"We are writing to you to express our concerns about the Delta Variant of COVID-19 and to recommend that our school district implement safety protocols beyond those that have been in place this summer to address this exigent threat. The rapid increases in COVID-19 cases, hospitalizations and deaths locally and throughout the US in recent weeks are alarming and require an appropriate response. Indeed, we are seeing rising COVID-19 cases in our practices."
"Please help us honor the health and sanctity of our children’s lives through your sincere attention to these recommendations. We would welcome the opportunity to collaborate with the district/school in promoting the health and safety of our community during this new and troubling phase of the pandemic. "
-Letter from the physicians of Cook Children's Hospital of Fort Worth to the leadership and school board of Fort Worth ISD
High resolution version of today’s graphic: https://drive.google.com/file/d/1RJKoiSUASljqYsXhQNoe2PlkxhbIn2pL/view?usp=sharing
BACKGROUND
Five days ago I posted about the forecast data for hospitalization and critical care usage for the State of Texas based on the data from the UT Austin COVID-19 Modeling Consortium. It was sobering to say the least. I referenced this data in my public comments to the Lewisville ISD school board this past Monday but it appears to no avail as they are not going to enact the pandemic measures that we as medical professionals consider necessary for safe operation of our schools.
In the last five days we have seen multiple school districts defy Texas Governor Greg Abbott as well as a number of lawsuits get filed. The number of school districts and counties doing what is right and placing lives above political considerations grows, but the pandemic trajectory has shown little sign of offering any hope for Texas hospitals in the next several weeks.
DATA SOURCES FOR TODAY
The top half of the graphic comes from the University of Texas COVID-19 Modeling Consortium forecast page. Can see their pandemic forecasts for the whole state of Texas (as I have done here) or by Trauma Service Areas (TSAs) which are based around metropolitan areas of the state. Check it out for yourself here: https://covid-19.tacc.utexas.edu/dashboards/texas/
The lower half of today’s graphic comes from the pandemic dashboard for the University of Texas Houston School of Public Health, www.texaspandemic.org. If you go to the "Hospitalizations" section of their page, at the bottom half of the page it breaks down ICU utilization and hospitalizations by Trauma Service Area (TSAs) again.
This is a map of the Trauma Service Areas and which counties fall in which TSA: https://www.dshs.texas.gov/emstraumasystems/TSA_CountyList2010_RAC.pdf
I cross checked UT Austin's data against UT Southwestern's forecast modeling data and they're in close agreement overall. You can review UT Southwestern's latest forecast data here: https://www.utsouthwestern.edu/covid-19/about-virus-and-testing/forecasting-model.html
HOSPITALIZATION AND ICU FORECASTS FROM THE UT AUSTIN COVID-19 MODELING CONSORTIUM
I've been following UT Austin's Modeling Consortium since the start of the pandemic and have found their work to be solid and of much use in determining the pandemic trajectory. The two plots here are for both daily hospitalizations and daily ICU patients in Texas- green plot is historical data and then it shows several model runs going past Labor Day weekend to 08 September.
I have listed three forecasts for each plot- the worst case scenario, the best case scenario, and the median case scenario. Think of the best case and worst case as the 95% confidence intervals for the median case. Think of the median case as like the most likely outcome but that can fall anywhere within the 95% confidence interval range.
These outcomes are based on current trends (as in societal behavior) remain as they are- no mask mandates, 100% in-person schooling, lower than desired vaccination rates, and no social distancing or capacity restrictions on public spaces.
I have also included what is currently available and that's from official State of Texas numbers.
Over on the left side of the top graphic I have the forecast numbers as they stood on 07 August when I made my previous posting about the impending crisis.
DAILY COVID HOSPITALIZATIONS IN TEXAS
We currently have 7,458 available hospital beds across the entire State of Texas. Assuming no changes in what we are doing *now* in terms of pandemic mitigation, the number of hospitalized COVID patients in Texas by 08 September could range from as low as 18,529 to as high as 51,855 patients.
And that's for 7,458 currently available hospital beds.
Yes, we could probably do surge capacity but where do get more physicians and nurses to staff those beds? Trained personnel is the bottle neck in hospital bed capacity.
