'Code blue': Texas COVID deaths higher than publicly reported - and spiking

The large refrigerated trailer suddenly appeared one day near the loading dock at HCA Healthcare Northwest, taking some on staff by surprise. But soon its purpose became clear. When a patient died last week in the hospital's intensive care unit - nearly full these days of critically ill COVID-19 patients - the body was packed in ice and moved into the trailer. The hospital's morgue was full. HCA officials confirmed the trailer was used as temporary storage until the body could be picked up by a funeral home. As other hospitals prepare to follow suit or have already done so, there is a stark new reality in Houston. In the early months of the pandemic, it seemed as if Texas as a whole, and Houston specifically, was mostly spared the worst of the crisis, especially compared with the Northeast. In a city and state so big, the number of cases remained relatively small. So, too, did the number of dead, with about 3,100 reported in Texas so far. Overrun hospitals and makeshift morgues happened elsewhere - not in a city with the largest medical center complex in the world. But Centers for Disease Control and Prevention data shows Texas is one of 24 states that publicly reports only confirmed COVID-19 deaths, not "probable" ones. And with rampant testing shortages in Texas, many patients likely died without being screened for the disease, experts said. Texas ranks 40th out of 50 states and the District of Columbia in deaths per 100,000 population on the CDC COVID-19 tracker. But that is potentially misleading since it compares Texas with 27 states that include "probable cases." Nearly 1 in 5 deaths reported in New York City, the national epicenter for COVID-19, was reported as a "probable." The surge of cases has left doctors, nurses and first responders in Houston overwhelmed, and scores of patients wait for 12 hours or more for emergency room care or ICU beds. On Friday, Gov. Greg Abbott warned that the death toll will rise. "What we're seeing now in states like Texas is comparable to what we saw in New York City," said Bob Anderson, chief of mortality statistics for the CDC. "It remains to be seen what we will see with the rate of death. The numbers may be smaller, but the pattern is there." Deaths are the ultimate lagging indicator, sometimes not occurring for many weeks after a person is first infected. And then it can take several more weeks until that death is recorded and shows up in the statistics, distorting public perception and the true scope of the crisis. For instance, on Thursday, Mayor Sylvester Turner, announcing the city's latest toll during a news conference, included the death of a woman who died nearly seven weeks ago on May 24. "The steep rise in cases that started about mid-June in many states will likely be seen in rising deaths very soon," said Jen Kates, director of global health and HIV policy at the Kaiser Family Foundation. "It is hard to see how they won't come." Waiting on stretchers The trajectory is now a nearly straight line heading north. On Tuesday, a milestone was reached as the daily count of new cases in Texas topped 10,000. Two days later, the number of statewide cases reached 10,214 - a tenfold increase from mid-May, when officials were alarmed that the number of cases was rising by 1,000 per day. As of Saturday, there were 255,763 confirmed cases in the state, according to a Houston Chronicle analysis of state data. In the Houston region, the number of confirmed cases reached 62,268 on Saturday, up more than 2,400 from the day before, the analysis shows. Houston's two safety net public hospitals are straining. On Friday, Ben Taub Hospital's ICU was at 66 percent capacity and Lyndon B. Johnson Hospital was at 113 percent. The surge is showing up in other ways as well. Sam Peña, Houston's fire chief, said in a recent interview with the Chronicle that his department is "overwhelmed." In the past three weeks the calls for help have jumped 30 percent, the majority being respiratory distress. When the state shut down in March, the fire chief said, his department was averaging about 800 calls per day. Now it is 1,100. And once at a hospital, if there is no bed immediately available, he said the patient waits on a stretcher in the emergency room hallway. 'It will go up' Researchers recently reported that a mutated coronavirus strain, the main one circulating in the Houston area, is more contagious than the original virus in China. But they have not found it to be more deadly. On Saturday, there were 3,156 confirmed deaths in Texas, translating into a fatality rate of about 1.23 percent. In the Houston region the death count stands at 642, or slightly less than the statewide rate. The current death rate in Texas has, in fact, gone down since April and May, when it was 2.4 percent and 2.8 percent, respectively. That has fueled critics of mandated precautionary measures such as masks and social distancing. The White House, too, has pointed to a decline in overall death rates as proof that the recent spike in new cases is not a big deal and that the country is winning its war with the virus. And it is true the demographic of the virus is now shifting to younger patients who may be better