Surge Conditions: Can LA Hospitals Keep the Oxygen Flowing?

Surge Conditions: Can LA Hospitals Keep the Oxygen Flowing?

As Los Angeles hospitals give record numbers of covid patients oxygen, the systems and equipment needed to deliver the life-sustaining gas are faltering.

It’s gotten so bad that Los Angeles County officials are warning paramedics to conserve it. Some hospitals are having to delay releasing patients as they don’t have enough oxygen equipment to send home with them.

“Everybody is worried about what’s going to happen in the next week or so,” said Cathy Chidester, director of the L.A. County Emergency Medical Services Agency.

Oxygen, which makes up 21% of the Earth’s air, isn’t running short. But covid damages the lungs, and the crush of patients in hot spots such as Los Angeles; the Navajo Nation; El Paso, Texas; and in New York last spring have needed high concentrations of it. That has stressed the infrastructure for delivering the gas to hospitals and their patients.

The strain in those areas is caused by multiple weak links in the pandemic supply chain. In some hospitals that pipe oxygen to patients’ rooms, the massive volume of cold liquid oxygen is freezing the equipment needed to deliver it, which can block the system.

“You can completely — literally, completely — shut down the entire hospital supply if that happens,” said Rich Branson, a respiratory therapist with the University of Cincinnati and editor-in-chief of the journal Respiratory Care.

There is also pressure on the availability of both the portable cylinders that hold oxygen and the concentrators that pull oxygen from the air. And in some cases, vendors that supply the oxygen have struggled to get enough of the gas to hospitals. Even nasal cannulas, the tubing used to deliver oxygen, are now running low.

“It’s been nuts, absolutely nuts,” said Esteban Trejo, general manager of Syoxsa, an industrial and medical gas distributor based in El Paso. He provides oxygen to several temporary hospitals set up specifically to treat people with covid.

In November, he said, he was answering calls in the middle of the night from customers worried about oxygen supplies. At one point, when the company’s usual supplier fell through, they were hauling oxygen from Houston, more than a 10-hour drive each way.

Branson has been sounding the alarm about logistical limitations on critical care since the SARS pandemic nearly 20 years ago, when he and others surveyed experts about the specific equipment and infrastructure needed during a future pandemic. Oxygen was near the top of the list.

Oxygen as Cold as Neptune

Last spring, New York, New Jersey and Connecticut faced a challenge similar to what is now unfolding in Los Angeles, said Robert Karcher, a vice president of contract services for Acurity, a group purchasing organization that worked with many hospitals during that surge.

To take up less space, oxygen is often stored as a liquid around minus 300 degrees Fahrenheit, about as cold as the surface of Neptune. But as covid patients filling ICUs were given oxygen through ventilators or nasal tubes, some hospitals began to see ice form over the equipment that converts liquid oxygen into a gas.

When a hospital draws more and more liquid oxygen from those tanks, the super-cold liquid can seep further into the vaporizing coils where liquid oxygen turns to gas.

Branson said some ice is normal, but a lot of ice can cause valves on the device to freeze in place. And the ice can restrict airflow in the pipes sending the oxygen into patients’ rooms, Karcher said. To combat this, hospitals could switch to a backup vaporizer if they had one, hose down iced vaporizers or move patients to cylinder-delivered oxygen. But that puts additional strain on the hospitals’ cylinder oxygen supply, as well as the medical gas supplier, Karcher said.

Hospitals in New York began to panic in the spring because the icing of the vaporizer was much greater than they had seen before, he added. It got so bad, he said, that some hospitals worried they’d have to close their ICUs.

“They thought they were in imminent danger of their tank piping shutting down,” he said. “We came pretty close in a couple of our hospitals. It was a rough few weeks.”

The strain on Los Angeles health care infrastructure could be worse given the now-common treatment of putting patients on oxygen using high-flow nasal cannulas. That requires more of the gas pumped at a higher rate than with ventilators.

“I don’t know of any system that is really set to triple patient volumes — or 10 times the oxygen delivery,” Chidester said of the L.A. County hospitals. “They’re having a hard time keeping up.”

The Oxygen Shortage Doom Loop

In and around Los Angeles, the Army Corps of Engineers has so far surveyed 11 hospitals for freezing oxygen pipe issues. The hospitals are a mix of older facilities and smaller suburban hospitals seeing such high demand amid skyrocketing cases in the area, said Mike Petersen, a Corps spokesperson.

One of the worst examples he saw included pipes that looked like a home freezer that had not been defrosted in some time.

The problem gets worse for hospitals that have had to convert regular hospital rooms to intensive care units. ICU pipes are bigger than those leading to other parts of a hospital. When rooms get repurposed as pop-up ICUs, the pipes can simply be too narrow to deliver the oxygen that covid patients need. And so, Chidester said, the hospitals switch to large cylinders of oxygen. But vendors are having a hard time refilling those quickly enough.

Even smaller cylinders and oxygen concentrators are in short supply amid the surge, she said. Those patients who could be sent home with an oxygen cylinder are left stuck in a hospital waiting for one, taking up a much-needed bed.

Extreme Rurality’

In early December, doctors serving the Navajo Nation said they needed more of everything: the oxygen itself and the equipment to get oxygen to patients in the hospital and recovering at home.

“We’ve never reached capacity before — until now,” said Dr. Loretta Christensen, chief medical officer for the Navajo Area Indian Health Service, in mid-December. Its hospitals serve a patient population in the southwestern U.S. that’s spread across an area bigger than West Virginia.

The buildings are aging, and they aren’t built to house a large number of critical patients, said Christensen. As the number of patients on high-flow oxygen climbed, several facilities started to notice their oxygen flow weaken. They thought something was broken, but when engineers took a look, Christensen said, it became clear the system was just not able to provide the amount of high-flow oxygen patients needed.

