Impossible choices inside Alaska’s inundated hospitals

Dr. Gina Wilson-Ramirez worked in the Providence Alaska Medical Center emergency room Sunday night, hours after the state’s largest hospital declared crisis standards allowing doctors to ration care.

Wilson-Ramirez worked as an urban search and rescue worker at the Pentagon after the 9/11 attacks. Twenty years ago, after firefighters extinguished lingering hot spots, she donned a Tyvek suit and a respirator and waded into a macabre slurry of thigh-high water, diesel fuel and charred bodies.

This week, she said, is worse.

“It’s worse because we’re deciding who’s going to die and who’s not,” Wilson-Ramirez said. “That definitely had an impact on my life. But nothing compares to having to ration care when there’s a cure available.”

Now people in the state’s medical community say they’re watching a sophisticated hospital system stumble under low staffing levels and a crush of COVID-19 patients spurred by the highly infectious delta variant.

Young pregnant women so sick with the virus they need a ventilator to breathe. People experiencing chest pain, a major heart attack symptom, waiting for hours in the ER. Gravely ill patients dying before they get care — or because someone else with better survival odds was prioritized for treatment.

Alaska is experiencing one of the sharpest surges of COVID-19 in the United States, with more people hospitalized with COVID-19 than at any other time during the pandemic and vaccination rates in the nation’s bottom third.

But the state is also uniquely isolated, with a vulnerable health system centered on a few big hospitals that normally transfer patients out to Seattle or Portland, where facilities are now also overwhelmed.

Some hospitals around the state are already rationing care, said Jared Kosin, president and CEO of the Alaska State Hospital and Nursing Home Association.

Kosin said he’s starting to see the answer to the question he’s fielded throughout the pandemic: When will things get bad enough to cause the state’s hospital system to collapse?

“You’re not going to see a collapse. … Care gets rationed to more extreme levels over time,” he said. “Right now the fact that it’s started is extremely unnerving because we live in the U.S. It’s the 21st century. We have the best medicine in the entire world, and we’re rationing it.”

‘I’ve never seen that before in my career’

Infectious disease specialist Dr. Ben Westley watched crisis care go into effect.

Westley, who works at Providence, consulted on two patients in recent days. Both had COVID-19.

One was in their 30s, the other older. The older patient was sicker. Both needed dialysis to clear the fluid that was clogging their lungs. That procedure removes waste products and excess fluid from the blood when infections, including COVID-19, lead to kidney failure.

There was only enough staff for one machine.

The sicker patient got dialysis during the day but the younger patient was placed on the equipment at night. The next day, Westley noticed his older patient was failing and learned the other patient was prioritized for treatment.

The decision made sense medically: The younger person was more likely to recover.

“I’ve never seen that before in my career,” he said. “Of course, the other patient didn’t survive.”

Providence hospitalist Dr. Leslie Gonsette said COVID-19 is adding to the stress on the system. Doctors and nurses say COVID-19 patients take more time and staff to treat.

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About half the patients with the virus Gonsette sees arrive with “clots all over their lungs.”

She recently saw a patient in his 40s with COVID pneumonia. He wasn’t improving despite being intubated and proned to help his breathing. The man needed treatment available in the Lower 48, using an “ECMO” — or extracorporeal membrane oxygenation — machine that replaces someone’s heart and lung function.

The Providence ICU team called five Outside hospitals, she said. None had the staff or machines to accept another patient immediately.

“He died the next day waiting to get transferred,” Gonsette said. “He quickly developed multiple organ system failure. His body shut down.”

Long ER waits, delayed care

The realities of Alaska’s challenging hospital situation are plainly obvious in the emergency room.

Twin Rent A Can portable toilets sit next the entrance of the Providence ER. That’s because the hospital is asking patients to wait outside in their cars to reduce crowding. Some people wait for hours.

And in an unprecedented situation, doctors are treating ER patients in the waiting room because there are no beds for them.

