‘Terrified’ Healthcare Workers Fear Lack of Protection Against COVID-19
“You wouldn’t send a soldier into war without a gun or body armor,” one doctor says. Hard-hit areas offer some tips.
As COVID-19 sweeps across the globe, doctors and other healthcare workers are witnessing limited availability of personal protective equipment (PPE), particularly appropriate masks, and being confronted by difficult situations that pit their desire to remain safe against their duty to help patients.
In the United Kingdom, for example, doctors in some cases are performing invasive procedures on patients positive for COVID-19 despite the fact that their size of N95 mask is not available, leaving them no choice but to go ahead wearing a surgical mask that does not provide the appropriate level of protection against infection.
“That’s a situation where the patient’s in extremis, you need to act quickly. Ideally you have the equipment, but it’s not there so you need to proceed. This is happening,” Asif Qasim, MBBChir, PhD (King’s College Hospital, London, England), founder and CEO of MedShr, told TCTMD.
That situation is not unique. There are reports from around the world that healthcare workers aren’t receiving the equipment they need as they toil away on the front lines of the fight against COVID-19. For a period of time on Thursday, #PPEshortage trended on Twitter.
The potential consequences are clear. There is the personal health risk—highlighted by the death of a doctor from COVID-19 in hard-hit Italy after he had to work without gloves due to a shortage—that gets inflated into a public health danger if enough doctors, nurses, and other healthcare workers get sick and are unable to come into work to care for growing numbers of infected patients. In that case, the system would get overwhelmed.
“If we can’t protect our healthcare workers, they can’t protect the public,” C. Michael Gibson, MD (Baim Institute for Clinical Research, Boston, MA), told TCTMD. “This is really reaching a crisis point.”
Gibson put up a couple of Twitter polls to get a sense of what’s happening on the ground. In one asking whether hospitals are rationing masks, nearly one-third of respondents said they didn’t have any masks and 40% said they had only one mask per day. Gibson said some healthcare workers have told him they have access to only one mask for every COVID-19 patient, “so different people would be asked to share the same mask.”
Governments seem to be hearing the concerns, having announced measures meant to address supply issues. In the United States, for instance, Vice President Mike Pence, who heads the coronavirus task force, this week asked construction companies to donate their N95 masks to local hospitals and stop ordering more for right now. He also announced that, through legislation, liability protection has been extended to manufacturers of N95 masks so more can be sold to hospitals, and that companies are ramping up production to meet the needs of healthcare workers.
That’s good news, “but the issue is that we need the masks today,” Gibson said, cautioning that “if we quarantine cities and we tell people to shelter in place, we may see disruption of supply chains, and the next issue will be how do you get masks that are available from someone like 3M to the hospitals.”
The concern among healthcare workers, at least in the UK, “stems, to start with, from having seen what’s happened in China and South Korea and Italy, and consistently seeing people there wearing what look like hazmat suits with full respirators for most of their patient contact,” Qasim said. He acknowledged that he’s not an expert on personal protective clothing, but said, “I think our expectation was that because we saw this coming we’d get similar protection.”
If we can’t protect our healthcare workers, they can’t protect the public. C. Michael Gibson
Another element of concern comes from “a feeling that the guidance coming from the [UK National Health Service] is pragmatic guidance based on the availability of equipment, to be frank. So I think there’s a perfect answer as to what should happen and then there’s a pragmatic solution,” he added, saying that N95 supplies, use of fit testing, and recommendations regarding PPE vary across hospitals.
And there appears to be good reason to be concerned. A study of 138 patients hospitalized with COVID-19 in Wuhan, China, where the novel coronavirus SARS-CoV-2 is believed to have originated, showed that 29% were health professionals.
Harriette Van Spall, MD (Population Health Research Institute, Hamilton, Canada), also noted that guidance on which healthcare workers should be wearing the most-protective N95 masks and when differs depending on where you look. There are situations in which personnel are not recommended to wear masks during encounters with patients who are asymptomatic. The problem with that is that SARS-CoV-2 can be transmitted in the absence of symptoms, which would suggest healthcare workers should be protected at all times.
“If the health and safety of the workers was the primary concern, these masks would be recommended for all exposures, but you can see how there’s variation, and a lot of the variation is driven by the lack of supply rather than by the science,” Van Spall said.
The relative lack of testing that has been done in the US compounds these concerns, Jason Wasfy, MD (Massachusetts General Hospital, Boston), told TCTMD. Clinicians should be assuming that everyone they encounter is infected because so few tests have been performed, but there are not enough masks to employ that strategy, he said.
