番茄社区

Clinicians on the front lines of the COVID-19 pandemic are scraping to find gowns, goggles, respirators, and other personal protective equipment (PPE) -- and coming up empty-handed.

Many are frustrated with their employers for tightening protocols and access to protective gear; others blame the government for not doing more to ramp up production of these goods.

"I just feel like apparently we're expendable," one California emergency room physician speaking on the condition of anonymity told 番茄社区.

In fact, in a recent 番茄社区 survey, 46% of respondents felt they didn't have adequate PPE, and 85% feared a lack of access in the future -- a sentiment echoed across social media, where healthcare workers are sharing their needs using the Twitter hashtag .

Obtaining N95 respirators posed a particular problem; often they were either unobtainable, rationed by administrators, or simply too difficult to locate at the point of care. Some clinicians reported wearing ponchos or cloth gowns instead of the disposable ones typically worn in such circumstances, and gauze or surgical masks in place of respirators.

One survey respondent, a physician working in an urban practice, said the supplier canceled the facility's requests for PPE due to high demand.

"We found out we would be allowed to order if we had a positive case," that doctor wrote. "Right now we are using goggles, gloves, disposable rain ponchos, and a very limited supply of N95s that were purchased at a local hardware store."

Another, a nurse practitioner, said masks are kept locked up and clinicians are required to sign them out at a main office with the patient's name, making them virtually inaccessible at the point-of service.

At Johns Hopkins in Baltimore, one emergency physician, speaking anonymously, told 番茄社区 that clinicians are reusing their plastic face shields and N95s, and said gowns will run out soon.

But it's the N95s he's most worried about: "I can't imagine any doctor going into a room for a suspected case without [an] N95 -- that's idiotic," he said.

Healthcare workers have been particularly troubled by the CDC's recently revised guidelines as to what's acceptable as PPE.

"Everybody knows that if [N95s] were accessible, then they would recommend us wearing them," said the California-based emergency physician who spoke anonymously to 番茄社区.

"I am scared. We are all scared," a Connecticut nurse, who declined a phone interview because her hospital instructed staff not to discuss hospital policies or new practices, told 番茄社区 in an email.

"We are told every day to defy the scientifically proven best practices on the simple basis that we do not have the correct or appropriate PPE. No one is backing us up and we are made to feel like pawns on the front lines. It's a scary feeling to know that no one cares about your life," she wrote.

Marcia Santini, RN, an emergency department nurse in Los Angeles and a member of the California Nurses Association, said her hospital has enough gloves, but ran out of face shields on Wednesday. Some staff are working without goggles.

Nurses are allowed one N95 respirator per day, and it's been a challenge to find even one when it's needed.

In the emergency room, a patient could go into cardiac arrest or respiratory arrest at any time, and "if you have to leave that patient to go run around looking for a mask, you're not giving the proper care," Santini said.

She added that as a matter of instinct, most clinicians wouldn't hesitate to respond to the patient first, but they shouldn't be put in that position.

The California emergency room physician shared similar concerns, noting that every day she hears the same thing in meetings: Staff are consistently told, "you have to not panic," but "everybody is tense."

She said clinicians fortunate enough to have an N95 respirator must write their names on the equipment and reuse them, which is not how they are meant to be used: They're meant to be disposable.

What bothers her most, she said, is that clinicians are sent into closed tents to assess COVID-19 patients, with inadequate protection: "You're basically walking into this respiratory cesspool of pathogens that you will inhale with your suboptimal mask," and "directors are telling you, 'You know what you got yourself into ... You chose to go into emergency medicine.'"

"Everybody but the U.S. has this crazy amount of personal protective equipment," she continued, noting that the Chinese in particular are especially well-covered. She said she just can't understand why the difference exists.

Santini said part of what makes clinicians so fearful is that the exact science of the virus and how it spreads is not well understood; she cited new research suggesting that the virus can live in the air for up to 3 hours.

"When we're swabbing patients, it tickles the back of their nose, and that produces a sneeze," Santini said, "and if you ... don't have the highest level of protection on, you can ... be exposed."

And while it seems obvious, one basic fact seems to keep getting overlooked: "If we get sick, we're vectors -- we could infect people ... If the nurses are sick, then our patients are going to be sick and our communities are at risk."

Federal Response

As for the government's response, President Trump authorizing the use of the "Defense Production Act," which gives him the ability to compel manufacturers to produce critically necessary equipment, including medical supplies -- but so far, he doesn't appear to have used those powers.

During a briefing on Sunday, the president described precisely how many of each individual PPE item had been sent to the hardest hit states "a number of days ago" from the Strategic National Stockpile.

As an example, New York has received 186,416 N95 respirators, 444,078 surgical masks, 84,56 face shields, 68,944 surgical gowns, 352 coveralls, and 245,486 gloves.

"The numbers are quite large," he said.

But that may not be enough. Craig Smith, MD, chair of the department of surgery at NewYork-Presbyterian/Columbia University Medical Center, who shares , said NYP alone uses about 40,000 masks a day, and estimates suggest that number could rise to 70,000.

The stockpile, which is meant to serve the entire country, only contains 75 million masks, he said, but the downstate region of New York runs through about 3 million a week.

By those estimates the 440,000 masks sent to New York from the stockpile would last for no more than a couple days.

