Imagine suffering a serious accident and calling 911 but not getting an ambulance immediately.
Or having a severe asthma attack and fighting for every breath but having to wait an extra minute or two for help.
The winter Covid-19 surge has been the worst surge of this pandemic in the US. And it’s impacting patients who don’t even have coronavirus by increasing ambulance response times and ER wait times.
“As resources get stretched thin, it just takes longer to respond,” said Shawn Baird, president of the American Ambulance Association.
While some parts of the country are experiencing more delays than others, many places are seeing delays of “two or three minutes over target times. Those tend to be averages,” Baird said.
“When you’re responding to a time-sensitive emergency, like cardiac arrest or stroke or severe shortness of breath, diabetic emergencies – a whole host of things that are not Covid-related, but you need someone timely – a few minutes can make a real difference in the outcome,” he said.
“If the current rate of surge continues, I would think we’re within just days or weeks of significant time delays.”
‘We’re now at that precipice’
It’s difficult for Americans to understand that if they seek immediate care, they may or may not get it now, said Dr. Ryan Stanton, a board member of the American College of Emergency Physicians.
“As Americans, we assume we always have access to care. We assume that the challenges of Covid are going to hit other people – not us,” said Stanton, an emergency physician in Kentucky.
“We’re now at that precipice that we warned about, that if we lose enough access, it’s going to be access for everybody. And we could lose lives. We could have permanent damage.”
At Stanton’s hospital in Lexington, “the Covid floor has spilled over to the entire hospital,” he said.
That influx can mean delays for anyone with mild or moderate emergencies. On good days, those patients have little to no delay in getting the care they need. But sometimes, “you may have to wait for three or four hours,” Stanton said.
“There are areas of the country and communities where that wait is significantly if not several times longer.”
And when hospitals get overwhelmed, “that totally adds to the problem that emergency ambulances face,” said Baird, the ambulance association president.
There are two major impacts on the ambulance system, he said.
First, “we often have to call around and verify which hospitals may be already at capacity or on divert,” meaning their resources are maxed out and they can’t take any more patients, Baird said. So that ties up ambulances.
Then, once an ambulance crew finds a hospital with space and resources, “we have to be able to transfer care to the ER team.”
Previously, those transfers took no more than 15 minutes. “Now it’s taking hours in some areas,” Baird said.
“In fact, I talked to an ambulance service in Visalia, California, (on Monday) morning – American Ambulance there – and they’re now deploying EMT and paramedic teams just to be stationed at the hospital to sit with ambulance patients that come in,” he said.
“One paramedic might have three or four patients that are arriving by ambulance. They’re monitoring outside the ER for up to hours before they can get admitted into the ER. But they have to be able to send their ambulances back out to answer other emergency calls. So they’re actually deploying their EMTs to basically work in a triage tent outside the hospital doors.”
When the next available bed is hours away
In the Birmingham, Alabama, area, Regional Paramedic Services has been transferring patients from local hospitals to out-of-state hospitals hundreds of miles away due to a lack of available beds and the need to increase bed availability.
“This takes ambulances several hours per patient to accomplish, stressing the medics and system,” Baird said.
In Muskogee County, Oklahoma, a medic has been assigned to work full-time at a hospital to attend to patients arriving by ambulance so the ambulance can respond to other 911 calls as the medic waits for a hospital bed to open up, Baird said.
And in hard-hit Los Angeles County, some ambulances with patients on board have waited for hours outside hospitals because they’re out of space.
“We are waiting two to four hours minimum to a hospital, and now we are having to drive even further … then wait another three hours,” EMT Jimmy Webb told CNN affiliate KCAL.
Since the current Covid-19 surge started around Thanksgiving, the number of 911 calls has increased about 20% to 30%, said Dr. Marianne Gausche-Hill, medical director of the Los Angeles County EMS Agency.
“We are seeing a large increase in cardiac arrests throughout the pandemic, especially during surge activity,” she told CNN in an email. “It is unclear if this is due to STEMI (heart attack) patients not seeking care or a primary additional impact of COVID.”
This month, Gausche-Hill wrote a memo to EMS crews saying some adult cardiac arrest patients shouldn’t be taken to a hospital if they can’t be resuscitated after 20 minutes of CPR.
If the patient has no signs of breathing or a pulse, EMS will try to resuscitate the patient for at least 20 minutes. If the patient is stabilized during that time, they would then be taken to a hospital.
But if no pulse is restored, paramedics will not take the patient to the hospital.
The guidance isn’t very different from how EMS previously handled cardiac arrest patients, Gausche-Hill said. In fact, many medics across the country have followed similar practices, Stanton said.
Still, the decision on whether to transport a patient is not easy, said Los Angeles County EMT Michael Diaz.
“It’s gotten to the point if somebody has coronavirus specifically, we’re just basically giving them 20 minutes. And if they’re not viable after 20 minutes, we’re making a rough decision,” Diaz said.
Los Angeles County sheriff’s deputies are often on site and stay behind to console family members and call the coroner, he said.
