Tanzina Vega: It's The Takeaway. I'm Tanzina Vega and thanks for being with me today. Hospitals stretched thin, healthcare workers overwhelmed, and too few resources. Those were the stories dominating the headlines in the early months of the pandemic. Now, once again, that's what we're hearing from some hospitals and clinics across the country with many others close behind.

COVID-19 numbers are rising dramatically nationwide with more than 20 states reporting cases at or close to record levels, translating into more people being hospitalized. I'm joined now by Frank LoVecchio, professor of emergency medicine at the University of Arizona, and Dan Goldberg, a health care reporter at POLITICO. Welcome to you both.

Frank LoVecchio: Thank you.

Dan Goldberg: Thank you so much for having me.

Tanzina: Frank, the last time we spoke, you were painting a picture of an overwhelmed hospital system in Arizona because of rising COVID cases. Where do things stand today?

Frank: Today in Arizona, we're at a much better spot. Our ICU cases are about 200 or so. During the peak, it was about 970. We were about 85% use at that time and we've dropped substantially. We are seeing numbers going on the wrong direction, though, with positivity rates, admission rates. We are seeing good things, though. People are staying home. When people stay home when they are sick, et cetera, and they get evaluated by electronic visits, et cetera, tends to be a little bit better for us because we don't see the burden in the hospital, but we are just at the beginning and things are going to get worse.

Tanzina: Frank, what are some lessons that you've learned over the past six months in working with patients and with having this virus that you're applying today?

Frank: That's a great question. What we've learned is there's not much we can do for it. We can talk about drugs. We can talk about supportive care. In the end, oxygen help, but if you don't need oxygen, there's not many reasons to keep you in the hospital. If your other sicknesses are in check, for example, your diabetes, your [unintelligible 00:01:53] your blood pressure, there's not much we can do for you, so we try to push people at home.

People are getting pulse oximetry even in an underserved hospital like mine. If the levels drop, we're telling the patients to come back. Never, if somebody's saturation was under 90%, would we tell them to stay home. Now, we're telling them go with 85, 86% oxygen content, something typically that was an automatic stay in the hospital. People tolerate low oxygen much more.

Tanzina: Why is that, Frank?

Frank: I think it's because they are able to breathe. We realize that the air moving out is not as big as a problem. Getting them oxygen is a little bit more of an issue, much different than things like pneumonia or other things that affects your brain, that causes you to stop breathing as well. It's a new disease. We're learning new things every day.

Tanzina: I just want to make sure in terms of PPE, ventilators, resources, are you all feeling like you have what you need, as you mentioned, should cases begin to peak even more in the state?

Frank: When we were at our peak, we were hit pretty hard and nobody came in for other diseases. Right now, because surgeries are open and other patients are still trickling in, I think there could be a stress to the system, but as we sit today, we're in a great spot. Unfortunately, around the country, that's not the case where you see places like Illinois, where they're getting 31,000 new cases. That's higher than any state in the country except for Texas, for example.

Tanzina: Dan, let's bring you in here, healthcare reporter for POLITICO. Give us a sense of how much of a rise we're seeing in hospitalizations around the country to Frank's point.

Dan: Right now, there are over 44,000 patients in hospitals. Just to give you some perspective, at the beginning of the month, there were only about 30,000 so we're up about 33% in the last four weeks. This is the most number of people we've seen in hospitals since the summer surge that peaked in July but really started to come down at the end of August.

Things are really bad around the country. Unlike in the spring, which was really focused in the Northeast, and the summer, which was really focused in the Southwest, this fall surge that we're seeing is much more uniform. It's pretty much everywhere. Utah, Texas, Idaho, the Dakotas, Wisconsin, they're all having capacity issues at their hospitals.

Tanzina: Dan, one of the big concerns back in the spring was hospitals having to make decisions about rationing care. Are you seeing that playing out differently now than it was in the spring, or are hospitals still being forced to make difficult choices about who gets care, to Frank's point, not necessarily who gets care but how much hospitalization time people have a need to have right now?

