Ashley Carvalho was a few hours into her night shift as a doctor in a Boise, Idaho, hospital earlier this month when she got a text from her fiancé asking how she was doing.
She thought about the COVID-19 patient, a man in his 40s, whose condition had deteriorated within an hour of her starting work that night. She thought of the conversation she’d had to have with his young family about switching to comfort care and then his death soon after.
She thought about the second person with COVID who'd died shortly after that, as well as the other patients filling up all 14 beds in the intensive care unit — all with the same disease, all unvaccinated — who required her attention.
She thought of the abuse she’d received from one man’s angry family members, who had berated her for not treating him with ivermectin, a deworming drug falsely promoted as a cure in conspiracy circles but that the FDA has warned against using in COVID patients. She thought of how police had to remove the man’s family after his son-in-law told her, “If you don’t do this, I have a lot of ways to get people to do something, and they’re all sitting in my gun safe at home.”
Her eyes welling with tears, she took a selfie and sent it to her fiancé: “It’s going like this,” she wrote.
Like other medical workers in her state, Carvalho is exhausted and exasperated. Idaho currently has the lowest vaccination rate in the country, and the number of vaccine doses administered hasn’t been climbing significantly — but infections have. As of Saturday, there were 686 patients hospitalized in the state with COVID, 180 of them in ICUs. That’s hundreds more than what flooded hospitals during the previous surge in December 2020, before safe and effective vaccines were widely available.
Carvalho and her colleagues cannot fathom how they’ve ended up in this situation. She has anger — certainly — but that requires too much energy. She’s mostly just sad and burned out.
“I think it’s just kind of a hopeless feeling,” she told BuzzFeed News after finishing her shift on Tuesday evening. “Last year at this time, I was very anxious about COVID, and I was just hoping and hoping for the day when we’d have a vaccine. It never occurred to me that there would be a day when we have a vaccine, and I’m actually more anxious now because we have something that can really prevent this and people aren’t taking it.”
Currently, 50 of the 51 COVID patients in ICUs part of the St. Luke's Health System — a chain covering southeastern Idaho, eastern Oregon, and northern Nevada — are unvaccinated. Hospitalizations have soared. In July, there were 33 patients with COVID across all the St. Luke's hospitals. This week, there were 289. Currently, more than two-thirds of all patients in St. Luke’s facilities are being treated for the same virus, Jim Souza, St. Luke’s chief physician executive, told reporters in an online briefing on Tuesday.
“That’s an unprecedented event in modern medicine,” he said.
Idaho is what a state looks like when it fails to flatten the curve. As in other Mountain States, beds are running out. In response to the crush of patients, which is not expected to slow anytime soon, the Idaho Department of Health and Welfare (DHW) last week activated crisis standards of care. When implemented by hospitals, these plans, first formulated in April 2020 with the hope they would rarely need to be used, help guide overwhelmed medical workers on how to ration scarce resources.
The crisis standards apply to all patients — not just those with COVID-19. “There are already many patients who’ve had to delay surgery or other treatments, and if you end up in a hospital, you may receive treatment in a waiting room or a hallway,” said DHW Director Dave Jeppesen. “Each nurse and doctor will be taking care of more patients than usual. You may have to wait much longer than normal for care. You may even have to be transferred to a care facility that could be hours away.”
Last Thursday, the day the crisis standards were first activated, one older adult came into a hospital after she suffered a stroke. In normal times, she would be held overnight for monitoring, but instead she was discharged that same day. The woman was Jeppesen’s own mother.
“Not only was it stressful that my mom had a stroke, there was added worry about the availability of healthcare when she went to the ER,” he said. “Things were different in the ER. There were other patients receiving care in the waiting area.”
If things truly reach their worst in Idaho, the crisis standards guide doctors in triaging which patients receive care and which won’t. They involve a complex calculation of health factors in order to save the most lives possible. In the event of a tie, doctors may have to resort to a lottery system. Hospitals may even institute a universal do-not-resuscitate order for all patients who suffer cardiac arrest — although this has not yet happened in Idaho and would never apply to children.
Susie Keller, the CEO of the Idaho Medical Association, told BuzzFeed News she’s been hearing nightmarish stories from members who are beginning to confront these rationing decisions — about who gets an ICU bed, a COVID patient or someone with cardiac arrest.
