‘The surge is here’: Houston hospitals deal with coronavirus spike

Over the past week, Dr Aric Bakshy, an emergency physician at Houston Methodist, had to decide which coronavirus patients he should admit to the increasingly busy hospital and which he could safely send home.

To discuss questions like these, he has turned to doctors at hospitals where he trained in New York City that were overwhelmed by the coronavirus this spring. Now their situations are reversed.

Thumbing through a dog-eared notebook during a recent shift, Dr Bakshy counted about a dozen people he had treated for coronavirus symptoms. His colleagues in Houston had attended to many more. Meanwhile, friends at Elmhurst Hospital in Queens told him that their emergency department was seeing only one or two virus patients a day.

“The surge is here,” Dr Bakshy said.

As Houston’s hospitals face the worst outbreak of the virus in Texas, now one of the nation’s hot zones, Dr Bakshy and others are experiencing some of the same challenges that their New York counterparts did just a few months ago and are trying to adapt some lessons from that crisis.

Like New York City in March, the Houston hospitals are experiencing a steep rise in caseloads that is filling their beds, stretching their staffing, creating a backlog in testing and limiting the availability of other medical services.

Attempts to buy more supplies — including certain protective gear, vital-sign monitors and testing components — are frustrated by weeks of delays, according to hospital leaders.

Methodist is swiftly expanding capacity and hiring more staff, including local nurses who had left their jobs to work in New York when the city’s hospitals were pummelled.

“A bed’s a bed until you have a staff,” said Avery Taylor, the nurse manager of a coronavirus unit created just outside Houston in March.

But with the virus raging across the region, medical workers are falling ill. Dr Bakshy was one of the first at Methodist to have Covid-19, getting it in early March. As of this past week, the number of nurses being hired to help open new units would only replace those out sick.

Methodist, a top-ranked system of eight hospitals, had nearly 400 coronavirus inpatients last Sunday. Nearly a week later — even as physicians tried to be conservative in admitting patients and discharged others as soon as they safely could — the figure was 575.

The flagship hospital added 130 inpatient beds in recent days and rapidly filled them. Now, administrators estimate that the number of Covid-19 patients across the system could reach 800 or 900 in coming weeks, and are planning to accommodate up to 1,000.

Other Houston hospitals are seeing similar streams of patients. Inundated public hospitals are sending some patients to private institutions like Methodist while reportedly transferring others to Galveston, 50 miles away.

“What’s been disheartening over the past week or two has been that it feels like we’re back at square one,” Dr Mir M Alikhan, a pulmonary and critical care specialist, said to his medical team before rounds.

“It’s really a terrible kind of sinking feeling. But we’re not truly back at square one, right? Because we have the last three months of expertise that we’ve developed.”

Houston’s hospitals have some advantages compared with New York’s in the spring. Doctors know more now about how to manage the sickest patients and are more often able to avoid breathing tubes, ventilators and critical care.

But one treatment shown to shorten hospital stays, the antiviral drug remdesivir, is being allocated by the state, and hospitals here have repeatedly run out of it.

Methodist’s leaders, who were planning for a surge and had been dealing with a stream of coronavirus patients since March, pointed to the most important difference between Houston now and New York then: the patient mix.

The majority of new patients in Houston are younger and healthier and are not as severely ill as many were in New York City, where officials report that over 22,000 are likely to have died from the disease.

But so far, the death toll has not climbed much in Texas and other parts of the South and West seeing a surge.

“We are having to pioneer the way of trying to understand a different curve with some very good characteristics versus the last curve,” said Dr Marc Boom, Methodist’s president and chief executive.

But he cautioned: “What I’m watching really closely is whether we see a shift back in age — because if the young really get this way out there and then start infecting all of the older, then we may look more like the last wave.”

Dr Sylvie de Souza, head of the emergency department at Brooklyn Hospital Centre, which on Friday reported no new coronavirus admissions and no current inpatient cases, said that she was receiving distressing text messages from doctors elsewhere in the country asking for advice.

“It’s disappointing,” she said. “It sort of brings me back to the end of March, and it’s like being there all over again.”

Many hospitals in New York during the earlier crisis essentially became all-Covid units and endured billions of dollars in losses.

But Methodist and some other private Houston institutions are trying to operate differently now after taking a financial beating from shutting down elective surgeries and procedures this spring.

With safety protocols and expansion plans in place, they are trying to maintain as many services as possible for as long as possible while contending with the flood of coronavirus cases.

“No one’s ever done that before,” Dr Boom said. “We were seeing all the harm from patients delaying care.”

Doctors and nurses have combed through lists of surgical patients, choosing whom to delay. The easiest surgeries to maintain are those that do not require a hospital stay, like treatment for cataracts. Some surgeons who used to keep patients overnight after knee and hip replacements are now allowing them to leave the same day.

The most agonising decisions concern the hospital’s robust transplant programme, in part because its recipients often require a stay in intensive care.

Dr A Osama Gaber, the programme’s director, spoke with a dialysis patient whose kidney transplant had been postponed from March. “She was in tears,” he said. “She almost wanted me to swear to her we’re not going to put her off again.” For now the surgeons plan to continue cautiously.

