Hospital administrators have worked feverishly in recent weeks to stretch staff and resources to accommodate increased patient loads brought on by the COVID-19 surge, but the influx of patients hasn't stopped. To avoid a situation like what happened in Italy, where so many patients converged on hospitals that many were left on gurneys in hallways to die alone, local hospital officials and consultants have quietly planned for months how to allocate scarce medical resources if demand for care eventually exceeds what's available.
Those who developed the plans now anticipate they may soon be activated.
"The community needs to know the situation is bad and getting worse," said Christopher Meyers, professor emeritus and former director of the Kegley Institute of Ethics at Cal State Bakersfield, who has served as a local hospital ethicist for more than three decades. Meyers helped Kern Medical, Adventist Health and Dignity Health earlier this year develop and update their plans for dealing with a crisis care situation at the area's major hospitals.
Under those plans, hospitals would switch modes in an overwhelm scenario from providing care to everyone who comes through the doors to allocating resources in a way that prioritizes treatment for those who would benefit most from it. The protocols for making such determinations touch on highly sensitive moral and ethical scenarios but are largely borrowed from a collective national body of work agreed upon by medical ethicists and care providers.
Still, it's a nightmare situation for any healthcare worker to be put in.
Faced with one ventilator and two patients who need it, who gets the potentially life-saving treatment?
If eight new COVID-19 patients need the drug remdesivir but a hospital has only enough for four patients, how will those doses be allocated? What factors go into that decision?
"We'll have to make decisions on who is going to get care and who is not, and gets sent away to go home," said Dr. Hemmal Kothary, Dignity Health's chief medical officer for several hospitals in Central California, including Bakersfield Memorial, Mercy Downtown and Mercy Southwest. Under an extreme crisis care situation, Kothary would be one of a number of people assembled to make the tough decisions.
He had a plea for the community: "We have to come together. We have to work together no matter where you are, Republican, Democrat, whatever you believe in, whatever you support. Because it’s going to destroy a lot of people."
A 'system under strain'
Epidemiological models have been strikingly accurate in predicting surges "and the best ones have long said that January will be the worst month," Meyers said.
Local hospitals are currently swamped with a surge set in motion following the Thanksgiving holiday. The fear is in the coming weeks, another swell of patients from the back-to-back Christmas and New Year's holidays will create another surge on top of the current one.
On Monday, there were close to 400 COVID-19 patients in local hospitals, a new high.
It's not just numbers and models foretelling this dark scenario. Meyers said he hears it from the healthcare workers he talks to on a regular basis.
Reports of more people on a ventilator than a hospital has ever seen.
A critical care nurse seeing more deaths in the past month than in the previous several years.
"We are flooded with patients," said Dr. Ronald Reynoso, who is chief medical officer for Adventist Health's Bakersfield and Tehachapi hospitals.
Signs of a mounting crisis are evident elsewhere, as well. Several local hospitals in recent days asked the county public health office to help them find extra staff. One hospital requested more ventilators from the county's stockpile, according to Kern County Public Health Services Director Matt Constantine.
"The system is under strain," Constantine said.
During the summer COVID-19 surge, the state sent in National Guard units to help at several Bakersfield hospitals. This time around, with so many other parts of California facing similar crises, that help isn't available, Constantine said.
Already most local hospitals have received a waiver from the state to go outside of legally-mandated nurse to patient ratios. It is one way hospital administrators can stretch their resources to continue providing traditional care. In addition, many hospitals are asking nurses and hospital staff to work overtime on scheduled days off.
Sobering plans and protocols
The federal government first asked counties to develop crisis care plans in 2007 and 2008. But in light of the real threat of having to invoke them after seeing how hospitals were inundated in New York and Italy early in the pandemic, local health officials took action earlier this year to update the plans and ensure they're ready to go.
"These are concepts we’ve always had on the shelf. It’s sobering to think we’re at a point where they’re needed," Constantine said.
Under those plans and protocols, a team at each hospital would be activated, made up of a rotating group of doctors, critical care nurses and hospital administrators. The committee would be called upon to triage cases as they arrive and determine who is most likely to benefit most from treatments that are available, based on specific medical criteria developed by national experts. Those decisions are then communicated to frontline care providers.
Palliative care would be provided to patients for whom care is not provided and information on hospice resources would be given to the family.
There is an appeal process, whereby a doctor treating patients could challenge the committee's decision. However, that appeal — which involves a hospital ethicist, chaplains and other experts — only involves a review of how the patients were initially scored and the appeals group cannot make unilateral decisions about who gets care.
A person's age, race, sex, disability status, religion and ability to pay legally cannot be an explicit factor in making the decisions. However, many of the protocols do assess factors such as an individual's likelihood of survival over the next year, which could bode poorly for the elderly, those with serious underlying medical conditions and people with traumatic injuries, for example a major head injury, or end-stage disease.
Operating in such dire circumstances could last anywhere from six hours to several days or a couple of weeks depending on how intense and sustained the influx of patients remains.
Some local hospitals have already printed fliers to be distributed to families coming into the ER, explaining the crisis situation and the shift in how care is provided. Similar fliers have been made up to hand out to staff.
Decisions no one wants to make
Kothary, who has practiced medicine for 20 years and was inspired to become a doctor from watching "Marcus Welby, M.D." as a child, said he believes the community is coming very close — perhaps within two weeks — of hospitals entering a crisis care mode.
Locally, the trajectory of COVID-19 has followed about two weeks behind Los Angeles, said Kothary, who also oversees two hospitals in Stockton and one in Merced. He has noticed what happens in L.A. is seen in Stockton a week later and in Bakersfield about two weeks later.
"It seems to jump Kern and go up north to Stockton and come back down," he said.
The Los Angeles Times has reported in recent days that hospitals there have diverted ambulance traffic and even closed their main entrances to the public.
Ambulance diversion is not an option in Kern County under local rules.
Unless things change, Kothary said he will likely activate crisis status at the Mercy and Memorial hospitals next week, which would put hospitals at the ready to call upon its committee if needed.
"We’ll call everyone (on the committees) and let them know to be ready if an issue comes up," he said. "We never want to ever go there but we also don’t want to be surprised."
In a 2014 interview with Bakersfield Life magazine upon being named chief medical officer for Dignity Health, Kothary said he was drawn to medicine because he "loved the idea of being in a small town taking care of people."
Now, the COVID-19 pandemic threatens to put him and his colleagues in a position no one would envy.
"Someone’s going to have to go to the family member and say we don't have the ventilator your family member needs," Kothary said. "That’s what keeps me up at night. Worrying about that."