The images are both real and unimaginable. Bodies loaded into refrigerated morgue trucks. Makeshift hospitals thrown up like MASH units. Navy ships anchored offshore.
New York, hit harder by the coronavirus than anywhere in America, is reeling from the pandemic, an example of what Florida could become in a few short weeks.
On March 22, New York had 15,000 total coronavirus cases and 9,000 in New York City alone. More than 50 people were dying every day. Already more than 370 people had died.
Florida is nearing that juncture: more than 11,000 people infected, 191 dead, 40 of them on Thursday alone. In two weeks, Florida is projected to lose more than 100 people per day.
Perhaps Florida will never experience the devastation of New York, with its larger, more condensed population and a mass transit system that helped carry the virus through the city. New York is expected ultimately to suffer more than 800 deaths a day, more than 80% higher than Florida at its peak.
But government and medical leaders here say they are preparing for far worse conditions than we’ve seen so far. Like New York, they are creating bed space in hospitals, recruiting more medical staff, creating field hospitals and stockpiling ventilators — all earlier in the crisis than New York did, they say.
But there are troubling signs here, too. On the ground, many people worry about a lack of testing, coordination among state and local officials and shortages of equipment to protect those on the front lines.
In addition, Florida’s hesitance to lock down the state, ordering everyone to stay home, may have left its citizens vulnerable for too long.
On balance, are we ready? We appear to have the hospital space and treatment options we need as the disease escalates. Florida’s fate might be determined more by whether the state can overcome its delays in testing, properly equip its medical professionals and persuade its residents to stay home until it’s safe.
Making room for patients
Compared with New York, Florida appears to be quickly creating hospital beds to treat coronavirus patients, although ICU beds could fall short of what’s needed.
On March 22, New York’s governor asked hospitals to come up with a plan to expand their capacity by at least 50%. The state had 53,000 hospital beds available at the time. To aid this dramatic scale-up, Gov. Andrew Cuomo canceled all elective, non-critical surgeries to free up staff, space and supplies.
Florida’s governor put a similar order in place on March 20, far earlier in the disease’s progression.
According to data from the Agency for Health Care Administration, Florida had 24,000 beds available as of Friday, as well as 2,250 ICU beds.
By the projected peak date of cases in early May, the Institute for Health Metrics and Evaluation believes Florida will meet its need for hospital beds but have a 27% shortage of ICU beds.
Jared Moskowitz, director of Florida’s Division of Emergency Management, said South Florida will be in position to cover shortages by leaning on field hospitals, which the state has built ahead of New York.
On March 22, Cuomo announced that a 1,000-bed hospital would be built at a large convention center. Later, a 1,000 bed Navy ship was added to the equation. Both began operating only this week.
Moskowitz said two 250-bed field hospitals are already available in Broward and Miami-Dade counties. The Miami-Dade hospital also has capacity to increase its bed count to 500 if necessary. As of now neither hospital is being used.
Moskowitz said plans have been submitted to the U.S. Department of Health and Human Services and FEMA to open another 250-bed indoor facility at the Miami Beach Convention Center and use two hotels in South Florida to add 500 more beds. More facilities such as hotels and dormant hospital buildings — like a rehab center at Jackson Memorial that was recently replaced with a new center — will be brought back online to house more beds.
Meanwhile, hospitals say canceling elective surgeries has given them the capacity to flip operating rooms into standard beds and ICU beds, as well as free up key nursing staff for a potential rush in coronavirus patients.
Dr. Stanley Marks, Memorial Healthcare System’s chief medical officer, said he has 300 beds on standby for the six hospitals in his system — in addition to the current capacity. He said the hospitals also will convert auditoriums, conference areas and classrooms into patient areas to create more bed space. Broward Health System and Tenet Healthcare’s hospitals said they will do the same.
Wael Barsoum, CEO of the Cleveland Clinic, said they have capacity to build up to 2,400 patient beds inside his hospitals, but also will convert outpatient facilities into more makeshift hospitals.
