Dying on the Waitlist — ProPublica


In early December, Miguel Fernandez lay unconscious within the intensive care unit at a Los Angeles space hospital. A mechanical ventilator pumped oxygen into his lungs, which had been ravaged by COVID-19. The 53-year-old was dying.

The perfect, and certain solely, likelihood of Miguel surviving was a remedy known as extracorporeal membrane oxygenation, higher generally known as ECMO. It might enable his lungs to relaxation whereas a machine infused his blood with the oxygen he wanted. However PIH Well being Whittier Hospital, the place he had been admitted, didn’t have any ECMO machines or the extremely educated workers wanted to run them. Solely a handful of hospitals in southern California did, and so they had been overrun with COVID-19 circumstances.

Because the starting of the pandemic, public well being specialists had been warning about the necessity to “bend the curve” — to stop the variety of COVID-19 circumstances from spiking so hospitals wouldn’t get overwhelmed.

However beginning in early November, the each day variety of COVID-19 hospitalizations surged in Los Angeles County, rising eightfold between then and the wave’s crest, which arrived simply after New Yr’s Day. Inside weeks, overflowing hospitals confronted precisely the forms of care-rationing selections specialists had feared. Hospitals arrange tents to extend capability, and ambulances circled for hours as they waited for beds to open. By early January, Los Angeles County emergency medical personnel were directed to preserve supplemental oxygen by solely administering it to the neediest sufferers, and to stop transporting to hospitals cardiac arrest sufferers who couldn’t be revived within the discipline. State officers dispatched refrigerated vehicles and thousands of body bags to the area.

Contained in the hospitals, for sufferers like Miguel, a dire state of affairs unfolded out of public view. Critically sick sufferers who would possibly survive with ECMO couldn’t get the remedy. Medical doctors had to decide on who obtained the remedy based mostly on who they thought had the very best likelihood to outlive. Some had been authorized, however needed to be placed on a waitlist. Many sufferers died ready.

“I don’t assume we ever thought we’d get thus far, not in California,” stated Dr. Jack Solar, who oversees this system that features ECMO at UCI Well being in Orange County, 30 miles southeast of Los Angeles. “ in the event you don’t have a mattress for any individual, they’re going to die.”

In some components of the nation, medical doctors can faucet into centralized programs to shortly discover any obtainable mattress for ECMO at any hospital within the area. That’s not the case in Los Angeles. Miguel’s caregivers and household must hack via purple tape and navigate an opaque, disconnected and typically unfair system to attempt to save his life.

Miguel, the oldest of seven siblings in a household of Mexican immigrants, was at all times the one who fastened issues. If somebody wanted a job, he would assist them discover work. If a automotive broke down, he would restore it. His sister, Margarita Rodriguez, described him as a “massive cuddly bear” who gave her hugs and at all times made her smile. Simply earlier than he was hospitalized, he had stopped by to patch a leak in her roof.

Now the household needed to discover a technique to repair Miguel.

They scoured the web with searches like “What do you do when a ventilator fails?” One evening, Margarita discovered successful story from San Diego about using ECMO. An ECMO machine takes over the work of a affected person’s lungs. It extracts blood from the physique and circulates it via a man-made lung that removes carbon dioxide and provides oxygen earlier than returning the blood to the physique. One study of sufferers at 68 U.S. hospitals discovered that critically sick COVID-19 sufferers like Miguel “had a significantly decrease threat of loss of life” in the event that they obtained ECMO throughout their first seven days in an ICU.

Miguel was comparatively wholesome apart from having COVID-19. He didn’t smoke or have any preexisting sicknesses like diabetes. He was chubby, however beneath weight cutoffs utilized by ECMO facilities to find out eligibility. Throughout the nation, sufferers like Miguel who had been close to loss of life on a ventilator at some point had been alive and leaving a hospital weeks later after present process ECMO.

