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  • Why is it difficult for children to get a bed at pediatric hospitals? It’s more complicated than you think | CNN

    Why is it difficult for children to get a bed at pediatric hospitals? It’s more complicated than you think | CNN

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    CNN
     — 

    Effie Schnacky was wheezy and lethargic instead of being her normal, rambunctious self one February afternoon. When her parents checked her blood oxygen level, it was hovering around 80% – dangerously low for the 7-year-old.

    Her mother, Jaimie, rushed Effie, who has asthma, to a local emergency room in Hudson, Wisconsin. She was quickly diagnosed with pneumonia. After a couple of hours on oxygen, steroids and nebulizer treatments with little improvement, a physician told Schnacky that her daughter needed to be transferred to a children’s hospital to receive a higher level of care.

    What they didn’t expect was that it would take hours to find a bed for her.

    Even though the respiratory surge that overwhelmed doctor’s offices and hospitals last fall is over, some parents like Schnacky are still having trouble getting their children beds in a pediatric hospital or a pediatric unit.

    The physical and mental burnout that occurred during the height of the Covid-19 pandemic has not gone away for overworked health care workers. Shortages of doctors and technicians are growing, experts say, but especially in skilled nursing. That, plus a shortage of people to train new nurses and the rising costs of hiring are leaving hospitals with unstaffed pediatric beds.

    But a host of reasons building since well before the pandemic are also contributing. Children may be the future, but we aren’t investing in their health care in that way. With Medicaid reimbursing doctors at a lower rate for children, hospitals in tough situations sometimes put adults in those pediatric beds for financial reasons. And since 2019, children with mental health crises are increasingly staying in emergency departments for sometimes weeks to months, filling beds that children with other illnesses may need.

    “There might or might not be a bed open right when you need one. I so naively just thought there was plenty,” Schnacky told CNN.

    The number of pediatric beds decreasing has been an issue for at least a decade, said Dr. Daniel Rauch, chair of the Committee on Hospital Care for the American Academy of Pediatrics.

    By 2018, almost a quarter of children in America had to travel farther for pediatric beds as compared to 2009, according to a 2021 paper in the journal Pediatrics by lead author Dr. Anna Cushing, co-authored by Rauch.

    “This was predictable,” said Rauch, who has studied the issue for more than 10 years. “This isn’t shocking to people who’ve been looking at the data of the loss in bed capacity.”

    The number of children needing care was shrinking before the Covid-19 pandemic – a credit to improvements in pediatric care. There were about 200,000 fewer pediatric discharges in 2019 than there were in 2017, according to data from the US Department of Health and Human Services.

    “In pediatrics, we have been improving the ability we have to take care of kids with chronic conditions, like sickle cell and cystic fibrosis, and we’ve also been preventing previously very common problems like pneumonia and meningitis with vaccination programs,” said Dr. Matthew Davis, the pediatrics department chair at Ann & Robert H. Lurie Children’s Hospital of Chicago.

    Pediatrics is also seasonal, with a typical drop in patients in the summer and a sharp uptick in the winter during respiratory virus season. When the pandemic hit, schools and day cares closed, which slowed the transmission of Covid and other infectious diseases in children, Davis said. Less demand meant there was less need for beds. Hospitals overwhelmed with Covid cases in adults switched pediatric beds to beds for grownups.

    As Covid-19 tore through Southern California, small hospitals in rural towns like Apple Valley were overwhelmed, with coronavirus patients crammed into hallways, makeshift ICU beds and even the pediatric ward.

    Only 37% of hospitals in the US now offer pediatric services, down from 42% about a decade ago, according to the American Hospital Association.

    While pediatric hospital beds exist at local facilities, the only pediatric emergency department in Baltimore County is Greater Baltimore Medical Center in Towson, Maryland, according to Dr. Theresa Nguyen, the center’s chair of pediatrics. All the others in the county, which has almost 850,000 residents, closed in recent years, she said.

    The nearby MedStar Franklin Square Medical Center consolidated its pediatric ER with the main ER in 2018, citing a 40% drop in pediatric ER visits in five years, MedStar Health told CNN affiliate WBAL.

    In the six months leading up to Franklin Square’s pediatric ER closing, GBMC admitted an average of 889 pediatric emergency department patients each month. By the next year, that monthly average jumped by 21 additional patients.

    “Now we’re seeing the majority of any pediatric ED patients that would normally go to one of the surrounding community hospitals,” Nguyen said.

    In July, Tufts Medical Center in Boston converted its 41 pediatric beds to treat adult ICU and medical/surgical patients, citing the need to care for critically ill adults, the health system said.

    In other cases, it’s the hospitals that have only 10 or so pediatric beds that started asking the tough questions, Davis said.

    “Those hospitals have said, ‘You know what? We have an average of one patient a day or two patients a day. This doesn’t make sense anymore. We can’t sustain that nursing staff with specialized pediatric training for that. We’re going to close it down,’” Davis said.

    Registered nurses at Tufts Medical Center hold a

    Saint Alphonsus Regional Medical Center in Boise closed its pediatric inpatient unit in July because of financial reasons, the center told CNN affiliate KBOI. That closure means patients are now overwhelming nearby St. Luke’s Children’s Hospital, which is the only children’s hospital in the state of Idaho, administrator for St. Luke’s Children’s Katie Schimmelpfennig told CNN. Idaho ranks last for the number of pediatricians per 100,000 children, according to the American Board of Pediatrics in 2023.

    The Saint Alphonsus closure came just months before the fall, when RSV, influenza and a cadre of respiratory viruses caused a surge of pediatric patients needing hospital care, with the season starting earlier than normal.

    The changing tide of demand engulfed the already dwindling supply of pediatric beds, leaving fewer beds available for children coming in for all the common reasons, like asthma, pneumonia and other ailments. Additional challenges have made it particularly tough to recover.

    Another factor chipping away at bed capacity over time: Caring for children pays less than caring for adults. Lower insurance reimbursement rates mean some hospitals can’t afford to keep these beds – especially when care for adults is in demand.

