Emergency rooms would likely be swamped, overflowing into “surge tents” outside. Intensive care units might fill to capacity. Test kits and masks could run low. And medical personnel would almost certainly get overwhelmed.
A coronavirus pandemic would strain California’s ability to quickly and effectively contain the disease. Although the state has confirmed less than 100 cases and a single death from COVID-19, experts are worried the state’s health care system couldn’t keep up.
State officials have already complained about the availability of test kits. Masks are in such short supply, the California Department of Industrial Relations has said it’s acceptable to use N95 masks — considered the most protective — that are past their expiration dates.
Now another potential problem looms: The state’s hospitals could run dangerously low on a vital piece of medical equipment: ventilating machines that could enable the sickest COVID-19 patients to continue breathing.
“If you project that this could go to millions of people, a certain percentage will wind up on ventilators and we may not have enough to meet that need,” said Phillip Porte of the California Thoracic Society, the association of physicians and other professionals who treat respiratory diseases.
California has wrestled for years with the possibility that a respiratory pandemic could outstrip the state’s supply of ventilators — and other crucial medical supplies — and force doctors to make painful life-and-death decisions about which patients receive treatment and which ones don’t.
In a statewide health care emergency, ventilators, antibiotics, ICU beds and other supplies might have to be “denied or discontinued or withdrawn in order to allocate limited resources,” the California Department of Public Health wrote in a lengthy 2008 study.
More than a decade later, health officials remain worried about supply shortages. At a Feb. 25 hearing on Capitol Hill, U.S. Sen. Patty Murray, D-Wash., pressed Health and Human Services Secretary Alex Azar about whether the nation has enough ventilators, masks and other equipment.
“Well of course not, or we wouldn’t be asking for a supplemental (appropriation) to seek more money to procure more of that,” Azar replied, according to a transcript released by Murray’s office. Congress passed an $8.3 billion appropriation to fight the coronavirus outbreak.
Hospitals already at capacity
As it is, the coronavirus scare comes at a difficult time for the state’s 370 general acute care hospitals.
The median wait time at California emergency rooms was more than five hours in 2018 for those who were admitted to the hospitals, according to the federal Centers for Medicare and Medicaid Services. The wait time was about half as long for those who were treated and released without admission.
Hospitals, nationwide, also “routinely operate at or near full capacity and have limited ability to rapidly increase services,” according to a report on COVID-19 last month by doctors at Johns Hopkins University’s Center for Health Security. “There are currently shortages of healthcare workers of all kinds. Emergency departments are overcrowded and often have to divert patients to other hospitals.”
The 2018 flu epidemic in the U.S. forced some hospitals to erect surge tents — “an inflatable, military-style hospital ward” — to care for the extra patients who flooded emergency rooms.
If the outbreak worsens significantly, hospitals would have to make 30 percent of their beds available for COVID-19 patients in one week’s notice, the report said. That might involve discharging other patients sooner than expected, converting single rooms to doubles, and taking other steps like placing patients in classrooms.
California’s nurses have repeatedly advocated for higher staffing levels and better equipment, and they say the coronavirus proves their point.
“We’ve dealt with Ebola. We dealt with H1N1, and we are right back where we were when we were dealing with those diseases and protections: lack of a plan, lack of preparation, lack of information and absolutely not the necessary equipment to protect our nurses from these diseases,” nurses’ lobbyist Stephanie Roberson said.
As for ventilators, health experts have long been aware of the potentially dire consequences of a shortage.
“In a severe influenza pandemic, hospitals will likely experience serious and widespread shortages of patient pulmonary ventilators and of staff qualified to operate them,” according to a 2011 report in the journal Health Care Analysis. “Deciding who will receive access to mechanical ventilation will often determine who lives and who dies.”
How bad could it get?
A 2005 study by the U.S. Department of Health and Human Services said nearly 65,000 Americans would need to go on ventilators in case of a moderate influenza pandemic. The number would shoot up to 742,000 if a severe pandemic struck, comparable to the 1918 flu that killed millions around the world.
Yet a 2010 federal study calculated there are only 160,000 ventilators available at America’s hospitals, plus another 10,000 in a “strategic national stockpile” run by the U.S. Centers for Disease Control and Prevention.
What’s more, a Johns Hopkins University study calculated that America has only 135,000 respiratory therapists capable of operating the machines.
In a worst case scenario, doctors may have to resort to lotteries to determine which patient gets placed on a machine, leaving the survival of someone’s loved one up to random chance.
