“During this pandemic, everyone you see could possibly have Covid-19,” says Susan Puckett, a physician assistant at Boulder Medical Center in Boulder, Colorado. “Every patient I see, I should be wearing a mask.” But three weeks ago, her clinic gave her one N95 mask, and told her she should keep it until it breaks. N95 masks are supposed to be single-use: see a patient, throw it away.
She’s used her single mask ever since, shift after shift. “It’s very surreal. I dreamed last night I would wake up and someone would say it’s a big April Fool’s joke,” she says.
What happens now that there are not enough masks and other personal protective equipment (PPE) — goggles, face shields, gloves, gowns, and other gear — for health care workers to protect themselves and others?
It has become an improvisational nightmare that goes against well established practices for infection control and heightens the risk of further spreading the virus. Medical staff all over the country are being asked to reuse their equipment, clean it with unproven methods, and use substandard materials — including trash bags — in the absence of adequate supplies.
As of early March, the US only had 12 million N95 respirators and 30 million surgical masks— just 1 percent of what is estimated to be needed during this pandemic. It’s a shortage with many causes, including a failure to stockpile supplies, confusion between state and federal agencies, and the lack of preparedness plans. And now the dire situation is endangering the very people who are working to save others.
“I’m terrified”: essential staff at risk
An emergency room doctor from Pennsylvania, who didn’t want to be identified because he’d previously gotten in trouble with his hospital for speaking out about the need for more PPE, has been given one N95 mask per week, and told to wear a surgical mask on top, which he is allowed to change between patients. (Surgical masks don’t effectively block the virus, but the heftier N95 masks, when fit properly, do.)
His neighbors recently gave him some extra N95s, allowing him to cycle between masks. “Who would have ever thought getting 10 masks at your door would bring you to tears,” he says, “but that’s where we’re at.”
These shortages endanger medical personnel, as well as the non-medical staff who work alongside them, like custodians and stockers. One such worker, a janitorial contractor at a hospital in southern Kentucky who doesn’t want to be identified for fear of losing his job, hasn’t received any training about Covid-19. When he asked his boss what he should do to protect himself, her response was “just wear gloves.”
“I’m terrified, to be honest with you,” he says. He is in charge of wiping down patient rooms, as well as cleaning a lab with biohazardous waste. He says he doesn’t have access to a mask, or paid sick leave. “All this for 11 dollars an hour,” he says. “Damned if you do, damned if you don’t.”
Lack of PPE is forcing the cancellation of important non-Covid-19 procedures
The PPE shortages have not only imperiled medical and facilities staff, they’ve also contributed to restrictions on non-Covid-related medical care. As services deemed “non-essential” get postponed or rescheduled in an effort to conserve PPE—including abortions, cancer treatments, and organ transplants—it contributes additional stress for both patients and their families, as well as medical staff.
A health care worker in a south Florida hospital, who didn’t want to be identified, says “There are things you don’t think, at first blush, would impact your clinical operations, but they do,” she says. The clinic where she works has now canceled all but emergency cases.
Her clinic has also instituted a no-visitor rule and is requiring patients themselves to wear masks. She explains these changes have big impacts on the clinic’s diverse patient population, mentioning a recent patient in her mid-90s, who was sitting in a wheelchair in the lobby when she walked in. “She was crying into her respirator. She wasn’t even wearing it correctly. She was upset that her daughter wasn’t allowed inside to be with her—she didn’t speak good English, and her memory wasn’t great.”
“The new normal has shifted so much,” says the worker, who, as part of her job, accompanies doctors on rounds to see patients. As recently as early March, a supervisor laughed at her for wearing a mask when she was recovering from a cold. “She said she didn’t want me causing pandemonium,” she recounts. “This was a week before mask-wearing was mandatory.” She is now given one surgical mask a day, and does not have access to N95s. She says she understands the clinic’s predicament, though. In her clinic, she says, they “are doing the best they can.”
Frontline workers say they don’t have information about how to protect themselves
Even if they had the proper protective gear, many frontline health care workers have received scant training for using it. In a recent survey of 8,200 nurses from around the country by the National Nurses United, a professional nurses association, as of mid-March, less than half had received training about Covid-19. And only 63 percent report having received critical training on safely putting on and taking off PPE in the previous year.
To add to the lack of equipment and training, there’s also a dearth of information about how to best make do during this dangerous equipment shortage.
As medical professionals scramble to try to find best practices for reusing PPE in decidedly not-best kinds of situations, researchers at Stanford University’s School of Medicine published a report in response to the coronavirus-driven mask shortage, suggesting some methods of cleaning and sterilizing PPE are better than others.
“We’re in uncharted territory,” says Larry Chu, professor of anesthesiology at Stanford University School of Medicine, stressing the general danger of reusing masks. “A used N95 mask is considered biohazardous waste.”
Although he says that people should follow their hospitals’ policies, and that they are not advocating specific approaches, “Our aim is to provide evidence to allow people to make the best decisions they can based on evidence.” In general, Chu wrote in the report that, for things like N95 masks, “to be useful, a decontamination method must eliminate the viral threat, be harmless to end-users, and retain respirator integrity.”
