Looking out the window in the town where I’m working tonight, I can see that low, heavy cloud cover which speaks of snow and ice.  Yes, I know that from watching the weather reports.  But also from growing up and living in Appalachia and watching 57 winters pass by.  There’s a look and feel to storms.  The sunny day yesterday, and now the stillness as if the clouds are starting to muffle things.  Of course, there’s also the massive run to the grocery store for milk and bread.  But that’s another topic.

This evening I’ll get ready for work, pack up some food, drive through for a coffee and go to Tiny Memorial Hospital in Southeast Emergistan (names and locations withheld to protect the innocent).  The last two nights were frustrating.  COVID is surging, of course. But this always been the time of year when respiratory illnesses show up.  RSV in children, pneumonia and emphysema in seniors, influenza all around.  Without question, COVID is straining a system that was already strained to near breaking two, three, five and ten years ago.

There are few inpatient beds in our rural Critical Access Hospital.  There are few specialists.  Certainly no critical care specialists, no neurologists or cardiologists, no interventional radiologists. There are no trauma surgeons or neurosurgeons.  In essence, none of the things that make up the normal function of a large teaching center.  (A little known reality of modern medicine in America is that this is very common.  Many hospitals have very little.  Only on television is there a call schedule featuring a pediatric neurovascular surgeon who moon-lights as a plastic surgeon and loves to come to the ER.)

There are, lately, not enough ED nurses; COVID has afflicted them and some have to work despite positive tests.  There aren’t sufficient OR nurses to run the operating room or critical care nurses to run even our small ICU.  And there are few places that will accept transfers.

But the ambulances continue to come in (where else would they go in these mountains) and the patients continue to arrive even with minor illnesses, assured by the bad-news driven media that they should really get tested.  This despite the sign on the door that says ‘we aren’t testing for COVID.’  Except for admissions and transfers of course.  But I understand.  Everyone is petrified. Even those who needn’t be petrified, like the young and otherwise healthy.  Terrified is the new cool.  If you aren’t terrified you’re informed that you just aren’t paying attention.

So tonight could be a challenge.  Over the course of 32 years of emergency medicine I have worked during storms.  And I know what can happen.  The best case scenario is that people who aren’t very sick look outside and say ‘I think I’ll stream some shows until the power goes out, maybe have some soup for dinner and just watch the snow fall.  Or maybe knock back a bottle of wine.’  If this is the predominant mind-set, the roads will be largely empty and I may find myself in the physician lounge resting as much as one can rest, with the knowledge that chaos is only one sick patient away.

The other scenario, and more likely in the current situation, is that we will continue to be busy.  And those who are even slightly worried about their symptoms will come to the hospital to beat the storm and go ahead and get tested for COVID or Flu, or treated with what they hope will make it all better.  Then, in the morning (or overnight) others will venture out and crash their cars, or fall on sidewalks, breaking hips or wrists.  Some may have severe, life threatening injuries They will need operating suites we do not have due to inadequate nursing staff.  Some of them will need to go to trauma centers or pediatric hospitals or other higher levels of care.

Unfortunately, ambulances may be tied up with local accidents or unable to venture across the mountains due to snow and ice.  Without doubt, helicopters will not fly in this weather.  Having spent my time in helicopters and around pilots I can tell you that they aren’t fans of ice or snow.  And I get it completely.

In addition, we may lose electricity. We may lose Internet.  Staff may have to sleep in the hospital rather than leave.  And it is likely that anybody who is homeless will come to the hospital, because there is nowhere else to go in the storm.

So we will be told to do our best and we will, as always.  We will be guided to store the patients where we can.  To work with what we have.  Patients will not understand why their loved ones can’t be transferred.  Specialists won’t understand that we don’t have specialists.  And as usual, we’ll get through the chaos at some point.  After which, doubtless, there will be donuts or pizza or something which is supposed to ease the trauma of the hopelessness and exhaustion.  Not just here, but in every hospital facing the same thing.

COVID has been eye-opening.  I believe that it is uniquely able to find and exploit medical vulnerabilities even in those who had no idea they were vulnerable.  (Thus the rare deaths of otherwise healthy young people.)  But COVID has also found and exploited the weaknesses of a system that should have ‘repaired the levees’ decades ago.  Without boring anyone with the recent history of emergency medicine, systems have counted on the emergency departments to be the ‘surge capacity’ for any crisis. Whatever can’t be managed in an office, or whatever an office doesn’t want to do, goes to the ED.  Whenever the state has insufficient psychiatric resources, patients are directed to the ED.  And whenever people have an infectious respiratory illness and their family doctors won’t see them, they come to the ED.

The problem is, there’s only so much space and staff.  And there’s nowhere to send anyone and no way to get them there.

So winter storm Izzy stands to make a bad situation even worse for a bit.

But rest assured, Izzy and COVID only illustrate the weaknesses of a system that has needed more beds, more physicians, more nurses, more medics, more ambulances and everything else for a very, very long time.

Stay safe.  Don’t drive in the weather unless necessary.  But if you need us, in my hospital or any of those hospitals like mine around the land, we’ll be there.  Snow, ice and COVID can’t stop that.


PS I’m starting up a Substack newsletter.  If you think you’d be interested in following me, it’s https://edwinleap.substack.com/.  (OK, not creative. It’s a work in progress.) It’s in Beta as they say.  I plan to go offer paid subscription content as well soon.

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