Tagged Hospitals

Nursing Homes Have Thousands Of Ventilators That Hospitals Desperately Need

As the number of COVID-19 patients climbs and health officials hunt for ventilators to treat them, nursing homes across the United States have a cache ― about 8,200 of the lifesaving machines, according to data from the Centers for Medicare & Medicaid Services.

Most of the machines are in use, often by people who’ve suffered a brain injury or stroke. Some of those residents are in a vegetative state and have remained on a ventilator for years.

State officials are working to consolidate ventilators where they are most urgently needed. But so far, the supply in nursing homes has not drawn the same attention.

Or course, commandeering those units would set up a monumental ethical dilemma: Do you remove life support for a long-term nursing care patient in order to give a COVID-19 patient a better chance of survival?

The highest number of machines, about 2,300, is in California, where the state has created designated nursing home units for people on life support, officially called subacute units but known pejoratively by some doctors as “vent farms.” New York has the second most, 1,822, according to state officials.

Already, one nursing home on Long Island has lent a nearby hospital 11 ventilators that were not being used, leaving just five for its residents.

“The hospital came to us last week and asked, ‘Do you have any ventilators?’” the nursing home assistant administrator said on the condition of anonymity because he was not authorized to speak to the news media.

“We left ourselves with the bare minimum,” he said. In all, three hospitals reached out to the nursing home for ventilators ― it had to say no to the other two.

New York Gov. Andrew Cuomo has announced an executive order that ventilators not in use by hospitals be redeployed to ICUs. And he’s calling in the New York National Guard to facilitate the order. “We know where every ventilator is,” Cuomo said Sunday.

Nursing home ventilators are not included in his order, but they are included in the state’s tally of the machines.

Dr. Michael Kalafer, a pulmonologist and the medical director at two San Diego subacute units, said he can’t imagine taking one of his patients off a ventilator because it’s needed for someone else.

“I severely doubt we’ll take [a hypothetical] Mrs. Smith off a ventilator because she’s 80 and has been on it for a few years and has not gotten better,” Kalafer said.

But these are precisely the decisions bioethicists are being asked to weigh in on as the country confronts the crush of COVID-19 patients overwhelming the health care system.

And in some cases, states have already decided to give people who are severely brain-injured a lower priority when it comes to access to ventilators. Disability advocates oppose such guidelines and filed complaints with the Department of Health and Human Services last month, according to ProPublica. And although states and health associations can draw up recommendations, they are not legally binding.

“From an ethical point of view, for people who are not conscious, if it’s a matter of removing people from a [ventilator] who are not going to recover, I think it’s a hard decision, but one that in an emergency has to be made,” said Ronald Bayer, a professor of sociomedical sciences at the Mailman School of Public Health at Columbia University.

Bayer has been a member of the World Health Organization and in 2011 served on an ethics subcommittee that advised the Centers for Disease Control and Prevention on the allocation of ventilators in the event of a severe pandemic.

He and several other ethicists said these decisions should not be made at the bedside but by triage committees or people in supervisory roles. And the guidelines ought to be uniform and transparent. That’s why the CDC, the state of New York and medical associations like the American College of Chest Physicians have drafted ethical recommendations for deciding how to ration lifesaving equipment like ventilators in the event of a pandemic.

The California Department of Public Health in 2008 released guidelines to follow during a health care surge: They don’t specifically address ventilator allocation, but rather resources in general. Doctors should consider the likelihood of survival and change in the quality of life as opposed to the ability to pay or the perception of a person’s worth when there are not enough medical resources to treat everyone in need.

When the New York State Task Force on Life and the Law updated its ventilator allocation guidelines in 2015, it considered the question of withdrawing ventilators from nursing home residents, or chronic ventilator patients, to save the lives of those who grow critically ill during a pandemic.

“Are we comfortable sacrificing this group in exchange for saving more lives?” asked Stuart Sherman, the executive director of the task force at the time.

That question drew much debate, but the group ultimately decided that “chronic” vent patients should not be included in the pool when considering how to allocate ventilators during a pandemic. The task force does recommend prioritizing ventilator therapy based on who is likely to survive using a SOFA ― Sequential Organ Failure Assessment ― score.

Cuomo, whose daily televised news conferences have made “ventilators” a household word, is not making decisions based on those guidelines. The task force report is not a binding policy document, according to a spokesperson from the governor’s office.

In the U.S., there are about 62,000 “full-featured ventilators,” the kind needed to treat the most severe cases of COVID-19. An additional 10,000 to 20,000 ventilators are in the government’s National Strategic Stockpile, and 98,000 basic models, the kind often in nursing homes, exist that could be used in a crisis.

In the simplest terms, ventilators push oxygen into the lungs. The machines in ICUs are more powerful and have better monitoring systems than those in a nursing home.

Kalafer’s patients need ventilators to do the work for respiratory muscles. He said they could be used in a pinch during the pandemic. But the real issue is finding enough staff trained to operate and monitor the machines.

Meanwhile, a group of bioethicists, physicians and public health experts are recommending that in a shortage, health care workers could disconnect people from ventilators who have little or no chance of recovery to put them in service of those who do.

The recommendation is the first of six listed in an article published in the New England Journal of Medicine last month.

It did not consider the people who’ve been on vents long term.

“Honestly, before you emailed me, I thought about those patients but never thought about the actual number and how important that might be,” said Dr. James Phillips, one of the paper’s authors and chief of disaster and operational medicine at George Washington University Hospital.

“For patients who have devastating neurological injury and are deemed to never recover and who require ventilation for the rest of their lives, I think it’s an ethical conversation to have with those families to determine if it’s a more appropriate use of resources,” Phillips said.

One ventilator can save multiple lives. The average time a person sick with COVID-19 who needed a ventilator was 11 days, according to an NEJM article that looked at critically ill patients in the Seattle region. Using that number, eight people could potentially be saved over three months.

It is an especially complex moral dilemma when considering the withdrawal of treatment from someone who has lived several years on a ventilator, said Govind Persad, an assistant professor at the University of Denver Sturm College of Law and one of the authors of the NEJM paper.

Persad offered a hypothetical scenario.

“A 78-year-old grandmother has been on ventilator support for 5 years in a subacute facility and is expected to remain on it for the foreseeable future. Covid-19 has reached a senior apartment complex nearby, and doctors are looking everywhere for more ventilators,” Persad wrote.

“They think one more ventilator would give them a chance of saving another 78-year-old grandmother in the senior apartments who is growing worse with viral pneumonia, and, once she is off the ventilator, to save some of her neighbors, who are not yet sick but who they expect to be sick in a few weeks.”

Who gets the ventilator?

Persad suggested it should go to the grandmother in the senior apartments because she is likely to need less time on the ventilator, enabling the ventilator to be used to save her neighbors later.

As he put it: “We save her in order to save more lives, not because of quality-of-life judgments.”

The real-life decision is more problematic and heart-wrenching.

Nancy Curcio’s daughter Maria, who was born with a disabling form of cerebral palsy, was on a ventilator as an adult in San Diego for about three months in 2004. She was eventually weaned off the machine but lived the remainder of her life in a nursing home with a breathing and feeding tube, unable to walk or talk. She died in 2017 at age 57.

“I would be very upset if a doctor said I have to take her ventilator away for someone to live,” Curcio said. “But I can understand in triage this is what a doctor has to do. Would I like it? No. I would want to run away with the ventilator.”

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Aging California Health Industry Public Health States

Cancer Patients Face Treatment Delays And Uncertainty As Coronavirus Cripples Hospitals

The federal government has encouraged health centers to delay nonessential surgeries while weighing the severity of patients’ conditions and the availability of personal protective equipment, beds and staffing at hospitals.

People with cancer are among those at high risk of complications if infected with the new coronavirus. It’s estimated 1.8 million people will be diagnosed with cancer in the U.S. this year. More than 600,000 people are receiving chemotherapy.

That means millions of Americans may be navigating unforeseen challenges to getting care.

Christine Rayburn in Olympia, Washington, was diagnosed with breast cancer in mid-February. The new coronavirus was in the news, but the 48-year-old did not imagine the outbreak would affect her. Her doctor said Rayburn needed to start treatment immediately. The cancer had already spread to her lymph nodes.

“The cancer tumor seemed to have attached itself to a nerve,” said Rayburn, who was a schoolteacher for many years. “I feel pain from it on a regular basis.”

After getting her diagnosis and the treatment plan from her medical team, Rayburn was focused on getting surgery as fast as possible.

Meanwhile, the coronavirus outbreak was getting worse, and Seattle, just an hour north of where Rayburn lives, had become a national focal point.

Rayburn’s husband, David Forsberg, began to get a little nervous about whether his wife’s procedure would go forward as planned.

“It did cross my mind,” he said. “But I did not want to bother with that possibility on top of everything else.”

Two days before Rayburn’s lumpectomy to remove the tumor, Forsberg said, the surgeon phoned, “pretty livid” with bad news. “She said, ‘Look, they’ve canceled it indefinitely,’” Forsberg remembered.

The procedure had been scheduled at Providence St. Peter Hospital in Olympia, a facility run by Providence Health & Services. Across Washington, hospitals were calling off elective surgeries, in order to conserve the limited supply of personal protective equipment, or PPE, and to prevent patients and staffers from unnecessary exposure to the new coronavirus.

“It just felt like one of those really bad movies, and I was being sacrificed,” Rayburn said.

“It was like we just got cut off from the experts we were relying on,” her husband said.

The hospital said it would review the decision in a few weeks. But Rayburn’s surgeon said that was too long to wait, and they needed to move to Plan B, which was to begin chemotherapy.

Originally, chemotherapy was supposed to happen after Rayburn’s tumor surgery. And rearranging the treatment plan wasn’t ideal because chemotherapy isn’t shown to significantly shrink tumors in Rayburn’s type of breast cancer.

Still, chemotherapy could help stop the cancer from spreading further. But as the couple figured out the new treatment plan, they ran into more obstacles.

“She needed an echocardiogram, except they had canceled all echocardiograms,” said Forsberg.

They spent days on the phone trying to get all the pieces in place so she could start chemotherapy. Rayburn also started writing to her local lawmakers about her predicament.

Hospitals Prioritize Urgent Cases

In mid-March, Washington Gov. Jay Inslee banned most elective procedures, but he did carve out exceptions for certain urgent, life-threatening situations.

“It actually said that it [the ban] excluded removing cancerous tumors,” Rayburn said.

Providence hospitals use algorithms and a team of physicians to figure out which surgeries can be delayed, said Elaine Couture, chief executive of Providence Health in the Washington-Montana region.

“There are no perfect decisions at all in any of this,” said Couture. “None.”

Couture would not talk about specific patients but said she assumes other cases were more urgent than Rayburn’s.

“Were there other patients that even had more aggressive types of cancer that were [surgically] completed?” Couture said. “As sick as you are, there can be other people that are needing something even sooner than you do.”

Couture said hospitals are burning through supplies of masks, gowns and gloves and need to make tough calls about elective procedures.

“I don’t like that, either, and it’s not the way that we want our health care system to work,” Couture said.

Across the Providence hospital system, personal protective equipment is being used much faster than it can be replenished, she said.

No Single Standard

At the American Cancer Society, Deputy Chief Medical Officer Dr. Len Lichtenfeld is hearing from patients across the country who are having their chemotherapy delayed or surgery canceled.

“There was someone who had a brain tumor who was told they would not be able to have surgery, which was, basically, and appears to be a death sentence for that patient,” said Lichtenfeld.

This is uncharted territory for cancer care, he said. Hospitals are making these “decisions on the fly” in response to how the pandemic looks in a particular community. “There is no single national standard that can be applied. I am afraid this is going to become much more common in the coming weeks.”

The cancer society recommends that people postpone their routine cancer screenings — for now.

The American College of Surgeons has published guidance on how to triage surgical care for cancer patients. But Lichtenfeld said every decision ultimately depends on the availability of resources at the hospital and the pressures of COVID-19. In Washington state, which has been hit hard, hospitals are shifting surgical space and beds away from other kinds of treatment.

“We need to forecast two to three weeks down the line when there are more patients that are ill,” said Dr. Steven Pergam, medical director of infection prevention at the Seattle Cancer Care Alliance. “We need to make sure there’s adequate bed capacity.”

Pergam said the care alliance is adjusting treatment plans and, at times, avoiding procedures that would keep cancer patients in the hospital for a prolonged period.

“It really depends on the cancer and the aggressive nature of it,” he said. “We have looked at giving chemotherapy in the outpatient department and changing the particular regimens people get to make them less toxic.”

But Pergam said they expect to keep doing urgent surgeries for cancer patients, even as the pandemic grows worse.

Christine Rayburn in Olympia was steeling herself for the months of chemotherapy to come: staying inside her home and even avoiding contact with her adult daughters, to avoid any possible exposure to the coronavirus.

Then, two weeks ago, the surgeon called again. She had persuaded the hospital to allow the surgery after all, 10 days later than initially planned.

Rayburn and her husband wonder what would have happened if they hadn’t spoken up or pushed to get her lumpectomy back on the hospital’s surgical schedule. Forsberg said it’s possible they could have ended up without the care Rayburn needed.

“If we didn’t say anything, in my mind that may be where we would be at,” he said. “But in our minds, that was not an option.”

This story is part of a partnership between NPR and Kaiser Health News.

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Multimedia Public Health

‘You’ve Been Served’: Wisconsin Hospitals Sued Patients Even During Pandemic

When her doorbell rang Sunday night, Blanche Jordan was just starting a new Game of Thrones puzzle on her living room floor.

Jordan, 39, is a breast-cancer survivor who is taking social distancing seriously, so she put on a mask before opening the door. A woman handed Jordan a paper and said: “You’ve been served.”

The paper was a court summons that said Froedtert Memorial Lutheran Hospital, Inc. was suing Jordan for $7,150. Just three weeks before, Jordan had paid off a different $5,000-plus Froedtert debt linked to a hysterectomy that her insurance did not cover.

A lawsuit was the last thing Jordan expected during a viral pandemic.

“This lady came to my door. She didn’t have a mask on. She didn’t have gloves. And she looked at me like I’m crazy because I had a mask across my face,” said Jordan, who lives in Milwaukee and works as a caregiver at an assisted living facility outside of the city. “I’m high-risk,” she said.

Life in Wisconsin, as in the rest of the country, has been transformed by COVID-19 in the past three weeks. Wisconsin declared a public health emergency on March 12, yet firms representing health systems in the state continued to sue patients over medical debt.

Jordan is one of at least 46 people sued by Froedtert in small claims court since March 12. Those cases are among at least 104 similar suits filed statewide by health systems over the same period, according to an analysis of small claims cases by Wisconsin Public Radio and Wisconsin Watch.

Steve Schooff, a spokesman for the hospital, said Tuesday that Froedtert “suspended filing small claims suits” as of March 18 in response to COVID-19.

“In addition, we continue to work with patients related to financial counseling and are allowing patients with financial hardship who are on a payment plan to defer payments while financial assistance is discussed with them,” he said.

Yet court records at the time showed at least 18 lawsuits filed on the hospital’s behalf since then, including 15 filed on March 31 alone. (The suit against Jordan was filed on March 17; she was served on March 29.) Schooff did not explain the discrepancy. All 18 of those cases have since been dismissed.

‘Really? In The Middle Of All This?’

Court records show that at least six additional health systems have also sued patients during the pandemic.

UW Health in Madison has filed 19 lawsuits since March 12. Marshfield Clinic, which covers northern, central and western Wisconsin, has filed at least 14 since that date, followed by Bellin Health, based in Green Bay (11); La Crosse-based Gundersen Health System (10); and Aspirus Grand View Health System, which serves parts of northern Wisconsin (3). Froedtert South, which serves southeastern Wisconsin, also filed one suit.

Bellin chief operating officer and chief financial officer Jim Dietsche said Thursday the health system ceased legal actions on debt collection on March 18, and that the nine suits filed since then were “an error and we apologize for that.”

The five other systems contacted for this story said they have since paused certain legal actions, which court records support.

Tom Russell, a UW Health spokesman, said the health system instructed its legal agencies on March 26 “to cease pursuit of any legal activity.”

“These should be stopped for now,” he said.

Tom Duncan, vice president and chief operating officer for Froedtert South, said his system has generally “suspended filing small claim suits” during the pandemic. “However, in rare circumstances, certain small claim suits may be filed to preserve Froedtert South rights. For example: If a medical debt has been in existence for six years, and the statute of limitations is about to end.”

One Madison resident described being “mortified” when a process server knocked on her family’s door on March 28 to serve papers for a UW Health lawsuit over $1,135.90 in medical debt. UW Health filed that lawsuit before March 26. In a phone interview, the resident asked not to be named in this story because she was embarrassed by the debt related to her husband’s heart condition.

“I couldn’t believe someone would do that,” she said about receiving legal papers during a pandemic. “They’re our bills, but really? In the middle of all of this?”

The woman said her husband offered the process server sympathy, apologizing that the man had to serve papers during a public health emergency.

