Nate Monroe: The view from a Jacksonville ICU, Florida's COVID-19 hot zone

Nate Monroe
Florida Times-Union
UF Health Jacksonville in downtown

COMMENTARY | It's a little past noon, and the Georgia pastor on the TV is deep into a sermon. This is definitely the sort of place one might need a sermon, could probably use a sermon, but it's also a place where, at this moment, there is no one to hear the holy man on the TV. In this particular room, in the intensive care unit on the seventh floor at UF Health Jacksonville, there is only a woman lying on a bed, unconscious, covered delicately with a beige blanket — a fragile thing. Even asleep, she looks exhausted.

She is infected with COVID-19, almost certainly the virus' perilous delta variant, and she is attached to one of the highest-tech ventilators the hospital has to offer — the supply of which is becoming "critical," one of the emergency doctors told me. If those run out, the hospital has a supply of something called "disaster" ventilators, but they're not as good as those high-tech ones.

The room next door is somehow even more unsettling. 

When those highest-tech ventilators aren't enough, when a patient's oxygen levels are still too low, and their organs begin shutting down, the more drastic step is to hook them up to something called an ECMO machine. There are a lot of acronyms in a hospital, but this one will stay with me. The ECMO machine bypasses the patient's lungs and heart, which is a jargon-y way of saying the machine essentially becomes that patient's lungs and heart so their real organs can rest. In this room, four nurses are trying to position a second woman, also unconscious, while she is hooked up to the ECMO machine. A note on the door indicates she's had her vital organs outsourced to this miraculous device since July 30. For the entire 20 minutes I'm in the ICU, those four nurses don't stop working in that second room.

Four nurses to one patient — just one patient of 39 in the ICU that day at UF Health's downtown campus, where there are 175 hospitalized total, along with an additional 62 at a separate campus on the city's Northside (where 23 more are in the ICU). Five patients died on Thursday.

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Down the hall, in a part of the hospital called 7 North, are the negative-pressure rooms. A little more than a month ago, there were two COVID-patients here. Now there are 29, with at least one more on the way. The unit is down one registered nurse and two patient-care techs.

"We're overwhelmed," a nurse there, Cecile Gonzales, told me. 

UF Health is Jacksonville's safety-net hospital and the only Level 1 trauma center in the city — another bit of jargon that means this hospital services some of the city's poorest patients and some of its most injured: When someone is shot, they're often taken here; when a prop plane crashes in south Georgia, the survivors probably end up here.

Many of them end up in the emergency intake on the first floor, which is probably the most chaotic room in the hospital because neither violence nor misfortune have taken a break during the pandemic. There are patients everywhere. There are beds in the aisles and in hallways, a COVID-era necessity. Close to me, I can see a man's bare foot sticking out behind a curtained bed. I can also hear the ventilator. Actually, I can hear several.

Inside the city's hospitals, everything has become a logistical puzzle, if not a bit of a nightmare. Staffing shortages mean nurses have to be moved to different departments, but it can take six weeks to train a nurse to work in a different department.

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And while hospitals can stop elective surgeries, they can't stop someone from developing appendicitis. Sure, COVID patients can take the negative-pressure rooms, but what about patients with tuberculosis who absolutely must be placed in negative-pressure rooms? That means different rooms must be outfitted with negative-pressure equipment, which works fine until even more COVID patients come. There is also, of course, the constant inventorying and shuffling of vital supplies: Oxygen, ventilators, masks. Outlying buildings on campus can be turned into surplus bed space, but that takes time — not just the time to set it up, but the recurring time it takes for nurses and doctors and techs to descend elevators, cross streets, ascend back up. Minutes collectively become hours — hours no one, in truth, really has.

This is Jacksonville's delta surge, among the worst outbreaks in the United States and a driver of Florida's record-breaking numbers this summer.

"It seems like a never-ending fight," David Caro, an emergency medicine doctor and UF Health's Disaster Medical Officer, told me.

In a lot of ways, reverting to 2020 COVID-19 conditions

Hospitalizations in Florida through July and August — up to 15,441 on Thursday, according to the latest numbers —  have shattered 2020's records. But the extent to which conditions have reverted back to, and in some ways even regressed, from last year's pandemic heights go beyond the topline figures.

COVID tests are once again a rare commodity, with turn-around times back to days or even a week or longer — strong indications even Florida's summer highs are understating the extent of delta's spread in the state.

Gov. Ron DeSantis' administration seems unfazed by — and perhaps even unaware of — the shortage. 

Previously:Nate Monroe: Ron DeSantis, once a rising star, is becoming a white dwarf

State Rep. Angie Nixon, D-Jacksonville, said Thursday she reached out to DeSantis' office to talk about the difficulties her constituents were having getting COVID tests. An aide to the governor connected her with someone at the state Department of Health, who, Nixon said, indicated there were no plans to open new sites in the city. The aide then had a suggestion: "Have they tried CVS," the aide asked in a text, which Nixon shared. "They are free and most of them are doing testing."

