The massive surge in coronavirus cases has left hospitals in Los Angeles County scrambling to handle the increasing numbers of patients showing up at their doors. Nowhere is that more evident than in hospitals' intensive care units, which are rapidly filling up with the worst COVID-19 cases.
"We have no ICU beds," says Brad Spellberg, chief medical officer of LAC+USC Medical Center, one of the area's largest hospitals. "We are just continually, 24 hours a day, scrambling to move patients around. The flood just continues."
As dire as the situation is, Spellberg says, it's going to get even worse.
The crush of cases spurred L.A. County health officials to send guidance to the four public hospitals it manages on how to ration emergency care, reports the Los Angeles Times. Instead of trying to save every life, the goal would be to save as many patients as possible. That means those less likely to survive would not get the same kind of care they would usually receive.
That type of triage is just weeks away, Spellberg warns.
"We are the safety net, that is the point. The safety net itself is stressed to the limit," he says.
More than 15,000 residents test positive every day, on average, in Los Angeles County. The average daily deaths from COVID-19 in the county stands at 94, and 281 statewide.
A staggering 6,155 Angelenos are currently hospitalized with COVID-19, and 20% of them are in the ICUs spread across the county's 80 acute-care hospitals.
"We are forecasting that in this current surge — between Nov. 1 and Jan. 31 — 8,700 people in Los Angeles County will die from COVID. That is nearly three times the number of people that died in the 9/11 terrorist attacks," said Dr. Christina Ghaly, director of the county Department of Health Services.
"The worst is yet to come," she warned reporters Wednesday during a conference call.
Spellberg fears Los Angeles is rapidly approaching the situation in New York City last April, where hospitals were overwhelmed with critically ill COVID patients.
What does that look like, on the inside? Spellberg says it's like "battlefield medicine," a frantic race to save lives when there aren't enough staffers to cope: "You've got nurses that are assigned 20 patients when they're only supposed to be assigned five. You've got doctors who haven't managed a ventilator in 20 years suddenly being responsible to manage ventilators."
"If it gets as bad as it did in New York, and if we don't slow this thing down in L.A., that's where we're going," Spellberg says.
'Right now the ICU is crazy'
ICU nurse Jun Jai has been feeling overwhelmed for weeks.
"Right now the ICU is crazy," he says. "It's so much worse than before."
For the past 10 months, Jai has worked with the sickest COVID-19 patients at LAC+USC Medical Center. Recently, it seems like every time he arrives at the hospital for another 12-hour shift, he learns that two or three of his nurse colleagues in the ICU have taken time off.
"All the nurses [are] burning out," Jai says. He's sympathetic and understands the need for a break, but it can have a domino effect on the workload of the remaining team: "Every day you go, it's nonstop running from morning to the evening. You can see so many nurses have depression."
Burnout isn't the only reason for the staffing crisis. Los Angeles County tracks infections among health care workers and first responders. During the second week of December alone, 2,191 health care workers tested positive for the virus — a 25% increase from the previous week.
Like other health care workers who treat COVID-19 patients, Jai has received little virus-testing from his employer. If he wanted a test, he had to go to a free city-run testing site on his days off, though he only managed to find the time for that a few times since the pandemic started.
After health care workers protested about this issue, state health officials released guidelines recommending that acute care hospitals regularly screen employees and new patients for the coronavirus. The weekly testing program was supposed to start Dec. 14.
Jai feels like his mental and physical health aren't his employer's priority.
"You do such a hard job but they don't support you. You feel like they are just using you. That's why so many nurses have left already," Jai says.
Jai immigrated to the U.S. from China in 1999, and he continues to follow Chinese media. He says Chinese media outlets frequently show images and footage of patients hooked up to ventilators — but he sees much less of that kind of content in the U.S., and he thinks that is one reason why so many Americans deny or minimize the seriousness of the pandemic. Americans, he says, don't understand what the coronavirus can do.
"The people didn't see the suffering, they didn't see the people who are sick. With a tube in your mouth and connected to the [breathing] machine you can't do anything," he explains.
After immigrating to the U.S., Jai worked in restaurants to improve his English skills and make money while also attending nursing school. Jai has now been an ICU nurse for more than 10 years, and he's proud of his work. But for the first time in his career, he's thinking of quitting.
Before the ICU shift: 'I would pray 'til I cried'
Chanel Rosecrans had just started a new job in February, working the night shift at a hospital in the San Gabriel Valley. She was 27, and while it wasn't her first nursing job, it was her first job in an ICU. Working in critical care had been a career goal. But when the pandemic hit just a few weeks later, she was shocked by the relentless onslaught of seriously ill COVID-19 patients.
