Working in the Hot Zone
The digital display opposite the doctors’ station in Seattle’s Harborview Medical Center emergency department details the hour’s ills and needs, room by room: headache, fever, chest pain, suicide attempt, drug detox, abdominal pain, seizure, psychiatric evaluation. From abscesses to overdoses, it’s a typical day. But these aren’t typical days. In the midst of the COVID-19 pandemic, anyone could expose everyone to the potentially lethal virus.
Seattle Pacific alumnus Steve Mitchell rises to the challenge of safely delivering emergency care, no matter the conditions. The physician exudes the calm confidence that comes from decades of reacting to emergencies large and small.
As medical director of Harborview’s emergency department — one of the state’s busiest, and the only Level I pediatric and adult trauma and burn center for Washington, Alaska, Montana, and Idaho — Mitchell helps lead 200 staff members and directs operations for the 65,000 emergency patients seen on average each year.
The medical center has experts, all the specialties, available 24/7, to care for patients with every type of critical physical and mental illness, injury, or crisis. The trauma center extends outside the hospital walls, too. Airlift Northwest, a flying ICU, brings 1,400 patients to Harborview annually.
Harborview is part of the UW Medicine health system, along with UW Medical Center — Montlake; UW Medical Center — Northwest; and Valley Medical Center.
“Since COVID, everything we do has been impacted. In the beginning, we thought the chances of somebody having COVID when something bad happens — they get randomly shot or something — were slim,” Mitchell said.
But in the first weeks of the pandemic, that very scenario played out: A young man in Yakima was shot, airlifted to Harborview, and he was COVID-19 positive. It wasn’t discovered until after he was in surgery.
“This crisis — the volume and the constantness of it, how it’s impacting everybody’s lives — means everything is new,” Mitchell said. “Every single thing in the emergency department has changed.
“We’re rethinking things we’ve been doing for decades. That’s the challenge.”
Adapting to a pandemic
As COVID-19 spread throughout the U.S., emergency rooms reconfigured themselves to separate suspected coronavirus cases from patients with other health emergencies. Harborview begins this process outside.
Initially, a large white triage tent was set up adjacent to the hospital. If people walked up to the emergency department and reported COVID-19 symptoms, they were brought directly into the tent for testing, including X-rays, if needed. About 24% of these patients tested positive.
“This crisis — the volume and the constantness of it, how it’s impacting everybody’s lives — means everything is new,” Mitchell said.
“The goal is to keep the number of patients with COVID out of the emergency department because it’s a fixed, small space,” Mitchell said.
One hallmark of emergency medicine is speed. When someone is having a heart attack or stroke, or is critically injured, the minutes until medical attention can determine life or death.
But now, the emergency staff’s first reflex — provide care in a matter of seconds — can betray them. The coronavirus has forced them to proceed more carefully, even as the clock is ticking.
In the large bay where ambulances and helicopters arrive, medics used to rush their patients inside. Hospital staff now step outside and, while maintaining distance, assess patients more slowly. They think through whether they’re wearing the proper personal protective equipment for the situation before bringing the patient inside.
The hospital is divided into hot and cold zones, referring to contagion status. Temporary barriers of plastic sheeting have been erected throughout the emergency department to remind people of the zones and to control pathways. Handwashing and the use of hand sanitizer are constants. The nurses wear surgical-type hats. Staff change clothes regularly. Everyone — workers and patients alike — wears masks at all times within the emergency department.
Solutions create issues and necessitate more solutions. For instance, how do masked staff members stay hydrated during a 12-hour shift?
“We used to eat and drink a bit at our desks in between writing notes and seeing patients. You didn’t take breaks. Now, you have to,” Mitchell said.
A nearby radio room currently serves double duty as a hydration station. The small room is filled with phones that ring to alert the staff of incoming traumas. In a disaster such as a landslide or train derailment, it becomes a command center, with Harborview staff performing regional triage to figure out which hospitals should receive which patients.
In quiet moments, it’s one of the few places where workers can now go, one at a time, unmask, and drink water or sip coffee.
Those working in hot zone, closed-door rooms with COVID-19 patients, wear layers of PPE and use a contraption called a PAPR that sends purified air into a hood. Once staff are with patients in isolation, they’re in the rooms for one to two hours at a stretch, both to provide the extensive care needed by very ill patients and to avoid going in and out, burning through protective equipment that needs to be conserved. “COVID patients require a lot of focus. They’re resource-intensive, and we use lots of PPE,” Mitchell said. “If you get three or four of those patients happening at the same time, it’s really challenging.”
Outside hot zone rooms, trained observers carefully watch the donning and removal of all PPE to ensure it’s worn correctly and removed safely. The layer by layer removal of gear is when providers are most at risk of exposing themselves to the virus.
