With counts of COVID-19 patients now rising rapidly just north of
California’s border with Mexico, hospital executives here are asking
federal officials to move “immediately” to screen the tens of thousands
of people crossing every day from densely populated Tijuana, a city of 2
million people, and other parts of the Baja peninsula.
Chief executives of two major California healthcare systems sent a sent a letter late Tuesday
to Health and Human Services Secretary Alex Azar. They worry their
systems will be overrun, not only from local San Diego cases, but from
people who traverse the border unknowingly bringing the virus with them.
Border an ‘Achilles Heel’
“What I’d like to see are health checks, just like we would
administer at an airport if we had an airplane coming in,” Chris Van
Gorder, president and CEO of Scripps Health, told MedPage Today
in an interview. One of Scripps’ five hospitals in Chula Vista, just 8
miles from the Tijuana border, is at risk of being overwhelmed with
COVID-19 patients. The border, he said, represents a regional “Achilles
heel” that could thwart efforts to prevent viral spread.
Van Gorder and Dan Gross, executive consultant for COVID-19 strategic
response for the five-hospital Sharp HealthCare system, want Azar to
have the CDC, in coordination with U.S. Customs and Border Patrol,
“immediately begin medical checks to protect public health and expedite
the free flow of critical goods and essential personnel,” as well as
deliver more personal protective equipment and pharmaceutical supplies
needed for standard and COVID-19 care.
Specifically, what’s needed are temperature checks “at the very
least,” and to enforce a mandated quarantine for suspected positive
individuals, they wrote.
Gross also wants appropriate agencies to educate border crossers
about the need to social distance and wear a mask, along with other
policies. If screening or answers to a questionnaire suggest infection,
the federal agencies should conduct COVID-19 testing, he said in an
email yesterday.
Though traffic is far reduced now because of the pandemic, still
40,000 to 45,000 people cross each day, on foot or in vehicles, through
three entry points into California. The vast majority come legally to
provide essential services in the food industry or in healthcare.
Expats Return for Care
The issue is one with obvious national significance because San Diego’s San Ysidro/Tijuana border has historically been the busiest land port of entry
in the Western Hemisphere. The region is vulnerable as well because
Baja California’s governor did not issue a shelter-in-place order until
March 30, more than 11 days after California Gov. Gavin Newsom issued
stay-at-home orders for his state.
San Diego County, with 3.4 million people, is inextricably tied to
Baja through business, culture, and social connections; thousands of
families have members living on both sides.
Some 250,000 to 400,000 “expat” citizens now live in Baja California,
many of them Medicare beneficiaries, and come back across to visit
their families, or to seek healthcare.
“We know for a fact that some individuals, both American and probably
non-American citizens, are coming through the border telling people at
the border that they have tested positive, and they want to seek
healthcare in the United States,” Van Gorder said in an interview.
And Baja California, which includes the dense cities of Tijuana,
Mexicali, Ensenada, and Tecate, have been reporting “a rapidly
increasing number of new positive cases per day, with a lack of
infrastructure, personal protective equipment (PPE), medication, and
workforce to control the spread of the virus,” the letter to Azar said.
“We also need the federal government to put pressure on Mexico to
enforce social distancing and shelter-in-place policies as we have done
in the United States,” they wrote.
Not Flattening the Curve
Of San Diego County’s 3,141 confirmed COVID-19 patients as of Monday,
796 reported addresses within six zip codes near the border, five times
what was reported three weeks earlier.
“There is a misperception that San Diego and Southern California are
flattening the curve and therefore supplies and attention can go
elsewhere. That is not the case,” their letter to Azar said.
The Sharp system operates 1,810 beds, but its Sharp Chula Vista
hospital has borne the brunt of the epidemic here. As of Monday, its
system had absorbed 38% of the county’s COVID patients who required
hospitalization, with 134 of them currently occupying a bed, Gross said.
Half of those patients were at Sharp Chula Vista, the 487-bed facility
just 7 miles from the Tijuana border. In addition, Sharp’s three medical
groups near the border have been seeing and testing patients, with
about one in five being positive for COVID-19.
Scripps Chula Vista, a 173-bed acute care hospital also near Tijuana,
now has 35 COVID-19 patients, or nearly half of the COVID-19 patients
now in Scripps hospitals. The two hospital chiefs say their 10 hospitals
combined have cared for 60% of the county’s COVID-19 patients requiring
hospitalization since the epidemic began.
At both hospitals, many COVID-19 patients are extremely sick, with 22
on ventilators and 25 in the intensive care unit in the Scripps system,
Van Gorder said.