She said a hospital in Gallup, New Mexico, put in new filters to maximize oxygen flow. After delays from snowy weather, a hospital serving the northern part of the Navajo Nation managed to hook up a second oxygen tank to boost capacity.

But medical facilities in the area are always a little on edge.

“Honestly, we worry about supply a lot out here because — and I call it extreme rurality — you just can’t get something tomorrow,” said Christensen. “It’s not like being in an urban area where you can say, ‘Oh, I need this right now.’”

Because of the small size of certain hospitals and the difficulty of getting to some of them, Christensen said, Navajo facilities aren’t attractive to big vendors, so they rely on local vendors, which may prove more vulnerable to supply chain hiccups.

Tséhootsooí Medical Center in Fort Defiance, Arizona, has at times had to keep patients in the hospital and transfer incoming patients to other facilities because it couldn’t get the oxygen cylinders needed to send recovering patients home.

Tina James-Tafoya, covid incident commander at Fort Defiance Indian Hospital Board, which runs the center, said at-home oxygen is out of the question for some patients. Oxygen concentrators require electricity, which some patients don’t have. And for patients who live in hogans, homes often heated with a wood stove, the use of oxygen cylinders is a hazard.

“It’s really interesting and eye-opening for me to see that something that seems so simple, like oxygen, has so many different things tied to it that will hinder it getting to the patient,” she said.

Published courtesy of Kaiser Health News (KHN), a nonprofit news service covering health issues. KHN is an editorially independent program of KFF (Kaiser Family Foundation), which is not affiliated with Kaiser Permanente.

ProPublica: States Need to Counter Vaccine Hesitancy Among People of Color

ProPublica: States Need to Counter Vaccine Hesitancy Among People of Color

Though African Americans are being hospitalized for COVID-19 at more than triple the rate of white Americans, wariness of the new vaccine is higher in the Black population than in most communities. The U.S. Centers for Disease Control and Prevention highlighted communities of color as a “critical population” to vaccinate. But ProPublica found little in the way of concrete action to make sure that happens.

Originally published by ProPublica

It will be up to states to make sure residents get the vaccine, but ProPublica reviewed the distribution plans of the nine states with the most Black residents and found that many have barely invested in overcoming historic mistrust of the medical establishment and high levels of vaccine hesitancy in the Black community. Few states could articulate specific measures they are taking to address the vaccine skepticism.

And it could be hard to track which populations are getting the vaccine. While the CDC has asked states to report the race and ethnicity of every recipient, along with other demographic information like age and sex, the agency doesn’t appear ready to apply any downward pressure to ensure that such information will be collected.

In state vaccination registries, race and ethnicity fields are simply considered “nice to have,” explained Mitchel Rothholz, chief of governance and state affiliates for the American Pharmacists Association. While other fields are mandatory, such as the patient’s contact information and date of birth, leaving race and ethnicity blank “won’t keep a provider from submitting the data if they don’t have it.”

In the initial stages, vaccines will go to people who are easy to find, like health care workers and nursing home residents. But barriers will increase when distribution moves to the next tier — which includes essential workers, a far larger and more amorphous group. Instead of bringing the vaccine to them, it’s more likely that workers will have to seek out the vaccine, so hesitancy and lack of access will become important factors in who gets the shots and who misses out.

“There are individuals who are required to be on the front line to serve in their jobs but perhaps don’t have equitable access to health care services or have insurance but it’s a challenge to access care,” said Dr. Grace Lee, a professor of pediatrics at Stanford University School of Medicine and member of the CDC’s Advisory Committee on Immunization Practices, which is tasked with issuing guidance on the prioritization of COVID-19 vaccine distribution. “We can build equity into our recommendations, but implementation is where the rubber meets the road.”

Hesitancy is Rooted in Medical Exploitation and Mistreatment

About a quarter of the public feels hesitant about a COVID-19 vaccine, meaning they probably or definitely would not get it, according to a December poll by the Kaiser Family Foundation. Hesitancy was higher than average among Black adults in the survey, with 35% saying that they definitely or probably would not get vaccinated.

Mistrust of the medical community among people of color is well-founded, stemming from a history of unscrupulous medical experimentation. The infamous Tuskegee study, conducted from 1932 to 1972 by the U.S. Public Health Service, still looms large in the memories of many Black Americans, who remember how researchers knowingly withheld treatment from African American sharecroppers with syphilis in order to study the disease’s progression.

But the injustices aren’t confined to the past. The National Academies’ Institute of Medicine has found that minorities tend to receive lower-quality health care than white counterparts, even when adjusting for age, income, insurance and severity of condition. Black Americans are also more likely to be uninsured and utilize primary care services less often than white Americans.

“It’s not just about history. It’s about the here and now,” said Dr. Bisola Ojikutu, an infectious disease physician at Massachusetts General Hospital. “People point to racial injustice across the system. It’s not just hospitals; people don’t trust the government, or they ask about the pharmaceutical industry’s profit motive. From the very beginning, Black and brown people are marginalized from the enterprise of research. They think: ‘So few people look like us in research, industry and academia, why should we trust that someone at that table is thinking of our interest?’”

When it comes to vaccinations, the consequences can be grave. Black and Hispanic people are less likely to get the flu shot than white people, according to the CDC. At the same time, Black Americans have the highest rate of flu-associated hospitalizations, at 68 people per 100,000 population, compared to 38 people per 100,000 in the non-Hispanic white population.

Health officials have tried to assuage vaccine concerns in the traditional way, by publicizing specific individuals receiving the shot. The U.S. began its mass immunization effort by injecting a dose of the Pfizer-BioNTech vaccine into the left upper-arm of Sandra Lindsay, a Black woman and critical care nurse in New York.

