At hospitals in Fresno, critically ill patients with nowhere to go are stuck in crowded emergency rooms. Doctors face such a dire shortage of intensive care beds at Community Regional Medical Center that patients who should be treated in specialized intensive care units were instead filling 12 of its 15 emergency room beds reserved for the severely sick and injured last weekend.

“That really bottlenecks us right in the front door,” said Rais Vohra, an emergency medicine physician at Fresno’s Community Regional Medical Center and the county’s interim health officer. “We’re very worried.”

At nearby Saint Agnes Medical Center, some non-Covid-19 patients on ventilators have temporarily overflowed into post-operative or emergency department beds as patients with the virus more than quadrupled from 32 to 135 since mid-November.

Both ICUs have reached their capacity, and in all, Fresno County had only nine available ICU beds on Monday for its nearly 1 million residents, according to state data.

“We are going to have a very hard, very hard winter,” said Jorge Martinez-Cuellar, an internist and medical director of hospital medicine at Saint Agnes Medical Center. “We feel that we are close to what is called a collapse in the system.”

As hospitals throughout California are filling up, dozens of counties are facing staff shortages that prevent them from expanding their ICUs to meet the surge.

Nearly two dozen counties had fewer than 10 available ICU beds on Tuesday, and four had all of their ICU beds full, according to state data.

When comparing available ICU beds to population, Imperial, Kings, San Benito, Madera, Fresno and Yolo counties are in the worst shape. All of them have zero or less than one ICU bed open per 100,000 residents, according to state data.

Another 13 counties have less than three open beds per 100,000 residents: San Bernardino, Riverside, Santa Cruz, Sonoma, San Joaquin, Kern, Lake, Humboldt, Nevada, El Dorado, Solano, Merced and Stanislaus.

Some hard-hit hospitals are already sending patients to other counties.

At the US-Mexico border, Imperial County has zero ICU beds available for a population of more than 181,000 people, and as of Dec. 3 had already transferred 37 Covid-positive patients to other counties since mid-November, according to Christopher Herring, county emergency medical services manager.

“We’re tired. We’re really getting to the point of lamaze (breathing) our way through the next nine months, having just done nine months,” said Adolphe Edward, CEO of El Centro Regional Medical Center, one of the county’s two hospitals. “It’s like an elephant giving birth after 18 months. It’s going to be exhausting, stretching.”

In Fresno, Vohra said he has to make difficult decisions about which emergency department patients to admit to the hospital as Covid-19 surges and accidents, shootings, drug overdoses and illnesses continue.

Last week, he hesitated to admit an immunosuppressed kidney transplant patient because of the shortage of beds.

“That person would have been like a slam dunk admission any other day of the year,” Vohra said, adding that transplant patients are at high risk of potentially lethal sepsis.

He worries that the crowded hospital puts his patient at risk.

“Number one, she’s going to be staying in the ER, for probably days, because there’s nowhere to put her. Number two, she may actually catch Covid. I mean, I hate to say that because it’s my hospital. But I have to be realistic.”

Not Enough Staff

California passed a devastating new milestone this week: More than 11,500 people were hospitalized with confirmed or suspected cases of Covid-19.

And hospitals are colliding with a major barrier to ramping up ICU care: too few doctors, nurses and others trained to to staff ICUs.

“Our hospitals are reporting 5 percent to 10 percent of their staff needing to be out, which is really high,” Vohra said. “When you think about a hospital system that has 10,000 employees, that’s 500 to 1000 people that are out.”

Some are out because they’re sick. More than 56,600 health care workers have been infected with the novel coronavirus in California since the beginning of the pandemic, and 221 have died, according to state data.

In Imperial County, about 10 percent of the staff tested at El Centro Regional Medical Center have come back positive for the virus, CEO Edward said.

Others are out because they are quarantining after a coronavirus exposure—at work or at home. At Martinez-Cuellar’s hospital in Fresno, 116 staff are under quarantine and 105 of them have tested positive for the virus.

Some are struggling with childcare and remote schooling. One emergency department nurse at Kaiser Permanente Oakland Medical Center, who asked not to be named for privacy reasons and because she hadn’t been cleared to talk to the press, said she’s had to cut down on extra shifts to homeschool her children.

“I was having to go in the back hallway to try to talk to a teacher of my daughter’s while doing everything else,” she said. “It’s such a juggling act.”

In Los Angeles County, state data reports 497 available ICU beds for 10 million people, or less than five per 100,000 population. Some individual hospitals are reaching capacity as the county reported more than 8,500 new cases Tuesday.

Nearly a quarter of the more than 3,100 people in L.A. hospitalized with the novel coronavirus are in the ICU, the county’s public health department reported Tuesday.

Los Angeles County + USC Medical Center, a county-run teaching hospital serving 10 million people, reached 95 percent occupancy of its roughly 120 ICU beds on Friday and has been closed to patient transfers, according to spokesperson Connie Castro.

“We are full with patients coming to us through the front door,” Castro said in an email to CalMatters. She said the hospital’s ICU reached 100 percent capacity during the July surge, and is concerned about it happening again. “Nothing about Covid-19 is typical.”

