As hospitals across the country weather a surge of COVID-19 patients, nurses, respiratory therapists and physicians in Seattle — an early epicenter of the outbreak — are staring down a startling resurgence of the virus that's expected to test even one of the most well-prepared hospitals on the pandemic's frontlines.
After nine months, the staff at Harborview Medical Center, the large public hospital run by the University of Washington, have the benefit of experience.
In March, the Harborview staff were already encountering the realities of COVID-19 that are now familiar to so many communities: patients dying alone, the fears of getting infected at work and the upheaval inside the hospital.
This forced the hospital to adapt quickly to the pressures of the coronavirus and how to manage a surge, but all these months later it has left the staff exhausted.
"This is a crisis that's been going on for almost a year — that's not the way humans are built to work," says Dr. John Lynch, an associate medical director at Harborview and associate professor of medicine at the University of Washington.
"Our health workers are definitely feeling that strain in a way that we've never experienced before," he says.
Until the late fall, the Seattle area had mostly kept the virus in check.
But now cases are rising faster than ever before, and Washington Gov. Jay Inslee has already warned a "catastrophic loss of medical care" could be on the horizon.
"This is the very beginning, to be honest, so thinking about what that looks like in December and January has got me very concerned," Lynch says.
Lessons learned from the spring surge
When the outbreak first swept through western Washington, hospitals were in the dark on many fronts.
It was unclear how contagious the virus could be, how many ICU beds would be needed and how widely it had spread.
ICU nurse Whisty Taylor remembers the moment when she learned one of their own nurses — someone young and active — was hospitalized on their floor and intubated.
"That's really when it hit .... that could be any of us," Taylor says.
Concerns over infection control and conserving PPE meant that nurses were delegated all sorts of unusual tasks.
"The nurses were the phlebotomists and physical therapists," says nurse Stacy Van Essen. "We mopped the floors and we took the laundry out and made the beds, plus taking care of people who are extremely, extremely sick."
A lot has changed since those early days.
The staff are now trained to go into COVID rooms and to be near patients, and the hospital has ironed out the thorny logistics of caring for these highly contagious patients, says Vanessa Makarewicz, Harborview's manager of infection control and prevention.
How to clean the rooms? Who's going to draw the blood? What's the safest way to move people around?
"We've grown our entire operation around it," Makarewicz says.
The physical layout of the hospital has changed to accommodate COVID patients, too.
"It's still busy and chaotic, but it's a lot more controlled," says Roseate Scott, a respiratory therapist in the ICU.
Harborview has also learned how to stretch its supplies of personal protective equipment (PPE) by keeping health care workers in patients' rooms for as long as possible. And as cases started to rise significantly last month, the hospital quickly reimposed visitor restrictions.
"In the past, we've had visitors who then call us two days later and say, 'oh, my gosh, I just came up positive,'" says nurse Mindy Boyle.
Boyle says months of caring for COVID patients — and all the steps the hospital has taken, including having health care workers observed as they don and doff their PPE — has dampened the fears of catching the virus while at work.
"It still scares me somewhat, but I do feel safe, and I would rather be here than out in the community where we don't know what's going on," says Boyle.
Some realities never change
Preparation can only go so far, though.
The hospital still runs the risk of running low on PPE and staff, just like so much of the country.
During the spring, the hospital cleared out beds and recruited nurses from all over the country, but that is unlikely to happen this time, with so many hospitals under pressure at the same time.
"All things point to what could be an onslaught of patients on top of a very tired workforce and less staff to go around," says Nate Rozeboom, a nurse manager on one of the COVID units. "We're all tired of this, tired of taking care of COVID patients, tired of the uncertainty."
Already, COVID's footprint at Harborview is expanding and bringing the hospital close to where it was during its previous peak.
"The fear I have personally is overwhelming the resources, using up all the staff and the numbers are still going to go up," says Roseate Scott, a respiratory therapist.
And Scott says the realities of caring for these desperately ill patients have not changed.
"When they're on their belly, laying down with all the tubes and drains and all these extra lines hanging off of them, it takes about four to five people to manually flip them over," Scott says. "It feels intense every time. It doesn't matter how many times you've done it."
Hospitalized patients are faring better compared to the spring, but there are still no major breakthroughs, says Randall Curtis, an attending physician at the COVID ICU and a professor of medicine at the University of Washington.
"The biggest difference is that we have a better sense of what to expect," Curtis says.
The few treatments that have shown promise, including the steroid Dexamethasone and the antiviral Remdesivir, have "important, but marginal effects," he says.
"They're not magic bullets.... people are not jumping out of bed and saying, 'I feel great. I'd like to go home now,'" Curtis says.
Whisty Taylor says nursing has never quite felt the same since she started on the COVID ICU.
"These people are in the rooms for months. Their families can only see them through Zoom. The only interaction they have is with us through our mask, eyewear, plastic," Taylor says. "We're just giving their body a run around trying to keep them alive."