Miguel’s oldest son, Miguel Jr., knew from his conversations with medical doctors that his dad wasn’t going to get higher by staying on the ventilator. “ECMO was his final hope, his finest likelihood to outlive,” Miguel Jr. stated. “It was ECMO or loss of life.”

A Determined Search

Miguel and his household had tried to guard themselves from the virus. Three of his 4 grownup kids stay in his house, and once they received contaminated within the fall, the household remoted as a lot as potential. Miguel stayed distanced on some nights by sleeping in an outdated RV he had within the yard.

The pandemic had compelled the prolonged Fernandez clan to chop again on household gatherings. Earlier than COVID-19, Miguel had typically organized get-togethers at his house on the southeastern facet of Los Angeles, for birthdays or graduations, or to observe soccer or grill. After his solely daughter, Jeannette, was accepted by UCLA final 12 months, he proudly walked round her send-off bash in a “UCLA Dad” T-shirt.

Credit score:
Sam Alden, particular to ProPublica

However Miguel needed to preserve working. He and two of his brothers owned a building enterprise that purchased and renovated properties. That they had flipped a whole bunch of properties, beginning 12 years in the past with an $80,000 fixer-upper in Compton and extra not too long ago a $2.5 million mission in Pasadena. Two of Miguel’s three sons labored with him. Even after COVID-19 struck his household, Miguel nonetheless needed to choose up provides and go to job websites.

In early November, Miguel began to really feel sick and went to a coronavirus testing website at an area recreation middle. Two days later he obtained an electronic mail telling him what he already suspected: He had COVID-19. By Nov. 15, he had a fever and evening sweats and was having bother respiration.

Regardless that he was getting sicker, Miguel didn’t need to go to the hospital. He knew individuals like him had been dying. Latino Angelenos have suffered the very best COVID-19 loss of life charge in Los Angeles County — virtually twice the speed of Blacks and about thrice the speed for whites.

However by Nov. 17, Miguel struggled to breathe as he walked from the toilet to the sofa. The household had bought an oximeter, a tool that measures oxygen ranges within the blood when clipped onto a finger. His oxygen stage had dropped to 77%, dangerously beneath the 95% thought-about on the low vary of what’s regular.

“We realized this was an actual emergency,” stated Jeannette, his 21-year-old daughter. Simply earlier than midnight, two of Miguel’s sons helped him into the passenger seat of the household’s Ford Explorer. Jeannette took the wheel and Miguel’s spouse, Alejandrina, received within the again seat.

Jeannette headed to PIH Well being Whittier Hospital, a 523-bed facility close to their house. Exterior the emergency room, the workers helped the 275-pound Miguel right into a wheelchair and put an oxygen monitor on his finger. It sounded an alarm. His spouse and daughter may see worry in his eyes; he didn’t say a phrase as he was rushed into the hospital. Jeannette and Alejandrina didn’t even get to say goodbye.

PIH Well being declined to make caregivers obtainable for interviews or reply questions on Miguel’s care. “PIH Well being won’t be able to supply a press release for this story,” a hospital spokesperson stated in an electronic mail.

Hospital data present that Miguel was given high-flow oxygen via a face masks and put in a mattress that allowed hospital workers to flip him on his stomach, boosting his oxygen stage to 93%. He was handled with steroids and an antiviral drug. Two days after admission, issues had been trying up.

Early within the morning of Nov. 22, Jeannette Fernandez, Miguel’s daughter, instructed the household’s group textual content that Miguel was enhancing.

Credit score:
Courtesy of the Fernandez household

Jeannette started offering updates via a gaggle textual content message labeled “Familia.” It included Miguel’s brothers, many cousins, nieces and nephews, dad and mom and his 4 kids. Miguel was “doing good,” she reported. Miguel spent his days studying messages on his cellphone, even when mendacity on his abdomen. He despatched his household photographs of his meals, and made particular requests of the hospital workers, asking for buttered sourdough toast and prune juice with breakfast.

