A nurse dressed in PPE is using a tablet while standing in the hallway in a hospital ICU where rooms are draped in protective sheeting.
A nurse sets up a video call with the family of an isolated Covid patient at Saint Claire Regional Medical Center in Morehead, Kentucky.

Unvaccinated Covid Patients Push Hospital Systems Past the Brink

In a Kentucky hospital bed at the end of November, a Covid-19 patient from the state’s latest wave of infections lay alone behind the glass isolation wall.

A high-flow oxygen mask pushed extra air into his damaged lungs. His heart beat fast, though he lay frail and still. His mouth opened and closed to take tiny gulps of air. It looked like he was suffocating.

Kentucky’s Covid landscape is a lot like what’s happening in the rest of the United States. In some places, like Lexington, more than 60% of the population is fully vaccinated. But in many others, like the Appalachian counties 100 miles east, the rates are well under 40%. Diabetes, heart disease, smoking and obesity are prevalent—risk-factors that can make a Covid case severe, or deadly.

That made the state a tinderbox when the latest surge of infections began this summer. Outbreaks in less vaccinated counties filled up small, local hospitals. Sicker patients, or those who couldn’t find space, went on to regional facilities. The most severe cases fed into the biggest and most advanced hospital in the state, the University of Kentucky Albert B. Chandler Hospital, until it too overflowed. Like the man gasping for oxygen in one of the state’s many Covid wards, the outbreak starved Kentucky’s hospitals of air, consuming every resource: staff, beds, supplies and time.

How Covid Swept Across Kentucky and Swamped Hospitals

Covid cases per 100 people per county, July 1 to Oct. 31, 2021
Source: U.S. Department of Health and Human Services

Immunization is often framed as an individual choice—particularly in Kentucky’s less-vaccinated regions. But a Bloomberg analysis of vaccine, infection and hospitalization data for the state, combined with interviews of more than 20 doctors, nurses and medical staff, show how low vaccination rates strain entire communities and health-care systems.

As a new winter wave of cases hits, those same dynamics are pushing hospitals around the U.S. to the brink. In Minnesota, doctors took out an ad in the Star-Tribune, pleading with people to get vaccinated. In Michigan, where 20 hospitals are running 97% occupancy or higher, an ER doctor wrote an opinion piece in the New York Times, warning that some facilities were close to being unable to provide care.

Those states will not be the only ones. A worrying new variant is spreading, hospitals are filling, and millions remain unvaccinated. If America keeps stress-testing its hospitals and their staff, some of them will break.

Anticipating the Covid Surge

Doctor Shelley Stanko was born in London, Kentucky, at Saint Joseph London hospital. She’s now its chief medical officer, overseeing more than 100 beds. A marathon runner, she is warm but to the point, with the speech rhythms of someone who has more to do than there are hours in a day to do it.

Her hospital is what’s known as a regional referral center. It sits at the gateway to Appalachian coal country to the east, and gets a flow of patients from the small, critical-access hospitals there, many of which may only have a few beds. A year ago during the winter wave that started in 2020, the virus hit Saint Joseph hard, but by this June cases were down and beds were emptying. Stanko took a vacation with her family in early July. But calls from the hospital started to come in, driven by the delta variant. By the time she got back, the numbers were headed up again.

“We realized this is not just a little blip, this is going to be a surge,” she said. “We had no idea of the scope of it.”

Doctor Shelley Stanko stands against the wall of a hospital room, holding a handrail, in front of an unoccupied hospital bed.
Shelley Stanko, chief medical officer at Saint Joseph London hospital in London, Kentucky.

Two hours north through backroads carved into the Appalachian mountains, Saint Claire Regional Hospital in Morehead serves much the same role as Saint Joseph, taking patients from the poor and rural counties around it. While it’s licensed to operate more than 150 beds, only about 80 were usually in operation before Covid.

Doctor William Melahn, Saint Claire’s chief medical officer, is from Queens, New York, by way of Boston. During his medical training, he was a member of the U.S.’s National Health Service Corps, and when he finished his residency, he had to serve in an area of high health-care need.

“This was on the list,” he said. He and his wife fell in love with the place and stayed.

