Earlier in the spring, physicians in the Sun Belt states, from California to Florida, watched as COVID-19 ripped through early hot spots and braced themselves for their own surges. But when most Southern states were able to tamp down initial infections and hospitalizations, many hoped that they had managed to put the worst of the pandemic’s first wave behind them.
It was only the beginning.
In the last few weeks, COVID-19 cases and hospitalizations have soared in Texas, Florida, Arizona, and other Southern and Western states, in large part due to the early and rapid reopening of restaurants and bars, relaxed social distancing, and inconsistent use of masks to quell the spread. Hospital administrators and physicians in those states are now facing the stress of a growing outbreak and quickly filling intensive care units (ICUs).
While the delay in their surge has allowed them to prepare and learn more about how to treat the virus in ways many hit by earlier surges didn’t have, they’re also facing additional frustrations, from fatigue to anxiousness that their fellow citizens have let down their guard in the attempt to slow the spread.
“It’s like you’re standing on the shore with a life jacket and you see the tsunami coming.”
Julie Trivedi, MD
Medical director of infection prevention for UT Southwestern Medical Center
For some doctors, seeing how hard the virus hit early hot spots felt like a warning sign for what was to come, especially as people ventured out of lockdown, often ignoring public health guidance.
“It’s like you’re standing on the shore with a life jacket and you see the tsunami coming,” said Julie Trivedi, MD, medical director of infection prevention for UT Southwestern Medical Center in Dallas, Texas.
A false sense of security
In March, Trivedi watched as horrifying news stories told of overflowing ICUs and climbing death counts in the Northeastern United States.
She wasn’t sure when or how badly her city would be hit. Maybe the fact that Dallas was more spread out and less reliant on public transportation than New York City would help slow the spread of the virus, or maybe the Texas heat would tamp it down, she thought.
And even as the hospitals in Dallas — like most throughout the country — canceled nonurgent surgeries, stocked up on personal protective equipment (PPE), and revamped their surge plans in anticipation of an influx of COVID-19 patients, they didn’t see a major spike.
Instead, throughout the spring, many communities in Southern and Western states, including Texas, California, Florida, and Arizona, saw relatively few COVID-19 cases and fewer hospitalizations, while other parts of the country reeled from the impact of the virus.
It was a relief that created a false sense of assurance, Trivedi believes.
In the last couple of weeks in June, she saw almost a doubling in the number of COVID-19 patients in her hospital.
“This is much higher than anything that we had earlier in the year,” she said. "Much of the rise is stemming from the gatherings that began with Mother's Day and Memorial Day and have continued since then without appropriate precautions such as masking and social distancing."
The same trend in communities throughout the Sun Belt has led public officials to roll back reopening efforts in recent weeks and has put health care providers in the position of facing a renewed crisis that many believe might have been mitigated with stricter adherence to public health measures.
Waiting for the surge
When Chelsea Carlson, DO, a third-year internal medicine resident at the University of Arizona College of Medicine - Phoenix, started seeing more people crowding in the grocery store without masks in mid-May, she had the sinking feeling that her job was going to get a lot harder.
“Now that everyone’s been on lockdown for the past couple of months, everyone’s gotten stir-crazy,” Carlson said in late June. “We’re seeing people not taking the virus as seriously.”
It’s been frustrating for Carlson, who canceled several vacations and has been strict about avoiding restaurants and gatherings, to feel that many people in Phoenix don’t understand the gravity of the pandemic.
“It’s just been really anxiety-provoking,” she said. “It’s really disappointing, and it’s really scary for me. We’ve already been running out of beds in our ICU. It’s just going to keep getting worse and worse.”
About a month after Arizona began reopening businesses in early May, the state began to see an increase in positive COVID-19 cases — from 681 new cases reported on May 31 to a peak of 4,797 reported on June 30, according to data compiled by the New York Times. On July 12, Arizona reported 2,488 new cases.
