While most every hospital in the United States has made some provisions for a possible swine flu crisis, not all seem to be experiencing the surge of patients for which their emergency departments and intensive care units have prepared.
On Tuesday, the ABC News Medical Unit contacted more than 60 hospitals from every region of the country to determine where the H1N1 activity appeared to be the heaviest, as well as which hospitals had swine flu patients in their intensive care units -- a sign that at least some cases were severe enough to warrant extraordinary treatment measures.
What the reports out of these hospitals suggested was that not only does the extent and severity of the illness vary from region to region, but in some cases it varies even among hospitals in the same state.
California is one such state. Dr. Larry Satkowiak, medical director of the emergency department at Children's Hospital Central California near Fresno, said that at his hospital, the virus has certainly added to the normal emergency department caseload.
"Compared to last year, we're up about 25 percent from last October," he said. "Most of that is due to flu-related illnesses."
Roughly 300 miles south, Dr. Jake Jacoby, hospital director for emergency preparedness and response at the University of California at San Diego, said all the plans are in place for dealing with a swine flu surge that has not yet occurred.
"We have not activated any surge steps at this point," he said. "We are ready to deal with larger numbers of patients, but so far we have not had to worry about that."
But he said the situation could change immediately.
"That's the nature of pandemic flu -- it comes in waves, and different cities are affected at different points in time. It is not unexpected that some cities will be worse than others."
"We're just not overwhelmed by the flu right now," he said. "It's difficult to predict for any one city whether you're going to get hit hard or not."
The Anatomy of a Swine Flu Surge
But where the virus has hit hard, the burden on already-strained emergency departments is unmistakable. In Ohio, a number of medical centers reported that the virus had taken hold in their coverage areas.
Ohio State University Hospital was one medical center that reported a heavy flu burden.
"We are not in a crisis at this point, but we are trying to determine what level we can handle," said Richard Davis, associate executive director of Ohio State University Hospital and the Ross Heart Hospital in Columbus, Ohio. "The intensive care unit capacity at Ohio State, and nationally, is running at a very high capacity normally. If you insert a new incremental demand, you have to make some adjustments to deal with that."
Davis said that as of Tuesday, out of a total of 38 medical ICU beds, there were only three that were unfilled.
"That's a pretty fine margin, frankly. We, like others, have a very thin excess when it comes down to ICU capacity."
Dr. Mark Moseley, medical director of the emergency department at the Ohio State University Medical Center, said the strain is not limited to equipment and resources; staff, too, are feeling the effects of the crush.
"You take all of our volume, all of the things we need to deal with in the [emergency department], and you throw on something where we are maybe seeing 20 or 30 more patients a day, it pushes that situation closer to the breaking point," he said. "I think the concern that all of us have is, 'How much more can you absorb?'"
Two of the cases at Ohio State University Hospital were severe enough to have required a technique known as extracorporeal membrane oxygenation, or ECMO -- a step up from the usual intensive care which is reserved for patients whose lungs are so severely damaged that they can no longer function properly.
A couple of miles across town, Dr. Dennis Cunningham, medical director of the epidemiology department at Nationwide Children's Hospital in Columbus, Ohio, said staff there have also been working hard to deal with the bump in emergency department visits.
"I will say that we have increased the staffing in our emergency department to more than our usual level, even during the winter," he said. "We're doing OK with space, but it is hard on the staff because people are working longer hours than they normally would."
Will It Get Worse?
But even as medical centers in Ohio appeared to be dealing with elevated activity from the virus, there were hints that the flu activity could be tailing off, at least slightly. According to Nationwide Children's Hospital, the combined number of patients who sought care at the hospital's emergency department and four urgent care centers peaked on Oct. 12 at 958 before it began to trend downward. On Oct. 22, the combined patient volume was only 661 -- still higher than the typical October average of 476, but a marked improvement over past weeks.
Satkowiak noted that not all of the patients with flu-like symptoms now pouring in to emergency departments around the country actually need to be there.
"We are seeing kids who do have the flu or flu-like symptoms, but the other thing we're getting is families who are pressing the [emergency department] button earlier because of what they're seeing in the news," he said. "We are also seeing a lot of primary care physicians who are pushing the ED button when their patients are seeing them with flu symptoms."
But with flu season around the corner, doctors agree that it is no time to relax.
"When you talk to infectious disease experts, what they will always say is that the only thing that is predictable about influenza is that it's unpredictable," Cunningham said.
"I've been doing this for 21 years, and there's just no way to predict what will happen with influenza," Satkowiak agreed. "We have no idea what the seasonal flu is going to do."