He said they have have identified 30,000 square feet of air conditioned building space that can be converted to an extra 400 beds for patients too sick to go home but not so sick that they need a ventilator.
Ventilators in storage
Just as critical is the need for ventilators, the machines that keep air pumping through infected lungs. Hospital leaders say they have many options to ensure that every person who needs a ventilator will get one.
According to the Institute for Health Metrics and Evaluation at the University of Washington School of Medicine, Florida will need roughly 2,050 ventilators during the peak of its pandemic in early May.
Moskowitz said the state has about 500 ventilators in storage and will soon add 2,000 more. But he did not specify when that target would be reached.
Locally, Miami-Dade County Mayor Carlos Gimenez said he had 708 ventilators available on Tuesday. A spokesman for Broward on Wednesday said 269 ventilators were available. Palm Beach officials declined to release their figures.
Dr. Kelley Davis, director of the Disaster and Emergency Management program at Nova Southeastern University, said research from China and New York show that of the 10% to 20% of coronavirus patients who require hospitalization, anywhere from 30% to 45% require a ventilator.
Based on that research, Florida could need about 800 ventilators, but that would scale up to 1,600 as cases doubled and 2,400 as if they tripled. South Florida could need at least 430, which seems within reach.
Often, Davis said, the number needed depends on the age of a patient and their underlying conditions. She said South Florida’s unique population makes it likely that the region will require more ventilators than average.
To bolster their stockpile, hospitals said they are looking to buy more ventilators, while also moving forward with plans to convert existing anesthesia machines into ventilators for extra support.
At the five Cleveland Clinic hospitals in Florida, CEO Barsoum said they have 280 ventilators between all of the hospitals, about twice as many as they need for their ICU. Nonetheless, they still have plans to convert machines and are already training anesthesiologists to manage ventilators in the ICU setting as opposed to the operating room.
Peter Antevy, an EMS physician and medical director who oversees emergency response for Davie, Coral Springs, Parkland and Palm Beach County, said if South Florida gets to a point where hospitals don’t have enough ventilators, doctors also plan to re-purpose BiPAP and CPAP machines used to treat people for sleep apnea to treat coronavirus patients with less severe conditions and free up normal ventilators.
“Any and every innovative idea is going to have to be utilized,” Antevy said.
In New York that is already happening. This week Gov. Cuomo purchased 3,000 additional BiPAP machines.
Behind on testing
Even with more ventilators, Florida will not be able to stay ahead of the coronavirus without testing more residents to identify hot spots and to help hospitals conserve healthy staff and equipment.
New York has consistently outpaced Florida — and the rest of the country — on testing for the virus. By March 22, the point where Florida lies now, New York was testing nearly 16,000 people a day, a figure the state has kept up since.
Thus far they have tested over 240,000 people — about one test for every 80 residents.
Florida has raced to increase testing and marked its biggest day yet on Friday, testing nearly 14,000 people. Roughly 106,000 tests have been issued statewide as of Saturday. Previously Gov. Ron DeSantis said he wanted to scale up to over 100,000 total tests. But that still amounts to one test for every 200 residents, far short of New York.
Dr. Ian Mcgruder, an internal medicine resident physician at Jackson Memorial Hospital, said faster and wider testing will be needed to get a handle on where the virus is spreading and protect hospital staff from unknowingly putting themselves at risk as more patients stream in.
“Prompt testing is one of the keys to gaining control and minimizing casualties,” he said.
While rapid-testing kits are coming to South Florida, most testing is being done at drive-thru sites. In addition to existing drive-thru sites in South Florida, DeSantis said he will open two more drive-thrus in Miami-Dade as well as another in southern Palm Beach County, which leads the state in deaths.
The county’s first drive-thru testing site did not begin operating until this week, and it was flooded with calls. The site received over 70,000 calls in one hour Thursday and scheduled over 800 appointments for Saturday. It was forced to close down the hotline afterward.
