The United States has entered the new year with record numbers of Americans hospitalized with coronavirus, straining a health-care system bracing for a post-holidays surge that has the potential to further stretch hospitals.

More than 131,000 covid patients were hospitalized nationwide as of Tuesday, eclipsing the record set in the last week of 2020. Facilities across the West and South are especially burdened.

Los Angeles County has been so overwhelmed it is running out of oxygen, with ambulance crews instructed to use oxygen only for their worst-case patients. Crews were told not to bring patients to the hospital if they have little hope of survival and to treat and declare such patients dead on the scene to preserve hospital capacity. Several Los Angeles hospitals have turned away ambulance traffic in recent days because they can’t provide the air flow needed to treat patients.

Arizona now has the nation’s highest rate of coronavirus hospitalizations. In the Atlanta area, nearly every major hospital is almost full, prompting state officials to reopen a field hospital for the third time.

The optimism that came with new vaccines and a new year is colliding with a grim reality: The United States has reached the worst stage of the pandemic to date, with the deadly results of holiday gatherings yet to arrive. Vaccine distribution is also off to a slow start, with at least 4.6 million inoculated, far short of the 20 million the Trump administration vowed to vaccinate by the end of 2020.

“We have so many crises happening simultaneously on multiple fronts,” said Saskia Popescu, an epidemiologist with George Mason University. “And all signs point to things getting a whole lot worse before they get better.”

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The back-to-back timing of Christmas and New Year’s Eve could have catastrophic results because many people develop symptoms roughly five to seven days after infection and are most contagious during the 48 hours before those symptoms appear. That means someone exposed to the virus on Christmas could be contagious by the time they attended a New Year’s party or began traveling home.

Just how badly the situation gets in the United States may depend on how widely the new variant that scientists believe is more contagious, but not deadlier or vaccine-resistant, is circulating. The variant has been reported in five states including Georgia, which reported its first case of the variant Tuesday. Officials in California said that 32 cases of the variant have been detected in San Diego County.

With estimates that the new variant could be 10 to 70% more transmissible, the Centers for Disease Control and Prevention said in a statement last week that it “could lead to more cases and place greater demand on already strained health care resources.”

New daily deaths and cases have increased by more than 20% over the last week, with more than 355,000 fatalities and 21 million infections. But experts say the toll on hospitals paints a clearer picture of the pandemic because of complications in reporting test results during the holidays.

States with the largest share of their populations hospitalized are largely concentrated in the South and West: Arizona, Nevada, Alabama, California, Georgia, Tennessee, Oklahoma, Mississippi, Texas and Delaware.

The situation in California has grown especially dire in recent days. On Tuesday, the state hit a new single-day record for hospitalizations, with 22,405 covid patients, more than 4,700 of whom were in intensive care units. And as cases continue to soar, the ability of hospitals and EMTs to save the sick will keep degrading.

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Hospital officials in Southern California said they were running low not just on ICU beds but also on ventilators and morgue space. But perhaps the direst shortage is now of oxygen. Because covid-19 is a respiratory disease that attacks the lungs, most hospitalized patients require oxygen. The sheer number of patients has placed such a strain on oxygen systems that some hospitals are struggling to provide adequate air pressure and flow into patients’ lungs. There are also shortages of portable oxygen tanks in ambulances and ones that are sent home with patients, making it difficult to discharge some patients even as hospitals run out of capacity.

In a directive Monday, the Los Angeles County Emergency Medical Services Agency told EMTs to conserve oxygen by only giving it to patients with oxygen saturation levels below 90%. To ease the backup at hospitals, county officials also issued a plan to set up tents just outside hospitals to create temporary “ambulance receiving spaces.” Officials hope that makeshift system will free up ambulances now sitting idle outside hospitals because their patients can’t be admitted.

“We’re no longer a wave or surge or surge upon a surge. We’re really are in the middle of a viral tsunami,” said Robert Kim-Farley, a medical epidemiologist at the UCLA Fielding School of Public Health.

On Monday, Gov. Gavin Newsom, a Democrat, announced a statewide plan and a team of officials focused on bolstering California’s oxygen supply. The Army Corps of Engineers has also been called in and is sending crews to update oxygen-delivery infrastructure at several aging hospitals – five in downtown Los Angeles and two in San Bernardino. Separately, state emergency teams have been deployed to refill oxygen tanks at 42 medical support units across the state. The state is also leasing mobile oxygen systems to bolster supplies and looking to order several hundred oxygen concentrator units. The overarching goal, Newsom said, is to reduce the stress placed on hospitals’ existing oxygen systems so they can maintain adequate air pressure for patients.

We’re no longer a wave or surge or surge upon a surge. We’re really are in middle of a viral tsunami.”
— Robert Kim-Farley, medical epidemiologist, UCLA Fielding School of Public Health

Expanding the oxygen supply doesn’t end the challenges for hospitals, Kim-Farley said.

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“When you get to that level of volume being pumped through, some of the pipes start to freeze up. You start running out of oxygen tanks that patients need to be sent home and discharged,” Kim-Farley said. “As the cases keep increasing you’re going to see those kinds of effects start to pile up. ICU beds get full. The ER gets backed up. Ambulances have nowhere to take patients. You get severe, chronic staffing shortages. Elective surgeries get canceled again. The ability to care simply degrades.”

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Arizona, once heralded for turning the corner after a summer surge, now has 69 of every 100,000 residents hospitalized with the virus – the highest rate in the country. Hospital leaders say they saw this coming a month ago, but they allege Gov. Doug Ducey (R) ignored their pleas to reimpose measures to curb the spread. State officials have said enacting restrictions would do little to curb transmission at private gatherings.