    Medicaid, which provides health care coverage to people with limited income, is a big part of the story, according to Joshua Gottlieb, an associate professor at the University of Chicago Harris School of Public Policy.

    “Medicaid is an extremely important payer for pediatrics, and it is the least generous payer,” he said. “Medicaid is responsible for insuring a large share of pediatric patients. And then on top of its low payment rates, it is often very cumbersome to deal with.”

    Pediatric gastroenterologist Dr. Howard Baron visits with a patient in 2020 in Las Vegas. A large portion of his patients are on Medicaid with reimbursement rates that are far below private insurers.

    Medicaid reimburses children’s hospitals an average of 80% of the cost of the care, including supplemental payments, according to the Children’s Hospital Association, a national organization which represents 220 children’s hospitals. The rate is far below what private insurers reimburse.

    More than 41 million children are enrolled in Medicaid and the Children’s Health Insurance Program, according to Kaiser Family Foundation data from October. That’s more than half the children in the US, according to Census data.

    At Children’s National Hospital in Washington, DC, about 55% of patients use Medicaid, according to Dr. David Wessel, the hospital’s executive vice president.

    “Children’s National is higher Medicaid than most other children’s hospitals, but that’s because there’s no safety net hospital other than Children’s National in this town,” said Wessel, who is also the chief medical officer and physician-in-chief.

    And it just costs more to care for a child than an adult, Wessel said. Specialty equipment sized for smaller people is often necessary. And a routine test or exam for an adult is approached differently for a child. An adult can lie still for a CT scan or an MRI, but a child may need to be sedated for the same thing. A child life specialist is often there to explain what’s going on and calm the child.

    “There’s a whole cadre of services that come into play, most of which are not reimbursed,” he said. “There’s no child life expert that ever sent a bill for seeing a patient.”

    Low insurance reimbursement rates also factor into how hospital administrations make financial decisions.

    “When insurance pays more, people build more health care facilities, hire more workers and treat more patients,” Gottlieb said.

    “Everyone might be squeezed, but it’s not surprising that pediatric hospitals, which face [a] lower, more difficult payment environment in general, are going to find it especially hard.”

    Dr. Benson Hsu is a pediatric critical care provider who has served rural South Dakota for more than 10 years. Rural communities face distinct challenges in health care, something he has seen firsthand.

    A lot of rural communities don’t have pediatricians, according to the American Board of Pediatrics. It’s family practice doctors who treat children in their own communities, with the goal of keeping them out of the hospital, Hsu said. Getting hospital care often means traveling outside the community.

    Hsu’s patients come from parts of Nebraska, Iowa and Minnesota, as well as across South Dakota, he said. It’s a predominantly rural patient base, which also covers those on Native American reservations.

    “These kids are traveling 100, 200 miles within their own state to see a subspecialist,” Hsu said, referring to patients coming to hospitals in Sioux Falls. “If we are transferring them out, which we do, they’re looking at travels of 200 to 400 miles to hit Omaha, Minneapolis, Denver.”

    Inpatient pediatric beds in rural areas decreased by 26% between 2008 and 2018, while the number of rural pediatric units decreased by 24% during the same time, according to the 2021 paper in Pediatrics.

    Steve Inglish, left, and registered nurse Nikole Hoggarth, middle, help a father with his daughter, who fell and required stiches, inside the emergency department at Jamestown Regional Medical Center in rural North Dakota in 2020.

    “It’s bad, and it’s getting worse. Those safety net hospitals are the ones that are most at risk for closure,” Rauch said.

    In major cities, the idea is that a critically ill child would get the care they need within an hour, something clinicians call the golden hour, said Hsu, who is the critical care section chair at the American Academy of Pediatrics.

    “That golden hour doesn’t exist in the rural population,” he said. “It’s the golden five hours because I have to dispatch a plane to land, to drive, to pick up, stabilize, to drive back, to fly back.”

    When his patients come from far away, it uproots the whole family, he said. He described families who camp out at a child’s bedside for weeks at a time. Sometimes they are hundreds of miles from home, unlike when a patient is in their own community and parents can take turns at the hospital.

    “I have farmers who miss harvest season and that as you can imagine is devastating,” Hsu said. “These aren’t office workers who are taking their computer with them. … These are individuals who have to live and work in their communities.”

    Back at GBMC in Maryland, an adolescent patient with depression, suicidal ideation and an eating disorder was in the pediatric emergency department for 79 days, according to Nguyen. For months, no facility had a pediatric psychiatric bed or said it could take someone who needed that level of care, as the patient had a feeding tube.

    “My team of physicians, social workers and nurses spend a significant amount of time every day trying to reach out across the state of Maryland, as well as across the country now to find placements for this adolescent,” Nguyen said before the patient was transferred in mid-March. “I need help.”

    Nguyen’s patient is just one of the many examples of children and teens with mental health issues who are staying in emergency rooms and sometimes inpatient beds across the country because they need help, but there isn’t immediately a psychiatric bed or a facility that can care for them.

    It’s a problem that began before 2020 and grew worse during the pandemic, when the rate of children coming to emergency rooms with mental health issues soared, studies show.

    Now, a nationwide shortage of beds exists for children who need mental health help. A 2020 federal survey revealed that the number of residential treatment facilities for children fell 30% from 2012.

    “There are children on average waiting for two weeks for placement, sometimes longer,” Nguyen said of the patients at GBMC. The pediatric emergency department there had an average of 42 behavioral health patients each month from July 2021 through December 2022, up 13.5% from the same period in 2017 to 2018, before the pandemic, according to hospital data.

    When there are mental health patients staying in the emergency department, that can back up the beds in other parts of the hospital, creating a downstream effect, Hsu said.

    “For example, if a child can’t be transferred from a general pediatric bed to a specialized mental health center, this prevents a pediatric ICU patient from transferring to the general bed, which prevents an [emergency department] from admitting a child to the ICU. Health care is often interconnected in this fashion,” Hsu said.

