Notes from the Field: COVID-19 in Washington State

Washington state is the epicenter of the COVID-19 outbreak in the United States. What is the situation on the ground?

This is very serious. Every nephrologist here at Providence Health Care is essentially on-call 24/7. I am personally covering the Special Pathogen Unit (SPU) at Providence Sacred Heart Medical Center.

Demand exceeds capacity for dialysis, ventilation, and other acute care services in some Seattle area hospitals, and Spokane is about two weeks behind Seattle. We are currently at greater than 90% capacity for hemodialysis and CRRT, even though our facility is a state-of-the-art 720-bed quaternary medical center, the sixth largest west of the Mississippi River.

We are developing an acute peritoneal dialysis program for extra capacity, something that hasn’t been done here since the 1980s.

The actual rate of AKI is also a major problem.

Tell us more about your medical center.

Providence Sacred Heart Medical Center has one of only a few SPUs in the US. The SPUs are sites conducting the National Institute of Allergy and Infectious Diseases/National Institutes of Health–sponsored clinical trial of remdesiver, and possibly other antiviral agents, for COVID-19. The research unit that I oversee is responsible for running the trial here. We are having patients with COVID-19 flown in from cruise ships and elsewhere to have access to the study treatment. Dialysis patients are being severely affected, and we are very concerned about workforce and resources to meet the needs.

What else can you tell us about the shortage of dialysis care?

We have not yet had to deny dialysis care here in Spokane. In places where capacity is already inadequate, basically, older people with severe illness and various comorbidities are not being dialyzed. They are put on comfort care.

With input from expert clinicians and bioethicists, we are now trying to develop criteria for patients to receive acute dialysis. We have not seen this in modern times. This harkens back to the early dialysis experience in the 1960s when Dr. Belding Scribner led the Seattle program. They also had to make very difficult decisions, but under totally different circumstances.

How would you encapsulate the current situation among those in the healthcare profession?

It’s physically, mentally, and spiritually exhausting.

We are looking back to the 1918 Spanish flu for guidance, including the comparison between how Philadelphia and St. Louis handled it. We are essentially no further along in dealing with a viral pandemic than we were then.

This is a national emergency, and this is where we need to put all our attention. It’s like a bomb dropped with viruses instead of nuclear radioactive particles. In hospitals, this is battleground medicine.

What advice would you give those in facilities that have not yet seen many patients with COVID-19?

• ■ Get ready for a lot of AKI. We don’t know the number because we don’t know the denominator, but be aware that if you are admitting lots of COVID-19 patients, you will have AKI.

• ■ Plan ahead because you will need human capacity, dialysis machines, CRRT, fluids, catheters. Do an environmental scan of your resources.

• ■ Plan for acute PD because you can use it if you run out of resources for hemodialysis and CRRT. My staff were like deer in the headlights when I brought up PD: “I’ve heard of it, but I haven’t done it.” I myself haven’t put a PD catheter in a patient in over 20 years. At our facility, all elective surgeries have been canceled indefinitely. Surgeons won’t be too busy during this time, so they will help with access for acute PD and with vascular access.

• ■ And, finally, share your story. Right now, we need to be sharing our lived experience through these notes from the field. We’re flying the airplane while we are still building it, and all together, we need to do the best we can to share our experiences until we have the time to sit down, analyze the data, and write the papers.