Meanwhile, an onslaught of memes and conspiracy theories characterizing the vaccine as harmful are making the rounds on social media. One reads, “Just had the covid-19 vaccine. Feeling great,” along with the picture of the character from the 1980 movie “The Elephant Man.” Another image circulating on Twitter features the photos of three Black people and claims they are suffering from Bell’s palsy due to the vaccine. The Twitter user who shared the image asked followers, “still want those Tuskegee 2.0 genocide vaccines?”

It may only take one or two negative headlines to further sow fear, said Komal Patel, who has 16 years of experience as a pharmacist in California. After two health care workers in the United Kingdom experienced allergic reactions to Pfizer’s vaccine, Patel said she saw anxiety spike on social media, even though regulators have said that only people with a history of anaphylaxis — a severe or life threatening immune reaction — to ingredients in the vaccine need to avoid taking the shot. “Just two patients, and here we go, there’s all this chatter.”

Key States Lack Concrete Plans to Promote Vaccines in Black Communities

It falls to states to make sure their residents of color are vaccinated. But the speed at which the vaccine needs to be disseminated means that states haven’t had much time to plan communications efforts, said Lee, from CDC’s advisory group. “How do we make sure messaging is appropriate? You may want to emphasize different messages for different communities. We don’t have the time for that.”

ProPublica found that few states can articulate specifically what they are doing to address vaccine skepticism in the Black community.

TexasGeorgia and Illinois’ state plans make no mention of how they plan to reach and reassure their Black residents. Black communities make up between 13% and 33% of the population in the three states, according to data from the U.S. Census Bureau. None of the three states’ health departments responded to requests for comment.

California’s state plan includes “a public information campaign … to support vaccine confidence,” but does not provide details apart from the state’s intention to use social media, broadcast outlets and word of mouth. In an email, the California Department of Public Health did not provide additional information about outreach to Black residents, only saying, “this is an important issue we continue to work on.”

A spokesman for New York’s Department of Public Health said the state has been working since September to overcome hesitancy with expert panels and events like Gov. Andrew Cuomo’s November meeting with community leaders in Harlem to discuss concerns with the Trump administration’s vaccine plan, specifically for communities of color.

“Governor Cuomo has been leading the national effort to ensure…black, brown and underserved communities have equal access to, and confidence in, the vaccine,” a Saturday statement said.

Dr. Georges Benjamin, executive director of the American Public Health Association, said: “Media outreach is not enough. TV ads are one thing, but usually public service announcements are at midnight when nobody is listening, because that’s when they’re free.” Normally, public health officials go to barber shops, beauty salons, bowling alleys and other popular locales to hand out flyers and answer questions, but due to the pandemic and limits on congregating, that’s not an option, Benjamin said, so officials need to plan a serious social media strategy. That could involve partnering with “influencers” like sports figures and music stars by having them interview public health figures, Benjamin suggested.

Dr. Mark Kittleson, chair of the Department of Public Health at New York Medical College, said he’s not surprised to hear how vague some of the state health plans are, because states often focus on providing high-level guidance while county or regional level health departments are left to execute the plan. But he said specific efforts need to be undertaken to reach residents of color. “Spokespeople for the vaccination need to be a diverse group,” Kittleson said. “Dr. Tony Fauci is fantastic, but every state needs to find the leading health care experts that represent the diversity in their own state, whether it’s Native American, African American or Latino.” Kittleson also suggested partnering with churches.“Especially in the African American community, when the minister stands up and says, ‘Folks, you need to take your blood pressure medication and take care of yourself,’ people listen to that,” he said. “The church needs to be brought into the fold.”

Maryland’s state plan acknowledges the distrust among Black and Latino communities as well as rural residents, and says it will aim to tailor communication to each group by working with trusted community partners and representatives of vulnerable groups. A Department of Health spokesperson said in an email that “as vaccination distribution continues to ramp up, we urge all individuals to get the vaccine.”

Florida’s written plan includes a messaging strategy for everyone in the state, but does not specifically address the Black community. A “thorough vaccination communication plan continues to be developed in order to combat vaccine hesitancy,” a spokesperson for the Florida Department of Health said in response to ProPublica’s queries.

In North Carolina and Virginia, however, health officials started preparing months ago to reassure residents about potential vaccines. North Carolina formed a committee in May with leaders from marginalized communities to guide the state’s overall response to the pandemic. Vaccine concerns were a priority, said Benjamin Money, deputy secretary of health services for North Carolina’s Department of Health and Human Services.

The politicization of the pandemic has mobilized the Black and brown medical scientific community to dig into the research and how the vaccines work, Money said, “so that they can feel assured that the vaccine’s safe and it’s effective and they can convey the message to their patients and to their community constituents.”

The committee is advising North Carolina officials on their vaccine messaging and hosting a webinar for Black religious leaders. Similarly, the Virginia Department of Health has staff devoted to health equity across racial and ethnic groups and is putting on a series of town hall-style meetings speaking to specific communities of color.

Black residents in Virginia have expressed concerns about how rapidly the early vaccines were developed, said Dr. Norman Oliver, Virginia’s state health commissioner.

“It all boils down to telling people the truth,” Oliver said. “The first thing to let folks know is that one of the reasons why these vaccines were developed so quickly is because of the advances in technology since the last time we did vaccines; we’re not trying to grow live virus and keep it under control or do attenuated virus and develop a vaccine this way.”

In addition to promoting reliable information, Virginia health officials hired a company to monitor the spread of vaccine misinformation in the state and to locate where falsehoods appear to be taking hold, Oliver said. The state hopes to target its communications in places where distrust is most intense.

The CDC has set aside $6.5 million to support 10 national organizations, according to spokesperson Kristen Nordlund. The funds are “to be disbursed by each organization to their affiliates and chapters across the country so they may do immunization-focused community engagement in the local communities they serve,” Nordlund said in an email. She didn’t respond to questions on whether the funds had already been disbursed and to which organizations.

