As Washington’s state death toll reaches 50, with new cases cropping up near-daily, it’s hard not to see a health system overwhelmed.

Hospital doctors, exposed to potential patients, are self-quarantining. So are a number of emergency room nurses, said one specialist at a Washington hospital, who asked to remain anonymous.

The University of Washington Medical Center has instituted a drive-through clinic to test any of its employees who are concerned they may have the coronavirus.

Nurses in Washington have expressed concern about a lack of available N95 masks, The New York Times reported.

At one point, pharmacies in Seattle were even running out of prescriptions because so many people were stockpiling medication, said Bert Green, a retired physician who was in self-quarantine after coming into contact with a family friend later found to have the disease.

But even as the coronavirus gains ground – and despite the fact that health workers are at particularly high risk of contracting it – primary and specialty care providers in Seattle and the surrounding areas are quietly going about their jobs.

They’re triaging potential coronavirus cases, working to keep their patients out of strained emergency rooms. They’re continuing to perform procedures and manage chronic conditions. And in some cases, they’re experimenting with open-air clinics and new appointment systems to try to keep their patients safer.

Closing gaps

About half of the patients at the Olympia Free Clinic, located about an hour and a half’s drive south of Seattle, don’t have homes.

The clinic, located in an old building that also provides housing and hygiene services, saw most of their patients during the day, to avoid conflicts with meal services and shelters.

But then coronavirus appeared in Thurston County. Dr. Mike Matlock, the clinic’s medical director, said they were concerned about having so many people – about 200 per day – congregating in the building. The clinic began seeing patients only at night, and only by appointment, in an attempt to minimize patient contact.

“It does diminish access a bit for patients we may be serving as a safety net for,” Dr. Matlock said. But safety was paramount.

Olympia Free Clinic also relies on a staff of volunteers, many of them older adults. They asked a number of them to stay home to avoid exposure. Not everyone went willingly.

Or at all. “I’m over 70 myself, so I have to think about whether I should be seeing patients,” Dr. Matlock said.

But for the patients who come in urgently seeking care – whether it’s for an injury or a chronic condition – “we want to make sure we don’t leave any gaps in care,” Dr. Matlock said.

“Chronic illnesses don’t stop for a crisis”

For Winnie Lee, a physician assistant at International Community Health Services (ICHS) in Seattle, it’s about continuity, too. “People’s chronic illnesses don’t stop for a crisis. They still have high blood pressure. They still have diabetes,” she said.

That’s not least because, she explained, people with some chronic health conditions may suffer complications from Covid-19.

And she feels like her work triaging patients is helping to keep the city’s strained health system under control. “If we’re not here, everyone goes to the ER,” she said. “They need to reserve their supplies and their workers for the people who need it most.”

Still, as Lee goes without her work, it’s not entirely without concern. “We’re wondering if we’re going to have a lot of protection for ourselves. You look at the supplies and you do worry, you do wonder.”

When it came to protective gear like masks, “we were really down to like one day,” said Rachel Koh, ICHS’s chief operating officer. Direct Relief provided the health center with a shipment of N95 and surgical masks, gowns, and other supplies. Without it, “we wouldn’t know how to continue to operate some of our programs.”

Even with the boost in supplies, “it’s challenging,” Koh said. “Especially when the first death was announced, and we found out that a patient of ours was also subsequently a confirmed case…you can imagine the staff anxiety.”

“An older dog”

Even when there are enough supplies to go around and protocols are followed, it’s not a fail-safe, said the specialist at the Washington hospital who requested anonymity. “Some nurses did use those precautions and they still did get infected” at the hospital where they work.

The specialist is still at work. “I’m an older dog. I’ve been through a lot. Of course I’m concerned, but I have not closed my practice,” they said. “It’s not going to change anything I’m doing right now.”

Still, it hasn’t been possible to do every procedure. One patient with Covid-19 urgently needed a procedure done in the specialist’s hospital, but “my nurses were very apprehensive and very concerned about the lack of guidelines,” they said.

“They felt that if it was not an absolute emergency, we should use some other way.”

The providers interviewed for this article all expressed a sense of obligation – to preserve continuity of care, to fulfill their mission of caring for vulnerable patients, to work through the personal risk.

But, as the specialist acknowledged, the end is not yet in sight.

“There’s a sense of panic right now at the hospital, because we’re preparing for more and more coronavirus,” they said.