By the end of the day Thursday, a spokesman said only 381 patients had been tested.
Lake Worth City Commissioner Omari Hardy tweeted Thursday that over 300,000 Palm Beach residents have already applied for testing. He said the current cap on testing capacity per day for the county is clearly not enough.
“Thousands of tests once or twice a week is barely a drop in the bucket,” he said.
Lacking medical supplies
Beyond testing, the lack of supplies for medical professionals threatens to cripple Florida’s response to the pandemic. Too many doctors and nurses say they lack the protective equipment they need to avoid getting sick themselves.
On March 24, New York Gov. Cuomo said he had distributed close to 340,000 masks, 145,000 gowns and 200,000 face shields to hospitals in New York City, Long Island and Westchester. Since then, access to supplies has been a constant need as cases continue to mount.
Moskowitz, the head of Emergency Management, said Monday that the state of Florida received 500,000 N-95 masks, 250,000 face shields and 200,000 gowns from a federal government stockpile. Securing more masks has been difficult, leading Moskowitz to openly plead on social media for more.
On Thursday night, a frustrated Moskowitz doubled down on those pleas while appearing on Fox News and blasted N-95 maker 3M for putting foreign sales above sales to states like Florida.
“Since when do we have a U.S. company who sells masks and I try to offer them money and they won’t sell them to me,” he said. “I’m relegated to making deals with brokers at costs that are 10 and sometimes 20 times the actual costs of these masks.”
Costs aside, he said, getting the masks is most important. “And we can’t even get them.”
While state officials attempt to wrangle supplies for the future, nurses and first responders on the ground say they have yet to see any supplies come from the state.
“If it’s happening, it’s happening at a slow pace,” said Jason Smith, president of the local firefighters union for the Broward Sheriff’s Office.
Smith said the supplies his 700 firefighters and paramedics are using have come from their own stockpile as well as new items they have been able to purchase on their own and secure from donations. He estimates they have enough to last 30 to 60 days, but he said that projection would change once coronavirus calls begin increasing in the coming weeks.
Martha Baker, a registered nurse at Jackson Memorial and president of its nurses union, said she has been told there is enough protective equipment stored in hospital warehouses, but the reality of what is being handed out on the floor looks different.
“Nurses are telling me they feel like they have to sing a song to get it,” she said.
Staffing up … and down
Florida is only now beginning to recruit the staff it will need for its expanded hospital facilities, but not on a statewide level.
Contrast that with New York, where Gov. Cuomo this week deployed emergency paramedics, nurses and ambulances from other parts of the country to help staff overwhelmed hospitals and field operations. He also launched an online portal to connect hospitals and health care facilities with potential staff, and 85,400 volunteers have signed up.
Florida has yet to issue such a call statewide, but locally they have started going out.
Broward County Mayor Dale V.C. Holness asked Thursday for volunteer doctors, nurses, pharmacists and therapists as well as administrative and clerical staff.
Dr. Davis of Nova Southeastern said that once Florida’s peak in cases bears down on hospitals, she imagines the state will issue a call to funnel workers from other parts of the state to hard-hit areas. “We do it during hurricanes,” she said. “People always answer the call.”
In the meantime, Gov. DeSantis signed an executive order Monday allowing recently retired law enforcement officers, first responders and medical professionals to return to work, which Moskowitz said would allow the state to tap more workers if needed. He said the state also has 300 nurses, doctors and physicians assistants on contract and 300 medics ready to deploy from the National Guard.
Smith, of the local firefighters union, said DeSantis’ order will allow him to scale up by 200 more first responders.
At Jackson Memorial in Miami, Baker said 300 nurses who normally work in operating rooms are being retrained to assist incoming ICU patients. If needed, more nurses can be tapped from the pediatric wings, which have seen about a 50% drop in visits recently.
