Beyond code red: Michigan hospitals wilt under double wave of COVID cases

GRAND RAPIDS—Seven weeks ago, as West Michigan’s largest hospital system faced an impending crisis, Dr. Darryl Elmouchi hesitated.

As the leader of Spectrum Health West Michigan, Elmouchi has been the public face of the hospital system’s pandemic response, and he was about to make yet another important announcement. For the first time in the nearly two-year-long battle against COVID-19, the hospital’s leaders planned to invoke a “code red” status for operations.

For Elmouchi, moving to code red in November gave him pause, not because it was unjustified, but because there was no code past red.

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If anything, conditions are now worse.

“I’d say we’re beyond red now,” Elmouchi said. “So, whatever the shade darker, that’s where we’d have to put ourselves from a staffing standpoint.”

On Monday, Michigan set yet another record for the number of people hospitalized with COVID-19. The numbers declined slightly by Wednesday, but remain near all-time highs. During previous waves of the pandemic, hospitals saw a rapid increase in patients, then another rapid decline. But this time around, health care workers have faced a double wave, the first of which crested in early December with a spike in patients sick with the delta variant of COVID-19. Now, a month later, the second part of the wave is hitting as a new variant, omicron, rips across the globe and once again fills Michigan’s hospitals.

For many hospital systems, this new surge arrives as thousands of hospital workers themselves are testing positive for the virus, putting a further strain on staffing.

“Basically everyone is picking up more and more hours,” says Lauren Irving, an ICU nurse at the University of Michigan’s Michigan Medicine in Ann Arbor. “We have travel nurses helping out, but some of them are getting sick as well. So a lot of us are just very tired, because we’ve been working overtime when people can’t make it in.”

Already, hospitals were short-staffed compared to previous stages of the pandemic. Now those shortages are forcing hospitals to close beds, even as more people are getting sick: On Wednesday, the total number of hospital inpatient beds available across Michigan was down 884 compared with the peak of the April 2021 surge. That includes about 250 fewer ICU beds.

The loss in hospital bed capacity isn’t because of a shortage of furniture or space. 

“The limiting factor is almost never space,” said Elmouchi. “The limiting factor is people.”

Meanwhile, the number of COVID patients in ICUs started climbing again last week, after briefly dipping in late December.

“The ICUs are kind of crazy right now,” Irving said. “They're still pretty full with COVID patients. We still see people getting very critically ill…. People are still on ventilators. Some people are getting this variant and (getting) a mild case. And in that case, they're pretty lucky … but we're still seeing people with this variant who are getting very, very sick.”

The surges and staff shortages continue to work as a self-perpetuating cycle: As more health care workers burn out, more burden falls on those who remain.

“You know, we're trying to band together, but we are all very tired of this,” Irving said. “I've had friends that have left nursing altogether. I've had friends that have left the ICU to go to what they think might be like a happier place like labor and delivery, or maybe a less stressful outpatient job.”

She doesn’t blame them. But she’s still passionate about working in the ICU, describing it as her  “calling.” She’s not ready to leave. 

“But the longer this goes on, the more it makes me think about other avenues of nursing I could do or even other jobs altogether,” she said.

Supply shortages

It’s not just the shortage of people that’s making things difficult for hospital workers. The same global supply chain problems leading to empty store shelves also mean empty supply closets at some hospitals.

“It’s one thing if you’re managing an office and you don’t get your staplers,” said Elmouchi, of Spectrum Health. “It’s another thing if you’re managing a neonatal intensive care unit, and you don’t get the feeding material that you think you’re going to get.”

Elmouchi said Spectrum Health, the largest employer in Grand Rapids and one of the largest organizations, has tens of thousands of products it uses on a monthly basis to keep operations running smoothly. Before the pandemic, a few dozen of those products might be on backorder. Now it averages closer to 400.

Some are trivial. Others are critical for patient care: A fluid that’s used for continuous dialysis machines. A popular blood thinner drug. A specific kind of tubing that’s used to administer intravenous pain medication.

“We’re a little like MacGyver every day where we’re coming up with fixes for things that … we can do, and we can make work, but it’s a whole lot of work, it’s very challenging,” Elmouchi said. “And when you have a whole lot of those compounded on each other, it’s really hard.”

“Elmouchi said figuring out these workarounds takes people, and time — both of which are already stretched thin. The supply problems just add to the stress and pressure building on health care workers.

And many of those workers are also doing jobs far different from what they were doing even just months ago.

‘I never got any kind of training’

“I was kind of thrown into this particular hospital because of the (most recent) COVID surge,” said Dr. Soumya Rangarajan, who was transferred from St. Joseph Mercy Ann Arbor to the hospital’s affiliate in Chelsea around Thanksgiving.  “My regular role is not to be a COVID doctor, my regular role is actually I'm a geriatrician.”

Until now, she hadn’t had to care for many critically ill COVID patients. 

“I never got any training,” Rangarajan said. “It was just like, ‘Here we go! All the patients are coming in!’ So it was a lot of learning on the job. I really felt like I was back to being an intern … suddenly having to relearn all of this from scratch.” 

Learning how to treat COVID patients also meant learning how to relate to them as a caregiver.

Before this, Rangarajan said, she’d blamed people who refused to get vaccinated, holding them responsible for unnecessarily extending the pandemic. But now, those people are the vast majority of her patients (88 percent of COVID hospitalizations and 86 percent of COVID deaths in Michigan are among people who weren’t fully vaccinated).

As Rangarajan cares for the people who are “so sick,” she finds herself forming close bonds with them and their family members.

“They’re really nice people,” she said. “And I'm feeling burned out, and a lot of my colleagues are feeling (that way) right now. But these individual patients, I can't blame. Because they're just getting information from somewhere, that's the wrong information about the vaccines. But I think in the end, they're victims, too. I just, I can't blame them, because they're the victims.”

For nurses like Melissa Boals, treating COVID patients is nothing new. An ICU nurse at Munson Medical Center in Traverse City, she’s seen “a lot of death” these last few years. But it never gets any easier.

“When someone's looking at you saying they can't breathe, and you look at them and you can tell they can't breathe, they're gasping for air, it is terrifying. You have to keep your cool and do what you need to do, but there's a level of fear. I mean, for me, I'm 51. And when my patients are younger than I am and that's happening, that's especially stressful.”

Still, two years into the pandemic, Boals said she has developed a grim sort of instinct about how her patients will handle the virus.

“I don’t even know how to explain it,” she said. “It’s come to the point where I feel like we can just tell who’s not going to do well. You just listen to someone’s lungs, you see how much oxygen they’re on and how many days this has been like this, and it’s like, ‘Oh gosh, I feel like this isn’t going to end well for this person. And unfortunately, after doing this for this many years, it’s pretty easy to tell.”

But after two years of rampant misinformation about the virus and how to treat it, some patients doubt those instincts, and doubt the advice of frontline healthcare workers like Boals.

Hospitals statewide have reported more aggression toward staff from patients, with both verbal and physical assaults on the rise. Boals says she hasn’t had any patients get physical with her.

“I’ve had patients be … verbally unkind, I guess, is a politically correct way to say it,” Boals said after a pause. “Disrespectful. We have families call and yell at you or yell at the doctors: ‘Why aren’t we doing this (treatment?) Why aren’t they getting better? Why aren’t you giving them this medicine that’s not approved?’”

Boals, whose hospital system has also been on “code red” status since November, said some people still don’t want to acknowledge COVID is real, even as it kills them or family members. She tries to stay calm and be comforting, but direct.

“We’re doing everything we can,” Boals said. “And sometimes it just doesn’t work.”