For 18 months now, local health officials have warned that a potential surge of COVID-19 cases had the potential to tear through the community with exponential growth and overwhelm Humboldt County's fragile healthcare system. And as the Journal went to press Aug. 31, closing what was by far the darkest month yet locally in the pandemic, it was clear that moment is upon us.
The numbers are grim. The county confirmed 2,004 cases for the month — more than it saw combined in the post-holiday surges of December and January — to go with 98 hospitalizations, which account for 30 percent of the county's total to date. Most alarmingly, the county — home to 0.003 percent of the state's population — recorded 22 deaths in August, roughly 1.5 percent of the state's COVID death toll for the month.
With this as a backdrop, Humboldt County Health Officer Ian Hoffman on Aug. 30 responded to an email from a local doctor that had been sitting in his inbox for a couple days. In it, the doctor pressed Hoffman as to why the county wasn't doing more to report cases and vaccination information by ZIP code to offer a localized risk assessment. Hoffman's response was blunt.
"The current state of COVID-19 in our community is that it is endemic, meaning it is everywhere," he wrote. "We should all assume now we come into (contact with) multiple people a day who have COVID-19, regardless of where you live in Humboldt. ... Spatial analysis was helpful earlier in the pandemic when the disease was not so endemic. Now, our only real tool to get out of this is vaccination."
But vaccination efforts have simply not kept pace with the spread of the highly contagious Delta variant and local systems have begun to buckle under the weight of the surge. Public Health has revamped its data collection and contact tracing efforts as staff — reduced with less state support in the wake of the state's June 15 lifting of most COVID-19 restrictions — has struggled to keep up with soaring caseloads. Local hospital capacity, meanwhile, has been pushed to the brink, with a record 38 COVID-19 patients, including a record 13 under intensive care as the Journal went to press, according to state database. And because hospitalizations generally trend a couple of weeks behind case counts, it seems the situation will almost assuredly get worse before it gets better.
The View from the ICU
When Karis Hassler answers the phone on Sunday, Aug. 29, the exhaustion is immediately evident in her voice. As the ICU nurse manager at St. Joseph Hospital, which cares for the vast majority of the county's COVID-19 patients and nearly all of those who are critically ill, Hassler is tasked with making sure the hospital's intensive care unit is staffed with enough nurses to care for its patients. It's a daily struggle, she says, especially as her staff grapples with burnout and fatigue as patients keep arriving — and dying — at an unprecedented rate.
"My unit is full of COVID," she says. "And as soon as a room empties because of tragedy, it fills right back up. ... We are caring for people who are our age and younger, and they're dying. And we're giving them everything we have. It's hard. A lot of what I'm doing right now is trying to figure out how to emotionally support these nurses who are beyond their breaking point right now."
While recruiting and retaining nurses has long been a challenge in Humboldt County, the pandemic has made it far worse. Burnout and fatigue are significant, Hassler says, adding that her unit has seen "quite a bit of turnover" over the last year and a half. Some nurses have simply re-evaluated their priorities and moved closer to family, she says, while the stress of treating COVID-19 patients has pushed others to leave intensive care nursing all together. Meanwhile, nurses have never been in higher demand, she says, so some have left to take traveling nursing jobs that promise pay as high as $10,000 a week.
So adequately staffing St. Joseph's ICU while giving nurses the time off needed to recharge between shifts has been an incredibly heavy lift, Hassler says.
"My days typically start at 6 o'clock in the morning if I don't get any 3 a.m. calls or texts," she says. "Then, I'm usually up until 9 p.m. or later trying to do work, just preparation and planning."
Hassler says the hospital has been searching out help from all corners — traveling nurses, staffing agencies, recruitment efforts — but securing reinforcements has been difficult. Sometimes, she says, she'll contract a traveling nurse only to have them not show up the day they're expected. The need, she says, is "just so vast across our nation."