Data Collection on the Race of Vaccine Recipients is Likely to be Incomplete

Every state has a vaccination registry, where data on administered shots is routinely reported, from childhood vaccinations to the flu shot. What’s new in this pandemic is that the CDC has requested all the data be funneled up to the federal level, so it can track vaccination progress across the nation.

“Race and ethnicity data should be recorded in states’ immunization data, but we do not know how reliably it is collected,” said Mary Beth Kurilo, senior director of health informatics at the American Immunization Registry Association. “We really don’t have good data on how well it’s captured out there across the country.”

Many immunization records are fed into the state’s registry directly from a doctor’s electronic health record system, Kurilo said, which can present technological stumbling blocks: “Is [the data] routinely captured as part of the registration process? Can they capture multiple races, which I think is something that’s become increasingly important going forward?”

When asked about historic rates of compliance and how they planned to gather information on race and ethnicity of vaccine recipients this time, health departments from Georgia, Texas, Illinois, Florida and California didn’t respond.

Maryland’s state plans indicate it intends to use information gathered through its vaccine appointment scheduling system, including demographic data gathered from recipients, to direct its communication outreach efforts. The Maryland Department of Health, which didn’t provide more detailed information, said it is “currently exploring all options as far as vaccine data reporting.”

North Carolina’s immunization records system routinely collects race and ethnicity information, and a spokesperson told ProPublica it has that type of demographic data for 71% of people in the system. Stephanie Wheawill, director of pharmacy services at the Virginia Department of Health, said that providers will be “asked to record that information” but didn’t elaborate on how the department planned to encourage or enforce compliance.

Data fields for vaccine recipients’ race and ethnicity are standard in New York, a spokesman said. But the state didn’t provide any details about rates of compliance in supplying that data.

“You’ve got to have the data to compare,” said Martha Dawson, president of the National Black Nurses Association and an associate professor at the University of Alabama at Birmingham’s nursing school. “Because if you don’t have the data, then we’re just guessing. There’s no way to know who received it if you don’t take the data.”

There is tension between gathering enough data to understand the extent of the rollout and the possibility that asking for too much information will scare away people who are already leery of the vaccine.

“The biggest concern people have is how will this information be used?” said Lee, from the CDC’s advisory group. “People need to trust that the data will be used with a good intent. “

Rothholz, with the American Pharmacists Association, said there could be ways apart from state registries to estimate vaccine uptake among minorities. “If I’m a community pharmacy in a predominantly African American community, if I’m giving away 900 or 1000 vaccines, you can track penetration that way,” he said. Geographic-based analysis, however, would depend on the shots being distributed via community pharmacies rather than by mass vaccination sites — a less likely scenario for the Pfizer vaccine, the first to be administered, which requires ultracold storage that will be difficult for many small pharmacies to manage.

It Will Be Up to Doctors and Community Leaders to Encourage Trust

The best way to help a worried individual, whether scared about data collection or the vaccine itself, is a conversation with a trusted caregiver, according to Dr. Susan Bailey, president of the American Medical Association.

“Time and again it’s been shown that one of the most valuable things to encourage a patient to undertake a change, whether it’s stopping smoking or losing weight, is a one-on-one conversation with a trusted caregiver — having your physician saying, ‘I took it and I really want you to take it too,” she said. “But patients have to have the opportunity to ask questions, and not to be blown off or belittled or feel troublesome for asking all their questions.”

“If someone says that they’re afraid of being a guinea pig, maybe drill a bit deeper,” Bailey suggested. “Ask, ‘What are you concerned about? Are you concerned about side effects? Are you concerned that not enough people have taken it?’”

The American Academy of Family Physicians uses the mnemonic “ACT” to guide their members in conversations with patients of color, president Dr. Ada Stewart said in an email: “Be Accountable and Acknowledge both historical and contemporary transgressions against Black, brown and Indigenous communities. … Communicate safety, efficacy and harms such that individuals can weigh their own personal risk to potential benefits, and exercise Transparency with regard to the development of vaccines and the distribution process.”

David Hodge, associate director of education at Tuskegee University’s National Center for Bioethics in Research and Health Care, urges Black and brown leaders such as pastors and community organizers to take control of the messaging right now and not wait for their local governments to tackle the issue.

“We’re not in a position right now to be patient. We’re not in a position to sit on the sidelines, we have to make it happen.”

Click here to sign up for “The Big Story” and other ProPublica newsletters.

Originally published by ProPublica

Covid in San Francisco: “We’ve Been Very Lucky” Despite “Hassles and Discomforts”

Covid in San Francisco: “We’ve Been Very Lucky” Despite “Hassles and Discomforts”

In March, during the first week of the San Francisco Bay Area’s first-in-the-nation stay-at-home order, Kaiser Health News spoke with emergency department physicians working on the front lines of the burgeoning COVID-19 pandemic. At the time, these doctors reported dire shortages of personal protective equipment and testing supplies. Health officials had no idea how widespread the virus was, and some experts warned hospitals would be overwhelmed by critically ill patients.

In the end, due to both the early sweeping shutdown order and a state-sponsored effort to bolster the supply chain, Bay Area hospitals were able to avert that catastrophe. The region so far has fared much better than most other U.S. metro regions when it comes to rates of COVID infection and death. Even so, with intensive care unit capacity dwindling to critical levels statewide, San Francisco on Thursday issued another drastic order, announcing a mandatory 10-day quarantine for anyone returning to the city who has spent time outside the region.

Amid this fierce second surge, we circled back last week to check in with Dr. Jeanne Noble, director of the COVID response at the University of California-San Francisco medical center emergency department, to get her reflections on the Bay Area’s experience. She explained how even as her hospital has made so many improvements, including recently launching universal testing so that everyone who comes to the emergency room is tested for COVID-19, the lockdown and burnout are wearing on her and her colleagues. The conversation has been edited for length.

