Dr. LouAnn Woodward, vice chancellor for health affairs and dean of the School of Medicine at the University of Mississippi Medical Center, spoke to the Jackson Free Press at length on Aug 7, sharing her concerns for an oncoming wave of hospitalizations and the long-term care requirements of COVID-19 patients.
Woodward also addressed the upcoming school year, candidly asserting that a limited delay was not, in her opinion, adequate to prevent the spread of the virus and the sudden quarantine of many Mississippi students.
Nick Judin: How is UMMC doing at the moment? The most recent update I'm aware of suggested full ICUs and 14 ICU patients receiving care in other units.
LouAnn Woodward: (On Aug. 6) it was around 10, the last I heard. So I know that we're somewhere still in that range.
So definitely still full—still a little bit of crisis care in other units.
Yes. The hospitals are full. The ICU is full.
I was grateful for the opportunity to speak with some of the frontline providers—doctors Wilhelm and Moriarity, nurses Moore and Carrigan. How are they dealing with the extended stress?
Early, there was a big rush of adrenaline. That was kind of what energized people and what carried people through the first couple months of this. But as that adrenaline rush from the very beginning has worn off, now people are just seeing it as the day-to-day reality and what we have to do. Just like when you talked to them before, and probably even more so now, they're very, very tired. They're exhausted. They are weary.
Everybody is just as committed. Nobody’s commitment or passion for their job has changed. It's just the fact that we don't have a firm end in sight, and that just makes you feel ... there's that uncertainty: When will it end? And I think it adds to the fatigue factor. You feel like you can muster up your energy and what you need to do for a certain amount of time, but then it kind of keeps on going. Not knowing when there's a firm end in sight, I think, adds to that level of fatigue.
I'm currently looking at MSDH’s extended charts of available hospital beds. We see five levels of hospital beds available over nine public-health districts. I've seen a lot of discussion of that: “Oh, Mississippi is not out of ICU beds. We have XYZ, these areas, these districts.” I want to demystify that process just a little bit. What ICU metrics—what levels of beds in districts—really matter, and what trends do we track to know when things are improving or declining?
The trends are declining when we consistently see all of the numbers heading in the right direction: the new case count, the number of hospitalizations, the number of deaths.
When we see all of those things consistently heading in the right direction, (things are improving). It is good when we have a day or two here and there where the numbers are a little bit lower than some we've seen, but I don't think we can declare victory.
It was the last couple of weeks of July when we were seeing those numbers of new cases reported each day—the 1,600, 1,700, 1,400 numbers. I anticipate in the next week or so is when we will feel that on the hospitalization side.
Typically what happens is after the patients are diagnosed and they're positive, the time from that to the hospitalization is usually a week or two weeks or something like that. (Up to) 15, 16, 20 days. And then the number of deaths follow that. So I don't believe we have seen the hospitalization impact of those really high numbers of newly diagnosed cases that we saw toward the end of July.
We do like it when we see some of the numbers that look a little bit better this week than they did last week, but until we see a consistent trend, I don't think we can declare victory. We have to realize that we still have a significant disease burden out there.
These patients are very sick, and they are staying in the hospital a long time, in the ICU a long time. So we get them in, and we don't get them out nearly as fast as people might assume.
When you asked me about ICU beds, and how when you look across the state, you might see some ICU beds.
It is very difficult to understand for people who don't live in (the health-care) world, but all ICU beds are not created equal. There are hospitals around the state, particularly small hospitals and hospitals (in) rural settings that have a small ICU. But there is a level of care—a level of complexity and a level of acuity—that can outstrip the resources available in some of these places.
So we have taken some patients here in our ICU who were actually coming from other ICUs. They get to the point where they need (for example) bedside dialysis. They need the support of a higher level of care; they're too sick for these smaller hospitals. So even though some hospitals have ICU beds that may be open, not all of them are equal.
And that's an important point—it's not intuitive. If I was not a medical person, and I was just looking at numbers, and I thought they were ICU beds available, I would feel very glad about that. But some of the ICUs in the outlying hospitals in particular—these patients are getting very, very sick.
Talk more about that.