And caring for COVID-19 patients takes a unique toll on providers, Hassler says, noting that a trauma surgeon at the hospital likened it to responding to "an extremely slow moving mass casualty event." First, she says, there's the sheer volume of patients, all of whom need intensive monitoring and care, which, coupled with hypervigilance and time needed to methodically don and take off personal protective equipment between interactions, is exhausting. And in a small community, that volume of patients almost ensures caregivers will have some connection to at least some of their patients — maybe their kids go to the same school or they are a friend of a family member — which adds to the trauma, especially when patients are isolated and can't have visitors. Then, she says, the disease is unpredictable and fast moving, even more so with the Delta variant.
"They're sicker," she says of the latest wave of patients. "And we've had instances where we think someone's doing great — they're up and walking around, even with their high flow oxygen, they can walk from bed to their recliner — then, suddenly, they're gone. These are people that my caregivers know in their personal lives. ... It's just a lot of grief. A lot of grief. We're experiencing a tremendous amount of tragedy."
Back in the December surge, staff pushed through, feeling they were holding the line for the community until a vaccine could provide a "light at the end of the tunnel," Hassler says. That hope has been replaced by the frustration of knowing nearly every case is preventable. (Hassler says it's "very rare" that a vaccinated patient comes into the ICU.)
"There are times where we struggle with anger," she says. "We're trying to be very careful about that. We chose this profession to help people. And sometimes the amount of hopelessness that comes with this pandemic is not what we were called here to do."
During an Aug. 26 virtual press conference, four masked local health officials took turns urging local residents to get vaccinated and warning that widespread vaccination will provide the only road out of this current surge and out of the pandemic.
"Data from the New York Times a couple of weeks ago showed that, in California, unvaccinated people are about 68 times more likely to be hospitalized with COVID than vaccinated people and 58 times more like to die, and state and local data bear those trends out, as well," said Communicable Disease Program Supervisor Hava Phillips.
Moments later, Hoffman said while vaccination is incredibly effective at preventing severe disease, hospitalization and death, local data also indicates its effective at reducing transmission. On Aug. 27, the county released data showing that daily case rates among fully vaccinated residents have dropped sharply since the county reinstated a mandatory masking order Aug. 7 — falling from 28 cases per 100,000 residents to 16 — rates among unvaccinated residents continue to rise, hitting 83 percent 100,000 residents.
Illustrating the informational divide fueling the pandemic, Hoffman concluded his introductory remarks at the press conference with a warning for residents regarding ivermectin, an anti-parasitic medication most commonly found in livestock dewormers.
"If you're hearing things about ivermectin being good for treating COVID, this is not a recommended treatment," he said. "It's well proven that it doesn't do anything to prevent severe outcomes or hospitalizations with COVID-19 and it is potentially very dangerous."
Responding to inquiries from the Journal, local feed and farm stores said they are increasingly getting calls from residents looking for ivermectin. One store manager reported his store had seen enough potential customers seeking out the stuff that it had taken the precautionary step of moving its only ivermectin product — an apple-flavored paste used for deworming horses — behind the counter.
Paul Shen, a hospitalist who also works in St. Joseph Hospital's ICU, recently had two COVID-19 patients die within a couple of days of each other. The first was a 45-year-old man. He was unknowingly a borderline diabetic and a bit overweight, but otherwise "pretty healthy and active" with no serious underlying conditions.
"He told me, 'I don't believe this COVID bullshit," Shen says, the disbelief still evident in his voice over the phone. "By the time he was there for a few days, toward the end of his life, he got it. He told me, 'I'm going to think about what you said about the vaccine.' Then he died."
Shen's voice trails off for a moment.
"It just feels like a waste of human life," he says. "Ninety percent of my patients that I discharge are actively looking to get vaccinated afterward. Because they understand. They've experienced it. I just don't understand why we're not learning from the entire country's collective experience of people getting sick and dying."
Shen has other stories, too. There was the 39-year-old rock climber and distance swimmer who had COVID and "recovered," but couldn't understand why he still couldn't walk 10 feet without getting short of breath. Shen says he explained that the man's COVID-19 induced inflammation had died down and he had no blood clots, that "the pieces I can treat from COVID, they're all treated."
"I said, 'I'm sorry, can I just ask you why you didn't get the vaccine?'" Shen says, "He just put his head in his hands and said, 'I just didn't,' and was obviously very regretful at that point."
