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Nancy isn’t exactly sure what happened to the protective equipment that she and other nurses usually use around patients with high-risk infections. One day the N95 masks were in their usual place, accessible to staff who needed them. Then they were locked up in a supply room. And then, “They were just gone.”
Nancy, who asked me not to use her real name because she fears retaliation, is a nurse who works in the critical care unit of a hospital south of Seattle. When I spoke with her on Saturday, her hospital hadn’t yet treated any patients who tested positive for Covid-19. But as the cluster of cases of the respiratory infection grows in the Seattle area, Nancy expects it’s only a matter of time. “It feels like you’re standing, waiting for a hurricane to come in,” she said.
Whenever and wherever the storm of illness touches, nurses and other medical professionals are some of the first to feel its impact. With so much still unknown about the transmission and progression of Covid-19, many feel that their hospitals and the government aren’t doing enough to protect them. Nurses have expressed particular fear and outrage about shortages of personal protective equipment, or PPE. Some are being told to reuse a mask designed for one-time use indefinitely; others are resorting to DIY cloth masks, which one health care worker likened to performing medical procedures in ski gloves. With testing for the virus still limited, hundreds of health care workers have been quarantined for long periods, sometimes without pay, because of exposure to symptomatic patients. “I go into work and there are nurses in tears, and they’re scared, and you don’t know how to comfort them,” said Nancy, who has worked in her field for three decades. “There is so much fear of the unknown at this point, and a lot of anger. We’re supposed to be protected and we’re not.”
The implications are serious not only for health care workers and their families but also for the entire health care system: If enough medical staff get sick, it could compromise care for patients seeking treatment for all matter of illnesses and conditions, from viral infections to heart attacks. In places where the pandemic has been most severe, including China and Italy, thousands of health care workers have become ill from Covid-19, and some have died, including Li Wenliang, the doctor who was censured for sending an early warning about the disease in Wuhan. There, health care workers were three times more likely to become ill than the general population. In Italy, about 9 percent of people sick from Covid-19 so far are health care workers, according to the International Council of Nurses. At least 13 doctors in Italy have died, including one who’d spoken to the media about having to treat patients without gloves.
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“We were trained and educated, repeatedly, that if you are dealing with an unknown, you use the maximum amount of protection,” said Michelle Gutierrez Vo, a charge nurse at a Kaiser Permanente hospital in California and a representative for the National Nurses United, the country’s largest union of registered nurses. Earlier in March, when worries about supply shortages began to grow, the Centers for Disease Control and Prevention relaxed recommendations for facial protection for frontline health care workers, saying that surgical face masks were “an acceptable alternative” to N95 respirators, which are tighter-fitting and protect wearers from smaller aerosol particles, “when the supply chain of respirators cannot meet the demand.” In a new guidance issued last week, the CDC advised health care workers to “use homemade masks (e.g., bandana, scarf) for care of patients with Covid-19 as a last resort,” if other masks were not available.
According to Gutierrez Vo, many nurses objected to the decision to downgrade acceptable protection, because it was made in response to supply shortages, not to scientific evidence about the comparative safety of mask options; she added that the guidance tacitly permitted hospitals to allow staff to go without full PPE. “If we do not preserve the health of the health care workers in the beginning of a pandemic, what are then are we doing?” said Gutierrez Vo. “We are really contributing to a manufactured shortage of our health care workers.”
The pandemic and shortage of protective equipment has forced many health care workers to make choices between their professional obligations and their own security, or their families’. “Imagine the fear of nurses like me,” said Gutierrez Vo, who has asthma. Nancy, the nurse in Washington state, is over 60 and is raising her granddaughter. “It’s scary for me. I feel like I shouldn’t be there,” she said. On list-servs, health care workers have shared stories about having to live apart from their families as the pandemic spreads.
