Kaiser Permanente nurses stood in the rain on Monday evening, March 23, chanting and singing. They weren’t calling attention to a contract dispute over pay or benefits. They were crying out for personal protection equipment, for work place safety, for basic tools to practice their profession. Over the past few weeks as the global coronavirus pandemic spread, and images of overrun Italian and Spanish hospitals and morgues took over our news feeds, medical professionals in the US sounded the alarm.
Medical supplies in hospitals will run low, they stated.
Personal protection equipment (PPE) stores are woefully inadequate, they warned.
We need help, they pleaded.
Instead of responding to the call, abiding by their own requirements, the federal government changed the rules of use, changed the guidelines for what events required protection, and how that protection should be deployed. Watching the pleas for PPE play out across social media, with fundraising efforts and donation calls going out in emails and newspapers, make the issue appear somewhat straightforward.
Gather supplies, give them to the hospitals, push manufacturers to produce more, and hope the numbers are sufficient.
But it is not that simple.
Not having enough N95 masks or medical gloves and full coverage gowns in stock, is only the beginning. How and when they get used, who gets protected, who does not, also are at play.
Internal hospital guidelines for Kaiser, issued March 18 state N95 respirator masks were only accessible to nurses when a patient with confirmed Covid-19 is receiving respiratory treatment. This directive would be fine, if every patient entering a hospital were tested and a positive or negative Covid-19 diagnosis was clear. The medical personnel could make the call on PPE from a position of knowledge.
This is not what is happening.
Due to the extreme dearth of testing kits nationwide, Kaiser, like the Los Angeles County Department of Public Health, has recommended global testing be put aside, and doctors have been instructed to only test patients if a positive result would change how they treat the patient.
If patients aren’t being tested, few will have a confirmed Covid-19 diagnosis.
No confirmed diagnosis means no access to full PPE. This in itself is a travesty. But it is not the only obstacle confronting those facing the pandemic on the front line.
The definition of how this new coronavirus is transmitted from person to person is mired in obscure arguments about what is, and is not, considered airborne vs. aerosolized. (This article in WIRED does a deep dive into the question). The protocols developed by the CDC, and followed by Kaiser management, lean heavily into the idea that the virus only spreads via droplets over 5 microns in diameter, and do not travel farther than six feet (generating our current six foot social distancing rule). Yet research into SARS and MERS, and early data on Covid-19, suggest these viruses can both be aerosolized and stay in that form in the air for at least three hours.
Cal/OSHA requires different standards of protection for medical professionals when a disease is aerosol transmissible vs. when it is not. And despite evidence that over 8% of the cases in Italy are among health care professionals, hospitals around this country are settling for the lower standard of protection.
I have to question whether the bottleneck in the supply chain, the stories of orders placed and delayed and then canceled, because someone from another state, another city, another hospital system, came in with a higher offer, is playing a part in this decision.
The CDC recently created guidelines for mask reuse, a suggestion that would have gotten you laughed out of a hospital just six months ago, but also makes me wonder about the supply chain. Standard protocol for masks and gloves and all personal protective equipment is to change all gear after each patient. This standard is not only about protecting the medical personnel wearing the PPE, but also to protect the patients being seen.
That nurses and doctors and technicians are now, under recently relaxed standards, issued a single pair of gloves and a surgical mask, not the N95 respirator masks we are seeing in the news, per shift raises profound questions about why medical professionals are being so poorly outfitted in the face of a pandemic. The fact that hospitals around the nation are accepting donations of gear and warning of potential delays in supplies, adds more fuel to that fire. Assuming we are not willing as a nation to leave our medical caregivers high and dry in a global pandemic, there are only two choices left for protecting them. Full personal protective equipment for every medical professional in every hospital nationwide, or global testing, administered by fully protected personnel, with results in 45 minutes to an hour maximum, for every patient entering an emergency room. We need one or the other.
Only then can we protect those who are protecting us.