Recent weeks have brought a new set of challenges to academic medical centers in the Northwest and the Gulf Coast of the United States in an already trying year.
In August and September, wildfires raged through millions of acres in Washington state, Oregon, and California, forcing thousands to evacuate their homes and coating the region in a cloud of toxic smoke.
At the same time, a record-breaking hurricane season that formed nearly two dozen named storms by the last week of September hit parts of the Gulf Coast with devastating flooding and wind damage that destroyed homes and left hundreds of thousands without power.
The nature of the disasters made efforts to prevent further spread of the virus that causes COVID-19 particularly complex. Those coordinating the emergency response struggled to combine evacuation practices with pandemic protocols such as social distancing, and poor air quality increased risk for respiratory issues.
“It’s been a remarkably challenging season,” says Steven Mitchell, MD, medical director of the emergency department at Harborview Medical Center and associate professor of emergency medicine at the University of Washington School of Medicine in Seattle. “Every week seems to bring a new challenge.”
But leaders at academic medical centers in the affected regions say that their experience with planning for previous disasters and the ongoing crisis response to COVID-19 has helped them manage the additional challenges.
“Emergency medicine sort of primes you to deal with this,” says Mitchell, who also serves as the medical director of the federally funded Regional COVID-19 Coordination Center for the Pacific Northwest. “It’s what we pride ourselves on — being adaptive to scenarios … and it’s been one of the most creative seasons of our lives.”
"Every week seems to bring a new challenge.”
Steven Mitchell, MD
Medical director of the emergency department at Harborview Medical Center in Seattle, Washington
Bracing for the storm
When it became clear that Hurricane Sally was headed straight for the Alabama coastline in mid-September, administrators at USA Health at the University of South Alabama in Mobile kicked into preparation mode.
They ordered extra personal protective equipment (PPE) to stockpile for staff in case weather and road conditions backed up deliveries. They called in additional staff to board at the hospitals before their shifts to ensure they had adequate staffing levels — and that staff weren’t deterred from coming to work by unsafe conditions. And, knowing that the floor that houses the intensive care unit (ICU) leaks small amounts of water when storms send rain flying horizontally toward the building, they moved all the ICU patients to an alternative site.
Because the health system leaders and staff had been through hurricanes before, they already had a plan to prepare for these challenges, explains Michael Chang, MD, chief medical officer for USA Health.
But with the COVID-19 pandemic, this year’s storm response has required some different approaches.
To maintain appropriate social distancing, they had to block off extra space as sleeping areas for staff. The health system also had to make the call to close outdoor COVID-19 testing sites because of the dangerous conditions.
“The kind of people that choose to work at tertiary care centers are the ones that will be ready to step up at all times.”
Michael Chang, MD
Chief medical officer for USA Health
Chang is concerned that, while the immediate threat of the hurricane passed quickly, the power outages it left in its wake inevitably caused community members to crowd at the few grocery stores and gas stations that regained power first, increasing the risk of spreading the novel coronavirus.
With two full months remaining in an incredibly active hurricane season and fears of an impending surge in COVID-19 cases, health care workers may be in for a tough fall and winter after an already taxing spring and summer.
That’s why USA Health planned a debriefing for its staff after the threat of Hurricane Sally passed, Chang explains. “This was our first hurricane in the COVID era. We will learn what did and didn’t work.”
A big part of the debriefing was checking in on the well-being of the staff, who are suffering from both personal and professional stress from the onslaught of crises this year but continue to show up to work.
“The kind of people that choose to work at tertiary care centers are the ones that will be ready to step up at all times,” he says.
When a respiratory illness and smoke-filled air collide
As wildfires ripped across Oregon in early September and forced some hospitals to evacuate, Mitchell, from the University of Washington, was in communication with hospitals throughout Washington state, Oregon, and Alaska to coordinate a plan to help if needed.
“We developed a statewide coordination center for COVID, so any one hospital isn’t overburdened with COVID situations,” Mitchell says. They were able to activate that same emergency management system to react to the crisis arising from the fires.
“We were ready, as a region, to move large numbers of really challenging patients,” he says.
At Oregon Health & Science University (OHSU) in Portland, the state’s only academic medical center and the designated regional hospital in emergencies, they also found that the ongoing response to the pandemic helped prepare them for the fires. They reduced the number of elective surgeries to preserve hospital capacity and actively monitored the air quality in the hospital to ensure the several layers of filtration were working.
“What was unique about this situation is that what we had already done and learned and prepared for in the context of COVID actually set us up for success in managing the wildfires,” says Renee Edwards, MD, MBA, chief medical officer for OHSU. “The CMOs [chief medical officers] across Portland and the state have built a tight network during COVID in a way that never existed before.”
Because Oregon was able to evacuate the hospitals that were in danger from the fires to other medical centers within the state, the hospitals in Washington state and Alaska didn’t have to accept the additional patients as they had planned.
“What was unique about this situation is that what we had already done and learned and prepared for in the context of COVID actually set us up for success in managing the wildfires.”
Renee Edwards, MD, MBA
Chief medical officer for Oregon Health & Science University
Things were quieter than expected in Seattle as the fires burned in other parts of the region, Mitchell notes. Still, the smoke from the fires dominated the air throughout the Pacific Northwest for days, driving an increase in patients presenting to the emergency department with breathing problems, particularly from vulnerable populations like the homeless, who had little refuge from the poor air quality.
This complicated the health care workers’ response to these patients, since shortness of breath is a symptom of COVID-19 and protocols require additional PPE, isolation, and negative pressure rooms.
“We’ve asked staff and faculty to step up clinical decision making and assessment to not discount what could be COVID-19 while still assessing for smoke-related injuries or complications,” Edwards says.
The cautious approach proved prudent when two patients who presented with a cough when the air quality was at its worst actually ended up testing positive for COVID-19.
And although the air quality in Portland improved after it rained, Edwards worries there will be long-term implications on Oregonians’ health, particularly in combination with a potential COVID-19 surge.
A national study done by the Harvard T.H. Chan School of Public Health in April found a link between areas with poor air quality and higher COVID-19 death rates.
There’s also the fear that evacuees from the fires, in many cases, were not able to physically distance themselves from groups of people, particularly those staying in shelters.
In August, the New York Times wrote about the plight of thousands of evacuees fleeing their homes in California to escape the danger of the fires, only to face the threat of the virus in evacuation centers after hotels filled up.
Oregon, which has fared better than most states in controlling the virus until now, may see a surge in cases following the evacuations, just as health systems across the country are bracing for the additional impact of flu season.
Edwards, who sits on Oregon Gov. Kate Brown’s medical advisory panel, says that the health system and the state will be looking at ways to increase COVID-19 testing and outreach in the coming weeks as they continue to stay on high alert for whatever challenges the rest of 2020 has in store.