Rob Williams rushed across the room on March 16 to hug his partner, Karl Watson, for the first time in days and share the news: The symptoms Williams had were not COVID-19, the disease caused by the novel coronavirus. His primary care clinic said his test was negative.

Together, Williams, a 45-year-old commercial airline pilot, and Watson celebrated by breaking quarantine. They went grocery shopping, then for a walk at Volunteer Park, where they encountered close friends, whom they greeted with a cautious foot tap.

But Williams’ celebration was premature. On March 20, Swedish Medical Center, where Williams had undergone coronavirus testing six days earlier, called to say in fact he was infected with COVID-19. Williams cycled through disbelief, anger and frustration, then worry and guilt.

“Karl immediately started crying. He was afraid that we had exposed people by going to the grocery store,” and they worried for the friends they’d met, Williams said. “I felt shame that I had gone to a public space. I felt sad that I had maybe infected somebody at the time when we should be slowing the spread down.”

Williams’ experience illustrates how two weeks ago, the newly overwhelmed health care system struggled to grasp test-notification protocols handed down by public health officials. Since then, COVID-19 has graduated from an abstract threat to an unprecedented disrupter that has cast a pall over even minor decisions, like shopping for groceries.

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Neither Williams’ clinic nor Swedish officials were aware of any other cases like Williams’, and Public Health — Seattle & King County hasn’t seen a pattern of mistaken negative diagnoses for COVID-19. But his primary care clinic has made changes to guard against it happening again.

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‘Sweat through the night’

Williams knew his job as a pilot put him at greater risk of catching the coronavirus. Before he’d become ill, he’d seen the posted coronavirus warnings for passengers and personnel at airports in New York, Miami, Philadelphia, Denver and San Juan, Puerto Rico.

“I’d also eaten at many restaurants,” he said. “I’d ridden the New York subway system, New Jersey Transit, Ubers, touched doors at the train station in Philly.” All the while, he abided by the public health recommendations to frequently wash his hands and avoid touching his face.

Around lunchtime March 11, Williams began to feel ill. He was in Denver for a routine, work-related medical exam, and was aware the doctor’s office had two people on staff who had tested positive for COVID-19, already making for “a nerve-wracking day.”

“I noticed in Denver that I was dizzy, and I wasn’t getting quite enough air,” Williams recalled.

He flew to Philadelphia as a passenger later that day, and by bedtime, his symptoms had intensified, with deep chills and a high fever.

“I completely soaked my bedding, just everything was wet,” Williams said. “I just sweat through the night.”

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He awoke feeling refreshed. His symptoms had subsided, which is not uncommon. Believing perhaps he’d caught the flu, Williams flew home to Seattle on March 12 on a plane with 120 vacant seats.

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That night, his chills and fever returned, along with shortness of breath. But in the morning, he felt well again. The pattern repeated itself March 13, when an elevated heart rate driven by his increasingly oxygen-starved lungs joined the usual parade of symptoms.

By the night of March 14, his racing heartbeat lasted hours without relenting, so he called the emergency room at Swedish Cherry Hill Campus, and was instructed to come in for tests.

A shocking call

The surreal scene that awaited Williams in the emergency room was unmatched by anything he’d observed during the six years he’d spent as a nurse’s aide and later a nurse at elder-care facilities and hospitals.

“The way people were covered up [in protective gear], it was a very scary environment,” Williams said. It was evident, he said, from the frenetic pace caregivers rushed between the alarming number of patients “how hard these people are working and trying to save lives.”

Williams spent a few hours at Swedish’s emergency room being tested for seven varieties of coronavirus and undergoing a chest X-ray. Doctors sent him home with ibuprofen for pain relief and an inhaler to ease his labored breathing. He was told his test results would be ready in a couple of days, and was instructed to follow up with Country Doctor Community Clinic, his primary care clinic, in two days, on March 16.

But the instructions were not explicit about whether he was to check with his primary provider for further treatment, or test results. So he called Swedish that day.

“The number of times that I was transferred and transferred and hung up on, I was like, this is ridiculous,” Williams said. When he finally reached a nurse who was able to review his medical file, Williams said she directed him to the instructions on his release paperwork recommending he follow up with his primary care clinic.

When Williams did call Country Doctor later that day, a nurse, reading from his electronic medical records, informed him his entire test panel had come back negative. But there was an unexpected caveat.

The readout, as visible to the nurse, showed only tests that had been completed. The COVID-19 line-item on the report was absent from the paperwork, but the nurse was unaware tests still pending would not be visible.

According to Raleigh Watts, executive director of the nonprofit Country Doctor Clinics network, that’s what led to the mistake. “For us, there wasn’t anything indicating that something was pending,” Watts said.

When the doctor who administered Williams’ test at Swedish called March 20 with a contradictory result of positive, he was stunned to learn Williams received premature results from his primary care clinic, because the lab results for his COVID-19 panel of the test had just arrived that day.

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“When [Williams] was tested by Swedish hospital, they told him to contact his primary care doctor for the test results. That’s actually not the correct thing for them to have told him,” Watts said. “He called us believing it was the right thing to do. Our nurses really wanted to help him. There’s a real sense of urgency to help people right now.”

Spokeswoman Mafara Hobson said Swedish officials were unable to determine what was said to Williams during his March 16 call. But Swedish policy for announcing test results, then and now, has been to provide them directly to patients tested by Swedish without involving a patient’s primary care provider.

Williams’ situation spurred Country Doctor to make operational and policy changes. It no longer gives out patients’ results from tests administered by other health care providers, Watts said, and one doctor is designated each day to reckon with COVID-19 issues. The clinic also now conducts about 80% of patient visits remotely.

“I don’t think there’s actually a systemic problem. I think during a few days of rapid scale-up in early March,  everyone in every health care facility was doing their best and trying to figure it out,” Watts said. “The reality two weeks ago is very different than today.”

Public Health — Seattle & King County spokesman Keith Seinfeld agreed the health care system is growing more familiar with the coronavirus test process as time passes.

“It’s an understandable mistake for a provider to read those things wrong,” Seinfeld said. “It doesn’t happen very often, as far as we know, but it can happen just because it’s not the sort of test result that they get all the time.”

Williams’ shock over the misdiagnosis has subsided, and he’s steadily recovering but continues to have lingering physical effects.

On what he described as his best day so far since contracting COVID-19, Williams said in a phone interview last week, “Even though I can take a full breath, I’m not getting quality oxygen. I feel like I’ve been around a campfire all night. My lungs are burned.”

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