Saint Claire is also one of the state’s regional Covid testing centers. People can drive up and get swabbed in their cars.

If the line of cars in the parking lot is short, Melahn said, things are good. But in late July, the line was getting longer.

A drone photograph shows the exterior of the hospital and its parking lot in the foreground with the Appalachian Mountains in the background.
Saint Claire Regional Medical Center in Morehead, Kentucky.

Covid Waves and Hospital Overload

U.S. hospitals almost always run close to the edge of capacity. There’s no spare money and staff to keep beds at the ready, and for a stressed hospital, every Covid admission can mean a canceled surgery, an overworked nurse or doctor, or a new space that has to be found.

Kentucky’s Covid data shows that the latest wave started, and reached its highest point, in the counties that had the lowest vaccination rates.

Hospitals in Less-Vaccinated Counties Had More Covid Patients

Share of Kentucky’s adult hospital patients with Covid in more- and less-vaccinated counties
Note: More-vaccinated counties were in the top 25% of Kentucky counties, based on average vaccination rates in June 2021. Counties with average vaccination rates are the middle 50%. Less-vaccinated counties are the bottom 25%.
Source: U.S. Department of Health and Human Services

When cases peaked in September, the least-vaccinated counties typically saw 1 in 4 hospital beds occupied by Covid patients, according to data from the U.S. Department of Health and Human Services. There were about half as many Covid patients in the best-vaccinated places.

But the wave of hospitalizations was enough to push all of them close to the edge.

At Saint Joseph in London, the patients from the last winter wave had been old and frail. The new ones in the late summer wave were young and relatively healthy. The bad ones were almost all unvaccinated.

Saint Joseph, like most hospitals, carefully tracks inflows and wait times for its emergency department. In dire circumstances, it will go on “divert”—telling ambulances that the hospital can’t accept any more patients, no matter what.

Lori Coots, director of emergency services said the hospital had only gone on divert twice in her 20 years there. Once was because of a bomb threat. The other was because of a tornado.

But as the Covid cases backed up, Saint Joseph had no choice. In early August, 24 patients were in the emergency department waiting for an inpatient bed, and 28 were waiting in the lobby—so Coots’s team told incoming ambulances to head for other hospitals. A few days later, there were 37 patients waiting for beds upstairs, and 32 more in the lobby. They went on divert again.

Less than a week later, Saint Joseph was on divert once again. But after two hours, they canceled it—every other hospital in the region was turning away ambulances as well.

“They had nowhere else to go,” Coots said. “So we just said, we’ll do the best we can.”

Coots is seated at a desk in an office at the hospital, flipping through papers stored in a folder.
Lori Coots, director of emergency services at Saint Joseph hospital in London, Kentucky.

There are consequences to a health system locked up by Covid patients. There were still strokes, heart attacks and accidents coming in. (Two weeks after these interviews, a tornado struck the other side of the state, killing more than 70 people.) But hospital beds around the state were full, and transfers to other hospitals were nearly impossible.

Coots said that at the height of the surge, Saint Joseph had patients waiting in the emergency department for days, on services the hospital did not have.

Saint Joseph Hospital Patient Capacity

Number of adult patients in hospital beds compared to pre-Covid capacity
Note: Hospitals typically staff a lower number of beds than they have space for. Before Covid, Saint Joseph operated about 100 inpatient beds.
Source: U.S. Department of Health and Human Services

Fifteen miles south, in Corbin, Baptist Health, a 273-bed hospital that serves much the same area as Saint Joseph, put together a team to try and find beds at other facilities.

“We called transfer centers. We called admission centers and coordinators for other health systems in Tennessee, Georgia, North Carolina, Virginia, Ohio, Indiana, Pennsylvania, trying to find beds,” said Teresa Cobb, the hospital’s director of nursing, clinical and regulatory services.

There were no beds anywhere.

Melahn, at Saint Claire, said they knew there would be little help. But still, they hit the phones. One day in early September, they ran out of options.

“We had gone through a list of 23 hospitals and they were all no,” Melahn said. “We looked at each other and we said, the next person who shows up, we’re just going to have to let them pass away. We have nothing left.”