    “If we don’t address the surging pediatric mental health crisis, it will directly impact how we can care for other pediatric illnesses in the community.”

    Dr. Susan Wu, right, chats with a child who got her first dose of the Pfizer-BioNtech Covid-19 vaccine at Children's Hospital Arcadia Speciality Care Center in Arcadia, California, in 2022.

    So, what can be done to improve access to pediatric care? Much like the reasons behind the difficulties parents and caregivers are experiencing, the solutions are complex:

    • A lot of it comes down to money

    Funding for children’s hospitals is already tight, Rauch said, and more money is needed not only to make up for low insurance reimbursement rates but to competitively hire and train new staff and to keep hospitals running.

    “People are going to have to decide it’s worth investing in kids,” Rauch said. “We’re going to have to pay so that hospitals don’t lose money on it and we’re going to have to pay to have staff.”

    Virtual visits, used in the right situations, could ease some of the problems straining the pediatric system, Rauch said. Extending the reach of providers would prevent transferring a child outside of their community when there isn’t the provider with the right expertise locally.

    • Increased access to children’s mental health services

    With the ongoing mental health crisis, there’s more work to be done upstream, said Amy Wimpey Knight, the president of CHA.

    “How do we work with our school partners in the community to make sure that we’re not creating this crisis and that we’re heading it off up there?” she said.

    There’s also a greater need for services within children’s hospitals, which are seeing an increase in children being admitted with behavioral health needs.

    “If you take a look at the reasons why kids are hospitalized, meaning infections, diabetes, seizures and mental health concerns, over the last decade or so, only one of those categories has been increasing – and that is mental health,” Davis said. “At the same time, we haven’t seen an increase in the number of mental health hospital resources dedicated to children and adolescents in a way that meets the increasing need.”

    Most experts CNN spoke to agreed: Seek care for your child early.

    “Whoever is in your community is doing everything possible to get the care that your child needs,” Hsu said. “Reach out to us. We will figure out a way around the constraints around the system. Our number one concern is taking care of your kids, and we will do everything possible.”

    Nguyen from GBMC and Schimmelpfennig from St. Luke’s agreed with contacting your primary care doctor and trying to keep your child out of the emergency room.

    “Anything they can do to stay out of the hospital or the emergency room is both financially better for them and better for their family,” Schimmelpfennig said.

    Knowing which emergency room or urgent care center is staffed by pediatricians is also imperative, Rauch said. Most children visit a non-pediatric ER due to availability.

    “A parent with a child should know where they’re going to take their kid in an emergency. That’s not something you decide when your child has the emergency,” he said.

    Jaimie and Effie Schnacky now have an asthma action plan after the 7-year-old's hospitalization in February.

    After Effie’s first ambulance ride and hospitalization last month, the Schnacky family received an asthma action plan from the pulmonologist in the ER.

    It breaks down the symptoms into green, yellow and red zones with ways Effie can describe how she’s feeling and the next steps for adults. The family added more supplies to their toolkit, like a daily steroid inhaler and a rescue inhaler.

    “We have everything an ER can give her, besides for an oxygen tank, at home,” Schnacky said. “The hope is that we are preventing even needing medical care.”

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  • Why urgent care centers are popping up everywhere | CNN Business

    Why urgent care centers are popping up everywhere | CNN Business

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    New York
    CNN
     — 

    If you drive down a busy suburban strip mall or walk down a street in a major city, chances are you won’t go long without spotting a Concentra, MedExpress, CityMD or another urgent care center.

    Demand at urgent care sites surged during the Covid-19 pandemic as people searched for tests and treatments. Patient volume has jumped 60% since 2019, according to the Urgent Care Association, an industry trade group.

    That has fueled growth for new urgent care centers. A record 11,150 urgent care centers have popped up around the United States and they are growing at 7% a year, the trade group says. (This does not include clinics inside retail stores like CVS’ MinuteClinic or freestanding emergency departments.)

    Urgent care centers are designed to treat non-emergency conditions like a common cold, a sprained ankle, an ear infection, or a rash. They are recommended if patients can’t get an immediate appointment with their primary care doctor or if patients don’t have one. Primary care practices should always be the first call in these situations because they have access to patients’ records and all of their health care history, while urgent care sites are meant to provide episodic care.

    Urgent care sites are often staffed by physician assistants and nurse practitioners. Many also have doctors on site. (One urgent care industry magazine says, in 2009, 70% of its providers were physicians, but that the percentage had fallen to 16% by last year.) Urgent cares usually offer medical treatment outside of regular doctor’s office hours and a visit costs much less than a trip to the emergency room.

    Urgent care has grown rapidly because of convenience, gaps in primary care, high costs of emergency room visits, and increased investment by health systems and private-equity groups. The urgent care market will reach around $48 billion in revenue this year, a 21% increase from 2019, estimates IBISWorld.

    The growth highlights the crisis in the US primary care system. A shortage of up to 55,000 primary care physicians is expected in the next decade, according to the Association of American Medical Colleges.

    But many doctors, health care advocates and researchers raise concerns at the proliferation of urgent care sites and say there can be downsides.

    Frequent visits to urgent care sites may weaken established relationships with primary care doctors. They can also lead to more fragmented care and increase overall health care spending, research shows.

    And there are questions about the quality of care at urgent care centers and whether they adequately serve low-income communities. A 2018 study by Pew Charitable Trusts and the Centers for Disease Control and Prevention found that antibiotics are overprescribed at urgent care centers, especially for common colds, the flu and bronchitis.

    “It’s a reasonable solution for people with minor conditions that can’t wait for primary care providers,” said Vivian Ho, a health economist at Rice University. “When you need constant management of a chronic illness, you should not go there.”

    Urgent care centers have been around in the United States since the 1970s, but they were long derided as “docs in a box” and grew slowly during their early years.