The household hoped Miguel can be house for Thanksgiving. However the course of COVID-19 is unpredictable.

At 11 p.m. on Nov. 22, Miguel texted his household, letting them know he anticipated to have a protracted evening. He wrote in a textual content: “if I need to make it to thanksgiving have keep awake and restore my oxygen ranges.”

When Thanksgiving arrived 4 days later, a scan of Miguel’s lungs revealed irritation and scar tissue. Medical doctors began him on a 10-day course of anti-inflammation remedy. “Be out by Christmas,” Miguel texted.

The household responded with encouragement. “Dangle in there we’re all with you,” wrote his sister Margarita. “Ten days go by actually quick.”

Miguel and Alejandrina Fernandez, his spouse, speaking on FaceTime when he was within the hospital.

Credit score:
Courtesy of the Fernandez household

However eight days later, on Dec. 4, Miguel’s oxygen ranges plummeted. The medical doctors put him on a ventilator.

Miguel was now preventing for his life.

Unable to go to him, the household prayed for his restoration. Each evening Miguel was within the hospital, his prolonged household gathered on Zoom at 7:30 p.m. Miguel’s 71-year-old mom, Martha, and 73-year-old father, Salvador, would lead an hour-long prayer session whereas clutching rosary beads.

The separation was particularly troublesome for Alejandrina, who had been married to Miguel since 1991. Miguel preferred to tease her when she watched her Mexican telenovelas: Why do you watch these exhibits when you’ve me? On Mom’s Day earlier within the 12 months, Miguel had stunned her by shopping for a pair of rings, getting down on one knee and proposing once more. The couple made plans to resume their vows on their thirtieth wedding ceremony anniversary this summer time. When he turned sick with COVID-19, Miguel assured Alejandrina he would get higher so they might get married once more. She promised she would anticipate him.

After Miguel was intubated, his household gathered within the parking zone exterior the constructing the place ICU sufferers are handled, to be as near him as potential. Miguel’s mom knelt on the pavement for 40 minutes, her arms clasped in prayer. She instructed her grandchildren that praying wanted to be sacrificial. It needed to harm to be efficient.

It was arduous for Miguel’s household to achieve the medical doctors to debate remedy choices, partly as a result of members of the family couldn’t go to. It was unattainable to construct a relationship on the bedside or buttonhole medical doctors on their rounds, the best way they might have in non-pandemic instances. They known as a number of instances a day, however it was troublesome to get clear info.

When a health care provider did name with an replace, Miguel’s daughter Jeannette would patch in her brother, Miguel Jr., and Miguel’s niece, Jhaimy Fernandez, a fourth-year medical pupil on the College of Vermont’s Larner Faculty of Drugs.

Miguel’s members of the family stated they had been those to carry up ECMO, shortly after he was intubated. The ICU physician treating Miguel instructed them ECMO was not an possibility, they recalled. Jhaimy requested a session with the palliative care crew, which focuses on serving to critically sick sufferers and their households make remedy selections. The palliative care crew, nonetheless, agreed with the ICU physician, she stated.

“They only thought it was outrageous for us to even take into consideration ECMO,” Jhaimy stated of the hospital’s medical doctors.

Miguel Jr. stated it appeared as if the medical doctors weren’t acquainted with his father’s medical historical past. They requested if he had diabetes, Miguel Jr. stated, which he didn’t. He didn’t have any preexisting circumstances that usually make sufferers unsuitable for ECMO. Though some ECMO facilities use age cutoffs, Miguel, at 53, was younger sufficient to be thought-about applicable for the remedy.

Carlos Fernandez, Miguel’s youthful brother and enterprise companion, stated it was irritating that the household needed to carry the ECMO choice to the caregiving crew.

“They only form of wrote him off,” he stated, including that it’s potential the remedy crew was simply overwhelmed. “He’s an older, Latino, chubby man. That’s the demographic the coronavirus is in search of.”