Dan: Unfortunately, yes. Utah has made that announcement, that they have begun to start rationing care. We should explain exactly what we mean by rationing care because sometimes, people get the sense that it means you're left out on the street. There are tons of little decisions made along the way that amounts to rationing care, even things like staying home when your levels are at 85 as opposed to what we would normally do and bring you into the hospital.

In Idaho, for example, they have closed a pediatric unit to turn it into a COVID unit. Now, that unit wasn't necessarily full, but that means if there is a pediatric case that would have gone to that hospital, now they're being diverted somewhere else. When a hospital closes its cardiac unit and turns it into a COVID unit, that's rationing care. Like I said, unfortunately, we are seeing more and more hospitals, especially in the Midwest and the Plains States, having to make decisions like that.

Tanzina: Frank, does that sound familiar?

Frank: Oh, absolutely. If you walk into a hospital today, as opposed to a year ago, it is much different. Areas that were never hospital beds are now COVID units, and pediatric places are moved all over to different spots in the hospital because this does not affect kids as much as the adults. In other words, the kids might get sick but not as severe as adults, so we're taking those hospital beds and using them as adult beds. Yes, the hospital looks much different. We use outside, before people walk in. We're lucky in California and Arizona because we have good weather where people can wait outside, but not the appropriate waiting room that you would normally have.

Tanzina: Frank, back in the spring when we spoke, you were asking people to wear masks, follow social distancing. Has the public listened?

Frank: Not in all states. If you look at the rates of people who wear masks, et cetera, it's much more prevalent in people that are over 60. Hand washing is much more prevalent, social distancing and avoiding crowds is much more prevalent in those over 60. In those under 21, especially teens, et cetera, I don't want to say it's non-existent, but it does not go as well. They don't tend to get as sick, so they don't really see the disease as a problem. If you look at a state like Dakota, which for unclear reasons, they are the highest state of not wearing masks, their rate is 105 patients getting COVID-19 out of 100,000 people, whereas the rest of the country is about 10 per 100,000 or so on average.

Tanzina: Dan, when you hear what the numbers that Frank is pointing out here, we have talked about there is no federal mask mandate. We know that. States have incorporated some mask mandates. Then there are lots of fighting. There's lots of in-fighting between-- lots of lawsuits about who should and shouldn't wear a mask. Is that leading or is that prompting some of this rise in cases, Dan, that we're seeing across the country? Just failure to comply with basic CDC guidelines?

Dan: Absolutely. It's become a political thing. We all know that. If you listen to very conservative governors, even the ones who resist mask mandates like Doug Burgum in North Dakota, they are strongly recommending that people wear masks. They are been begging people to wear masks for months. There is no serious scientist, including those in the Trump administration like Deborah Berkshire or CDC director, Robert Redfield, who will tell you that masks don't make a huge difference. In fact, the CDC estimates that it could save hundreds of thousands of lives.

There are a myriad of reasons why people don't do it. Again, some of it has become political. Like Frank said, some of it is because they're younger and don't think that they'll get the virus or if they get the virus, it won't be that bad. The problem is people who get the virus tend to spread it and often, they spread it to people who are more vulnerable. That's exactly why we're seeing hospital numbers go up, because people aren't wearing masks. As the cold weather creeps across the country, more people are gathering indoors. The activities that used to take place outside at parks and things like that are now taking place inside, where the virus is prone to spread.

Tanzina: Dan, earlier in the pandemic, back in the spring, the tri-state area governors all cooperated in terms of setting limits and lockdown requirements, et cetera. Are we seeing similar cooperation among states in different parts of the country, in terms of different regions coming together to say, "Okay, let's coordinate efforts here to contain the spread," or not?

Dan: Not the way we saw early on in the pandemic. I think the virus in March and April was so new and so rampant that governors were more apt to work together to control the spread and really shut down large swaths of their economy. Given where we are eight months into this, there's much less political will for those broad shutdowns. It's not to say the governors aren't cooperating with each other where they can or that there's any backbiting or anything like that. It’s just that there isn't that same political will to move in unison. I think governors have really learned or at least now are much more in favor of more targeted approaches.

