Yale Daily News
As healthcare workers at the Yale New Haven Hospital system face the highly transmissible Omicron variant, they described a new form of chronic stress from an increased caseload and a lack of state support.
As of Jan. 7, 775 patients in the YNHH system — which includes five hospitals throughout Connecticut — are currently hospitalized with COVID-19, according to Mark D’Antonio, the YNHH media relations coordinator. This number has grown more than 50 percent in the past week, from 513 COVID-hospitalized patients on Dec. 31. It’s also a seven-fold increase from the beginning of December, when there were just over 100 COVID-hospitalized patients at YNHH.
Omicron appears to be less deadly than previous variants. Still, of the 437 hospitalized patients at the Yale New Haven Hospital in particular, 67 are in intensive care and 33 are on ventilators. The YNHH system has over 300 ventilators, YNHH CEO Marna Borgstrom added in a Dec. 31 press conference.
However, the variant is highly transmissible. On Jan. 8, Connecticut’s 7-day daily case average was 7,940, a 172 percent increase from 14 days ago. And the sheer number of hospitalized patients has been overwhelming, nine YNHH employees said.
“Our problem is not primarily the ICU,” Chief Clinical Officer Tom Balcezak said during the press conference. “It’s just the total volume of patients.”
That increased volume, combined with what they see as an inadequate public response, has overwhelmed many doctors, nurses and other YNHH employees, even as they strive to provide high-quality care.
Extraordinary Demand
As a YNHH intensive care unit physician of 10 years, Elaine Fajardo has experienced plenty of “overwhelming duties outside her usual sphere of practice,” she said. But when the Omicron variant emerged and COVID-19 again tore through her unit, she witnessed a burdened medical system like she had never seen before.
When a COVID-19 patient is transferred to the ICU, “things are getting worse” and nurses put the patient on high flow oxygen, explained Luke Davis, a YNHH critical care physician. On oxygen, the patient looks “deceptively well – they often can carry on a regular conversation as if they were just in bed at home.” While some patients will recover, Davis explained that “many others will suddenly decompensate and require intubation, deep sedation, chemical paralysis of all voluntary muscles, and mechanical ventilation. What follows is an exhausting battle to stabilize these patients that may require constant vigil at the bedside by the full ICU team for hours upon end, with the patient constantly on the verge of death.”
When treating COVID-19 patients in this phase, staff position the patients on their stomachs, frequently change ventilators, draw blood and perform urgent procedures to address collapsed lungs, according to Davis.
“[The patients] become shells of their former selves,” said Raksha Madhavan, a third-year internal medicine resident at YNHH. “If it becomes clear to us that the possibilities of survival are slim, we talk to [the patients’] families about transitioning to ‘comfort measures only,’ and allowing them to die with comfort and dignity rather than getting rib-breaking CPR.”
Caring for the severely ill is especially difficult because of the increase in patients. With such large caseloads, there is limited time and staff to devote to each patient, according to Andrew Ulrich, interim chair of the department of emergency medicine.
Staffing is a particular issue because of infections among YNHH employees. Although staff take protective measures throughout the hospital, Omicron is highly transmissible and many employees have gotten sick themselves.
“We have very sick patients and our own staff is getting sick. Staffing is a challenge; there is stress in every division of the healthcare system,” Fajardo said. “This is when the level of quality of care gets sacrificed.”
At the press conference, Borgstrom said that infected employees have to isolate for seven days before returning to work instead of the CDC-recommended five.
Ulrich explained that the Omicron surge is having a “cascade effect” on movement throughout the hospital — because of the “backed-up” intensive care units and operating rooms, emergency rooms sometimes have no place to send patients in the hospital.
YNHH employees are also concerned that COVID-19 will impact patients who come in for other reasons. Borgstrom said that YNHH has multiple “contingency plans” in case the hospital needs to delay scheduled surgeries so that resources can be redirected to severely ill COVID-19 patients. Davis told the News that there has been a 20 percent reduction in the “operative caseloads,” with “low-acuity” procedures being delayed until the Omicron surge begins to decline. Some patients have also had to reschedule surgeries after testing positive in the days before their procedure.
“When the hospital is full, it’s not only the patients with COVID that suffer,” Naftali Kaminski, Chief of Pulmonary Critical Care and Sleep Medicine, told the News. “Elective procedures are not luxury procedures. People don’t get surgery because they want to, but because something is wrong with them.”
Borgstrom noted that delaying scheduled surgeries, in addition to posing health risks for certain patients, could create backlogs down the line. This is what happened last year: canceled surgeries in 2020 led to “extraordinary demand” half a year later.
A Trust Crisis
Michael Ivy, Deputy Chief Medical Officer at YNHH, said that Omicron presents different challenges from previous surges.
During earlier surges, “there was a lot of fear, the fear of getting ill, the fear of the unknown,” he told the News. “And the volume of patients coming in and the mortality rate was very high, because we didn’t have any of the treatments that we have available now. There was a lot of fear and anxiety, real acute stress. Now, two years in, it’s not acute stress anymore, it’s chronic stress.”