The woman, who works for a Madison-based nonprofit, saw things differently. “That’s a choice, too. I wouldn’t be able to sleep at night.”

Medical Debts And State Response

Some hospitals have stopped the practice of suing patients in recent months following investigative reporting by Kaiser Health News, MLK50, ProPublica and other outlets.

Jessica Roulette, an attorney with Legal Action of Wisconsin, which provides free legal services to low-income people, said medical bills often fall below things like rent, utilities and food in the “hierarchy of bills and obligations.” Most people facing hospital lawsuits are working and “underinsured,” with plans that leave them on the hook for thousands of dollars in health bills, Roulette said.

Bobby Peterson, executive director of ABC for Health, a nonprofit public-interest law firm in Madison, called it stressful under normal circumstances to face a medical debt lawsuit.

“Today it’s a whole new ballgame,” he said, referring to workers who have lost their jobs and possibly health insurance during the pandemic.

Peterson saw a possible disconnect between some hospitals’ recent decisions to stop suing and the law firms they’ve retained.

“Are the hospitals communicating their own policies internally? And are they communicating with their hired guns out there, making sure that they back off?” Peterson asked.

Paycheck To Paycheck

The state of Wisconsin considers Blanche Jordan, the Milwaukee caregiver, an “essential” worker during the pandemic, meaning her job is not subject to the “Safer At Home” order. She works five days each week at an assisted living facility from 7 a.m. to 3 p.m., alternating work on the weekends. The pay — $15.75 per hour — barely covers her expenses.

Rent, health insurance, utilities and the nearly $300 in garnishments by Froedtert that recently ended, left Jordan with little of her $1,300 biweekly paycheck to spend on other necessities. She filed for bankruptcy in 2016 when, despite being insured, she said she could no longer afford to pay off her debts from treating her aggressive breast cancer.

That journey briefly left her homeless following an eviction, but she generally manages to pay her current landlord on time, Jordan said.

“I’m blessed to have a landlord that’s understanding because his wife died of breast cancer,” she said.

Jordan said her most recent medical debt stemmed from a hysterectomy that was separate from but related to her cancer treatment. She chose Froedtert to perform the procedure, considering it “the best hospital that we have in Wisconsin.”

What she did not realize, she said: Froedtert did not accept her insurance, which she purchased on a federal exchange created by the Affordable Care Act. Hospital administrators accepted and ran her insurance card, Jordan said, but never mentioned that her insurer would not cover the procedure.

In 2019, a judge in the Milwaukee County Small Claims Commissioner Court awarded Froedtert a judgment against Jordan for about $5,300, including court fees, which the hospital claimed by garnishment of her wages. She finished paying that debt during the first week of March — only to be served papers for the alleged $7,150 debt three weeks later.

Jordan assumes this covers the remainder of the bill for her hysterectomy, which she remembers totaling around $12,000. Wisconsin caps small claims at $10,000.

She will eventually see her day in court, although it’s not clear when. The coronavirus postponed her court date to May 28, assuming court proceedings resume by then.

Until then, Jordan will continue to take care of people at the assisted living facility, and she will otherwise stay isolated at home, she said, likely playing Scrabble or Uno with her family.

This story is part of a partnership that includes Wisconsin WatchWisconsin Public RadioNPR and Kaiser Health News.

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Cost and Quality Courts Health Care Costs Health Industry Insurance Public Health States

Must-Reads Of The Week From Brianna Labuskes

Hello! It is once again Friday, which means I’m going to attempt to do my very best to give you a snapshot of some (read: a fraction) of the best stories from the week amid a flood of them.

But first! Take yourself on this journey about how the most well-known coronavirus image (that gray blob with stone-like texture and red crowns and colored flecks) was made. Sometimes when the government is creating informational illustrations it focuses on the vector or the symptoms, but for this coronavirus the CDC’s Alissa Eckert and Dan Higgins went with what’s called a “beauty shot.” It’s a very cool read!

All right, here we go:

The confirmed number of confirmed cases globally ticked past a million this week in a grim milestone that experts still say represents only a percentage of the actual cases out there. The U.S. had recorded over 250,000 cases as of press time, with more than 6,500 deaths.

President Donald Trump invoked his wartime powers to help manufacturers secure supplies needed to make ventilators and protective face masks, but is it too little, too late? New York Gov. Andrew Cuomo, whose state has become the epicenter of the nation’s outbreak, said on Thursday it will use up all available ventilators in less than a week. Meanwhile, FEMA said that most of the ventilators Trump promised to obtain won’t be ready until June.

Governors are distraught over their inability to obtain the needed supplies, likening the process of requesting the equipment to eBay auctions. “You now literally will have a company call you up and say, ‘Well, California just outbid you,’” Cuomo said.

Another roadblock is that 2,000 of the ventilators in the national stockpile are unusable because of a lapse in a contract that left a monthslong gap, during which the machines weren’t being properly maintained.

In the meantime, General Motors has shrugged off Trump’s attacks on the company (he said GM and its chief executive were dragging their feet on the project) and are moving full-throttle ahead at producing the needed equipment. “Every ventilator is a life,” said one GM exec.

With so much focus on ventilators, doctors are being advised on how to ration care and being told that they’ll be supported in their decisions not to perform futile intubations.

One quick note on that front: New York lawmakers are moving on legislation that would grant sweeping civil- and criminal-liability protections to hospitals and health care workers dealing with coronavirus patients.

And even though there’s a ton of attention on ventilators, the survival rate of any patient who requires one is only 20% — meaning that even without a shortage, they can only help a fraction of patients.

In other important news on the preparedness front:


Trump warned Americans this week that “hard days” lie ahead and that people should be braced for a “bad two weeks,” with the White House projecting that the death toll could be somewhere between 100,000 to 240,000. For what it’s worth, disease forecasters were mystified over where the task force got those numbers, mostly because we don’t yet know enough about the virus.

(What helped change Trump’s mind, considering he’d previously mused that the country could return to normal in time to fill the pews on Easter? Polling numbers.)

To help states deal with the crisis, CMS relaxed safety rules for hospitals, giving them unprecedented flexibility. The changes include what counts as a hospital bed, how closely certain medical professionals need to be supervised and what kinds of health care can be delivered at home.

The administration decided not to follow suit after a handful of states reopened their exchanges, though Trump seemed to hint that the possibility was still on the table “as a matter of fairness.” Also, to note, if people have lost their insurance because of their jobs, that counts as a qualifying event and they have 60 days to enroll in the federal exchanges, regardless of what Trump does with a special session.

And although Drs. Anthony Fauci and Deborah Birx, along with Vice President Mike Pence, have emerged as the leading voices of the administration’s pandemic response, Trump’s son-in-law Jared Kushner has taken charge behind the scenes. Critics say its adding confusion to an already chaotic situation.

And reports continue to emerge that the Trump administration was cutting pandemic detection positions in China just months before the outbreak.

In other news on the administration:


House Speaker Nancy Pelosi will be creating a special committee to oversee the implementation of the $2.2 trillion stimulus package and any other coronavirus legislation coming down the pike. “Where there’s money there’s also frequently mischief,” Pelosi said, in perhaps one of my favorite quotes of the week. Meanwhile, House Democrats may be raring to get started on a fourth stimulus package, but Republicans are pumping the brakes. At the very least, they say, they want to see how the current stimulus package plays out.

The news came the same day as it was reported that 6.6 million Americans filed for unemployment benefits. That eye-popping number blows past all previous records. And experts say it represents only a sliver of the economic devastation the virus is wreaking on the country. There are many affected Americans who remain uncounted — some have lost jobs or income and did not initially qualify for benefits, and others, encountering state unemployment offices that were overwhelmed by the deluge of claimants, were unsuccessful in filing.

In other news about Congress and the economic damage from the outbreak:


The Democratic National Convention, expected to draw as many as 50,000 visitors, was postponed from July to August in one of the largest disruptions to the 2020 elections so far. On the other hand, Wisconsin is going ahead with its primary on Tuesday, which is causing mixed reactions … including apoplectic rage.

More stories on elections:


Much focus this week was on serology tests that serve the dual purpose of finding Americans who can safely return to some normalcy and helping researchers find treatments for COVID-19. Experts are fairly unified on the fact that to get the country back into operation, we need a way to identify those who are now immune to the disease. And using plasma collected from recovered patients is a century-old practice (which, to be clear, has had mixed results in past diseases).

Beyond studies on actually treating the coronavirus illness (a small study out this week showed a much-touted malaria drug combo had positive results), doctors are also trying to figure out how to treat the phenomenon known as “cytokine storm,” in which the body’s own immune system attacks its organs. This is thought to be the cause of some of the severe cases seen in younger patients.

On a side note, the Food and Drug Administration on Sunday issued an emergency-use authorization for hydroxychloroquine and chloroquine, despite scant evidence that they work against COVID-19.


With Florida (and three other states who had been hesitating) finally caving into pressure to issue the stay-at-home order, the vast majority of Americans are now huddled at home. The good news is that the extreme measures seem to be working in California, which was an earlier disciple of flattening the curve.

Google, meanwhile, is offering the government a report on “mobility data” to help states recognize where social-distancing measures are failing, with a specific focus on how foot traffic has increased or declined to six categories of destinations: homes; workplaces; retail and recreation establishments; parks; grocery stores and pharmacies; and transit stations.

Although things might seem a bit grim right now because of these measures, a look at data from the 1918 flu pandemic shows cities that locked down emerged from the crisis stronger economically than those that didn’t. One caveat, though: Because working-age people were harder hit by the 1918 flu (and the coronavirus strikes worse among older generations), any comparisons might not hold.


So, onto some of the stories I find most fascinating … aka the science behind all of this.


I’m going to cut this off here, or else this will no longer be able to be called the Breeze. If you want a more comprehensive roundup, please check out the Morning Briefings from the week, which are chock-full of more stories than you could ever finish reading. Including ones on workers’ protests and the supply chain; the gun store debate; how jails are “ticking time bombs;” autocrats’ power grab; snapshots from a New York in crisis; health disparities; and a call to arms for medical workers that doesn’t guarantee coverage of potential hospital bills.

Please have a safe and restful weekend, if possible!

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Global Health Watch

Pandemic-Stricken Cities Have Empty Hospitals, But Reopening Them Is Difficult

As city leaders across the country scramble to find space for the expected surge of COVID-19 patients, some are looking at a seemingly obvious choice: former hospital buildings, sitting empty, right downtown.

In Philadelphia, New Orleans, and Los Angeles, where hospitalizations from COVID-19 increase each day, shuttered hospitals that once served the city’s poor and uninsured sit at the center of a public health crisis that begs for exactly what they can offer: more space. But reopening closed hospitals, even in a public health emergency, is difficult.

Philadelphia, the largest city in America with no public hospital, is also the poorest. There, Hahnemann University Hospital shut its doors in September after its owner, Philadelphia Academic Health System, declared bankruptcy. While not public, the 496-bed safety-net hospital mainly treated patients on public insurance. Philadelphia Mayor Jim Kenney began talks with the building’s owner, California-based investment banker Joel Freedman, as soon as his administration saw projections that the demand for hospital beds during the pandemic would outpace the city’s capacity. Not long after negotiations started, city officials announced the talks were going badly.

“Mr. Freedman was difficult to work with at times when he was the owner of the hospital, and he is still difficult to work with as the owner of the shuttered hospital,” said Brian Abernathy, who is Philadelphia’s managing director and heading the city’s COVID-19 response.

In New Orleans, where the soaring COVID-19 infection rate is disproportionately high compared with its population, Charity Hospital sits vacant in the middle of town. The former public hospital never reopened after Hurricane Katrina in 2005. The Louisiana State University System, which owns the building, incorporated Charity Hospital into the city’s new medical center, but the original building remains vacant. Instead of using it during the pandemic, the New Orleans Convention Center is being converted to a “step-down” facility with the capacity to treat up to 2,000 patients after they no longer need critical care.

Elsewhere, city governments have struck deals with the owners of empty hospital buildings to lease their space. At St. Vincent Medical Center in Los Angeles, the city is paying $236 per night per bed, for a total of $2.6 million each month.

In Philadelphia, Freedman offered the Hahnemann building to the city for $27 per bed per night, plus taxes, maintenance and insurance, which the city would pay directly. All told, that added up to just over $900,000 per month.

“I think he is looking at how to turn an asset that is earning no revenue into an asset that earns some revenue, and isn’t thinking through what the impacts are on public health,” Abernathy said of Freedman. “I think he’s looking at this as a business transaction rather than providing an imminent and important aid to the city and our residents.”

This isn’t the first time Freedman has come under fire by Philadelphians for his handling of the hospital. Its closure sparked protests from city officials, health care unions, and even presidential hopeful Bernie Sanders. Critics speculated that Freedman, whose private equity firm bought the struggling hospital in 2018, didn’t try in earnest to save it and planned to flip it for its valuable downtown real estate. Notably, Hahnemann’s real estate was parsed out into a separate company, Broad Street Healthcare Properties, also owned by Freedman, and not included in Philadelphia Academic Health System’s Chapter 11 bankruptcy petition.

A representative for Freedman said the building has an interested buyer, and that is one reason Broad Street Healthcare will not let the city use the building at cost.

“We’re offering this facility because of the public benefit in a health crisis, but it comes at a cost to the property owner,” said Broad Street representative Sam Singer.

As urban hospitals have struggled in recent years, it’s become increasingly common for private equity to get involved: Big firms buy struggling medical centers with the promise of financial support and to improve their operations and business strategy. When things go right, the business succeeds, and the private equity firm sells it in a public offering or to another bidder for more than it paid.

In other cases, though, the firms load companies up with debt, take dividends out for themselves, sell off valuable real estate and charge fees and high-interest loans, leaving a company in a much weaker position than it would have been otherwise, and often on the verge of bankruptcy.

“The house never loses,” said Eileen Appelbaum, co-director at the Center for Economic and Policy Research. “The private equity firm makes money whether the company succeeds or it doesn’t.”

For instance, Steward Health Care was able to expand from its base in Massachusetts to a 36-hospital network nationwide with backing from Cerberus Capital Management. Now, said Appelbaum, the chain of community hospitals is stuck paying rent to Iasis, another private equity-owned company, on all its properties, while also struggling to stay in the black. The network announced last week it would furlough non-clinical workers across nine states because the requirement to cancel elective surgeries caused too great a financial strain.

Freedman’s private equity firm is called Paladin Healthcare, and it has previously bought and managed hospitals in California and Washington, D.C., where it helped the struggling Howard University Hospital out of the red. Paladin then sold the hospital to Adventist HealthCare last summer.

Urban hospitals like Hahnemann have struggled to stay afloat in recent years, in part due to their lack of privately insured patients. Hospitals often finance the care of uninsured patients or those on Medicaid by treating those with private insurance, which reimburses the hospitals faster and at a higher rate. At Hahnemann, two-thirds of patients were on Medicaid or Medicare. While a financially struggling public or nonprofit hospital might continue serving a poorer community, a for-profit hospital has different incentives, said Vickie Williams, a former law professor for Gonzaga University.

“If your urban hospital is purchased by a for-profit company and it doesn’t perform sufficiently, they don’t have the same necessarily mission-driven directives to keep that hospital functioning for the good of the community at a loss,” said Williams, who is now senior counsel for CommonSpirit Health in Tacoma, Washington.

Freedman has said that he tried to sell the Hahnemann property to a nonprofit and requested money from the city and state to keep it open, but neither option worked.

Following news that Philadelphia had abandoned negotiations with Freedman, calls to seize the property in order to save lives came pouring in, including from elected officials.

“Eminent Domain was created for situations like #Hahnemann,” City Council member Helen Gym wrote on Twitter. “This is a public health emergency and Philly is the largest city in the nation WITHOUT a public hospital. We cannot allow unconscionable greed to get in the way of saving lives. Eminent domain this property.” Legal experts say the lengthy process of eminent domain and the requirement to pay the owner fair market value for the building make it an unlikely mechanism for an instance like this.

But in public health emergencies, local, state and federal governments do have broad authority to commandeer private property, such as hotels, convention centers, university dormitories or even defunct hospitals for disaster response. Williams, whose research has focused on preserving hospital infrastructure during a pandemic, said that so far in the United States, that hasn’t had to happen ― at least not in the traditional sense.

In Pennsylvania, the governor’s emergency declaration gives him the authority to “commandeer or utilize any private, public or quasi-public property if necessary to cope with the disaster emergency.” A health department representative said all options remain on the table in the event that the city’s hospital bed capacity is overrun.

In the interim, the mayor made a deal with Temple University to use its basketball arena, which would have the capacity to treat 250 non-critical patients, at no cost to the city.

This story is part of a partnership that includes WHYY, NPR and Kaiser Health News.

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KHN’s ‘What The Health?’: All Coronavirus All The Time


Can’t see the audio player? Click here to listen on SoundCloud.


The medical and economic needs laid bare by the coronavirus pandemic are forcing some immediate changes to the U.S. health system. Congress, in its latest relief bill, provided $100 billion in funding for the hospital industry alone. Meanwhile, the federal government has quickly removed previous barriers to telehealth and other sometimes controversial practices.

