It had already been a long week for the emergency room at Cook Children’s when Dr. Corwin Warmink, medical director of emergency services, spoke to a Zoom gallery of journalists in early September. 

Every year in his 18 years at Cook Children’s, he said, his team expects a “bump” in visitors when school starts — around 300 children a day. But that Monday, two days before this virtual press conference, there were more than 600. About half of those were kids with COVID-19 illnesses or concerns. 

“We run one of the biggest, baddest, busiest ER in the country at 300 (visitors),” he said. “And we’d go up to 400 and even 500 in the past, but at 600, we’re physically unable to care for kids in a timely fashion.”

He was tired and angry. He urged parents to get vaccinated, wear masks and require the same of their kids. As he wrapped up, his voice caught. “I get paid — and everything in my training and career — was to not freak out,” he said. “But I’m freaking out.” 

The Zoom conference provided a small glimpse of the exhaustion medical providers have experienced as wave after wave of COVID-19 cases pummel their hospital systems. 

Burnout, competition from staffing agencies and providers’ own illnesses have helped spur staffing shortages at hospitals around the county and country. Those shortages, in turn, affect patient care. Cook Children’s closed its urgent care in Hurst in late August to redirect staffing and resources; by the time of this story’s publication, the location had yet to reopen.

“This move should sound an alarm,” said Wini King, the hospital’s chief of communications, diversity, equity and inclusion, on the same call. “Or it should be like a canary in the coal mine, so to speak, for what may be to come if we don’t take measures as a community to slow down the spread of COVID-19.” 

Ahead of an impending flu season, hospital systems are looking to the public, the state and each other to stay steady as the pandemic approaches the end of its second year. 

‘Razor-thin’ staffing before the pandemic

In the early months of the pandemic, nearly 30% of reporting hospitals in the U.S. faced an immediate shortage of health care workers, according to a 2021 study in Infection Control & Hospital Epidemiology. About 16% reported a shortage of nurses. 

Nearly two years in, staffing struggles remain. 

“Hospitals across the country have reported shortages of all types of health care workers,” according to a statement by Akin Demehin, director of policy at the American Hospital Association. “The scope and severity of the shortages varies from hospital to hospital and region to region, but are especially concerning in areas experiencing renewed surges of COVID-19 hospitalizations.”

Although COVID-19 hospitalizations in Tarrant County have been declining since early September, “staffing is still very tight” in hospitals across north Texas, according to Stephen Love, the president and CEO of the Dallas-Fort Worth Hospital Council.

“When I talk to the hospitals, if I ask, ‘What is your No. 1 issue?’” he said. “It’s staffing.”

“When I talk to the hospitals, if I ask, ‘What is your No. 1 issue?’ It’s staffing.”

– Stephen Love, president and CEO of the Dallas-Fort Worth Hospital Council

Staffing problems existed in Tarrant County and across the country long before the pandemic began. 

Nurses, for example, are the “primary providers of hospital patient care,” according to the American Association of Colleges of Nursing. If a person works in health care in the U.S., they’re more likely to be a nurse than another profession. 

“We were on a pretty razor-thin shortage of nurses to begin with,” said Valentina Gokenbach, a professor at the TCU and UNTHSC School of Medicine. Gokenbach has nearly 50 years of experience as a hospital administrator; most recently, she served as the chief nursing officer at Baylor Scott & White All Saints Medical Center in Fort Worth. 

Competition for nurses locally has been “very, very intense” long before the pandemic began, she said: “In our area, especially in Fort Worth, I could walk outside my hospital and throw a rock in any direction and hit another hospital.”

Reports of nurse shortages across the U.S. peppered the 1990s. In 2001, the office now known as the U.S. Government Accountability Office examined the issue and warned of a “serious shortage” on the horizon. 

The shortage came to pass. “The U.S. is running out of nurses,” according to the headline of a 2016 story in The Atlantic. Then, another study, which ran not long before the pandemic began, predicted a shortage of hundreds of thousands of nurses across the U.S. by 2030.

The reports cited, in part, an aging population and an aging workforce that’s caring for them. More people with chronic illnesses like obesity and diabetes contributed to the need for care, Gokenbach said.

“And then we overlay COVID on top of everything, and that just threw everybody into a tailspin,” she said. 

“And then we overlay COVID on top of everything, and that just threw everybody into a tailspin.”

– Valentina Gokenbach, professor at TCU and UNTHSC School of Medicine

‘When the first wave came, it was a tsunami’

There were good days, even in the pandemic, for Devin Hanrahan-Finch, an emergency room nurse at Texas Health Southwest. “I think that’s why I stayed as long as I did,” she said. Her last day on the job was June 18. “I couldn’t handle the fail anymore,” she said. (Courtesy photo | Devin Hanrahan-Finch)

When Devin Hanrahan-Finch worked as an emergency room nurse at John Peter Smith Hospital in Fort Worth, a colleague told her how to compartmentalize what they’d seen that day: “We’re going to make this into a Quentin Tarantino film, and we’re going to put a weird frame around it, and then we’re going to turn it off,” she said. “And it was like, ‘OK. Movie’s over.’” 