Q: How are you doing at UCSF right now? 

We’re OK in terms of our numbers. We have our ICU capacity; today’s numbers are 74% occupied. Acute care is a little bit tighter; the emergency department is seeing an increase in patients. [Editor’s note: As of Sunday, ICU capacity had dropped to 13%.]

We did have a period of time before this last surge where we often had a few days with no COVID patients. That was great. That ended in late September. This morning we have 11 patients on ventilators in the ICU.

I think we’re the first hospital in the state for universal testing. Everyone who comes to the ER gets tested. I’ve been working on this for months, but it’s new this week. Now we have testing, so we don’t have to do so much guesswork.

Q: When we spoke during the week of the first stay-at-home order, back in March, you were very worried. How do things compare now?

The supply [of masks] is just much better than it was back in March. In March, we had furloughed engineers from our local museum, the Exploratorium, making us face shields, and we started a makers lab in the library across the street to make supplies. It doesn’t feel like that this time around. We have a longer horizon.

I think in terms of our COVID care and our hospital capacity, we are fine. But my own sort of perspective on all of this is: When are we going to be done with this? Because even though things are smoother — we have PPE, we have testing — it’s a tremendous amount of work and stress. Frankly, the fact that my children have not been in school since March is one of my major sources of stress.

We’re all working way more than we ever have before. And nine months into it, the adrenaline is gone and it’s just purely exhausting.

Q: Can you tell me more about that, the physical and emotional toll on the hospital staff?

We don’t allow eating in the ED anymore, so we don’t have break rooms. Especially if you’re the supervising doctor, you need to do this elaborate handoff to another doctor if you need to eat. You know, it’s 10 hours into your shift and you want a cup of coffee.

The hassles and the discomforts. Wearing an N95 day after day is really uncomfortable. A lot of us have ulcers on our noses. They become painful.

And the lack of being able to socialize with colleagues is hard. The ED has always been a pretty intense environment. That’s offset by this closeness and being a team. All of this emotional intensity, treating people day after day at these incredible junctures in their lives — a lot of the camaraderie and morale comes from being able to debrief together. When you’re not supposed to be closer than a few feet from one another and you don’t take off your masks, it’s a lot of strain.

People are much less worried about coming home to their families. It hasn’t been the fomite disease we were all worried about initially, worried we’d give our kids COVID from our shoes. But there’s still the concern. Every time you get a runny nose or a sore throat you need to get tested, and you worry about what if you infected your family.

Q: So will you and your colleagues be able to take a break over the holidays?

We’ll see what happens. We’re just now starting to feel like we’re seeing the post-Thanksgiving numbers. But I think that even without having to do extra shifts in the ED, certainly for someone like me doing COVID response, there’s always a huge number of issues to work through. We just got the monoclonal antibodies, which is great, but that’s a whole new workflow.

I think what is going to bother people the most is that we are in lockdown. Kind of longing for that relaxation and time with family that we’re all kind of craving.

Q: It sounds like things are hard, but the hospital is in a relatively good place.

I was deployed to the Navajo Nation and helped with their surge in May in Gallup, New Mexico, and that is much, much harder than what we’ve faced in the Bay Area. In Gallup, at Indian Health Service, they were incredible in just the can-do attitude with way fewer resources than we have here. As of this summer, they had had the worst per capita surge in the country. They redesigned their ED essentially by cutting every room in half, hanging plastic on hooks you would use to hang your bicycle wheel. They hung thick plastic and right there doubled their capacity of patients they could see.

Our tents at UCSF are these blue medical tents with HVAC systems, heaters, negative pressure. They are really nice. There they had what looked like beach cabanas — open walls with just a tent overhead. In March and April they were taking care of patients in the snow. In the summer, it was hot and windy. When I was there, almost every single one of my patients had COVID.

That level of intensity was not something we had to go through in the Bay Area. Not to say that it’s easy [here]; I just told you all the ways it’s hard. But everything is relative. In terms of the COVID landscape, we have been very lucky.

Q: The Bay Area was early to close and has had stricter regulations than many parts of the country. As someone directly affected, what do you think of the response?

I think that we have benefited from early closures, unquestionably, when we did our shelter-in-place in March and probably saved 80,000 lives. It was really a tremendous and a bold move.

We’ve done some things well and other things not so well. We were very late to implement closures in a targeted fashion. Restaurants and dining reopened this summer, and a lot of us couldn’t figure out why indoor dining was open. Why is indoor dining something we need to even be considering when we’ve just barely flattened our curve? It was very predictable that cases would go up when dining happened. And they did.

We need to evaluate what is more important for our society and well-being, and to say what is the risk associated with that activity. Schools are of high social value. And [the closures are] really hard for kids. We’re seeing a lot of adolescents with suicidal ideation brought to the emergency department, which is related to school closure. I would put dining and restaurants as being of minimal social importance and very high risk.

We could have done this better. Closing [down society] when numbers go up is reasonable and that saves lives. But I think we know enough that it should not be an across-the-board closing. I mean, with this latest order, they temporarily closed [park playgrounds]. And we’ve been telling people to go outside. It’s like, what? Are you kidding?

This story was republished courtesy of KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Nurse of the Week 2020: A Year of Extraordinary Nurses

Nurse of the Week 2020: A Year of Extraordinary Nurses

In a year in which so many nurses displayed bravery, suffered hardships, and shone in countless ways, DailyNurse might easily have featured a “Nurse of the Day” instead of a Nurse of the Week.

Nurses have always gone the extra mile to communicate with patients and make them feel more comfortable and cared for, and we all know former patients who were so inspired by their nurses that they decided to enter the profession themselves. As 2020 raised the curtain on the Year of the Nurse, though, no one could have anticipated it would be a watershed year in which nurses became global icons of hope and courage.