The day after Thanksgiving, a team of researchers issued a dire warning in a memo to the Arizona Department of Health Services. Failure to issue a shelter-in-place order to stave off a crisis in hospitals “risks a catastrophe on a scale of the worst natural disaster the state has ever experienced. It would be akin to facing a major forest fire without evacuation orders,” the memo said.

Ducey instead loosened restrictions on outdoor dining several days later. He prohibited gatherings over 50 people, double the threshold sought by medical groups, but declined to take other measures they urged, such as a statewide mask mandate and ban on indoor dining.

Hospital leaders, front-line workers and experts condemned Ducey for refraining from imposing sweeping mitigation measures. After Arizona became the epicenter of an early summer crisis, Ducey, who opposed shutdowns and mask mandates, reversed himself by allowing localities to impose mandatory masking and temporarily closed bars, gyms and theaters. With some mask mandates lifted and businesses reopened, Ducey’s recent approach has been to urge voluntary compliance, such as by asking residents to celebrate Christmas safely outdoors and with masks on.

“Our state is doing very little to slow transmission of virus. We have a very lax policy environment. Our businesses are open,” said Joe Gerald, a University of Arizona researcher who has been tracking the spread of the virus and was among those urging a shelter-in-place order. “The virus is just basically transmitting almost uninhibited through our population.”

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The hospital crisis the researchers had warned of came true. Hospitalizations climbed past their summer peak in mid-December and have been steadily rising since then. Just 7% of the state’s ICU beds have been available since the new year started. The seven-day average of new cases has surpassed 8,000, up from 5,700 on New Year’s Eve.

At Banner Health System – the state’s largest hospital network – several facilities are now over 125% of their licensed occupancy, and elective surgeries have been suspended since Jan. 1.

To expand the workforce, the health system is recruiting 2,000 contractors such as travel nurses and respiratory therapists. Central office staff with medical licenses have been deployed to the front lines, and those who cannot practice medicine are answering phones, transporting supplies and performing other basic tasks. Banner staff working in Colorado, where cases are declining, have been shifted to Arizona.

But unlike during the summer surge, Arizona has much stiffer competition now for health-care workers.

“Right now the entire country is essentially in uncontrolled spread, so every single state is looking for those same limited resources,” said Marjorie Bessel, chief clinical officer at Banner Health. “It’s a sad situation to not have had more mitigation be undertaken when all the science showed us exactly what’s happening is exactly what we predicted.”

Pressed on the rising cases and hospitalizations, Ducey said last months that the government had little ability to curb the spread of the virus at private gatherings. He rejected calls from the state superintendent of schools to keep schools virtual for two weeks as a holiday quarantine period.

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A spokesman for Ducey did not return emails seeking comment. Cara Christ, Arizona’s top public health official, said aggressive shutdown measures would not have staved off a spike driven by family gatherings and an influx of winter visitors seeking warm weather.

“If you look at California, they have some of the strictest restrictions in the country and are still seeing elevated cases,” Christ said in an interview. “It’s not that we loosened the restrictions from this summer when we successfully brought the rates down significantly. What we are finding is people, when they are with people they love and trust, are letting their guard down.”

Cleavon Gilman, an emergency room doctor in Yuma, Ariz., said he’s seen an uptick in patients arriving short of breath and with low oxygen levels since the new year. They include grandmothers infected after family gatherings, Mexican immigrants who rode packed buses to agricultural jobs and people in their 20s and 30s. Many patients, he says, are coming in after their lungs have been irreparably damaged, and he is bracing for more of them to die.

“It’s very demoralizing sometimes to work here and to know the science and for it to be ignored,” said Gilman, who drew national attention and a call from President-elect Joe Biden for bringing attention to the state’s lack of hospital beds. “A lot of people are going to die because of failed leadership.”

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Nearly every major hospital in the metropolitan Atlanta area is now full, prompting state officials to reopen a field hospital at the World Congress Center, one of the nation’s largest convention centers. Northeast Georgia Health System says its four hospitals are running out of ways to expand capacity after setting up cots in gyms, creating temporary spaces in hallways and, in some cases, treating patients while they are still inside an ambulance.

“We are holding our breath and waiting to see what the next two or three weeks might bring post-holiday, and hopefully we don’t see a massive spike,” said Sean Couch, a spokesman for the system.

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Eight of the 10 U.S. counties reporting the largest per capita increases in their caseload are small, rural Georgia counties.

In other states, the worst-case scenarios did not materialize. Hospitals in New Mexico did not need to ration care as authorized a month ago by Gov. Michelle Lujan Grisham, a Democrat. States in the Upper Midwest and the Dakotas, which experienced some of the worst spikes in cases and hospitalizations before Thanksgiving, are starting to see cases level off.

Public health experts say the country faces a similar challenge it did last spring: buying time. In the early months of the pandemic, authorities urged the public to “flatten the curve” by following stay-at-home orders to give hospitals time to expand their capacity and protect their staff. They are pleading with Americans to keep following basic precautions – wearing masks, socially distancing, avoiding crowds – with the promise of a vaccine on the horizon.

“I’m trying to hold onto the hope that the vaccines represent,” said Angela Rasmussen, a virologist at the Georgetown Center for Global Health Science and Security. “As flawed as the rollout has been, at the very least it is hope. It feels like we’re at the bottom of the well looking up at a very distant light.”