Friday, September 18, 2020

Covid for Assholes

 

Covid the most mysterious virus since the last one be that Zika, Ebola, H1N1, SARS, Hep B, Herpes, AIDS, pick one continues to dominate the fear factor of captive Americans thanks to Crazy Dopey Grandpa's inability to communicate effectively

 As I worked out in the gym this morning ignoring the signs to not open the window I began to workout when a man came in and for 30 minutes grunted and huffed his way through some sweat filled mania workout and another woman came in sat on equipment then texted for most of her 20 minutes in and then washed down the sit up chair she was using went to the bathroom for several more I assume texting and then she also left. At that point I removed my mask finished my run and then wiped down my equipment and shut the windows and turned the air conditioning back on. The most dangerous thing in the room aside from the coughing, huffing asshole was that air conditioner recirculating air. Opening the windows is essential but again this rational thought cannot be accomplished here as no one reads shit all about this, instead they are sure the endless closing of spaces, wiping them down, taking temps and washing hands is the key to prevention. WRONG WRONG WRONG. It is avoiding close contact without masks with anyone for any time frame over 15 minutes or so. I am over going places with people so I have to mask up and cannot walk in the air alone mask off, sitting reading or just enjoying my time being out. I have a two hour train ride on Monday so this should be interesting I suspect I can do my part to avoid to close of contact but we shall see. 

That said I have no changed my behavior at all since the beginning. I wear gloves to the store and throw them out the minute I am out as I cannot touch a lemon, then wash my hands and if I don't like it then put it back to stares. So with gloves my handling of items seems to be ignored. I could have put them on coughed and wiped my ass with them but who would know that? As for packages and groceries I just handle them as I always do, I do wash my fruit and veg and put them in the proper bags for preservative means, any items in containers the store provides I change out for my own as they again are better measures to preserve the food. And then I wash my hands and slap down a bleach martini! The whole Covid is on a box is hilarious as again we would all be dead by now. And if Covid was transmissible through food prep and handling we would all be dead by now. 

The absurd bullshit down to not touching items in a store and having any item returned sit for 72 hours is laughable. My favorite is the spa that makes you put bags on shoes while you are being serviced. BWHAAAA. The issues again folks is contact and ventilation. Note the Starbucks story or even the hairdresser in St Louis where the only one infected was a co-worker whom she had unmasked contact with while servicing over a 100 clients between the. The key is covering transmission methods and that is down to masks and of course wisdom of monitoring your own behavior. That last one seems to be a problem. I would talk about the best and brightest the college students and their overwhelming need to party down in a pandemic. What a group of fucking assholes. That is America's future. And they vote. Two things that make me glad to be old. And no I won't be in a restaurant eating anytime soon. I will sit outside under a heat lamp or light matches. It is again the time indoors and the proximity. So I had my hair done it took over an hour and quarantined for three days after that, and again when I had my hair dyed. Why? Because I cannot trust others to be as responsive. 

So head out to those raves and rub up against someone and see how that works for you. It is why I will not go for a conventional massage despite needing it as being naked in a closed off room scares the shit out of me and frankly will negate the benefits. I will not go to a Yoga class unless they have windows that open. And insist on having windows, air filtration versus cleaning the fucking pen and washing your hands when you arrive. Sorry that is just a panacea to calm you. 

This is why schools are not opening as they cannot maintain that essential critical element of clean circulated air and done so with enough distance between the students, teachers and other staff. Get it? You don't. Well you are an asshole. 

 


 

 The Most Likely Way You’ll Get Infected With Covid-19 You don’t have to sanitize your apples anymore, but you do have to wear a mask

 Dana G Smith 

This story is part of “Six Months In,” a special weeklong Elemental series reflecting on where we’ve been, what we’ve learned, and what the future holds for the Covid-19 pandemic. 

At the beginning of the pandemic in March, Jeffrey VanWingen, MD, a Michigan family physician, scared the bejeezus out of people and infuriated food scientists. During his 13-minute video, which went viral on YouTube and has been viewed over 26 million times, VanWingen tells people that when they come back from the grocery store, they should leave groceries outside for three days, spray disinfectant onto each product, and soak produce in soapy water. His rationale was that those items might carry the novel coronavirus and could potentially infect people after they come into contact with them. 