“Five people died that day and that’s what saved us,” he said.

Two hospital employees work at a nurses’ stand in the ICU adjacent to patient rooms covered in plastic sheeting.
The Covid-19 ICU at Saint Claire Regional Medical Center in Morehead, Kentucky.

Who Was Being Hospitalized for Covid?

The University of Kentucky was on the receiving end of many of those calls for help.

If “you’re a young person who’s got really bad lung disease, you’re not going to Saint Joseph,” said Doctor Ashley Montgomery-Yates, who runs U.K. Health Care’s medical intensive care unit and oversees inpatient care. “You might show up there, but they’re immediately going to call us.”

At U.K.’s capacity command center, nurses in neat cubicles take a stream of calls, taking down details of transfer requests. Some patients are cleared for admission right away, while others may get sent for a consultation. A typical month sees about 2,000 inbound calls, and the center buzzes with the rhythm of the dozens of emergency rooms around the state, picking up in the afternoon and staying busy through the night.

Staff at University of Kentucky Health Care’s capacity command center in Lexington, Kentucky.
Staff at University of Kentucky Health Care’s capacity command center in Lexington, Kentucky.

In the hierarchy of the state’s hospitals, U.K. is at the top, with 945 beds, including about 150 ICU beds and a 200-bed pediatric hospital. It’s the central point in a loose web of regional hospitals like Saint Claire and Saint Joseph, each about an hour away. Scattered around the state are even smaller facilities, rural and isolated communities, often with just a handful of beds and staff.

Last fiscal year, U.K. took in 19,000 patients from other hospitals, which it says makes it the biggest transfer center in the country. It’s where patients from around the region get sent for complex heart surgeries and organ transplants, or when doctors run out of other options. It soaks up the worst and most challenging patients, whose cases would overwhelm the resources or experience at smaller hospitals.

“There’s no level of acuity we can’t handle,” said Montgomery-Yates. She pulls shifts at the capacity center, which gives her intelligence about what’s happening around the region.

“We got a call from Missouri, from an ER doctor who had literally called 47 different hospitals, trying to get a 28-year-old who was intubated somewhere where they could get help,” she said. “We got calls from Alabama. I mean, they had to skip a whole state to get here.”

As cases surged in Kentucky, U.K. made a decision: the hospital would accept only in-state patients, and only the ones they had a unique ability to help. They told many doctors who were used to sending their worst to Lexington that they were full, and it was time to be realistic about a long-shot patient, and to talk to the family about how things were likely to end.

“If the sink is full, you can’t put six more drops in it,” Montgomery-Yates said.

One of the most advanced procedures University of Kentucky performs is ECMO, which stands for extracorporeal membrane oxygenation. Developed in the 1950s for heart surgeries, an ECMO machine pulls depleted blood out of the patient and returns it full of oxygen. It allows a surgeon to bypass the heart and lungs, taking them out of the loop so they can be operated on. With Covid patients, it’s a final prayer—a way to give the lungs a chance to heal, or to buy a patient enough time for a lung transplant.

“These are without a doubt the sickest patients in our hospital,” said Doctor Kevin Hatton, who runs the ECMO unit. Hatton comes from a family of Kentucky coal miners. He keeps a well-worn coffee maker and a sleeping pad in his small office. Two sticky notes stand ready by his office door: The first says “conference call,” the other says “sleeping.”

ECMO is in short supply: There are fewer than a dozen ECMO machines available for Covid patients at U.K. Before Covid, two or three patients might be using them—there was almost never a need for more. As the surge progressed, Hatton began getting four and five calls a day. The hospital kept a waiting list. At the peak of the surge, it grew 20 people long.

One young man in his 20s had been on an ECMO machine for over a month. (Personal details of patients in this story have been obscured or changed to protect their privacy, in some cases.) A tube nearly the size of a garden hose protruded from the jugular vein in his neck. Another was in the femoral artery near his groin. Snaked through the isolation wall were lines from eight different IV pumps, controlling the drugs he was getting. He lay motionless as the device cycled his blood in and out.

A photograph of the exterior of the University of Kentucky Albert B. Chandler Hospital in Lexington.
University of Kentucky Albert B. Chandler Hospital in Lexington.