But big fights are still brewing, including whether the federal government will reopen the Affordable Care Act marketplaces it runs and whether states can use emergency powers to ban abortions as “elective medical procedures.”

This week’s panelists are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Margot Sanger-Katz of The New York Times and Alice Miranda Ollstein of Politico.

Among the takeaways from this week’s podcast:

  • The ACA was passed on the heels of the Great Recession. The coronavirus outbreak has produced the first big economic downturn since then, and the law’s provisions to expand Medicaid and to provide an insurance option to those without jobs could provide a critical safety net during this crisis.
  • About a dozen states running their own ACA insurance marketplaces have opened up enrollment again to let people who did not enroll in the fall but are feeling the pinch from the coronavirus pandemic to reconsider. President Donald Trump said this week that he is mulling a similar move, but the messages from the administration on such action have been confusing.
  • People who had insurance through work and have lost their jobs don’t need a special enrollment period to sign up for an Obamacare plan. They are eligible because their job situation changed. However, the administration has not been publicizing that message.
  • Hospitals are eager to receive the $100 billion appropriated by Congress in response to the influx of patients with COVID-19, the disease caused by the coronavirus. But the administration has not yet said how that money will be apportioned.
  • A handful of states have prohibited abortions during the coronavirus emergency because, officials say, they are seeking to preserve protective gear for hospital staff treating COVID-19 patients. But it’s not clear that the abortion procedures ― especially medication abortions — are interfering with efforts to safeguard protective clothing or masks needed by hospitals. And women who do not get abortions will consume far more medical care by remaining pregnant and giving birth.

Also, this week, Rovner interviews KHN’s Liz Szabo, who reported the latest KHN-NPR “Bill of the Month” installment about a patient who underwent a very expensive genetic test. If you have an outrageous medical bill you would like to share with us, you can do that here.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:

Julie Rovner: The New York Times’ “A Ventilator Stockpile With One Hitch: Thousands Do Not Work,” by David E. Sanger, Zolan Kanno-Youngs and Nicholas Kulish

Joanne Kenen: The New Yorker’s “The Life and Death of Juan Sanabria, One of New York City’s First Cornavirus Victims,” by Jonathan Blitzer

Margot Sanger-Katz: Bloomberg News’ “Hospitals Tell Doctors They’ll Be Fired If They Speak Out About Lack of Gear,” by Olivia Carville, Emma Court and Kristen V. Brown

Alice Miranda Ollstein: The Washington Post’s “Trump Ban on Fetal Tissue Research Blocks Coronavirus Treatment Effort,” by Amy Goldstein


To hear all our podcasts, click here.

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California Hospitals Face Surge With Proven Fixes And Some Hail Marys

California’s hospitals thought they were ready for the next big disaster.

They’ve retrofitted their buildings to withstand a major earthquake and  whisked patients out of danger during deadly wildfires. They’ve kept patients alive with backup generators amid sweeping power shutoffs and trained their staff to thwart would-be shooters.

But nothing has prepared them for a crisis of the magnitude facing hospitals today.

“We’re in a battle with an unseen enemy, and we have to be fully mobilized in a way that’s never been seen in our careers,” said Dr. Stephen Parodi, an infectious disease expert for Kaiser Permanente in California. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.)

As California enters the most critical period in the state’s battle against COVID-19, the state’s 416 hospitals — big and small, public and private — are scrambling to build the capacity needed for an onslaught of critically ill patients.

Hospitals from Los Angeles to San Jose are already seeing a steady increase in patients infected by the virus, and so far, hospital officials say they have enough space to treat them. But they also issued a dire warning: What happens over the next four to six weeks will determine whether the experience of California overall looks more like that of New York, which has seen an explosion of hospitalizations and deaths, or like that of the San Francisco Bay Area, which has so far managed to prevent a major spike in new infections, hospitalizations and death.

Some of their preparations share common themes: Postpone elective surgeries. Make greater use of telemedicine to limit face-to-face contact. Erect tents outside to care for less critical patients. Add beds — hospital by hospital, a few dozen at a time — to spaces like cafeterias, operating rooms and decommissioned wings.

But by necessity — because of shortages of testing, ventilators, personal protective equipment and even doctors and nurses — they’re also trying creative and sometimes untried strategies to bolster their readiness and increase their capacity.

In San Diego, hospitals may use college dormitories as alternative care sites. A large public hospital in Los Angeles is turning to 3D printing to manufacture ventilator parts. And in hard-hit Santa Clara County, with a population of nearly 2 million, public and private hospitals have joined forces to alleviate pressure on local hospitals by caring for patients at the Santa Clara Convention Center.

Yet some hospitals acknowledge that, despite their efforts, they may end up having to park patients in hallways.

“The need in this pandemic is so different and so extraordinary and so big that a hospital’s typical surge plan will be insufficient for what we’re dealing with in this state and across the nation,” said Carmela Coyle, president and CEO of the California Hospital Association.

Across the U.S., more than 213,000 cases of COVID-19 have been confirmed, and at least 4,750 people have died. California accounts for more than 9,400 cases and at least 199 deaths.

Health officials and hospital administrators are singling out April as the most consequential month in California’s effort to combat a steep increase in new infections. State Health and Human Services Secretary Mark Ghaly said Wednesday that the number of hospitalizations is expected to peak in mid-May.

Gov. Gavin Newsom said there were 1,855 COVID-19 cases in hospitals Wednesday, a number that had tripled in six days, and 774 patients in critical care. By mid-May, the number of critical care patients is expected to climb to 27,000, he said.

Newsom said the state needs nearly 70,000 more hospital beds, bringing its overall capacity to more than 140,000 — both inside hospitals and also at alternative care sites like convention centers. The state also needs 10,000 more ventilators than it normally has to aid the crush of patients needing help to breathe, he said, and so far has acquired fewer than half.

Newsom and state health officials worked with the Trump administration to bring a naval hospital ship to the Port of Los Angeles, where it is already treating patients not infected with the novel coronavirus. The state is working with the Army Corps of Engineers to deploy eight mobile field hospitals, including one in Santa Clara County. And it is bringing hospitals back online that were shuttered or slated to close, including one each in Daly City, Los Angeles, Long Beach and Costa Mesa.

The governor is also drafting a plan to make greater use of hotels and motels and nursing homes to house patients, if needed.

But the size of the surge that hits hospitals depends on how well the public follows social distancing and stay-at-home orders, said Newsom and hospital administrators. “This is not just about health care providers caring for the sick,” said Dr. Steve Lockhart, the chief medical officer of Sutter Health, which has 22 hospitals across Northern California.

While hospitals welcomed the state assistance, they’re also undertaking dramatic measures to prepare on their own.

“I’m genuinely very worried, and it scares me that so many people are still out there doing business as usual,” said Chris Van Gorder, CEO of Scripps Health, a system with five major hospitals in San Diego County. “It wouldn’t take a lot to overwhelm us.”

Internal projections show the hospital system could need 8,000 beds by June, he said. It has 1,200.

In addition to taking precautions to protect its health care workers — such as using baby monitors to observe patients without risking infection — it is working with area colleges to use dorm rooms as hospital rooms for patients with mild cases of COVID-19, among other efforts, he said.

“Honestly, I think we should have been better prepared than we are,” Van Gorder said. “But hospitals cannot take on this burden themselves.”

Van Gorder and other hospital administrators say a continued shortage of COVID-19 tests has hampered their response — because they still don’t know exactly which patients have the virus — as has the chronic underfunding of public health infrastructure.

Kaiser Permanente wants to double the capacity of its 36 California hospitals, Parodi said. It is also working with the garment industry to manufacture face masks, and eyeing hotel rooms for less critical patients.

Harbor-UCLA Medical Center, a 425-bed safety-net hospital in Los Angeles, is working to increase its capacity by 200%, said Dr. Anish Mahajan, the hospital’s chief medical officer.

Harbor-UCLA is using 3D printers to produce ventilator piping equipped to serve two patients per machine. And in March it transformed a new emergency wing into an intensive care unit for COVID-19 patients.

“This was a shocking thing to do,” Mahajan said of the unprecedented move to create extra space.

He said some measures are untested, but hospitals across the state are facing extreme pressure to do whatever they can to meet their greatest needs.

In March, Stanford Hospital in the San Francisco Bay Area launched a massive telemedicine overhaul of its emergency department to reduce the number of employees who interact with patients in person. This is the first time the hospital has used telemedicine like this, said Dr. Ryan Ribeira, an emergency physician who spearheaded the project.

Stanford also did some soul-searching, thinking about which of its staff might be at highest risk if they catch COVID-19, and has assigned them to parts of the hospital with no coronavirus patients or areas dedicated to telemedicine. “These are people that we might have otherwise had to drop off the schedule,” Ribeira said.

Nearby, several San Francisco hospitals that were previously competitors have joined forces to create a dedicated COVID-19 floor at Saint Francis Memorial Hospital with four dozen critical care beds.

The city currently has 1,300 beds, including 200 ICU beds. If the number of patients surges as it has in New York, officials anticipate needing 5,000 additional beds.

But the San Francisco Bay Area hasn’t yet seen the expected surge. UCSF Health had 15 inpatients with COVID-19 Tuesday. Zuckerberg San Francisco General Hospital and Trauma Center had 18 inpatients with the disease Wednesday.

While hospital officials are cautiously optimistic that local and state stay-at-home orders have worked to slow the spread of the virus, they are still preparing for what could be a major increase in admissions.

“The next two weeks is when we’re really going to see the surge,” said San Francisco General CEO Susan Ehrlich. “We’re preparing for the worst but hoping for the best.”

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

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Listen: COVID-19 Stresses Rural Hospitals Even Before They Have A Single Case

KHN Midwest correspondent Lauren Weber appeared on WOSU’s “All Sides with Ann Fisher” out of Columbus, Ohio, to talk about the coronavirus pandemic’s impact on rural hospitals. Weber recently reported on the financial implications for such hospitals even before they handle any COVID-19 cases.

Almost half of the nation’s rural hospitals already operated in the red on a good day. Rural hospital CEOs now warn that some soon may be unable to pay their workers because they’ve had to cancel elective procedures, therapy, tests and other visits that bring in most of their revenue. Despite the recent federal bailout, their doors may close when the community most needs them.

Click here to listen on WOSU’s website.

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More Than 5,000 Surgery Centers Can Now Serve As Makeshift Hospitals During COVID-19 Crisis

The Trump administration cleared the way Monday to immediately use outpatient surgery centers, inpatient rehabilitation hospitals, hotels and even dormitories as makeshift hospitals, health care centers or quarantine sites during the coronavirus crisis.

The Centers for Medicare & Medicaid Services announced it is temporarily waiving a range of rules, thereby allowing doctors to care for more patients.

Hospitals and health systems overwhelmed with COVID-19 patients will be able to transfer people with other medical needs to the nation’s 5,000 outpatient surgery centers, about half of which are affiliated with hospitals. This will give the country thousands of additional hospital beds and operating rooms, some of which have ventilators or anesthesia gas machines that could be repurposed as ventilators.

Outpatient surgery centers will be allowed to treat patients with other critical needs — such as serious injuries, cancer or heart attacks — unrelated to COVID-19, allowing hospitals to conserve scarce resources and reduce the risk of infection to these patients.

Until now, federal regulations allowed outpatient surgery centers to care for patients for a maximum of 24 hours.

“Transferring uninfected patients will help hospital staffs to focus on the most critical COVID-19 patients, maintain infection control protocols, and conserve personal protective equipment,” the agency said in a statement.

Many outpatient surgery centers had closed after being told to halt elective procedures. A coalition of anesthesiologists in recent weeks called for them to stop performing nonessential surgery and assist hospitals.

The waivers “will allow hospitals to save more lives” by performing “surgeries and procedures that can’t wait until the pandemic is over,” said Bill Prentice, CEO the Ambulatory Surgery Center Association, an industry group.

Before the CMS announcement, the California Ambulatory Surgery Association had expressed its willingness to help.

The outpatient centers “want to be part of the solution as the entire healthcare industry must rise to meet this enormous challenge,” said Michelle George, president of the California Ambulatory Surgery Association, in a statement issued Monday morning. “We have valuable resources to lend to this crisis — whether it is staff, space, equipment, supplies or other capabilities. ASCs are coordinating with the public health teams on local and regional levels to identify how their facilities can be utilized most effectively on a case by case basis.”

Advocates who have pushed for surgery centers to assist hospitals praised the move.

“This is a great step in fighting this pandemic,” said Dr. Adam Schlifke, an anesthesiologist and clinical assistant professor at Stanford University in California.

“We recognize that it’s going to be hard,” Schlifke said. “It’s extremely complicated, but we are here to support all the surgery centers that will need to convert as a result of this order.”

The waivers will allow hospitals to hire local physicians and health care providers to address potential surges; transfer critical equipment, including telemedicine equipment, to doctors’ offices; and provide meals and child care for their health care workers.

Hospitals will be able to triage sick patients at community locations, then send them to the most appropriate facility, according to CMS.

“Front-line health care providers need to be able to focus on patient care in the most flexible and innovative ways possible,” said CMS Administrator Seema Verma. “This unprecedented temporary relaxation in regulation will help the health care system deal with patient surges by giving it tools and support to create nontraditional care sites and staff them quickly.”

Even with additional facilities, hospitals and health care systems could run out of staff, especially as health providers become sick with COVID-19. Although surgery centers typically employ their own nurses, they tend to share surgeons with local hospitals.

More than a dozen states and health care associations had requested waivers. The CMS move means that other states will no longer need to apply for waivers.

Texas had taken the lead in recent days, even before the new announcement, by permitting hospitals to use off-site facilities. Texas Gov. Greg Abbott last week signaled his interest in using outpatient surgery centers to expand care by ordering them to tell the state how many ventilators they possess.

Among other sweeping changes:

  • Ambulances will be allowed to transport patients to outpatient surgery centers, community mental health centers, federally qualified health centers, physician’s offices, urgent care facilities and any locations furnishing dialysis services when a dedicated kidney failure treatment center isn’t available. Hospitals will be able to charge for services provided outside their four walls and emergency departments can use telehealth services to evaluate sick people.
  • Physician-owned hospitals can temporarily increase their number of licensed beds, operating rooms and procedure rooms, according to CMS.
  • Instead of going to crowded emergency rooms, patients could go to off-site locations to be evaluated by emergency health care providers using telemedicine. That change will help preserve space in the emergency room for those who need it most. CMS will allow health providers to treat more patients via apps or telephone and bill at the same rate as in-person visits.
  • Physician assistants and nurse practitioners will be allowed to order tests and medications that may have previously required a physician’s order, as long as state law allows it. Also, certified registered nurse anesthetists will no longer have to work under the supervision of a doctor, freeing up physicians to focus more on patients and less on supervising.
  • To reduce the need for patients with health problems unrelated to COVID-19 to go to a doctor’s office or hospital, doctors will be allowed to monitor patients remotely with devices that can measure a patient’s oxygen saturation levels using pulse oximetry.

Health care experts have been suggesting the administration offer such waivers for weeks. The country has “got to muster all reasonable facilities and personnel,” said Arthur Caplan, a bioethics professor at NYU Langone Medical Center. “The best way to ration is to avoid it by stretching resources and sharing.”

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Already Taxed Health Care Workers Not ‘Immune’ From Layoffs And Less Pay

Just three weeks ago, Dr. Kathryn Davis worried about the coronavirus, but not about how it might affect her group of five OB-GYNs who practice at a suburban hospital outside Boston.

“In medicine we think we’re relatively immune from the economy,” Davis said. “People are always going to get sick; people are always going to need doctors.”

Then, two weeks ago, she watched her practice revenue drop 50% almost overnight after Massachusetts officials told doctors and hospitals to stop performing elective tests and procedures. For Davis, that meant no more non-urgent gynecological visits and screenings.

Late last week, as Davis and her partners absorbed the stunning turn of events, they devised a stopgap plan. The 35 nurses, medical assistants and secretaries they employ would have two options: move from full-time to part-time status or start collecting unemployment. Doctors in the practice would take a substantial pay cut. Davis said she’s hearing from colleagues who may have to permanently close their offices if the focus on crisis-level care continues for months.

“It’s shocking,” she said. “Everyone has been blindsided.”

Atrius Health, the largest independent physician group in Massachusetts, said patient volume is down 75% since mid-March. It is temporarily closing offices, placing many nonclinical employees on furlough and withholding pay for those who remain. The average withholding is 20%, and the company pledges that pay withheld will be returned. The lowest-paid workers, those earning up to $55,000, are exempt.

“What we’re trying to do is piece together a solution to get through the crisis and keep employed as many people as we can,” said Dr. Steven Strongwater, Atrius Health’s CEO.

Atrius cares for 745,000 patients in clinics that often include primary care, specialists, radiology and a pharmacy under one roof.

Strongwater said physician groups must be included when the federal government distributes $100 billion to hospitals from the $2 trillion stimulus package.

