citizens. Once again, the nation must flatten the curve. This need not involve a lockdown. We now know that the coronavirus mostly spreads through the air, and does so easily when people spend prolonged periods together in poorly ventilated areas. People can reduce their risk by wearing masks and avoiding indoor spaces such as restaurants, bars, and gyms, where the possibility of transmission is especially high (no matter how often these places clean their surfaces). Thanksgiving and Christmas gatherings, for which several generations will travel around the country for days of close indoor contact and constant conversation, will be risky too.
Preliminary results suggest that at least one effective vaccine is on the way. The choices made in the coming weeks will influence how many Americans die before they have a chance to receive it, and how many health-care workers are broken in the process.