In his 11 years as an EMT, Diaz said, “I’ve never seen anything like this.”
A few minutes can make a big difference
When ambulance systems get overwhelmed in one community, “the system is designed to be able to borrow from the next neighboring county,” Baird said.
But with this Covid-19 surge, “the emergency (is) happening everywhere. And happening simultaneously.”
“There’s no mutual aid to turn to. They’re all facing the same emergency we are,” Baird said.
“Ultimately that can lead to longer response times. It can lead to a triaging of what gets a response versus what may not get a response.”
For those suffering a heart attack or stroke, every minute is critical.
“If you’re having a stroke, and you might have some left-sided disability or inability to speak or swallow, if we get you to a stroke center that can undertake the right intervention, within the exact number of prescribed minutes, that can be alleviated,” Baird said.
“Or if we can’t, that can be a permanent disability.”
The greatest impact on young people can be delayed responses to car crashes and other unexpected trauma.
“Typically people in their teens and 20s, trauma is the No. 1 reason we see them. And that could be in a car accident. It could be that you’re partying with friends and the deck falls in. There are alcohol-related incidents,” Baird said.
“If we’re stressed and can’t respond to calls, it’s every kind of call that we’re going to be delayed on,” he said.
“I think young people tend to think they’re invincible. But I suspect most of them can think of a situation where they either directly or know of a friend who had a serious accident, or something happened. … And imagine, ‘Well what if I had to wait twice as long to get an ambulance? And I was bleeding on the side of the road?’ And that is a reality people need to be thinking about.”
Another reality check: “We’ve definitely transported many, many people in their 30s and 40s who have to be ventilator-supported. Which is really something that I think young folks just can’t imagine happening to someone their age,” Baird said.
Some lower priority calls might not get an ambulance transport at all, he said.
For example, someone who had a simple fall may get “referred to a call center with a medical expert online – a paramedic or nurse who can talk to a patient on a lower acuity call and see if they really need an ambulance to respond, or if there might be some other way to handle their request.”
And while big cities have gotten lots of attention in this pandemic, rural areas often suffer from fewer resources.
“For emergency ambulance service, often rural communities have only one or two ambulances in them,” Baird said.
“If they’re tied up and busy, that means that the next response is coming from a community or maybe several communities over.”
What doctors and medics fear the most
Despite the recent small dips in Covid-19 numbers, health experts predict the pandemic will get worse before most Americans can get vaccinated.
One possible reason: A variant strain of coronavirus first detected in the UK is now spreading in the US.
Evidence shows that strain is more contagious than others. And it might become the dominant strain in the US by March if people don’t double down on safety precautions, said researchers from the US Centers for Disease Control and Prevention.
“I worry desperately in the next six to 12 weeks, we’re going to see a situation with this pandemic unlike anything we’ve seen yet to date,” said Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota.
“That is really a challenge that I don’t think most people realize yet.”
Stanton, the ER doctor in Kentucky, has noticed disturbing trends that are fueling this Covid-19 surge.
“We’re seeing a lot of (coronavirus) go through entire households. And I’ve admitted almost whole families,” Stanton said.
“I think everybody assumes that: 1) If they get a negative test before they travel, that they were fine, and there was no way they could spread it; or 2) Not realizing how mild the symptoms can be, especially in younger people, they can potentially spread it,” he said.
“So they’re like, ‘Oh, yeah, we had somebody who had a cough and some congestion and headache. But we didn’t think anything about it because they didn’t have a fever.’ And that’s another fallacy, is to assume you have to have all the classic symptoms of Covid. You don’t.”
He said it’s important to remember “a negative test does not mean you don’t have it. In fact, we’re seeing a lot of false negatives. And we can’t brush off ‘allergies’ when we’re going out and seeing people.”
Stanton said he most fears the possibility of rationing care down the road.
“When we run out of resources, we run out of resources for everybody. We run out of access for everybody,” he said.
“It doesn’t matter who you are, how much money you have, how much you contributed to a hospital, how injured or sick or whatever it may be that you have. When we run out, we run out. And that includes young people with car accidents and things they would never predict. That includes people who have a history of heart disease, people with chronic medical conditions.”
Baird said he’s most worried about people getting lax about Covid-19 precautions, leading to even more strain on the ambulance system.
“One of my big fears is that as the public and maybe in particular younger people who feel less vulnerable just get fatigued by this whole thing and sort of give up on the public health measures,” he said.
“The combination of that, plus this strain that’s way more contagious running around, (I fear) we’ll have more cases.”
But don’t wait until you or a loved one needs emergency care before taking Covid-19 precautions seriously.
“Covid is impacting all of us,” he said. “And while you may not have personally experienced a loved one or family member or someone you even just know closely who’s had Covid and had serious effects from it, or even death … millions of Americans have experienced knowing someone,” Baird said.
“The sooner we can all get on board together to end this thing with interventions that we know work – wearing a mask, social distancing, washing our hands – the sooner we can get on with our lives.”