It’s not clear if that money will stop the tide of layoffs and lost pay at hospitals as well as in doctor’s offices. A Harvard Medical School physician group will suspend retirement contributions starting April 1.

Beth Israel Lahey Health, the second-largest hospital network in Massachusetts, announced executive pay cuts Monday.

“The suspension of elective procedures and decline in visits to our primary care practices and urgent care centers have resulted in financial challenges,” wrote CEO Dr. Kevin Tabb in an email to employees. Tabb said he would take a 50% salary cut. Other executives and hospital presidents in the system will forgo 20% of their salaries for the next three months.

“Although executive leadership compensation is being reduced, we will never compromise on doing the things that are essential to protect your safety and the safety of our patients,” Tabb told staff.

Dallas-based Steward Health Care has told hospital employees in Massachusetts and eight other states where it operates to expect furloughs focused on nonclinical staff. In a statement, Steward Health Care said it prepared for the pandemic but is experiencing a “seismic financial shock.”

“Elective surgeries are the cornerstone of our hospital system’s operating model — and the negative impact due to the cancellations of these procedures cannot be overstated. In addition, patients are understandably cautious and choosing to defer any nonemergency treatments or routine visits until this crisis has passed.”

Dr. Kaarkuzhali Babu Krishnamurthy, an assistant professor of neurology at Harvard Medical School who studies medical ethics, said employers need to think more carefully about the ethics of asking doctors and nurses to live on less when many are working longer hours and putting the health of their families at risk.

“At a time when health care systems are calling on doctors and nurses to do more, this is not the time to be making it more difficult to do that,” said Krishnamurthy.

There’s talk of redeploying laid-off health care workers to new COVID-19 units opening in shuttered hospitals or to patient overflow sites. Tim Foley, executive vice president for the largest health care union in Massachusetts, 1199SEIU, is promoting the development of a staff registry.

“It is more important, now more than ever, to explore all options to maintain the level of urgent care needed across the state and we look forward to working with all stakeholders to do just that,” Foley said in an email.

This story is part of a partnership that includes WBUR, NPR and Kaiser Health News.

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Coronavirus Patients Caught In Conflict Between Hospital And Nursing Homes

A wrenching conflict is emerging as the COVID-19 virus storms through U.S. communities: Some patients are falling into a no man’s land between hospitals and nursing homes.

Hospitals need to clear out patients who no longer need acute care. But nursing homes don’t want to take patients discharged from hospitals for fear they’ll bring the coronavirus with them.

“It’s a huge and very difficult issue,” said Cassie Sauer, president of the Washington State Hospital Association, whose members were hit early by the coronavirus.

Each side has legitimate concerns. Hospitals in coronavirus hot spots need to free up beds for the next wave of critically ill patients. They are canceling elective and nonessential procedures. They are also trying to move coronavirus patients out of the hospital as quickly as possible.

The goal is to “allow hospitals to reserve beds for the most severely ill patients by discharging those who are less severely ill to skilled nursing facilities,” Seema Verma, administrator of the Centers for Medicare & Medicaid Services, said a few weeks ago as the federal agency relaxed rules restricting which Medicare patients can receive nursing home care.

Nursing homes are alarmed at the prospect of taking patients who may have coronavirus infections. The consequences could be dire. The first nursing home known to have COVID-19, the Life Care Center in Kirkland, Washington, saw the virus spread like wildfire. It killed 37 people.

“We’re looking at case fatality rates of 30, 40, 50% in nursing homes when coronavirus gets introduced,” said Christopher Laxton, executive director of AMDA — the Society for Post-Acute and Long-Term Care Medicine, which represents nursing home medical directors.

Fears extend to patients with other conditions, such as strokes or heart attacks, who’ve been in the hospital and do not have COVID-19 symptoms but could harbor the virus.

In its most recent guidance, the American Health Care Association, an industry trade group, said nursing homes can accept patients “who are COVID negative or do not have symptoms.” If someone has symptoms such as a dry cough or fever, they “should be tested for COVID-19 before being admitted to the facility.” If someone is COVID positive, they should be kept only “with other COVID positive residents.”

But nursing home doctors worry this doesn’t go far enough. According to a resolution by the California Association of Long Term Care Medicine, nursing homes should not have to take patients known to have the coronavirus unless “they have two negative tests that are 24 hours apart, OR 10 days after admission AND no fever for 72 hours.” A new AMDA resolution echoes this caution.

“We have an obligation to our patients to draw the line,” said Dr. Michael Wasserman, president of the California association. “Increasing the number of COVID-19 positive residents in facilities — whether these facilities have patients with the virus or not — raises the risk of infecting the uninfected and dramatically increasing the number of deaths.”

For their part, hospital leaders say an emphasis on testing before discharging patients is impractical, given the shortage of tests and delays in receiving results.

“Many nursing homes are requiring a negative COVID-19 test even for patients who were in the hospital for nothing to do with COVID,” said Sauer in Washington state. “We don’t agree with this. It’s using up very limited testing resources.”

Nowhere are tensions higher than in New York, where Gov. Andrew Cuomo has said 73,000 extra hospital beds will be needed within weeks to treat a surge of COVID-19 patients. Hospitals in the state have 53,000 beds.

On Wednesday, the New York State Department of Health issued an advisory noting: “No resident shall be denied re-admission or admission to the NH [nursing home] solely based on a confirmed or suspected diagnosis of COVID-19.”

Speaking on behalf of nursing home physicians, AMDA voiced strong opposition, calling the policy “over-reaching, not consistent with science, unenforceable, and beyond all, not in the least consistent with patient safety principles” in a statement.

Some nursing homes are sending residents with suspected coronavirus to hospitals for evaluation and then refusing to take them back until tests confirm their negative status.

“Essentially, they’re dumping patients on hospitals and saying, ‘Too bad — you’re stuck with them now,’” said a consultant who works closely with hospitals and spoke on the condition of anonymity.

Others want to do their part to serve COVID-19 patients. “It is our obligation to keep the health care system flowing,” said Scott LaRue, president of ArchCare, the health care system of the Archdiocese of New York.

LaRue has no illusions about keeping the coronavirus out of ArchCare’s five nursing homes, which, combined, have 1,700 beds.

“In New York City the virus is everywhere,” he said. That means it has to be managed, not avoided. “Our intention is to take COVID-19 stable patients” and move them to a single floor at each nursing home, he said.

That will happen under two conditions, LaRue said. First, ArchCare will need sufficient personal protective equipment — gowns, masks and face shields — for its staff. Currently, the system can’t get face shields. It was due to run out of gowns by Wednesday.

Second, ArchCare will need to test whether its protocols for managing COVID-positive patients are working. Those include putting patients in isolation, monitoring them more closely, limiting the number of people who can go in, and ensuring that staff use personal protective equipment and are trained properly.

So far, only one of its nursing home patients is known to have COVID-19.

“We won’t know for 14 days if the steps we’re taking are working,” LaRue said.

But it’s unrealistic to expect other nursing homes to follow suit.

“I would be surprised if 10% to 15% of skilled nursing facilities in the U.S. could take a COVID-positive patient and treat that patient safely while ensuring that other residents in the home are safe,” said David Grabowski, a professor of Health Care Policy at Harvard Medical School.

In a new commentary in the Journal of the American Medical Association, Grabowski calls for establishing “centers of excellence” to care for patients recovering from COVID-19 and building “temporary capacity” in hot spots where the need for post-hospital services is likely to surge.

That’s beginning to happen. On Tuesday, Cuomo announced that a field hospital being built by the U.S. Army Corps of Engineers to house overflow coronavirus patients at the Jacob K. Javits Convention Center in New York City would include 1,000 beds for patients who don’t need acute care services.

On Wednesday, a unit of Partners HealthCare, a large Massachusetts health care system, announced a new center for patients recovering from COVID-19 on the fourth floor of Spaulding Hospital for Continuing Care, a long-term care hospital in Cambridge. The center, set to open soon, will have 60 beds and accept patients from Massachusetts General Hospital and Brigham and Women’s Hospital.

In the Twin Cities area of Minnesota, Allina Health, which operates 11 hospitals, is partnering with Presbyterian Homes & Services to convert a 50-bed skilled nursing home to a “step-down site,” said Dr. Emily Downing, a vice president of Allina Health. The goal is to help COVID-19 patients recover so they can return to nursing homes or senior living communities.

Katie Smith Sloan, president of LeadingAge, which represents not-for-profit nursing homes, home care agencies and assisted living centers, said she was hearing about nascent plans to reopen closed nursing homes for COVID-19 patients. Government agencies need to make financing available to build extra capacity to care for these patients, she said.

As for patients who need less intensive care or who need to be quarantined after the hospital to ensure they aren’t infectious, other options exist.

“King County has bought a hotel and is leasing another and is looking at what are now empty ambulatory surgery centers or a Christian summer camp in the area,” said Sauer of the Washington State Hospital Association.

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Federal Judge Rules Medicare Patients Can Challenge ‘Observation Care’ Status

Hundreds of thousands of Medicare beneficiaries who have been denied coverage for nursing home stays because their time in the hospital was changed from “inpatient” to “observation care” can now appeal to Medicare for reimbursement, a federal judge in Hartford, Connecticut, ruled last week.

If the government does not challenge the decision and patients win their appeals, Medicare could pay them millions of dollars for staggeringly high nursing home bills.

To receive coverage for nursing home care, patients must first be admitted to the hospital as inpatients for three consecutive days. Time spent in the hospital for observation doesn’t count, even though they may stay overnight and receive some of the same treatment and other services provided to inpatients.

And there’s another big difference: While inpatients can file an appeal with Medicare if they question any other coverage denial, observation patients cannot. So, in 2011, seven Medicare beneficiaries and their families sued the Department of Health and Human Services, in what became a nationwide class action lawsuit.

On Tuesday, U.S. District Judge Michael Shea ruled that the patients are entitled to appeal if they are admitted as inpatients to the hospital by their doctor but later switched to observation care by their hospital. However, he said patients whose doctors initially place them in observation care under Medicare’s “two-midnight” rule cannot appeal because that rule requires doctors to base their decision on medical judgment. If the doctor determines that a patient’s stay is unlikely to stretch over two midnights, the patient would most likely receive observation care, though there are exceptions.

Shea’s decision applies to all traditional Medicare beneficiaries who experienced such a switch since Jan. 1, 2009, spent at least three days in the hospital and were enrolled in Medicare’s Part A hospital benefit. If they win their appeal, most hospital expenses and any nursing home bills they paid would be reimbursed under Part A.

Shea estimated that hundreds of thousands of beneficiaries would be able to seek repayment.

Lawyers at the Department of Justice argued that doctors and hospitals make admission decisions so patients can’t ask the government to change a decision it didn’t make. A DOJ spokeswoman declined to comment on the decision or whether the government would appeal. They have until May 25 to decide.

Ervin Kanefsky, one of the plaintiffs in the case, spent five days in the hospital as an admitted patient after fracturing his shoulder. When he was about to leave, a hospital official told him his status had changed to observation. He had to pay $9,145 for a month-long stay in the nursing home that Medicare refused to cover.(Courtesy of Ervin Kanefsky)

But the physician’s decision is not final because it is “reviewed by the hospital’s ‘utilization review staff,’ a team each hospital participating in the Medicare program must have in place to review whether the physician’s decision is correct under mandatory, nationwide standards set by the Centers for Medicare and Medicaid Services,” the judge wrote.

Alice Bers, litigation director at the Center for Medicare Advocacy, one of the groups representing the plaintiffs, said the decision recognized that “Medicare coverage is subject to due process protection.”

“If I had gone home, I would have died,” said Ervin Kanefsky, 94, a plaintiff from suburban Philadelphia. He was admitted to the hospital as an inpatient after fracturing his shoulder in a fall. When he was about to leave after five days to recuperate at a nursing home, a hospital official told him his status had changed to observation. With one arm in a sling, stitches in the other and unable to hold onto his walker, he learned Medicare wouldn’t pay for the nursing home.

“I had to pay $2,000 just to get in the door,” he said, and his month-long stay in 2016 cost $9,145. He called Medicare numerous times, wrote a letter to the hospital’s president and contacted his congressman for help. “I tried every which way,” he said, to no avail.

Medicare has temporarily suspended the three-day inpatient admission requirement during the coronavirus emergency.

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Listen: How Hospitals Are Preparing For Surge In COVID-19 Patients

California Healthline senior correspondent Anna Maria Barry-Jester appeared on KALW’s “Your Call” on Friday to discuss how hospitals are preparing for a surge in COVID-19 patients.

Dr. Mark Ghaly, the state’s secretary of Health and Human Services, said on Wednesday that COVID-19 cases in California continued to double every three to four days ― a pace on par with New York, where some hospitals are already overwhelmed by coronavirus patients.

As of Friday afternoon, the number of coronavirus cases in California topped 4,000 and at least 85 people had died.

Hospitals have been shifting patients with less urgent medical needs to other facilities to free up beds and working to boost supplies of personal protective equipment for medical staff, but still face shortages of both.

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California Public Health States

Para luchar contra el coronavirus, médicos y enfermeras retirados vuelven a trabajar

Laura Benson se retiró de la enfermería en 2018, pero hace pocos días volvió a presentarse a trabajar en New Rochelle, Nueva York, donde se registró uno de los primeros grupos de casos de COVID-19.

“Las enfermeras somos entregadas”, dijo. “Si no hay suficiente gente, simplemente te presentas”.

Con más de 40,000 casos confirmados, Nueva York es ahora el epicentro del brote de coronavirus en el país: casi la mitad de los más de 92,900 casos en todo el país hasta el viernes 27 de marzo al mediodía.

Anticipándose a una grave escasez de personal médico para tratar el flujo de pacientes enfermos, el gobernador Andrew Cuomo y otros funcionarios hicieron un llamado para que médicos, enfermeras y otros profesionales de salud retirados desempolvaran sus guardapolvos y regresaran al trabajo.

Para el jueves 26, habían respondido 52,000 personas.

Funcionarios de otros estados, incluidos California, Colorado e Illinois, han hecho pedidos similares para que los profesionales de salud retirados den un paso adelante.

En el condado de Westchester, en Nueva York -que incluye New Rochelle y otras ciudades al norte de la ciudad de Nueva York- su ejecutivo, George Latimer, dijo que cerca de 90 enfermeras retiradas y un puñado de médicos respondieron después que publicara un mensaje en la página de Facebook del condado en busca de ayuda.

No hay un plan definitivo para desplegar con los voluntarios médicos, explicó Latimer. Pueden ser necesarios para atender a pacientes por fuera del coronavirus, o para ayudar al personal del Westchester County Center, que ahora funciona como un hospital temporal.

Laura Benson(Courtesy of Laura Benson)

Benson, de 60 años, trabaja para el Departamento de Salud del condado. Enfermera practicante con especialidad en oncología, pasó 20 años en el Albert Einstein Cancer Center en el Bronx. Se retiró de un trabajo en una compañía de dispositivos médicos, donde trabajó con pacientes con tumores cerebrales. También enseña a estudiantes de enfermería en un colegio comunitario.

En su primer día como voluntaria jubilada, Benson llamó por teléfono a pacientes que habían sido examinados recientemente para detectar el nuevo coronavirus para explicarles las pautas que deberían seguir para protegerse a sí mismos y a los demás.

Si hay una necesidad, dijo, está “absolutamente” dispuesta a trabajar directamente con pacientes que tengan COVID-19.

“Pienso en la persona en esa cama de hospital”, dijo. “Me gustaría que alguien la cuide”.

Benson no está particularmente preocupada por el virus, ya que trabajó durante la crisis del sida y trató a los pacientes incluso antes que la gente entendiera qué era esa enfermedad. “Sigues las pautas y te proteges”, explicó.

El mejor papel para muchos profesionales médicos retirados puede ser ayudar detrás de escena, dijeron expertos, liberando a colegas más jóvenes para que puedan centrarse en la atención directa del paciente.

Una razón para esto: la edad.

“Mi única preocupación es que muchas de estas personas retiradas estén en grupos de alto riesgo” con mayor probabilidad de verse gravemente afectados por COVID-19, dijo el doctor Arthur Fougner, presidente de la Sociedad Médica del Estado de Nueva York.

Otra preocupación es si los jubilados están actualizados con sus conocimientos médicos.

“Si han estado sin trabajar por más de dos o tres años, debes preocuparte que estén al día”, dijo el doctor Janis Orlowski, director de atención médica de la Asociación de Colegios Médicos Americanos.

Además, las licencias estatales de los proveedores de atención médica pueden haber caducado si han estado retirados por unos años. Renovarlas puede llevar mucho tiempo.

Aun así, “si alguien todavía tiene su licencia y está dispuesto a regresar, deberíamos recibirlo”, dijo Orlowski.

Michele Pedicone es una de esas profesionales. La terapeuta de atención respiratoria dejó su trabajo en Seattle el año pasado para dirigir el área de educación clínica en el departamento de educación de terapia respiratoria de la Universidad Médica SUNY Upstate en Syracuse, Nueva York.

