We Train For This

Audrey Fraizer

Audrey Fraizer


“No one wants to be the first in the nation in these types of situations, but these are the types of situations that public health and its partners train and prepare for,” Chris Spitters, M.D., Health Officer, Snohomish Health District.

The 911 call to Snohomish County 911 (Washington, USA) on Jan. 16 among the first calls in a cataclysmic chain of the rapidly developing pandemic.

The Snohomish County resident in his 30s was traveling through Sea-Tac Airport after a trip to China near the Wuhan region, Hubei Province, China, where in Dec. 2019 an outbreak of coronavirus disease 2019 (COVID-19) was first identified amid an outbreak of respiratory illness cases.

On Jan. 19, the patient self-reported to a clinic in Snohomish County.
He had been hospitalized with pneumonia in early January. Nasal specimens were collected and sent to the Centers for Disease Control and Prevention (CDC). On Jan. 20, the United States had its first laboratory-confirmed case of COVID-19.

In late January, there were 300 cases confirmed worldwide and, although Snohomish County has been cited as the first case reported in the U.S., the coronavirus outbreak in this country was not spread by a single transmission. According to Chris Spitters, M.D., Health Officer, Snohomish Health District., the virus was likely introduced in several regions, with Seattle being one of them.

“I think it’s reasonable to assume, given reports that the ones we’ve have and the others around the country, that introduction may have occurred prior to mid-January as we initially suspected,” Spitters said. “While that’s of scientific and academic interest, it doesn’t really change where we sit today or where we have to move ahead in the future.” 1

No matter how the virus reached the U.S., or how, Snohomish County health officials swung into action, combatting what evolved into a national crisis with a data-driven approach honed to pandemic proportions.

“No one wants to be the first in the nation in these types of situations, but these are the types of situations that public health and its partners train and prepare for,” said Spitters.2

Initial precautions

Snohomish County EMS Medical Program Director Eric Cooper, M.D., Snohomish Fire Deputy Chief Scott Dorsey, and Spitters held a conference call with the receiving hospital to coordinate the patient’s transport and care.

The ambulance crew was issued Personal Protective Equipment (PPE)—high-level respirators, eye protection, and disposable gloves and coveralls. A patient isolation pod (ISOPOD) was loaded on the truck. An ISOPOD is designed to go on top of a stretcher over a patient, trapping airborne droplets and reducing healthcare workers’ exposure to the medical risk during transport.

The patient was told not to approach responders. He was suited and placed in the ISOPOD and transported to Providence Regional Medical Center in Everett (Washington, USA). Once the transfer of care was complete, the ambulance was given a hot water scrub down in the parking lot.

Collect and measure

Public services and healthcare organizations developed a joint community mitigation strategy to minimize social and economic impacts of COVID-19. County fire service agencies serving nearly 83% of the county established a Fire Coordination Center to provide unified tracking, planning, and response to the outbreak.

The Snohomish County 911 communication center started operating the Medical Priority Dispatch Protocol (MPDS®) 36 in surveillance mode. They tested a Plan, Do, Study, Act (PDSA) cycle on running alternative response options with trucks responding to low-level calls.

Control charts were developed to evaluate process performance and a FirstWatch COVID-19 trigger tool and software called QI Macros were used to analyze patterns and trends.

“Early on, it was hard to understand the virus’s exact symptoms,” Cooper said. “Data was informing the process.”

Each case was documented to tease out more data: distribution according to gender (fairly equal), and prevalence of symptoms (shortness of breath, fever, and general weakness were priority complaints), for examples. An unexpectedindicator of COVID-19 was a fall or head injury for patients taking blood thinners. PPE effectiveness tracking helped determine the amount of supplies necessary. The appointed science officer created a COVID-19 procedure manual.

“The playbook is updated every day and distributed to all agencies,” Dorsey said. “We want everybody to stay on the same page.”

They redesigned elements of their already rigorous tracking process to track daily performance in the COVID-19 environment. Further along in the process, they linked the dispatch code to the ESO report and hospital outcome data to determine patient transport and consideration of an alternate destination for less severe cases.

Secondary impacts

The coronavirus affected the community in multiple ways, according to the Snohomish County 911 Facebook page:3

April 21: Today marks three months since Snohomish County had the first U.S. COVID-19 diagnosis. Since then, our county has experienced over 2,300 confirmed cases and we’ve lost over 95 members of our community. While the number of new cases appears to be flattening, we continue to face stressful and uncertain times, and the impact on our City will likely be felt for a long time. This added stress and uncertainty can have unforeseen impacts on our community members. While overall crime in the City is down, our officers have seen an increase in domestic violence-related calls. If you experience a domestic violence situation, there is help. Call 911, our officers are still out there protecting our community 24/7 during this pandemic. If you need informational resources about domestic violence you can also contact The National Domestic Violence Hotline at 1-800-799-7233.

Increasing public resistance of calling 911 to avoid transport was a secondary impact that resulted in an intensive community relations campaign. A 1-800 number was established to answer questions and texting the word “Coronavirus” to 211-211 gave access to the latest information on COVID-19, including county-level updates, and resources for families, businesses, students, and more.

The Facebook page also featured how to follow the “Stay-at-Home" orders of the Governor and drop-off points for PPE.

Learning as they go

The incredible challenge facing their agency has increased Snohomish County EMS’s knowledge about making decisions within ambiguous environments, although admittedly it’s a learning curve all the way.

“The best decisions come from the data we’re gathering and using the control charts to truly understand what is happening,” Cooper said. “We’ve learned that there’s not always time to give the why behind the what.”

Dorsey said change is the one constant.

“Expect it,” he said. “The way you did something last week may not be the way to move forward this week. Learn to grow with it.”

Finally, it’s imperative to keep the information overload under control. Document. Use only what you need and make it meaningful.

“Identify the data you need, and act according to what it’s telling you,” Cooper said.

As of Oct. 20, slightly more than nine months after initial calls to 911, more than 8 million people in the U.S. have been infected with the coronavirus and more than 220,000 have died.


1 Klein S. "Coronavirus 'Patient Zero' was not Snohomish County man, health officials say." MYNorthwest. 2020; May 15. https://mynorthwest.com/1876403/coronavirus-patient-zero-snohomish-county/ (accessed Oct, 23, 2020).

2 “Case of 2019 novel coronavirus confirmed in Washington state resident.” Washington State Department of Health. 2020; Jan. 21. https://www.doh.wa.gov/Newsroom/Articles/ID/1068/Case-of-2019-novel-coronavirus-confirmed-in-Washington-state-resident-20-006 (accessed Oct. 20, 2020).

3 Snohomish County 911. 2020; April 21. https://www.facebook.com/sno911/posts/706398666776713

Audrey Fraizer is managing editor of the Journal.