They are needing treatment modalities that not all hospitals are able to provide. In some cases, it's the drugs that are in those clinical trials. Not all places are able to provide that service. Not all places are able to provide bedside dialysis. There's cardiac support called ECMO, and in fact most places cannot provide critical trials, the bedside dialysis or the ECMO. So not all ICU beds are equal.
I also want to talk about staffing, because that's in a real pinch. (The biggest challenge is) the critical-care nursing workforce in particular. This also applies in some degree to respiratory therapists and to the physicians that work in critical care. But the critical-care nursing workforce especially. A critical-care nurse in a hospital that very rarely sees patients as sick as these is not as trained, as up-to-date, as critical-care nurses who routinely take care of these very, very, very sick patients. So our critical-care workforce is particularly strained and stressed right now.
They are unbelievably proud of what they do and unbelievably dedicated. We have been trying to work the groups and teams so that there's the opportunity for some people to be off for several days to get a little bit of a break. Honestly, they're resistant to doing that. You can see how tired they are. We know how tired they are. They know how tired they are, but they feel like they are manning the ship, and they are not going to blink. And so the skillset that an experienced critical-care nurse has is not easily replaced by somebody who doesn't work in that environment all the time.
One of the things that all of the medical professionals at UMMC have made very clear is that coronavirus is not just a respiratory disease. It is a total-body virus, which means that there is not one thing that an ICU can be provided—a ventilator—and then they can care for any kind of treatment modalities. There are countless manifestations of this virus. Therefore there's an enormous amount of expertise and technology that is needed to treat it. Is that correct?
That is right. So this is a virus that is spread by aerosolized droplets, which is the respiratory mechanism, but that's really where it ends, as far as being categorized as a respiratory virus.
It is an unusual virus. We are learning as we go. That is also unusual—to be in the middle of something like this, and to be dealing with a pathogen that is so unknown.
People (use) the analogy of working on the engine of an airplane while you're in flight. That's literally what we feel like we are doing, sometimes with parts that were made in another country (wherein) we can't necessarily even read the labels. But we have learned in our own experiences, we have learned (through being) in constant contact with physicians—critical-care, emergency-medicine, infectious-disease physicians—and experts from all around the country.
It has been a very odd, unusual virus that has behaved in highly unpredictable ways. The range of symptoms that people have is stunning. Everything from asymptomatic carriers, to just some mild aches and pains, to blood-clotting disorders, to heart-failure issues, to pneumonia and respiratory issues, all the way up to death.
We are seeing patients who have recovered from the acute phase, having chronic symptoms for an extended period of time. And yet again, you have another person who has no difference in their risk profile, who barely has what they consider just two or three days of “I didn't feel too good. I had a little cough, and now I'm fine!”
So the range of symptoms and the effects on different individuals being so highly unpredictable is also something that's just very unusual with this virus.
Something that has been discussed but not dissected is the long haul of COVID-19 recovery. Can you contrast the (challenge) of a coronavirus patient with another hospital or ICU patient, in terms of the space and expertise that is taken up?
I can speak to the acute phase. For the long-term, chronic phase we'll see related to the coronavirus, we are just scratching the surface. In this country, we're just now at the point where we have patients that have been recovered for a few months.
Like I said, some of them are fine. Others have some long-term (lingering effects). What the future (holds for) these long-term effects is yet undetermined from the standpoint of the acute needs of taking care of these patients: the breadth of knowledge, the availability of specialists, be it cardiac, coagulation, pulmonary, renal—all of these different specialists are needed for different patients who have whatever type of manifestation they have.
And then (there are) the day-to-day, additional layers of work that are required in taking care of these patients. So for example, in the ICU where we have known COVID patients that are in a room, the nurses, the respiratory therapists, the other members of the care team cannot just pop in and out of a room to check on a patient, to look at a line, to check the monitor, to administer meds, to do whatever they need to do in a quick and easy way like you can in many cases.
So (there are) requirements on the PPE—putting them on and off—and the additional layers of safety that are required for these patients takes a lot of extra supplies, energy and effort. And honestly, if you are in a situation where you and a fellow nurse are at the bedside of a patient and you've got your N-95, you've got a surgical mask over that, a face shield over that, you've got a gown on, you've got gloves and you're trying to communicate with each other. Even the act of simple communication back and forth with the health-care team is more challenging with all of that on than if you and I are just sitting here having a conversation.