Con sus clases ahora en su mayoría en línea y las prácticas de los estudiantes, suspendidas, tiene tiempo para volver a la atención clínica. Pedicone contactó a dos hospitales cercanos para ver si podían usar sus servicios y espera trabajar tres o cuatro días a la semana.

“Sinceramente, no sé lo que me están pagando; el dinero no es un problema “, dijo Pedicone, de 54 años.” Es lo correcto”.

Los terapeutas respiratorios, los médicos de cuidados críticos y las enfermeras capacitadas en la operación de ventiladores que ayudan a los pacientes hospitalizados a respirar se encuentran entre los especialistas que se espera que comiencen a escasear a medida que la pandemia de coronavirus empeora en Nueva York y en otros lugares, según un análisis de la Sociedad de Medicina de Cuidados Críticos.

La expansión de la oferta de trabajadores de cuidados intensivos será clave para manejar la pandemia de coronavirus, dijo Ashish Jha, director del Instituto de Salud Global de Harvard, en una sesión informativa la semana del 23 sobre asuntos de la fuerza laboral de atención médica patrocinados por el Commonwealth Fund.

Una opción que los encargados de formular políticas han discutido es que los estados podrían permitir, por ejemplo, que los profesionales médicos que se retiraron en los últimos cinco años con licencias vigentes obtengan una licencia automática de tres o seis meses sin tener que hacer muchos trámites, dijo Jha.

Mientras tanto, los sistemas de atención médica están desarrollando sus propias estrategias.

Northwell Health posee y opera 19 hospitales en la ciudad de Nueva York, el condado de Westchester y Long Island. La semana del 23, el sistema de salud ha tenido más de 700 pacientes con COVID-19, en comparación con solo 40 pacientes la semana anterior, según Terry Lynam, vicepresidente senior del sistema de salud.

Northwell ha estado planeando cómo fortalecer al personal desde enero, contó Judy Howard, vicepresidenta de adquisición que supervisa la contratación de personal. Desarrollaron una lista de 200 enfermeras jubiladas a las que se ha contactado para evaluar su interés en regresar al trabajo remunerado de alguna manera. Hasta ahora, 28 han firmado, dijo Howard.

En este momento, están pidiendo a las enfermeras jubiladas que trabajen en el centro de llamadas del sistema de salud y compartan las responsabilidades para capacitar a las nuevas enfermeras. Algunas trabajan en atención directa al paciente. Otra posibilidad es que colaboren en las instalaciones que Northwell ha establecido para cuidar a los hijos de los miembros del personal durante la pandemia de coronavirus.

“Si alguien realmente quiere trabajar cuatro horas a la semana o le gustaría trabajar 10 horas a la semana, trabajaremos con ellos para satisfacer sus necesidades”, dijo Howard.

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Must-Reads Of The Week From Brianna Labuskes

Hello! We have once again reached Friday, and I’ll do my best to give you a snapshot of the biggest health news from the week. But, first, I must dispel some bad advice that I’ve seen: Everyone wants to see your pet on those video conferences! Don’t hide them away in this time of need! Show us the doggos, the cats, and the … whatever this is. (A porcupine, I think?) Also make sure you’re following DogsOfKFF on Twitter for some of the best content on that social media platform.

All right, onto the news.

As predicted, the United States has surpassed China in the number of confirmed coronavirus cases, with nearly 93,000 to China’s nearly 82,000, as of 1 p.m. ET Friday. According to Johns Hopkins’ tracker, we also have surpassed 1,300 recorded deaths. (Worldwide, we’re at more than 566,000 and over 25,000 deaths.) Meanwhile, all that data comes with an asterisk in that most experts believe there are far more cases going unrecorded either because of testing flaws or overwhelmed state health departments that can’t keep up. Either way, not exactly something we want to be first in.

Meanwhile, the House came back to Washington to approve the $2.2 trillion stimulus package the Senate managed to send through this week (more on that in a second), despite concerns over lawmakers’ safety. There had been (dim but existent) hope earlier in the week that the House might be able to pass the legislation by unanimous consent. But that seemed too easy to be true, and it was. Concerns that a voice vote would be derailed by objections from a libertarian Kentucky lawmaker went unrealized, and the House passed the legislation Friday afternoon. The bill now goes to President Donald Trump, who is expected to sign it.

So what exactly is in that legislation?

— Direct payments of $1,200 to millions of Americans, including those earning up to $75,000, and an additional $500 per child

— $100 billion for grants to hospitals, public and nonprofit health organizations and Medicare and Medicaid suppliers, including a 20% bump in Medicare payments for treating patients with the virus

— $221 billion in a variety of tax benefits for businesses, including allowing businesses to defer payroll taxes, which finance Medicare and Social Security, for the rest of the year

— More than $25 billion in new money for food assistance programs, like SNAP

— Expanded jobless aid, providing an additional 13 weeks and a four-month enhancement of benefits, and extending the payments for the first time to freelancers and gig workers

— $377 billion in federally guaranteed loans to small businesses and the establishment of a $500 billion government lending program for distressed companies

— Millions in aid for states to begin offering early voting or voting by mail

— A rule that blocks foreclosures and evictions during the crisis on properties where the federal government backs the mortgage

— The suspension of federal student loan payments for six months and waives the interest

Predictably, some sectors (like cruise ships) were unhappy with being left out, but for once some people were pleased — for example, the hospital industry, which got the $100 billion it asked for.

For those of you, like me, who love a good tick-tock, here are a few inside looks at how Senate leaders and White House advisers struck a quick, expansive deal in a Washington that typically seems incapable of compromise.

The New York Times: As Coronavirus Spread, Largest Stimulus in History United a Polarized Senate

Politico: Inside the 10 Days to Rescue the Economy

The Washington Post: The Dealmaker’s Dealmaker: Mnuchin Steps In as Trump’s Negotiator, but President’s Doubts Linger With Economy in Crisis

The urgency of the legislation was underscored by an astronomical jump in jobless claims this week. Nearly 3.3. million Americans applied for benefits, up from 200,000 during pre-outbreak days. The “widespread carnage,” as one economist put it, is expected to get worse. While the stimulus package is expected to help mitigate some of the devastation, many have said it should be looked at as just the beginning.

It seemed strangely appropriate this week that the health law turned 10 amid a pandemic — the legislation’s journey to here has been anything but smooth, why should this anniversary be? But one ripple effect of the pandemic and economic fallout might actually be a boost to the health law, which is likely to serve as a crucial safety net for many Americans who possibly lost their employer-sponsored coverage in the past few weeks. States have already started reopening their marketplaces, and the federal government is being urged to follow suit.


Trump chafed this week at the drastic measures states are putting in place to try to curb the outbreak, raising eyebrows when he said he’d like to see church pews full by Easter. Public health experts have warned that lifting the social-distancing measures would result in a surge of cases that slam an already stretched-thin hospital system. But for Trump, who has tied his reputation to the well-being of the stock market, the economic toll seems too much. (The rhetoric also started a truly bizarre push from conservatives for older Americans to sacrifice themselves for the good of the country.)

The president’s most recent proposal to kick-start parts of the country is identifying places by risk level and applying strategies to match. But experts, like Dr. Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases, warn that even “cool spots” that aren’t seeing many cases might be in for a surge coming down the pike.

Meanwhile, Gov. Andrew Cuomo has said that New York’s experience presages America’s future. But some say that’s not necessarily accurate. Leading specialists say that while it is likely that devastation similar to New York’s will emerge in other places, there’s hope that in lower-density areas, where there are fewer factors like mass transit to exacerbate the spread, the outcome might be different.

Realistically, though, Americans will need to eventually think about returning to normalcy. Are there exit strategies from this complete lockdown that would work effectively? Here’s the problem: All the experts say success relies on extreme, aggressive and widespread testing to isolate the sick before they can give it to anyone. This has not exactly been America’s strong suit in recent weeks.


There are two storylines that have taken hold to demonstrate how much this pandemic will strain the hospital system, the first being the lack of ventilators available. States and hospitals have been pleading with the federal government to invoke war powers to jump-start the manufacturing process on the equipment. This comes as doctors are being forced to split ventilators between patients (a risky practice), planning to make the tough ethical decisions to ration care, creating policies to not resuscitate, searching for alternative treatments despite the dangers they might pose, and being warned that morgues are reaching capacity.

But Trump, who had been set to announce a partnership with GM to produce up to 80,000 ventilators, balked this week at the $1 billion price tag that came with it. “I don’t believe you need 40,000 or 30,000 ventilators,” he said, in a reference to New York, where Gov. Andrew Cuomo has appealed for federal help in obtaining them. “You go into major hospitals sometimes, and they’ll have two ventilators. And now all of a sudden they’re saying, ‘Can we order 30,000 ventilators?’”

The second notable thread throughout the country is a lack of personal protective equipment for health care workers on the front lines of the epidemic. There might be a long medical tradition of accepting elevated risk in the middle of a crisis, but many health care workers are frustrated that they’re being put in that position. Some are resorting to using hand-sewn masks, which do little to protect them and trash bags for surgical gowns. But others are drawing a line in the sand.

Meanwhile, something that might get missed with everyone’s attention directed at the coasts: Atlanta’s mayor is warning that its hospitals are at capacity.


Gilead, whose antiviral drug is getting a lot of buzz, was granted orphan drug status for the treatment because there are fewer than 200,000 cases of COVID-19 in the States right now. The designation would have granted Gilead lucrative perks, like the ability to keep generic competitors from the marketplace. But the news was meant with rage-filled incredulity from, uh, pretty much everyone, and so the company rescinded the request. As one expert said: “I think it’s embarrassing to take something that’s potentially the most widespread disease in the history of the pharmaceutical industry and claim it’s a rare disease.”

Meanwhile, an antimalarial drug is getting tons of attention after Trump touted it as a possible game changer. But a new, more carefully constructed study that finds it did little to help patients in China shows why people shouldn’t be looking for a quick, miracle cure. Researchers say this doesn’t disprove that the drug works but is a good check on expectations, especially when people are trying to self-medicate with the drug — resulting in shortages for those who need it for other illnesses and fatal consequences for others.

On the good-news front (there is some!), Moderna said there could be a vaccine ready for the fall for health care workers under emergency use authorization, ahead of the wider release that’s not expected to come for about a year.

And another treatment that some scientists are hopeful about is the practice of injecting recovered patients’ blood into new patients. The strategy is at least a century old but has scattershot results. “It’s not exactly a shot in the dark, but it’s not tried and true,” says one scientist. Still, in this era, people are willing to try what they can.


And here are some other interesting stories to get you through the weekend.

Federal Response:

Politico: Trump Team Failed to Follow NSC’s Pandemic Playbook

Politico: Those Who Intentionally Spread Coronavirus Could Be Charged As Terrorists

The New York Times: As Coronavirus Surveillance Escalates, Personal Privacy Plummets

2020 Elections:

The New York Times: Joe Biden, Struggling for Visibility, Faults Trump’s Response to Coronavirus

The New York Times: Is All of 2020 Postponed?

From The States:

Stateline: One Governor’s Actions Highlight the Strengths — and Shortcomings — of State-Led Interventions

The New York Times: Governors Tell Outsiders From ‘Hot Zone’ to Stay Away as Virus Divides States

NBC News: Entire Senior Home in New Jersey, 94 People, Presumed to Have Coronavirus

Science And Innovation:

The New York Times: The Virus Can Be Stopped, But Only With Harsh Steps, Experts Say

The New York Times: Warmer Weather May Slow, But Not Halt Coronavirus

The Washington Post: What Research on Coronavirus Structure Can Tell Us About How to Kill It

The Washington Post: The Science of Why Coronavirus Is So Hard to Stop

Reuters: Smokers Likely to Be More at Risk From Coronavirus: EU Agency

Public Health:

ProPublica: Domestic Violence and Child Abuse Will Rise During Quarantines. So Will Neglect of At-Risk People, Social Workers Say.

NBC News: Anti-Abortion Groups Seek Halt to Abortions During Coronavirus Pandemic

Politico: New York’s Health Care Workforce Braces for Influx of Retirees, Inexperienced Staffers


That’s it from me! Have a safe and healthy weekend!

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In Coronavirus Relief Bill, Hospitals Poised To Get Massive Infusion Of Cash

Congress is on the verge of approving a massive funding bill that would steer an unprecedented amount of cash to the nation’s hospitals that are or soon will be struggling to cope with the COVID-19 pandemic.

While the bottom-line number for that aid is close to $200 billion, it remains to be seen how fast the federal Treasury will move the money and whether it will get to where it is most needed.

“It provides what we asked for,” said Chip Kahn, president and CEO of the Federation of American Hospitals, which represents for-profit facilities. “Are all the resources here the right ones? We’ll find out.”

The Senate, after nearly a week of negotiations among Republicans, Democrats and the White House passed the bill Wednesday night. It is scheduled for a vote in the House on Friday.

About $100 billion of the funding is intended to, as the bill puts it, “reimburse … eligible health care providers for health care related expenses or lost revenues that are attributable to coronavirus.”

Hospitals are experiencing something unique in this pandemic. Not only are they being forced in many cases to turn away their usual sources of revenue, like joint replacements and other elective procedures, but they are also experiencing a surge in very sick COVID-19 patients likely to consume large amounts of hospital resources for a long time.

That $100 billion will be administered by the U.S. Department of Health and Human Services’ assistant secretary for preparedness and response. The position was created by a 2006 law passed in the wake of Hurricane Katrina intended to centralize authority over public health emergencies. Among other things, the office oversees the Strategic National Stockpile, which stores drugs and other medical equipment to be used in emergencies.

But already people spot potential trouble spots in this bill. That so-called preparedness office “does not have the capacity to run such a massive provider payment program,” wrote Kim Monk, a health policy consultant with Capital Alpha Partners, in a note to clients and reporters. “It will be a major challenge to distribute the funds in an equitable manner and also fast enough to help hospitals and other providers financially devastated by the pandemic, primarily due to the deferral of lucrative elective procedures.”

Christopher Holt of the conservative American Action Forum wrote in his summary of the bill: “Unfortunately, there isn’t much detail in the legislative text regarding this $100 billion or how it will be disbursed.”

That ambiguity hasn’t stopped hospitals from already jockeying to make sure they get their share.

“The money needs to not run out before you get to the big places,” said Dr. Atul Grover of the Association of American Medical Colleges, which represents teaching hospitals. While the federal funds might be the difference between staying open and having to close for some smaller, rural facilities, he said, the large, urban hospitals have a “larger magnitude of losses and concentration of patients.”

But while urban hospitals are caring for the bulk of patients, the need for financial help in rural areas is even more dire, said Maggie Elehwany of the National Rural Health Association. “A lot of these facilities were already vulnerable,” she said, adding that half of all rural hospitals “are already operating at a loss.”

Elehwany said that while rural hospitals are grateful for the help coming their way, the organization is unhappy that a specific amount was not set aside for rural health care. “They just don’t have the cash on hand to deal with this,” she said, particularly after having to close down outpatient and elective services.

The legislation is surprisingly vague on exactly how the money will be distributed, although most of those who have been working to shape it assume that HHS Secretary Alex Azar will likely have a major role to play. Typically a pot of money that large would come with strict formula requirements.

The bill includes several other provisions aimed at helping hospitals.

For example, under the legislation, hospitals would be given an immediate 20% bonus for costs associated with treating patients with COVID-19, the illness caused by the coronavirus. The federal government is also canceling a 2% across-the-board cut in Medicare reimbursements that was set up in an earlier budget bill and putting off some payment reductions planned for hospitals that treat large numbers of low-income and uninsured patients.

It also includes money to help hospitals buy protective gear for doctors, nurses and other personnel working with coronavirus patients.

And most hospitals would be able to collect a no-interest-for-a-year loan equal to a previous six months of Medicare funding they received. Hospitals in rural and other underserved areas would be eligible for 125% of that amount in advance.

But even that could be problematic, according to the National Rural Health Association’s Elehwany. “How are hospitals that are already operating at a loss going to be able to pay that back?” she said. Some of the facilities she’s been in contact with “only have cash on hand for the next couple of days” and are having difficulty obtaining needed supplies and keeping staff.

Kahn of the for-profit hospital group, who has been involved in nearly every major piece of health legislation for the past three decades, noted that “this is an unprecedented program by anybody’s definition. There’s never been a fund this large that was designed to be handed out in grants, particularly a fund with the expectation of all involved that it will be distributed very rapidly. But the crisis is upon us.”

HealthBent, a regular feature of Kaiser Health News, offers insight and analysis of policies and politics from KHN’s chief Washington correspondent, Julie Rovner, who has covered health care for more than 30 years.

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Help Wanted: Retired Doctors And Nurses Don Scrubs Again In Coronavirus Fight

Laura Benson retired from nursing in 2018, but this week she reported for work again in New Rochelle, New York, where the first cluster of COVID-19 cases occurred a few short weeks ago.

“Nurses are used to giving of themselves,” she said. “If there’s not enough people, you just do it.”

