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Hospitals in Jackson and Douglas counties are overwhelmed

No part of Oregon is dealing with a bigger COVID-19 surge right now than Southwest Oregon. Dr. Jason Kuhl, chief medical officer at Providence Medford Medical Center, and Dr. Jason Gray, chief medical officer at CHI Mercy Health in Roseburg, update us on what their hospitals are facing.

This transcript was created by a computer and edited by a volunteer.

Dave Miller: This is Think Out Loud on OPB. I’m Dave miller. We’re going to spend most of the show today talking about what’s happening in Oregon hospitals. In the middle of the hour we’ll hear what the COVID surge of unvaccinated Oregonians is like for ICU nurses. But we start with hospital leaders in southwest Oregon, the region that’s been most impacted by this surge. Jason Kuhl is the Chief Medical Officer for Providence Medford Medical Center. Jason Gray is the Chief Medical Officer at CHI Mercy Health in Roseburg. Welcome to you both.

Jason Kuhl: Thank you.

Jason Gray: Thank you. It’s a pleasure.

Miller: Jason Gray first. Let’s start with the nightmare scenario come true. Yesterday you announced that a COVID patient died in the emergency room while waiting for a bed in the ICU. What can you tell us about what happened?

Gray: Yeah, Dave, I’d love to. To begin with, we’d obviously like to express our sympathy, not only to the family of this patient but every family that’s been so cruelly impacted by COVID. This is a great example. It’s a tragic and heartbreaking but a real example of how the demands for medical care we’re experiencing currently in southern Oregon are exceeding the available medical resources. Those resources we see can be physical: beds, ventilators. But more importantly, they can also be the human elements: the nurses, the doctors, the technicians. And this is an example of the demand exceeding the available supply. I would like to point out though that this patient did continue to receive care in the emergency department from the physicians, the nurses and the specialists while we were searching for a critical care bed.

Miller: But I imagine it’s not the same kind of care that’s possible? For example, do you have ventilators in the emergency department?

Gray: We can do ventilators in the emergency department. You’re correct though. It’s not the same environment. It’s not as convenient for the physicians, the specialists. We are asking nurses, emergency department doctors to step beyond their comfort zone and take care of some patients or conditions that normally would be in the critical care unit or the cardiac care unit. And it places them, it places everyone in a very difficult situation.

Miller: Jason Kuhl, how much capacity do you have, ICU bed capacity or regular hospital bed capacity, do you have right now in Medford?

Kuhl: Yeah, Dave. At this time the hospital is significantly above 100% of our staff-bed capacity. Some of our units are approaching 120% of that capacity. And literally, we’re out of physical beds.

Miller: Can you help us understand what it means to be 120% capacity?

Kuhl: When we think about our nurse staffing ratios, that is saying that we have 20% more patients than what our nurses usually are matrixed to care for. We have nursing staff capacity and bed capacity and, at this point, our physical bed capacity is exhausted as well. As we speak, we are now in the process of moving to shared patient rooms, up on our medicine services, and trying to make additional rooms in our surgical service areas. We’re looking at making our cath lab [catheterization laboratory], where individuals get heart stents, into ICU beds, just because there are none in Region 5. As of this morning, I believe there was one potential ICU bed open here in southern Oregon and I’m sure that’s filled up by now.

Miller: So if I understand what you’re saying, in terms of the overcapacity, in terms of staffing, it sounds like what it means is, even if you are able to get an ICU bed, you’re not currently able to get the same level of care that this disease would require because there simply are not enough people-hours in the day to provide that care.

Kuhl: Yeah, that is correct. And, to that end, we’ve reached out to the National Guard, to our state government officials and FEMA. They’re doing everything they can to scramble resources to assist us down here. And that’s much appreciated. But this is a national issue where there is not enough contract nursing, not enough traveler nurses available to staff any of our hospitals. To that end, we don’t have the physical beds anymore and we certainly don’t have the staff available to continue to care for the onslaught of patients we’re seeing.

Miller: What will the National Guard be doing? My understanding is they actually arrived this week. So what will they be doing in your hospital?

Kuhl: Yeah, it’s a welcomed resource and much needed. At this point, the National Guard are going to assist with noncaregiver type of work. They’re going to help with our environmental services, making sure that our hospital remains clean and at the top of our ability to promote good hygiene and safe practices. They’re gonna help with access, monitoring at our doors to limit the traffic through the hospital. They’re gonna serve as runners to support our need for rapid resupplies of our personal protective equipment on the units. So they’re really helping hands. Whatever we can do that’s non-patient-care-facing, where we’re able to keep them safe, we’re deploying them in that manner. So again, it’s a much-needed resource that is deeply appreciated.

