Author’s Note: I am not an authorized representative of any hospital but am writing broadly from my knowledge of experiences at medical centers across the Puget Sound region, an epicenter of the recent coronavirus outbreak in the United States.

Editors’ Note: This article was accepted on March 16, 2020, and was accurate at that time. Because information about SARS-nCoV-2 and COVID-19 is evolving rapidly, please verify these recommendations and information.

The first case of COVID-19 at Providence Regional Medical Center in Everett, Washington, was diagnosed Jan. 20, 2020, in an intensive care unit patient who had recently traveled from Wuhan Province in China. We had heard about the epidemic breaking out of China, yet it came as a sobering shock to my colleagues and me when we realized the illness was at our local facility.

The real diagnostic challenge began about a week into the epidemic, when we started seeing patients with features of COVID-19 at various facilities across Puget Sound. We had large numbers of patients who had possibly been exposed, many of whom were showing symptoms that could be compatible with the disease.

Since that first case, we’ve seen a lot of patients with clinical features consistent with other descriptions that have been given—patients with cough, sore throat, and fever. Most patients had typical presentations, though some older adults did not mount a fever response. Many patients have had leukopenia, and some have had high transaminases. Some people had only mild symptoms, but we couldn’t definitively diagnose because no testing was available at that time. We had to assume that such patients might have COVID-19, so we sent them home for self-quarantine.

Triage and Treatment

We quickly learned to focus on the patients who appeared very ill. We’ve found that the clinical presentation was quite different from typical cold symptoms or common flu. Patients might present with a little labored breathing and mild hypoxia. However, the chest X-ray often looked substantially worse than the patient appeared. One could see a classic viral pattern of bilateral patchy ground-glass infiltrates.

We learned to recognize that as a highly alarming sign. In our experience, once patients develop that, the progression to severe respiratory complications is likely. For sick patients coming into the emergency department, this can often happen quickly, within hours. We’ve seen some patients who went from slight hypoxia on arrival to needing intubation eight hours later, displaying a severe viral pneumonia or even an acute respiratory distress syndrome pattern. We’ve been surprised by how dangerous this virus is, how it can make certain people very ill very quickly. That is in line with the Chinese experience, but it has still been disconcerting to see up close.

We found that common temporizing measures used for patients with respiratory distress such as bilevel positive airway pressure (BiPAP) and high-flow nasal cannula oxygen don’t seem to avert this progression. One might be able to buy a little time this way, but even with these measures, these sick patients have eventually needed intubation. This contrasts with other medical conditions, such as congestive heart failure, where such interventions might be all that are needed. More recent experience suggests that ventilator-sparing strategies may have merit; this is very much a learning process. We’ve tended to avoid both BiPAP and high-flow nasal cannula because of concerns that they might increase aerosol particle formation and thus make the virus more transmissible to health care workers.

Computed tomography scan seems to be quite sensitive to coronavirus, at least in patients having moderate or severe symptoms, probably even more sensitive than the polymerase chain reaction tests that we have. However, pragmatically, it is not very useful as a screening tool for large numbers of patients due to the time needed to perform the procedure and decontaminate the scanner between uses. It may be useful in some situations when the diagnosis of coronavirus is unclear, but we’ve mostly been treating presumptively until test results come back.

Hospital Ops Tips

Our hospitals had learned some lessons from the SARS epidemic in 2003, the H1N1 epidemic in 2009, and the Ebola crisis in 2014, lessons that had been written into their disaster plans. As the scale of the crisis became apparent, the hospitals quickly implemented these plans, which greatly helped with mitigation. Because of inability to test early on, we were unable to contain the crisis in the Puget Sound region, but we did go directly into mitigation to help flatten the disease curve.

The most-effective hospitals that have responded to this have had an internal command center staffed 24 hours a day. These staffers are knowledgeable about the plan and can coordinate different service lines, ensuring that resources are being allocated where they are needed most. That’s been a critical element.

Triaging potential coronavirus patients from other visitors to the emergency department is also essential. In one hospital, we gathered all the patients with respiratory complaints in a single area of the emergency department. Because of the high level of contagiousness of coronavirus, each emergency department in our regional hospitals has had to develop its own way to implement appropriate isolation criteria. When private rooms have not been available, some hospitals have performed triage in the waiting room and had patients wait in their cars to be notified via cellphone when a room is available. Some places have also used pop-up tents outside the department to do some prescreening.

Now that we’ve seen more community transition of the virus, some places have developed drive-through station testing, like the ones used extensively in South Korea. People can drive up, get their temperature and oxygen level tested, and get swabbed to receive the results by phone at home. I think we will see more of those as the epidemic continues.

Stellar Staff Response

As the crisis has developed, the staffing needs have changed. Fortunately, the public has received the message to stay away from the emergency department unless they are seriously ill. Recently, patient volumes in the emergency departments have been down in some cases. Because of this, we’ve been able to shift some providers from a fast-track shift to the respiratory unit so we can have extra focus on the really sick people. We’ve been very flexible in changing provider staffing based on the needs of the moment.

We all got fitted for N95 masks for seeing high-risk patients or doing high-risk procedures using full airborne precautions. Our health care workers quickly got in the habit of being very diligent with their personal protective equipment. As has been covered in the media, some clinicians have been anxious about potential shortages in personal protective equipment. At centers in our region, I don’t feel that such worries have impacted care yet. However, we all share concerns about whether the supply chain will hold up on a long-term basis.

Situations like this one bring out many fears for health care providers, just like they do in the rest of the population. However, we’ve seen that events like this also tend to bring out the best in people. People approach it as a war zone; they buckle up and get the work done. If a provider gets sick or has to self-quarantine, someone else steps up to fill the shifts.

What Comes Next

We need guidance from the federal government about how the regulatory framework of medicine is going to adapt to this widespread epidemic. According to EMTALA, any patient who comes to the emergency room must receive a screening exam and stabilizing treatment. We embrace EMTALA as emergency physicians, but it’s not clear exactly how it should be implemented in these innovative modalities of emergency screening and health care delivery. We are pleased to see clear guidance from the Centers for Medicare & Medicaid Services about how EMTALA shall be applied in these settings so that we are confident what we are doing is compliant. Some clinicians also worry about the potential for malpractice suits when delivering medical care under these difficult circumstances. Congressional action could put such concerns to rest.

In my opinion, the hospitals around the region have displayed an outstanding response to the crisis. However, we already have days in which every intensive care unit bed in the region is full, days in which a specific hospital might have used up all their ventilators. Our hospitals have been very agile in creating more capacity, canceling elective surgeries, and opening new intensive care unit wings. However, we are all very concerned about how the health care system will hold up if we see an exponential growth in transmission.

Dr. Yore is a Past President of the Washington chapter of the ACEP and a practicing emergency physician at North Sound Emergency Medicine in Everett, Washington.