    They have become more popular over the past two decades in part due to pressures on the primary care system. People’s expectations of wait times have changed and it can be difficult, and sometimes almost impossible, to book an immediate visit with a primary care provider.

    Urgent care sites are typically open for longer hours during the weekday and on weekends, making it easier to get an appointment or a walk-in visit. Around 80% of the US population is within a 10-minute drive of an urgent care center, according to the industry trade group.

    “There’s a need to keep up with society’s demand for quick turnaround, on-demand services that can’t be supported by underfunded primary care,” said Susan Kressly, a retired pediatrician and fellow at the American Academy of Pediatrics.

    Health insurers and hospitals have also become more focused on keeping people out of the emergency room. Emergency room visits are around ten times more expensive than visits to an urgent care center. During the early 2000s, hospital systems and health insurers started opening their own urgent care sites, and they have introduced strategies to deter emergency room visits.

    Additionally, passage of the Affordable Care Act in 2010 spurred an increase in urgent care providers as millions of newly insured Americans sought out health care. Private-equity and venture capital funds also poured billions into deals for urgent care centers, according to data from PitchBook.

    Urgent care centers can be attractive to investors. Unlike ERs, which are legally obligated to treat everyone, urgent care sites can essentially choose their patients and the conditions they treat. Many urgent care centers don’t accept Medicaid and can turn away uninsured patient,s unless they pay a fee.

    Like other health care options, urgent care centers make money by billing insurance companies for the cost of the visit, additional services, or the patient pays out of pocket. In 2016, the median charge for a 30-minute new insured patient visit was $242 at an urgent care center, compared with $294 in a primary care office and $109 in a retail clinic, according to a study by FAIR Health, a nonprofit that collects health insurance data.

    “If they can make it a more convenient option, there’s a lot of revenue here,” said Ateev Mehrotra, a professor of health care policy and medicine at Harvard Medical School who has researched urgent care clinics. “It’s not where the big bucks are in health care, but there’s a substantial number of patients.”

    Mehrotra research has found that between 2008 and 2015, urgent care visits increased 119%. They became the dominant venue for people seeking treatment for low-acuity conditions like acute respiratory infections, urinary tract infections, rashes, and muscle strains.

    Some doctors and researchers worry that patients with primary care doctors – and those without – are substituting urgent care visits in place of a primary care provider.

    “What you don’t want to see is people seeking a lot care outside their pediatrician and decreasing their visits to their primary care provider,” said Rebecca Burns, the urgent care medical director at the Lurie Children’s Hospital of Chicago.

    Burns’ research has found that high urgent care reliance fills a need for children with acute issues but has the potential to disrupt primary care relationships.

    The National Health Law Program, a health care advocacy group for low-income families and communities, has called for state regulations to require coordination among urgent care sites, retail clinics, primary services, and hospitals to ensure continuity of patients’ care.

    And while the presence of urgent care centers does prevent people from costly emergency department visits for low-acuity issues, Mehrotra from Harvard has found that, paradoxically, they increase health care spending on net.

    Each $1,646 visit to the ER for a low-acuity condition prevented was offset by a $6,327 increase in urgent care center costs, his research has found. This is in part because people may be going to urgent care for minor illnesses they would have previously treated with chicken soup.

    There are also concerns about the oversaturation of urgent care centers in higher-income areas that have more consumers with private health care and limited access in medically underserved areas.

    Urgent care centers selectively tend not to serve rural areas, areas with a high concentration of low-income patients, and areas with a low concentration of privately-insured patients, researchers at the University of California at San Francisco found in a 2016 study. They said this “uneven distribution may potentially exacerbate health disparities.”

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  • Opinion: ‘We can barely breathe.’ How did Britain’s treasured NHS get so sick? | CNN

    Opinion: ‘We can barely breathe.’ How did Britain’s treasured NHS get so sick? | CNN

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    Editor’s Note: Dr. Roopa Farooki is an Internal Medicine Doctor for the NHS in South East England. She is the author of “Everything is True: A Junior Doctor’s Story of Life, Death and Grief,” on the first 40 days of the Covid-19 pandemic. The views expressed in this commentary are her own. Read more opinion on CNN.



    CNN
     — 

    I’m writing this towards midnight, having just finished a set of four 13-hour shifts in my small, coastal hospital’s Accident & Emergency (A&E) department.

    It’s hard to describe the helplessness we feel, as doctors, every time we walk through the emergency waiting room, packed with patients, knowing we can only review and treat one person at a time.

    Knowing that when we see someone really sick, who needs admission, that they might be waiting on that chair or trolley for over 24 hours before a bed on the ward becomes free.

    I’m an internal medicine doctor for the UK’s National Health Service – better known as the NHS. I’m currently on the medical on-call team – the majority of patients who come through the front door at A&E are referred to us.

    Government-funded and free at the point of care, the NHS is a source of national pride.

    And it is in crisis.

    There aren’t enough beds for our patients. Trying to include an extra bed on each side of the ward, is akin to trying to make more space in a car park by simply drawing the lines closer together.

    And then, there are not enough staff to care for the beds that we do have. When we manage to make a patient well enough to be discharged, we find we cannot, as there is no one in the community to care for them.

    No one to help with the non-medical activities of daily living, such as washing and dressing.

    Across the NHS, health care staff have been feeling the strain of years of underfunding.

    We work in hospitals where in the A&E, a consulting room to review and examine a patient is a luxury, and the doctors queue up for them.

    I recently had to perform a lumbar puncture – where a needle is inserted into the patient’s spinal canal, to measure and collect cerebrospinal fluid for testing – normally a procedure that you could do at the bedside.

    But this patient didn’t have a bed in A&E, even though they clearly needed one, and was just lying down on two chairs pushed together.

    I managed to get a consulting room for 30 minutes and did the procedure there, before I was told to leave by the emergency department consultant. It seems I shouldn’t have been allowed to occupy the room for even that long.

    My own son came into our A&E not so long ago. He had a dislocated shoulder after falling off his bike, on a day when I happened to be working at a different hospital.