In a dialogue with Miguel’s daughter within the early afternoon of Dec. 7, a health care provider known as his prognosis “very poor,” in response to notes in his hospital file.

That replace, nonetheless, was adopted by extra hopeful information. The household’s insistence had paid off. His medical doctors had now determined he was, the truth is, a candidate for ECMO. The household doesn’t know what modified their minds, and the medical data don’t describe how the medical doctors arrived at that call. The medical crew instructed the household Miguel can be transferred quickly to a website the place he may obtain the brand new remedy.

A Tangled System

That afternoon, a hospital affected person case supervisor started the hassle to seek out Miguel an ECMO mattress.

There is no such thing as a central database that hospital workers can faucet into to shortly work out the place within the better Los Angeles space an empty ECMO mattress would possibly exist. Case managers usually must name hospitals one after the other, navigating every facility’s explicit forms and coordinating all of it with Miguel’s insurer.

“It’s a nonsensical, haphazard assortment of stakeholders, and the pandemic has discovered the fault strains in it,” stated Dr. Douglas White, a doctor who directs this system on ethics and determination making in essential sickness on the College of Pittsburgh College of Drugs.

A key cause ECMO is being rationed within the U.S. is an absence of regional coordination, White stated. “If one hospital has no ECMO [units], however one other 50 miles away has one, there must be a system in place to attach them,” he stated. “That is the way you forestall the necessity to ration.”

In Arizona, the state well being division created the Arizona Surge Line early within the pandemic to coordinate care statewide for critically sick sufferers, stated White. Greater than 4,000 sufferers, together with many from hard-hit Native American reservations, have been transferred via this clearinghouse, in response to White. The system is concentrated on capability for all critically sick sufferers, so it’s broader than simply ECMO remedy. Nevertheless it’s an instance of how you can join sufferers to the assets they want in actual time, he stated.

In Washington and Oregon, ECMO program administrators can log in to a doc that shows the provision of ECMO beds all through the area.

In 2016, the administrators of Minnesota’s six ECMO facilities created a consortium to assist with pandemic and emergency operations, stated Dr. Matthew Prekker, a pulmonologist and significant care specialist at Hennepin County Medical Middle in Minneapolis. The consortium established uniform eligibility pointers to ensure all critically sick sufferers get a good likelihood on the remedy.

If half the state’s medical facilities attain capability, it triggers an emergency convention name between the ECMO middle administrators, who steer sufferers to open beds. “We’re nicely organized,” stated Prekker. “We don’t work in silos.”

Los Angeles has huge educational medical facilities, however no real-time coordination on discovering ECMO beds. Earlier than COVID-19 there had not been a have to coordinate such a excessive quantity of sufferers, stated Dr. Peyman Benharash, director of the grownup ECMO program at UCLA Well being. He stated when COVID-19 hit, ECMO medical doctors created a casual group chat so they might coordinate sufferers and assets, however it’s not one thing case managers can entry. Benharash stated his middle doesn’t use a ready record, as a result of he desires case managers to proceed looking for any hospitals that may have a mattress obtainable. If UCLA is full, it tells case managers to name again in 12 hours.

The shortage of a centralized system in Los Angeles may end up in a scramble for case managers and medical doctors as sufferers’ lives dangle within the steadiness.

On the afternoon of Dec. 7, Miguel’s medical data present, the PIH Whittier case supervisor known as Miguel’s insurance coverage firm. There was no assure the insurer would conform to a remedy that may simply run into the six figures. Insurance coverage firm rejections of ECMO will not be unusual, in response to ECMO administrators. However in Miguel’s case that didn’t appear to be an impediment. The insurer instructed PIH that the College of Southern California’s Keck Hospital, the Ronald Reagan UCLA Medical Middle and Cedars-Sinai Medical Middle is perhaps choices. The case supervisor left a message at USC and offered UCLA with Miguel’s info. Cedars-Sinai got here again with a no, saying Miguel didn’t meet its standards for ECMO remedy.