With more than 39,000 confirmed cases, New York is now the epicenter in the U.S. of the novel coronavirus outbreak, accounting for almost half of the more than 85,500 cases nationwide as of late Thursday evening. Anticipating a severe shortage of medical personnel to treat the influx of sick patients, Gov. Andrew Cuomo and other officials put out a call for retired doctors, nurses and other medical professionals to dust off their scrubs and return to work. By Thursday, 52,000 people had responded.

Officials in other states, including California, Colorado and Illinois, have issued similar pleas for retired medical professionals to step forward.

In New York’s Westchester County, which includes New Rochelle and other towns north of New York City, County Executive George Latimer said about 90 retired nurses and a handful of doctors responded after he posted a message on the county’s Facebook page about a week ago seeking help.

There’s no definite plan for deploying the medical volunteers, Latimer said. They may be needed to replace personnel sidelined by the coronavirus or to help staff the Westchester County Center being repurposed as a temporary hospital.

Benson, 60, is working for the county health department. A nurse practitioner with a specialty in oncology, she spent 20 years at the Albert Einstein Cancer Center in the Bronx. She eventually retired from a job at a medical device company, where she worked with patients who have brain tumors. She also teaches nursing students at a community college.

Nurses are used to giving of themselves. If there’s not enough people, you just do it.

Laura Benson

(Photo courtesy of Laura Benson)

On her first day as a retiree volunteer, Benson phoned patients who had recently been tested for the novel coronavirus to talk them through the guidelines they should follow to protect themselves and others.

If there’s a need, she said, she is “absolutely” willing to work directly with patients who have COVID-19, the illness caused by the coronavirus.

“I think about the person laying in that bed,” she said. “I’d want someone to take care of them.”

Benson is not particularly worried about the virus, having worked through the AIDS crisis, treating patients before people understood what that disease was. “You follow the guidelines and protect yourself,” she explained.

The best role for many retired medical professionals may be to fill in behind the scenes, said experts, freeing up younger colleagues to focus on direct patient care.

One reason for this: age.

“My only concern is that many of these retired folks fall into high-risk groups” more likely to be seriously affected by COVID-19, said Dr. Arthur Fougner, president of the Medical Society of the State of New York, a professional group for physicians.

Another concern is whether retirees are up-to-date in their medical knowledge.

“If they’re out for more than two to three years, you have to worry about them being current,” said Dr. Janis Orlowski, chief health care officer for the Association of American Medical Colleges, which represents the academic medical community.

In addition, health care providers’ state licenses may have lapsed if they’ve been retired for more than a few years. Renewing them can be time-consuming.

Still, “if someone still has their licensing and is willing to come back, we should grab that,” Orlowski said.

Michele Pedicone is one such professional. The respiratory care therapist left her job in Seattle last year to head up clinical education at SUNY Upstate Medical University’s respiratory therapy education department in Syracuse, New York. With her classes now mostly happening online and student clinical placements on hold, she has time to step back into clinical care. She contacted two nearby hospitals to see if they could use her services and expects to work three or four days a week.

“I honestly don’t know what they’re paying me; the money isn’t an issue,” said Pedicone, 54. “It’s the right thing to do.”

Respiratory therapists, critical care physicians and nurses trained in operating ventilators that help hospitalized patients breathe are among the specialists expected to be in severely short supply as the coronavirus pandemic worsens in New York and elsewhere, according to an analysis by the Society of Critical Care Medicine.

Expanding the supply of intensive care workers will be key to managing the coronavirus pandemic, said Ashish Jha, director of the Harvard Global Health Institute, at a briefing this week on health care workforce issues sponsored by the Commonwealth Fund.

I honestly don’t know what they’re paying me, the money isn’t an issue. It’s the right thing to do.

Michele Pedicone

One option policymakers have discussed is that states could allow, for example, medical professionals who retired in the past five years with licenses in good standing to get an automatic three- or six-month license without having to do a lot of paperwork, Jha said.

In the meantime, health care systems are developing their own strategies. Northwell Health owns and operates 19 hospitals in New York City, Westchester County and Long Island. This week, the health system has more than 700 patients with COVID-19, compared with just 40 patients last week, according to Terry Lynam, a senior vice president at the health system.

Northwell has been planning how to beef up staff since January, said Judy Howard, vice president of talent acquisition at the health system who oversees hiring, except for physician leadership. They developed a list of 200 retired nurses whom they’ve been contacting to gauge their interest in returning to paid work in some capacity. So far, 28 have signed on, Howard said.

At this time, they’re asking retired nurses to work at the health system’s call center and share responsibilities for training new nurse employees. Some are working in direct patient care. Another possibility is for retired nurses to staff facilities that Northwell has put in place to care for staff members’ children during the coronavirus pandemic.

“Whether someone really wants to work four hours a week or would like to work 10 hours a week, we’ll work with them to meet their needs,” Howard said.

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Health Industry Public Health States

Hospital Suppliers Take To The Skies To Combat Dire Shortages Of COVID-19 Gear

Hospitals in the New York City area are turning to a private distributor to airlift millions of protective masks out of China. The U.S. military is flying specialized swabs out of Italy. And a Chicago-area medical supply firm is taking to the skies as well — because a weekslong boat trip across the ocean just won’t do.

The race to import medical supplies reflects a nationwide panic over a dwindling supply of the masks, gowns and other protective gear that health care workers need amid the growing coronavirus pandemic. Demand is outstripping what’s available due to a damaged supply chain heavily reliant on China and a struggling Strategic National Stockpile. U.S. manufacturing giants like 3M have not yet made up the difference.

A sweeping national survey out Wednesday drives home that nearly a quarter of hospitals have fewer than 100 N95 masks on hand and 20% report an immediate need for ventilators. In the hardest-hit areas, like New York City, the shortages are potentially life-threatening to patients as well as health care workers.

About 260 health systems representing 990 major hospitals responded to the March 16-20 survey by Premier Inc., a group purchasing organization that negotiates with suppliers for discounts. While the survey provides a fresh picture of nationwide hospital operations, the number of U.S. COVID-19 cases has soared tenfold since the survey began ― from fewer than 5,000 to more than 55,000 as of Wednesday afternoon.

“Absent additional interventions from the government or private sector, we don’t foresee the current status quo changing,” said Soumi Saha, senior director of advocacy for Premier. “And the current status quo is not acceptable.”

Saha said the national stockpile “is intended to be a band-aid, not a long-term solution.” Premier called on the Trump administration to either further implement the Defense Production Act to ramp up domestic manufacturing or provide more clear direction on which medical supplies are needed and streamline distribution. FEMA announced Tuesday it did not use the Defense Production Act for test kits after previously stating it would.

The alarm bells ringing from the hospital community come in contrast to a more subdued message from FEMA, which is helping hospitals procure needed goods.

“The private sector can directly purchase [personal protective equipment] from manufacturers and distributors, as they normally do,” FEMA press secretary Lizzie Litzow said in a statement. “The private sector can also accept donations from other private sector entities.” The statement pointed to a “how to help” document that outlines how individuals and companies can share supplies or other resources.

In recent days, volunteer efforts have ramped up to help health providers who’ve taken to Twitter and other social media with pleas for more protective gear. Grassroots efforts have sprung up, with veterinary, computer, construction and industrial businesses donating goods while sewing circles churn out cloth masks.

During a White House press briefing Tuesday, President Donald Trump said FEMA is distributing more than 8 million N95 respirators, 14 million surgical masks and 2.4 million face shields.

“The federal government is using every resource at its disposal to acquire and distribute critical medical supplies,” the president said.

3M, a major American manufacturer of the N95 masks, said on March 20 it had doubled its global output of the crucial N95 respirators and plans to further increase output. Currently, over 30 million industrial and health care specific N95s are being produced for U.S. health care use by the company each month. Shipments totaling half a million 3M masks were scheduled to start arriving in New York and Seattle on Monday from its South Dakota plant.

The influx of goods comes as health care providers are now using four to 10 times more protective gear once a COVID-19 patient enters their doors than they typically use. This has forced hospitals already dealing with cases to scramble even more than health care facilities yet to get any cases, though shortages are crippling all areas of the health care industry.

“It’s a total change in what we are used to as a society around availability,” said Cathy Denning, senior vice president of sourcing operations for Vizient, an analytics and advisory firm that also does health care group purchasing. “From our perspective, it’s this unbelievable place we find ourselves in — realizing we have a vulnerable supply chain.”

As the coronavirus crippled China, the center of commerce for low-margin products like face masks and sanitizing wipes, the U.S. supply chain began to fall apart. With global competition for the same safety gear, the crisis deepened, and big national suppliers aren’t coming up with enough products to meet the crushing demand.

And waiting about a month for a cargo ship of supplies to arrive from China is a luxury of time that hospitals cannot afford ― even though ships can carry over 10 times more supplies than a cargo plane could.

Medline, a Chicago-area medical supplier, started delivering face masks by airplane last week after manufacturing resumed in China. According to spokesperson Stacy Rubenstein, flying the supplies in will shorten the “manufacturing-to-dock” time by three to four weeks, and the firm will not be passing along the “significant increase in cost” to customers.

But the demand is still 300% higher than traditional inventory levels, Rubenstein said in an email.

Elsewhere, hospitals are reaching out to Michael Einhorn, president of Dealmed, the medical products distributor and supplier working with 12 New York metro area hospitals — desperate for products he cannot always secure.

“Does it cost the hospitals a lot of money? No question about it. But right now, that’s what they need to do to secure product,” Einhorn said. “We can’t wait for it to come overseas.”

He’s paying up to $40,000 for shipments arriving on multiple planes from Shanghai to New York’s John F. Kennedy International Airport and Los Angeles International Airport — and sometimes losing money due to the high shipping costs.

The other backstop for hospitals was the national stockpile, which has come up far short.

Despite receiving 49,200 N95 masks, 115,000 surgical masks, 21,420 surgical gowns, 21,800 face shields and 84 coveralls from the national stockpile, the Colorado Department of Public Health and Environment estimated in a press release Monday that those supplies would last approximately one full day of statewide operations.

Einhorn said that hospitals are panicking, having lost faith in the supply chain as they cannot find products they so desperately need.

“The strategic national stockpile, with all due respect, was a failure,” he said.

The hospitals reported in the survey that their supply of N95 masks are their chief concern, with the best-supplied hospitals having about a 10-day supply on hand.

Hospitals identified hand sanitizer as the second-most pressing shortage, with 64% of respondents saying they were already running out. Next was surgical masks, which provide less protection than the N95 masks. Nearly half of hospitals had fewer than 1,000 on hand; a quarter of them reported going through 1,000 per day.

To keep up with that kind of demand, Einhorn said, more needs to be done to secure the products from China.

“One of the things we have been asking for is assistance getting these products quickly from China to here,” said Einhorn. “Instead, we’re doing drives of people dropping off three boxes of face masks.”

Related Topics

Global Health Watch Health Industry Public Health

Think Like a Doctor: The Boy With Nighttime Fevers

Photo

Credit

The challenge: A healthy 7-year-old boy suddenly starts having fevers and night sweats. Can you figure out why?

Every month, the Diagnosis column of The New York Times Magazine asks Well readers to sift through a difficult medical case and solve a diagnostic riddle. This month we present the case of a boy who has fevers topping 102 degrees every night for over a month. His parents sought help from nearly a dozen doctors in two states before a diagnosis was made.

Below I’ve given you the information that was available to the doctors who figured out the cause of the boy’s fevers. It’s up to you to use this information to put his story together for yourself.

As usual, the first person to crack the case gets a copy of my book, “Every Patient Tells a Story,” and, of course, that fabulous feeling you get when you solve a really tough puzzle.

The Patient’s Story

“I think you need to take him back home.” Her brother’s voice was calm, but she could hear an undertone of anxiety even over the poor cellphone reception that was all she could get from rural Colorado. “He needs to see a hematologist. It could be a virus, but it could also be something else.” He didn’t say it, but she knew what he was thinking: cancer.

Her son, just 7 years old and always a little delicate, had been sick for nearly a month. He was fine during the day, but every night he’d spike a fever of 102 or 103.

Even before they’d come to the mountains for a much needed vacation, she’d taken him to see his pediatrician at home in Minneapolis several times. At each visit, the doctor or one of his partners had looked the boy over closely, and each time he’d seemed fine.

It was probably viral, she was told, time after time. But he seemed to be having one viral infection after another.

A Vacation Cut Short

The day before they left for Colorado, the boy’s father took him to the doctor’s office one more time.

Maybe it wasn’t viral, the pediatrician acknowledged, and prescribed a “Z-pak” — a five-day course of azithromycin. Don’t cancel the trip, the doctor reassured him. He’ll get better.

But he hadn’t. While on vacation, his mother took him to a walk-in clinic, where they’d checked his blood. A worried looking doctor told her that he didn’t know what was wrong with her boy. He should probably see a cancer specialist.

Now she was really worried. There weren’t any specialists anywhere near the bucolic town where they were staying. That’s when she’d sent the test results to her brother, a researcher in immunology. He wasn’t a doctor, but he passed the results to friends who were, and they were worried, too.

Thin and Pale

The family headed home right away, but the 4th of July was coming. They couldn’t get in to see a hematologist until Tuesday.

By now the boy was starting to look sick. He was pale and had dark circles under his eyes. Small for his age — consistently in the fifth percentile for height and weight — he now looked even smaller, thinner. He was a quiet child, always had been. Thoughtful and comfortable in the company of adults, as so many only children are. Even now he never complained.

Nothing hurt. He was simply tired. His fevers started coming a little earlier, peaking a little higher. His mother noticed a cough and wheezing sometimes. Always a picky eater, with these intermittent fevers, very few foods seemed appealing. She tried to hide the terror she felt when he seemed to be fading as she watched.

A Long Line of Specialists

The hematologist examined the boy and sent off more blood. Definitely not cancer, he said. He suggested seeing a gastroenterologist.

The gastroenterologist got an M.R.I. of the child’s digestive system. Nothing there. He noticed the boy’s wheezing and gave him an inhaler, then referred mother and child to a rheumatologist and an infectious disease specialist.

It seemed to the parents that this had to be an infection, but the earliest they could get in to see the infectious disease doctor was the following week. For the boy’s mother, the delay now seemed intolerable.

It had been five weeks since the fevers first started. In that time, the boy had lost nearly 10 pounds. They’d seen eight doctors in two states. They’d all been very nice, thorough, thoughtful, but had no answers.

By the weekend she was desperate. The boy needed to be in the hospital. Couldn’t they see how sick he was? She couldn’t wait for the specialist. She took him to the emergency room of the big university hospital.

The E.R. doctors, like all the doctors they’d seen so far, were kind and thoughtful, and so gentle with her delicate son. But like all the other doctors, they had no answers. They prescribed another inhaler for the boy’s wheezing, since the first hadn’t helped. They also urged her to see the infectious disease specialist. His appointment was just a couple of days away.

TB or not TB?

The boy was sitting quietly between his parents watching a video on his tablet when Dr. Bazak Sharon and the infectious disease fellow he was training entered the exam room. Dr. Sharon’s first thought was that the child looked as if he had tuberculosis.

He’d seen a lot of TB in this clinic, but it was usually among immigrant families who had traveled to Minneapolis from countries where the disease was common. Like this boy, kids with TB were usually thin, sickly looking, pale and quiet. But based on what his fellow told him, the child had no exposures that would put him at risk for this disease. He’d only been out of the country once – to Canada. He’d visited the beaches of South Carolina and the deserts of Arizona, and most recently the mountains of Colorado. But TB was rare in all these locales.

Dr. Sharon introduced himself to the child, who looked up immediately and smiled. How do you feel, he asked the boy? His temperature had been recorded at 103 degrees. I feel good, he’d answered pleasantly. Does anything hurt? No.

His heart was beating rapidly – nearly 140 beats per minute, but that was probably due to the fever. There were several enlarged lymph nodes in the child’s neck and his groin, though none under his arms. Otherwise his exam was unremarkable.

Getting Worse

Dr. Sharon had reviewed the blood tests that had already been done but wanted to see if anything had changed. And given that the only localized complaint was cough and wheezing, he wanted to get another chest X-ray.

Reviewing those studies that night, Dr. Sharon saw that the boy was slowly getting worse. He saw patients at that clinic only once a week and was reluctant to wait that long before having him seen again. He thought they needed an answer much sooner than that.

You can see the note from Dr. Sharon and his fellow here.

Dr. Sharon’s Note

The note from the patient’s visit to the hospital.

To the Hospital

Dr. Sharon called the family the next morning. He’d reached out to one of his friends and colleagues, Dr. Abraham Jacob, who could see them. They should go to the University of Minnesota Medical Center Fairview, where Dr. Jacob would orchestrate a thorough workup. That would be the fastest way to get an answer.

Based on the assessment by Dr. Jacob and his resident and the recommendations from Dr. Sharon, the team reached out to specialists in hematology-oncology and in rheumatology. And since his chest X-ray was abnormal and he had enlarged lymph nodes, they wanted to get a CT scan as well.

You can see the note from Dr. Jacob and his resident here.