A key strategy to maintain services is increasing what hospital officials call throughput: discharging patients as quickly as is safely possible. Yet it is not always clear who is ready to leave.

Alexander Nelson-Fryar, a 25-year-old treated for coronavirus pneumonia at Methodist, was discharged from the hospital this past week. Hours after he left, he said, he began labouring to breathe and an ambulance sped him back to Methodist.

By the end of the week, he was in intensive care receiving a high dose of pressurized oxygen.

As cases began rising in New York, some overwhelmed emergency departments sent home coronavirus patients only to see them return gravely ill or die.

“We realised there was no way of predicting which direction a patient would go,” said Dr De Souza, the emergency department director in Brooklyn. As a result, she said, she came to believe that any patient aside from those with the mildest symptoms should be admitted to the hospital or otherwise monitored.

But doctors in Houston are tightening criteria for admission. Dr Bakshy, the Methodist emergency room doctor, who trained at Bellevue and Mount Sinai in New York, said that he was conferring with his former colleagues.

“We all have questions about who truly needs to be hospitalised versus not,” he said. “If we had unlimited resources, of course we’d bring people in just to make sure they’re OK.”

Now, he said, a patient has to have low oxygen levels or serious underlying conditions “to really justify coming into the hospital,” although exceptions can be made.

Another challenge in New York and Houston has been determining who is infected and needs to be isolated from others. Nearly 40 per cent of all emergency room patients at Methodist are now testing positive; some of them lack symptoms.

Because test results are sometimes delayed by more than a day, Dr Bakshy and his colleagues have had to make their best guesses as to whether someone should be admitted to a ward for coronavirus patients.

Hospitals in New York tended to move patients within their own systems to level loads. In Houston, the wealthier institutions have joined together to aid those least able to expand capacity.

This past week, Methodist sent a team to a nearby public hospital to accept transfer patients. Top officials from Methodist and the other flagship hospitals that make up the Texas Medical Centre, normally competitors, consult regularly by phone.

They have been coordinating for days with the county’s already overwhelmed safety-net system, Harris Health, taking in its patients. The private institutions have also agreed to take turns, with others in the state, accepting patients from rural hospitals.

One morning this past week, Molly Tipps, a registered nurse, brought some medications to an older patient at the Methodist ward outside Houston. “I have the dexamethasone for your lungs,” she told the patient, Dee Morton.

Preliminary results of a large study, released last month but not yet peer-reviewed, showed that the drug, a common steroid, saved lives among those who were critically ill with Covid-19 or required oxygen.

Ms Morton, aged 79, said she was confident she would recover. “I’m going to make it to 80,” she said.

A much lower proportion of patients have been dying from the virus locally and nationally than they were several months ago.

The ward where Ms Morton is being treated is inside a long-term acute-care facility and is known as the Highly Infectious Disease Unit.

Created to treat Ebola several years ago, it now serves as a safety valve for the Methodist system. It takes in coronavirus patients who are improving but for various reasons — from lacking housing to living in a nursing home that will not accommodate them — cannot go home.

In Ms Morton’s case, she was too weak, and after transferring to the unit, some signs of infection, including a fever, rebounded.

At Methodist’s flagship hospital in central Houston, 72-year-old Rosa V Hernandez, a patient in the intensive care unit, has pneumonia so severe that if she had fallen sick several months ago, she would probably have been put on a ventilator and made unconscious.

But doctors, based on the experiences of physicians in New York and elsewhere, are avoiding ventilators when possible and are maintaining Ms Hernandez on a high flow of oxygen through a nasal tube. She is on the maximum setting, but can talk to the clinical team and exchange text messages with her daughter, who is also a Methodist inpatient with the coronavirus.

“I took it seriously,” Ms Hernandez said of the virus. But she joined a small party of eight people for her granddaughter’s birthday, a decision she now described with regret. “Just a birthday cake. What’s a birthday cake without health?”

She is getting remdesivir, an antiviral that was tested in clinical trials in New York and Houston, among other cities, and a new experimental drug.

Methodist was part of two remdesivir trials. But because the research has ended, it and other hospitals now depend on allotments of the drug from the state. As virus cases increased, the supplies ran short, said Katherine Perez, an infectious-disease specialist at the hospital.

“In Houston, every hospital that’s gotten the drug, everyone’s just kind of used it up,” she said.

The hospital received 1,000 vials, its largest shipment ever, a little over a week ago. Within four days, all the patients who could be treated with it had been selected, and pharmacists were awaiting another shipment.

A new chance to test remdesivir in a clinical trial in combination with another drug may provide some relief. As cases rise, Methodist researchers are being flooded with offers to participate in studies, with about 10 to 12 new opportunities a week being vetted centrally.

Without solid research, “your option is to do a bunch of unproven, potentially harmful, potentially futile, interventions to very sick people who are depending on you,” said Dr H Dirk Sostman, president of Methodist’s academic medicine institute.

The New York Times