The case supervisor, after speaking to Miguel’s insurer, tried two extra hospitals. One, UCI Well being in Orange County, didn’t have any ECMO beds obtainable. A second, Windfall Saint John’s Well being Middle in Santa Monica, stated it might evaluate Miguel’s data.

Through the COVID-19 surge, ECMO facilities had been screening the rising variety of sufferers to prioritize these with the very best possibilities of survival. At 5:08 p.m., after three hours of working the telephones, the case supervisor turned over the search to a colleague. Quickly after, UCLA known as to say it wouldn’t take Miguel as a result of he had a hematoma and blood clotting.

A Prayer Answered

Because the case managers looked for an ECMO mattress, Miguel’s mom was again within the hospital parking zone holding a vigil for her son. This time, she hid a prayer card and string of rosary beads beneath the inexperienced leaves of a day lily to guard Miguel when she was not there.

Jeannette up to date the group textual content on Dec. 7, saying that Miguel was nonetheless depending on a ventilator.

Credit score:
Courtesy of the Fernandez household

The seek for an ECMO mattress didn’t make progress for many of the day on Dec. 8. The longer Miguel trusted a ventilator, the better the prospect he would both die or undergo issues that would disqualify him for ECMO. Even with out issues, prolonged ventilator time may rule out ECMO. By now, he had been intubated for 4 days. Some applications won’t take a affected person who has been intubated greater than per week.

“On the subject of any individual needing ECMO, they’ll fail in a short time,” stated Solar.

The subsequent day, on Dec. 8, the palliative care crew supplied a grim prognosis in a phone name with Miguel’s household: “We instructed them that Mr. Fernandez was not more likely to get well at this level,” in response to hospital data. The household stated it nonetheless needed the hospital to make each effort to avoid wasting Miguel if his coronary heart stopped.

All through the day on Dec. 8, a staffer on the Saint John’s switch middle was making an attempt to achieve somebody at PIH to debate Miguel’s case. At 8:33 that night, a case employee at PIH wrote that she had obtained a name from Saint John’s. The switch contact stated he had “been making an attempt to get in touch with [case manager] all day and left VMs however nobody known as again.”

The subsequent day, a PIH case employee famous within the data that she had missed messages from Saint John’s as a result of it was her day without work.

Saint John’s had been calling PIH with excellent news: The hospital had accepted Miguel for its ECMO program and would admit him as quickly as a mattress turned obtainable. Over the following few hours, paperwork was faxed forwards and backwards between the hospitals, and the insurance coverage firm was contacted for approval.

“Nice information!!!” Jeannette introduced in a message to the household group chat, including a coronary heart emoji. “My dad received accepted to St. John’s hospital in Santa Monica!!”

The plan, she knowledgeable the group, was for Miguel to be moved later that day.

Credit score:
Sam Alden, particular to ProPublica

A Life-Saving Remedy

At Saint John’s, Dr. Terese Hammond was receiving as much as three requests a day to make use of ECMO to deal with sufferers like Miguel. Hammond had been instrumental in beginning the hospital’s ECMO program after she was recruited in 2018 to supervise essential care. She had labored with the remedy at USC, the place she headed up the pulmonary essential care fellowship.

Neighborhood hospitals like Saint John’s don’t usually have the funds or specialised workers for an ECMO program. Even in america — which spends about twice as a lot per particular person on well being care as different developed nations — greater than 90% of hospitals don’t provide ECMO. In Los Angeles, the established applications are positioned at massive educational medical facilities like USC, UCLA and Cedars-Sinai.

At Saint John’s, non-public donors got here up with the cash to purchase a dozen ECMO items, which may value as much as $85,000 every, Hammond stated. The hospital can look after as many as eight ECMO sufferers directly, relying on staffing.

Hammond was an early believer in utilizing ECMO to assist COVID-19 sufferers whose lungs had been failing. Practically each one of many COVID-19 sufferers handled with ECMO at Saint John’s transferred in, some from greater than an hour away.