 Six months later, we’ve learned a lot about how SARS-CoV-2 spreads, and it turns out most of VanWingen’s tips are largely unnecessary and some are flat-out dangerous (you should never bleach your food, but hopefully you already knew that). Instead of obsessing over objects and surfaces, scientists now say the biggest infection risk comes from inhaling what someone else is exhaling, whether it’s a tiny aerosol or a larger droplet. And while a virus traveling through the air sounds terrifying, the good news is there is a safe, cheap, and effective way to stop the spread: wearing a mask. 

Here are the three primary pathways of transmission, and what experts know about them six months in. Surfaces don’t seem to matter as much as originally thought The surface or fomite theory — that you’ll get infected by coming into contact with objects that carry the virus, called fomites, like door handles, shopping carts, or packages — was the original leading contender because that’s how scientists and epidemiologists think most respiratory diseases are spread. For example, when a person sick with a cold coughs or sneezes, tiny snot and saliva particles that carry the virus go shooting out of their nose and mouth and land on nearby surfaces. If someone else touches that surface and then touches their mouth, nose, or eyes they could become infected with the virus. This is why we’re supposed to wash our hands before eating or preparing food, and after using public transportation, or touching door handles, especially during cold and flu season. “I’m not saying that you can’t get it, that it’s impossible to get it from surfaces, but a very specific set of events have to occur for that to happen.” 

Supporting this idea, an early study published in the New England Journal of Medicine found that SARS-CoV-2 survived on various surfaces for several days, including 24 hours on cardboard and 72 hours on plastic. Public health organizations recommended hand hygiene as the first line of defense against the virus, and there were runs on Lysol wipes and hand sanitizer at supermarkets and drugstores, the supply chains for which still have not recovered. 

The problem, says Emanuel Goldman, PhD, a professor of microbiology and biochemistry at Rutgers University, is that the experiments those recommendations were based on “were the wrong experiments to do” because they were not representative of how people come into contact with the novel coronavirus in the real world. “They started out with a humongous, totally unrealistic amount of virus at the beginning of the experiment, and then, sure enough, they found virus at the end. But they started out with so much more than you would ever encounter in real life,” he says. “You would have to have 100 people coughing and sneezing on one small area of surface to get the amount of virus that was used in the papers that reported the survival of the virus on surfaces.” It turns out that despite the catastrophic harm it’s caused, the novel coronavirus is actually quite fragile, and it doesn’t like being out in the open where it can dry up. 

 According to the NEJM paper, the virus’s half-life is a relatively short six hours, meaning that every six hours 50% of the virus shrivels up and becomes inactive or noninfectious. That means if you start with 100 virus particles, after six hours that number halves to 50 particles; six hours later there are 25 virus particles left, and fewer than 10 virus particles remain after 24 hours. However, if there are huge quantities of virus to start, many more will be left behind after each six-hour window, and it will take longer for all of the virus to disintegrate. Instead of buying another can of Lysol, maybe invest in an air purifier, more comfortable two-ply cloth masks, or even an outdoor fire pit or space heater. “If you start out with a realistic amount, and a realistic amount would be between 10 and 100 virus particles, because that’s what a droplet of a cough or sneeze is likely to have, then your virus is gone in a day,” Goldman says. “Now, I’m not saying that you can’t get it, that it’s impossible to get it from surfaces, but a very specific set of events have to occur for that to happen.”