Baja in Trouble
Adding to these challenges is that Tijuana “is having an immense,
immense crisis with this pandemic,” Gross said. “Their hospitals are
full, and we’re hearing stories of ambulance and pre-hospital care
programs being overwhelmed, and a very high mortality rate within
Tijuana. And we know they are very, very challenged with inadequate
personal protective equipment supplies.”
As of last week, “they had just a handful of ventilators in the
entire (Tijuana) community, and we have unofficial requests coming to
San Diego for personal protective equipment, ventilators, and other
supplies. They have a real issue in Baja, and they are our neighbors,”
Van Gorder said.
He said the lack of supplies in Baja California hospitals and growing
infections in Mexico may push more people to seek care in San Diego,
especially if they have family or jobs here, and that’s a worrisome
concern.
“We have cases all the time where someone is dropped off at the
border and a U.S. ambulance is called to take that patient to the
closest emergency department, and that would be Scripps Mercy Chula
Vista or Sharp Chula Vista,” he said. On Tuesday, the Scripps hospital
was in the process of testing nine patients with symptoms suggesting
COVID-19, and four of them had come back positive, with most of the
others pending. “Of the nine, five have a definite cross-border travel
history within the past week or so,” Van Gorder said.
Unfortunately, “our supplies are so tight, I don’t think there’s any
healthcare system here that can afford to send a whole shipment of our
supplies down there. We don’t know whether we’re going to have a spike.
And we’re easing up on restrictions, letting people go to the beach
again. It won’t be long before we’ll open up some other businesses and I
clearly think we’re going to see camel humps.”
It’s also unclear how well that those living south of the border are observing prevention guidelines.
It’s hard to know which patients are truly San Diego County
residents, and which ones have traveled from Mexico for care, Van Gorder
acknowledged. “Frankly, we have people who may not be citizens who are
using addresses here in the U.S., whether they are living here or not,”
he said.
‘About to Stop Breathing’
Juan Tovar, MD, an emergency medicine physician and Scripps’
physician operations executive in Chula Vista, said many of these
patients are very sick and near death when they come through the door.
“At the beginning, we saw a lot of people who just wanted to be
tested. They ranged from minimal to no symptoms to the direly ill. Now
we’re treating people who are coming in much sicker, with advanced
symptoms and some of them are getting intubated,” or going on
extracorporeal membrane oxygenation, Tovar said.
“There are people who come in so sick, they are about to stop
breathing,” he said. “This is a tough disease, (and) a large percentage
of the people who get intubated do not get extubated.”
Though it’s widely believed that COVID-19 is most acute in the aged,
at Scripps Chula Vista, more common is the patient 35 to 60 years old.
The common link: comorbidities, such as congestive heart failure,
diabetes, obesity, and hypertension, conditions often more common in
Hispanic communities.
For some patients who might not do well with intubation, the hospital
is implementing proning combined with high-flow nasal cannula oxygen
therapy.
Worried CBP Personnel
Complicating the COVID-19 border issue is the safety of U.S. Customs and Border Protection personnel, Van Gorder said.
“I’m in almost daily contact with the CBP, and they’re not concerned
about stopping people coming across the border. They’re concerned about
the safety of their own employees … because there’s a huge number of
patients in the Mexicali area, and CBP has a large contingent of
employees out there.”
Van Gorder said Scripps is working with its affiliated Pioneers
Hospital, a 107-bed facility in Brawley, in agrarian Imperial County
just to the east of San Diego and 26 miles north of the Mexicali border,
to get CBP personnel tested.
The official Baja California case count was about 1,400 as of Tuesday, according to government presentations on Facebook with 464 others under investigation and 190 deaths, but it’s unclear how accurate those case counts are.
In their request letter to Azar, Van Gorder and Gross ask for more
federal supplies “because of the inadequacy of medical resources in
Mexico and its impact on San Diego.” They need testing supplies, PPE,
and pharmaceuticals for both San Diego and Mexico.
Both Gross and Van Gorder are now acutely aware how one
under-recognized element such as the border can change the course of an
epidemic from coming under control to not being under control because of
conditions out of their control.
“Look how quickly, all of a sudden, something just five miles away, a
variable has the opportunity to reshape our experience within our
country. Everyone needs to have a broad vision … not just focusing on
their own community … but be aware that what surrounds them can affect
them in very dramatic ways.”
Added Van Gorder, “If all of a sudden we see a spike down the road,
everything we’ve been trying to prevent, which is the overwhelming of
our healthcare system — well, we can find ourselves overwhelmed again.”
https://www.medpagetoday.com/infectiousdisease/covid19/86219
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