“It’s really disappointing, and it’s really scary for me. We’ve already been running out of beds in our ICU. It’s just going to keep getting worse and worse.”
Chelsea Carlson, DO
Third-year internal medicine resident at the University of Arizona College of Medicine - Phoenix
Similar trends occurred in other states that reopened early and rapidly. In Texas, new positive daily cases jumped nearly sevenfold — from 1,578 on May 31 to 10,909 on July 9, the New York Times reported.
In Houston, Texas, the fourth most populous city in the country, a spike in hospitalizations in early July strained ICU capacity, leading several of the city’s largest hospitals to keep patients in the emergency department for prolonged periods while they waited for a bed, NBC News and ProPublica reported last week.
“In March and April, we saw cases, but never hit capacity,” said Salim Virani, MD, PhD, a cardiologist, professor of medicine, and fellowship director at Baylor College of Medicine in Houston. “It looks like now is the time we will have to go ahead and execute those plans … We are extremely concerned with the trends we are seeing.”
Parkland Health and Hospital System in Dallas had converted its operating rooms into a COVID-19 unit in the spring, since surgeries had been canceled. The hospital had just begun to return the space to surgeons for rescheduled procedures when the number of patients started to go up again, said Roberto de la Cruz, MD, the system’s chief medical officer.
He had been hoping that a surge would hold off until the fall or winter, when epidemiologists predicted a second wave of the virus to hit, but it turned out that the first wave hadn’t truly peaked in Dallas yet. By the end of June, COVID-19 had become the third-highest cause of death in Dallas County, behind heart disease and cancer, de la Cruz said.
“We had to reimplement adaptability and flexibility,” he said in late June. “Every day seems to be our all-time high.”
Time to learn
While physicians in the South and Southwest are now facing worsening conditions in their COVID-19 units, they have nonetheless felt some relief that their surge is coming months into the pandemic, giving them more time than their colleagues in Seattle, New York City, and other early hot spots had to prepare and learn about the virus.
In early March, when reports of surges in the United States were circulating, protocols began to change in the Texas Medical Center in Houston.
“One of the wonderful things about health care today is the opportunity for collaboration — and rapid collaboration.”
Robert Goldszer, MD, MBA
Chief medical officer and senior vice president for education and research at Mount Sinai Medical Center
For Brian Mbah, MD, a third-year emergency medicine resident at Baylor College of Medicine, that meant mentally preparing before every shift and adapting to the new way of doing things — including donning and doffing PPE, communicating with patients and families virtually, and washing hands more frequently.
While he saw some COVID-19 patients in the spring, the hospitals were not overwhelmed as he had feared.
“I feel like we had a chance to become more familiar with the process of things," Mbah said.
Even as the number of seriously ill COVID-19 patients he’s seeing in the hospital has surged, he feels more comfortable with carefully approaching the patients using the knowledge he’s gained from data collected in previous epicenters.
“One of the wonderful things about health care today is the opportunity for collaboration — and rapid collaboration,” said Robert Goldszer, MD, chief medical officer and senior vice president for education and research at Mount Sinai Medical Center in Miami Beach, Florida.
His 700-bed teaching hospital saw its first COVID-19 patients on March 9 — and on March 11, his physicians were on a video call with doctors in Wuhan, China, where the outbreak originated — to learn from their experiences. In the following months, there would be calls with hospitals in New York City and around the world to determine what treatments were working.
“The publishing of data and information — that has been very, very rapid,” Goldszer said. “We’ve learned a lot very quickly.”
Many hospitals now have access to treatments that were unproven weeks ago, such as remdesivir, a drug that the Food and Drug Administration approved for emergency use with severe COVID-19, and convalescent plasma, which introduces antibodies from recovered patients to help fight off severe infection.
Experts have also passed on knowledge about COVID-19 complications, such as those that affect the heart.