 Regardless, it’s critical that people keep washing their hands — although that’s something we should all be doing for normal hygiene anyway — but, Goldman says, you don’t have to do anything excessive, like disinfecting your groceries. Close range droplets are the new leading theory In May, the CDC updated its guidelines to state that fomites were not a major source of transmission. Instead, the agency said, the primary route of infection was probably virus-laden droplets — those snot and saliva particles that are at the root of the fomite theory. But instead of worrying about them after they land on surfaces, the bigger concern now is coming into contact with the droplets while they’re still in the air. When you expel air — whether it’s by sneezing, coughing, talking, singing, shouting, or even breathing — tiny bits of saliva, ranging in size from an imperceptible mist to visible spittle, are pushed out. Heavier particles fall to the ground relatively quickly and are categorized as droplets, while the tinier particles stay afloat in the air for longer. When talking and breathing, the typical droplet trajectory is about three to six feet, hence the six-foot distancing recommendation. If the droplets are expelled with more force, like with a sneeze or a cough, they can travel further before hitting the earth. Being in close contact with someone raises the risk that you’ll be exposed to the small droplets they’re expelling, and many scientists now think that’s how most people become infected with the virus. One reason is that a virus inside a freshly exhaled droplet is more likely to be alive and infectious than a virus that’s been sitting on a doorknob for several hours. The other reason is that, in close range, breathing in the air that someone else just breathed out is going to expose you to a higher quantity of virus particles — called the inoculum — than after the droplets disperse and fall to the ground. “It’s not that [surface spread] can’t happen, it’s just that the likelihood is less than if someone was actually right in front of you breathing live virus in their droplets onto you,” says Nahid Bhadelia, MD, an infectious diseases physician and associate professor at the Boston University School of Medicine. “That is a much bigger inoculum, [and] it’s much more likely that there’s a lot more live virus in it, so that’s why it’s a higher risk.” 

As a result, social distancing has become one of the recommended ways to prevent transmission, the idea being that if you stay more than six feet away from someone, you won’t be hit by the majority of their exhaled droplets. Supporting this theory, most people catch the virus from someone they live with and presumably are in frequent close contact with.

 In one study from China, for example, an infected person had a 17.2% chance of spreading the virus to a family member who lived with them, but just a 2.6% chance of giving it to someone outside the home. “I think people have this preconceived notion that if it’s airborne it’s like the measles or like smallpox where it only takes one viral particle to infect you, and this is almost certainly not the case with this coronavirus. Most coronaviruses are probably in the hundreds.” However, there have been several documented instances of infections that don’t fit with droplet or surface spread because they happened even when people maintained their distance. Perhaps the most famous example is the choir rehearsal outside of Seattle, Washington, a superspreader event where 52 out of 61 people were infected during a two-and-half-hour practice. What’s notable about this case is that the singers maintained distance from each other and used plenty of hand sanitizer, per safety guidance at the time. Also, the infected person was presymptomatic, so they weren’t coughing or sneezing and projecting droplets further. Despite all this, one person was still able to infect 52 others. A study conducted in hamsters in a lab (that’s right, it turns out hamsters are the best animals in which to study coronavirus spread) found similar results in a more controlled environment. 

The researchers showed that the animals could infect each other not only through direct contact when they were housed in the same cage, but also when they were separated in different cages in the same room. Based on these studies and other mounting evidence, many scientists began to believe that the virus is transmitted through droplets and aerosols, those tiny mistlike particles that can travel farther through air currents and remain afloat for longer. Aerosol transmission has gradually gained acceptance Despite these observations, some public health experts were initially reluctant to say that the virus is airborne, partly because they didn’t want to alarm the public. There are also debates between epidemiologists, virologists, and aerosol engineers about what the word airborne really means — whether the size of the particles or their behavior (how quickly they fall to the ground, whether they can be carried on a gust of air) matters more, and what questions must be answered before a disease can be defined as such. Part of the resistance to calling Covid-19 airborne is also rooted in history. For centuries, doctors and scientists didn’t know how diseases spread. 

One theory was that infections traveled in invisible clouds called miasmas or “bad air.” It wasn’t until the 1860s that Louis Pasteur’s germ theory of disease began to take hold, cemented in the 1890s with the discovery of viruses. As a result, scientists waged a campaign during the early 20th century to discredit the idea of miasmas and airborne spread with the goal of getting the public to take germs — and personal hygiene — seriously. “That became the paradigm of epidemiology and infectious diseases from 1910 until now,” says Jose Luis Jimenez, PhD, a professor of chemistry at the University of Colorado, Boulder who specializes in aerosols. “For medicine, during all this time, a disease going through the air is extremely difficult. It’s an outlandish proposition.” As a result of this legacy, public health experts initially believed that SARS-CoV-2 couldn’t be spread through the air because the presumption was that virtually no diseases were. There have been a few exceptions made over the years, but those were for viruses that are so contagious they couldn’t conceivably be spread any other way — namely, measles and chickenpox. “For diseases like measles and chickenpox, because they are extremely transmissible, the evidence became too obvious,” Jimenez says. “They’re so transmissible through the air that it just became undeniable, and they were accepted as transmitted through aerosols.” 