Dr. Jacob’s Notes

Here are the notes from the pediatrics department.

Breathing Through a Straw

It was the results of the CT scan that really got things moving. It was the middle of the day when the resident was paged by the radiologist. The pictures showed that the lymph nodes in the boy’s chest were so swollen that they were pressing on the trachea – the breathing tube – so that it was almost completely cut off. Essentially he was breathing through the equivalent of a cocktail straw.

Any additional swelling could cut off the boy’s breath completely. You can see an image from the CT scan here.

Photo

This CT scan shows the patient’s chest. In a child of this age, the trachea is normally eight to 12 millimeters wide. Much of the gray tissue surrounding the trachea and esophagus is swollen lymph nodes.

This CT scan shows the patient’s chest. In a child of this age, the trachea is normally eight to 12 millimeters wide. Much of the gray tissue surrounding the trachea and esophagus is swollen lymph nodes.Credit

A normal trachea in a child this age is four to six times the size seen in the scan. The image added even more pressure to make a diagnosis and treat the child before he got sicker.

Solving the Mystery

A diagnosis was made within the next 24 hours. Can you figure out what the boy had, and how the diagnosis was made?

The first person to offer the correct answers to these two questions will get a copy of my book and that sense of triumph that comes from nailing the right diagnosis when it really matters.

Rules and Regulations: Post your questions and diagnosis in the comments section below. The winner will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.

In a Hospital, Health Care Until the Clock Runs Out

Photo

Credit Jordin Isip

A 37-year-old man was admitted to a hospital several months ago with seizures. His M.R.I. was frightening, showing a brain full of holes. Medication controlled the seizures, but the drugs were just Band-Aids on a big, undiagnosed problem.

The patient was not particularly alarmed (which in itself was fairly alarming). His brain was riddled with infection or tumor, but all he wanted to do was get out of the hospital and go back to his life.

By all accounts, it was a troubled, isolated, drug-ridden existence in a fleabag hotel, a life free from anything resembling regular medical care. Still, he was ready to be on his way.

The only way to diagnose his problem was a brain biopsy. “Anything to get out of here,” the patient said, and signed a consent form.

The biopsy was performed uneventfully, and small specimens of the abnormal tissue were sent to the lab for a diagnosis. That was on a Friday.

By Monday, everyone was ready for an answer. By Tuesday, it was hard to tell who was more impatient, the patient pacing the hallways or his doctors pestering the lab.

On Wednesday, with the specimens still being processed and another weekend looming, the case had attracted the notice of the administrators known in hospital vernacular as the discharge police.

Within minutes, it seemed, the patient was out of that expensive acute-care bed and on his way to the subway, clutching a thick sheaf of instructions, appointment slips and prescriptions, still without a diagnosis, brain full of holes, but free at last.

Your reaction to this story will almost certainly depend on your understanding of the word “hospital.” The word has connotations of care and comfort dating to the Middle Ages, but its meaning is changing so quickly that even the people who work in one cannot agree on what it is.

Once hospitals were where you found a doctor when you suddenly needed one; now doctors are all over the place, from big-box stores to storefront clinics. Hospitals were where you were headed if you were very sick; now you can heed your insurer’s pleas and choose a cheaper emergency center instead.

Hospitals were where you stayed when you were too sick to survive at home; now you go home anyway, cobbling together your own nursing services from friends, relatives and drop-in professionals.

Once hospitals were where you were kept if you were a danger to yourself or others. They still serve this function — although, perhaps, the standards for predicting these dire outcomes have tightened up quite a bit.

These days, it may be easier to define hospitals by what they are not. They are not places for the sick to get well, not unless healing takes place in the brief interval of time that makes the stay a compensated expense.

Hospitals are definitely not places for unusual medical conditions to be figured out, not if the patient is well enough to leave.

Like the hospital, the patient with holes in his brain was also a puzzle of ill-defined words. He was very sick, yet not all that sick. Whether he could survive at home depended strongly on the meaning of “survive” and “home.”

He was well enough to be an outpatient, but he was far from well, and had never managed to be a successful outpatient. He was not suicidal, at least not in any immediate sense. The big holes in his brain made it even less likely that he would adhere to the complicated instructions for his new outpatient life.

But then again, a hospital is a place where hope reliably springs eternal.

The patient’s young doctors certainly hoped for the best for him. They gave him a slew of prescriptions, and expressed their hopes that he would take the pills and keep his far-flung appointments, at one of which his brain biopsy report would be retrieved and his medications adjusted accordingly.

Not so long ago, the multiple ambiguities of this patient’s case would have kept him in the hospital until at least some of the uncertainty had been resolved. In fact, it would have been considered close to malpractice to let a patient like him out the door. Now it is considered downright medieval to keep him in.

I’m sure you would like to know what happened to the patient. His doctors would, too, but he is missing. His phone goes unanswered. The name of an emergency contact is blank in his records — he refused to provide one.

It’s anyone’s guess if he filled his prescriptions. He kept none of the appointments made for him.

The results of his biopsy showed a perfectly treatable condition, an infection that the pills he was sent home with should have helped. Perhaps he got better, perhaps not.

The young doctors will never know if they managed his case correctly — that’s “manage” in its medical sense. In the word’s other senses (“succeed despite difficulty” among them), they now have a reasonably good sense of how they failed.

A Doctor on Schedule, Rarely on Time

Photo

Credit James Yang

The minute I got on that bus, I knew I was in trouble. The driver sat at the stop just long enough to miss the green light. Then he inched along till he missed the next light and the one after that. He stopped at every stop even though not a soul was waiting.

The 20-minute trip to work stretched to a half-hour, then longer. I was late, late, late.

But this was a driver with a mission, clearly way ahead of schedule and trying to get back on track. He was very early; now I was very late. We were two people with competing, mutually exclusive agendas, and the one in the driver’s seat was bound to win.

A half-hour later, still sweating from racing the last five blocks on foot, with patients piling up in the waiting room, I became the one in the driver’s seat, with the mission and overriding agenda. Woe betide those with competing plans.

Just like that driver, I work under two mandates. One is professional: getting my passengers from point A to point B without breaking the law or killing anyone. The other one is less exalted but generally far more visible: I run according to a schedule that I ignore at my peril.

“She’s running late,” they mutter out in the waiting room. And indeed, she runs late for exactly the same reasons your bus runs late: too many slow-moving passengers lined up to board. Not enough buses or drivers. A person in a wheelchair requiring extra attention. Horrible traffic.

Not only does she often run late, but your poor driver — er, doctor — can run only so late before disaster ensues. She has obligations not only to you and your fellow passengers twitching in annoyance, but to a host of others, including the nursing and secretarial staffs and the cleaning crew at the end of the line. She can’t pull that bus in at midnight if everyone is supposed to leave by 7 p.m.

So when there is enough work to last till midnight, my agenda shifts, and not so subtly. Everyone can tell when I begin to speed. Every visit is pared down to the essentials. All optional and cosmetic issues are postponed, including most toenail problems and all paperwork. Chatting is minimized.

As a bus driver once said to me when I was foolish enough to start a conversation about his speed: “Lady, just get behind the white line and let me drive.”

Medicine is full of competing agendas. Even at the best of times, the match between the doctor’s and the patient’s is less than perfect, sometimes egregiously so. Some residents are now trained specifically in “agenda setting,” the art of successfully amalgamating all concerns.

But when it’s all about speed, an advanced skill set is required.

A patient has been waiting weeks for his appointment, anxiously rehearsing his lines. Bad luck that he showed up on a day I need him in and out in 19 minutes. He spends his first 18 unwisely, pretending everything is fine, making small talk, not quite mustering the courage to say what’s on his mind.

Then just as he is being ushered gently to the door, he pauses. “Oh, by the way …”

“Oh, by the way” is an infamous schedule buster. It means something bad: a suspicious lump, a sexually transmitted disease. Further, it is so common that an entire literature now addresses the “oh, by the way” phenomenon and how to tame it.

One favored tool is: “What else?” That question, asked by the doctor early in the visit, is intended to probe the patient’s agenda before it trumps the doctor’s.

As one set of researchers wrote: “The ‘what else?’ technique uncovers pertinent fears and anxieties up front and prevents an ‘oh, by the way, I have been having some chest pain’ from surfacing at the end of a visit.”

In other words: My agenda is to adopt your agenda, and then rework it so that I can drive on. Brutal, perhaps, but effective.

Very rarely do things work out for me the way they did for that driver who made me so late to work. Occasionally I have so much time that I can dawdle along the route.

I remember clearly the last time that happened. “How’s work?” I began. “What are you doing for exercise?” “Any hobbies?” “Your family, are they well?” I progressed rapidly through seatbelts, bike helmets, family medical history, end-of-life preferences — every single stop my bus typically has no time to make.

Every answer was “fine,” “yes,” or “I dunno.” Then the patient stood up: “Look, I have places to be. Are we done?”

We were two people with competing, mutually exclusive agendas. But that time the one in the driver’s seat lost.

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Think Like a Doctor: The Tired Gardener

The Challenge: Can you figure out what is wrong with a lively 67-year-old gardener who develops a daily fever and shaking chills along with chest pain and a dry cough?

Every month, the Diagnosis column of The New York Times Magazine asks Well readers to solve a real-life diagnostic mystery. Below you will find the details of a case involving a retired maker of surgical supplies who starts having daily fevers along with chills, chest pain and a dry cough.

I’ll give you the same information the doctor was given before he made this diagnosis. Will you be able to figure out what’s wrong?

As usual, the first reader to submit the correct diagnosis gets a signed copy of my book, “Every Patient Tells a Story,” and the pleasure of puzzling out a tough but fascinating case.

The Patient’s Story

“NoNo says he doesn’t feel good,” the 9-year-old girl said of her grandfather, handing her mother the thermometer. The woman dried her hands on her apron and took the device. She squinted at the little electronic numbers. Just under 102 degrees.

Her father had been sick for weeks. Feverish, weak, not eating. It was late summer and the tomatoes and eggplants in the garden were ripe, but he hadn’t even walked through his garden for days, so she knew he wasn’t feeling well. But this was the first time he’d admitted that something more serious might be going on.

It was about time. She’d taken her 67-year-old father to several doctors over the past two months. They’d looked him over and given him antibiotics, but it hadn’t helped.

“Tell NoNo that if he’s feeling sick he’s got to go to the hospital,” she told the little girl. She darted back to her grandfather’s room then quickly returned. “He says he’s ready to go.”

The woman wasn’t sure exactly when her father had started to get sick, but six or seven weeks earlier she had noticed that he was no longer the first one out of bed. Instead of being up and out before 7 a.m., he wouldn’t get up until late morning. And he started to have strange shaking chills each afternoon and evening, followed by a fever — regular as clockwork.

He looked sweaty and pale. She asked him what was wrong, but he said he was fine. Or sometimes he’d say he felt a little tired. After an hour or two the fever would pass and he’d just look tired, but the next day, or sometimes the day after, the fever would be back.

The First Diagnosis

The woman first took her father to his regular doctor. Knowing how much he loved to work in his garden, the doctor figured he probably had Lyme disease. It was summertime, and Lyme was common in the area of Connecticut where they lived. Plus, he practically took root in the half-acre garden back behind the house where he lived with his wife and their children and grandchildren.

This was the first summer the woman could remember where her father wasn’t out in his garden every single day. This year it seemed that whole weeks would go by when he did nothing but look out the window at his beautiful handiwork.

Her father took antibiotics for the presumed Lyme. It didn’t help.

A Second Diagnosis

When the patient went for a follow-up visit, he told his doctor that his stomach was bothering him a bit. So he was referred to a gastroenterologist. That doctor diagnosed Helicobacter pylori – a bacterium tough enough to survive the acid environment of the stomach that can cause pain and ulcers.

He took two weeks of treatment for that — three medications to kill the bug, and one to neutralize the acid they thrive in. That didn’t stop the daily fevers, either.

Recently the man’s wife noticed that he’d developed a dry cough. Was this a pneumonia? His doctor gave him yet another antibiotic. And he was still taking that pill when he agreed to go to the emergency room.

Pneumonia?

So three generations — wife, daughter and granddaughter — got in the car with the man they loved and drove to the hospital where the daughter worked.

The emergency room was quiet when they arrived, and after explaining that the patient had been having fevers for weeks, the patient and his entourage were taken into the back so he could be seen right away.

He did have a fever but otherwise looked pretty healthy. The doctors there seemed to focus on the cough and fever. They figured he had a pneumonia that wasn’t responding to the antibiotics he was taking. And when a chest X-ray failed to show any sign of pneumonia at all, the doctors sent him home.

You can see the note from that first visit to the Emergency Department here.

First ER Visit

If Not Pneumonia, Then What?

The next day, the man felt no better. His daughter was distressed. Her father was sick. Antibiotics weren’t working. And he was getting worse.

She called his primary care doctor again. He was also worried, he told her. But he didn’t know what to suggest.

What if she tried a different emergency room?, she suggested. They had gone to Yale-New Haven Hospital initially because that’s where she worked, but what if they went to the smaller branch of the hospital, St. Raphael’s Hospital, less than a mile away. They had different doctors there, and the hospital had a different feel — local and friendly rather than big and academic. Maybe they would find a doctor there who could help them figure out what was going wrong. It was unorthodox, the doctor told her, to shop around emergency rooms. And it wasn’t clear what another E.R. visit might do. But he was also worried about the patient, and it was certainly worth a try.

Another E.R. Visit

So early that evening they all got back into the car and drove to the St. Raphael campus. The E.R. was bustling when the family came in. Once again he had a fever – 101.6 degrees. His family explained how sick he’d been, how tired. And yet when the doctor examined him, he seemed well enough. He couldn’t find anything abnormal beyond the fever.

The labs told a slightly different story. His red blood cell count was low. So were his platelets – a type of blood cell that helps blood to clot. What was particularly strange was that these two findings had been checked the day before at the other E.R. and had been fine. And there was some evidence that he had some liver damage.

And when tested for viral hepatitis — a common causes of abnormal liver tests — he tested positive for hepatitis A and possibly hepatitis B as well.

He was admitted to St. Raphael’s Hospital because of his worsening anemia and viral hepatitis.

You can see the note from this second emergency room visit, and the admission note from the night team here.

The Second ER Note

Admission Note

Fitting the Pattern

The next morning, Dr. Neil Gupta saw the patient. Hearing the patient’s story, and the diagnosis of hepatitis A infection, was a little puzzling. Patients with hepatitis usually have mild flu-like symptoms, with a loss of appetite, nausea and vomiting, plus fatigue, low-grade fever and a generalized sense of being unwell. Certainly this patient didn’t feel well, but he had no nausea, no vomiting. And his fever came in spikes. The pattern didn’t really match.

Dr. Gupta sat down with the patient’s family and reviewed all the symptoms and the timeline. Then he reviewed all the labs. He sent off a bunch of tests.

You can see Dr. Gupta’s note here.

The Doctor’s Note

Solving the Mystery

Dr. Gupta was finally able to figure out what was wrong with this man. Can you?

The first person to figure out what is really going on with this 67-year-old gardener gets a copy of my book and that lovely sense of satisfaction that comes from making a tough diagnosis.

Rules and Regulations: Post your questions and diagnosis in the comments section below. The winner will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.

Giving New Doctors the Tools They Need

Photo

Credit Early Wilson

They say if all you have is a hammer, everything looks like a nail. I wonder, then, why my toolbox often seems so inadequate for fixing my patients.

I open one recent afternoon in clinic with a middle-aged man I’ve come to know well. He’s drunk. His breath smells of alcohol and he slurs his words. He tells me his brother’s in jail, his mother died, and he punched a neighbor who tried to steal his wallet. In the past year, he’s been admitted to the hospital countless times for everything from falling to getting injured in a fight to failing to take his medications.

“High risk for readmission,” an automated email plops into my inbox each time he’s admitted. Thanks, I’m on it.

I search for mental health and substance use resources we haven’t yet exhausted. I speak briefly with a psychiatrist and case manager and a social worker who is arranging transportation back to the housing he’s in danger of being thrown out of.

“Maybe we increase his mood-stabilizer?” I offer, mostly just to say something. When all you have is a hammer…

The afternoon doesn’t get easier. I see a patient whose heart failure had been in good control with a telemedicine service that had checked his weight at home and adjusted his medications accordingly. But the service has been cancelled, and now he’s in our clinic, gasping for air as fluid fills his lungs.

He’s followed by an older man who’s been on opioid painkillers for a decade — and who I now suspect is selling extra pills on the street. I’m running 45 minutes late by the time I greet an understandably frustrated woman who, a computer alert informs me, is overdue for her first colonoscopy. She balks when I bring it up, and I don’t have the words or the time to convince her otherwise.

The afternoon was not unusual. At the end of most days, I find myself searching for nails that I can hammer.

Part of the problem is the tool kit we assemble during medical training. We’re educated largely in a biomedical framework. We diagnose disease with textbook knowledge and prescribe medications because those are the hammers we have.