Health care workers have turned to social media and neighborhood list-servs, begging for donations of protective equipment. A behavioral health worker at a Providence hospital in Portland, Oregon, posted in several Facebook groups asking for mask donations, and then drove around town before and after work to collect them from porches. She got a few dozen paper surgical masks and about 15 N95s, which she brought in to the hospital, after leaving one in her mailbox for a friend to pick up before her nursing shift. A few days later, staff on the psych unit where she works were told they were not allowed to have or wear masks of any kind, because their unit is not considered high risk. Peter Utas, an emergency room doctor who works at a hospital in Los Angeles, said he’d purchased dozens of respirators for his staff, along with 110 gallons of isopropyl alcohol from a garden supply store, in hopes that the hospital could use it to replace the disinfectant wipes that had run out. (So far, he hasn’t heard back from the administration.)
The slow pace of testing has only heightened the confusion. If staff were able to get test results more quickly, they would have a better sense of when to use precious protective equipment. Currently, access to testing varies by facility and region, and those who are able to get a test often wait several days for results. As of Sunday, according to Utas, about 144 patients were admitted and awaiting test results in the hospital where he works; results were taking five to seven days, sometimes more, to come back from a diagnostic company.“You don’t have any information about what you’re dealing with,” Utas said. “Do they have coronavirus? Do you have be to suiting up for all of this? Or do they have a run-of-the-mill pneumonia?”
“We were totally blindsided,” said Tara, a nurse who works at two clinics in the San Francisco area, because of the slow pace of testing. (She asked me to withhold her last name.) Earlier in March, she treated a patient with symptoms consistent with Covid-19, and he coughed in her face during a physical exam. That wasn’t unusual, she said; what was unusual was the way his lungs sounded when she listened to his breathing. At the time, the virus was not thought to be spreading in the community, and testing was mostly available only to people who’d traveled recently in China, so Tara’s patient wasn’t tested. When Tara became ill a few days later, she had trouble getting a test herself. After it came back negative, she went back to work—only to become increasingly ill in the next few days. She was unable to obtain a second test to rule out a false negative.
Hospitals, governors, and groups including the American Medical Association and the American Nurses Association have asked the Trump administration to use the Defense Production Act to compel manufacturers to produce more protective equipment, but so far the White House has refused to do so. “We’re a country not based on nationalizing our business,” Trump said on Sunday. Using the act would not nationalize private businesses; instead, it allows the government to order manufacturers like automakers and clothing companies to make certain items, which the government would then purchase. The White House’s recent plan for buying and distributing 500 million respirator masks specifies a distribution timeline as long as 18 months. In the absence of federal action, some state leaders are diverting equipment to hospitals from other industries, and some manufacturers, including a furniture maker in Washington state, are starting to produce protective equipment. On Monday, an alliance of 14 unions representing workers in the building and construction industry announced a partnership with National Nurses United to donate N-95 masks and other protective equipment.
While the spread of Covid-19 among health care workers in China and Italy presents a cautionary tale, other places have been more successful in protecting medical staff and controlling the virus. Surgeon and writer Atul Gawande reports that Singapore and Hong Kong had similar limitations with N95 masks and other protective equipment, yet were able to limit the virus’s spread among health care workers via “the standard public-health playbook,” including social distancing within health care settings, basic hand hygiene, more nuanced quarantine policies under which workers who’d had only “brief, incidental contact” with infected patients were asked to self-monitor rather than isolate, and “a surge in health-care capacity (supplies, testing, personnel, wards), and coördinated, unified public communications with clear, transparent, up-to-date guidelines and data.”
In the United States, as Gawande notes, the government has been “unforgivably slow” to implement many of these measures. The lack of transparency and mixed messaging from officials has been particularly damaging; many of the health care workers I spoke with said that because of poor communication and constantly changing guidelines, they simply don’t trust hospital administrators or government authorities to keep them safe.
“From the highest level of leadership…it’s been mismanaged and mishandled,” said Michael D. Jackson, a nurse in the emergency department at UCSD Medical Center. “It wasn’t taken seriously, supplies weren’t taken seriously, the effects of the illness—the leadership didn’t pay attention to it. They played politics with the lives of our health care providers and our citizens.”