In late April, a patient came into my hospital, in Houston, from the county jail. He’d been sitting and talking with some of the other inmates when he’d felt heavy cramping in his thighs; the cramps had spread quickly to his belly, and then to the rest of his body. He knew what this meant—he’d experienced sickle crises his whole life. People with sickle-cell disease, a congenital illness, lack an enzyme that helps the hemoglobin molecules in their blood maintain shape. Ordinarily, red blood cells look like disks; in a sickle crisis, they fold in half, becoming crescents. The misshapen cells can’t properly transport oxygen, and they jam together and form clots, blocking the flow of healthy cells that can. The cramps are signs of oxygen starvation in the muscles. During the ten months that he’d been held in jail, awaiting trial, my patient had been hospitalized for sickle crises four times.
My partner on the overnight shift had started him on Dilaudid, for the pain, and on oxygen and I.V. fluids, which would help reshape his blood cells. He’d also administered a coronavirus test. At that time, there was little consensus about how the coronavirus would affect Texas; some doctors and politicians, practicing a new form of Texan exceptionalism, were predicting that our state would never see a major surge. Still, everyone who came to the hospital was concerned. When I saw my patient in the morning, he was lying motionless. He had no fever or shortness of breath, but was worried about COVID-19.
“Honestly, I don’t think you have the coronavirus,” I told him. I wanted to ease his worries while we waited for the test results, but it wasn’t just that; although we knew that detention centers made social distancing impossible, we hadn’t yet seen spikes in cases there. As I left, I flapped my P.P.E. gown in his direction. “Sorry I’m wearing this,” I said. I watched as he shifted his right leg to relieve pressure on his ankle, which the sheriff had cuffed to the bed.
The coronavirus had drifted into Houston like a gentle rain—floating over the city, collecting here and there. The first cases appeared in early March, but hospitals didn’t start to see a spike in admissions until early April. Infections mounted, but our considerable medical capacity was never overwhelmed. (Houston is a world-class medical city, home to more than eighty-five hospitals; mine, the Ben Taub Hospital, is situated in the Texas Medical Center, the largest medical complex in the world.) As ever, we compared ourselves with New York—a city with three and a half times our population that was experiencing more than sixty times as many coronavirus deaths. Why was the course of the pandemic so different in Houston? Perhaps our cars were protecting us, or maybe the sprawling layout of our city created social distancing by default. Our distancing measures, which had begun in March, seemed to have successfully kept the pandemic at bay. That success may have contributed to an overly relaxed attitude toward testing: although the governor, Greg Abbott, had promised drive-through swabbing, it never meaningfully materialized. Today, Texas ranks forty-third in the country in coronavirus testing per capita.
In May, businesses started to reopen. On the first of the month, movie theatres, restaurants, and malls returned to twenty-five-per-cent capacity, or fifty-per-cent capacity in rural areas with few confirmed cases; hair salons followed, then gyms, without the use of locker rooms and showers. Houstonians were confused and divided on the subject of reopening, and government guidance was contradictory. Lina Hidalgo, a Democrat and the Harris County executive, ordered the wearing of masks in public on April 22nd; five days later, Abbott, a Republican, issued his own order, contradicting hers. On April 24th, county officials announced that they were closing a pop-up medical shelter at the city’s NRG Stadium; it had cost seventeen million dollars to build and had gone completely unused.
The uncertainty extended into the medical profession. Throughout the spring, even doctors argued about where the city sat on its COVID-19 curve, and about what the shape of that curve would ultimately be. Physicians were divided into two camps: those who thought that we had somehow bypassed the first surge, and those who believed that the storm was still gathering and would strengthen when we began reopening. I belonged to the latter camp, struck by the fact that, even though coronavirus hospitalizations in April hadn’t reached crisis levels, there was a long stretch during which Houston, despite its lockdown, never saw two consecutive days of decline in case counts.
We could and did argue over the meaning of the data. In the absence of widespread testing, who could say whether the numbers we were seeing—six hundred new cases statewide on April 1st, eight hundred on April 15th—were signs of a crisis averted or indications that the virus was spreading despite lockdown and waiting to pounce? Now we know what those signs were forecasting. It doesn’t take long for a virus as contagious as this one to spread; Governor Abbott let phased reopening start at the beginning of May, and on June 16th Texas saw its first true spike—forty-two hundred new cases in one day.
Before a virus makes itself plainly visible, it hides; you have to look for it. In the case of the coronavirus, which often travels asymptomatically, looking for it means testing. Just a few hours before my sickle-cell patient arrived, the hospital had announced that it was closing down a combined medical-surgical unit because twelve employees there had tested positive. An infection-control team determined that the localized outbreak hadn’t been caused by a failure of hygiene or P.P.E.: the nurses had followed protocols. Apparently, even with precautions in place, the virus had found a way to spread.
In April, the journal Emerging Infectious Diseases published a paper written by researchers at Huoshenshan Hospital, in Wuhan—one of the emergency facilities focussed on COVID-19 that the Chinese government had constructed in a matter of days. The authors of the study had swabbed different objects in wards that had housed COVID-19 patients—doorknobs, trash cans—to find out which surfaces might be acting as vectors. They learned, among other things, that twenty per cent of computer mouses in the general wards had traces of the virus. In the hospital that they studied, no staff members were infected—a testament, the researchers concluded, to the effectiveness of hand-washing and P.P.E. This was reassuring news. Still, I kept thinking about those computers. Many years ago, before our hospital made the switch to electronic records, I wrote out my histories and physicals by hand, using my own pen—fine-tipped, so that I could fit everything onto a single page. Now I input my orders using a keyboard and mouse shared with several other doctors and nurses. What other kinds of centralized infrastructure could provide an opening for the virus? At our hospital, the blind spot turned out to be not computers but break rooms. The infection-control team believes that the virus spread in the rooms where nurses and techs take a load off, and where they tend not to wear P.P.E.