It was an infuriating suggestion because anyone on the ground here knows most testing sites, including pharmacies, are so backed up some won't even allow patients to book an appointment. Every reporter in town has heard these anecdotes: Residents who paid hundreds of dollars for tests, drove as far as Orlando to get tests, or were simply unable to find any.

"It's disgusting," Nixon said.

In that vacuum, local officials have tried to fill the gap: Mayor Lenny Curry requested and the Jacksonville City Council approved using $4 million to open five sites for free COVID-19 testing and vaccinations.

The state, too, has stopped publishing daily infection reports as it had previously done until June. Florida numbers instead go only to the Centers for Disease Control every day, but that agency's reports — unlike Florida's previous daily reports — don't break down infections and deaths by county, making it harder to understand delta's trajectory across Florida, which has not been uniform. DeSantis did concede Thursday, during a news conference, that returning to sharing county-level data "may not be a bad idea going forward," but nothing has happened so far.

Florida has never really tried contact tracing.

And DeSantis has limited the ability of local governments and school boards to implement measures like mask mandates that had previously help to curb the spread, and he has tried to prohibit private companies, like cruise lines, from requiring vaccine passports.

COVID and local schools:Duval School Board approves mask requirement with opt-out clause

Vaccines remain the most powerful tool available to end the pandemic — several doctors asked me to communicate the importance of people getting them — but in Florida, the decision to get one has been framed in terms of personal choice rather than as a vital public-health measure. When demand for vaccines waned, the state's health department did nothing. DeSantis touts their efficacy but insists it's only a personal decision, undermining outreach efforts aimed at convincing skeptics — who, echoing DeSantis, often insist it's their personal business, rather than a public-health imperative that affects everyone around them.

That message may have taken hold in a place like Jacksonville, which before delta's arrival still hovered just below 50 percent of its population vaccinated — a rate below the state and national average.

With testing once again limited, less data available than at any point in the pandemic, a portion of the populace locked into vaccine denial with the state's top leader unwilling to move them, and fewer tools at the disposal of local officials to combat spread, Florida is flying blind.

DeSantis leading Florida's reactive COVID response

Florida is also abiding too much suffering.

Florida is locked into a herd-immunity strategy — a fringe view in the medical world but the one DeSantis has long believed is the best way to manage this pandemic. What that has translated to in terms of policy is little effort on the front end to prevent infection — because a herd-immunity theorist like DeSantis believes spread is inevitable. The response, in other words, is not proactive but reactive.

And so, DeSantis' chief response effort thus far was to pledge state resources to help people after infection. At a news conference in Jacksonville on Thursday, DeSantis committed to opening a pop-up site in the city that will offer monoclonal antibody treatments, a therapeutic that can help some COVID patients stave off serious symptoms as long as the infection is caught quickly enough. He made general promises to open more in other cities, and to create a strike team that can offer the treatment on-site at long-term care facilities, but offered no specifics on those future plans.

More:Gov. DeSantis unveils Jacksonville site for getting Regeneron treatment of COVID infections

Caro, UF's chief disaster officer, told me monoclonal antibody treatments have shown some promise — the hospital administers the treatment to patients who qualify — but it presents challenges. One of those is making sure the patient has caught the infection early enough, which, with testing scarce, can be difficult. It is a resource-intensive treatment that requires staffing and space. There is also, it seems to me, a failure of logic in the governor's approach: A state that can't convince enough residents to get a free vaccine will have a tough job convincing the sick — at the critical early stages of their infection — to seek out an experimental therapy.

"We have yet to find a magic bullet," Caro told me.

The more consensus view of pandemic management is to create layers: Prevent infections on the front end — especially through vaccines, and in areas of high spread, measures like indoor masking — buying hospitals more time to administer better treatment on the back end. The state should be doing more to make free testing easier to attain, and it should be in the neighborhoods where vaccination rates are lowest, going door-to-door, partnering with pastors and churches.

It was clear to me, witnessing a Jacksonville hospital on the brink, a series of pop-up sites offering antibody treatments will not bail Florida out of its delta surge, or perhaps even make a dent. It was clear to me a reactive approach, rather than a proactive one, is very likely why Florida is where it is today: Worse off than at any point during the pandemic.

Most of all, it was clear to me that a herd-immunity strategy is simply no way to manage a pandemic, and it is certainly not good leadership: Using death rates as the only measure of success or failure overlooks an entire spectrum of suffering possible with this damn virus. Most of the patients I saw will survive, but for some it will have come at great cost. I'm thinking, of course, about those two unconscious women in the ICU, one whose mechanical lungs and heart sat at her bedside, the other a silent witness to a sermon she could not hear.

This scale of human suffering was not inevitable. It was avoidable. And if we can't agree on that much, we've already lost this war.

Nate Monroe's City column appears every Thursday and Sunday.

nmonroe@jacksonville.com