The lack of PPE faced by some hospitals didn’t materialize for Harborview, in part because supplies shared by their four-hospital system could be quickly shuffled to the area of greatest need.
“We were never in dire straits with PPE. We had some days when we only had three or four left of this or that, but we always seemed to get out of that worry,” said hospital spokesperson Susan Gregg.
Before the outbreak, Harborview was already near capacity. It’s a “safety net hospital” — a medical center that cares for patients without insurance or means to pay, so it’s always full. Waiting patients would choke the emergency department hallways. Not anymore. The statewide canceling of non-essential surgeries and treatments immediately increased capacity, and former overflow rooms were converted to COVID-19 units. More people avoided the emergency room unless absolutely necessary.
At the beginning of the outbreak, Mitchell said Seattle was a lot closer than people realized to the overwhelmed hospitals seen in New York. “If it wasn’t for social distancing and actions by state government, there’s no doubt we would have been as bad off,” he said.
Previous coronavirus outbreaks of SARS and MERS elsewhere in the world helped Harborview’s leaders better understand how to protect their staff from viral threats. In the aftermath of the Ebola outbreak in 2014 in West Africa, Harborview became the referral center for the region in case that virus surfaced in the Pacific Northwest. The U.S. Department of Health and Human Services required hospitals to submit preparedness plans for how they would handle the emergence of a serious infectious disease.
“Previous coronavirus outbreaks of SARS and MERS elsewhere in the world helped Harborview’s leaders better understand how to protect their staff from viral threats.”
Harborview equipped an isolation room for treating Ebola patients, and those plans informed procedures for dealing with the emergence of COVID-19.
The deep tragedies
The isolation brought on by COVID-19 is by far its most challenging aspect, Mitchell said. He recalled one of his coronavirus patients, a man in his 70s, was drowning in lung fluid when he arrived at the emergency department. He wasn’t getting enough oxygen and was fighting for air with each shallow breath. Mitchell could read the fear in his eyes.
The patient needed to be quickly intubated — a tube put down his throat to make breathing easier, with the help of a ventilator — but as sick as he was, Mitchell knew he likely wouldn’t survive, and once intubated, couldn’t speak.
Against his better judgment as a doctor, against instincts urging care as fast as possible, Mitchell acted with his heart: With little else to offer his dying patient, he delayed intubating so his patient could speak with his daughter over the phone one last time.
“We can’t hug these dying patients. Their families are barred from their bedsides due to infection risk. We’re all wearing masks that obscure our faces. These are deep tragedies,” he said. “If we can’t help people get well, we try to provide care and comfort for the end of life.”
Everyone finds the no-visitor policy gut-wrenching, especially during patients’ final hours, Mitchell said. Since it was enacted, he’s seen countless examples of providers helping patients reach family and friends, sometimes offering their own phones.
Mitchell listens to the politicians and public-health officials debate when, where, and at what pace to reopen the country. He watches the curve flatten, rise, and fall.
Mitchell fears for paramedics and EMTs, at the front of the front-line workers. He worries about longterm care facilities, where the virus swept like wildfire through senior populations and, on average, 30% of the staff have fallen sick. He worries about the disproportionate impact of COVID-19 on Blacks and Hispanics. He worries about the virus loose among those on the margins: the imprisoned and the homeless.
Mitchell is worried about a future surge in cases. He’s been on planning calls with state officials to strategize how to deal with a potential, perhaps inevitable, surge.
“I’m very proud of our community for following the stay-at-home order; it’s absolutely made a difference,” Mitchell said. “I acknowledge many people are economically suffering because of it.
“But I do get angry at open disregard for rational behavior. Those who are most angry about the stay-at-home restrictions are also the most able to take care of themselves if they get sick. We have to remember, only a small percentage of the population has been exposed.”
The physician’s path
Practicing medicine was not a foregone conclusion for Mitchell.
He attended SPU from 1985 to 1987, living in Hill Hall and forging friendships he still holds dear. Atypically, he also worked full time as a firefighter and paramedic. He left college after his sophomore year to attend two different paramedic schools in yearlong programs.
“I loved the fire department. I loved being a paramedic,” he said. “Going into homes in times of great need — it’s such an intimate setting. I fell in love with caring for people at their most vulnerable.”
As a medic, working with patients felt sacred and meaningful. And he found himself yearning to do more of it, not as just one aspect of his profession.
Mitchell eventually returned to school, completing his undergraduate degree in psychology at the University of Washington when he was 28.
He was at a crossroads in his life, uncertain of his next steps. “I kept asking, ‘OK, Jesus, what am I to be about?’” A spiritual mentor noted his pastor’s heart. He contemplated a business degree or attending seminary.
Deep soul searching led him to medical school. “God’s will is where your deep gladness meets the world’s deep needs,” said Mitchell, paraphrasing theologian Frederick Buechner. “Medicine was where my calling met my heart’s desire.”
