It seems appropriate that our local hospital — the Central Vermont Medical Center — sits on a hill, above most of the communities it serves. It’s not that we gaze up with reverence, for CVMC is a fallible institution staffed by fallible humans. But when we or a loved one fall ill, we need hope. And by custom and intuition, the quest for hope often is attended by an upward gaze.
Seldom have we needed hope more than over these past two years. Since 2020, the COVID-19 pandemic has disrupted every semblance of life as we knew it, and has ended the lives of more than 6 million people worldwide, some 980,000 Americans, and more than 600 Vermonters. (Right now — dare we say it aloud? — the pandemic seems to be waning in our little corner of the world, although the BA.2 subvariant clouds the horizon.)
Through it all, central Vermont has not been spared, nor has the hospital that serves us. Every facet of its operations seems altered, starting at the front door. A set of stanchions channels visitors to a desk where they’re met by employees who screen for COVID symptoms and direct them to the area they seek; there, chairs are widely separated and reading materials have been removed to prevent contamination by touch. (Masks, of course, are ubiquitous.) The same is true at the Emergency Room entrance. Austerity has replaced the congeniality that hospitals normally try to convey to a clientele that would rather be almost anywhere else.
Yet, based on this writer’s experiences during the COVID years, once a patient or visitor reaches the actual medical providers at CVMC, that sense of austerity disappears. The providers are solicitous and kind. One might surmise they’ve found that their own comfort and cheer depends in large measure on their ability to instill those feelings in the people who have come to them for help — and that if the coronavirus can be contagious perhaps empathy can be, too.
“You know, I’m really proud of the staff here,” says Robert Patterson, vice president of human resources and clinical operations at CVMC. “They’ve shown incredible resiliency, and I think they’ve done wonderful work, and that they care deeply … for our community and our patients.”
“But I will say,” he adds, “that they’re tired. It’s been a really hard period of time, and we really appreciate our staff prioritizing their patients and taking care of them [when] at the same time they have challenges at home. They’ve had kids who are out of school because of an exposure or schools or daycares closing down, or family members who have contracted COVID, while they’re trying to balance taking care of our patients. It’s been a very difficult process for them, and I think they are definitely fatigued.”
The pandemic era, for CVMC and other hospitals, can be roughly divided into two periods: the early days, with a new and alarming illness that the medical community hadn’t figured out how to respond to (beyond keeping everyone at the maximum feasible distance from everyone else) — and the later period, when they knew more about its means of transmission, masks and other protective equipment became commonly used, and eventually vaccines were developed.
This prolonged second period has not been easy; that’s when the Delta variant arrived and Vermont’s cases, and mortalities, spiked. Then came Omicron.
According to communications manager Hjonis Hanson, CVMC saw its greatest influx of COVID-19 admissions this past January and February, 2022, hitting a pandemic-high of 14 COVID inpatients in the final week of January. Adding to the stress, the height of the Omicron outbreak coincided with staff members being most afflicted — not so much by the disease as by the impacts on their families that Patterson described (above). Up to 75 hospital employees missed time at work during that time because of “COVID-related precautions.”
(By late March the numbers had shrunk to just a couple patients a week diagnosed positive for COVID, and just a few staff members absent at any given time.)
Nevertheless, despite the escalation in cases staff better understood there was less mystery about the disease than there had been at the start, and the hospital had deployed protocols — which shifted and evolved as COVID did, itself, but which provided at least a certain measure of routine.
“Very early on, in 2020,” Patterson recalls, “we shut down a lot of outpatient services. We had our employees flexing to different departments. So we had people, for instance, in rehab who were doing COVID screenings at the doors.”
As diagnosis and prevention strategies emerged, CVMC continued shuffling staff.
“We started doing testing, we set up vaccine clinics,” says Patterson. “We started moving all these different kinds of initiatives forward and were able to utilize staff to kind of meet those needs.”
While there have been reports of hospitals elsewhere reaching their limit on medical equipment — for example, forcing doctors to choose which patients would be put on ventilators because there weren’t enough for them all — Patterson insists nothing of the sort has happened at CVMC.
“We have a great capacity to take care of COVID patients,” he says. “We don’t have any limitation of equipment or resources whatsoever.”
