ER doctors ‘manage chaos’ amid COVID-19 surge in Michigan


Emergency doctors and nurses in Michigan are seeing a massive increase in patients seeking care in hospital EDs, a mixture of ailments not seen before in previous COVID-19 surges.

Some people are flocking to hospital EDs suffering from such traditional emergencies as stroke, chest or abdominal pain, visits which they might have tried to avoid last year.


Others, those in their 30s or 40s, and some teenagers and children, are coming in with COVID-19 illnesses or symptoms, ED healthcare workers tell Crain’s.

Dr. Robert Takla, chief of emergency medicine at 615-bed Ascension St. John Hospital and Medical Center, said patient volumes have been steadily increasing for the past month. Staff is tiring, but energized by a common desire to help all comers, he said.

“It is very busy, but we manage chaos. That’s what we do as ER physicians. We try to take chaos and make it into an orchestra,” said Takla, adding: “People aren’t coming in for nonsensical things. Some of it is COVID-related, but a lot of it is also due to patients sometimes putting off coming to the ER or going to their primary care doctors because of previous COVID concerns. There may be some unintentional neglect.”

Dr. Rob Davidson, an ED doctor based in Fremont and affiliated with multiple hospitals, said half of the patients entering small and rural hospitals in West Michigan have COVID-19.

“The fortunate thing that’s going on now versus the wave in the fall and last summer, and it is a testament to the vaccines, is that they are younger. We are seeing 40-year-olds and some in their 50s. Some of these people are very sick and are getting admitted to the hospital,” said Davidson, who also is president of the Committee to Protect Medicare, a national group of doctors who support expanding the Affordable Care Act.


“We aren’t seeing as many people go into the ICU, so the curve of deaths is definitely flatter,” he said.

Even as the state surpasses 5 million vaccine doses, several hospitals have limited visitation, delaying some elective surgeries and procedures and expanded ICU capacity and medical floors for COVID-19 patients. Beaumont started setting up outdoor patient triage stations in front of its Grosse Pointe hospital emergency department. Its hospitals in Farmington Hills and Dearborn are also considering the same move.


“Some of our hospitals have gone back to establishing a curbside triage center for some of the intake of these patients as they come to our emergency centers,” said Dr. Nick Gilpin, Beaumont’s medical director of infection prevention and epidemiology. “That’s just to help sort of balance the load in our emergency centers.”

Four hospitals reached 100% bed capacity last week — Beaumont Hospital Troy, Ascension St. Joseph Hospital in Tawas City, Sheridan Community Hospital and Ascension Standish Hospital — and 30 more have exceeded 90%, according to the Michigan Department of Health and Human Services on April 15.

Two hospitals that were at 100% capacity on April 12 dropped to 91% April 15: McLaren Macomb in Mt. Clemens and Ascension Macomb-Oakland in Warren.

Nearing maximum capacity are hospitals that are part of Henry Ford Health System, Beaumont Health and Detroit Medical Center. For example, Henry Ford Macomb Hospital in Clinton Township was at 97%, Beaumont Hospital Wayne at 94%, Detroit Receiving Hospital at 98%, Beaumont Hospital Dearborn at 97% and Beaumont Hospital Farmington Hills at 95%.

More than 19% of Michigan hospital beds hold COVID-19 patients, up from 15% two weeks ago. Some 32% of ICU beds are full of COVID-19 confirmed or suspected patients, the state said.


Despite the crowded EDs and long waits, Bob Riney, president of hospital operations for six-hospital Henry Ford Health System, said people should not delay coming to the hospital or clinic for needed care.

“Our emergency rooms have processes to ensure that you are kept safe and to take good care of you,” Riney said. “If you delay care, you will complicate your own medical condition. And you will complicate the resources required from the health care community.”

In the Michigan Thumb, Dr. Mark Hamed, director of emergency and hospital medicine at McKenzie Health System in Sandusky, said multiple facilities are seeing an increase of patients with COVID-19 symptoms. McKenzie has medical centers in Port Sanilac, Croswell, Peck and Sandusky.

At eight-hospital Beaumont Health, Susan Grant, the system’s chief nursing officer, said “hundreds and hundreds of (patients are) coming through our emergency rooms and being admitted to our hospitals and our intensive care units.”