    He was treated relatively quickly, with pain relief, his shoulder popped back into place by the emergency department doctor. His X-ray repeated and checked before being discharged.

    Still, he was shocked, visibly shocked at the place where I have spent much of my working life.

    Military personnel were on call to fill the gap during a strike by ambulance workers over a government pay dispute.

    It’s different when you see your everyday reality though naïve eyes. He saw the elderly patients on the jigsaw of trolleys crammed into the department, pushed against the wall, squeezed in the gap between the bed and nursing stations.

    He saw the fluids hanging from rails where we had no stands, lines running into the patient’s forearms. He saw the oxygen fed into their noses from cylinders propped along the bed, the cacophony of beeping machines and alarms.

    It doesn’t look like it does on the TV. It doesn’t even look like it does on reality TV.

    Sometimes though we can fix a patient’s problem in reasonable time. The patient’s treatment, albeit in an uncomfortable chair, can still be started. And after 24 hours of antibiotics or fluids or other interventions, they can improve enough to be discharged home.

    That happened first thing this morning. It was a relief for the patient, their family and me, that I could send him home with oral antibiotics, some two days after he had come into the emergency department.

    In this instance, he had not been left in the waiting room the entire time. We had placed him in a small room with five other patients having interventions in their chairs.

    In these closeted spaces, informal bonds form. The patients in those rooms look out for each other. If you call out a name, and someone is too hard of hearing to answer, or in the toilet, the others will let you know where they are.

    I’m always apologizing to patients. And to their families. I’m humble about the care that we can offer, with the resources and staffing that we have.

    I’m always worrying that while we’re managing the medical issues – while I’m monitoring arterial oxygenation by taking regular blood gases from their radial arteries, while our nurses are administering medication, while our radiologists are reporting the imaging – that our patients are suffering socially and psychologically.

    I encourage them to call their families when they’re in the emergency department, and plug in their phone.

    I urge them to keep up their food and fluid intake, while stuck in the trolley or chair. “Please have a cup of tea, and a snack, and a meal, whenever someone comes round to offer you one,” I say.

    “Even if you don’t feel like it now, you might want it a bit later.”

    How is this different from the pandemic? In many ways, it’s not. Then, we worked with the understanding that we might walk into a virus, get ill, and maybe even get critically ill. That’s not changed.

    Many of the patients I admitted over Christmas, sitting in the same space as other patients, later tested positive for Covid-19 or Influenza A.

    Nurses employed at South Tees Hospitals NHS Foundation Trust strike outside the James Cook Hospital on January 18, 2023.

    When I wrote an account of the first 40 days of the Covid-19 pandemic, from the start of lockdown, I described the unprecedented nature of the situation, the compromise for patients and my health care colleagues.

    “Death and deterioration have been impossibly normalized. You’re living in impossible times,” I wrote.

    I never thought that almost three years later we would still be working like this. I had hoped to look back at that time with learning and wisdom, knowing that it was extraordinary, that we got through it, and hoping that I had done enough to help.

    But now, that egotism, that sense of what we are doing as individual clinicians is in any way significant, seems foolish.

    We are caught in a trap of underfunding that means what we can offer patients isn’t enough. In medical terms, this is a chronic condition, like heart failure. We are now suffering an acute exacerbation, so the fluid that should have been pumped around efficiently is now filling our boots and our lungs. We can barely breathe.

    The junior doctors, that is any doctor who is not a consultant, have experienced more than a decade’s worth of sub-inflation pay awards, amounting to a 26% decrease in pay since 2008.

    Recently it has been reported that as many as 40% of my junior doctor colleagues will leave the NHS next year.

    From my personal experience, that seems optimistic. No one that I know wishes to remain in the NHS once their training contract finishes. They are talking about taking a year off, agency work, heading abroad where there is better pay and conditions, having more time to see their families.

    They want anything other than what they have experienced for the last three years.

    NHS Accident & Emergency departments felt the brunt of Covid-19 and Influenza A cases this winter.

    Already this winter we’ve had several strikes from ambulance workers and nurses, with more planned this week.

    But next year, every day will be like a strike day, if something isn’t done to prevent our clinical staff from giving up and burning out.

    And the tragedy is that this feels orchestrated. This chronic disease, this failure of our hearts, has been deliberately mismanaged; with the decade of persistent underfunding, it is as though the medication that we need has been withheld, to a point of crisis.

    And then the political leadership essentially say to us, “Look, you just can’t work anymore. You’re not well.” As though it is our fault.

    Our treasured NHS. I still find it extraordinary that I can organize expensive tests and start life-saving treatments and procedures, from the emergency room to the intensive care unit, that would cost hundreds or thousands of pounds, and ask nothing more from a patient, for all of this, than their time in the hospital.

    I still feel that being a doctor is the best job in the world, providing care for those who need it. And I have been so proud to be an NHS doctor, giving back to the place which looked after my sister through her breast cancer and chemotherapy, and me through the birth of my children.

    The NHS will exist as long as there are those who will fight for it.

    But we’re all so tired. People clapped for us during the pandemic, and it felt empty, performative at the time.

    It means nothing when we are left to fight for the NHS on our own.

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  • It’s Beginning to Look a Lot Like Another COVID Surge

    It’s Beginning to Look a Lot Like Another COVID Surge

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    When I called the epidemiologist Denis Nash this week to discuss the country’s worsening COVID numbers, he was about to take a rapid test. “I came in on the subway to work this morning, and I got a text from home,” Nash, a professor at the City University of New York, told me. “My daughter tested positive for COVID.”

    Here we go again: For the first time in several months, another wave seems to be on the horizon in the United States. In the past two weeks, reported cases have increased by 53 percent, and hospitalizations have risen by 31 percent. Virus levels in wastewater, which can provide an advance warning of spread, are following a similar trajectory. After the past two years, a winter surge “was always expected,” Nash said. Respiratory illnesses thrive in colder weather, when people tend to spend more time indoors. Thanksgiving travel and gatherings were likewise predicted to drive cases, Anne Rimoin, an epidemiologist at UCLA, told me. If people were infected then, their illnesses will probably start showing up in the data around now. “We’re going to see a surge [that is] likely going to start really increasing in velocity,” she said.