Furthermore, he says, “We’re not turning patients away, and we haven’t done that at all. We’re able to accommodate patients as needed.”
A local physician (not formally interviewed for this story, and therefore not identified here) explained that a major reason CVMC has been able to handle its patient load is that vaccination numbers here and in Vermont as a whole have been high. Even though Vermonters were stunned by the explosion of COVID cases and deaths last fall and early this winter, the physician pointed out that an 80% vaccination rate still left some 125,000 unvaccinated people and an untold number of vaccinated but immune-compromised Vermonters dangerously susceptible to the virus.
“That’s a lot of people,” he said.
“And,” he added, referring to that startling outbreak, “that’s the nature of pandemics. They’re like wildfires.”
He explained that a fire might seem to have been brought under control but then spring up unexpectedly someplace many miles away. That happened not far from here in the 1918 flu epidemic, the doctor said. By midyear or so in 1919 it seemed to have been largely contained, when a deadly outbreak erupted in southern Maine. It was an ember, among the last in that terrible scourge, but no less frightening for that.
For the record, a hospital spokesperson reported in mid-March that during the current pandemic there were “11 deaths at Central Vermont Medical Center where the patient had a COVID-positive diagnosis.”
COVID and Our Children
Vermont healthcare advocates have pointed out for years that mental health has never been given equal weight and consideration as physical health in traditional insurance and healthcare practices in the U.S. Dr. Anna Hankins, medical director of Pediatric Primary Care at CVMC, adamantly says that the two are inseparable in pediatric medicine. It’s through that lens that she weighs the effects of the COVID-19 pandemic on her patients.
Hankins agrees that although some children have gotten very ill and have been hospitalized with COVID, the vast majority have mild cases. In part, she credits Vermont’s high vaccination rates for children and adolescents.
“That said, what we’re dealing with is the challenge and the stressor of what happens to children when you put them in remote learning and take away their [personal interactions]. It was sort of like a great experiment, right? What happens when you cancel sports and put kids on iPads for learning? We’ve learned it’s really bad for kids, and bad for teenagers. And we’ve seen that mental health fallout — adolescents having eating disorders and needing hospitalizations at much higher rates than prior. … I’ve seen that in my own practice.
“If you had called me in 2018 and asked me what is helpful for kids’ mental health I would have said they need plenty of sleep and regular routines in their lives and a loving household,” says Hankins, herself a mother of four. “I would not have said ‘They need to be in school, and they need to be in sports, and if they’re not in sports they need other kinds of activity.’ I would not have been super-pro every teenager having a job — like, maybe that takes away from school.
“Now I just recognize that kids need to get out of the house and interact with their friends and have responsibilities. Without that, it’s been bad for them.”
Physicians, she emphasizes, are not venturing out of their element when they express these concerns.
“I see kids from birth through 19 or 20,” she says. “A huge part of medical care is social and emotional health. So when I see children who have anxiety, depression, disordered eating, body dysmorphia, attention deficit hyperactivity disorder, developmental delay, behavioral problems secondary to recurrent early-childhood stressors. … These are all things I see, diagnose, and treat.”
These intertwined physical and emotional maladies existed before the pandemic, and they’ll persist after. But with their potentially long-term effects, it challenges the accepted wisdom that the coronavirus goes easier on the young.
Do the Math
Here are some numbers — approximations, it must be stressed — that frame the decisions Patterson and other CVMC administrators make on a regular basis: 70 and 1,700.
The first number reflects the ongoing “budgeted volume” assessments administrators calculate regularly: that is, the number of inpatients (people admitted for care) the hospital can accommodate. Seventy, he clarified on a day early in March, “is actually above budgeted volume. Today we’re at that.”
Seventeen hundred (1,700), by contrast, is the rounded-off number of people who work there. “But,” Patterson said that day, “we have about 200 positions open right now.”
The pandemic had a lot to do with the high patient census — but it was because COVID numbers had been declining, enabling people who had deferred their care early in the pandemic to finally come in for treatment. Patterson described it as something of a non-COVID surge.
“They’re in need of catching up. So it’s a busy time at the hospital.”
A complicated one, too. Consider surgeries.
