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Israeli hospitals see first signs of system’s collapse from coronavirus

The Ein Karem branch of Hadassah Hospital in Jerusalem recently closed its internal medicine ward’s intensive care unit, which is supposed to treat the ward’s non-coronavirus patients. The unit’s staff was needed to augment the coronavirus ICU, which currently has 22 patients in very serious condition and on ventilators.

The closure left the hospital with only one non-coronavirus ICU – the one in the surgery ward, which is meant to handle post-operative patients and trauma victims. It is currently at full capacity.

“But the surgical ICU doesn’t have enough space,” said Prof. Dror Mevorach, who is currently running the regular internal medicine ward as well as one of the hospital’s four coronavirus wards. “Right now I have a [non-coronavirus] patient who needs intensive care, and I have no place to move him. So we’re forced to treat him in the ward.”

Hadassah isn’t alone. Due to the rise in the number of seriously ill coronavirus patients – which is currently nearing 400, including 118 on ventilators – many hospitals’ ICUs are under heavy pressure. And as their activity becomes increasingly devoted to coronavirus patients, regular patients are paying the price.

Mevorach termed the situation at Hadassah Ein Karem as “the first signs of a collapse.”

“Admittedly, it isn’t the kind of collapse we saw in Italy or Spain, where they reached the point of not ventilating patients,” he said.

“But the moment you don’t have [ICU] space to care for patients from the regular ward, that’s the beginning of a collapse.”

“Granted, Jerusalem is a ‘red’ city,” he added, referring to cities with a particularly high concentration of coronavirus patients. “But what’s happening now in the hospitals here could soon become the norm in hospitals throughout Israel, thanks to the opening of the school year and the winter.”

Roughly a quarter of Hadassah Ein Karem’s 85 coronavirus patients have only mild cases, and a few have moderate cases. But most are seriously ill, including the 22 on ventilators.

Moreover, when talking about hospitalized coronavirus patients, Mevorach said, “mild” only refers to their coronavirus symptoms.

“They have other diseases too, like cancer or heart failure, which create additional problems.”

Ever since the coronavirus began spreading in Israel in February, medical staffers have been working seven days a week, aside from the brief three-week period during which the number of patients declined.

“Permanent pressure on the medical staff is also a sign of collapse,” Mevorach said. “We’re working seven days a week. We currently have four doctors in quarantine, and the number of patients is rising. Every coronavirus ward has 20 beds, and in recent days, we haven’t had a day with fewer than 18 patients in the ward.”

Though some experts say the virus’ reproductive rate seems to be declining, “we haven’t felt it,” he added.

Shaare Zedek Medical Center in Jerusalem has 55 coronavirus patients, about a third of whom are seriously ill. Over the past two weeks, it has had to transfer some of its coronavirus patients to hospitals in the center of the country so that it will still be able to treat other patients. This indicates that if current trends continue, even hospitals in areas without high concentrations of coronavirus patients may become overloaded.

Dr. Joseph Mendelovich, Shaare Zedek’s deputy director for medicine, said the workload was lower during the first wave of the virus, because non-coronavirus patients largely stayed away.

“But it was clear that this was temporary. In the second wave, hospitals with 1,000 beds are at full occupancy, with patients in the corridors. And on top of that, we’re also operating a full coronavirus system.”

ICUs are the weak link at Shaare Zedek, too. “We’re significantly short of staff,” Mendelovich said. “We’ve reduced the volume of activity in regular intensive care to divert staff” to the coronavirus ICU.

“We’re careful not to lower the standard of care, but we’re paying a price for this,” he added. “People are pushing themselves to their limits – doing extra shifts, not taking vacations. And it’s only summer, not yet the peak of the hospitalization season, which comes in winter.”

Rambam Medical Center in Haifa has also closed its internal medicine ICU to bolster its coronavirus wards. Dr. Michael Halberthal, the hospital’s director, said Rambam always has a heavy workload “because seriously ill patients from the entire north come to us.” Until recently, however, it had only one coronavirus ward.

“But yesterday we were asked to open another ward, and we were forced to close the internal medicine ICU to do it,” he said. Now, it’s “engaged in a juggling act” to try to treat both coronavirus and non-coronavirus patients by using all the hospital’s other ICUs – “the surgery ICU, the cardiology ICU, even the pediatric ICU.”

The hospital has 10 seriously ill coronavirus patients. Of these, six require ventilators, including two who need ECMOs, which are similar to heart-lung bypass machines.

In preparation for a future war in which it might come under missile fire, Rambam has an underground facility in addition to its regular facility. “The underground hospital has 770 beds and 170 ICU slots,” Halberthal said.

“But activating it for coronavirus patients would almost completely shut down all other hospital activities,” due to the shortage of staff.

At Sheba Medical Center in Tel Hashomer, the number of regular ICU beds has been cut in half because so much of the ICU staff has been transferred to the coronavirus ICU. Most of Sheba’s 33 coronavirus patients are seriously ill, including nine on ventilators.

“We have four patients on ECMOs, and this takes up a large portion of our ICU staff,” said Prof. Ehud Grossman, director of the hospital’s internal medicine department. “We’ve reduced the number of beds for regular patients by more than 50 percent. Coronavirus patients require a lot of energy and resources.

“ECMO treatment requires having a staffer with the patient round the clock,” he explained. “And given the conditions under which the staff is working, with protective gear, every staffer has to leave every so often, requiring someone to replace him, since the patient mustn’t be left unmonitored.

“Unlike during the first wave, the patients connected to ECMOs today are people who are nearly healthy otherwise – people aged 50 to 60, with a few blood pressure problems,” he added.

Grossman said that “based on the models and forecasts we were given, there should have been around 310 seriously ill patients nationwide. We’re already close to 400. Until a few days ago, the number of patients on ventilators was 99, and now it’s already 118. The forecasts aren’t exactly coming true.

“We’re on the brink,” he added. “If this is the direction, and nobody does anything, we’ll reach collapse.”

Late last week, the so-called “barometer” task force issued its first report. The task force consists of senior hospital physicians charged by the coronavirus point man, Prof. Ronni Gamzu, with monitoring the hospitals’ situation and warning him when they’re approaching collapse.

The report noted that unlike during the first wave of the virus, when non-coronavirus patients largely stayed away, today the volume of non-coronavirus patients is almost back to normal.

But coronavirus wards need a staff-to-patient level almost double what other patients require, and they also need more equipment. This causes “an asymmetry in the allocation of staff and equipment in favor of the coronavirus wards,” it said.

The result is that 30 to 50 percent of ICU resources nationwide are now devoted to coronavirus patients, along with 25 to 50 percent of internal medicine resources.

The situation is worst at hospitals in the Jerusalem and Tel Aviv areas, since they are handling most of the coronavirus patients.

Medical staffers at most hospitals have heavy workloads, especially in coronavirus wards, and “over time, burnout will undermine the hospitals’ ability to cope,” the report said. “At some hospitals, signs of burnout are already evident, and their ability to cope has eroded.”

Header: A coronavirus unit at Sheba Medical Center, Tel Hashomer in July, 2020. Credit: Emil Salman

Source: Ido Efrati – HAARETZ