"There was no way I could, as one person, replace a full staff of ICU nurses," she says. "We were on a skeleton staff."
She asked that we not name the facility because she wants to return to work there in the future.
Because the coronavirus is so contagious, each patient is kept isolated in their own room. Rosecrans spent her night shifts rushing between rooms, closely monitoring patients on breathing equipment and keeping track of their multiple medications. The patient rooms would get so hot from all the machines, and she had to wear so much PPE that she'd end up dripping in sweat.
Since relatives weren't allowed to visit, Rosecrans spent a lot of time on the phone with family members. Often she had to explain that there were no other medications left to try, and nothing else the medical team could do, to keep their loved one alive. She had always wanted to work in the ICU, and she expected, as part of that, to see patients die, but the sheer number and pace of the coronavirus deaths shocked her.
"It just felt like ticking time bombs," Rosecrans says. "I didn't want to have to just sit and wait for all these people to pass away, but it felt like all these people were just doomed. It was just really hard to accept. I don't think I ever really did accept it."
Before her shift, she would sit in her parked car, outside the hospital, and wrestle with feelings of dread.
"Before work, I would pray 'til I cried," she says. "Begging God [to] please not let me lose a patient tonight. I can't take it."
After more than eight months in the ICU, Rosecrans quit in October. It just seemed impossible to balance work and life. She wasn't eating enough, and on her days off all she had time for was catching up on sleep. Caring for COVID-19 patients had left her physically and emotionally exhausted.
She wonders if she contributed to the staffing problem by leaving.
"I feel horrible that I'm not there fighting that fight with what's left of my colleagues. But everyone has their limits," she says.
A call for new ways to support nurses and prevent burnout
In her new job, Rosecrans is a surgical nurse for a plastic surgeon in Beverly Hills. But staffing agencies still contact her, trying to persuade her to come back to intensive-care work, even for short-term gigs. As coronavirus cases have surged, the calls have come more frequently — and they're not just asking her to travel to understaffed hospitals in other states. Now the demand is local, too, and they want her to fill in at local hospitals.
But Rosecrans continues to say no, even when the money sounds enticing. "I don't see what the point of going right back would be because I feel like they're going to be operating in that crisis mode."
Other ICU nurses have quit, but the strain of the pandemic isn't just affecting critical care, according to Megan Brunson, the immediate past president of the American Association of Critical Care Nurses.
"There's not a nurse — no matter what their specialty, whether ICU or not — who is not having COVID in their face every single day," says Brunson, who works with COVID-19 patients in a Dallas hospital.
Brunson says nurses need more support, and that includes more discussion and acknowledgement of the unique emotional burdens of nursing, particularly for those who are witnessing, firsthand, frequent deaths from a new and unpredictable disease.
"When you have whole families coming into an ICU, [and you see that happen] many times, that's morally very distressing," Brunson says. "You're taking care of the mom, the dad and the adult children all in the same ICU," Brunson says.
Brunson says paying attention to something as seemingly simple as scheduling can have a big effect on a nurse's ability to recharge. Supervisors should look at how often each individual nurse is working the usual 12-hour shift and take into account their sleep routines.
"Working Monday, Wednesday, Friday, on a day shift, that might be completely fine. But on a night shift that could be detrimental to their sleep, working every other day," she explains. "I think even just having the conversation acknowledges the strain, versus this panic mode of getting the nurses in the door to cover the shifts."
Brunson says hospitals might try doing longer "debriefs." It's an idea borrowed from the military, another institution that grapples with employee burnout and retention because of the dangerous and stressful nature of the work. During debriefs, which could be in person or virtual, nurses would be encouraged to discuss the challenges of their jobs, and share their concerns or suggestions on what could be improved, with a guarantee that the feedback would be shared with managers.
But it's incumbent on the hospital to make it a priority, Brunson says.
"Nurses have to be given the place and the time to do it, otherwise they go home into this silo with their thoughts and feelings. And I don't think that it's offered as much as it should be," she says.
Shorter huddles — at the beginning and end of shifts with the entire interdisciplinary health team of doctors, nurses and therapists — is another opportunity to insert recognition, Brunson says.
"That's not necessarily the large hourlong heart-to-heart, but that is a place for nurses to feel valued. And also to bring up concerns in a bigger forum, you know, with respiratory therapy, with physicians, because we're all in this together, in collaboration," she says. "That recognition is so powerful."