COVID-19 cases have been on a "nearly vertical" upward trajectory for the last two weeks, Gov. Jay Inslee said in a press conference on Tuesday. But health care workers dealing with the current surge fear what COVID-19 numbers will look like two weeks from now, after those who defied public health guidelines have returned from their risky trips to eat pumpkin pie with their third cousins.

University of Washington residents, the doctors-in-training working on the frontlines, worry about contracting COVID-19 themselves. For the residents I spoke to for this story, however, the biggest worry isn't their own health but rather how their absence might impact the hospital.

Alex Amadi, the lead negotiator for the Northwest branch of the Resident and Fellow Physician Union, said UW hospitals may be "in a crisis situation" when it comes to the number of available beds and available staff if hospitalizations continue to rise.

At a press conference Wednesday, Seattle and King County public health chief Dr. Jeffery Duchin noted the county's daily hospitalizations have risen "three- to fourfold every day." For the last three weeks, he added, "We've seen between 100 and 160 hospitalized per week, and that number was in the low 50s for most of November."

When the coronavirus hit Seattle last spring, hospitals could tap into travel nurses and travel doctors for staffing help, since so few other hospitals had severe outbreaks. But now the luxury of being first is gone. Hospitals across the country are reaching capacity, and that pool of reserve staff is tapped.

Exposure to COVID-19

Last month, Harborview Medical Center experienced a COVID-19 outbreak that killed one patient and infected three other patients and 10 Harborview staff. The outbreak forced 30 other staffers into quarantine.

Axel Adams, a 28-year-old second-year resident in the emergency department, said more of his colleagues had called out sick with COVID-19 recently than in the early days of the pandemic. The call-outs can drastically impact the way his department functions, which leads to fatigue and burnout, he said.

UW Medicine informs residents whenever they've potentially been exposed to COVID-19, but health privacy laws prevent the hospital from saying who caught the virus. Adams laughed wearily when he described the emails to me.

"There's this kind of stress response, and it’s like, 'Okay, I was exposed to someone in addition to the patients, but I don’t know who it was," Adams said.

As COVID volumes grow, so do the number of "exposure" emails, which increases Adams's fatigue. He thinks about his older attending doctors getting sick, which seems inevitable. He also thinks about himself and his co-residents getting sick, as they tend to do higher-risk procedures in close proximity to patients.

"You can wear your PPE and be careful outside of work," Adams said, "But it's probably only a matter of time before someone gets very ill."

As bad as it is now, in a month it'll be worse, Adams said.

He said he's focusing day-to-day on limiting his risk so he can stay healthy. "There this comrades-in-arms sort of mindset," Adams said, "You want the department to be as healthy as possible because that’s the best thing for the hospital."

The Threat of Sick Doctors

As cases rise and hospitalizations increase, more doctors will become sick. Dr. Nathan Schlicher, the President of the Washington State Medical Association, said at Inslee's press conference that his staff was already falling ill. Betsy Scott, a registered nurse and the vice president of SEIU 1199, said two nurses called out sick in her hospital recently and "there will be no one to cover for them."

If any UW resident calls out sick, someone else from the department who is either off work that day or doing other less-hands-on work has to cover the shift. This is particularly challenging for small departments where an off-the-clock resident always faces the possibility of being called in to cover. Usually, because of the impact calling out sick has on their peers, residents are reluctant to take sick time, Adami explained.

This fall, Adami's union negotiated with UW Medicine to provide paid sick leave for residents if they come down with COVID-19. Before that negotiation, UW Medicine required sick residents to use their own limited vacation time for that recovery period. Even though the new policy is better, residents infected with COVID-19 only receive paid time off if they contract the virus at the hospital.

Lola Mudgistratova is a fourth-year UW resident in the emergency medicine department who kept referring to the outbreak in the spring as "last year." She said she works in emergency rooms across Seattle but spends the bulk of her time at Harborview. If she falls ill, she's worried about what will happen to the ER, a department she says "runs lean." She is among 12 residents in the department and doesn't think it would be able to function if three residents fell ill.

"We’d be in 'oh shit' mode," Mudgistratova said, "We’d be understaffed, and an understaffed ER is a dangerous ER."

What Could Come Next

If people don't change their behaviors and obey COVID-19 restrictions, Schlicer said, the next peak won't come until February. In the meantime, if hospital capacity keeps decreasing, hospitals will need to stop all but the most critical surgeries, and sick people, including sick people without COVID-19, will suffer.

To battle surges, doctors who don't work in the Intensive Care Unit will need to be redeployed to the ICU to treat COVID-19 patients. Even though Amadi's union negotiated with UW Medicine to give high-risk or pregnant doctors the choice of where to be redeployed, residents won't have a ton of sway on where they're sent if the hospitals need to do surge staffing.

"We’re going to be in a situation where everyone needs more support, and there isn’t any," Amadi said.

If the situation is dire enough, doctors will need to start triaging people—determining who to treat and who not to treat—because they won't have the ability to treat everyone, Adami said.

Residents are aware of this reality. Mostly, though, according to Adami, spending the better half of eight months being constantly on edge has rendered them numb.

The public can help to avoid this fate by wearing masks, socially distancing, and staying home. Unless you're sick. Mudgistratova emphasized that sick people—not just COVID-sick people—should absolutely come to the hospital. Too many people avoided the ER in the spring when they faced life-threatening situations, she said. "The hospital is for everyone, not just COVID patients," Mudgistratova said.

For Adams, the second-year resident, all he can do is try to keep up with learning his "bread and butter" emergency medicine procedures while trying to "become as much of an expert as possible at managing coronavirus." He and his colleagues are doing all this work and risking their lives for low salaries and without hazard pay.

"It's certainly an interesting time to be in training," Adams said.