Pandemic of Unpreparedness

And a wee bit of advice...

The last few shifts I worked at Tiny Memorial Hospital were frustrating and scary. The hospital was full and the ER was full. The weather was bleak (a second storm that hit the Southeast after Izzy but without the panache). The ambulances couldn’t drive anywhere and the helicopters generally couldn’t fly.

This contradicts the generally accepted view of modern American medicine which is, ‘I can have anything, anywhere, anytime.’ This is a belief foisted on us by assorted medical television shows (I won’t name names) but without any real basis in reality. In point of fact, a great deal of what we do in medicine can only happen in certain larger facilities with lots of specialists and resources.

Once, while working in a small hospital in a semi-rural area, a very gracious, worried young gay couple came to me in the ER. ‘I have AIDS and I’ve recently moved here and need an HIV specialist.’ I politely told them that the town didn’t have anyone who fit that description but helped point them in the right direction to a nearby urban area.

That doesn’t mean that small hospitals don’t give outstanding, life-saving care. They absolutely do, and I speak from having worked in them. But you can’t get that emergent cardiac catheterization for heart attack, the removal of that clot that caused the stroke, the NICU for a critically ill newborn or even an OB in many small locations. We have recently had patients with kidney stones in shock from infections that can’t drain, and for which we don’t have a urologist or even an OR (or surgical nurses) if we had a urologist anyway.

I have said all of this before. But it bears repeating.

The reasons? It’s so ridiculously convenient and also disingenuous to say ‘well it’s just COVID and if people all got vaccinated we’d be right as rain.’ Despite my belief in the importance of vaccination, this is wholly untrue.

Just as COVID exposes vulnerabilities in the human body it exposed the frailty of the medical system.

We have hospitals without available beds, and hospitals without enough nurses or physicians. (The phenomena are linked.) We have ambulances without paramedics. We have patients in need, stuck in places where they can’t get essential, life-saving care. This is not a rare, one-off that only I see in rural Emergistan. This is across the country and my colleagues in community hospitals can bear witness.

Why do we struggle? For decades, health systems prioritized profit over preparation and didn’t pay for enough beds or enough staff. For decades we got through difficult flu seasons which overwhelmed us, and we said ‘whew, glad that’s over!’ Nothing changed to prepare for the next round.

To make a bad situation worse, unit secretaries (possibly the most important and underfunded position in any hospital), nurses, physicians, paramedics and others were let go because they did not want the COVID-19 vaccination. These were the same ‘frontline heroes’ who worked through the early, uncertain days of the pandemic and risked not only their own lives but those of their families. The powers that be were fine with that risk calculation. The masses leaned out their windows and cheered, rang bells and celebrated those who faced down the virus, treating the sick and pronouncing the dead.

Now, those same heroes are enemies of the state, enemies of the people, enemies of science. So we have even less staff. Hospitals have beds that can’t be used for lack of physicians and nurses and smaller hospitals, like mine, are dealing with medical problems far beyond our capacity as we make non-stop calls to other facilities hoping and praying for beds so that the critically sick, critically injured and woefully complex can go to higher levels of care. It makes for a daunting run of shifts, I can tell you. After my last nights I was beyond relieved to walk out the door and go home.

In twenty-nine years of practice (32 if you count residency), I’ve never felt this consistently hopeless. And I’m pretty darn resilient. And again, no, not because of the ‘pandemic of the unvaccinated’ but because our system is reaching a point of no return. It may be that between burned out and exhausted staff who quit, senior staff who retire and staff inexplicably fired in the midst of this madness, we will take years to recover our capacity.

So given this hard reality, I have a bit of advice. If you have have to go to the ER, think about where you’re going. If you have a complicated medical condition, managed by specialists in a large center, that’s the place to be. They can’t turn you away from the ER. But if you come to see me at Tiny Memorial Hospital I’ll gladly stabilize you and try to figure out the problem. But if you need higher levels of care and I call and ask to transfer you to that larger center, they can absolutely refuse to accept you depending on your situation and their capacity at the time. This is federal law. There are a few things large centers will generally take: serious trauma, heart attacks, some strokes, very sick children and OB patients. Beyond that, you may wait days or even a week or more to leave the place where you arrive for the hallowed halls of large centers.

Not long ago I saw a patient who had undergone spine surgery at Large Memorial Hospital the day before and was having a complication. I called to send him back. ‘He does not meet our criteria as we are at capacity.’

‘I know, but you just operated on him.’

‘I understand Dr. Leap, but we cannot accept the patient at this time.’

Sometimes they’ll offer a wait list. Often they’ll just say ‘call back tomorrow when we reassess.’

This is a problem everywhere. It isn’t the fault of small hospitals doing more with less and it certainly isn’t the fault of large hospitals overwhelmed day and night and fighting the good fight. God help everyone laboring in this time.

Mind you, if you feel that you are in danger, if you have dangerous symptoms like chest pain, sudden severe headache, trouble breathing, passing out, intense abdominal pain, by no means should you drive a long distance to another hospital. Please go to your nearest emergency department. Come to see me and my colleagues. We’ll work it out and give it our best.

Just don’t be surprised when you’re in the small hospital for a very long time. Because even as the severity of current COVID strains decreases, even as vaccination increases, the systemic issues at hand are too vast for sudden repair.

I really don’t know when the end will be in sight. Not the end of the pandemic of COVID mind you. I think that’s coming.

What I don’t see an end to is the pandemic of unpreparedness.