Although the rapid rise in patients has been challenging, nine employees expressed satisfaction with the health system’s management of the Omicron surge. Assistant Professor of Clinical Pediatrics Sharon Ostfeld-Johns told the News that YNHH has provided sufficient personal protective equipment, clear communication about its plans and accessible mental health resources.
The outside world, though, is a different matter. Multiple YNHH employees expressed frustration with the public response to the pandemic, at both the federal and state levels.
“Health care workers sometimes just feel like they’re out here fighting this thing on their own,” said Madhavan. “The kind of mobilization needed from governments, both at the state and national level and globally, just isn’t happening. And I think that knowledge, coupled with the work, is why we’re all really feeling stressed.”
Kaminski said that he had initially been optimistic about the Biden-Harris Administration’s approach to the COVID-19 pandemic. Now, he said that he thinks the CDC has made multiple missteps: prematurely relaxing its masking guidelines, delaying the endorsement of booster vaccines and reducing recommended isolation periods for people infected with COVID-19.
The same is true at the state level. Kaminski said he wants Governor Ned Lamont to announce a state of emergency in recognition of the severity of the Omicron outbreak and potentially reintroduce some restrictions on activities. Both Madhavan and Kaminski agreed that a statewide indoor mask mandate is essential. They argued that the current wave of infections and deaths was preventable and the result of policy inaction rather than a lack of scientific understanding.
In the state of Connecticut, vaccinated individuals are not required to wear masks indoors, while the city of New Haven has kept its mask mandate in place.
“It’s much easier to go to war when you trust your chief of staff and your generals,” Kaminski told the News. “There has to be a much more serious plan from the state and a message that they have our back. Strangely enough, we felt better in this sense [in] March, April 2020.”
The Omicron surge is also different from previous waves because the majority of COVID-hospitalized patients are unvaccinated. Multiple employees reiterated that vaccinated and unvaccinated patients receive the same quality of care. However, some of them also expressed frustration that many people are continuing to congregate indoors without masks and avoid vaccinations.
“Seeing people outside not wearing masks, it is a source of stress for clinicians,” Ivy said. “There is acute stress for the patient who is angry and upset about being sick, and there is this kind of existential stress that people are just not willing to do the right thing and just don’t believe us or trust us.”
Additionally, some YNHH staff are now facing increased levels of hostility. At the beginning of the pandemic, employees said that despite the stress and uncertainty, they generally felt supported by the public.
Fajardo expressed concern that healthcare professionals are losing empathy for patients and are leaving the profession in droves. A number of health-care workers have quit their positions or left the profession entirely because of moral distress, exhaustion and hostile treatment by their patients or hospitals. These losses are putting a dent into the already COVID-fueled chronic short-staffing across the U.S.
“What I am worried about is empathy. Health care providers are becoming less empathetic to patients who aggressively tout misinformation,” Fajardo said. “When you encounter a patient in the hospital who is asking for Ivermectin, it is frustrating because you can try to have a conversation about the vaccine based on data or evidence but have it refuted by things that aren’t true.”
Now, YNHH has had to hire off-duty police officers at outpatient testing sites because of what Balcezak called “unruly behavior.”
“People need to be civil and kind to one another,” Borgstrom said. “We have lost that. People pushing and shoving in testing lines does not help anybody.”
Calls for Change
YNHH employees emphasized that the continuation of the Omicron surge, and the stress it has placed on the health system, is not inevitable. More support from state and local policymakers is essential to end this surge, they said.
Only 61.19 percent of New Haveners are fully vaccinated and 70.31 percent of city residents have received at least one dose of the Pfizer or Moderna vaccine as of Jan. 7. While New Haven officials have encouraged residents to receive their booster shots as well, no data is available on the percentage of New Haveners who have received a booster shot.
To Ulrich, it is “critically important” that people receive the COVID-19 vaccine and booster. While about 65 percent of COVID-19 patients at YNHH are unvaccinated, it is “uncommon” to see a vaccinated and boosted COVID-19 patient, Balcezak said. The one to two vaccinated and boosted COVID-19 patients that he has seen were severely immunocompromised.
“The solutions to a global pandemic are global and not individual,” Ostfeld-Johns said. “Public health failures are lethal – most recently our governor choosing not to institute a state-wide mask mandate.”
In December, Lamont said there was “no need” for a statewide mandate because “we have capacity in our hospitals, and people are doing the right thing.” Lamont could not be reached for comment over the weekend.
Connecticut reported 10,076 new COVID-19 cases and the United States reported 900,047 new COVID-19 cases on January 7, according to the New York Times.
“[Healthcare workers] really don’t get the luxury of being numb to numbers like that,” Madhavan said. “It would be helpful if people would try to put themselves in our shoes, and really think about what it means to even have one person die or one person go into the ICU, and like having to break a family’s heart and deliver that news. I think that people might be a little bit more empathetic to our plight.”
The YNHH system has serviced New Haven since 1826.