Tanzina: We're seeing some of those targeted approaches here, at least in the Northeast. My neighborhood itself was one of the micro-communities that was under quarantine for a couple of weeks because we had seen a spike in cases. Is that where you see the enforcement headed as we head into the colder months?

Dan: I think that's absolutely where we're headed. We see it in Newark. I saw Hoboken, just across the river, announce new restrictions. We're seeing that in Illinois, another big state, in California and Ohio. Governors are breaking their states up either into counties or, as Cuomo did, into hot zones. Some are doing it by zip code. I think that's probably the next phase. That's at least what people are going to try to do to try and stem the growth of the virus at this point.

Tanzina: Frank, just curious. There's been a lot of concern, as cases begin to increase, about the possibility of a twindemic, which would be flu season and COVID-19 cases colliding. Are you concerned about that?

Frank: Absolutely, yes. It's a nightmare. If you come into the emergency department or your primary care doctor's office and say, "I have a fever, cough, et cetera," I cannot tell the difference if it's influenza A and B or if it's COVID. People say, "Well, the loss of taste, et cetera." That happens with the flu, sure, not as prevalent as COVID-19 and you can't hang your hat on it. You could say, "Get a test." The influenza tests are borderline useless, the rapid ones, especially during flu season. We just treat empirically that if we think you have it, it's flu season, we usually treat you for the flu.

For COVID-19, we know the tests are not that accurate. I think a lot of people, unfortunately, are going to have to quarantine. They're going to come in with a fever. I'm going to say you might have the flu, most likely you have the flu, but I still have to tell you because your COVID-19 test, even if it's negative, I have to still tell you to quarantine or be away from people for at least 10 to 14 days. It's very, very unfortunately difficult for us as clinicians, and we're going to be overwhelmed in the hospital with people.

I think something that you brought up earlier is about masks, et cetera, and distancing, and fallowing stuff. Don't do it for yourself. Just realize that much like Italy and other countries, about 10% of people that were admitted were hospital workers. Unfortunately, it's not so much doctors as nurses. Nurses are in there. I might be in the room for 10 or 15 minutes. A nurse is in there for hours, doing all things that people wouldn't even imagine doing, touching their secretions, sucking out secretions while they're on a ventilator, sending their body fluids for testing, et cetera.

About 4% of them died. It's pretty crazy. You went into healthcare. You didn't go in to fight a war but unfortunately, it's becoming somewhat of a war.

Tanzina: Our thoughts are with all of the healthcare workers as they battle this third wave. Thank you so much. Frank LoVecchio is a professor of emergency medicine at the University of Arizona. Dan Goldberg is a healthcare reporter at POLITICO. Thanks so much.

Frank: Thank you.

Dan: Thank you so much for having me.

Tanzina: As we just heard, hospitals across the United States are being overwhelmed as COVID-19 surges in almost every state in the country. Early on in the pandemic, the country's hotspots were largely urban centers like New York, but now we're seeing a shift to less populated parts of the country. In more rural communities, healthcare systems are being stretched to capacity, especially in states like Wisconsin, where the number of people hospitalized for COVID-19 has tripled in the past month. For more on this, we're joined now by Rob Mentzer, rural communities reporter for Wisconsin Public Radio. Rob, welcome back to the show.

Rob Mentzer: Thanks for having me.

Tanzina: Tell us about the rates of COVID-19 in Wisconsin's rural communities. How is it that they've been spiking?

Rob: It was, in fact, the case that in the first wave of the pandemic, Milwaukee and some of the state's urban areas were harder hit. It started, really, over the summer to see a lot more activity in rural counties. Then in the most recent spike that began at the beginning of September, it's rural areas by and large that have been hit the hardest. That includes parts of northern Wisconsin, central Wisconsin, as well as northeastern Wisconsin, the Fox Valley, which is more urbanized area. Those are among the hardest-hit areas right now.