“We now have to validate there’s profit, and we’ve been ready to do this,” she stated. “I’ve individuals alive right now due to ECMO.”

Miguel’s household didn’t must look arduous for these success tales. Los Angeles Police Division detective Michael Chang was an early ECMO affected person at Saint John’s whose near-death expertise was featured in local news reports.

Chang had been assigned to theft and gang investigations however was shifted early within the pandemic to working in uniform at COVID-19 testing websites, meals giveaways and supermarkets. On March 30, he was admitted to a small Orange County hospital close to his house with COVID-19. Six days later, he was intubated and positioned on a ventilator.

As quickly as Chang was intubated, his spouse, Dana Chang, tapped right into a community of police contacts searching for extra superior care. A captain put her in contact with an LAPD reservist who can be a surgeon, she stated. That physician instructed her about Saint John’s and its ECMO program. He known as Hammond, and a switch was organized.

“He was going downhill quick,” Dana stated of her husband. “If I left him there, he would have died.”

Chang arrived by ambulance at Saint John’s on April 7 and was instantly hooked as much as an ECMO machine. On the night of April 12, he was faraway from the machine. He left the hospital 5 days later.

Michael Chang typically nonetheless experiences shortness of breath and bouts of a dry cough, however he credit ECMO with saving his life. “Previous to me getting it, I had by no means heard of ECMO,” he stated. “I had no concept what this factor is. The world must find out about this.”

Of the 39 COVID-19 sufferers positioned on ECMO at Saint John’s because the begin of the pandemic, 15 are alive right now. Hammond stated most of them virtually actually would have died with out ECMO.

Hammond is the primary to warning that ECMO isn’t a miracle treatment. About half the COVID-19 sufferers present process ECMO die within the hospital, in response to a registry of greater than 3,400 COVID-19 sufferers worldwide, although some facilities have reported survival charges of as excessive as two-thirds.

Miguel’s household stated they knew ECMO wasn’t a assure, simply an opportunity, one thing the medical doctors at PIH had been telling them he didn’t have there. If it didn’t work, they stated, they’d take consolation in figuring out every part potential had been completed to assist him.

The Ready Checklist

The information of Miguel’s pending switch to Saint John’s shortly gave technique to a bigger actuality: There have been a number of sufferers like Miguel in Los Angeles.

COVID-19 was surging. The variety of COVID-19 sufferers in intensive care items had doubled within the three weeks since Miguel was hospitalized. At PIH Whittier, two weeks earlier than he was admitted, 17 sufferers had COVID-19. The week Miguel arrived, that quantity swelled to 47. By the point he was intubated, there have been 76. By Dec. 7, when the ECMO search started, there have been 93.

At Saint John’s, the ICU was full and unable to absorb any new sufferers. Whereas Hammond had authorized the switch of Miguel and had an ECMO machine to deal with him, there have been no beds obtainable.

The ready record was not one thing the household may see or monitor. There was no technique to know who was forward of Miguel, or why, or how briskly individuals had been transferring up the record. At the least on the deli counter or DMV, they might see numbers on a board, monitor their progress and ensure nobody jumped the road. With Miguel’s life within the steadiness, his household was utterly at midnight.

“My dad didn’t have anyone that will name to make him a precedence,” stated Miguel Jr. “There was no manner for us to carry anybody accountable for what they had been saying. We simply needed to take them at their phrase.”

Credit score:
Sam Alden, particular to ProPublica

Hammond stated the ready record isn’t influenced by a affected person’s wealth or social standing, solely whether or not they’re medically certified and “more likely to survive this remedy.” Within the case of Miguel, she had authorized him for ECMO when different hospitals stated both they’d no room or he didn’t meet their standards.