As surprising as it may sound, by comparison, the novel coronavirus is not very contagious. Each person who gets infected with SARS-CoV-2 will, on average, spread it to two or three other people. A person with measles will infect 15 others. Jimenez says the WHO initially cited the coronavirus’s relatively low infectious rate as a reason why it couldn’t be spread through the air. “[They] are confusing an artifact of history with a law of nature,” Jimenez says. “They are thinking it is a law of nature that if a disease goes through the air, it has to be extremely contagious.” It wasn’t until a public outcry from over 200 scientists that the WHO finally conceded in July that aerosol transmission was possible. 

So if the novel coronavirus is airborne, why isn’t it as contagious as measles? One reason could be that measles is a heartier virus (remember that SARS-CoV-2 is relatively fragile) and can survive longer in those tiny aerosols. Another potential difference is the infectious dose — the amount of virus required to start an infection. Scientists still don’t know exactly how much of the novel coronavirus is needed to make someone sick, but it’s likely higher than conventional airborne viruses. 

“What’s the infectious dose via the respiratory route is really probably the last piece of this that isn’t completely answered yet,” says Joshua Santarpia, PhD, an associate professor in the department of pathology and microbiology at the University of Nebraska. “I think people have this preconceived notion that if it’s airborne it’s like the measles or like smallpox where it only takes one viral particle to infect you, and this is almost certainly not the case with this coronavirus. Most coronaviruses are probably in the hundreds.” Another question that needed to be answered before many public health experts could accept that SARS-CoV-2 was airborne was whether it could even survive in those smaller aerosol particles. Some viruses can’t because they dry up too quickly without a larger liquid droplet to support them. However, many scientists feel this issue has been put to rest with two recent papers (which have yet to be peer-reviewed) that provide what some have called the “smoking gun” for aerosol transmission: live, replicating virus collected from the air of Covid-19 patient hospital rooms. “Confidently, what you can say is that things that we consider aerosols, not droplets, have both [viral] RNA and [live] virus in them that is capable of replication in cell culture,” says Santarpia, who led one of the studies. “I think that between the two of [our studies], you can say that aerosols are infectious… meaning that probably we’re looking at something that’s airborne.” How to protect yourself from all transmission routes By now, most scientists and public health experts agree that SARS-CoV-2 can be spread by both droplets and aerosols, particularly in close range, although no one knows which is the dominant route of transmission. “I think it’s a false dichotomy to think of this as airborne versus droplet. Most things exist on a range,” Bhadelia says. 

 What matters more is whether people know how to properly protect themselves from the virus. Fortunately, the prevention steps for both transmission routes are largely the same: keep your distance and wear a mask. Evidence of the importance of masks, in particular, has been mounting, not only because they trap outgoing particles from escaping, which protects others, but also because they block larger incoming particles from getting into a person’s airways, protecting the mask wearer themselves. And even if some viral particles do get through, the viral dose will still be much smaller, so the person will be less likely to get seriously ill.  

A clear example of the benefits of masks is a recent outbreak in South Korea, in which one woman at a Starbucks infected 27 other customers — whom officials assume were not wearing masks because they were eating and drinking — but none of the employees, all of whom were masked the entire time. Aerosol transmission does increase the importance of one additional protective step, which is proper ventilation and air filtration. Airflow, either introducing new air into a room or filtering the existing air, can disperse and dilute any infectious aerosol particles, reducing a person’s potential exposure.Being outdoors is the ultimate ventilation, and for months public health officials have recommended that people socialize outside rather than in. However, with winter and colder temperatures coming, indoor air filtration and adherence to masks will become even more important. “The important thing on the public side is air handling, reducing the number of people in enclosed indoor spaces, and wearing a mask,” says Bhadelia. “[Aerosol transmission] explains why indoor settings are so much more important and contribute so much more to new infections than outdoor settings do.” 