Whether You’re a Hero, or Merely Awesome, Take a Bow…

Boston HCWs celebrate arrival of Covid-19 vaccine in December.

The public has long admired nurses, but this year, the world has watched nurses brave the pandemic to work in seemingly impossible conditions, act as stand-ins for patients’ absent families, and leave home to speed to the relief of overwhelmed hospitals all over the US.

Nonetheless, many of our 2020 Nurses of the Week (NotW) eschewed the word “hero.” If you glance at remarks from our 2020 Nurses of the Week, you might note that while they take pride in their work, few sound like they are ready to accessorize their mask with a Superman cape. Naturally, they are happy to see their work recognized, but nurses constantly go out of their way to make patients feel less frightened and alone. As frontliner Tabatha Kentner said, “This is what we do. This is why we’re here.” Nurses save lives—and when they cannot, they comfort patients in their final hours and console distraught families. It’s not an occasional phenomenon; it is an everyday occurrence. The name and photo in Wednesday’s NotW feature could easily be your own because your expertise and empathy make you a Nurse of the Week every day of the year.

On the last Wednesday of 2020, DailyNurse salutes the Nurses of the Week who made their mark during the Year of the Nurse!

Great (and Caring) Communicators

Nurse of the Week Emily Fawcett is an RN at Lenox Hill Hospital
RN Emily Fawcett, Lenox Hill Hospital, NYC.

A recurring theme is nurses who use their unique talents to raise patients’ and staff members’ spirits. Some, like Marc Perreault and Lori Marie Kay, shared their musical gifts. At Lenox Hill Hospital during the height of the New York City outbreak, Emily Fawcett helped boost morale in her ICU by meeting with staff for positive-thinking “hope huddles” before starting their shifts.

Danielle Fenn applied her language skills to comfort non-English speaking Covid patients. Others, like Tabatha Kentner, have been acting as “angels” (the word angel comes from the Greek angelos, which means “messenger”) and facilitating virtual visits so patients and their loved ones can commune even in isolation (and when necessary, say their final goodbyes).

Advocates and Public Servants

RN Andrea Dalzell on Good Morning America.

2020 was a year in which nurses stepped forward, spoke up, and got involved in public and civic health. Expect to see more of this in 2021 and years to come (we hope!). Metastatic breast cancer survivor Stephanie Walker is tirelessly advocating for cancer patients and patient education in North Carolina. Another indefatigable advocate, Andrea Dalzell, is on a mission to invite wheelchair-bound people to enter the nursing profession.

NYPD’s new Special Victims Unit head Michael King is a veteran SANE—and he is determined to improve the treatment of rape victims by police and other first responders. American Academy of Nursing (AAN) “Living Legend” Mary Wakefield is sharing her public health expertise and experience in the Obama administration with the Biden-Harris transition team.

Another AAN “Living Legend,” 85-year-old Marie Manthey, is promoting frank, open dialogues between Black and White nurses, and calling upon all White allies to combat structural racism and unconscious bias.

Frontline Troopers

Nurse Anna Slayton
Anna Slayton, BSN, RN-BC

Tens of thousands of nurses this year packed their bags and took off to lend a hand in the nation’s hotspots. Reports on horrific conditions in hard-hit city hospitals were a virtual Bat-Signal for many nurses. They stashed extra masks in their suitcases, said goodbye to their loved ones, and flew to the most dangerous hotspots in the country (even nurses who had never been on a plane before!).

Texas nurse Anna Slayton, who parted from her family to spend 77 days on the New York frontlines, felt compelled to help, telling DailyNurse, “I ultimately knew it was my duty.” And in April, after flying from Tennessee to a desolate—but noisily grateful—NYC, ED nurse Kirsten Flanery declared, “I made the right decision on coming up here. I’m ready to make a difference!”​

Difficult Takes a Day, Impossible Takes a Week

Nurse of the Week Felicia Shaner with her two daughters.
LPN Felicia Shaner and daughters.

Many nurses combine massive multitasking efforts with hard work to pursue their studies, and some fight to overcome dire health and financial obstacles in their quest to start a nursing career. Felicia Shaner was so drawn to the profession that she embarked on her nursing studies while living in a homeless shelter… with a toddler and a baby on board! degrees while working as hospital custodians. Rebel Nurse Jalil Johnson (of Show me Your Stethoscope fame) had spent his last $5 when he enrolled in an LPN program. And Brianna Fogelman had a lung transplant in her junior year of nursing school and took her nursing finals with a tube in her chest.​

Is There a Nurse in the House?

Former CCN/Cardiac Care nurse Hollyanne Milley and spouse.
Former CCN/Cardiac Care nurse Hollyanne Milley and spouse.

2020 was also a year in which nurses acted as first responders in unexpected times and places. Pamela Zeinoun saved the lives of three premature infants after the devastating August 4 explosions in Beirut. Indiana trauma nurse Colby Snyder rushed to the assistance of two people who collapsed in public within a 3-week period: the first had a seizure at her grocery store, and the second fell while Snyder was volunteering at the polls on Election Day. ​​ ​

Former CCN/cardiac care nurse Hollyanne Miley (whose husband is Joint Chiefs of Staff Chairman Mark Milley) is also a good person to have at hand when out-of-the-blue seizures occur. And VA nurse Maria VanHart impressed “official” first responders by her swift, efficient, and empathic treatment of survivors at the scene of a fatal highway accident.

DailyNurse salutes all of its readers, and all nurses. If you know of someone who warrants a Nurse of the Week nod, send your suggestion to editor@dailynurse.com. Best wishes for a happier, healthier, evidence-based New Year!