LA+USC has space to open another 100 ICU beds, but the limitation is staff.

“ICU doctors and nurses are not commodities,” Castro said. “They are precious limited resources, and we cannot just grow more of them in an emergency.”

Transferring Patients

Across the Central Valley, ICUs are in trouble. In Madera County, they are at 100 percent capacity, according to the public health department.

In San Joaquin County, hospitals are operating at 123 percent licensed ICU capacity, county EMS specialist Marissa Matta told CalMatters. It’s not quite a record high in San Joaquin County—the hospitals hit 149 percent capacity in July. But, “hospitals are being challenged in a time of year that is normally already very busy,” Matta said.

Some rural counties without ICUs of their own rely on larger hospitals to take their sickest patients. Since October, Modoc County—wedged into the corner where California, Oregon and Nevada meet—has had to transfer nine especially sick patients to other hospitals in Northern California, Oregon and Nevada, according to Stacy Sphar, the county’s director of health services.

And in Mariposa County, home to the Yosemite Valley, test positivity rate has spiked since the beginning of November to reach 17.1 percent, about double the state average. Without an ICU, the county had to transfer sicker patients to the Central Valley over the past two weeks, according to county public health officer Eric Sergienko.

Typically, that includes hospitals in Modesto as well as Vohra’s congested Community Regional Medical Center in Fresno.

“We have the ability to do an improvised ICU should we have to hold patients but this is clearly not the preferred option,” Sergienko said.

Even small counties that do have their own ICUs need to transfer patients who require a higher level of care than they can provide. Colusa County, for instance, has three ICU beds—none of which were occupied as of Monday, according to county counsel Marcos Kropf. (State data reports that zero ICU beds are available in Colusa. The state did not respond to a request for clarification.)

But Colusa County has nevertheless needed to transfer patients to hospitals elsewhere, including Chico, Roseville and Marysville. And in Marysville, the only ICU serving nearly 176,000 people in Sutter and Yuba counties is full, according to a health advisory.

Phuong Luu, health officer for both Sutter and Yuba counties, wrote that the surge has led hospitalizations at Adventist Health and Rideout in Marysville to almost triple. Monica Arrowsmith, a hospital spokeswoman , would not say whether the ICU was at capacity or whether the hospital had enough staff, but she said it has access to additional supplies, expertise and support from the rest of the Adventist Health system.

Luu, however, said the ICU “is full because of the surge in Covid-19 patients needing ICU level care. There are not enough ICU nurses to expand for more ICU beds,” according to the health advisory. “The current Covid-19 situation is dire in Yuba-Sutter.”

California Gov. Gavin Newsom said the state has requested 815 medical staffers, including 435 specifically for ICUs, from contractors and most are expected within a week, with Imperial County a high priority. The state has also asked the federal government for help staffing ICUs.

Imperial County’s El Centro Regional Medical Center plans to open 21 beds in a 50-bed parking lot tent facility today with staffing from the state, according to hospital CEO Edward. He also said the state will allow the hospital to increase the number of patients each nurse can care for. He hopes the changes will help the hospital increase its staffed ICU beds to 32 from 20.

Exhausted Healthcare Workers

The onslaught of cases after nine months of a pandemic are pushing healthcare workers to the brink. The word repeated by each healthcare worker CalMatters interviewed was “exhausted.” “Oh man. Exhausted and frustrated,” said one Northern California emergency medicine physician, who asked that her name and hospital not be named because she had not been cleared to speak to the press. “And a little scared about what’s going to happen soon.”

Already, she said, she’s finding it increasingly difficult to transfer patients needing specialty care. “I called every single hospital in Northern California out to Reno and all the Bay Area hospitals, and they all refused to take this patient,” the doctor said, adding that she found a local doctor who could help. “For those non-Covid patients who still need speciality care, that’s going to prove to be a big problem.”

Even at hospitals that still have room in their ICUs, healthcare workers are feeling the emotional toll of the prolonged pandemic.

“It’s really going to be dependent on this post-Thanksgiving surge,” said Nick Sawyer, an emergency medicine physician at UC Davis Health. “There is a very real possibility that we will overwhelm the system and people will end up in a hospital that is overwhelmed, that doesn’t have the staffing that is necessary to provide that best care.”

Sawyer said that he traveled to New York to help the overwhelmed hospitals during the early days of the pandemic, and was shaken by what he saw there.

“Families have to say goodbye to their loved ones over Facetime,” he said. “It’s devastating to the family. It’s devastating to the nurses. It’s devastating to the physicians. It’s just not a normal thing we’re used to doing. And it’s so impersonal, for something that’s so personal.” Before that experience, he said, it wouldn’t even register when he heard an ambulance siren.

“Now when I hear an ambulance go by, I feel this heaviness in the pit of my stomach of like, ‘Is that another coronavirus patient that’s going to be going into the hospital?’” he said. “I’m emotionally exhausted by it, even though we’re just getting going.”