“That’s a horrible situation,” said state Sen. Richard Pan, D-Sacramento, a physician.
California hospitals say they’re ready
State officials didn’t respond to requests seeking the numbers of ventilators in the state, and Sacramento’s major hospitals wouldn’t disclose how many ventilators they have, but insisted they’re ready for the coronavirus.
UC Davis Medical Center has “a substantial number of mechanical ventilators,” said spokesman Charles Casey.
Sutter Health released a statement saying its personnel “are trained and equipped to provide high-quality care while protecting care providers, hospital staff and other teammates. We have a number of proactive measures in place to address situations while maintaining patient safety.”
Kaiser Permanente, whose Roseville hospital was caring for the first known coronavirus fatality in California, declined to provide its figures. Dignity Health didn’t provide them either.
“To ensure each of our facilities have what they require, we have multiple contingency plans in place and have a tracking system so we can replenish or move supplies as needed among our facilities,” Dignity spokeswoman Joann Wardrip said in an email. “We are also working closely with the public health departments so we can access their external resources if ever needed.”
Attempting to calculate the number of ventilators in California isn’t easy, but a rough approximation is possible.
The California Thoracic Society says every intensive care unit bed has a ventilator — and data from the California Department of Public Health shows the state’s hospitals have about 7,500 licensed ICU beds for general patients. The department says hospitals have another 4,100 ICU beds for newborns.
The availability varies greatly depending on where you live. Sacramento County hospitals have 532 licensed ICU beds, including beds for newborns. Placer County’s total is 122, while San Francisco’s is 505.
Phillip Porte, executive director of the Thoracic Society, said nursing homes have ventilators, too, but “not as many as you think.”
A major pandemic could be especially challenging in smaller metropolitan areas, whose hospitals serve broad territories. In 2015 officials from across California conducted a “tabletop exercise” designed to simulate the impacts of a major flu pandemic.
The results for Shasta County (population 180,000) were sobering: Anywhere between 39 and 445 people would need ventilators. The Shasta County Health & Human Services Agency announced Friday that two residents who were suspected of having the virus tested negative.
The county wasn’t able to provide data on how many ventilators the county has. But state figures show that Shasta hospitals have 86 ICU beds, including beds for newborns.
Dr. Art Reingold, an epidemiology expert at the UC Berkeley School of Public Health, cautioned that the numbers of available ventilators may be misleading.
After all, not everyone who needs one will fall ill at the same time, and each person who gets sick won’t need to be on them for the same amount of time, he said.
“That makes it a complicated calculation,” he said.
Ventilator lotteries?
The issue has worried scientists, emergency-preparedness officials and others for years. A white paper by the U.S. Centers for Disease Control and Prevention three years ago acknowledged that the agency’s Strategic National Stockpile of about 10,000 ventilators “might not suffice to meet demand during a severe public health emergency.”
In 2015, the New York State Health Department, anticipating a dramatic shortage of ventilators, released a 272-page guide on how the machines would be “ethically allocated” during a flu pandemic.
That might mean using a lottery to decide who gets a ventilator.
The guidelines say that if a number of similarly sickened patients with equal likelihoods of survival come into a facility without enough ventilators to serve them, “a randomization process, such as a lottery, is used each time a ventilator becomes available because there are no other evidence-based clinical factors available to consider.”
That sort of strategy would be difficult to carry out, said Art Caplan, director of the medical ethics program at New York University’s Langone Medical Center. There would be resistance from doctors, who’d be reluctant to take patients off machines unless it was clear their odds of survival were low, he said.
Meanwhile, such policies would prove difficult to enforce.
“If you have guidelines, you have to enforce them,” Caplan said, “and it’s never clear who is enforcing them.”
Caplan said an added worry as the outbreak spreads is that America’s healthcare system is notoriously bad at sharing resources, and it lacks enforceable plans for scenarios that require moving patients to new facilities that have the equipment they need, Caplan said.
“That’s crucial,” Caplan said. “If you have to move (patients), who’s going to coordinate it? Who are the ambulances? Who’s paying? You’ve got to make them all play ball and, generally speaking, that’s not a virtue of the current health system.”
Pan, the California state senator, said avoiding a dire scenario where there aren’t enough ventilation machines and other life-saving treatments to go around is precisely why public health officials have been giving a consistent message: Aggressively wash your hands, get your flu shots, and stay home when you’re sick.
If everyone takes steps to avoid getting others sick, it could prevent burdens on an already overworked public health and hospital system, Pan said.
“Let’s not panic; let’s all work together to try to avoid the spread of the disease,” he said.