On March 1, four days after COVID-19 killed its first Washingtonian, Alexander Adami was called in to work the night shift on an intensive care unit at Harborview Medical Center. Adami, a second year resident in internal medicine at the University of Washington, was filling in for a physician who'd been sent home after being exposed to the first patient who'd died with the virus.

When he showed up for work, Adami discovered that one of the patients on the rotation was being tested for COVID-19, and that person was looking "very bad, as if they would need to be intubated," he said.

Two problems immediately presented themselves. The first was that UW Medicine had not yet trained Adami nor the senior resident on the shift to care for COVID-19 patients. Such care required the use of special protective equipment and adherence to certain procedures, which the ICU supervising physician had to track down and teach "on the fly," Adami said.

The other problem? When you need to "intubate" someone, i.e. shove a tube down their throat, you need to have an anesthesiologist. And, according to Adami, "there was not a single anesthesia attending who was trained to enter that room that night."

The team ended up calling in an anesthesiologist who could handle the situation if need be, and the patients were cared for accordingly. But Adami believes poor management from UW administrators needlessly put everyone in the ICU that night at risk.

"It shows how little attention UW was paying to this," Adami said.

Lack of Training

Despite the fact that an Everett hospital treated the first man in the U.S. with the virus back in January, Adami said UW hadn't adequately prepared by early March: "They just said they were monitoring the situation and they'll come up with a training plan at some point. Then they had to scramble."

The Accreditation Council for Graduate Medical Education (ACGME) published expectations for resident training on COVID-19 patients on Feb. 19.

Aside from not training residents on how to treat COVID-19 patients more than a month after Patient Zero landed in Washington, other signs, for him, pointed to administrative disfunction. During that first week in March, Adami said UW was sending residents "five, six, seven emails a day with information that would change hour to hour."

A representative from UW Medicine did not return a request for comment by my deadline. I'll update when I hear back. In the meantime, a spokesperson for the program told the Seattle Times that every hospital in its system "had a surge-capacity plan being adapted for the outbreak," and that "daily planning sessions monitor our available beds, supply usage, and human resources."

Training for residents, who make up 20% of the doctors in King County, has since ramped up, and things are running "much smoother" now that "frontline people in infection control" are more or less running the show, Adami said.

"Definitely Not Good for Morale"

However, on March 11 UW added insult to injury by hitting residents with a "final offer" on a contract the college has been negotiating with University of Washington Housestaff Association for nearly a year now.

The new offer gives residents a 2% raise, increased travel and home call stipends by next year, an added week of vacation in two years (bringing the total up to four), and a fully subsidized UPASS.

Residents describe the raise as a pay cut, given its failure to match the local cost of living increase of 2.5%, and given the fact their last contract secured 3% raises. They also point out the paucity of the travel/home call stipend relative to similar institutions, and add that a vast majority of programs already offer four weeks vacation.

"It's a blow, to be honest," said Krishna Prabhu, an internal medicine resident. "They offered that to us in the middle of this epidemic, and we’re on the frontlines here. Definitely not good for morale."

"There are people working 28-hour shifts in the ICU, and there is no other class of health care worker that’s doing that." Prabhu continued. "It’s a hard thing to do without COVID-19, and now with it the workload has increased tremendously."

"The normal stuff that continues to happen is hard. It’s not like traumas are going to stop happening. You're still going to have folks who have heart attacks," Adami added. "We just don’t have the staff or the equipment to do it if it really gets bad. And it really doesn’t help having the majority of our employers look at this stuff and offer a contract that says they really don’t value us enough. It doesn’t inspire many people wanting to stay here afterwards. And I think that’s a sentiment many in this residency will have after all this."

Nevertheless, They're Persisting

Right now, Prabhu said, different hospitals are handling COVID patients in different ways. At Harborview, non-resident physicians rule out patients presenting symptoms for the virus, and a dedicated team cares for confirmed cases. But the ICU is a different story. There, a team of four residents (who work 28-hour shifts every fourth day), along with supervising physicians, also care for COVID-19 patients.

At UW Medical Center and at the Veterans Administration hospital, COVID-19 patients are being distributed across resident and non-resident teams. "They're turning Northwest Hospital into a COVID hospital. There are 24 people there who are positive," Adami said last Wednesday. At the moment, internal medicine doctors primarily care for those patients, but "that could always change if that epidemic grows like we expect it to," Prabhu said.

Though many were disheartened by the latest contract offer, several residents are volunteering to transfer out of their "easier" rotations to help overloaded hospitals screen and treat COVID patients or absorb non-COVID patients. Adami says there's also talk of having residents from surgical and anesthesia specialties help take care of non-COVID patients on the medical side.

Prabhu remains "cautiously optimistic" about turning things around. "We’re adaptable, and we'll continue to find solutions and the ingenuity within our spirit. Though all residents are still working on an expired contract, we’ll continue to show up because we’re doing it for our patients, our community, and our country," he said.