COVID-19 pressure mounts in the Sun Belt

Sherry Tutt remembers her big sister LaKecial Tutt—or Keshia to some, “Mz. Pinky” to others—combing her hair when they were little. Then as teenagers, they used to fight over the house phone. It drove their mom, Doris LaVon “Von” Sims, crazy, but the three women were close: “We were all each other had,” Tutt said.

“Had.” Tutt’s mom and sister died of COVID-19 on the same day, June 9, at different hospitals in the Dallas–Fort Worth metroplex. Tutt contracted the virus too, but she wasn’t hospitalized. The family had been careful: They wore masks and stayed away from large gatherings. Still, they became ill mid-May, and Von and Keshia were both hospitalized by the end of that month. Coronavirus cases are on the upswing again, and Tutt is on a crusade to remind people to take the illness seriously.

“It bothers me to see people being so cavalier about it, the coronavirus, but it enrages me when I see people say the death rate is so low, because that death rate affects somebody,” Tutt said. “I don’t want anybody to negate the fact that the death rate is low because it’s still someone’s loved one."

Many states across the country—including Arizona, Texas, and Florida—are especially strained under the new upward trend in case counts: On Sunday, Florida reported record high cases, surpassing 15,000 new positive tests in a single day. Officials in major Texas cities, including Austin, San Antonio, Houston, and Fort Worth, are sounding the alarm that local hospitals are running out of available space for incoming patients. Arizona hospitals are under unprecedented strain, with the Arizona Department of Health Services reporting on July 10 that patients filled 90 percent of the state’s intensive care hospital beds.

But scientists still have lots of questions about the coronavirus and how it’ll affect healthcare systems. I spoke with medical workers preparing for a long fight that could bleed into winter, when medical providers are busiest.

Even if a person’s chances of dying of COVID-19 are low—figures in the United States appear to show around 41 deaths per 100,000 population and of confirmed cases, slightly more than 4 percent—the virus’s novelty means scientists are just beginning to gain insight into potential long-term negative effects. A small but growing body of research indicates that some patients may experience lasting lung or vascular dysfunction, as well as neurological complications.

Doctors are increasingly adding “COVID-19” to a list of patient comorbidities—conditions such as asthma, diabetes, and hypertension—on patients’ electronic health records so they can better monitor how that disease may affect people down the road. Tara Cavazos is a doctor of nursing practice (DNP) who runs a Dallas clinic. She and her partners have discussed how to follow up with their many COVID-19-positive patients, like performing a chest X-ray three months after infection to assess any lingering lung damage. Bottom line, Cavazos says, if you can avoid getting COVID-19, do.

“It’s something that’s not predictable. We don’t know how you’re going to respond,” Cavazos said, citing the July 8 death of a North Texas woman in her 20s. She had no preexisting conditions. “Even though you’re young and healthy, we can’t guarantee that we can keep you well.”

Short of herd immunity or a highly effective vaccine—which likely won’t come until late 2020 at the earliest—medical practitioners are keeping their heads down and personal protective equipment (PPE) on. But caring for an influx of COVID-19-positive patients wears on doctors and nurses, making a long-term perspective important.

Dr. Matt Bush is a Dallas emergency room physician in leadership with Questcare, a network of hospital-based providers and urgent care clinics. His organization staffs 750 providers in more than 50 facilities across multiple states. Bush said New York City was an outlier in its high volume of cases and deaths earlier this year, but it’s not unreasonable to compare some areas—such as Tucson, Ariz., and parts of Texas’ Rio Grande Valley—to former hotspots like New Orleans and Detroit.

But it’s not just major metropolitan areas that COVID-19 may overrun.

“These rural communities maybe only have a couple of ventilators, a couple ICU beds, a couple ICU-trained nurses. And some people who live in rural areas don’t have normal access to medical attention anyway, so maybe they have chronic diseases that are unmanaged when COVID hits their town,” noted Katy Vogelaar, DNP. She runs a faith-based clinic in Dallas that serves indigent and uninsured patients.

Some hard-hit states—Texas and Florida among them—reopened their economies with gusto, which may account for some of the surge in cases. An increase in testing capabilities is part of the upward trend too.

To know how to deploy resources, government officials and public health experts constantly monitor data: test results, available hospital beds, ICU beds, and ventilator availability. But there are difficulties in projecting which municipalities may be next for a flare-up. Experts attribute the magnitude of the disease in New York to several factors—transportation, population density, international travel to the city—but that doesn’t explain why similar large cities like Chicago or London haven’t seen the same level of rapid and widespread COVID-19 infection. Bush conceded “there’s a lot we still just don’t know” about the disease.