However, in addition to the PPE from the stockpile, the private sector is also voluntarily "helping to produce and supply much-needed masks, swabs, sanitizers, ventilators, and everything else," Trump said during a press briefing on Saturday.

Hanes, the clothing company, is in the process of transforming large swaths of its factories to enable them , and car manufacturers, such as , have committed to producing ventilators. In addition, are stepping forward to produce hand sanitizer.

During the Saturday briefing, Vice President Mike Pence said manufacturers would be producing "millions of surgical masks in a matter of weeks" and that the Department of Health and Human Services had just placed an order for hundreds of millions of N95 masks.

"We have the act to use in case we need it, but we have so many things being made ... by so many [companies]," Trump said. "They've just stepped up."

Asked at the briefing how soon such supplies would reach clinicians, Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, said, "It's going to be days, I would hope," not weeks.

For those serving possible COVID-19 patients, it doesn't seem to matter how many masks have been ordered or are being produced if clinicians can't access them now.

Deborah Burger, RN, president of National Nurses United (NNU), said it's "unconscionable" that the president hasn't directed private manufacturers to mass-produce PPE.

"If [nurses] are not protected and safe, more people will die, and the virus will continue to spread in greater numbers," she told 番茄社区 via email.

'Some Level of Protection'

On a , Michael Bell, MD, deputy director of the CDC's Division of Healthcare Quality Promotion, explained the CDC's decision to revise its earlier recommendations around the use of N95 respirators, to preserve their use for "procedures and activities that have the highest risk for healthcare personnel" -- for instance, "aerosol-generating" procedures, such as intubations.

But for routine assessments, there's "enough evidence to suggest that surgical masks or other face masks provide some level of protection," he said, noting that such masks would block "direct exposure" from any respiratory secretions to a clinician's mouth and nose.

He also said studies comparing N95s with surgical masks "have not demonstrated a major difference" to date, but the issue is still being studied.

CDC officials also stressed that the most effective use of a mask is to put it on the patient who's coughing.

They also suggested that clinicians help preserve equipment by not using N95s during trainings, wearing the same respirator through several patient encounters, using products beyond the manufacturer's shelf-life date, and reusing masks.

Capt. Lisa Delaney, speaking as a member of the CDC's COVID-19 Response Worker Health and Safety Team, did warn that reusing masks increases the risk of contact transmission and should be implemented with caution: Reuse is one of the "extreme recommendations," she said, but "it may be your only option."

CDC released two guidances about optimizing supply -- one for and one for . The face mask guidance recommends designating healthcare personnel who have "clinically recovered from COVID-19" to provide care for COVID-19 patients, or wearing a bandana or scarf as a "last resort," when no other masks are available.

Scarves and bandanas are not actually PPE, the agency noted, and "their capability to protect [healthcare personnel] is unknown."

The agency stressed its N95 guidance offers "crisis capacity" strategies which are "not commensurate with current U.S. standards of care." It includes a decision-making chart graded by clinician activity type, and whether the patient is masked.

Bonnie Castillo, RN, executive director of NNU, in a March 12, called the rollback of the CDC's prior recommendations "completely outrageous" and "irresponsible."

"We are not going to be silent and let our employers or our government agencies put us in harm's way," Castillo said.

Seeking Solutions

Between , to funnel unused equipment from research labs to hospitals, and grassroots efforts where ordinary Americans construct homespun masks and face shields, volunteers are stepping forward to help.

Students at Georgetown University School of Medicine in Washington, D.C., having been temporarily booted from clinical rotations due to the pandemic, started , modeling their program on the basic food-drive concept.

They are asking their colleagues, as well as health and science students with connections to research labs -- many of which are closed -- to help track down items like unopened masks, gowns, gloves, bleach, and bleach wipes, and request that they be donated to local hospitals.

Hannah Day, a third-year medical student at Georgetown, who was pulled off her clinical rotation last week, noted that while each medical school will decide independently whether to cancel or postpone classes, a lot of medical students are going to have a fair amount of free time now and "we definitely feel like there's a lot we can do."

Asked whether students were specifically requesting certain kinds of PPE, Day said, "it's whatever they can get." If gowns aren't available, "we'll take plastic rain ponchos from the dollar store."

So far, nearly 50 schools and organizations, roughly half of them medical schools, have expressed interest in the project.

Meanwhile, at Johns Hopkins Medicine, Roy Ziegelstein, MD, vice dean for education, and Peter Espenshade, PhD, associate dean for graduate biomedical education, called for volunteers to help construct face shields.

Participants meet on site in Baltimore. They must self-attest to being asymptomatic for fever and respiratory issues and are stationed six feet apart. Cleaning staff continually sanitize the work environment, according to a description of the program, which has been vetted by the school's Hospital Epidemiology and Infection Control/Prevention Office.

As of March 15, volunteers have constructed at least 1,000 masks, which have already been approved for use by Infection Control. Volunteers aim to make at least 30,000 more packets of PPE, which include not only masks but bleach wipes and hand sanitizer as well, according to a press representative for Johns Hopkins Medicine.

Providence St. Joseph Health, with locations in several western states, has organized a similar program, a , asking those with the skill and the machinery to do so, to sew masks for front-line clinicians.

The effort is currently focused on western Washington state, but the health system plans to grow the initiative in the coming days and weeks to allow anyone to participate.

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