Dr. Nicholas Cosentino just came off a two-week shift at the hospital. Two COVID-positive people spent more than eight hours on oxygen — in the waiting room, Cosentino said.

Some patients are waiting as long as 50 hours in the ER before beds open in the hospital, he said. Patients with chest pain waited for hours, “unheard of” because it’s so important to treat heart attacks fast.

He’s cared for young pregnant women who chose not to get vaccinated and quickly become seriously ill with COVID-19. Pregnancy makes women more vulnerable to any virus. Several providers described one expecting mother who died with the virus.

“I’ve never seen as many young and sick people as we have. People my age who are saying goodbye to their loved ones as they head towards the ventilator,” said Cosentino, who is 35. “It’s just awful.”

Gonsette’s day Friday started with an emergency call about a new, unvaccinated patient who was getting worse despite treatment with monoclonal antibodies. They would probably need a non-invasive ventilator.

The patient was 20 years old.

Wilson-Ramirez worked Sunday night into Monday at Providence. At one point, there was only one high-flow ventilator the hospital tries to use before intubating someone. Her patient, who didn’t have COVID-19, needed the ventilator. So would any seriously ill COVID-positive patients who came in.

About a third of the hospital’s patients have the virus.

“We kept trying to wean him off the oxygen so we could use it in case somebody else needed it,” she said. “The way we’re getting equipment freed up is mainly when we’re discontinuing care on people. And it’s not always because they’re living.”

‘Not just about me’

Doctors and nurses say the COVID-19 patients they’re seeing are almost all unvaccinated.

Unvaccinated people accounted for sixteen of 17 COVID-infected patients at Soldotna’s Central Peninsula Hospital on Friday, operating at 106% capacity. People with the virus filled all nine of the hospital’s ICU beds.

A new Centers for Disease Control and Prevention report shows that, even with the delta variant in play, fully vaccinated people are five times less likely to get infected, 10 times more likely to avoid hospitalization and 11 times less likely to die with the virus compared to unvaccinated people.

Staffing shortages are a major factor in the inability of hospitals to handle the surge of patients, providers say.

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A longstanding nurse shortage that’s plagued Alaska for years has been made sharply worse by the fatigue and burnout of providing care during a pandemic. More recently, there are absences among health care workers either infected with COVID-19 or quarantined as close contacts.

Hospital leaders say there’s little if any truth to the contention made by many, including Anchorage Mayor Dave Bronson, that vaccination requirements are prompting a mass exodus of employees.

The hospital has added extra doctors to help ICU physicians and added a service to help hospitalists like her, Gonsette said. Nurse practitioners in the ICU are coming in on their days off.

Gonsette and Providence Chief of Staff Dr. Kristen Solana Walkinshaw testified before the Anchorage Assembly on Tuesday in hopes of encouraging the public to slow the spread of COVID-19 by getting vaccinated or masking.

Doctors and nurses say some of their unvaccinated COVID-19 patients now say they regret not getting the shot.

One of Gonsette’s ICU patients, 56-year-old Pablo Diaz-Fontao, got vaccinated during a video call Thursday with reporters that was coordinated by the hospital.

Diaz-Fontao initially needed “extremely high amounts” of oxygen before improving, Gonsette said in an interview earlier this week.

Diaz-Fontao, a Cuban-born Anchorage resident who works for Alaska Airlines, said during the call he was healthy and didn’t think he needed to get vaccinated. He also didn’t want the government telling him what to do.

“But now when I see the situation, I see it’s not just about me, it’s about people around me,” he said.

Others fight any talk of the vaccine, even as they struggle to breathe.

Nurse Caitlin Kovacevich’s patient at Providence was on high-flow nasal cannula to help his virus-addled lungs.

“He wanted to talk about vaccine conspiracy theories with me,” Kovacevich said. “When you’re requiring that kind of support, you barely have enough breath to roll over or stand up and use the bathroom.”

