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Staff photo by Troy Stolt / Dr. Aaron Cohen, a critical care specialist at Erlanger, is photographed at the end of his shift on Thursday, Nov. 19, 2020, in Chattanooga, Tenn. "In the last two to three weeks, it's gotten to the point where it's scaring us. We're now coming into work and wondering if we're going to have double or triple the amount of patients that we had the day before," Cohen said.

Chattanooga hospitals raced furiously to prepare for a COVID-19 surge this spring. Instead, they got an eight-months-long rising tide that's now pushing staff to the brink of their abilities.

Providers knew the fast-spreading virus could quickly overwhelm a health care system. When images of overflowing New York City hospitals filled TVs and social media in March and April, state and local leaders swiftly implemented stay-at-home orders, turning what could have been a tidal wave of patients in Chattanooga into a trickle.

After a month, COVID-19 was well controlled and restrictions were gradually lifted. Residents returned to many pre-pandemic activities, fueling a second, larger wave of patients this summer — which prompted Hamilton County Mayor Jim Coppinger to implement a public face mask requirement.

Although hospitals were taxed in July and early August, by then employees had learned a lot about how to better treat the novel virus since the early days of the pandemic.

But as fall came and a third wave began to surge, driven largely by patients from rural counties without mask mandates, it was clear that more needed to be done to curtail the spread.

In a letter dated Oct. 30, the chief executive officers representing five hospital systems — CHI Memorial, Erlanger and Parkridge in Chattanooga, Rhea Medical Center in Dayton, Tennessee, and Hamilton Health Care in Dalton, Georgia — along with the president of the Chattanooga-Hamilton County Medical Society, sent a plea to mayors across the region.

"We are once again at a crossroads and have little time to act to flatten the curve of COVID-19, and to save the lives of many in the Chattanooga and North Georgia regions. COVID-19 cases and hospitalizations are on the rise again. While cases have not reached the high levels experienced in July, they are advancing at a rapid rate," the letter states.

The letter states that if the trend continued, hospitals would experience capacity issues that would affect not only coronavirus patients but all who rely on their care.

"We urge you to take the bold step forward in stemming the spread of this virus by mandating masking in public places for every resident above the age of 12," it says. " The stealth nature of COVID-19 transmission is the single most important factor to remember when deciding to wear a face mask in public or even in small gatherings. It is a simple, pragmatic solution that will reduce transmission of the disease."

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Letter from hospital CEOs and the medical society president to mayors in the Chattanooga region

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In the following three weeks, Coppinger would renew Hamilton County's mask mandate, but no new policy actions would be taken. Tennessee's previous records for new coronavirus cases and hospitalizations were shattered, and Gov. Bill Lee asked residents to make "good, common-sense decisions" to slow the spread of disease.

Now, the fears spelled out in the letter are being realized.

"When COVID first came around back in March, we felt like people were doing what they needed to — wearing masks, social distancing and staying home to flatten the curve," said Dr. Aaron Cohen, a critical care specialist treating coronavirus patients at Erlanger Hospital. "In the last two to three weeks, it's gotten to the point where it's scaring us. We're now coming into work and wondering if we're going to have double or triple the amount of patients that we had the day before."

Dr. Sanford Sharp, medical director of laboratories at CHI Memorial Hospital, said he tries to have sympathy for people in smaller communities who may not want to socially distance or wear masks, thinking perhaps they don't understand the gravity of the situation.

"They may not know anybody who's had severe disease," Sharp said. "Those of us here in the hospital, we can't escape it. It's right in our face. We know how bad it is."

A hospital's ability to care for patients is more dependent on staffing than physical bed space, Tennessee Health Commissioner Dr. Lisa Piercey said during a news conference last week.

"Throughout Tennessee, COVID patients account for approximately 20% of all inpatient beds and 30% of all ICU beds," she said. "And you've heard our hospital partners say many times, their ability to maintain available beds for all conditions, not just COVID, is not unlimited. Now, this is primarily due to staffing challenges, secondary to under-supplied and overextended healthcare workers."

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Staff photo by Troy Stolt / Brea Johnson, a registered nurse in the medical intensive care unit at Hamilton Medical Center, is photographed at the end of her shift on Friday, Nov. 20, 2020, in Dalton, Georgia. "When we go home, because we've seen so many poor outcomes, the first thing we think of as a nurse is what could we have done differently," Johnson said of treating COVID-19 patients in Whitfield County. "Right now, we just don't know."

Registered nurse Brea Johnson has been caring for coronavirus patients in the medical intensive care unit at Hamilton Medical Center since the beginning of the pandemic. She said this time of year is always busy due to an influx of patients with influenza, and she expects to see even more with COVID-19 after Thanksgiving.

Coronavirus has hit Whitfield County, Georgia, where she works especially hard. Last week, the county led the state in its rate of new cases.

As she left her shift on Friday evening, she recounted "constantly feeling defeated" on her drive home.

"When we go home, because we've seen so many poor outcomes, the first thing we think of as a nurse is what could we have done differently," Johnson said. "Right now we just don't know. It's a battle every day, and most of the time we're losing."

(READ MORE: What Chattanooga area nurses treating COVID-19 patients had to say after work)

During a public board meeting Thursday, Dr. Jay Sizemore, one of Chattanooga's leading infectious disease specialists, said the region's current COVID-19 response is "insufficient" to save the hospitals from the worsening crisis. Erlanger, where Sizemore practices, has been forced to make staffing adjustments and expand the hospital's designated COVID-19 units in order to accommodate the current patient load.

"From a numbers perspective, we have been substantially higher with the number of hospitalizations than ever before — even our previous highs at the end of July and in early August," Sizemore said.

Chattanooga hospitals serve a large region encompassing Southeast Tennessee, Northwest Georgia and Northeast Alabama. The area's significance as a regional medical hub has grown over the years as more rural hospitals shutter their doors and the ones that remain often operate with less staff and fewer specialties.

Tina Gerardi, executive director of the Tennessee Nurses Association, said the coronavirus took longer to reach rural communities, whereas metro hospitals have been working around the clock since March. Even if a hospital hasn't reached capacity, staff at these larger hospitals are feeling the brunt of COVID-19 burnout, she said.

"Those are the folks that aren't getting the relief, and those are the areas that are needing the staffing," Gerardi said. "It's not just nurses, it's everybody — the physicians, the nurses, the respiratory therapists and now we're getting into the cold and flu season. Capacity in the winter is always an issue anyway, and on top of that there's COVID."

Sharp said what makes the current surge different from previous ones is that it's not concentrated in certain pockets of the United States, like the Northeast or the South.

"In the earlier surges, nurses from one region were able to help other regions," he said, recalling when travel nurses went to relieve New York City hospitals. "But we can't do that now, because COVID is in all regions."

"That's definitely scary," Sharp said. "It's gonna be hard to put out the fire when it's not a flare-up. It's the whole country."

Staff photographer Troy Stolt contributed reporting to this story.

Contact Elizabeth Fite at efite@timesfreepress.com or follow her on Twitter @ecfite.

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