  Armed with this knowledge, think about how you can make fall and winter safer, both physically and mentally. Instead of buying another can of Lysol, maybe invest in an air purifier, more comfortable two-ply cloth masks, or even an outdoor fire pit or space heater. Be prepared to meet friends outside in colder temperatures or insist upon masks, even in your home. We’ve still got a long way to go before we can declare victory over the novel coronavirus, but at least we know more now than we did six months ago. And you don’t have to sanitize your apples anymore.

Flood at the Gates

I was not one to join the chorus of applause, pot banging, horn honking or any other expression of gratitude or hero acknowledgement to any health care professional; however, I do feel that UPS, USPS, Transit professionals, Grocery clerks and others such as dry cleaners, laundry's and the Amazon warehouse workers do. None of the non-professional blue collar individuals who stayed working during the lockdown signed up for a pandemic, had no idea that they would be at a significant risk as they commuted to work and employers failed to provide necessary PPE, health care, paid time leave or had an established protocol for safety and well being for both staff and customers. I shopped at Whole Foods during it all, prior to mask mandates, prior to any screens erected and sheer confusion as to what, where and how we were to get through this. I traveled on public ferries going out of my way to avoid subways and paths but did so with masks, gloves, and other clothing to obscure my face to prevent virus transmission. I stripped down immediately after coming home, showered, did laundry and not one single food item went into the frig or cupboards without wiping them down, transferring them into my own containers if possible. I kept physically distant the entire time and still do, getting off PATH if the train is too crowded and just one single person is unmasked. I have limited the subways to 15 minutes or less and I move again if necessary to quickly limit exposure. Where is my applause? 

The reality is that we somehow did a Jesus complex on these people and in reality their employers, the owners and investors in many hosptials (some they closed before Covid which led to further problems), that the lack of centralized communication and transport, the failure of private medical care to open the doors, leaving public hospitals overwhelmed after years of under-funding and in turn the simple lack of again a coordinated and comprehensive effort by the Trump Administration to ensure all facilities had what they needed to effectively treat the virus and the patients appropriately. And in turn this lead to many deaths that need not be and also contributed to the spread as over 7% (the last estimate I read) of the infections were health care professionals. Most deaths were in facilites that housed and treated the elderly and in turn most of the infections again were attributed to warehouses that process food. So while you sit home ordering your sofas online the persons putting that in boxes, the dudes cutting up your chicken for your Seamless delivery were getting infected, taking it into the community and dying. They were unable to access health care nor was it made available to them with proper testing, time off and of course insurance to pay for it all. So where is their applause? As for the deaths and infection rates among health care workers has a lot to do with the failure of the boards, the directors and of course the local and state agencies for not funding them, maintaining and managing the faciliites to run on a daily basis well let alone in a situation of emergency that Covid wrought. Some did as they looked to major events from natural disasters to terrorists attacks or mass shootings to change their protocol in crisis but few to none were ready for a highly infectioous virus to arrive on the shores with little warning and little direction from the Federal Government. Again we have learned that all this no to low government thing doesn't actually work, does it? And when you put the national care of eduacation, health and justice in the hands of private enterprise you get what we got, shitty health care, workers getting sicker and of course failure to handle a crisis.

  Hospitals for Years Banked on Lean Staffing. The Pandemic Overwhelmed Them. 

Russell Gold, Melanie Evans| The Wall Street Journal. June 18 2020

Banner Health had figured out how to get ahead in the modern health-care industry. The Phoenix-based nonprofit hospital system relentlessly focused on costs. It trimmed labor, the largest expense for any hospital. Last year, it carried 2.1% fewer employees for every bed filled, compared with the year before. It also moved away from pricey hospital settings. Visits at free-standing clinics and surgery centers grew 12% in 2019, while its hospital emergency rooms were flat. The result was a financial powerhouse with $6.2 billion in cash and investments and a bond rating that is the envy of corporate financial officers. But when the pandemic hit, the strategies that had helped it become a model for other hospital systems suddenly became weaknesses. In early June, as Arizona’s count of Covid-19 cases began to rise by 1,000 a day, Banner’s hospitals filled with very sick patients needing one-on-one help from critical-care nurses. There weren’t enough. Banner and other well-funded hospitals muddled through, but in doing so they overtaxed existing nurses, had to train others on the fly and relied heavily on rapidly hiring temporary staff, including more than 1,000 nurses and respiratory therapists on expensive short-term contracts. Those moves helped drive up prices for traveling nurses, putting them out of the reach of neighboring hospitals. Nurse pay for contracts signed by the state, which eventually did much of the hiring, rose to $145 an hour from $85 for intensive-care specialists. Draining that limited pool meant that poorer hospitals were unable to find help when they needed it. Medical research concludes that being short-staffed at any time leads to worse outcomes and higher hospital death rates. 