But consider the skills I would need to be more effective in just this one clinic session: understanding social issues that contribute to health; marshaling support resources like case management, social work and rehabilitation centers; exploring my patients’ values and goals and encouraging behavior change; leading interdisciplinary care teams; employing new technologies and methods of patient engagement like telemedicine; and appreciating how health systems fit together to influence an individual patient’s care — from home care and community centers to clinics and hospitals. None have traditionally been emphasized in medical education — and, unsurprisingly, doctors in training like myself are often ill-equipped to practice in today’s health care environment.

Medicine has long been a discipline predicated on memorization, which made sense in a world of textbooks, microscopes and information monopoly. But rooting medical training primarily in knowledge acquisition is increasingly insufficient and inefficient. In an era of big data, Google and iPhones, doctors don’t so much need to know as they need to access, synthesize and apply. We’re increasingly asked to consider not just patients, but communities. We’re expected to practice not as individuals, but as team members. And now — liberated from carrying every diagnostic and treatment detail around in our heads — we have both the responsibility and the luxury of deciding what a doctor should be in the 21st century.

Some medical educators are trying to figure it out, with a greater emphasis on new technologies, collaborative care, wellness and community health.

The new Dell Medical School at the University of Texas, Austin, which enrolls its first class in June, is hoping to revolutionize medical education. The school plans to focus on helping students understand how health systems, communities and social issues contribute to individual health through a variety of innovative methods.

Instead of traditional lecture halls, Dell’s students will learn in collaborative workspaces with a curriculum that emphasizes team-based management of patients. They’ll take weekly classes with pharmacy, nursing, social work and engineering students. Dell’s “Innovation, Leadership and Discovery” program affords students an entire year to pursue projects related to population health and delivery system redesign.

Dell also features a unique collaboration with the university’s College of Fine Arts — known as the Design Institute for Health — to bring design thinking to health care. Here students will learn to think about everything from better hospital gowns and more hospitable hospital rooms to how patients access services online and how to make waiting rooms obsolete.

“It’s an incredible gift to start from scratch,” said Dr. Clay Johnston, the school’s first dean. “We can start by looking at where the biggest gaps and problems are. Then say, O.K., given those needs, what should doctors and the medical system look like in the future?”

The health system Kaiser Permanente recently announced its own plans to open a medical school in 2019, in Pasadena, Calif. The medical school, like the health system, will emphasize integrated care, the latest medical evidence and new technologies like online doctor visits.

“We recognize the importance of providing care in alternate settings,” says Dr. Edward Ellison, who is helping to oversee the creation of the school. “We’ll take care of you when you’re sick. But we’ll also help you stay healthy when you’re home.”

While most medical schools are trying to get students out of lecture halls and into hospitals, Kaiser Permanente hopes to get students out of hospitals and into communities. Students will visit patients in their homes to see how they live and what behavior change looks like in living rooms instead of hospital rooms. They’ll also be trained as emergency medical technicians — riding in ambulances alongside other medical professionals, responding to accidents, violence and trauma in their communities.

The American Medical Association, for its part, has provided over $11 million to established medical schools to reimagine their curricula and better prepare students for a rapidly evolving health care environment.

Older physicians, medical educators, policy makers and patients will continue to debate what doctors should be taught and what they should know. But the deeper question is how doctors can learn to think — to solve problems that can’t be solved with the tools we currently have. Because ultimately, there’s no better hammer than that.

Dhruv Khullar, M.D., M.P.P. is a resident physician at Massachusetts General Hospital and Harvard Medical School. Follow him on Twitter: @DhruvKhullar.

Picking Up an Infection in the Hospital

Photo

Credit Stuart Bradford

When the emergency room doctor pulled the blanket aside, looked at my elephant-size inflamed leg and said, “Whoa!” I knew that wasn’t a good sign.

Nor was the reaction of the emergency room nurse, who glanced down at my bizarrely swollen extremity, then started nervously backing away.

Health care practitioners are trained not to show their feelings, but there are clearly times when things look so bad that even they can’t hide their reactions.

I was in the emergency room at Los Robles Hospital in Thousand Oaks, Calif., because a few days earlier I had undergone what was supposed to be a relatively straightforward outpatient procedure to remove a skin growth on my leg. A couple of days after the surgery I felt fine. The surgeon told me I could drive whenever I was up for it, so we took our grandchildren to the Magic Castle in Hollywood. Running from room to room to see the different sleight-of-hand acts, I no longer felt fine. Now I felt a searing knife-like pain in my leg, which soon began to swell in size.

I went back to see my surgeon, who looked a little concerned. You have an infection, she said. Take these two antibiotic pills, schedule a Doppler scan for the next day, and all should be well.

That night, my leg got even bigger; from the waist down one side of me looked like I weighed 350 pounds (I’m not even half that.) My wife and I spoke to the surgeon, who was vague. “You could go to the E.R. if you want,” she said. “Or wait.”

I went and was admitted immediately. That night, a Doppler study showed no life-threatening blood clots. With no beds available, I was kept in the emergency department overnight, taking catnaps while trying to blot out the screams and moans from down the hall, before being given a room, and intravenous antibiotics, the next morning.

“This is very serious,” said Dr. Barry Statner, the infectious disease specialist who came to see me the next day in my hospital room. “We’ll cure you,” he said while firing questions at me about my medical history. “But you need to know, this is very serious.” I wondered if I was going to lose my leg.

For the first time in my life, I had entered the world of the powerless sick. Like most people, I had long heard about the dangers of contracting infections in hospitals or surgical centers, but I never took them seriously. I assumed that, except for the worst cases, such as those caused by improperly disinfected scopes and other instruments, they were little more than a minor annoyance.

In fact, infections kill, and they do so regularly, even to people who are otherwise healthy.

“There are diseases that can take a regular healthy person and destroy them within hours,” Dr. Statner told me. “You don’t get a second chance. People don’t realize how rapid and lethal infections can be.”

In the United States in 2014, one in 25 patients contracted a hospital-borne infection on any given day, according to the Centers for Disease Control and Prevention. Some 722,000 Americans developed such infections in hospitals in 2011, and about 75,000 died during their hospital stay.

I count myself as somewhat lucky. My wound was infected with a relatively run-of-the-mill strain of Staphylococcus aureus, and after a week in the hospital, followed by two weeks hobbling around the house, where a nurse visited daily to pack my wound with prodigious amounts of gauze, I was on the road to recovery. I was fortunate it wasn’t one of the more serious infections that lurk around hospitals, like MRSA, a “super bug” strain of Staph that is resistant to most antibiotics, or C. difficile, which can cause months of relapsing and severe diarrhea.

No one knows how my infection happened. It was the first, and only, case of this type of infection at the surgical center that year, I was told by Dr. Richard Hoberman, the medical director and the anesthesiologist who had put me under general sedation during my surgery. Clearly shaken by what happened to me, he unexpectedly popped in to my hospital room early in my stay to apologize.

My infection resulted in my being “the subject of several very uncomfortable meetings with the hospital administration” and a five-page written report, Dr. Hoberman said. (They passed on sharing a copy of that report with me.)

Hospitals are anxious to reduce hospital-borne infections, to reduce deaths and improve their reputations. There are also immediate financial incentives: Medicare may penalize hospitals for infections acquired in the facility.

The medical center I’d gone to for my surgery, associated with Los Robles Hospital, practices all the well-known standard forms of infection prevention: constant washing of hands; sterilizing equipment; giving patients preoperative antibiotics; cleaning operating room surfaces and thorough cleaning at night. In addition doctors are not allowed to enter the operating room wearing the same scrubs they wear in the street. To prevent the spread of microbes, cellphones and jewelry are banned, as well as ties.

But infections still happen. While most infections happen at the time of surgery, according to Dr. Statner, they can occur in the hospital room as well. A break in the skin, a lapse in the handling of a paper surgical cover, lackluster cleaning, intravenous lines or catheters that remain in too long — all can result in infection.

In the end, stamping out infections depends on the vagaries of human behavior. “Medical care is done by people. There can be gaps in quality. People must remember to do certain things,” said Dr. Arjun Srinivasan, the associate director for health care associated infection prevention programs at the C.D.C.

“Far too many Americans get sick in the hospital,” said Dr. Thomas R. Frieden, director of the C.D.C. “The importance of making care safer cannot be overstated.” One limitation is that the C.D.C. can only recommend, not mandate, practices to reduce infection, he said. And because hospitals are owned by various corporations, it can be a challenge to know how effectively patients are being protected in any one hospital. If a patient is moved from one hospital to another across town, he said, it “can cause problems,” given that one hospital may have less rigorous infection-reduction policies than another.

Hospitals are experimenting with new disinfection techniques. For example, some disinfecting machines using ultraviolet light are so powerful that no one is allowed in the room when they are in operation. And routine measures like thorough hand washing, and having patients thoroughly shower using chlorhexidine before surgery is helping bring infection rates down in the United States in recent years. In the three to six years before 2014, depending on the type of infection, the rate of surgical-site infections has dropped by 17 percent, C. diff by 8 percent and hospital-borne MRSA by 13 percent, according to the C.D.C. However, there was no change in the rate of urinary tract infections caused by catheters between 2009 and 2014.

Infection rates have dropped even more steeply in Britain, where total MRSA reduction from 2004 is now 80 percent, according to Dr. Mark Wilcox, the head of medical microbiology at Leeds Teaching Hospitals and the head of the C. difficile task force for Public Health England. Leeds Hospital used to see 15 to 25 MRSA infections per month; now it gets five per year, he said.

Dr. Wilcox attributes their success in part to having a coordinated, single health system for the entire country. To encourage hygiene, National Health Service hospitals post current infection rates on boards that can be seen by doctors, patients and visitors. Hospitals are “obsessional” about hand hygiene, Dr. Wilcox said. To do the best cleaning job, health workers must be “bare below the elbows,” with no watches on the wrist. Lab coats, while making a doctor look professional, are also banned, as they can brush up against patients and transfer bacteria from one patient to the next.

Hospitals that fail to meet infection reduction targets are visited by a “hit squad improvement team” that demands a new plan, Dr. Wilcox said. Those that fail lose the right to decide how to spend some of their annual budget.

“A decade ago, people would say that only a small proportion of infections are preventable,” said the C.D.C.’s Dr. Srinivasan. “Now we know that a large proportion are preventable. We’ve turned that paradigm on its head.”

Think Like a Doctor: Sick at the Wedding Solved!

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Credit Anna Parini

On Thursday, we asked Well readers to take on a challenging case. A 38-year-old man who traveled to the mountains of Colorado for his brother’s wedding suddenly became ill. He had fevers and chills, chest pain, a severe headache and a sore throat. There was so much going on that it was really tough to see what might be underlying it all. More than 400 of you offered your diagnoses, but no one got it completely right. I had to choose two winners, each of whom was the first to get at least part of it right.

The correct diagnosis was:

Lemierre’s disease caused by an invasive strep infection

One of the winning answers came from Dr. Hediyeh Baradaran, a chief resident in the radiology department of Weill Cornell Medical Center. She recognized that an invasive strep infection could cause both the inflamed heart muscle diagnosed at one hospital and the abscess found at the other. She didn’t mention the Lemierre’s. That diagnosis was offered by Dr. Ariaratnam Gobikrishna, a cardiologist with Montefiore Medical Center in the Bronx.

The Diagnosis

In 1932, Dr. André Lemierre reported on 20 patients he’d seen who became ill with a sore throat and then went on to develop a clot in their jugular vein. The clot was infected with bacteria, and the disease spread from the jugular to the lungs, bones, brain and other organs when tiny pieces broke off, seeding the infection throughout the body. The illness came to be known as Lemierre’s disease, or syndrome.

Lemierre’s is rare, most commonly seen in teenagers and young adults. And it is frequently misdiagnosed, at least initially. In one study of hospitalized patients, a correct diagnosis of Lemierre’s was made, on average, five days after admission.

Most of the time the infection is caused by an unusual bacterium called Fusobacterium necrophorum, but it has been associated with other bugs as well. And no matter which bacterium caused it, in the era before antibiotics, Lemierre’s was practically a death sentence, with 90 percent of patients dying. Even now, it’s not a disease to be taken lightly. Up to 18 percent of patients will die of the infection.

However, it wasn’t some rare infection behind this man’s illness. Blood cultures drawn at Anna Jaques Hospital in Newburyport, Mass., where the patient went after returning home, revealed an underlying disorder that is much more common and much less feared: strep throat. There are millions of cases of streptococcal infections in this country every year, usually in the throat or on the skin. But in a tiny fraction of these cases, the bacterium will invade the surrounding tissues and cause a life-threatening illness, as it did with this man.

Both the Lemierre’s and the myocarditis were caused by this strep throat gone wild. This kind of invasive infection must be treated with antibiotics. This patient was taking an antibiotic, doxycycline, because the doctors were worried initially that he might be suffering from some kind of tick-borne infection, but that antibiotic is ineffective against most types of strep.

How the Diagnosis Was Made

After the patient’s flight back from Colorado to Boston, he had ended up in Massachusetts General Hospital, where he’d been diagnosed with myocarditis, or inflamed heart muscle. He began to feel a little better and returned home, but after a day he began to feel worse again. He was pale and sweaty, the way he’d been in the mountains. And the shaking and fevers were back. His headache was terrible, almost as bad as it had been in the hospital, where it had brought the man to tears — something his wife had never seen before.

The patient’s wife called Mass General several times with her concerns; the doctor who’d cared for the patient there suggested she take him to a local hospital. And that’s when she turned to her husband and gave him a choice: She could drive him to the hospital or she could call an ambulance, but he was going to go to the hospital – and he was going to go now.

At the Anna Jaques emergency room, the couple met Dr. Domenic Martinello. He heard their complicated story of traveling to Colorado and feeling sick, then returning to Boston and feeling sicker; then going to Mass General and getting a diagnosis of myocarditis, but not getting better. After a quick exam, Dr. Martinello decided to focus on the most prominent symptoms at that moment: the headache, the neck and throat pain, and the fever.

Scanning the Head and Neck

He would start with a CT scan of the head, he told the patient and his wife. And if that didn’t provide an answer, he would get a CT scan of the neck. And if he still had no answer, he would get a lumbar puncture, or spinal tap. One of those tests, he was certain, would provide the answer.

The head scan was completely normal. There was no tumor, no blood clot and no sign of increased pressure. That was important because Dr. Martinello suspected that the patient had some kind of meningitis, and if the scan had shown increased pressure, he wouldn’t be able to do a spinal tap. But as it turned out, a spinal tap wasn’t needed.

The emergency room doctor wanted the CT of the patient’s neck because it was swollen and tender. The patient had told him he had a sore throat, yet when the doctor looked in his throat he saw nothing. Could there be an abscess seeded deep in his oral pharynx from some earlier infection? Is that what was causing his throat and neck pain?

Photo

The arrow is pointing to a clot (darker gray) within the jugular vein (lighter gray).

The arrow is pointing to a clot (darker gray) within the jugular vein (lighter gray).Credit

It was the right question, though the result was not what Dr. Martinello expected. There was a small abscess. More worrisome, there was a blood clot in the patient’s jugular vein, on the patient’s right side. He had Lemierre’s disease, a rare infection that Dr. Martinello had seen only once before. You can see the clot in the CT image shown here.

Transferring to a Bigger Hospital

Now that Dr. Martinello knew what was making this man so sick, he was worried that his small community hospital was not prepared to care for him. They didn’t have the kind of specialists he needed on call 24/7. It seemed clear that the patient needed a hospital with more resources. So Dr. Martinello arranged for the patient to be transferred to a sister hospital, Beth Israel Deaconess Medical Center in Boston.

Identifying the Bug

Dr. Andrew Hale was the infectious disease specialist on duty the night the patient arrived at Beth Israel. When the patient and his wife arrived at the B.I. emergency department, Dr. Hale hurried to meet them. He spoke to husband and wife and reviewed their complicated history of the past week or so. But he also learned that both children had come down with strep throat while their father was at Mass General. It was an important discovery since, although unusual, it was well known that strep could cause Lemierre’s, He ordered another set of blood cultures and started the patient on broad-spectrum antibiotics.

Because the patient had been started on intravenous antibiotics while at Anna Jaques, there was a good chance that these cultures wouldn’t grow anything, but he needed to try. He also knew that Dr. Martinello had drawn blood cultures from the patient before he had started on the intravenous antibiotics, and was optimistic that these cultures would show what the bugs were. Identifying the bacteria that were causing the infection was important so that the antibiotics could be more narrowly targeted.

The cultures from Anna Jaques grew out Strep pyogenes, the most common cause of strep throat. The patient continued on antibiotics for six weeks and started a three-month course of a blood thinner to keep the clot from growing or spreading.

How the Patient Fared

That was a year ago. The patient is completely recovered. It was kind of funny, he told me recently. Even though his throat was painful, the sore throat seemed insignificant compared to the shaking chills, the fever, the headache. “I thought of it as kind of a sidebar, when in fact it was the main event,” he said.

Both he and his wife have read up on the illness and come up with a new family motto: Take strep seriously.