The patients who do best on an ECMO machine tend to be younger and healthier. In normal times, Hatton might be willing to chance a 65-year-old patient. With the overwhelming demand from Covid, he drew the line at 50. Just less than half survive and make it off the machines.

Health-Care Workers Faced ICU Burnout

If beds and machines were stretched thin, hospital staff were stretched even thinner.

Joelle Craft is an ICU nurse at Saint Claire. The hospital built surge units to handle all of the patients coming in, but was still packed with Covid cases. She remembers a day when she rushed to help intubate a patient, and tried to reach his family in case he didn’t live.

“I remember them trying to call his wife and we were holding his hand saying it would be okay,” she said. Within a few minutes he was dead. As she headed back to the surge unit, she looked down the hallway. “This is like a war hospital,” she remembered thinking.

“I put somebody in a body bag every day that I worked, for two months,” she said.

Saint Claire Hospital Patient Capacity

Number of adult patients in hospital beds compared to pre-Covid capacity
Note: Hospitals typically staff a lower number of beds than they have space for. Before Covid, Saint Claire operated about 80 inpatient beds.
Source: U.S. Department of Health and Human Services

Others had cases they couldn’t forget.

Doctor Brad Baker had a patient at Saint Claire, an older woman, whose family had asked for a meeting. He reminded himself not to be defensive—maybe they weren’t happy with her care. But her husband had a request: They’d been married for 60 years, and it was the woman’s birthday—they’d never spent one apart since they had met.

So they covered the husband in protective gear, everything they could fit on him, and he sat with his sedated wife as the ventilator pumped air in and out of her lungs. He pulled out birthday cards from family and friends and read them to her, card by card. He told her he loved her, that he was there with her, and that he knew she could hear him.

The man asked Baker to help him hang the cards in the room. The next day, Baker called the family and told them that she had died overnight.

He cried when he recalled that day, tears running down his face into his surgical mask. There was beauty in that moment, he said, in caring for the woman. Two hours later, he was in another wing of the hospital with three patients dying at the same time.

Doctor Brad Baker is seated in the last row of chairs in Saint Claire’s chapel.
Brad Baker, a doctor at Saint Claire Regional Medical Center in Morehead, Kentucky.

Unvaccinated Filled the ICU

In mid-September, hospitals in Kentucky were more full with Covid patients than they ever had been: Of the 7,190 adults hospitalized in the state for any reason, more than 30% had confirmed or suspected Covid, according to data from the U.S. Department of Health and Human Services.

Three months later, many hospital ICUs were still dealing with those patients. As Stanko toured the ICU, an urgent page went out over the loudspeakers—a woman in the ICU was crashing: “Code blue, room 279.” A team of nurses sprinted down the hall. “She’s my patient,” she said, and ran after them.

In Lexington two days later, Montgomery-Yates thought about how things got this way. Months before, she helped create U.K.’s mass inoculation clinic at the football stadium. Because of her, more than 100,000 people got vaccinated there. She worked shifts and gave injections in the freezing cold, and said it was the proudest moment of her career.

And yet her ICU was full of unvaccinated Covid patients, from all over the state. These were her people. She’s from a small town called Danville, 45 minutes south of Lexington, and when her rapid-fire speech slows down for a moment, a drawl creeps in.

“I feel like a failure,” she said. “On some level physicians have failed, because 99% of us think vaccines are the answer. And yet the communities, the people who are our people, don’t trust us.”

Portrait photograph of Doctor Ashley Montgomery Yates, who runs University of Kentucky Health Care’s intensive care unit and oversees inpatient care. She is seated on a window sill and looking out the window several floors above ground-level at the medical center.
Ashley Montgomery-Yates, a doctor at University of Kentucky Health Care in Lexington, Kentucky.

When unvaccinated Covid patients showed up in her ICU, she used to get angry. Now she wonders what happened, and how to fix it.

“We have to convince them in order to save ourselves,” she said. Because the strokes, and the heart attacks, and the cancers—they’re all still coming in. “If they don’t get vaccinated,” she asks, “how am I ever going to get my hospital back?”