Miller: Jason Gray, how does what you’re experiencing right now in Roseburg compare to the previous worst days of the pandemic last year?

Gray: At this point, there really is no comparison. The worst of our days last year, we have tripled that census on it. We may have had 18, 20 patients; now we’re running 50, 56 patients — COVID patients — per day. In addition to, as Dr. Kuhl is elaborating, all of the other care needs that are there. We also believe, looking at the projections, we still have a significant ways to go. We could need an additional 30-35 beds just for COVID patients, leading to the same capacity issues, the same staffing issues. We’ve closed our operating rooms. We’ve converted a freestanding ambulatory surgery center which is connected to our building into an additional 30 bed medical unit in order to be able to increase capacity.

Miller: When you say you closed operating rooms.. I feel like this is an important thing to linger on just for a second because it’s not like you’re saying people can’t get nose jobs now in Roseburg, right. We were talking about very serious, very important surgeries that cannot happen in Douglas County right now?

Gray: It’s a good point to clarify. We are only performing emergent and urgent procedures on that. So if there’s a trauma that comes in — an orthopedic injury, a car wreck, a heart stent — we’re preserving capacity so we can still attempt to meet those needs. It’s the procedures that could wait a week or two or three or four on it; those right now are being delayed and postponed. There are urgent procedures that are of medical benefit, that might be a cancer surgery. We have a committee, composed of our surgeons and bioethicists, who can review those cases, decide what has the appropriate urgency or the impact to life, limb, or care and those are the ones that are proceeding. The rest are being paused at this point.

Miller: So you’re at the point right now where you have a panel that is making these medical, ethical decisions, that is quite literally about how to ration surgical care? Those conversations are happening right now in your hospital?

Gray: Those are difficult conversations that we are undertaking in order to triage, then take care of the most serious patients first, the next level, and then the priorities under that. It’s a point that many, most healthcare providers, nurses, physicians really had hoped we would never get to.

Miller: I was struck by a quote I saw yesterday; this was in an article by KLCC. It was from the Douglas County Public Health Officer. He said, “Unfortunately one of the most common ways people are leaving the hospital is to die. We had four deaths today which freed up four beds. But that’s not the way we want to make space in the hospital.” I’m wondering.. Given how much, Jason Gray, you and Jason Kuhl have talked about the need for ICU beds, how quickly you have to put another patient in a bed after an earlier patient dies.

Gray: Only as long as it takes to adequately clean and disinfect that room. There is another patient waiting for that ICU bed immediately.

Kuhl: Yeah, I would agree with that, Dr. Gray, that we turn those rooms around as quickly as possible because there’s someone else in line awaiting that bed. And we have done the same in relation to a case discernment for our surgical patients and are in a similar model of care. I’m sure most of the other hospitals in Oregon and southern Oregon are in those same boats, having to provision decisions around capacity to do those cases. Again, most of those may be elective cases that we have canceled and we are preserving capacity for those trauma patients and other cases that need to go immediately. But we have never before been in a care paradigm where we’ve had to do that to the extent that we are right now.

Miller: Jason Kuhl, my understanding is that you’re actually retraining some staff to work in other roles in the hospital in order to fill gaps in staffing. What might that look like in practice?

Kuhl: Where we’re at currently is we have postoperative orthopedic nurse practitioners who help round on our orthopedic joint replacement cases and our spine cases, who do inpatient medicine but not the level of inpatient medicine that would be requisite of a hospitalist who cares for our sick medical patients. So we have redeployed two of those this week to manage 20-25 patients that are admitted with COVID or other medical comorbidities. That’s not enough. And so we are grateful for a primary care medical group of internal medicine providers and family physicians, who have not practiced inpatient medicine for anywhere from 5 to 20 years, who are willing to come back into the inpatient arena and pick up patients as well.

Miller: Even after not practicing for as many as 20 years. They’re back now..