We look at these numbers on a day-to-day basis, and that gives us a lot of dependency on trends, seven-day growth, daily averages. But if a hospitalized patient remains hospitalized for X days, weeks, months on average, then it follows that this doesn't just threaten the hospital system during whatever peak we're currently experiencing. Those beds are taken up weeks or even months down the line. These hospitalizations make the whole system less flexible far ahead of time, even if our numbers “plateau.” Is that correct?
That is absolutely right. And in fact, there have been a few days in the last couple of weeks where our greatest pain-point here at UMMC was not the ICU beds for the COVID patients, but actually the ICU beds for the other non-COVID patients who needed a critical-care bed for whatever reason, a stroke, a heart attack, an intracranial hemorrhage, somebody in a bad wreck. It has put a crunch on those beds as well because of the beds that are taken up with a COVID patient.
Does UMMC have the capacity to handle a serious flu season right now?
So it depends on where we are with the coronavirus.
Today we are full. We have been full for weeks. If we had a large influx of flu patients right now, we would be in that much more of a pinch, and in a difficult place. When the beds are full, the beds are full. What can you do?
The best-case scenario is that the statewide mask mandate is taken seriously, and that over the next couple of weeks—and I think it will take more than two—over the next, let's say two to four weeks, we as a state can get to a place where the spread is not as high.
Then perhaps going into flu season the hospitals across the state will have a little bit of flexibility for increased volume that you see during flu season. Like I said, we're full right now, and when you're full, you're full. We could not accommodate a whole influx of flu patients at this point.
I worry about flu season a lot. Many of the symptoms that people will present with the flu are similar to what we know are some coronavirus symptoms. So we'll be in a position in just a few months of trying to distinguish, “Is this flu, or is this coronavirus?”
That'll just be part of the testing that we'll have to do for the patient, but while you're doing the testing and trying to sort these things out, of course, you're using up PPE as you go along until you know for sure that it is not coronavirus. I feel so uneasy about the PPE situation.
I want to make sure that people understand when you say we're going to be in a pinch, when you say we don't have the capacity—if the numbers look like they do now, and we have the kind of flu season that we've seen in recent years, what does UMMC look like? What do the hospitals across the state look like? What is the triage plan?
As I said, we're full. If we stay full as flu season hits, and we have not gotten any relief from decreased numbers of COVID patients, then we will not be able to take transfers from other hospitals. I think these patients will have to be cared for in other places, in other hospitals. I think it will ripple out and flow across the state.
I think it looks ugly. We here at the medical center are looking at every potential area that could be converted into a patient-care use area. And, of course, (looking) at the cost to do that. So we're trying to look under every rock and figure out what we could do to potentially open more beds.
Now, if we do that, we've got to staff them. So that brings in another challenge. We've had some communications with the Mississippi State Department of Health about the concept of a system of care—particularly for COVID, much like we have the level-one trauma system in the state—so that if a trauma patient has a certain injury, we know there are certain hospitals that can take care of this patient. (In this way) the patients are distributed in a rational way, in a way based on data. If we could move in that direction, I think that could help with the chaos of the situation.
You called for a (statewide) mask mandate: The governor granted it for a two-week period. You suggested that we'll need a little bit more time than that. Should that decision have come earlier?
It's easy to say that now. Now, looking at the numbers, and looking (at) where we are in Mississippi, I would say yes, it should have. But I wouldn't want to be the governor, to be the person having to make that call, knowing that many people in Mississippi don't want the mask mandate and won't follow a mandate willingly.
I think the governor tried to balance what he knows is the will of so many citizens in the state of Mississippi with what he was hearing from the health-care professionals. So from the health-care side, I wish we would've done it earlier. But there are a whole lot of people out there in the state who would not have complied with it.
My hope is just that they will comply with it now. And as I said, I anticipate two weeks will not be an adequate amount of time—that we’ll need a little more time with a mask mandate to try to get ahead of it a little bit.
You also called for a statewide delay to the school year. The governor chose a piecemeal strategy there as well. Estimates show that the governor's delay order affected only 7% of Mississippi schoolchildren. And 2% of that seven is in Jackson Public Schools, which have already canceled in-person classes. Is 5% enough?