Social media has been rife with harrowing tales of overrun medical facilities and dwindling resources. But Bush said most hospitals will be hesitant to raise the “‘we’re overwhelmed’ flag.” The same goes for providers. Many may be used to caring for 12-15 patients a day, but now they find themselves caring for 22-25 patients in a 12-hour shift.

“The tricky question is, when does ‘over capacity’ become ‘unsafe?’ There is real, true data that’s been there for a long time that shows when hospitals are crowded, patients don’t do as well,” Bush said.

When they’re overburdened, doctors transition into a triage mentality: “You do the interventions that matter most, but you have to kick up the pace of your work,” Bush said. And with all hands on deck, there’s not a team on standby to relieve stressed or weary clinicians during their shifts. Add to that the discomfort of wearing PPE for 12 hours straight, and you’ve got a recipe for burnout.

One nurse practitioner in a major healthcare system in Arizona, whom WORLD is not naming because she is not authorized by her employer to speak to the media, told me that during a recent 13-hour shift, she personally attended to 56 patients—about triple her usual load. She thinks some of those patients are using—or misusing—hospital resources for COVID-19 testing instead of going to their primary care physician or a drive-thru testing site. Still, she said COVID-19 has thrown off the “medical gut” she has been trained to develop as a nurse practitioner.

“The crazy thing about COVID has been that we’ve seen some people with very normal oxygen saturations and without a fever, but then you take a chest X-ray,” and the results are troubling, she said. The key symptoms keep changing, too: “At first, we were trained to look for fever, fever, fever,” but now she said that’s not always a reliable indicator of COVID-19 infection.

She and her colleagues are exhausted. And it’s not even winter yet, when patient volumes routinely increase due to flu and respiratory viruses.

Vogelaar described the medical community’s general annual rhythm: gearing up for flu season in October, staying focused through a slog of respiratory illnesses in January and February, then breathing a sigh of relief in March. “But this year, we are anticipating our [winter patient volume] is going to increase drastically with COVID,” she said.

She and her colleagues are concerned that there’s not a “reliable point of care test” that would quickly and accurately help providers determine which patients have flu and which have COVID. On the one hand, the protocol doesn’t change: treat the symptoms. But patient anxiety is real. Vogelaar said her practice is expecting the “fear factor” seen in a typical cold and flu season to “increase tenfold.”

We’re far removed now from the “healthcare heroes” appreciation events that seemed commonplace in April, when entire cities would take to balconies and front steps to cheer on medical industry professionals at predetermined times. Bush’s organization is trying to coach its providers that this is a “marathon, not a sprint.” They’re expecting COVID-19 to be an “18-month run,” and they’re taking steps to keep patients and providers safe. That means equipping doctors and nurses with adequate PPE and educating them on the latest coronavirus techniques and therapies, which seem to be changing “month to month, week to week, day to day right now,” Bush said.

He’s also focused on keeping his physician teams agile and ready for deployment to hotspot regions, as he did earlier this month in Tucson. When an ICU in the city became overwhelmed, Bush pulled together a team of doctors from throughout Questcare’s network and sent them to relieve busy hospital workers. They did the same when COVID-19 overran New York and New Jersey hospitals earlier this year.

After weeks of plateauing mortality rates, the uptick in COVID-19 cases around the country is just beginning to correspond to an increase in deaths. Both Bush and Vogelaar agree that doctors and nurses have become more adept at treating critically ill COVID-19 patients. “If you get it today, you have a better chance of surviving than you did three months ago,” Bush said. Another possible reason deaths haven’t matched spikes in positive cases: Younger people are getting the disease. The Arizona-based nurse practitioner I spoke with said she’s seen a noticeable jump in 20- to 40-year-old patients who have fewer complications and better outcomes.

But Vogelaar warned it’s possible we may see the death toll rise significantly in the weeks to come.

“Mortality is a lagging indicator,” she said. “And the typical stay of someone in the ICU with COVID is about three weeks. So we are going to be maybe a month to five weeks lagging in our mortality, based on current reporting and the trends that we have now.”

Back at Von Sims’ home, daughter Sherry Tutt is sorting through the belongings of her deceased mom and drowning in a flood of memories. Each object reminds her of some connection Tutt now misses, as when she came across dozens of unopened dollar store purchases. They used to go deal-hunting together.

Tutt’s mother would call her multiple times a day: “And she’d say, ‘I’m coming over to your house today when I get off work. We’re going to go to the Dollar Tree by your house.’ And I don’t have a person to call like that now. I just feel this void.”