Workplace Safety Issue
Van Spall called this a workplace safety issue. “No other profession is exposed to risk without their workplaces providing safe equipment,” she said. “You think of firefighters and military and police. None of them would be expected to purchase their own equipment. But increasingly we’re seeing shortages that force healthcare professionals to purchase protective equipment for themselves.” She noted that the masks available on the retail market, though they may be N95s, might not be up to industry standards.
Proper protection with masks also requires fit testing, which has proven challenging to get in many organizations, Van Spall said.
Knowing that your people are going in and risking themselves and not giving them the protection they need—there’s an inherent ethical concern about it. Harriette Van Spall
There are multiple reasons health systems should be making sure their workers have adequate protection. “Strategically institutions should ensure that their workforce is safe not only to maintain a supply of workforce but also to make sure that they’re not increasing their risk of nosocomial spread, and by that mechanism increasing the risk of community spread,” Van Spall said.
Underscoring a major problem with the shortage of PPE and the variations in recommendations, she noted that in China, where healthcare workers now have extensive experience with managing COVID-19, standards for protective gear have evolved to include head-to-toe protection because clinicians wearing N95 masks were getting infected.
This raises red flags, Van Spall said. “Knowing that your people are going in and risking themselves and not giving them the protection they need—there’s an inherent ethical concern about it.”
In some cases, the ethical issues may be more overt, with some physicians on social media saying that they’ve been warned by hospital leaders about wearing surgical masks in the hospital because of the possibility of causing panic.
With the shortage of appropriate masks, healthcare workers have had to come up some work-arounds, including buying their own masks (when they can find them) from hardware stores. Guidance from the Centers for Disease Control and Prevention (CDC) on strategies to optimize the supply of facemasks even includes a recommendation to consider using scarves or bandanas as a last resort. “However, homemade masks are not considered PPE, since their capability to protect healthcare personnel is unknown,” the CDC states. “Caution should be exercised when considering this option. Homemade masks should ideally be used in combination with a face shield that covers the entire front (that extends to the chin or below) and sides of the face.”
Gibson cited research looking at the types of materials that provide the greatest ability to filter particles—two layers of a dish towel and a vacuum cleaner filter performed well. Filtration is just one aspect of an effective mask, however, and these types of jury-rigged masks did not fare as well as a standard surgical mask in fit tests assessing the capability of preventing particles from getting in around the edges of the mask.
“So if you do have to resort to a homemade approach, you probably better tape it up around the edges so that particles can’t get in that way,” Gibson said. He wouldn’t speculate on whether the situation will eventually require those types of solutions, but he reiterated that many healthcare workers have reported not having any masks at all.
Due to the shortages, healthcare workers have taken to reusing equipment that would typically be tossed after each use, and in the setting of such uncertainty, have generally opted for less-protective options like standard surgical masks. “In general, in medicine, when there’s uncertainty about whether something’s safe, you go for the safer thing, but that’s not possible because of these shortages,” Wasfy said.
Van Spall said that some workers have gone online to educate themselves about the best ways to get in and out of protective equipment that they have available to them and buying masks for themselves when they can. “There’s a large element of having to think about your own protection and getting the knowledge, skill set, and supply in order to do that,” she said.
The shortage of appropriate PPE is certainly taking a toll on the mental well-being of frontline healthcare workers, with widespread reports of fear, sleepless nights, and families concerned for their loved ones who are exposing themselves to the risks of COVID-19 every day.
Van Spall said she tends to be less prone to anxiety, but “even I am concerned about my health and safety” in the setting of asymptomatic spread and an insufficient supply of PPE. The inherent conflict between the desire to preserve protective equipment for clinicians who treat the highest-risk patients and the desire to protect oneself from possible infection transmitted by an asymptomatic patient causes anxiety, she explained.
Qasim cited the increasing numbers of COVID-19 cases and related deaths as a source of stress for healthcare workers. While some countries seem to be getting the situation under control, Italy remains in a bad place and the UK seems to be heading in that direction, he said. “We don’t have enough equipment now and in some ways it feels like this is just beginning.”
The degree of mental strain is great, Qasim indicated.
“I’ve been a doctor for over 20 years. It’s the first time I’ve heard my peers across multiple specialties say that they’re terrified,” he said. “Tough, hard-working, resilient, skilled doctors across multiple acute and invasive specialties using that same word, terrified, because what they know is that they are going to encounter positive patients, that there’s a significant chance that not only will they get infected but they might get a significant viral load from it. And if they get infected, there’s a significant chance that they’ll need respiratory support or intensive care. The outcome from patients who undergo ventilation is very poor in this condition.”
So What Can Be Done?
Over the next several days, while healthcare workers await the promised supply of masks, donated masks bought up by the panic-shopping public or from construction companies may bridge the gap between need and supply, Gibson said.