The staffing pain in Arizona is emblematic of what took place in hospitals across the country during the pandemic, according to dozens of interviews with hospital executives and workers, public-health officials and industry experts. Hospitals by design were supposed to be lean and efficient, pushed that way by the market and government policies. But that left the U.S. dangerously unprepared. 

 “You’re looking at a private-sector entity that suddenly has to take on the world’s largest public-sector response,” said John Hick, medical director of emergency preparedness for Hennepin Healthcare, a public hospital system in Minneapolis. “They’re not prepared for it because there’s no incentive to do that.” 

 Banner Health said it acted prudently in keeping its pre-pandemic nursing staff lean. It said it had a cross-trained staff and that the system successfully expanded capacity during the worst of the pandemic, in part because of its financial strength. “You’re never going to sit there with 500 more nurses if they don’t have the patients,” said Peter Fine, the longtime CEO of Banner. “It’s this balancing act that literally goes on in every health-care organization around the country, all the time, in projecting what their business activity is [and] what staffing they need to support that business activity.” The health-care system has faced pressure over decades to improve financial performance, even as per capita spending has soared.

 Hospitals are pushed by Medicare and insurance companies to trim waste, and by bondholders and shareholders to boost income. Health-care systems have spent the past decade tightly managing staff and pursuing scale through acquisitions to better negotiate terms with health-insurance companies. Deal making across the hospital sector picked up with passage of the Affordable Care Act and has largely remained strong in the past decade, with an average of 84 combinations a year among general, surgical, specialty and long-term care hospitals, according to Irving Levin Associates, a research firm. Labor is typically the largest expense at any hospital, and nurses make up 42.7% of hospital payrolls, according to federal labor department data.

 In 2016, as an improving economy drove higher wages and signing bonuses for nurses, labor expenses grew faster than the median hospital’s overall operating expense, according to Moody’s Investors Service. Median operating expenses overtook hospital revenue that year and the next, squeezing margins and forcing hospitals to take a tighter grip on labor costs. In recent years, hospitals have shifted resources to outpatient settings for a growing number of lucrative, high-volume procedures such as knee replacements, bolstering staff outside hospitals where the sickest patients get care. For the past decade, the amount Medicare has spent per beneficiary on inpatient hospital services has grown 0.4% a year, compared with an average 7.9% growth in spending on outpatients, according to federal data. 

The upshot is fewer hospitals, with less capacity for intensive services. There has been a 12% decrease in the number of hospitals between 1975 and 2018, American Hospital Association data show—even as the U.S. population has grown about 50%. Even large nonprofit hospitals, which receive federal and local tax breaks and treat two of every three patients in the U.S., according to federal data, have adopted similar financial models. 

 “They are not the ‘Little Sisters of the Poor’ charitable institutions that hospitals once were back in the 19th century,” said Martin Gaynor, an economics professor at Carnegie Mellon University who studies the health industry. “These are big businesses.” 

 The global crisis exposed weaknesses in the “just-in-time inventory” of nursing staff in the same way it did for personal protective equipment, ventilators and other vital supplies. More than 5,300 Arizonans died of Covid-19, more than half in Maricopa County, where Phoenix is located. Strapped hospitals in the state’s smaller cities tried to move patients into Tucson and Phoenix. 