This forecast compared to five days ago shows some reductions in the median case scenario and the best case scenario but an increase in numbers with the worst case scenario.
DAILY COVID INTENSIVE CARE UNIT PATIENTS IN TEXAS
We currently have 321 ICU beds across the entire State of Texas and by official number, 6,655 ventilators. Assuming no changes in what we are doing *now* in terms of pandemic mitigation, the number of COVID ICU patients in Texas by 08 September could range from as low as 4,834 to as high as 13,537 patients needing ICU care.
AND THAT IS FOR JUST 321 AVAILABLE ICU BEDS. IN THE WHOLE STATE OF TEXAS.
Not every ICU patient will need a ventilator. Early in the pandemic, about 75% of patients admitted to an ICU for COVID needed a ventilator. Thanks to what we now know about treating serious infection, that percentage is now about 50% of ICU patients will need mechanical ventilation.
CURRENT ICU AND HOSPITAL BED MARGINS IN TEXAS
The lower graph comes from the University of Texas Houston School of Public Health and shows the occupancy in ICUs across Texas by trauma service area (TSA) as well as occupancy in regular hospital beds. The fraction occupied by COVID patients is shown as well.
I have added a red line to show the 10% margin. In watching this data over the course of this pandemic, that's roughly where margin can easily be eaten up inside of 24 hours by a surge in COVID admissions.
In terms of ICU margins, the most critical TSAs are the following:
Laredo, Corpus Christi, Galveston, Bryan/College Station, and Lufkin 0%
(note Lufkin is -2% suggesting overflow)
Austin 1%
Abilene 2%
Killeen 2%
Waco 4%
Victoria 4%
Lubbock 5%
Dallas/Fort Worth 5%
Paris 5%
San Antonio 5%
Houston 6%
Lower Rio Grande Valley 6%
Wichita Falls 8%
Amarillo 9%
El Paso 9%
In terms of general hospital bed margins, the most critical TSAs are the following:
Laredo 0%
San Antonio 8%
Galveston 8%
Dallas/Fort Worth 9%
A priority email went out this evening from Parkland Hospital, the main hospital in Dallas County, this is what was shared about the contents of the email on one physician social media group:
“Things are getting worse at Parkland. Just got a priority email stating as of yesterday our region has 2500 Covid related admissions, with a daily increase of 5-10%."
"They outlined “possible likely” future steps including limiting in person outpatient appts (in favor of virtual) and shifting outpatient staff (including physicians, nurses and allied health) to the inpatient side."
"Stay safe everyone, I’m afraid it’s about to get rough.”
TAKE HOME MESSAGES
1/ Hospitalizations are lagging indicator. What hospitalizations look like NOW is a reflection of the pandemic environment 3-4 weeks ago. What we do NOW as a society will influence hospitalizations and ICU admissions in the days going into September.
2/ Compared to five days ago, ICU margins across Texas have deteriorated quickly. And we're not even in the worst of it even if we were to follow 1/2 of the best case scenario outlined above.
3/ In the absence of swift, broad ranging intervention, we will face a hospitalization and ICU crunch unprecedented in our state's history. It will be a mass casualty event of the highest order the likes our state has never seen since the Galveston Hurricane of 1900. I have never seen the numbers this bad, even during the holiday surge that stretched from the end of October 2020 well into January of this year. I said this same exact thing five days ago. Nothing has changed in the intervening five days.
4/ Keep in mind we need ICU beds for things like car accidents, heart attacks and strokes, diabetic complications, victims of violence and accidental injuries. Where should we send them when the need for ICU beds due to COVID is outstripping what is available by a degree unprecedented in our state's history?
5/ The medical and scientific community has made repeated warnings about the Delta variant's impact with schools in Texas going 100% in-person with no mask mandates. That would be throwing gasoline on this fire. Pediatric hospitalizations are on the increase to historic levels nationwide. The mutations in the genetic code for the Delta variant make it a clear and present danger to those who choose to not be vaccinated and those who are too young to be vaccinated. I emphasized this point explicitly to our local school board this past Monday night to no avail.