Tanzina: Today, we're really focusing in on hospitals and healthcare facilities. Are the facilities in rural communities in Wisconsin prepared? Do they have enough ICU beds? Do they have enough personal protective equipment, for example? Do they have enough ventilators?

Rob: Sure. Rural hospitals planned for this. The planning did begin back in the very first wave of the pandemic. Rural hospitals would make plans to make sure they had PPE. They had surge plans for how they would increase bed space as needed. Those plans are now being put into effect. There are areas, rural hospitals, that absolutely have been overwhelmed. The state overall right now is at about 85% capacity in hospitals, 88% capacity in ICUs, but of course, that is not evenly distributed.

There are hospitals near to me in central Wisconsin that are at 100% or higher, and that are transferring patients out to other facilities. Of course, at the smallest rural hospitals, they often don't have an ICU. In those cases, they're not set up to deal with the worst-off patients or the highest risk patients, and they have to transfer them to other facilities.

Tanzina: That requires resources, the transferring of patients. It also requires staff. Tell us a little bit about the resources. Do these hospitals have the financial resources to be able to transfer patients if they need to do that? Do they have enough staff to treat the patients who are there?

Rob: Rural hospitals had a hard time financially before the pandemic began. This has been a strain on their facilities, and in all ways, and financially, and staff in every way, emotionally. There have been a number of grants. I've spoken to rural hospitals that got loans through the federal relief act. There are other more local grants and state funds that have gone to some of these rural facilities. Overall, if you talk to people at rural hospitals, they will say that there are big structural problems but that they are weathering the pandemic here in Wisconsin.

The staffing issue is a serious one because as overall infections have increased, they've increased among healthcare workers too. Recently, the Aspirus health system, it's a very large health system that covers a lot of Wisconsin and the upper peninsula of Michigan, said that nearly 9,000 of their employees system-wide had or were suspected of having COVID. That demonstrates the problem. There are real staffing issues in some of these places as employees are infected with the disease and can't work in some of these units.

Tanzina: One of the most interesting things is the fact that governor Tony Evers, who's a Democrat, has been at odds with the Republican-led state legislature. There have been lawsuits, even, about whether or not Wisconsin residents should be forced to wear masks. How has that affected what you're seeing in rural communities in terms of the COVID-19 uptick?

Rob: Well, the issue is just extremely politicized. In Wisconsin, the governor is a Democrat, the legislature is controlled by Republicans, and they have been at odds on these issues from the beginning. The legislature did, in fact, sue the governor over the statewide mask mandate. More recently, the administration ordered a capacity limit for bars and restaurants and some other indoor spaces to 25% of their overall capacity. That was immediately the subject of a lawsuit. It was suspended by a temporary injunction by a judge. Then it was put back in place, and now it's back off.

I think you can imagine why these things don't have the same impact when they're on and off and on and off and is perceived as a political issue. It just doesn't connect in the same way with the public. Meanwhile, the legislature has not met since April in Wisconsin and shows no indication that they will meet to consider responses to the spike that we're having now.

Tanzina: Rob, another interesting development that's happened in the past 24 hours regarding the state of Wisconsin is that the Supreme Court decided not to extend the deadline for mail-in voting in the state. What has that meant for voters, particularly those in rural communities?

Rob: Absentee ballot requests just absolutely skyrocketed in Wisconsin. There have been about 1.8 million of those made, and that's all parts of the state. That includes rural communities absolutely. It is now too late to mail your ballot back in and reliably be confident that it will be in in time, given the latest Supreme Court ruling. The advice from all parties and all voting groups is that if people have an absentee ballot, now they should turn it in in person.

I did see, just this morning, data that said that of those 1.8 million requests, 1.5 million have been returned already, are accounted for. That's a lot of absentee ballots that are in and counted for. You can bet that political partisans and activists will be sweeping the state to work on those last 300,000 or so.

Tanzina: Rob Mentzer is a rural communities reporter for Wisconsin Public Radio. Rob, thanks so much.

Rob: Thank you.

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