“None of us would have imagined going through that extraordinarily difficult time (last year) that we would be here again, same time this year, and that we would be working and seeing so many patients who are infected with coronavirus.”

“Our nurses, our doctors, respiratory therapists, our teams are tired, and they’re worn. And they’re not only physically tired and worn, they’re emotionally tired and worn,” said Grant, adding: “That emotional exhaustion has come from experiencing and being present for observing the the enormous toll that this virus has taken on patients on families on their own personal lives.”

Terri Dagg-Barr, an ED nurse at McLaren Macomb and chief steward of the OPEIU Local 40, said the hospital has been filling up over the past two weeks. The ED has been regularly holding 40 patients waiting for an inpatient bed, she said.

“You walk in and it is just insanity. Every room is full. The waiting rooms are always full. You see wheelchair after wheelchair,” Dagg-Barr said. “It takes eight to nine hours to find an ER bed and people are waiting two days for a hospital bed.”

Dagg-Barr said the nurses and technicians are getting exhausted. “It is a constant struggle to treat patients. You look down the hall and see more and more patients,” she said. “People are just sicker. Everyone took a break from seeing their doctors, and now they are coming into the ER.”

Jeff Morawski, a cardiac catherization nurse at McLaren Macomb, said people are coming in with heart attacks, strokes and various traumas.

“We are full and the hospital hasn’t stopped doing procedures. We are holding ICU patients in the ER and in my department, we are still doing cardiac cath procedures,” said Morawski, who also is president of OPEIU Local 40. “(Managers) are asking for volunteers to watch these patients (overnight).”

Dr. Seth Krupp, medical director and vice chair of operations in emergency medicine at Henry Ford Health, said Henry Ford Macomb has the system’s highest number of COVID-19 patients. He said all hospitals have delays getting patients admitted as most are nearing maximum capacity.

“We’ve just seen exponential growth in our patients. We feel it in lots of ways. The pace of growth feels similar to the first wave in March and April, but the patients we are serving is different,” Krupp said.

“Fewer patients need to be on ventilators because we are seeing younger populations,” he said. “The first wave our overall volume was down by half. The second wave we probably were down by 30 percent. This wave, we’re probably closer to down by the order of 10 percent.”

Riney said Henry Ford Macomb has been limiting some elective surgeries and procedures or redirecting them to other system hospitals.


“Our other four hospitals (in metro Detroit) continue to provide a full slate of services to meet the needs of our patients,” even though bed occupancy is above 90%, Riney said.

At St. John, Takla said the Catholic hospital is busier now then late last fall, but not as busy as April 2020 when the initial COVID-19 surge hit Michigan.

“March and April of 2020 was probably the biggest disaster of our ER professional career and hopefully never to be repeated,” Takla said.

But now, the volume of patients has greatly accelerated. “We are seeing people with more serious conditions, higher acuity, who require more medical attention,” he said.

Last week, Ascension St. John Hospital’s bed occupancy rate was listed by the state on April 15 as 74 percent, but Takla estimates those numbers are closer to 90%. Other Ascension hospitals in Southeast Michigan are in the mid-80s, Ascension Providence Hospital Novi at 86 percent and Ascension Providence Hospital Southfield at 85%.

“Patients are unfortunately waiting a little bit longer. But we’ve had safety mechanisms in place where we have a medical screening examination that’s taking place when the patients arrive,” said Takla, adding that the sickest patients are treated first.

On staffing, Takla said staff fatigue has set in with some frustration among doctors and nurses that Detroit is facing yet another surge at a time when vaccines are being administered to everyone over the age of 16.

“There is great camaraderie and teamwork. It’s a lot easier when when we’re all working together,” Takla said.


Many healthcare experts are asked: Why is the latest COVID-19 surge happening?

Takla believes it comes from a combination of factors, including the more contagious variant from the United Kingdom, B.1.1.7. Michigan has now reported 3,020 confirmed cases of the B.1.1.7 variant. In addition, there are 11 confirmed and two probable cases of the B.1.351 strain first detected in South Africa.