For Hanrahan-Finch, the film that was a nearly 20-year career as a nurse in Tarrant County ended June 18 after a grievous year that overshadowed those that came before it. 

“I loved that job. I loved what I did. I loved who I talked to. I loved being involved with people. I loved the whole thing,” she said. “And then time wore on.”

In 2017, she moved from John Peter Smith Hospital to Texas Health Southwest in Fort Worth. When the pandemic began, her team didn’t immediately feel the first wave, “but when the wave came, it was a tsunami.” 

At first, her patients were older, people with pre-existing conditions. As months passed, she started losing patients in their 30s and 40s who looked, medically, like she did. 

“It’s a strange thing to watch another human being die,” she said. “It is a strange thing to watch another human being react to their person dying.”

She tried not to follow her patients from the emergency room to the intensive care unit. More and more frequently, her colleagues in the ICU told her that the patients she’d overseen in the emergency room weren’t going to make it, “and that became the normal instead of the abnormal.” 

As winter turned to spring, she felt a kind of tired that couldn’t “be cured by sleep.” When she drove to work each day, her heart beat wildly. She lost sympathy for her patients, and if she told them it was going to be OK, she felt like she was lying.

“I was anxious. I was angry. I was hateful in my important relationships,” she said. “I mean, it just got ugly.”

She calls it “soul exhaustion,” and by May, she’d felt it long enough. 

​​“I literally could not involve my five senses anymore,” she said. “And that was the basis of my decision. Like, I can’t smell this anymore. I can’t smell like this anymore. I can’t feel like this anymore.”

‘They’re just really, really tired’

On a team call last week, leaders at JPS Health Network discussed “the state of our providers,” said Diana Brodeur, the network’s vice president of communications. They’re worried, specifically, about post-traumatic stress disorder.

“While we aren’t seeing a huge influx of new COVID patients, the patients we do have are very, very sick and many will not make it despite incredible efforts and all the best resources we have,” she said. “That is devastating for care providers — to have all the tools and all the knowledge and not be able to save these people.”

Patients who are more sick require higher levels of care, which in turn require more providers or providers with specialized training, Gokenbach said. The pressure in the early months of the pandemic created a crucible within hospitals that strained health care workers already in place and required the system to find more.

At Baylor Scott & White All Saints Medical Center, the COVID-19 patients needed to be isolated, which meant staff entering their space layered in personal protective equipment. 

“Nurses couldn’t just keep taking their PPE off and on,” Gokenbach, who was the hospital’s chief nursing officer when the pandemic began, said. “We had to create units where the nurses would put their PPE on and go into a unit that was negative pressure,  and they never came out.” 

These isolation units required more people at the bedside, and they required people like “runners,” who moved between units without donning PPE, she said. Hospitals like hers relied on staffing agencies to bring in temporary nurses, some of whom chose to leave the bedside and receive higher pay for the same work through those agencies.

“Everybody needs nurses right now,” Gokenbach said. “So they had the options, and a lot of them decided to exercise those options.”

Other nurses left because they didn’t want to put their family members at risk, she said. Still others have dealt with their own illnesses or, simply, couldn’t do it anymore. 

At Cook Children’s, some urgent care locations were operating with half their normal staff in early September, according to Kara Starnes, the medical director of urgent care services.

“We’re losing a lot of staff due to burnout,” Starnes said at the Zoom press conference in September. “People are tired. They’re exhausted. They’re being asked to work overtime, come in extra to help out when there’s call-ins. They’re just really, really tired.”

Gokenbach hopes people remember how much these jobs require of health care workers right now and do whatever they can to protect themselves from COVID-19. Still, she’s conflicted about the hospital systems’ recent vaccine mandates for employees. It felt “demonizing,” she said, for health care workers who “were once heroes in the eyes of everybody because they were there,” she said. “And that breaks my heart.”

People gather outside of Texas Health Harris Methodist Hospital Fort Worth to protest the employee vaccine mandate in August. (Cristian ArguetaSoto | Fort Worth Report)

Systemwide vaccine mandates did contribute to the loss of staff, but barely. 

By the end of September, fewer than 85 hospital employees of more than 23,000 at Texas Health Resources hadn’t been vaccinated or sought an exemption to the mandate, according to a statement from CEO Barclay Berdan. At Cook Children’s, around the same number out of more than 8,000 hospital employees left because of the mandate, Kim Brown, a spokesperson for the hospital, said. 

As of Oct. 1, about 98% of their more than 40,000 employees met the requirement, according to a statement from Baylor Scott & White Health

The state steps in, and providers help each other

Throughout the pandemic, the state has provided funding to bring out-of-state medical staff in-state as a stopgap. 