Arizona created a statewide transfer system and moved 2,451 patients, sometimes hundreds of miles. But some hospitals rejected transfer requests, despite reporting open beds. It “wasn’t due to lack of space or stuff, it was staff,” said state health official Lisa Villarroel. No hospital could fully prepare for a surge on the scale of the coronavirus pandemic, said disaster experts, but boosting nurse staffing outside a pandemic and routinely training staff to swap roles would better prepare them for sudden waves of patients. The goal is to avoid a having to deploy a “crisis standard of care,” a method of triaging who gets medical care when a system runs out of critical resources—including health-care practitioners. Arizona activated its crisis standard in late June. 

Banner postponed certain needed surgeries as it redeployed operating room nurses and technicians to help elsewhere in the hospital. Other Phoenix hospitals did the same. Banner said the state’s crisis standards didn’t influence its decision. Banner, Arizona’s largest private employer, was formed in 1999 in a merger and has a 43.5% market share of Phoenix’s inpatient hospitalization, more than the next two largest chains combined. Mr. Fine, the CEO, is one of the highest paid executives in the industry. His 2018 compensation was $10.3 million; a year earlier, his $25.5 million compensation was the highest of any nonprofit health executive that year, according to a Wall Street Journal analysis of filings.

A Banner spokeswoman said he received several years of deferred compensation, inflating his annual salary figure. Over the past five years, Banner Health has reported a combined $941 million in operating income and another $1.09 billion from its investments, according to Banner financial disclosures. Banner expanded into urgent care, building and buying 51 locations since 2016, and has a joint venture to expand from nine to 34 ambulatory surgery centers over the next three years, continuing its goal of shifting patients away from hospitals. It also plowed income back into existing facilities. It recently spent $857 million expanding and modernizing its two largest hospitals, in Phoenix and Tucson. To attract bond buyers and maintain high ratings, Banner expanded its cash reserve, which helps keep its cost of capital low. 

Banner Health finances about one-third of its investment in technology, property and equipment with debt, which now totals about $4.1 billion, said Dennis Laraway, chief financial officer for the system. “The stronger the credit, the cheaper the capital, the better the price,” Mr. Laraway said. Early in the pandemic, Arizona wasn’t as hard hit as some parts of the country. But the state’s new daily cases soared 10-fold between late April and late June. The state’s governor in late March ordered hospitals to be ready within a month to increase their available beds by as much as 50%, which Banner and other hospitals did. But they didn’t also ensure there would be enough skilled nurses to handle the possible crush of sick patients. “They needed to come up with a staffing plan,” Arizona Department of Health Services Director Cara Christ said. 

“They didn’t have to staff those plans.” Banner said it employs 11 full-time emergency-preparedness staff and first drafted its pandemic response plan a decade ago, which it activated in March. In June, as patients poured in from Northern Arizona, Banner halted transfers to Banner-University Medical Center Phoenix, one of its premier facilities, according to a spokeswoman. It shifted patients to Banner’s other area hospitals to manage the strain on its hospitals, including its staff. Brittany Schilling, a 27-year-old ICU nurse at Banner-University Medical Center Phoenix, said her hospital reached capacity several times in June. She recalls hearing several “Code Purple” announcements, an indication that her unit was at its capacity. Nurses at some of Banner’s Phoenix hospitals went from working three shifts a week to five. “I do feel like it has taken a toll, for sure. Physically. Mentally. Emotionally,” said Ms. Schilling. 

 

 Banner pulled staff from its ambulatory centers to help its ICUs. Lacking needed qualification, they were often paired with ICU-certified nurses. “We put them through very quick training programs to upskill their capabilities,” Mr. Fine said. It eventually trained and reassigned 700 employees. It also hired 898 nurses and 113 respiratory therapists on short-term contracts. By shuffling patients across its hospitals and hiring more staff, Banner ultimately denied only 13 transfer requests from the state and accepted 870 patients through the state-coordinated transfer center, a spokeswoman said. Less financially strong hospitals, which tend to be public or rural, were more vulnerable. Well-funded hospitals across the country soaked up much of the available supply of traveling nurses, leaving the rest priced out of the market. “Demand is through the roof,” said Alan Braynin, chief executive of Aya Healthcare Inc., a health-care staffing agency. Aya had 506 requests for ICU-registered nurses in June. By mid-July, the number of job requests was up to 2,870. In the early summer, Maya Jones’s phone began to buzz several times a day with recruiters. 