The city of Houston has its own blind spots. The county jail, where my sickle-cell patient had been held, is one. At the end of April, three hundred and eight inmates and a hundred and eighty staff members had tested positive for the virus. At the hospital, my patient’s red blood cells had stopped sickling and his cramping had abated; his movement got easier, and I weaned him off the Dilaudid. Still, I had to deliver the bad news.
“I’m sorry, sir, but your test came back positive,” I said.
He looked up at the ceiling, his body still. I hadn’t thought to connect his sickle crisis to COVID-19, but the disease, which is still not fully understood, does affect the circulatory system. I kept him a few extra nights, to monitor his blood counts, then he was discharged back to the jail. Not long afterward, a doctor I know who works there told me more about the conditions inside, which sounded dire. For a long time, nurses at the jail had been given two N95 masks and eight surgical masks, meant to last for two weeks; coronavirus tests were taking days to turn around; positive patients were being moved to isolation, but space there was limited. (A spokesperson for the jail said that, thanks to an improved supply of masks, nurses are now provided with N95s whenever they need them.) A few weeks after my patient went back, seven hundred and eighteen inmates and more than two hundred staff members had tested positive, and three people had died. The blind spot had become a hot spot. Every night that week, I saw inmate after inmate brought into the E.R., each in a bright-orange jumpsuit, an ankle cuffed.
In its own way, my hospital—a “safety net” institution where undocumented immigrants and people without insurance often come—has been a blind spot, too. Early in the spring, when many private hospitals in Houston were seeing decreasing numbers of COVID-19 patients, our numbers continued to rise, slowly but steadily. Houston is home to more than half a million undocumented immigrants, and some doctors speculated that our numbers were rising because the undocumented were afraid to go to other hospitals; it was easy to imagine that, without outreach and testing, many had been weighing the risk of deportation against the need to seek treatment for shortness of breath.
The rising numbers at our hospital may lag behind the rise in cases. I’ve long marvelled at the necessary tolerance of the uninsured. Nearly twenty per cent of Houstonians lack insurance—the highest proportion in any large American city. Some uninsured patients, who can’t receive regular dialysis at a clinic, visit our emergency room three times a week; beforehand, they eat bunches of bananas or slurp the sludge of canned tomatoes to push their potassium levels to dangerous heights—a nutritional hack that guarantees that they will receive dialysis immediately. I’m finding that some of my patients are exhibiting the same level of tolerance with COVID-19. Many say that they have suffered from fever and shortness of breath for a week, maybe two, before coming in for care.
Now, even with our low levels of testing, the surge in Texas is impossible to miss. Since Memorial Day, Texas Medical Center hospitals have seen a thirty-six-per-cent increase in admitted COVID-19 patients; the number of infections citywide has grown by a hundred and fifty per cent. Texas Medical Center’s I.C.U.s were at ninety-eight-per-cent capacity this week. Three weeks from now, if these trends continue, the city’s I.C.U.s will be overwhelmed.
The state is currently in Phase 3 of Governor Abbott’s reopening plan. Restaurants are operating at seventy-five-per-cent occupancy, and aquariums, salons, offices, and bars have all been reopened to some degree; even carnivals and fairs will soon resume at half capacity. The state tells employers and residents to “take action based on common sense,” but the definition of common sense seems to be up for debate. At every stage, Texas has struggled to meet its own benchmarks for reopening, but that hasn’t stopped it from pressing ahead. At a press conference on Monday, Abbott acknowledged that the current spike was unacceptable, and said that, if the virus’s spread continues, “additional measures are going to be necessary”; on Thursday, he issued an executive order postponing elective surgeries. But he has declined to roll back any of the reopening.
At Ben Taub, we are already confronting the realities of completely full I.C.U.s. In Hail Mary fashion, we are bringing to bear all of the resources that the regular, medical-surgical floor has to offer while we wait for I.C.U. beds to open. On a night shift last week, I added a spray of saline to a patient’s high-flow oxygen, delivered via nasal cannula, in the hope that the slightest bit of moisture could help stave off the need to intubate. Whenever I hear a Code Blue called over the P.A. system, my reaction is split: I lament what’s happening to a patient in cardiopulmonary arrest, and I think immediately of a patient in waiting, wondering whether this announcement means that an I.C.U. bed will soon become available.
Around the world, successful reopenings have been enabled by robust testing, contact tracing, isolation, and treatment programs. Some states, such as Massachusetts, are investing heavily in those systems. In Texas, testing efforts remain confusing and stunted. (My mother recently had to drive thirty miles for a test.) The state has fallen short of its contact-tracing goals, which disease modelling has shown to be too modest by half. In any case, even the best public-health program would be stymied by the large group events that our hasty reopening is making possible. The storm has arrived in Houston. Harris County’s COVID-19 Threat Level System is on orange—the second-highest level; Hidalgo has said that the city is “on the precipice of disaster.” Meanwhile, the Texas G.O.P. convention is set to go forward downtown, in July.
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June 26, 2020 at 08:20AM
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The Coronavirus Surge That Texas Could Have Seen Coming - The New Yorker
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