Mitchell returned to SPU in 1996 to take post-baccalaureate pre-med classes for two years before he started medical school at the University of Washington at age 33.
Despite his advanced skills in emergency medical care, leading Harborview’s emergency department was not on his radar.
“I never would have taken that first step if I knew where I’d end up today,” said Mitchell, chuckling. “I never wanted to be an ER doc. I thought about geriatrics or palliative care. I wanted to see ‘regulars.’”
He finished medical school and his residency at 40 and began working in Harborview’s emergency department in 2006. He became its medical director in 2016.
“Never been busier”
For the first few months of the outbreak until early May, Mitchell worked seven days a week, routinely putting in 100 hours. In addition to patient care, there were systems, physical spaces, and procedures to set up, manage, and evaluate.
“It’s been exhausting,” he admitted. “It was a career already known to be high-paced and intense, and COVID doubled that. We’ve been going nonstop since Feb. 29. I’ve never been busier, not even close.”
The risks go hand-in-hand with the pace. Nationwide, more than 169,000 health care workers have been infected, and more than 700 have died from COVID19, according to the Centers for Disease Control and Prevention data released in October.
Harborview hasn’t experienced a large number of workers who have gotten sick. The COVID-positive rate for employees is about the same as in the general population. Mitchell credits the low rate to access to testing and having proper PPE.
Among his many duties, Mitchell counsels fellow physicians who are fearful and stressed.
“I want to keep our community as safe as possible, and part of accomplishing that is keeping supplies like N95 masks on hand and intelligently applying their use,” he said. “We can’t make decisions out of fear. We have to be guided by evidence and rational sense. My biggest prayers each day are for wisdom and for the absence of fear.”
Mitchell is vigilant about keeping his family healthy, too, but has not chosen to temporarily live apart from them as some health care workers have done. Before he heads home to his wife and three children, he often showers, washing his hair and scrubbing his skin, no doubt removing layer upon layer of oft-used hand sanitizer. He changes his clothes and shoes. He doesn’t want anything to stand between him and the hugs that greet his arrival.
He calls the evening walks he takes around the neighborhood with his family “restorative communion,” the only exercise he can currently fit in.
For the first month of the outbreak, sleep was a challenge, despite the punishing pace. “I just couldn’t get my mind to turn off,” he said.
Now that the emergency department is more organized with more systems in place, Mitchell says he’s sleeping better.
Regional and national leadership
It’s unclear at this point who was “patient zero” in the United States. As researchers learn more about the pandemic’s roots, it looks likely that the virus entered the U.S. via multiple paths and at multiple times.
But Washington seems to be the place where it initially took hold in this country.
“As the first place with a major outbreak in North America, we have both a duty and an expectation to write about our experiences and findings, and to help others prepare,” Mitchell said.
He’s already written three papers for medical journals, and a fourth is under review. With the breakneck speed of learning in the midst of this crisis, he says he could write an article every day, if time allowed.
Given Harborview’s experience in providing regional leadership, in early March they were asked to set up the Regional COVID Coordination Center, with Mitchell serving as medical director.
The coordination center is tasked with watching the COVID-19 cases reported by all hospitals and nursing homes in the region and doing whatever necessary to level the caseloads so no one is overwhelmed. They’re working to make PPE and testing available to nursing homes and adult family homes, and making plans to move patients, if needed, from hospitals exceeding capacity.
“I am so proud of Harborview,” Mitchell said. “Even though hospitals are hemorrhaging money right now, we committed resources for the good of the region.”
Hospitals aren’t the only ones hemorrhaging money, of course. Despite that, Mitchell lauds the community for helping health care workers in myriad ways.
“This crisis is really hard. But we’re also discovering things every day, and that’s exciting,” he said. “It’s been beautiful to watch my colleagues at work in the midst of this. People have been completely selfless.”
When the regional coordination center needed a software platform to track the number of ventilators, ICU beds, regular beds, COVID patients, and staffing for every hospital in Washington, Microsoft came up with a speedy solution.
“Things that normally take years took days,” Mitchell said.
The hospital feared running out of face shields, so community members responded by creating a prototype that could be rapidly and inexpensively reproduced on 3D printers.
Even meals have been donated. “I didn’t pay for lunch for months,” Mitchell said. “There’s incredible generosity in our community.”
At the end of another long shift in the trauma center, Mitchell is introspective: “I feel called and uniquely prepared for this moment in time, not only with my emergency medicine experience, but also because I know paramedics and have relationships with area hospitals from my years in the fire department.
“This is a life-defining moment for all us,” he said. “I don’t know when life will return to ‘normal.’ I think even after a vaccine is developed, it will be years before things are normal again.”
Photos by Eugene Lee