On June 24th, as Texas was beginning to reckon with its dramatic spike in coronavirus cases, I received a phone call from an alarmed friend. He’d heard a rumor about Houston’s Ben Taub Hospital, where I work as an internist: apparently, it was so full of patients that some seeking treatment for COVID-19 were lining the hallways, while others had left after spending too long in line. “Do we have a New York situation on our hands, or what?” he asked.
I’d been working at the hospital for four weeks without a break. The stress on the system was evident, but I hadn’t seen anything like what he described. “We’re busy, but it’s not chaos,” I said. Still, I was unnerved, and, after hanging up, I took a walk around the hospital to make sure I hadn’t missed something. The emergency room and its waiting area were orderly and nearly empty. At the triage station, a single patient wearing a mask stood calmly while his blood pressure was being taken. I greeted the nurses on the medical-surgical units: “How’re y’all doing?” They seemed overworked but in control. In the I.C.U., doctors in gowns clustered around computer workstations, rounding as they normally did. It was hardly a scene from a disaster film.
In one hallway, a set of flat-screen televisions explained what I was seeing. They showed the capacity levels of hospitals across Harris County, which includes Houston. The county as a whole was on the edge: of its 1,614 I.C.U. beds, 1,509 were full. Around five hundred of those patients were sick with COVID-19; the rest suffered from the mix of conditions that were typical before the pandemic. Ben Taub Hospital, I saw, had reached “saturation,” which meant that incoming ambulances were being diverted elsewhere. The grim statistics contrasted oddly with the calm atmosphere surrounding me, but also made sense of it. My hospital, evidently, was “saturated” and empty at the same time.
I’ve since learned that this situation isn’t unusual at overburdened hospitals during the pandemic. Earlier this spring, when I first began worrying about whether Houston had enough resources to handle a spike in infections, I thought mostly about equipment and space. I counted our hospital’s ventilators and negative-pressure rooms, taking the concept of an I.CU. “bed” literally. Now I understand that Houston, a first-rate medical city, doesn’t lack space or equipment. If our hospitals can’t accept more patients, it’s because we don’t have enough I.C.U. nurses to care for them. Our scarcest resource is human.
In late March, patients with COVID-19 started arriving at my hospital. To avoid exposure and conserve P.P.E., I treated my first patient with the virus mostly from the hallway, calling him on the phone. The nurses took a different approach. “We’re in there all the time,” one told me. Day and night, she and her colleagues were checking his vital signs, helping him use the bathroom, and addressing the alarms emanating from the medical devices surrounding him. At that point in the progression of the illness, they were doing most of the work that COVID-19 required. My only job was to see whether the patient’s breathing was improving. When he left the hospital fully recovered, I was happy but not proud. I had little reason to be: the victory belonged to the nurses and respiratory therapists.
In the treatment of virtually all diseases, the number of personnel needed increases as the level of care escalates. For COVID-19, the most basic level of care involves a nasal cannula—a forked tube leading from an oxygen tank into the nostrils—which delivers about twice as much oxygen as is contained in ordinary air. On the medical-surgical wards where such devices are used, a single nurse can oversee the care of five patients. But people with more advanced cases of COVID-19 have fluctuating oxygen levels and more extensive needs. Respiratory therapists must visit at least once every six hours; doctors must order more frequent blood draws, vital-sign checks, and heart monitoring. In the intermediate-care units where patients like these are treated, the nurse-to-patient ratio is one to four.
In the I.C.U., where patients receive an even higher level of attention and care, each nurse can work with only two at a time. Often, many people must converge to offer care simultaneously. “Proning,” which has emerged as a valuable therapeutic advance in the treatment of severe COVID-19, is a good example of work-intensive I.C.U. care. A patient who is proned is flipped from her back to her belly while her breathing tube, I.V.s, and monitors are kept intact and attached; many hours later, the move must be reversed. During the pandemic, proning has been shown to make a life-saving difference for some patients; it allows the fluid in the lungs to redistribute itself, opening up new areas to oxygenation. But carefully flipping an unconscious, paralyzed patient can require as many as six people—nurses, assistants, therapists, and sometimes doctors, each gowned in P.P.E.—to coördinate their efforts, as though they are moving a large sculpture. In order for an I.C.U. to prone large numbers of patients each day, it must be fully staffed.
Staffing, therefore, shapes I.C.U. capacity just as much as equipment. Not long ago, I received a phone call from a nurse who was caring for a patient of mine; we suspected that she had COVID-19, and though her vitals weren’t necessarily concerning, she wasn’t looking great. Within half an hour of my arrival at her bedside, she had been intubated at my request. Our I.C.U.s were full, meaning that the ratio of nurses to patients there was holding steady at one to two. But the critical-care team and the hospital’s nursing leadership were able to accommodate her, finding not just a room where she could receive I.C.U.-level care but also a dedicated, trained nurse. I recalled something Esmaeil Porsa, the chief executive of Ben Taub Hospital, had said in an interview: “If somehow, magically, there’s a group of ten or twenty I.C.U. nurses that I can have, then I can transform more of my beds into I.C.U.s.”
But there are rarely extra nurses to be found—and so a COVID-19 spike ends up diverting staff from the hospital as a whole. At Ben Taub, nurses have been moving from the medical-surgical wards to intermediate care, or from intermediate care to the I.C.U. (Similarly, internal-medicine doctors like me, who are used to seeing patients in medical-surgical units, have begun working in I.C.U.s under the supervision of critical-care doctors.) The ratio of nurses to patients in the I.C.U. has occasionally climbed to one to three, or higher. Meanwhile, the need to stretch personnel trickles down. A nurse on a medical-surgical unit might now be responsible for eight patients instead of four—a lower ratio that increases risks.
Nurses aren’t interchangeable; many have extensive training and experience in specific areas, such as post-anesthesia, labor and delivery, or burns. Last week, as the number of new coronavirus cases per day in Texas passed ten thousand, and as I.C.U.s across Houston grew even more saturated, I called up a former I.C.U. nurse I know who now works as an administrator at a large, private hospital near mine. I asked her how the nurses there were doing. “We are not O.K.,” she said. Under the pressures of the surge, the nurse-to-patient ratio in her I.C.U. was regularly being pushed to one to three, and many nurses were working six twelve-hour shifts each week. With more COVID-19 patients coming in, the hospital had opened pop-up units, which had stretched nursing ratios further. “People think a nurse is a nurse is a nurse, but they are just as specialized as doctors,” she said. In patient care, , nothing is as stressful as having to learn new tasks and replicate them quickly. Many nurses were showing signs of burnout.