• suzansongmd

Fighting COVID-19: Don't let health care workers become collateral damage

Crystal Wong MD, Suzan Song MD, MPH, PhD, and Sara Kerley, MD

Published in KevinMD on 4/1/2020

Last week’s death of the first nurse to die from COVID-19 in New York City infuriated health care colleagues who blamed his death on lack of protective gear. Across the U.S., health care workers are scrambling to design makeshift personal protective equipment, also known as PPE. Nurses are resorting to wearing Hefty trash bags because they have run out of gowns. Physicians managing the most seriously ill patients are reusing the same single-use mask for the entire shift, for as many days as possible. Emergency room nurses are cutting plastic soda bottles to make face shields. Health care workers are even making masks out of plastic wrap and rubber bands and soliciting the general public to sew homemade masks.

The PPE shortage in the U.S. stems from a combination of supply chain problems and misinformation. We need more PPE, and we must act now to address these issues. Recommended personal protective equipment (PPE) for treating patients with COVID-19 are: a medical mask, face shield or goggles, gown, and gloves. N95 respirator masks are also recommended, especially for procedures such as placing a breathing tube in a patient who needs mechanical ventilation.

According to the Department of Health and Human Services, we will need 3.5 billion masks over the course of a year to deal with the pandemic. The Strategic National Stockpile has 30 million surgical masks and 12 million N95 masks—only 1 percent of the number required. Health systems typically stock enough PPE to last for several months under normal conditions, but a rapid surge in hospitalizations can quickly deplete PPE stores. A hospital in Georgia treating COVID-19 patients used up five months’ worth of PPE in only six days. Proper PPE reduces the risk of infection in health care workers, who are especially vulnerable—their risk is up to 6 times higher than that of the average person. In China, infections among health care workers were largely due to a lack of PPE. Approximately 3,000 health care workers were infected, of which 15 percent were severely or critically illMore than 22 have died. But once health care workers in Wuhan had access to proper PPE, not a single one of 42,000 health care workers was infected.

As the pandemic accelerates in the U.S., we are losing our health care responders due to a nationwide lack of PPE. In Ohio, 1 in 6 patients with COVID-19 are health care workers. Last week, Boston hospitals reported more than 160 health care workers infected, and at one hospital, the number of infected workers was five times the number of patients with COVID-19.

Supply chain disruptions are a major cause of the PPE shortage, since China produced 50 percent of the global supply before the pandemic. Other nations, such as India and those in the European Union, have restricted or banned the export of masks because they are having difficulty meeting their own internal demand. The U.S. also does not manufacture enough PPE to equip its health care workers.

Confusing guidelines about the proper use of PPE have also created an artificial shortage. At the beginning of the pandemic, the Centers for Disease Control and Prevention (CDC) recommended using N95 masks when treating patients with known or suspected COVID-19. In recent weeks, the CDC has amended its recommendations to state that surgical facemasks are an “acceptable alternative” when N95 masks are not available. Some hospitals have interpreted this to mean that facemasks are just as good as N95 masks and are refusing to distribute N95 masks to their staff, even for procedures that require the maximum amount of protection. Physicians who dared to speak out against the lack of proper precautions at their hospitals have been retaliated against and even fired.

What’s worse, the CDC recently recommended using bandanas as PPE when no more masks are available. The repeated downgrading of safety recommendations in spite of known best practices is harmful, because hospital administrators use CDC guidelines to justify providing inadequate protection to health care workers and forbidding staff from using PPE they have personally purchased.

Misinformation about what constitutes safe practices puts health care workers at risk for getting infected, who, in turn, may spread the infection to their patients, coworkers, and the community. We need clinicians to be heard in close collaboration with administrators, scientists, and government in order to develop a unified understanding of the pandemic.

Some believe that health care workers signed up for this kind of exposure. But we are not martyrs. Despite metaphors of physicians as soldiers entering battle, we did not have informed consent that we could lose our lives, do harm to our patients, or engage in battle without any protective gear.

Others may argue that because COVID-19 has a global mortality rate of 3.4 percent, the vast majority of people with COVID-19 will survive, and therefore concerns about preserving the health care force are an overreaction. But according to the World Health Organization, the mortality rate is dependent on the health care response—meaning that a sub-par response results in more deaths. What’s more, about 1 in 5 people with COVID-19—including younger healthy adults—will have severe or critical illness, which most people experience as trouble breathing to the point of needing oxygen or a ventilator.  If you’re unlucky enough to be infected with severe symptoms, who would you want to be treating you?

We have the capacity to mitigate some of the dire effects of this virus. We are at a fork in the road—act now to protect health care workers by addressing the supply chain problem and providing clear guidelines backed by scientific evidence. Or choose to continue to allow our skilled health care staff to fall ill, worsening the spread of infection and further straining our overburdened health care system. In which case, I hope our politicians and hospital administrators are brushing up on ventilator management, since they’ll be the ones caring for our sickest patients.

Crystal Wong, Suzan Song, and Sara Kerley are physicians.