able to fight off the disease. Increased testing has also meant that the virus is caught earlier and treatment in hospitals is proving more successful as doctors better understand the coronavirus. But health experts caution that the virus can be slow to develop. The CDC estimates it can be up to 14 days after exposure for symptoms to appear. Once sick, it can be another two weeks to a month or longer before a case results in death. "One of the big things that people who don't want to implement social distancing say is, 'Hey, so what if cases and ICU admission are going up, so long as mortality is not going up?'" said Dr. Peter Hotez, dean of the National School of Tropical Medicine and professor of pediatrics and molecular virology and microbiology at Houston's Baylor College of Medicine. "Well, No. 1, it will go up," he said. "It may not go up as steeply as it did in New York because we're better prepared to handle it - we know how to provide better ICU care now - but it will go up." And in fact, Wednesday and Thursday had 218 new deaths statewide in just 48 hours, according to a Chronicle analysis of state data. The growing deaths have now triggered emergency measures across Houston's hospitals. HCA Houston Healthcare said the refrigerated trailer at Houston Healthcare Northwest was needed briefly last week because the hospital morgue is small. But the hospital system said it was "likely" the same preparedness measures will be used at its other hospitals. Similarly, Memorial Hermann Health System said it has used such makeshift morgues in the past and is deploying them "as needed" across its system, while Baylor St. Luke's Medical Center said it has a refrigerated trailer on site that has not been used yet. Other hospital systems said the potential use of the temporary morgues is part of an overall strategy should the situation worsen. Even if the death rate remains steady or rises only slightly, Dr. David Persse, Houston's chief medical officer, said the math is not on the city's side amid such dramatic increases in cases. "One percent of a big number is still a big number," he said. "It's a lot of people dying." 'It may never be counted' Health experts also worry that the true scope of the local crisis may never be measured accurately. For instance, if an ambulance crew arrives and a person is already dead or dies on the way to the hospital they will not be tested for the virus. "We have a team that we've deployed with the health department to conduct testing at nursing homes, but we don't do a test for patients in the field during emergency responses," Peña said. And if a patient dies in the emergency room from a heart attack or organ failure but there is not clear indication that the death was caused directly or indirectly from the virus, they also may not be tested, health officials acknowledge. Admitted patients are now routinely tested, doctors said. "If they are not tested in the ER or a doctor does not write that it is COVID-presumed, it may never be counted," Persse said. Anderson at the CDC said that unless COVID-19 is specifically listed as cause of death or as a contributing factor on the death certificate, it will not be included in that agency's data. "It is absolutely possible we are missing some," he said. In Texas, a death can be certified by medical professionals or government authorities, depending on jurisdiction. In Harris County, if a body is turned over to the medical examiner's office, it will be tested if there is suspicion of the virus, said Michele Arnold, public information manager at the Harris County Institute of Forensic Sciences. Of the 1,990 deaths certified by that agency since March 1, a little more than 10 percent, or 253, have been tested for COVID-19, she said. Of those, roughly half came back positive. Still, not all who test positive will have COVID-19 listed as the cause of death if they died from something unrelated, she said. Front-line doctors are skeptical that all of the deaths they see are being accurately counted. "The death certificate I signed on June 30 with a confirmed lab test is still not being reported as a COVID death," said one HCA Healthcare Northwest physician on Thursday. "We see the death rate is rising every day. All day we are hearing 'code blue' called overhead for a different bed in the intensive care unit," he said, describing the signal that a patient's heart has stopped. "We know those are COVID patients fighting for their lives. The numbers being reported are lagging behind what is happening on a daily basis." Persse said he understands that reporting lags or gaps can be frustrating to the public and damaging to those trying to beat back a crisis. But what is truly distressing, he said, is that it could have been prevented. What people do, how vigilant they remain, the precautions they take, are the true predictors of the virus' toll on the city. "It's hard to predict because it is totally up to us," he said. "The death rate depends on us." Lisa Gray and Matt Dempsey contributed to this report. jenny.deam@chron.com twitter.com/jenny_deam zach.despart@chron.com twitter.com/zachdespart

'Code blue': Texas COVID deaths higher than publicly reported - and spiking

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