    Winter has ushered in some of the pandemic’s worst moments. Last year, Omicron’s unwanted arrival led to a level of mass infection across the country that we had not previously seen. The good news this year is that the current rise will almost certainly not be as bad as last year’s. But beyond that, experts told me, we don’t know much about what will happen next. We could be in for any type of surge—big or small, long or short, national or regional. The only certain thing is that cases and hospitalizations are rising, and that’s not good.

    The pandemic numbers are ticking upward across the country, but so far the recent increases seem especially sharp in the South and West. The daily average of reported cases in Mississippi, Georgia, Texas, South Carolina, and Alabama has doubled in the past two weeks. Hospitalizations have been slower to rise, but over the same time frame, daily hospitalizations in California have jumped 57 percent and are now higher than anywhere else in the United States. Other areas of the country, such as New York City, have also seen troubling increases.

    Whether the nationwide spike constitutes the long-predicted winter wave, and not just an intermittent rise in cases, depends on whom you ask. “I think it will continue,” Gregory Poland, a professor of medicine at the Mayo Clinic, told me. “We will pour more gas on the fire with Christmas travel.” Others hesitated to classify the uptick as such, because it has just begun. “It’s hard to know, but the case numbers are moving in the wrong direction,” Rimoin said. Case counts are unreliable as people have turned to at-home testing (or just not testing at all), though hospitalizations and wastewater readings remain reliable, albeit imperfect, metrics. “I’ve not seen a big enough change to call it a wave,” Susan Kline, an infectious-diseases expert at the University of Minnesota Medical School, told me.

    But what to call the ongoing trend matters less than the fact that it exists. For now, what happens next is anyone’s guess. The dominant variants—the Omicron offshoots BQ.1 and BQ.1.1—are worrying, but they don’t pose the same challenges as what hit us last winter. Omicron drove that wave, taking us and our immune systems by surprise. The emergence of a completely new variant is possible this year—and would change everything—but that is considered unlikely.

    The lack of data on people’s immune status makes it especially difficult to predict the outcome of the current rise. Widespread vaccination and infection mean we have a stronger wall of immunity now compared with the previous two winters, but that protection inevitably fades with time. The problem is, people fall sick asynchronously and get boosted on their own schedules, so the timing varies for everyone. “We don’t know anything about how long ago people were [vaccinated], and we don’t know anything about hybrid immunity, so it’s impossible to predict” just how bad things could get, Nash said.

    Still, a confluence of factors has created the ideal conditions for a sustained surge with serious consequences for those who get sick. Fading immunity, frustratingly low booster uptake, and the near-total abandonment of COVID precautions create ideal conditions for the virus to spread. Meanwhile, treatments for those who do get very sick are dwindling. None of the FDA-approved monoclonal antibodies, which are especially useful for the immunocompromised, works against BQ.1 and BQ.1.1., which make up about 68 percent of cases nationwide. Paxlovid is still effective, but it’s underprescribed by providers and, by one medical director’s estimate, refused by 20 to 30 percent of patients.

    The upside is that few people who get COVID now will get very sick—fewer than in previous winters. Even if cases continue to surge, most infections will not lead to severe illness because the bulk of the population has some level of immunity from vaccination, previous infection, or both. Still, long COVID can be “devastating,” Poland said, and it can develop after mild or even asymptomatic cases. But any sort of wave would in all likelihood lead to an uptick in deaths, too. So far, the death rate has remained stable, but 90 percent of people dying now are 65 and older, and only a third of them have the latest booster. Such low uptake “just drives home the fact that we have not really done a good job of targeting the right people around the country,” Nash said.

    Even if the winter COVID wave is not ultimately a big one, it will likely be bad news for hospitals, which are already filling up with adults with flu and children with respiratory syncytial virus, or RSV. Many health-care facilities are swamped; the situation will only worsen if there is a big wave. If you need help for severe COVID—or any kind of medical issue—more than likely, “you’re not going to get the same level of care that you would have without these surges,” Poland said. Critically ill kids are routinely turned away from overflowing emergency rooms, my colleague Katherine J. Wu recently reported.

    We can do little to predict how the ongoing surge might develop other than simply wait. Soon we should have a better sense of whether this is a blip in the pandemic or something more serious, and the trends of winters past can be helpful, Kline said. Last year, the Omicron-fueled surge did not begin in earnest until mid-December. “We haven’t even gotten to January yet, so I really think we’re not going to know [how bad this surge will be] for two months,” Kline said. Until then, “we just have to stay put and watch.”

    It is maddening that, this far into the pandemic, “stay put and watch” seems to be the only option when cases start to rise. It is not, of course: Plenty of tools—masking, testing, boosters—are within our power to deploy to great effect. They could flatten the wave, if enough people use them. “We have the tools,” said Nash, whose rapid test came out negative, “but the collective will is not really there to do anything about it.”

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    Yasmin Tayag

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  • Will Flu and RSV Always Be This Bad?

    Will Flu and RSV Always Be This Bad?

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    In the Northern Hemisphere, this year’s winter hasn’t yet begun. But Melissa J. Sacco, a pediatric-intensive-care specialist at UVA Health, is already dreading the arrival of the one that could follow.

    For months, the ICU where Sacco works has been overflowing with children amid an early-arriving surge of respiratory infections. Across the country, viruses such as RSV and flu, once brought to near-record lows by pandemic mitigations, have now returned in force, all while COVID-19 continues to churn and the health-care workforce remains threadbare. Most nights since September, Sacco told me, her ICU has been so packed that she’s had to turn kids away “or come up with creative ways to manage patients in emergency rooms or emergency departments,” where her colleagues are already overwhelmed and children more easily slip through the cracks. The team has no choice: There’s nowhere else for critically ill kids to go.