More than 8,000 medical personnel have come to Texas since August

This deployment is fully funded by the state and will be reimbursed by the Federal Emergency Management Agency, according to Douglas Loveday, spokesperson for the Texas Department of State Health Services. As a result, more out-of-state staff are working in Texas now than any other time during this current wave. 

These personnel were originally funded through September, but the legislature extended the funding through October. An extension could happen again if needed, Loveday said, but “nothing definitive yet.” 

In the meantime, the state is monitoring COVID-19 hospitalizations to determine when to start “decreasing the number of medical surge staff,” he said. 

Hospitals in north Texas have received more than 1,500 people from the state, according to Love, with the Dallas-Fort Worth Hospital Council. 

“(The state) brought in all areas related to supplemental staffing, but certainly focused on critical care,” Love said. “And for that, we’ve been very appreciative.” 

The sickest patients need health care workers equipped to provide that critical care, Brodeur, with JPS Health Network, said.

“The acuity level of our patients is high, meaning they are often more sick and require greater or more intense care to get well,” she said. “Delivering that care requires people with advanced training and knowledge.”

JPS Health Network is “actively recruiting in all areas across the hospital,” but with a special focus on “highly skilled, highly trained nurses,” she said. 

That’s meant, in part, promoting a full-tuition scholarship for employees at JPS Health Network who hope to become nurses. It’s also meant creating seasonal opportunities with high rates and low-commitment contracts for traveling nurses.

While hospital systems look outward for more staff, they’re also looking inward. 

When the pandemic began, hospital leaders across North Texas turned to each other, sometimes weekly, to discuss best practices and share resources, Love said. Hospitals within systems, too, transferred patients when one hospital couldn’t handle any more. Physicians called their colleagues across the country and world to talk about treatments. 

“The collaboration, the camaraderie, has just been tremendous,” Love said. And, he said, he thinks it’s “saved lives and helped treat this COVID pandemic.”

‘We’ll get through it’

Despite collaboration across hospitals, lowering rates of hospitalizations and help from personnel outside the state, local systems remain in triage.

In early August, JPS Health Network announced it would start pushing back elective surgeries. In mid-September, Cook Children’s announced the same thing. Two weeks earlier, they’d closed their Hurst urgent care location. 

As winter approaches, Love, with the Dallas-Fort Worth Hospital Council, is worried about the flu. 

“At this time last year, not having vaccines, people were very diligent about wearing their masks,” he said. “One of the positive byproducts of that: We had a very light to nonexistent flu season. We’re concerned that we may have a flu season this year that we didn’t have to deal with last year.”

To temper a further crippling of the system, he’s asking people to remember the health care workers. 

“The staff has worked hard. They’ve been at this 19 months. They’re very fatigued,” he said. “And if you want to do something to really help the staff, wear a mask and get your vaccine, because 95% of the people we’re treating for COVID are unvaccinated. So preventable. So unfortunate.”

Gokenbach, with the TCU and UNTHSC School of Medicine, remains hopeful. 

“I think what’s going to happen is we’re going to learn a lot about this disease, as we continue to move forward, and we’re going to get control of it,” she said. “It’ll just be a matter of getting control of it.” 

It happened with tuberculosis, she said, and it will happen with COVID-19: “We’ll get through it.”

‘I have this kind of internal levity back’

On Hanrahan-Finch’s last day as a nurse, she ended up staying late. “There were people everywhere, bodies everywhere,” she said. Her last patient, a person who’d had a stroke, pulled through, and when she walked out past the ambulance bay for the last time, she paused. 

“​​For just a minute, I stood there in my scrubs and my tennis shoes and thought, ‘Maybe I shouldn’t go.’” 

The moment passed. She remembered her day. She remembered her husband and kids and what life might be like “on the other side” of this season. She would cry all the way home — and she’s not a cryer. Still, she knew why she was leaving. 

“I think that’s what kept my feet moving,” she said. “Potential.”

Hanrahan-Finch works in IT now. These days, her morning routine is thoughtful, not harried. Her kitchen is clean. Her laundry is done. If she wants to watch grasshoppers in her yard for 15 minutes, she does. She’s made it her “life’s work, currently” to rid her yard of an armadillo. “It’s so exciting,” she said. “It’s all so nerdy.”

A feral cat in a nearby barn gave birth recently, and she marvels at the kittens. “It’s so minuscule and probably meaningless, but to see these little kittens — it’s a big deal.”

She and her husband, they laugh. “I have this kind of internal levity back,” she said. “And it’s who I was before all of this.”

Part 2

Alexis Allison is the health reporter at the Fort Worth Report. Her position is supported by a grant from Texas Health Resources. Contact her by email or via Twitter. At the Fort Worth Report, news decisions are made independently of our board members and financial supporters. Read more about our editorial independence policy here 

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Alexis Allison covers health for the Fort Worth Report. When she can, she'll slip in an illustration or two. Allison is a former high school English teacher and hopes her journalism is likewise educational....

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