Dancing in the Streets: US Nurses Welcome Covid Shots

Dancing in the Streets: US Nurses Welcome Covid Shots

American nurses are becoming iconic images of hope as they receive the first SARS-CoV-2 vaccinations approved for emergency use.  A gathering of reporters, officials, and healthcare providers applauded when they witnessed the first vaccination in Oklahoma, as Erica Arrocha, RN administered the state’s first Covid-19 vaccination to a colleague, RN Hanna White, at Integris Baptist Medical Center. White told reporters, “Hopefully this is the start of something better.”

California nurse Helen Cordova was the first in the state to get a Covid shot.
ICU nurse and NP Helen Cordova was the first Californian to get a Covid shot.

New York ICU nurse Sandra Lindsay, the first US healthcare worker to receive a shot, told journalists, “I trust the science,” as her vaccination was recorded and livestreamed to millions of viewers.

The first in line for vaccination in Minnesota was Minneapolis frontline VA nurse Thera Witte, who declared, “I’m feeling hopeful that this is the beginning of the end” of the deadly pandemic that has so far taken over 377,000 lives in the US and 1.65 million lives worldwide.

There were even impromptu parties. When the first shipment of the Pfizer BioNTech vaccine arrived in Boston, there was dancing in the streets (or the hospital parking lot)—on a chilly Massachusetts day in December-—that immediately went viral.

The first Californian to be vaccinated had initially been dubious. ICU nurse and NP Helen Cordova at Kaiser Permanente Los Angeles Medical Center changed her mind, but she still understands the mistrust. Her training, though, prompted her to research the science behind the new vaccines: “That’s probably the best thing to do, educate ourselves, get the information ourselves,” she told ABC7 in LA. “As I started to dig in a little more, I felt more at ease. I started changing my stance on it. I went from ‘absolutely not’ to ‘sure, here’s my arm, let’s do it!’”

“It’s important not just for me, but for all of those that I love.” In New Jersey, the first to roll up her sleeve was Maritza Beniquez, an emergency department nurse at University Hospital in Newark. As state governor Phil Murphy looked on with journalists and healthcare workers, Beniquez was exuberant after receiving the state’s first SARS-2 shot on her birthday: “I couldn’t wait for this moment to hit New Jersey. I couldn’t wait for it to hit the U.S!”

And as humans cannot resist an opportunity to thrill one another with foreboding rumors of sinister events, false social media posts started to appear almost as soon as states began to vaccinate healthcare workers. So, if patients, friends, or family cite the nonexistent “42-y/o nurse in Alabama found dead 8-10 hours” later from anaphylactic shock, well, what did you expect? Share a real social media event like the Boston MC flash mob, and tell them you’re keeping your mask on even after your second vaccination, as epidemiologists say we will probably have to wait until mid-late 2021 to gauge the efficacy of the vaccines.

Boston Medical Center workers went all out to celebrate the arrival of the vaccine.
“I Think We Can Send You Home…” A Covid Patient’s Encounter with Unconscious Bias

“I Think We Can Send You Home…” A Covid Patient’s Encounter with Unconscious Bias

Unconscious bias could be a matter of life or death.

“Doctors aren’t listening to us, just to be quite frank. We’re dying, three times more likely. And knowing that going in, some doctors not caring as much for us, it’s heartbreaking.”

—Serena Williams (2018 post-pregnancy interview with BBC)

In mid-March, Karla Monterroso flew home to Alameda, California, after a hiking trip in Utah’s Zion National Park. Four days later, she began to develop a bad, dry cough. Her lungs felt sticky.

The fevers that persisted for the next nine weeks grew so high — 100.4, 101.2, 101.7, 102.3 — that, on the worst night, she was in the shower on all fours, ice-cold water running down her back, willing her temperature to go down.

“That night I had written down in a journal, letters to everyone I’m close to, the things I wanted them to know in case I died,” she remembered.

Then, in the second month, came a new batch of symptoms: headaches and shooting pains in her legs and abdomen that made her worry she could be at risk for the blood clots and strokes that other COVID-19 patients in their 30s had reported.

Still, she wasn’t sure if she should go to the hospital.

“As women of color, you get questioned a lot about your emotions and the truth of your physical state. You get called an exaggerator a lot throughout the course of your life,” said Monterroso, who is Latina. “So there was this weird, ‘I don’t want to go and use resources for nothing’ feeling.”

It took four friends to convince her she needed to call 911.

But what happened in the emergency room at Alameda Hospital only confirmed her worst fears.

At nearly every turn during her emergency room visit, Monterroso said, providers dismissed her symptoms and concerns. Her low blood pressure? That’s a false reading. Her cycling oxygen levels? The machine’s wrong. The shooting pains in her leg? Probably just a cyst.

“The doctor came in and said, ‘I don’t think that much is happening here. I think we can send you home,’” Monterroso recalled.

Her experiences, she reasons,  are part of why people of color are disproportionately affected by the coronavirus. It is not merely because they’re more likely to have front-line jobs that expose them to it and the underlying conditions that make COVID-19 worse.

“That is certainly part of it, but the other part is the lack of value people see in our lives,” Monterroso wrote in a Twitter thread detailing her experience.

Research shows how doctors’ unconscious bias affects the care people receive, with Latino and Black patients being less likely to receive pain medications or get referred for advanced care than white patients with the same complaints or symptoms, and more likely to die in childbirth from preventable complications.

In the hospital that day in May, Monterroso was feeling woozy and having trouble communicating, so she had a friend and her friend’s cousin, a cardiac nurse, on the phone to help. They started asking questions: What about Karla’s accelerated heart rate? Her low oxygen levels? Why are her lips blue?

The doctor walked out of the room. He refused to care for Monterroso while her friends were on the phone, she said, and when he came back, the only thing he wanted to talk about was Monterroso’s tone and her friends’ tone.

“The implication was that we were insubordinate,” Monterroso said.

She told the doctor she didn’t want to talk about her tone. She wanted to talk about her health care. She was worried about possible blood clots in her leg and she asked for a CT scan.

