The patients are younger this time. Their course of treatment involves a new cocktail of drugs, and their ventilator settings have changed.
The doctors, nurses, respiratory therapists and other health care workers at their bedsides are more experienced and have a better sense of what to expect. But their days are still long, their patient loads are still overwhelming, and their hopes for a cure are still being researched in laboratories.
Six months into the pandemic’s grasp on Baton Rouge, the capital city’s coronavirus curve stands out for its two distinct spikes: one in the spring and another in the summer. It’s one of only a few places in Louisiana, or America for that matter, that have seen two comparable bumps. Roughly 200 infected people died in East Baton Rouge Parish in the pandemic’s first two months, and after some quiet weeks, nearly 200 people have died in the three months since.
New Orleans, by contrast, had an early and brutal explosion of the virus in the spring and a mostly quiet summer, whereas Lafayette and Lake Charles felt their first real blast of cases this summer after a slow spring. Dr. Jeffrey Shaman, an infectious disease expert at Columbia University said one of the key questions that people in public health circles have been watching is whether cities will be subjected to separate, distinct waves of coronavirus of similar severity over and over again.
Health care workers in Baton Rouge have now been at the mercy of coronavirus twice. Dianne Teal, chief nursing officer for Ochsner Health System’s Baton Rouge campus, has told her charges to stop thinking about the pandemic as an isolated event, and start thinking about it like a two-year deployment with multiple battles along the way.
As in a war, each skirmish is distinct.
“The second wave is very different,” said Dr. Mohammad Pirzadah, a pulmonologist and critical care physician at Our Lady of the Lake. “For us, psychologically, we are prepared. We knew what we are dealing with, plus we had some therapies and guidelines in place. But from a workload standpoint, it’s as much as the first surge.”
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Baton Rouge’s twin spikes stand out, but they aren’t entirely unique. The north shore, the Houma/Thibodaux area and Shreveport also saw early surges in the spring that repeated themselves this summer.
The state now appears to be on the downslope of its second spike — new cases statewide are down 46% from the peak of 15,025 cases diagnosed in the week ending July 27. But Baton Rouge hospitals are still slammed. The region has been averaging only about 30 available ICU beds, with more than 180 in use.
If that number were to get dangerously low, officials could adjust. In April, during the first wave, the Baton Rouge region nearly doubled its ICU capacity. Back then, an average of 98 ICU beds were available, while 275 were in use. Hospitals freed up bedspace by halting most procedures in the spring that might have required a patient to be admitted to the ICU — a costly measure they do not want to repeat.
While case volumes look much larger in Baton Rouge’s second wave, that’s partly because coronavirus case counts in the spring represented a smaller slice of the population — only those sick enough to get tested. This summer, the numbers represent a wider range of people, including the asymptomatic.
It’s still too early to say how the second surge will affect deaths, said Dr. Alex Billioux, assistant secretary for the Louisiana Department of Health’s Office of Public Health.
Early figures make it appear the number of deaths during Baton Rouge’s second surge are down from the first. Certainly, the pace has been slower: East Baton Rouge recorded 56 deaths in July, compared to 128 deaths in April, for example. And Shaman said mortality rates have dropped during the second surge as the ages of people getting infected have also gone down.
But more deaths might still be on the way.
Dr. Stephen Brierre, a pulmonologist and critical care physician at Baton Rouge General Medical Center, said gravely ill coronavirus patients are still being admitted to the ICU. He said hospital officials generally use 28 days after admission as the marker for mortality rates, and many patients admitted last month to the hospital still haven’t reached their 28th day yet.
“We don’t have a good eye on what the mortality rate will be in this second surge,” Brierre said.
Billioux said that if the Baton Rouge region sees another spike in deaths from the second surge, it’ll happen soon. He’s anxious.
Relief after first surge short-lived
In May and June, health care workers breathed a sigh of relief as the tsunami of coronavirus patients subsided into a more manageable number. For a few weeks, they reverted to normal rhythms of hospital life.
Surgical nurses who had been deployed to coronavirus units returned to their operating rooms to try to clear backlogs of surgeries that had been put off in the spring. Pulmonologists tried to catch up on the weeks they’d spent sidelining their outpatient practices, as patients with lung cancer and COPD waited.
By early summer, Our Lady of the Lake was down to about 20 coronavirus patients, after having housed more than 200 at the height of the spring surge. Baton Rouge General wound down to just eight dedicated ICU beds for coronavirus patients – two of them empty – after having north of 50 ICU beds for COVID-19 in the spring.
Cheers rang out at Ochsner on June 20 when the Baton Rouge campus discharged its final coronavirus patient. The celebration didn’t last long: hours later, a new one was admitted.
As summer stretched on, the lessons hospital administrators learned this spring about how to quickly transform empty space into ICU beds were necessary again. It was like someone lifted the handle on a dripping faucet.