    Similar stories have been pouring in from around the nation for weeks. I recently spoke with a physician in Connecticut who called this “by far the worst spike in illness I’ve seen in 20 years”; another in Maryland told me, “There have been days when there is not an ICU bed to be found anywhere in the mid-Atlantic.” About three-quarters of the country’s pediatric hospital beds are full; to accommodate overflow, some hospitals have set up tents outside their emergency department or contemplated calling in the National Guard. Last week, the Children’s Hospital Association and the American Academy of Pediatrics asked the Biden administration to declare a national emergency. And experts say there’s no end to the crisis in sight. When Sacco imagines a similar wave slamming her team again next fall, “I get that burning tear feeling in the back of my eyes,” she told me. “This is not sustainable.”

    Read: The worst pediatric-care crisis in decades

    The experts I spoke with are mostly optimistic that these cataclysmic infection rates won’t become an autumn norm. But they also don’t yet fully understand the factors that have been driving this year’s surge, making it tough to know with certainty whether we’re due for an encore.

    One way or another, COVID has certainly thrown the typical end-of-year schedule out of whack. Respiratory viruses typically pick up speed in late fall, peak in mid-to-late winter, and then bow out by the spring; they often run in relay, with one microbe surging a bit before another. This year, though, nearly every pathogen arrived early, cresting in overlapping waves. “Everything is happening at once,” says Kathryn Edwards, a pediatrician and vaccinologist at Vanderbilt University. November isn’t yet through, and RSV has already sent infant hospitalizations soaring past pre-pandemic norms. Flu-hospitalization rates are also at their worst in more than a decade; about 30 states, plus D.C. and Puerto Rico, are reporting high or very high levels of the virus weeks before it usually begins its countrywide climb. And the country’s late-summer surge in rhinovirus and enterovirus has yet to fully abate. “We just haven’t had a break,” says Asuncion Mejias, a pediatrician at Nationwide Children’s Hospital.

    Previous pandemics have had similar knock-on effects. The H1N1-flu pandemic of 2009, for example, seems to have pushed back the start of the two RSV seasons that followed; seasonal flu also took a couple of years to settle back into its usual rhythms, Mejias told me. But that wonky timetable wasn’t permanent. If the viral calendar is even a little more regular next year, Mejias said, “that will make our lives easier.”

    This year, flu and RSV have also exploited Americans’ higher-than-average vulnerability. Initial encounters with RSV in particular can be rough, especially in infants, whose airways are still tiny; the sickness tempers with age as the body develops and immunity builds, leaving most children well protected by toddlerhood. But this fall, the pool of undefended kids is larger than usual. Children born just before the pandemic, or during the phases of the crisis when mitigations aplenty were still in place, may be meeting influenza or RSV for the first time. And many of them were born to mothers who had themselves experienced fewer infections and thus passed fewer antibodies to their baby while pregnant or breastfeeding. Some of the consequences may already have unfurled elsewhere in the world: Australia’s most recent flu season hit kids hard and early, and Nicaragua’s wave at the start of 2022 infected children at rates “higher than what we saw during the 2009 pandemic,” says Aubree Gordon, an epidemiologist at the University of Michigan.

    Read: What a ‘tripledemic’ means for your body

    In the U.S., many hospitals are now admitting far more toddlers and older children for respiratory illnesses than they normally do, says Mari Nakamura, a pediatric-infectious-disease specialist at Boston Children’s Hospital. The problem is worsened by the fact that many adults and school-age kids avoided their usual brushes with flu and RSV while those viruses were in exile, making it easier for the pathogens to spread once crowds flocked back together. “I wouldn’t be surprised,” Gordon told me, “if we see 50 to 60 percent of kids get infected with flu this year”—double the estimated typical rate of 20 to 30 percent. Caregivers too are falling sick; when I called Edwards, I could hear her husband and grandson coughing in the background.

    By next year, more people’s bodies should be clued back in to the season’s circulating strains, says Helen Chu, a physician and an epidemiologist at the University of Washington. Experts are also hopeful that the toolkit for fighting RSV will soon be much improved. Right now, there are no vaccines for the virus, and only one preventive drug is available in the U.S.: a tough-to-administer monoclonal antibody that’s available only to high-risk kids. But at least one RSV vaccine and another, less cumbersome antibody therapy (already being used in Europe) are expected to have the FDA’s green light by next fall.

    Even with the addition of better tech, though, falls and winters may be grueling for many years to come. SARS-CoV-2 is here to stay, and it will likely compound the respiratory burden by infecting people on its own or raising the risk of co-infections that can worsen and prolong disease. Even nonoverlapping illnesses might cause issues if they manifest in rapid sequence: Very serious bouts of COVID, for instance, can batter the respiratory tract, making it easier for other microbes to colonize.

    A few experts have begun to wonder if even milder tussles with SARS-CoV-2 might leave people more susceptible to other infections in the short or long term. Given the coronavirus’s widespread effects on the body, “we can’t be cavalier” about that possibility, says Flor Muñoz Rivas, a pediatrician at Baylor College of Medicine. Mejias and Octavio Ramilo, also at Nationwide, recently found that among a small group of infants, those with recent SARS-CoV-2 infections seemed to have a rougher go with a subsequent bout of RSV. The trend needs more study, though; it’s not clear which kids might be at higher risk, and Mejias doubts that the effect would last more than a few months.

    Gordon points out that some people may actually benefit from the opposite scenario: A recent brush with SARS-CoV-2 could bolster the body’s immune defenses against a second respiratory invader for a few days or weeks. This phenomenon, called viral interference, wouldn’t halt an outbreak by itself, but it’s thought to be part of the reason waves of respiratory disease don’t usually spike simultaneously: The presence of one microbe can sometimes crowd others out. Some experts think last year’s record-breaking Omicron spike helped punt a would-be winter flu epidemic to the spring.