“People have become lax in social distancing, not masking up, especially those between 20 and 40” who are still unvaccinated, he said

“We are seeing a younger generation being really frustrated with cut off and maybe maybe taking more chances,” he said. “Some may have put a false sense of security in the vaccine as well. They’re not a passport of immunity, and they don’t necessarily prevent those that have been vaccinated from carrying the virus and potentially spreading it to others.”

On the other hand, Takla said far fewer people ages 65 or older are presenting in the ED compared with March and April of last year. “They are vaccinated or more diligent in taking care of themselves, probably a little bit frightened, and that is what’s motivating them. It’s probably a combination of adhering to the appropriate necessities to decrease COVID transmission, as well as being vaccinated.”

Those under 50 who are hospitalized are sick with COVID-19 with all the classic symptoms, Takla said. Most, however, don’t require oxygen or mechanical ventilators.

“Fortunately, the mortality rate is significantly lower,” he said. “Because they’re younger, they don’t have as many comorbidities.”

But Takla said he has seen a few pediatric patients with COVID-19 in the 1 to 14 age range. Daily pediatric COVID-19 admissions have increased by more than 250% since Feb. 19 and there are now 50 pediatric patients hospitalized as of April 15, up from 41 the week before, the state said.

“They’re having some of the similar symptoms of like nausea, vomiting, diarrhea, abdominal discomfort,” he said. “I would say less of the shortness of breath type of presentation.”


Hamed said McKenzie has not hospitalized any pediatric patients. “We do see them, but they have more mild symptoms. Some they have symptoms that look like croup, a real harsh cough, barky cough. It’s treatable with oral steroid.”


Most patients coming into McKenzie are between ages 40s to 60s.

“A few older ones. One was 90 and lived in a nursing home and was not vaccinated,” Hamed said.

But there are some “long-hauler” COVID-19 patients coming back to the hospital.

“They are in the “recovered” phase,” Hamed said. “They are out of the acute illness, and two to five weeks later they are having difficulty breathing, fatigue. They have post-COVID syndrome. Their oxygen levels are on the lower side, 80 to 85%.”

Hamed also is having trouble finding medical beds for some COVID-19 patients, a fact some ER doctors say might happen more in the coming days.

“I was on a 24-hour shift (April 12) at McKenzie, and I never had so much difficulty trying to get a patient (transferred) out,” Hamed said. “I literally called 14 hospitals in Detroit, Port Huron and Saginaw to try and transfer … no one had a bed.”

At McKenzie’s ED, Hamed said four of the five rooms are negative pressure rooms reserved exclusively for COVID-19 patients.

“We use them as overflow rooms for COVID patients. We have been at that status since April of last year,” he said. “We haven’t had to utilize it much until now. Now, it’s literally all four rooms are occupied. We’re doing a good job of separating them from the non COVID patients. How long do we keep that up is the big question.”


Davidson said the biggest reason people go to the ICU is to get advanced oxygen support for their breathing. Patients in the ER or ambulance can receive high-volume supplemental oxygen support, but ventilator support is typically given in ICUs.

“We also place people in the ICUs because a lot of people with COVID are getting gastrointestinal symptoms, vomiting, diarrhea, and they end up severely dehydrated. Sometimes they can be septic,” Davidson said.

Since spring break and Easter between March 24 and April 4, Hamed said the surge of patients to hospitals has been building.

“I told my staff to be prepared. It’s gonna get worse over the next week or two, then we will assess at that point,” Hamed said. “Because patients are much worse, they are going to be in the hospital for days, even after it is over. We may have a declining number of cases, but with a lot of people in hospitals, it’s still gonna cause a strain in the healthcare system.”

With all three hospitals in Macomb County above 91% bed capacity, Morawski said he can guess why so many people in the community are becoming infected. He said most people in public settings — stores, restaurants and bars — don’t wear masks.

“People are just not taking it seriously. As nurses, our message is we need people to take things more serious. This means, ‘Wear your damn mask,'” Morawski said. “Go out when you have to but social distance. No one is telling you they have to get a vaccine, but you should consider it. This isn’t a political discussion anymore. It is life or death.”


Source: modernhealthcare.com

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