“Well, you know, the CT scan is radiation right next to your breast tissue. Do you want to get breast cancer?” Monterroso recalled the doctor saying to her. “I only feel comfortable giving you that test if you say that you’re fine getting breast cancer.”

Monterroso thought to herself, “Swallow it up, Karla. You need to be well.” And so she said to the doctor: “I’m fine getting breast cancer.”

He never ordered the test.

Monterroso asked for a different doctor, for a hospital advocate. No and no, she was told. She began to worry about her safety. She wanted to get out of there. Her friends, all calling every medical professional they knew to confirm that this treatment was not right, came to pick her up and drove her to the University of California-San Francisco. The team there gave her an EKG, a chest X-ray and a CT scan.

“One of the nurses came in and she was like, ‘I heard about your ordeal. I just want you to know that I believe you. And we are not going to let you go until we know that you are safe to go,’” Monterroso said. “And I started bawling. Because that’s all you want is to be believed. You spend so much of the process not believing yourself, and then to not be believed when you go in? It’s really hard to be questioned in that way.”

Alameda Health System, which operates Alameda Hospital, declined to comment on the specifics of Monterroso’s case, but said in a statement that it is “deeply committed to equity in access to health care” and “providing culturally-sensitive care for all we serve.” After Monterroso filed a grievance with the hospital, management invited her to come talk to their staff and residents, but she declined.

She believes her experience is an example of why people of color are faring so badly in the pandemic.

“Because when we go and seek care, if we are advocating for ourselves, we can be treated as insubordinate,” she said. “And if we are not advocating for ourselves, we can be treated as invisible.”

Unconscious Bias in Health Care

Experts say this happens routinely, and regardless of a doctor’s intentions or race. Monterroso’s doctor was not white, for example.

Research shows that every doctor, every human being, has biases they’re not aware of, said Dr. René Salazar, assistant dean for diversity at the University of Texas-Austin medical school.

“Do I question a white man in a suit who’s coming in looking like he’s a professional when he asks for pain meds versus a Black man?” Salazar said, noting one of his own possible biases.

Unconscious bias most often surfaces in high-stress environments, like emergency rooms — where doctors are under tremendous pressure and have to make quick, high-stakes decisions. Add in a deadly pandemic, in which the science is changing by the day, and things can spiral.

“There’s just so much uncertainty,” he said. “When there is this uncertainty, there always is a level of opportunity for bias to make its way in and have an impact.”

Salazar used to teach at UCSF, where he helped develop unconscious-bias training for medical and pharmacy students. Although dozens of medical schools are picking up the training, he said, it’s not as commonly performed in hospitals. Even when a negative patient encounter like Monterroso’s is addressed, the intervention is usually weak.

“How do I tell my clinician, ‘Well, the patient thinks you’re racist?’” Salazar said. “It’s a hard conversation: ‘I gotta be careful, I don’t want to say the race word because I’m going to push some buttons here.’ So it just starts to become really complicated.”

A Data-Based Approach

Dr. Ronald Copeland said he remembers doctors also resisting these conversations in the early days of his training. Suggestions for workshops in cultural sensitivity or unconscious bias were met with a backlash.

“It was viewed almost from a punishment standpoint. ‘Doc, your patients of this persuasion don’t like you and you’ve got to do something about it.’ It’s like, ‘You’re a bad doctor, and so your punishment is you have to go get training,” said Copeland, who is chief of equity, inclusion and diversity at the Kaiser Permanente health system. (KHN is an editorially independent program of KFF, which is not affiliated with Kaiser Permanente.)

Now, KP’s approach is rooted in data from patient surveys that ask if a person felt respected, if the communication was good and if they were satisfied with the experience.

KP then breaks this data down by demographics, to see if a doctor may get good scores on respect and empathy from white patients, but not Black patients.

“If you see a pattern evolving around a certain group and it’s a persistent pattern, then that tells you there’s something that from a cultural, from an ethnicity, from a gender, something that group has in common, that you’re not addressing,” Copeland said. “Then the real work starts.”

When doctors are presented with the data from their patients and the science on unconscious bias, they’re less likely to resist it or deny it, Copeland said. At his health system, they’ve reframed the goal of training around delivering better quality care and getting better patient outcomes, so doctors want to do it.

“Folks don’t flinch about it,” he said. “They’re eager to learn more about it, particularly about how you mitigate it.”

Still Unwell

It’s been nearly six months since Monterroso first got sick, and she’s still not feeling well.

Her heart rate continues to spike and doctors told her she may need gallbladder surgery to address the gallstones she developed as a result of COVID-related dehydration. She decided recently to leave the Bay Area and move to Los Angeles so she could be closer to her family for the long recovery.

She declined Alameda Hospital’s invitation to speak to their staff about her experience, concluding it wasn’t her responsibility to fix the system. But she wants the broader health care system to take responsibility for the bias perpetuated in hospitals and clinics.

She acknowledges that Alameda Hospital is public, and it doesn’t have the kind of resources that KP and UCSF do. A recent audit warned that the Alameda Health System was on the brink of insolvency. But Monterroso is the CEO of Code2040, a racial equity nonprofit in the tech sector and even for her, she said, it took an army of support for her to be heard.

“Ninety percent of the people that are going to come through that hospital are not going to have what I have to fight that,” she said. “And if I don’t say what’s happening, then people with much less resources are going to come into this experience, and they’re going to die.”

This story is part of a partnership that includes KQEDNPR and KHN.

KHN (Kaiser Health News) is a nonprofit news service covering health issues. It is an editorially independent program of KFF (Kaiser Family Foundation), which is not affiliated with Kaiser Permanente.

Listen to the Chapter Podcasts for Jonas and Kovner's Health Care Delivery in the United States


Gain a better understanding of the current state of the US health care system and how it might impact your work and life.

You have Successfully Subscribed!