However, the lost revenue from elective surgeries and the decrease in non-coronavirus visits has led hospitals to furlough nurses. Other health care workers say their hospitals are reducing staff hours, forcing paid time off or reducing pay.
Leaders at these hospitals pledge that they will be able to staff back up once a surge of coronavirus patients arrives, but Baker said the weeks before that happens should be used to prepare, instead of sending workers home.
“This is not a time to be furloughing nurses. We need to be training them,” she said. “If we turn into an Italy or New York, we are going to need all hands on deck.”
Fragmented health care
Even if adequate staff is available, a lack of coordination among emergency responders and health care systems could hinder Florida’s response effort and put lives at risk.
In New York, Councilman Francisco Moya of Elmhurst said he watched one public hospital in his district become overrun with patients in a matter of days, leading to viral videos online. Once cases started to cluster dramatically, the hospital had long lines of people waiting to get tested, 13 deaths in one day, and too many bodies for the morgue to handle.
Moya said a misstep that the health care system in New York made early on was not communicating effectively with each other and shifting resources to areas that needed it most. Instead, some hospitals became overrun while others barely had patients.
To address that issue, Gov. Cuomo said Tuesday that the normally separate public and private health care systems in New York would merge. “The distinction of private and public, that has to go out the window,” he said.
Antevy, the EMS physician and medical director, said he is worried there isn’t enough coordination yet between different hospital systems and emergency responders in Florida to deal with sudden outbreaks like the one that hit Elmhurst.
Moskowitz said hospitals do have that communication in place and will use it. He also said a unified command system is an “interesting concept” but would be difficult to pull off in sprawling Florida. “You can’t just move a patient from Dade to Orlando.”
However, Smith, of the local firefighters union, said the lack of communication and planning extends beyond hospitals.
He pointed to a March 30 letter addressed to Broward County commissioners and signed by the Broward County Medical Association, the Greater Broward EMS Medical Association and other first responders.
The letter points out a lack coordination from the local emergency management and department of health staff to process equipment needs from first responder organizations and monitor real time health care needs.
It also notes instances where separate organizations have been called to carry out the same mission — such as evaluating nursing home needs in the county. “This redundancy wasted local resources and increased the possible exposure at these facilities,” the letter said.
Smith said that his employees as well as other first responders have yet to feel a sense of organization from his county leaders and the state, which worries him as Florida nears its peak in patients.
Antevy said he still must gather information about where to take coronavirus patients himself by working contacts at hospitals. That will work for now, he said, but it won’t when certain communities become deluged and EMS workers need real-time information fast.
“We’ve been asking for that information, but we haven’t gotten it yet,” he said.
Stay at home
Aside from the lack of testing and the dearth of medical supplies, Florida may have neglected its most powerful weapon against the pandemic: requiring millions of healthy residents to stay home to keep the disease from spreading.
New York’s governor issued a stay-at-home order on March 22, three days after California became the first state to do so. In the days after, state after state followed suit — but not Florida.
Gov. DeSantis defended his decision over and over for weeks, calling it a “blunt” measure and preferring instead to cede the decision to local counties.
On Wednesday, DeSantis finally changed his mind and issued the order after President Donald Trump’s coronavirus task force extended social distancing guidelines for 30 days. “I think its clear that that represents effectively a national pause,” he said.
Dr. Davis said she can understand the governor’s hesitance, but as a medical professional she said it was misguided. “It should have been done a lot sooner.”
While defending his position in previous days, DeSantis seemed to suggest that Floridians wouldn’t listen to a stay-at-home order even if he issued one.
Davis said getting anyone to stay home for a prolonged time is difficult, and she still sees families congregating at supermarkets and stores.
But she said the picture might look even worse without state leaders clearly conveying that staying in is a priority and a social obligation — even if it’s not easy to do.
“Stay home and have patience,” she said the message should be. “Don’t just think of yourself.”
Andrew Boryga, aboryga@sunsentinel.com, 954-356-4533 or Twitter: @borywrites