Then, Shen says, there are patients for whom he's detailed a course of treatment only to have them or their family member Google an experimental drug or therapy on their phones and ask why Shen hasn't recommended it. Usually, Shen says, they are depending on articles or social media posts from "unverified, poorly documented sources."
"I don't know what's going on with information or misinformation on the internet these days but it's really causing a problem for us on the front lines," he says. "It definitely is a source of burnout. ... I went through a lot of training to become an expert in this field. Having to convince someone I know what I'm doing, I've never encountered that with any disease in the past. It's a new territory and it's hard to process."
The current situation in the ICU feels senseless, Shen says, with unvaccinated people coming in at escalating rates when there is a free preventative measure readily available. He says providers also have to grapple with the fact that they're treating patients whose decision not to have gotten vaccinated has put providers — and their families — at increased risk.
"The providers that I work with, the doctors, many just feel defeated," he says. "Some are very angry, just having to deal with something that's preventable, yet many people decide the vaccine is not for them because of a lifestyle choice. But that lifestyle choice endangers those around them, including hospital staff and their doctors. It just doesn't seem socially responsible."
Shen says the Delta variant is proving harder to treat than past iterations of COVID-19, and that patients are coming in sicker into the ICU — sicker, and younger. But it's the breakdown of some COVID-19 patient's trust in their providers that's been the hardest to square, he says.
"It does feel like a slight, like I'm being dismissed," he says. "It's disheartening having to deal with disease that could have been prevented. On both fronts, I feel somewhat defeated."
On the morning of Aug. 30, Hassler answers the Journal's phone call for a scheduled follow up interview but says she can't talk — she has to orient a new nurse who just arrived at the hospital. When she calls back a short time later, Hassler says the state is sending a team of nurses to work in St. Joseph's ICU the following day — but she won't say how many. She's used to these things falling through and doesn't want to count chickens — or even hope for chickens — until they've hatched.
And while there was a brief time when Hassler says she hoped the state team might give her nurses a reprieve — maybe some time off to de-stress and recharge — the continuing rise in hospitalizations will likely make that impossible.
"I think it's still going to be all-hands-on-deck," she says, adding that the reverberations of the current caseloads are felt throughout the system. The burnout, she says, extends beyond doctors and nurses to respiratory therapists, the environmental services team, radiology, lab workers, biomed technicians and even the hospital's supply department, which has to make sure providers have everything they need to care for patients, from PPE to oxygen. "It's a tremendous lift from the entire care team."
And, Shen and Hassler say, there's a growing fear things will only get worse before they get better.
Hassler says St. Joseph — which has a plan to surge to as many as 80 COVID beds — is constantly looking at how it will care for the next wave of patients. The hospital has a lot of ventilators and a lot of resources it has yet to use, she says.
"Each day, we're just waiting to see if we need to expand our ICU or even put two patients in one room, and that's terrifying," she says.
Officials have repeatedly said beds and ventilators won't be the limiting factor in the local healthcare system's ability to provide care amid a COVID surge, but the number of trained professionals that can be tapped to staff those beds will be. When systems have been pushed to the brink elsewhere, it's led to devastating impacts, with healthcare workers in Los Angeles and New York forced to triage care, deciding which patients should be prioritized for limited supplies and staff. In some places, those decisions have had profound impacts on caregivers' mental health, leading to suicides. Hassler says she's grateful a plan is in place at St. Joseph to form an independent panel that will take those decisions out of the hands of bedside providers, should they become necessary.
"It's just frightening to think that it looks like it is possible, that we could get there," she says. "That's alarming. That's extremely alarming when there is a free and available preventative measure."
The bottom line, Hassler says, is caregivers are exhausted, burnt out and scared the worst is yet to come, as new COVID-19 patients continue to show up daily.
"They're just — they're breaking," she says, adding that she hopes the community will step up to care for its caregivers by masking, practicing social distancing and hand washing, avoiding gatherings and, most of all, getting vaccinated.
"We just need everybody to do their part," she says.
Thadeus Greenson (he/him) is the Journal's news editor. Reach him at 442-1400, extension 321, or firstname.lastname@example.org. Follow him on Twitter @thadeusgreenson.