A small hospital in the fight of its life against the deadly coronavirus

Kirkland, Washington

AT 6:04pm on Tuesday night, the staff at EvergreenHealth in Washington state got another warning: two more patients with respiratory troubles were on their way to an emergency ward that had already been flooded with coronavirus patients.

Doctors, nurses, technicians and respiratory therapists rushed to get each other prepared, handing out blue gloves, tying on each other's yellow gowns and helping fit white helmets inflated by clean air - the visors opaque from the repeated cleanings with bleach they had undergone over the past brutal week.

Workers slid open the doors to room 4 and room 18 on a special sealed wing of the emergency department ready to receive the 43rd and 44th suspected or confirmed coronavirus patients under the hospital's care that night.

"We focus on the swarm method," said Amy Updike, the emergency department clinical manager. "Some of them are coming in pretty sick and need interventions right away, and you see how much time it takes to prepare for these patients."

Unlike any other hospital in the United States, the staff at the hospital in Kirkland, Washington, has faced the brunt of the rapidly escalating coronavirus outbreak. So far, 65 people who have come through the hospital have tested positive for the virus, a number that grows by the day. Fifteen of them have died - half the nation's death toll - mostly residents of a nearby nursing home devastated by the illness.

While much of the country is just starting to see clusters of cases emerge, the hospital east of Seattle offers a window into the challenges set to cascade through the United States healthcare system, testing the resilience of workers, the readiness of institutions and the flexibility of supply chains. The past few weeks have seen medical workers operating at the very edges of their capabilities, facing a virus so virulent that some patients were dying within hours of coming down with their first symptoms.

Strained supplies

Caregivers who had been sent home into quarantine had to be called back to work to face the overwhelming task at hand. Engineers spent late nights scrambling to overhaul rooms so that contaminated air could not escape. Sanitation and janitorial crews struggled to swab down rooms where even a trace of the virus could infect the next patient. Supplies were so strained that nurses turned to menstrual pads to buttress the padding in their helmets.

But through it all, they have kept coming to work, even after some expressed worries about risks to their own health and what they might bring home to their families. A new-employee orientation on Monday was packed.

"We have not had issues with staff not wanting to come in," Barb Jensen, the manager of trauma services, said as workers rushed to bring the new patients into the emergency room. "We've had staff calling and say: 'If you need me, I'm available.'"

The hospital had not had any coronavirus patients in late February, when a growing number of cases around the country prompted federal authorities to expand guidelines for who could get tested for the virus.

Dr Francis Riedo, the medical director for infectious disease, picked two patients already at the hospital who were critically ill with severe pneumonia. He figured it was probably a one-in-a-million possibility.

"I felt like I was dropping a line into the middle of the Pacific Ocean and thinking maybe I'll come up with something," said Dr Riedo.

The only case in the Seattle area had emerged more than a month earlier, a man who had tested positive after returning from China. Since then, five weeks had gone by with no more cases. The day after the two pneumonia patients were sampled, Washington state officials announced that they had discovered a case of coronavirus that was not linked to the original case, nor to anyone who had recently travelled to a coronavirus region, meaning that the virus was likely spreading through the community on its own.

Within hours, Dr Riedo was sure of it. The lab tests on the pneumonia patients came back showing both of them positive for the coronavirus. Someone called EvergreenHealth's CEO, Dr Jeff Tomlin, and asked him if he was sitting down before breaking the news.

"I think everybody knew that our work lives were going to be dramatically changed, as well as a lot of our lives in general," Dr Tomlin said.

There was an immediate rush to isolate the patients, identify others who had been exposed and test some of the other patients who had respiratory issues; several of those would soon come back positive as well. Over the next few days, a steady influx of patients began coming from Life Care Center, the nearby nursing home now linked to 19 deaths.

Source of anxiety

Before the virus arrived, the hospital had only about 15 negative-airflow rooms, which allow the flow of air to be directed inward so that contaminants don't spill out and infect others. The building's engineers have since made space for 58 patients in such rooms.

"We know what we have now," said Dr Ettore Palazzo, chief medical and quality officer. "We want to project for what potentially could come. And so we continue to work with them on finding areas that can be converted."

An immediate source of anxiety was identifying all workers who had been in contact with the first two pneumonia patients. "The number initially was pretty staggering just for those two," Dr Riedo said of the number of patients. "When we realised we had eight or nine or 10, you realise that you're now casting a net that if you sent everybody home, you would not have an operational hospital."

The hospital decided to bring some of the asymptomatic caregivers back, even if they had been exposed. The hospital said it was screening them twice per shift and requiring them to wear masks.

But the masks themselves were becoming a precious commodity. A whiteboard was set up in the hospital's command centre conference room listing available supplies. The most recent tally showed 42,000 surgical masks, which get used at a rate of about 6,000 per day.

With concerns about sustainability if the outbreak became worse, conservation measures were ordered. Instead of replacing face shields for their air-purifying helmets, staff members are now required to use bleach wipes to wash them after each use.

Tupperware containers have been brought in from local supermarkets to store goggles and masks in the hope that they will last longer.

Mary Shepler, the chief nursing officer, said managers have been talking with vendors and other hospitals and seeking to tap the national emergency stockpile to make sure they will have what they need if things get worse.

An unexpected shipment of supplies to update the helmets has temporarily relieved the need to rely on sanitary pads. "Do we want to use those? No," noted Ms Shepler. "If it's that or nothing on their foreheads, they're choosing."

In some ways, she pointed out, healthcare workers at the small suburban hospital know they are probably part of a trial run on how the nation responds to a global pandemic. "There's just another community waiting for this to happen," she added. "This is our new normal in some ways." NYTIMES

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