On Dec. 10, Miguel Jr. shared the dangerous information on the household chat that his father’s switch had not taken place the evening earlier than as hoped. “We now have been calling my dads switch case supervisor on the hospital and we even known as saint johns and spoke to one in every of their case managers to attempt to velocity up the switch course of however there’s not a lot we will do however anticipate a mattress to open,” he texted to the Familia group.

The subsequent two days introduced extra ready. “Name to Windfall St Johns to comply with up on ECMO spoke w/ Rachel, nonetheless no mattress. no motion but, identical standing,” Miguel’s caseworker at PIH wrote in her notes for Dec. 11.

By now Miguel had not been respiration on his personal for per week and was turning into “an increasing number of troublesome to ventilate,” in response to hospital data.

The household didn’t perceive what it meant when hospitals stated they’d “no beds” of their intensive care items. Jeannette and Miguel Jr. known as Saint John’s to ask if they might purchase a mattress for his or her father. They did analysis to seek out out if donations had been allowed to fund extra beds on the hospital, however had been instructed it doesn’t work that manner.

Jeannette imagined methods to get contained in the hospital and see along with her personal eyes that each one of its 266 beds was occupied. She appeared into turning into a volunteer at Saint John’s and located an utility on-line.

Hammond stated the phrase “not having a mattress” was a euphemism for missing sufficient nurses, respiratory therapists, perfusionists and medical doctors to look after sufferers who want intensive care. Saint John’s expanded its ICU capability from the conventional 23 beds to 40, however including past that meant stretching the workers too far.

On the morning of Dec. 12, practically 5 days after the seek for an ECMO mattress started, the case supervisor instructed Miguel’s household that he was in “the highest 3” of these ready for an ICU mattress at Saint John’s, in response to the medical data.

Jeannette up to date the group textual content on Dec. 12, saying that Miguel was third on an inventory of individuals ready for an ICU mattress at Windfall Saint John’s Well being Middle in Santa Monica.

Credit score:
Courtesy of the Fernandez household

Lower than an hour later, a crew of medical doctors and nurses hurried to Miguel’s room at PIH. The hospital had known as a Code Blue. Miguel’s coronary heart had stopped. The crew began chest compressions and administered medicine to restart his coronary heart. It labored, however Miguel had suffered harm to his kidneys and different organs.

The subsequent day round midday, somebody from the Saint John’s switch middle known as a nurse at PIH Whittier to say that when once more no beds had been obtainable. The PIH case supervisor instructed Saint John’s that Miguel was in multi-organ failure, and may not survive the ambulance journey to the opposite hospital. Two hours later, Saint John’s knowledgeable PIH it might now not take Miguel as a affected person “attributable to change in situation.”

At 5:23 p.m., one other Code Blue alert was sounded. This time, Miguel didn’t survive. In his room, a hospital employee gathered gadgets left behind after his 26-day keep: an Apple laptop computer, an iPhone and a pair of cracked black-rimmed glasses.

“Individuals Are Dying Ready”

Miguel’s spouse, Alejandrina, at his funeral on Dec. 30, 2020.

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James Carbone for ProPublica

The story of Miguel’s loss of life and his household’s scramble to get him doubtlessly life-saving care has develop into a well-recognized one for Hammond.

She stated she has had as many as seven individuals on her ready record at one time, all in equally determined conditions.

“A part of the PTSD I’ve, the nightmares I’ve, are as a lot having to say no and having individuals die on a ready record,” she stated. “These are all issues that symbolize a whole lot of ethical harm for physicians. We all know the constraints the surge positioned on our skill to do the very best we will. Persons are dying ready.”

The rationing isn’t restricted to Los Angeles. It’s taking part in out throughout the nation.

In Dallas, the ECMO unit at Baylor College Medical Middle receives each day requests from throughout Texas and neighboring states on behalf of desperately sick COVID-19 sufferers. Their final likelihood at survival may come down as to whether Baylor has a mattress. “Just a few days in the past I had 5 sufferers on my waitlist,” Dr. Gary Schwartz, a lung transplant surgeon who leads the ECMO program at Baylor, stated in an interview. “Two handed away whereas ready. It’s completely horrible.”