6/ What we learned about schools as transmission vectors for COVID last year DOES NOT APPLY THIS YEAR. The Delta variant has changed that game and our assumptions from last year are going to be overturned in the worst possible way if they are not abandoned by school boards across Texas quickly.
PARTING THOUGHTS
I'm beyond frustrated at this point. I will leave you with a quote from veteran news anchor Dan Rather:
"The nurses, doctors, orderlies, and every other healthcare worker who sacrificed and risked their lives do not deserve this insanity. They held the line until vaccines arrived just to be treated with contempt from people who will demand care when the get sick - which many will."
PAST PANDEMIC POSTS
WHEN POLITICS IS MORE IMPORTANT THAN LIVES (12 August 2021):
https://www.facebook.com/jp.j.santiago/posts/10219314135261090
RESOLUTE ACTION IS NEEDED NOW (11 August 2021):
https://www.facebook.com/jp.j.santiago/posts/10219307334851084
OH YEAH, HE DEFINITELY SAID IT (10 August 2021):
https://www.facebook.com/jp.j.santiago/videos/532381177877817/
HE SAID WHAT? (09 August 2021): https://www.facebook.com/jp.j.santiago/posts/10219302093640057
QUICK UPDATE: TEXAS ACADEMY OF FAMILY PHYSICIANS STATEMENT (09 August 2021):
https://www.facebook.com/jp.j.santiago/posts/10219299843863814
TEXAS HOSPITALIZATION CRISIS POINT (07 August 2021):
https://www.facebook.com/jp.j.santiago/posts/10219292575242103
SCHOOLS AND COVID RISK: DFW METROPLEX (06 August 2021):
https://www.facebook.com/jp.j.santiago/posts/10219288099490212
COVID TRENDS: TEXAS (03 August 2021):
https://www.facebook.com/jp.j.santiago/posts/10219275998347691
NEW VARIANT OF CONCERN: AY.3 (DELTA SUBVARIANT) (22 July 2021): https://www.facebook.com/jp.j.santiago/posts/10219219371852064
HE SAID WHAT? A WARNING FOR THE UNITED STATES (12 July 2021): https://www.facebook.com/1141591254/posts/10219175207947994
WHERE IS THE DELTA VARIANT SURGING? (11 July 2021):
https://www.facebook.com/1141591254/posts/10219170740476310
COVID VARIANTS TABLE UPDATE (30 June 2021):
https://www.facebook.com/jp.j.santiago/posts/10219119070944604
MAYO CLINIC GRAND ROUNDS: VACCINES AND VARIANTS (14 June 2021):
https://www.facebook.com/jp.j.santiago/posts/10219031846404045
THE MOLECULAR BIOLOGY OF THE E484K MUTATION (10 May 2021):
https://www.facebook.com/jp.j.santiago/posts/10218832046529173
IMMUNOLOGY 101: THE IMMUNE SYSTEM- REPOST/UPDATE (05 May 2021):
https://www.facebook.com/jp.j.santiago/posts/10218801066954703
COVID VARIANTS OVERVIEW AND UPDATE (22 April 2021):
https://www.facebook.com/jp.j.santiago/posts/10218722676514991
NEW COVID VARIANT OF INTEREST: B.1.617 (18 April 2021):
https://www.facebook.com/jp.j.santiago/posts/10218699298170547
CASE SURGES CAN RESULT IN COVID VARIANTS (12 April 2021):
https://www.facebook.com/jp.j.santiago/posts/10218657527966318
THE OVERVIEW & STATUS OF COVID VARIANTS (9 April 2021):
https://www.facebook.com/jp.j.santiago/posts/10218637120816152
QUICK UPDATE: THE COVID FAMILY TREE (01 February 2021):
https://www.facebook.com/jp.j.santiago/posts/10218211054244754
COVID MUTANTS: VARIANTS OF CONCERN (31 January 2021):
https://www.facebook.com/jp.j.santiago/posts/10218204381877949
COVID MOLECULAR BIOLOGY: THE SPIKE (6 January 2021):
https://www.facebook.com/jp.j.santiago/posts/10218019683340601