I don't think it is. I mean, that's my own opinion. Just looking at what we’re seeing from the standpoint of the contagiousness of the virus. I think we need more.
So you reiterate your call for a statewide delay to give it until September.
Right, I think if we wear our masks and do all of those things, and we delay the start of school until after Labor Day or September, that puts us in a better position to be prepared for the children to go back to school.
You're very clear on this. It needs to be statewide, and it needs to be not a week or two weeks; it needs to give us until after Labor Day to let these things take effect. We are running out of time at this point. There are already schools opening up. What are your concerns if we start seeing schools opening up? If we start seeing outbreaks like Corinth?
I think the best environment for the students is something that is very consistent for the students and the families—the parents—that they can rely on, know what the plan is, and there's not a start and stop, start and stop.
I worry about the situation being very disruptive. If we start too early, and we have outbreaks, and therefore we have to quarantine and stop school, convert to all virtual ... I worry about the disruptive nature of that to the students and the families, as parents are trying to work, and everybody's just trying to live their lives.
I think if we could be a little more prepared, and we're in a better place when we started, hopefully we could avoid that. I think the schools need to be prepared to fluctuate as needed between in-person and online, or some other virtual method of teaching, and the schools need to have access to testing.
So when they have an outbreak, they can do some tests, get some quick results and resume normal activities as soon and as safely as possible.
Now what I've heard out of Corinth Public Schools is that there's no mandate for a quarantined child to even get a coronavirus test. It's just up to their parents. If they want to do it, they can, if they don't want to do it, they don't have to. So will we really even have an idea of what these outbreaks will look like?
I don't really know enough about (the situation) to give you any kind of response. I think we would just have to reach out to the Department of Health and look to them. And perhaps the school system itself, the Mississippi Chapter of American Academy of Pediatrics, and some of those in the field to really weigh in on some of those issues.
Mississippi is currently in the worst spate of coronavirus deaths since the virus came to the state. At various times in the last week, we had the most deaths per capita of the entire nation. What impact is that having on our hospital system and what impact should it display? When we have 20, 30, 50 deaths on multiple days in a week, but our hospitalizations are steady, does that suggest that a large death toll is concealing a continuing spike in hospitalizations?
I think that what it shows is that, as people are dying of the virus—and many of them are dying in hospitals—our hospitalization rate and the number of patients in the hospital are remaining steady. That is just showing that as soon as one bed becomes open, it is filled again by another patient.
So if a patient dies at the hospital, there are two or three patients waiting to get in that bed.
What I'm hearing from you is that with the death toll like this, we really cannot trust even a stable hospitalization trend.
Well, I wouldn't say we can't trust it. I think the numbers are what they are, but I think what is underneath that number is the fact that these hospital beds are being quickly refilled with other patients.
I want to investigate that: Yes, the beds are being filled. And especially with ICU, I can see how an ICU bed becomes available, and someone moves from a med-surg bed into an ICU. Without the deaths where would those cases have gone?
Right. Right! So either they're being held in the emergency department or they are staying at home. They are being seen in hospitals all across the state, hospitals and clinics. The patients are still there just because we don't have beds to put them in. The patients are still there, and they are still sick.
We are just frantically trying to move the chess pieces and make the best beds and the most beds available for the patients. But they're not going away. I mean, the patients are still there. They're being held in the emergency department.
Is demand for testing in a slump? Mississippi currently has one of and often the highest case-positive rate in the country, shifting daily but consistently above 20%. Shouldn't we see testing at least attempting to race ahead of that?
So it would be fantastic to be able to test more broadly.
I do think that that is something that the Mississippi State Department of Health desires, and it's something that we desire: to be able to offer more broad availability for testing. I think that would be good, and that would be helpful, yes.
Executive Director of Communications Marc Rolph: My understanding is that ramping up testing isn't just a snap of the fingers. Mississippi has gotten to a critical mass on that, so I don't know what it would take. I know here at the medical center we've really ramped it up to a lot of capacity. So I don't know the specifics of testing being able to increase dramatically across our state.
State intern Julian Mills contributed to this report. Read the JFP’s coverage of COVID-19 at jacksonfreepress.com/covid19. Get more details on preventive measures here. Email state reporter Nick Judin at [email protected] and follow him on Twitter @nickjudin.