Along with Amy Price, a senior research scientist at Stanford, Chu found that many methods of attempting to clean or sterilize masks may destroy the virus — like alcohol or bleach — and also damage the mask. Microwaves generally just make masks melt. Soap and water are ineffective on masks (but great for hands). Ultraviolet radiation appears to work, but can be difficult to deploy adequately, as UV frequency and coverage has to be exact, and repeated use breaks down the mask’s filtration capacity and fit. Hydrogen peroxide also degrades masks with repeated use.
“My personal choice of methods,” Chu says, after testing five models of N95s from three different manufacturers, “is dry heat, because it did the least damage to the mask over multiple cycles, and the fit was preserved.”
Specifically, they tested masks at 158 degrees Fahrenheit in a hot-air oven for 30 minutes. An alternative method of applying heat effectively, he says, is using hot water vapor from boiling water for 10 minutes. But, “it’s really important not to bring anything you suspect of being contaminated into your own home to disinfect in any way,” says Price, because of the risk of further spreading infections.
The Centers for Disease Control and Prevention (CDC) has just issued crisis standards for decontamination and reuse of N95s, for hospital-based industrial decontamination. Chu and Price note that regardless of the sterilization method used, health care workers should request their own masks be returned to them, both for issues of fit and to reduce the possibility of cross-contamination.
But these methods of best practices in the worst of times haven’t yet made it to hundreds of thousands of medical staff currently being asked to reuse PPE.
One oncologist nurse at an outpatient unit in New York City, who was worried about repercussions of being identified, says she’s given one N95 mask per week and told that if it gets dirty, she should take it home and wash it in the sink.
“Even vapors from your mouth break down the integrity of that barrier, so washing it kind of defeats the whole purpose,” she says. She doesn’t have access to face shields, but she does have goggles, “like the ones you wear in chemistry class,” that she wipes down at night. She adds that while she’s been asked to reuse masks, she feels safer than colleagues at other New York City institutions, where she’s heard of nurses forced to resort to wearing Hefty trash bags due to shortages of gowns.
Even basic supplies, like disinfectants, are hard to come by now. “We have to go around every night and lock the Purell away,” she says. On any given day, patients and families steal about half of the sanitizer bottles from exam rooms.
She still can’t believe that the situation in New York has gotten so bad. “If you’d told me a month ago we wouldn’t have enough PPE, I would have told you that you were nuts,” she says. “I had a lot of faith in institutions.”
ER doctor: “I’m paralyzed by fear”
The repercussions of PPE shortages are already here: Although the CDC is not publicly reporting how many health care workers have tested positive for Covid-19, this week, there were at least 31 cases just in Oregon. At least two health care workers in Georgia, two in New York, and an emergency room physician in New Jersey have already died. Some hospitals, like Northwestern Memorial Hospital in Chicago, are so worried that intensive procedures could infect health care workers without PPE, they are contemplating do-not-resuscitate orders for dying Covid-19 patients.
These dire straits are unlikely to change soon. The chief operating officer of Medicom, a Canadian company that makes masks, recently told the New York Times that they are at full capacity, and increased production “will take anywhere between three to four months.”
The ER doctor in Pennsylvania, who is also a spokesperson for the American College of Emergency Physicians, doesn’t mince words. “It’s a total clusterfuck. There’s no leadership at the top. States are having to outbid each other for supplies because the federal government has refused to take a role, or is taking a role too little or too late.” He begged for a coordinated federal effort using the Defense Production Act, to kickstart production of PPE supplies.
The lack of federal direction has allowed gross price gouging. Even when basic equipment, such as gloves and surgical masks, are available to purchase, they are marked up many times their standard price, putting further strain on already-stressed states and health systems. ProPublica reports that New York state is now buying masks at 15 times the normal price.
In the meantime, it is not just infection that is threatening to waylay health care workers facing a shortage of PPE. A doctor in Bellingham, Washington, who pleaded for better protections for his staff, was recently fired. Other health care professionals, the New York Times reports, are being threatened for wearing PPE they procure on their own.
For the Pennsylvania ER doctor, the crisis is personal. His wife, who is also a doctor, is pregnant. “I come home, my wife is sitting there, and I’m paralyzed by fear. Did I get it? Am I passing it on to her? What’s it going to do to my kid? These are the fears everyone — doctors, nurses, janitors cleaning the room after a Covid-19 patient — has right now. In the ER, we see the worst aspects of humanity, and yet this trumps everything.”
This weekend, he started coughing and developed a fever. He went to get tested April 1, but says due to backlogs, he won’t know his results until the weekend, at the earliest. “Don’t call us heroes,” he says.
“Just help us be prepared — keep us safe.”
Lois Parshley is a freelance investigative journalist and the 2019-2020 Snedden Chair of Journalism at the University of Alaska Fairbanks. Follow her Covid-19 reporting on Twitter @loisparshley.