“As the second wave hit, eight beds turned to 20 beds, which turned to 32 beds, which turned to 38 beds in the period of two weeks,” Brierre said.
Health care workers had expected and prepared for another stream of coronavirus patients, but the speed took them by surprise.
“There was a bit of, ‘Oh now, really?’” said Shantelle Graves, a respiratory therapist and director of respiratory care for the Lake. “We thought we were getting some relief, then realized we weren’t, so the stress level goes up as the patient count goes up.”
The good news, Graves said, was that this time, the hospital had more of the supplies that respiratory therapists needed: ventilators, intubation supplies and filters for breathing devices.
Adding new staff has been hard. Hospitals across the country are fighting to hire respiratory therapists right now, and Graves said the Lake was lucky to score a few staffers from the May 2020 graduating class. Still, they could use more.
Hospitals are also in better shape with personal protective equipment. Workers took drastic measures to preserve supplies during the first surge – reusing N95 masks for weeks, wiping off gowns between uses. There’s still a focus on conserving PPE, but workers say they aren’t reusing supplies as often.
Different patients, better therapies
As Baton Rouge’s second spike continued to grow, health care workers noticed key differences in their patients. During the spring, most of them were coming from group settings like nursing homes. Many were also older and more vulnerable.
But patients streaming into hospitals during the second spike have been younger and healthier on balance. In many cases, they’ve picked up coronavirus from friends, family members, outings in their community – instead of from a living situation or a job that routinely exposed them.
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“This is definitely a different type of surge in which it’s even more important to wear a mask and social distance, because this is coming from the community,” said Pirzadah of the Lake.
The good news is that more of the younger, healthier patients can be treated without life support, Pirzadah said.
Physicians also say they’re thankful that they now have a better sense of what works for coronavirus treatment, and what doesn’t. Patients hospitalized in the spring with coronavirus often received hydroxychloroquine to treat it, based on early promise. That’s no longer happening at hospitals, after multiple studies have concluded there’s no benefit – and may actually be some harm – in treating coronavirus with hydroxychloroquine.
Patients are now receiving dexamethasone, remdesivir and plasma from people who have previously had coronavirus. Dexamethasone, a steroid, has shown promise in reducing coronavirus deaths. Remdesivir, an anti-viral, is believed to cut the length of hospital stays.
Dr. William Schaffner, an infectious disease professor at Vanderbilt University Medical Center, said such therapies are undoubtedly making a difference in cutting death counts.
“Our capacity to get people out of the intensive care unit and then out of the hospital has been much improved,” Schaffner said.
Brierre was dubious about remdesivir in late April. Since using it, though, he said he’d call himself an “optimistic skeptic.” The jury is also still out on plasma, and the Food and Drug Administration this week put emergency authorization for its usage on hold.
“We still don’t have a definitive answer on convalescent plasma, but because patients were infected in the first wave and recovered, we have a larger donor pool,” Brierre said.
Pirzadah said that as he learns about coronavirus, he keeps thinking back to the HIV epidemic, which was raging in his early years as a doctor.
“It’s just amazing that after a couple of decades, I’m going through an entirely new illness with the same sort of process where you start out with nothing, you add therapies, you come out with a cocktail and you wait,” he said. “The pace of change with COVID has been a lot quicker than my experience with HIV.”
A changing virus?
There’s debate among scientists about whether the coronavirus is mutating to become more infectious, but less deadly, as it spreads. Billioux said there’s merit to that belief.
He said that all viruses mutate, and most mutations are “silent,” having no effect or not getting passed on. But he said that when viruses become more easily transmitted, it often makes them less lethal.
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Other viruses have followed that arc, because more infectious viruses are more apt to find new hosts, but deadlier strains can’t keep spreading and surviving after they kill off their hosts.
As the historian John Barry explained in his book about the Spanish flu pandemic, “The Great Influenza,” RNA viruses — which include coronaviruses, influenza and HIV — tend to mutate quickly and often. But Shaman said that while he can get on board with the possibility of the new virus becoming more transmissible, it has plenty of time to reproduce before killing off the person who carries it.
"That doesn’t at all jive with what this coronavirus does because it doesn’t kill people immediately," Shaman said. "It’s thought they do a good chunk of their shedding before symptoms begin.”
Among the members of the coronavirus family, Billioux said, SARS, MERS and SARS-CoV-2 – the virus that causes the COVID-19 infection – appear to be the deadliest. But other coronaviruses are often the culprits behind the common cold.
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Time will tell if SARS-CoV-2 changes lanes. Schaffner said there’s no scientific evidence of it happening yet, and said it’s remarkable that it has remained stable for as long as it has.
“There may be a middle ground,” Billioux said. “It may be never as deadly as SARS and MERS, and never as mild as the common cold.”
Staff Writer Jeff Adelson contributed to this report.