    Even if all of these variables were better understood, the vagaries of viral evolution could introduce a plot twist. A new variant of SARS-CoV-2 may yet emerge; a novel strain of flu could cause a pandemic of its own. RSV, for its part, is not thought to be as quick to shape-shift, but the virus’s genetics are not well studied. Mejias and Ramilo’s data suggest that the arrival of a gnarly RSV strain in 2019 may have pushed local hospitalizations past their usual highs.

    Read: Will we get Omicron’d again?

    Behavioral and infrastructural factors could cloud the forecast as well. Health-care workers vacated their posts in droves during the pandemic, and many hospitals’ pediatric-bed capacity has shrunk, leaving supply grossly inadequate to address current demand. COVID-vaccination rates in little kids also remain abysmal, and many pediatricians are worried that anti-vaccine sentiment could stymie the delivery of other routine immunizations, including those against flu. Even temporary delays in vaccination can have an effect: Muñoz Rivas points out that the flu’s early arrival this year, ahead of when many people signed up for their shot, may now be aiding the virus’s spread. The new treatments and vaccines for RSV “could really, really help,” Nakamura told me, but “only if we use them.”

    Next fall comes with few guarantees: The seasonal schedule may not rectify itself; viruses may not give us an evolutionary pass. Our immune system will likely be better-prepared to fend off flu, RSV, rhinovirus, enterovirus, and more—but that may not be enough on its own. What we can control, though, is how we choose to arm ourselves. The past few years proved that the world does know how to drive down rates of respiratory disease. “We had so little contagion during the time we were trying to keep COVID at bay,” Edwards told me. “Is there something to be learned?”

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    Katherine J. Wu

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  • ERs Seeing Huge Rise in Cases of Sexual Assault

    ERs Seeing Huge Rise in Cases of Sexual Assault

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    By Steven Reinberg 

    HealthDay Reporter

    FRIDAY, Oct. 21, 2022 (HealthDay News) — Victims of sexual assault are seeking treatment in U.S. emergency rooms in growing numbers, with University of Michigan (UM) researchers detecting a 15-fold increase between 2006 and 2019.

    Rapes and other forms of sexual assault occur every 68 seconds in the United States, and their number rose from 93,000 in 2006 to nearly 140,000 in 2019, according to data from the U.S. Federal Bureau of Investigation.

    The increase in people seeking emergency medical care after sexual violence, however, is greater than the growth of those turning to the police for help, the study authors said.

    And while there are more sexual assaults occurring, greater awareness and hospital coding changes are also contributing to the spike, the researchers noted.

    “Overall destigmatization — whether that’s due to the Me-Too movement or other social-political movements — have made people feel safer coming and seeking care,” said lead researcher Emily Vogt, a UM medical student.

    It’s not clear if people who go to the ER after a sexual assault are not going to the police, Vogt added. Perhaps “they feel like that’s the only place they can go,” she said.

    For the study, Vogt and her colleagues used data from millions of emergency department visits. They found that in 2006, more than 3,600 men and women aged 18 to 65 sought emergency care following a sexual assault. In 2019, that number jumped to nearly 55,300. (For support, contact RAINN, the Rape, Abuse and Incest National Network hotline).

    Vogt’s team found that those seeking ER treatment were disproportionally younger women and poorer.

    However, despite the rise in ER care, hospital admissions after a sexual assault decreased by 8% — from just under 13% to 4%. Most patients (95%) were sent home, the findings showed.

    Admissions may have dropped because of lack of insurance, fewer empty beds, or victims not wanting to be hospitalized due to privacy concerns, Vogt said.

    Patients who were admitted tended to be poorer and have Medicaid. Victims aged 46 to 65 were also more likely to be hospitalized than younger people, possibly because the assault exacerbated other medical conditions, Vogt said.

    Overall, emergency department visits increased by 23% during the same period, with sexual assault accounting for less than 1% of visits. Yet hospital charges for sexual assault visits topped $233 million in 2019, up from $6 million in 2006, the researchers reported.

    ERs can do better in helping patients after a sexual assault, Vogt said. “The emergency department, even though it’s a better place to go than nowhere, is probably not the best place. We need better kinds of outpatient care,” she suggested.

    Vogt anticipates sexual assault numbers will continue to swell. “We didn’t even get to look at the years of the COVID-19 pandemic, which we already know from other studies has certainly increased rates of sexual assault,” she explained.

    “A lot of these patients are getting sent home, and it’s unclear whether they are getting the attention they deserve,” Vogt said. “We know these patients are at higher risk for [post-traumatic stress disorder], substance abuse, and psychiatric problems as a result of the trauma they’ve experienced.”

    The report was published online Oct. 20 in JAMA Network Open.

    Dr. Elizabeth Miller is a professor of pediatrics at the University of Pittsburgh School of Medicine. She said sexual violence remains a significant public health concern.

    “Sexual violence reporting and care-seeking is not evenly distributed across populations, and inequities persist,” Miller said. “The health consequences of sexual violence remain underrecognized by our health system, especially among survivors who are marginalized because of sexism, racism, heterosexism and ableism,” added Miller, co-author of an accompanying journal editorial.

    Miller agreed there is both increased awareness of sexual violence and growing incidence.

    “As a result of lots of community campaigns to make the experiences of sexual assault more visible, more people appear to be seeking care. But it does appear globally, we saw an increase in interpersonal violence, including childhood sexual abuse, sexual assault and intimate partner violence during the pandemic,” she said.

    And, she pointed out that people who are already marginalized because of gender identity, sexual minorities, females and people with disabilities experience higher incidences of sexual violence.

    Miller added that survivors of sexual assault should expect to be treated with respect by law enforcement and by emergency room staff. “They should know that they can also ask for a trained sexual assault nurse examiner, and they can also ask for a victim services advocate to be present during a forensic exam,” she said.

    However, more is needed to improve survivor-centered care in ERs. “We need to understand how best to provide meaningful support for survivors and to not contribute to retraumatizing individuals who have experienced an assault,” Miller said.

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