Crisis care becoming reality

Rationing medical care, viewed as the worst-case scenario of the pandemic, is becoming a reality in a few parts of the country as coronavirus infections remain at surge levels, the Washington Post reported Friday. Hawaii has released health care facilities and workers from liability. Idaho public health officials expanded crisis care protocols statewide this week, and a hospital in Montana’s capital is also rationing care.

There are national guidelines for crisis standards, but plans vary from state to state and hospital to hospital. They give hospitals flexibility about which patients to prioritize — ICU bed decisions based on survival chances, for example — and provide legal protection for doctors. Such a declaration doesn’t automatically mean patients won’t get care.

Alaska does not have a statewide declaration of crisis standards of care. The state established a crisis-care committee this week, according to the Alaska State Hospital and Nursing Home Association.

State health officials developed statewide guidelines in March 2020 as the pandemic got underway, the 37-page “Patient Care Strategies for Scarce Resource Situations” based on Minnesota protocols.

Providence’s crisis-care decision process is aligned with the state plan, but the hospital also uses a specific ethics guidance to help make sure any actions are consistent with the hospital’s values as a Catholic Health Care ministry, a hospital spokesperson said.

At Providence, officials have said they will not give lower priority to people who aren’t vaccinated for COVID-19 under crisis-care protocols. The hospital last week established an ethics triage committee available 24/7 to help doctors make difficult decisions.

‘Everybody in the system is suffering’

Other hospitals in Alaska have so far avoided an official crisis-care declaration, but many report grueling conditions as patients face long waits or delayed surgeries.

Rural hospitals are sometimes unable to transfer patients within Alaska. Staff must treat severely ill people they normally send to other hospitals for higher levels of care. One outlying facility nearly ran out of oxygen last week. Fairbanks Memorial Hospital last week began reconfiguring meeting rooms for patient care.

At Mat-Su Regional Medical Center near Wasilla, emergency department director Dr. Tom Quimby said he’s seen emergency patients wait as long as five hours. The hospital set new records through the summer in the emergency department, and not just because of COVID-19.

But by Thursday, there were 42 COVID-positive patients at Mat-Su Regional, about 40% of the 105 people hospitalized. The ICU was entirely filled with virus-related patients, all of them on ventilators. The hospital is using nine times more oxygen than usual. More than half the emergency patients have COVID-19.

Quimby, whose emotionally raw testimony at a Mat-Su school board meeting earlier this month went viral, was just getting off another long shift Thursday afternoon.

“Our staff is super stretched and today was no exception. We have a number of very, very ill people with non-COVID things, and then you dump all the COVID on top of it,” he said. “And it’s really challenging and stressful because every place is really full.”

One of his patients needed a life-saving procedure by a gastroenterologist, a specialty Mat-Su doesn’t offer. Quimby said he got Providence to take the patient, but they warned him that the patient would have to wait in the ER, get his procedure and probably go back to the ER — even though he needed ICU-level care.

Quimby described the frustration of seeing a situation that’s preventable with vaccines and other measures now compromising care for people without the virus. The hospital expanded its COVID-19 unit and pulled staff from the operating room and other areas into the emergency department after ending nearly all non-urgent procedures.

“Everybody in the system is suffering and it’s really, really difficult, and then on top of that, just the politicization. I think that’s taken a huge toll on all health care workers to see what’s happening here and then walk out into the world or, you know, social media and hear a bunch of people saying all this is nothing and nothing’s happening,” he said. “Frankly, a lot of us have lost friends and whatnot, over it. So it’s tough, it’s really tough.”

Mat-Su Regional, like other hospitals around the state, is working with the Alaska Department of Health and Social Services on crisis-care planning if it comes to that.

“It’s on the table. We don’t take that lightly,” Quimby said. “We’re going to stretch every resource to the limit before we do something like that. But it may become a necessity.”