Schwartz stated his middle, one of many busiest within the nation, averaged about 120 ECMO sufferers a 12 months earlier than COVID-19. In 2020, that quantity grew to 158, and the quantity would have been increased if he had had extra capability. “Fairly truthfully, there was a further 50 to 100 who had been applicable however there have been no assets for them,” he stated.

National guidelines created by the Extracorporeal Life Help Group, a consortium of hundreds of ECMO centers, basically name for rationing because the demand for ECMO spikes in areas saturated with COVID-19 circumstances. As surge ranges escalate, “we advocate that choice standards develop into extra stringent to make use of this useful resource for these most certainly to learn,” in response to the rules.

Some facilities have moved to implement an age cutoff for ECMO, or decrease the age in current pointers. At Baylor, the utmost age of these thought-about applicable for ECMO was dropped to 60 from 75 earlier than COVID-19, Schwartz stated. He stated one other middle within the area diminished its age vary to 50 or youthful as a result of it was overwhelmed with requests. “Most of the sufferers at first had been aged, and we had been afraid that if we had a number of these people who the youthful individuals, 30 to 40, wouldn’t have that obtainable,” he stated. Schwartz stated he has colleagues in Europe who assume an age restriction is unethical. “In an ideal world, we’d be utilizing [ECMO] for the individuals most certainly to outlive,” he stated.

Schwartz and the administrators of different ECMO facilities in Dallas created an advert hoc group chat on WhatsApp to attempt to preserve observe of the place beds had been obtainable as hospitals crammed to capability. “The true query is can we be taught from this and alter sooner or later to some form of centralized course of?” Schwartz stated.

Hammond stated the ECMO administrators in Los Angeles have the same association the place they textual content one another to seek out empty beds. The surge in Los Angeles is waning, and circumstances all through the nation are additionally happening. However new variants of COVID-19 are rising, posing a menace of contemporary surges. Hammond hopes the expertise with COVID-19 will immediate the creation of a proper, everlasting community to coordinate the care and motion of critically sick sufferers in Southern California.

Miguel’s niece, Jhaimy, will develop into a health care provider in 5 months and has been interviewing to do her household medication residency coaching in Los Angeles. She’s at all times been conscious of well being care disparities, and went to medical faculty to seek out methods to enhance the system.

“It simply pains me to see how typical a case my uncle was,” she stated. “He was Hispanic, mid-50s, a necessary employee, not trusting of the well being care system. He match all of the checks.”

On Dec. 30, Jhaimy was one in every of dozens of members of the family who gathered to bury Miguel in a sprawling cemetery close to his house.

A household good friend organized a fundraiser to assist defray the price of the funeral. Miguel was his household’s major supply of earnings, and since his loss of life, payments have mounted.

A blue and white floral association spelling out “PAPA” was positioned on a stand close to his grave. Beneath it was {a photograph} of a youthful Miguel, sporting a white button-down shirt and a leather-based jacket.

The specter of COVID-19 hung over the graveside service. Everybody wore a masks. Miguel’s mom slumped over his casket, gripping it with arms coated in clear medical gloves. She wore a face defend and a material masks.

Miguel’s sister, left, and mom, at his casket.

Credit score:
James Carbone for ProPublica

The burial didn’t carry Miguel’s members of the family a lot closure. Jhaimy stated she has questioned what would have occurred if her uncle had not been so afraid to go to the hospital. Would he have survived if he had been handled sooner?

Miguel Jr. and Jeannette are troubled that Miguel’s medical doctors didn’t current ECMO as an possibility, after which resisted the concept when the household steered it.

The household nonetheless thinks about what would have occurred if an ECMO mattress opened up in time.

“I imagine with ECMO he would nonetheless be right here right now,” Miguel Jr. stated. “He by no means received the prospect to battle.”


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