“It’s not a sudden nightmare. It’s a nightmare we’ve seen coming, and our physicians have been warning about this,” Keller said. “We have not yet hit our peak.”
Souza, the St. Luke’s chief physician, said his network has already mobilized teams to assist clinicians in making “very morally challenging decisions.” He’s not aware of any patients who’ve died yet because of rationed care, but he thinks it’s just a matter of time. “I do not know the names of any such people yet, but I do believe we will know their names,” he said.
As the Delta variant of the coronavirus tears through Idaho and the rest of the US, Souza said he and his St. Luke’s colleagues have noticed several important differences from the December 2020 surge. Patients are younger (averaging 58 years old, down from 72), they are sicker and require more mechanical ventilation, they are staying in the ICU longer, and they are dying more frequently (the ICU mortality rate has jumped from 28% to 43%). Some 80 people have died from COVID in St. Luke’s hospitals in just the past three weeks.
“In a really morbid exercise, just in the month of September, if you look at the ages of the people we have lost and you apply to them average lifespans, we have lost more than 1,100 life years,” Souza said. “Can you imagine that? And for the people who say, ‘We all die sometime.’ Yes, we do. But these people didn’t need to die now. They didn’t need to die like this.
“Can you imagine all the life and experience contained within those 1,100 years?”
Medical groups in Idaho have pleaded with residents to get vaccinated but have been met with resistance among many in the deeply conservative state — a symptom of the politicization of the vaccines by some on the right. Idaho’s Republican governor, Brad Little, received a COVID vaccination he dubbed “safe and effective” in January, but months later he signed — like other conservative governors across the country — an executive order banning state officials from requiring residents to get vaccinated in order to access facilities. Citing the need for “fewer government regulations,” this month Little also stated he would challenge plans from President Joe Biden to require US companies with more than 100 employees to mandate either a vaccine or routine testing for staff.
Misinformation is also rampant. Republicans in one county that includes Boise this month voted to appoint a fringe doctor who has called vaccines “fake” to a regional health board. Elsewhere, a home healthcare nurse who watched false conspiracy theory videos on YouTube told her family not to get vaccinated, even as their mother was in a coma with COVID. The nurse then became infected herself and died last month. Her mother has recovered, but has said she is still not certain whether she will take a shot.
The charged environment has left medical workers feeling abandoned and even resented for continuing to advocate for health measures the public no longer seems interested in. “The good wishes from the beginning of the pandemic feel like they’ve all but dried up,” said Souza, whose 15-bed clinic in the resort town of McCall was defaced with a swastika over the weekend.
Kenneth Krell, a doctor in an Idaho Falls hospital, told the Idaho Statesman that the early days of the pandemic when he and his colleagues were applauded as heroes are long gone.
“I think we all have some commonality that the public [is no longer] our allies,” Krell told the newspaper. “But, in instances that are surprising, patients sometimes have some real hostility. They say they couldn’t have COVID, that this is all a lie, even as we’re getting ready to intubate them.”
Carvalho, the Boise doctor, said she now compares medical workers to Vietnam War veterans, who saw the public turn against them. “We’re tired of being pointed fingers at, of being called the bad guy, for trying to promote a vaccine that is lifesaving,” Carvalho said. “I know there’s good people out there, but it really does feel like the public is not on our side.”
Even primary care providers who’ve looked after a patient’s family for 20 years are now hearing they are no longer trusted, according to Keller with the Idaho Medical Association. At work, Idaho medical workers face an onslaught of unnecessary death, she said, but outside they’re part of a community of people who act as if the pandemic doesn’t exist. “It’s pretty disheartening,” she said. “I think they feel like they’re living in two different worlds.”
In Idaho Falls, Krell was driving into work on a recent Saturday and felt beleaguered. He’d received a call that the ICU was overwhelmed, and even though it was his day off and he’d been working shifts of 36 hours, he got in his car and headed in. He knew his colleagues would, too.
When he arrived at Eastern Idaho Regional Medical Center, he stopped in front of a whiteboard and wrote a message for his coworkers — which later went viral when it was shared on social media.
“In the end what sustains us, and what we will remember about having survived this madness, are the remarkable people who endured this with us, the best of humanity — all of us — who demonstrated the best of our calling,” he wrote. “We endured this together, and supported each other. We saved lives and lost lives, and we did both with compassion and competence.
“We will not forget this.”