Qasim said that in the UK and US in particular, the community must press to make sure that all healthcare workers get the proper PPE. “That means making sure that the supply chain’s intact, making sure that manufacturing is increased, making sure that distribution is good, and doing it rapidly,” he said. “You wouldn’t send a soldier into war without a gun or body armor or a helmet.”
In the bigger picture, Gibson said, “we’ve got to reduce the surge of cases” through social distancing. And then other measures, in addition to protecting healthcare workers directly with appropriate PPE, may include creating specialized COVID-19 hospitals—as was recently done with Carney Hospital in Boston—to isolate affected patients, concentrate resources, and contain the spread of the virus.
In general, in medicine, when there’s uncertainty about whether something’s safe, you go for the safer thing, but that’s not possible because of these shortages. Jason Wasfy
The experience of South Korea, which managed to get its COVID-19 outbreak under control relatively efficiently, may be informative. Duk-Woo Park, MD (Asan Medical Center, Seoul, Korea), explained to TCTMD that his hospital, the largest in Korea, implemented strict infection control practices that allowed for more selective use of N95 masks. People with recent travel to a high-risk geographical area; those who had received a text message warning of close contact with a COVID-19-positive case; those who had visited any location also visited by a known COVID-19 patient; and those with fever or respiratory symptoms were not allowed access. For that reason, N95 masks were generally reserved for clinicians working in the emergency room or selective triage centers; healthcare workers in other hospital areas made do with dental masks.
A shortage of N95 masks—and comparable KF94 masks used in public—was still seen in South Korea, but these measures, along with social distancing techniques and widespread testing employed nationwide, mitigated the impact, Park explained. The lack of N95 masks could be more problematic in hospital systems with less-strict screening for COVID-19, he added.
Van Spall cited a number of measures that don’t involve PPE, but instead processes of care, that could better protect healthcare workers. Those include isolating COVID-19 patients in different units and locations within hospitals; confining physicians to certain locations within hospital systems; having different entry and exit points for clinicians and patients to reduce cross-infection rates; excluding visitors and clinicians who are not required to be at the hospital; using telemedicine more effectively; deploying home care resources; and employing a community hub for screening and detection.
Italian hospitals also implemented separate emergency rooms for COVID-19 intake and other emergency visits.
“Things that prevent the congregation of patients, visitors, and healthcare providers at the highly dense hospitals I think can reduce the overall burden of infection, can prevent acquiring new infection, and in that process, can reduce the demand for some of these supplies,” Van Spall said.
Mirvat Alasnag, MD (King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia), whose country has not seen a surge in COVID-19 cases yet, said lessons learned during the outbreak of Middle East respiratory syndrome-related coronavirus (MERS-CoV) several years ago have given Saudi Arabia a bit of an advantage during the current situation. MERS-CoV led to the implementation of various pathways and protocols that involve such strategies as isolating affected patients, using separate healthcare teams to care for infected patients, and having contingency plans in place. Those efforts can help ease any strain on the supplies of PPE and other types of equipment, she indicated.
“It’s a whole process,” Alasnag told TCTMD. “You have to make sure everybody’s up to speed, knows when they need to use this protective equipment, when to call for it, what the pathway is, what to do if a patient is negative, if a patient is suspicious, if a patient is positive, and who you need to call to get the protective equipment and masks.”
‘People Are Stepping Up’
Qasim pointed out that even though doctors and nurses have difficult jobs every day, most don’t put themselves at extreme risk during a normal practice day.
It’s not normal for the vast majority of doctors and nurses to get up in the morning, go to work, and know that they’re facing a significant health risk by doing it. Asif Qasim
“This is not business as usual. It’s not normal for the vast majority of doctors and nurses to get up in the morning, go to work, and know that they’re facing a significant health risk by doing it,” he said, noting that many doctors who have either left practice or retired are now coming back to help out during the pandemic.
“People are stepping up and they’re doing what’s required, and I think it’s evidence of the commitment and loyalty that people have to one another as clinicians and to their patients,” he added. “It’s an extraordinary thing to see.”
Van Spall also touched on the sacrifice healthcare workers are being asked to make during this chaotic and dangerous time, often in the absence of appropriate protective gear. Safety for those on the front lines of the pandemic translates into benefits for society at large, she pointed out.
“With infectious disease, I bring my risk home and I expose my two little ones to it and my spouse to it, and so my whole family takes on the risk. Our neighbors take on the risk,” she said. “And it’s that much more important because one person down in this kind of setting means that several others will follow . . . . So it’s a matter of protecting a few for exponential gain. It’s a strategic investment, and there needs to be an emphasis on it to decrease the burden of this infection on society.”