“We do know that complications that affect the heart and the vascular system are very frequent with COVID-19,” said Virani. “Because of experiences in other countries and other regions in the U.S., now we are more and more attuned to how to take care of these patients — what are tests we need to order, what medications, and what complications to look out for … These are all lessons we have learned taking care of patients and learning from our colleagues both within and outside the U.S. who went through earlier surges of COVID-19.”
Physicians also say that they have learned how to use high-flow oxygen more effectively and thus have been able to avoid the use of intubation and ventilators. And, at least so far, the death tolls have not climbed as dramatically as they did in New York City in late March and early April.
This also might be influenced by the fact that more of the people becoming infected are younger, and while some can still suffer severe complications, they have a far lower death rate than older populations, said de la Cruz.
Goldzser expects there to be more deaths in the coming weeks, but not as many as there were in the spring. “They’re still very, very ill,” he said. But “we’re better at taking care of them.”
Another key issue that plagued early hot spots — shortages of protective equipment essential to keeping health care workers safe — is again resurfacing, as some providers have reported difficulty procuring PPE in recent weeks.
In Phoenix, certain protective equipment and testing supplies have become hard to come by and could be even more scarce if the surge continues its trajectory, said Dan Quan, DO, an emergency physician and interim chair of emergency medicine at Valleywise Health and the University of Arizona College of Medicine - Phoenix.
However, Parkland Health System in Dallas and Mount Sinai in Miami Beach have been able to maintain adequate supplies while being careful to monitor needs, limit access to COVID-19 patients, and avoid being wasteful, their chief medical officers said.
Spreading the message to stop the spread of the virus
Physicians who saw the delayed surge coming say they see an additional role for health care professionals, particularly considering mixed messaging from national, state, and local officials about wearing masks and social distancing.
De la Cruz does frequent media interviews to spread the word about how strained hospitals are becoming.
“We need people to take [the virus] seriously,” he said. “It’s frustrating when you see people actively undermining that message.”
Goldszer believes that it’s up to him and fellow physicians to set an example for the community by following public health guidelines themselves.
“We — as residents, physicians, students — we should be making sure we’re great examples all the time,” he said. “Being leaders 100% of the time: wearing your mask, staying apart, washing your hands, not touching your face.”
Aditya Grover, MD, a third-year internal medicine resident at the University of South Florida Morsani College of Medicine in Tampa who has volunteered to help treat COVID-19 patients, laments the loss of social interaction but feels it’s his responsibility to set an example.
“We’re all very social people. We want to be out there in the warm weather with our friends and doing fun social things,” he said. “[But] people really take example from health care workers. I think it’s up to us to really follow all the rules that we’re preaching to make sure that we set a positive example for everyone.”
Facing the mental fatigue
For many front-line workers in Sun Belt states, the past few months have already felt like a psychological marathon as they hustled to prepare their hospitals, adjusted to new safety protocol, and continued to treat patients — all while anticipating an impending surge.
Trivedi started following COVID-19 in January and worked long hours without allowing herself a day off for months, feeling the responsibility of ensuring her colleagues developed protocols that kept them safe.
“That really impacted me,” she said. “The fatigue. The mental exhaustion.”
Some employees at Parkland Hospital System in Dallas went as many as four months without taking a day off, de la Cruz said. He was overworking himself until colleagues encouraged him to take a break to help cope with the stress.
“People are emotionally and physically drained,” he said. “It’s frustrating to see us here now and to not understand how high we will go.”
For Quan, in Phoenix, the inability to escape thinking about the pandemic, even outside of work, has proved particularly taxing.
“You hear about COVID-19 nonstop on the news. You talk about it at work,” he said. “It’s really difficult to deal with because it’s everywhere.”
Now, as they steel themselves for what lies ahead, physicians and health care leaders hope that the combination of months of preparation and renewed public health messaging efforts will help stem the tide of COVID-19 casualties moving forward.
“I’m hoping, instead of a tsunami, it’s more like a rising tide,” Trivedi said.