Kuhl: ..On the inpatient side, yes. They’re in the outpatient clinics seeing patients on what we call the ambulatory side of a patient care. And they are coming back in. They were trained to do this type of care in their medical school and residency programs. But they are stepping back in — under the supervision of our inpatient physicians — to manage these patients in somewhat of an extender position. So they can round on the patients, place orders, cover phone calls from nurses, and talk with the hospitalist attending physicians to make sure that the care is appropriate. But everybody’s spread so thin that we need to practice in these unorthodox ways. And it’s creating a lot of moral distress and compassion fatigue amongst caregivers in relation to being pulled into clinical practices that they’re no longer familiar with. We’re doing the same with our anesthesia providers, who know how to run ventilators, know how to intubate patients and do procedures. The anesthesia group here in southern Oregon, Anesthesia Associates of Medford, is on board to come in and support our emergency department to do procedures as well as support our ICU in rounding on critical care patients and running their ventilators for us.

Miller: I have to say you both sound calm right now. But everything you’re talking about.. it makes me feel like you’re a MASH unit, that you’re in the middle of a war and just triaging as best as you can. The word you used just there, Dr. Kuhl, was it’s unorthodox. It also sounds terrifying.

Gray: You raise a good point and that really leads to, as you mentioned, the moral distress that the staff are experiencing. This has been going on now for 16, 17 months. To many staff it’s been like running a marathon at a sprinter’s pace and the emotional, the physical reserves are exhausted. Things in the civilian world we had hoped and had never really trained for.

Miller: Dr. Gray, how is this time different emotionally than the previous surges which happened before vaccines were widely available? We can’t say this enough: so much of what we’re talking about is preventable. The vast majority of people who are hospitalized or in ICUs right now are unvaccinated. They would not be there if they had been vaccinated. I’m curious how that affects the morale of caregivers.

Gray: That’s a great point. What we’re seeing here in Roseburg is that about 90% of our COVID patients are unvaccinated, very slightly day by day. It is a bit discouraging to many of the caregivers when they are seeing the end effects of a potentially preventable disease — preventing hospitalizations, preventing deaths — by vaccines. Early on in the course, there was a lot unknown about what is COVID, how is it spread, how do we treat it. Fortunately, over the course of the year and a half, we’ve learned a lot about that. Now, though, it is that fatigue, that burnout aspect and that frustration with the potentially unvaccinated segments of population that can be contributing to this.

Miller: Dr. Kuhl, the phrase Dr. Gray used right there was that it can be a bit discouraging for staff. I’ve got to say that that strikes me as gentle language. I can imagine some health care professionals are much more upset than that.

Kuhl: Yeah, to be frank about it, it is difficult. I think there is growing frustration and it stems from the fatigue. It’s exhausting to see preventable deaths in the unvaccinated population. Jackson County, Region 5 has had the most COVID-related deaths, I think, running for the past two weeks. And by far the highest case count of COVID patients are new cases burgeoning over the past week. It’s heartbreaking to have to deal with it. It is difficult to see that we can’t provide care to both our COVID patients and non-COVID patients to the level we’d like to or are used to. Out in the community here in Jackson County, I was saying this morning that, going into stores, people may wear masks into the store but quickly take them down in somewhat of a sign, it seems like, of civil disobedience. It’s hard to see that and then come to work and work long hours, be asked to work overtime for days on end and put your own self in harm’s way to care for these individuals. So again, the moral distress is there, the compassion fatigue is there. What we’ve been telling staff is that it’s our job to come in to care for anyone who enters our doors. It’s our mission and our service to our community and we’ll continue to do that. And I know everybody has their rights to choose to not get vaccinated, but there is a social responsibility that goes along with that. That if you choose not to get vaccinated, please don’t put everybody else in the community at risk because of that choice.

Miller: Jason Gray, I’m curious if you ever thought that you’d be in a situation like this where a not insignificant number of people in your community, including many elected officials in Oregon and all around the country, just don’t believe you when you are saying things in attempt to save their lives or save the lives of other people in the community.

Gray: Yeah, I agree. I think none of us ever believed we’d be in this situation. The degree to which vaccination and face masking has become politicized is really astonishing. It’s very difficult now to have a rational, objective discussion about vaccines or face masks with a larger society. I think Dr. Kuhl really summed it up well: it is difficult for our staff yet our staff are still — ingrained in our psyche — we still take care of whoever comes in that door, regardless of the decisions or the omission of decisions they’ve made that put them in this place.

Miller: You mentioned staff. We’re going to hear, after a short break, directly from ICU nurses in the Portland area. But Jason Kuhl and Jason Gray, thanks very much for joining us today.

Kuhl: Thank you.

Gray: Thank you, appreciate it.

Miller: Jason Gray is the Chief Medical Officer at CHI Mercy Health in Roseburg. Jason Kuhl is the Chief Medical Officer for Providence Medford Medical Center.

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