An ICU nurse on a three-month assignment at Johns Hopkins Hospital, she said the offers kept rising. “I don’t know how they got my number, but once these people have your number, they don’t lose it,” she said. The 26-year-old Virginia native signed a two-month contract beginning in August at the Chandler Regional Medical Center in the Phoenix area. It pays nearly three times what a contract she signed in January pays. By mid-June, the staff at Valleywise Health, a large public hospital in Phoenix, was worn down from pulling extra shifts. Sherry Stotler, the chief nursing officer, tried to hire 20 to 30 traveling nurses. “We needed to let people take time off,” she said. She was able to hire only six. “We weren’t getting a lot of bites because everyone was competing for the travelers,” she said. Valleywise, usually the hospital of last resort in the Phoenix region, began to turn down transfer requests from rural hospitals that wanted to send their sick patients to a better-equipped urban hospital.

 The situation was also chaotic at Yuma Regional Medical Center, a three-hour drive southwest of Phoenix on the Mexican border. The hospital had struggled to recruit to its remote location even before the pandemic, said Diane Poirot, the hospital’s chief human resources officer. During the crisis, the hospital paid top prices for temporary staff, only to have them recruited for better-paying jobs, Ms. Poirot said. 

Yuma Regional pulled nurses from its operating rooms, canceling surgery to free up staff. But on peak days in June, it was transferring as many as 11 or 12 patients a day on helicopters and airplanes, because it didn’t have enough nurses. Normally patients would be moved to Phoenix hospitals, but as that city strained under the surge, Yuma patients were moved elsewhere, said Glenn Kasprzyk, regional chief operating officer for Global Medical Response Inc., which handles about 60% of the state’s ambulance traffic. 

As Covid-19 cases climbed, nurse Yasmin Salazar said she was overwhelmed as the Yuma Regional emergency room flooded with patients gasping for air. “We weren’t used to how fast they were crashing,” said Ms. Salazar, who has worked in the emergency room for six years. Staff from other parts of the hospital were brought in to care for less-critical patients, but despite the reinforcements, nurses in the emergency room were stretched too thin for the number of critically ill who needed their help, Ms. Salazar said. She couldn’t leave one dangerously sick patient to help when an emergency code sounded in the room next door. “I couldn’t go,” she said. “We all had a critical patient.”

 Yuma Regional’s ICU also filled up. Typically, an intensive-care nurse is assigned to one or two patients. That increased to three to four patients for each nurse as the surge took off, said Gail Galate, one of Yuma Regional’s intensive-care nurses who works overnight in the hospital. “You spend all night figuring out, ‘What am I going to do for the next emergency?’ ” she said. “ ‘What am I going to do for the next person that crashes?’ It’s just nonstop.” Even though Banner was able to increase staffing, nurses at its hospitals were still stretched at the peak of Arizona’s surge. 

Charles Krebbs was taken by ambulance to Banner Thunderbird Medical Center on July 11, less than a week after his 75th birthday and after experiencing a fever and shortness of breath. It could be hard to get nurses on the phone, his daughter, Tara Swanigan, said. When Mr. Krebbs’s breathing worsened, he was moved to the ICU and placed on a ventilator. By Aug. 7, Mr. Krebbs’s health had declined and his daughter was allowed to visit for one hour to say her goodbyes. A night nurse with whom Ms. Swanigan had bonded on the phone switched shifts to be there to comfort her. Afterward, she watched through a window as they removed his ventilator. He died a few minutes later.

“They were overwhelmed, but we know that they did everything they could to treat my father.” she said. In early July, the state health department’s Dr. Christ took the uncommon step of saying the state would hire traveling nurses on behalf of hospitals who could not, even with bonus offers. 

 It contracted with Vizient Inc. to recruit nearly 600 intensive-care and medical-surgical nurses, all of whom had to come from outside Arizona to prevent intrastate poaching. By the time the contract was signed and nurses began to be placed in smaller cities such as Yuma and Flagstaff, it was the end of July, according to Vizient. 

By Aug. 7, half of the contracted nurses were on the job. But Arizona’s patient count was half its July peak and falling. The cavalry arrived, but after the battle was over.