We hear it all the time. Systems or processes are overwhelmed and there are dire predictions regarding potential scenarios in our future. People argue for resource allocation based upon circumstance and their prognostications for the future. It is somewhat reminiscent of the assiduous hurricane preparation we witness the year immediately after each "big one," followed by a steady retreat to complacency as we lose our appreciation for the severity of what we have lived through.
Imagine hospitals overcome with too many patients. Imagine a scenario in which hospitals would pitch tents in an attempt to accommodate an epidemic "in every state." Imagine a situation so dire that staff is stretched and strained, overtime becomes a necessity, "friends and family" are precluded from visiting those in the hospital, and facilities turn to "canceling elective surgeries." OK, it is 2021 and no one needs to imagine any of that. If you lived through the great pandemic anywhere but under a rock, the recent reality is all-too-well-known. The oxymoronic juxtaposition of the last 18 months, our reliance upon medical professionals and others, and the current push to separate the uninoculated from employment is challenging in this context.
But, consider that all of those effects were quoted in an article well before SARS-CoV-2 came to call in 2020. All of those dire consequences were a reality in America in 2018 as an "influenza epidemic" swept through our midst. It was "especially bad" and the system was "overwhelmed," Time reported in January 2018: Hospitals Overwhelmed by Flu Patients Are Treating Them in Tents.
Facility managers complained that they were “managing, but just barely.” Facilities were described as "inundated" and medical appointments were unavailable. States declared emergencies. Tents were pitched and care was rendered in "places where we normally wouldn’t, like in recovery rooms.” Emergency rooms were overwhelmed. Facilities strove to handle the "surge" in viral complaints, including the flu. I do not recall much news coverage of that urgency.
There were staff shortages. Nurses pulled from other departments to care for the virus patients. Schedules were altered, and enhanced pay was offered to cover the needs. Extra shifts were worked, and some described the situation as "difficult and overwhelming." And, it was essentially the flu. The great flu epidemic of 2017-18 was a challenge. And, one might think, a learning moment. A year later, there was reflection in 2019 on the lessons. Healio reported Bad Flu Season Tests U.S. Hospitals.
It reported that hospitals had learned from the 2017-18 challenges. However, the article lead with concerns that "America’s health care systems would still be seriously challenged by another bad influenza season." There was lamentation of a lack of funding and preparedness for events like the 2017-18 influenza "surge," which impacted an "estimated 48.4 million people." There was, it seems, history occurring around us, but without our noticing too much.
There were also lamentations regarding the need for people to be vaccinated. There was praise for hospitals that had begun vaccination programs for employees, though no mention of mandates, terminations, or recriminations. Prevention was stressed as a critical element in the effort to manage treatment resources. However, there was not discussion of masking, social distancing, or hand-washing. As a non-physician, I lack the qualifications to make such recommendations, but washing hands and maintaining distance seem minor accommodations to prevent illness. I was admittedly surprised that such precautions did not merit discussion.
One expert was quoted regarding the failure to plan. He lauded those hospitals that had persevered through the 2017-18 influenza because "they had a pandemic preparedness plan in place." He describes how that thinking and planning had benefitted those engaged in managing care facilities. One critical element that was noted was for patients "to be discharged as promptly as medically appropriate to make sure there were enough beds available." One might wonder if discharging patients when medically appropriate is ever not the right answer? Is that really just an urgency/emergency thought? Or, is that what "medically appropriate" means? In non-surge, is there a tendency to retain patients beyond what is "appropriate?"
The 2019 article warned that "hospitals may not be prepared for an influenza pandemic." It warned of a "tight" supply of hospital beds. It noted that "Intensive care unit facilities are finite, ventilators are finite, the staff that is knowledgeable about managing patients on ventilators is finite." That remains persistently true, all resources are by definition finite. One expert warned that in the event of "a major new pandemic influenza virus," facilities and resources would be "very, very challenged.” And, that came to pass in 2020. Throughout a long experience with SARS-CoV-2, we witnessed stretched resources, overwrought personnel, and a multitude of challenges.
There was discussion of "surge capacity." This is "unused capacity just sitting there waiting for a crisis to happen.” One expert explained that the investment in "overbuilding . . . capacity" for a potential sporadic spike in demand may not make financial sense. That capacity has cost all the time, though it may be used little or even none of the time. Will students study for medical careers if the supply drives down compensation in those fields? Despite the financial challenges of preparedness, the article noted the 2017-18 flu season “brought preparedness issues to the surface" in that regard. But, there was no rush to build capacity.
The authors were critical of federal funding. They lamented physical facilities and personnel shortages. There was criticism for the manner in which "medical surge strategies" were developed and coordinated. In the end, there was criticism for the overall "funding for hospital or public health preparedness." Critics were broadly disdainful and asserted this widespread flu event illustrated challenges that are as important in any "surge" event though some other catastrophes may be more localized than a flu epidemic, more susceptible of addressing through outside help or patient transport. Thus, the "surge" impact could be localized or widespread, approachable in various manners, and essentially dynamic in impact or response.
The recap concludes with the admission that predicting flu season severity is difficult. There was no prediction of COVID-19 or similar, so we might presume predicting such a pandemic is equally challenging. It lamented the lack of public understanding regarding the benefits of prevention (again no discussion of details such as hand washing or distancing), and warned that "an increase in hospitalizations by even just a few percentage points" could again push hospitals "beyond their capacity.” It warns hospitals that while responses may vary, "hospitals would find it more challenging and disruptive than if they were better resourced, prepared and rehearsed in implementing medical surge strategies.”
In short, the recommendations were to study the 2017-18 influenza surge. There was recognition that facility and personnel supply may be outstripped by demand. Precautions and education were advocated, with a major focus on avoiding the need for medical care, and the burdens on the system. Thus, there was lamentation, prognostication, and prediction. And yet, the 2020 pandemic of SARS-CoV-2 and COVID-19 seemed to nonetheless catch many unprepared and unaware.
It is important that these challenges were recognized, discussed, and forewarned before COVID-19 was a thing. Some of the predictions and foreboding came to pass in 2020 and beyond. Perhaps there will be more recognition in the wake of COVID-19. Like many, I do not recall the 2017-18 flu season. Despite the impacts it had, it did not impact me. Perhaps the broader impacts of COVID, the longer impacts of COVID, the deeper impacts of COVID will lead to improved "surge" planning, capacity, and preparedness? Or, perhaps with our hospital ships, field hospitals, and more we medically responded fairly effectively to the surge of a modern pandemic?