“We have elected periodically to delay or reschedule some surgeries that were elective [not critical to a patient’s survival] but that needed to have admissions. We have not stopped elective same-day surgeries where people could be discharged; we’ve continued to do those all along. And this week we’re not delaying any surgeries, including where patients are admitted.”
As for being “above budgeted volume,” Patterson emphasized that it’s a prediction.
“It doesn’t mean we’re above the number of people we can take care of. I think that’s important for people to know.”
Surely, though, those 200 open positions weren’t making it any easier. Patterson listed several factors that have contributed to a 5% greater turnover than usual: senior employees who retired early rather than enduring the stressful conditions imposed by the pandemic; employees with familyies concluding that their priorities lay at home, attending their children, or not even having a choice in the matter as schools and daycares closed; and in some cases CVMC nurses seizing the opportunity to become “travelers” — well-paid, temporary nurses, finding work elsewhere, which, unfortunately, leaves CVMC needing to hire travelers to replace them.
The Need for Nurses
Truthfully, though, the pandemic has merely exposed a long-simmering problem. In 2018, Patterson says, the state of Vermont performed an analysis that projected a need for 1,800 registered nurses (RNs) to meet forecasted needs by 2020. Updated this year, that projected need increased to 2,600, plus more than 500 licensed practical nurses.
“We graduated less than 300 RNs in 2018, and we still graduate less than 300 RNs from Vermont colleges,” said Patterson. “Then, you have a subset of those RNs who don’t intend on staying [in Vermont]. Do the math. It’s not very optimistic.
“And it’s not only nurses. We have shortages in our radiology department, and there’s a variety of ancillary services where we have staffing challenges as well.”
Statistics such as these contributed to an unprecedented mid-year request that CVMC and the UVM Medical Center made jointly on March 18 to the Green Mountain Care Board — the regulatory agency that authorizes hospital budgets in Vermont — for a 10% rate increase for the remaining half of the hospitals’ fiscal year. Even with the assistance of federal COVID-19 relief funds, CVMC projects a budgetary shortfall of $5 million. The hospitals cited inflation as the major cause of their financial woes, but staffing shortages also played a large part. The vaunted law of supply-and-demand has created a significant pay differential between full-time resident nurses and contracted nurses from “away.”
Patterson is bullish about CVMC’s “Pathways” program, which pays and trains existing staff, while they’re working, to advance their qualifications — LPNs, for example, becoming RNs. Another new program recruits international nurses to work and settle in central Vermont. (For more on these important efforts, see “Medical Center Uses Career Growth, Foreign Nurses,” The Bridge, March 9, 2022). Yet he acknowledges that they won’t solve the immediate staffing problem.
“The travelers,” he says, “aren’t going away anytime soon.”
Progress — and its Antithesis
A pandemic — a public emergency — carries the force to bring people together. Despite the physical distance and the barriers (masks, shields) they must maintain, there’s a unity of purpose that ultimately is the only way for society to survive. Pediatrician Hankins has seen the staff at CVMC rise to the occasion.
“We’re having to figure things out kind of rapidly as things keep changing,” she says, “and having to do that even with staffing shortages. Yet we know how to pitch in as a team and support each other. Yet there’s a lot of fatigue. For one thing, in the past we’ve been able to leave work at work and go home. But COVID doesn’t stay at work.”
Particularly in the early going she found herself at evening time thinking back on her interactions with her patients that day and wondering whether she had taken every precaution she could have to keep her family safe.
“Now it’s gotten more routine,” she says. “And we’re vaccinated. We can rely on it.”
For the medical staff that’s been a great leap forward, and they’ve sought to share it.
“One of the things we’ve done at our clinic that I’m really proud of is that we have the COVID vaccine and we’ve been vaccinating not just our teenagers, but our parents. So, every visit, we’re asking parents, ‘Are you vaccinated? Would you like us to vaccinate you today?”
“Early on, even if they weren’t ready, that was greeted with gratitude. [People said] ‘I’m so glad you guys are taking this so seriously!’”
“Now it’s a hard ‘No.’ And irritation and anger and defensiveness. And that’s hard, because I’m coming from a place where I care about you, I care about your health, and I strongly recommend this.
“So to have that greeted with anger makes it hard to keep checking in and doing what I know is the right thing to do. It makes it like, you dread asking.”