By Gary Evans, Medical Writer

Emergency physicians and other frontline clinicians are trying to hold the line against an accelerating coronavirus pandemic in the United States, even as they fear for their own safety and that of their families and colleagues. As this report was filed, the healthcare system was facing a major test as a surge of COVID-19 patients were presenting at some hospitals and were grimly anticipated in others.

A shortage of personal protective equipment (PPE) — particularly N95 respirators — ratcheted up the anxiety, as did the accumulating media reports of healthcare worker deaths, illness, and home quarantine. The epicenter of the coronavirus outbreak in the United States is New York City, which reported 45,707 cases of COVID-19 and 1,374 deaths as of April 1.

“I get very anxious when I am about to go into work,” says Avir Mitra, MD, an emergency medicine physician at Mount Sinai Beth Israel Hospital in New York City. “The night before, I start getting anxious.”

Some ED physicians worry more when they leave work and head home. Torree McGowan, MD, FACEP, an emergency physician at St. Charles Medical Center in Bend, OR, is starting to see the first wave of coronavirus infections in her area.

“I am definitely concerned,” she tells Hospital Employee Health. “My husband is immunosuppressed, so I shower and change clothes before I leave work. I am trying very hard to stay away from my family, and we are strictly socially isolating. I am not going anywhere but work, home, and then the bare minimum that we need to do [in the community].”

Healthcare workers are particularly concerned about a change in the CDC recommendations, which said wearing a surgical mask for COVID-19 patients was acceptable if N95 respirators were unavailable.1 (See CDC recommendations in this issue.)

“The initial recommendation when this was coming out of China was N95s [or equally effective respirators],” McGowan says. “Now, we are being told surgical masks, but there is a lot of concern about whether that is being driven by the science or the shortage of N95s.”

A Temporary State

The CDC recommendations allow wearing a surgical mask for general care of coronavirus patients, while still requiring respirators for aerosol-generating procedures. Those wearing surgical masks should still don gloves, gowns, and eye protection. The patient should be masked for source control of the virus.

“This is a temporary state of affairs,” Michael Bell, MD, deputy director of the CDC Division of Healthcare Quality Promotion, said at a recent meeting at the agency. “The intent would be that once the supply chain [issues] are resolved, we would go back to recommending respirator protection once it is available. This is a pivot that we are making so we are not painted into a corner. We don’t want to wait until everything is gone and there isn’t anything left for those high-risk procedures. Now is the time to do this.”

As of April 2, the CDC reported 213,144 cases and 4,513 deaths in the United States. The World Health Organization global count surpassed 500,000 cases with more than 16,000 deaths.

“If you look at the vast outbreak in China, it peaked and started to resolve in three or four months,” Bell said. “We are now in month two. We probably have two or three more months of work to do in terms of accommodating this. Everything we do we have to try to be nimble, making sure what we have said so far doesn’t get in the way, and getting ready for what happens next.”

A last-ditch and widely ridiculed CDC recommendation calls for healthcare workers to use “scarves or bandanas” with a face shield if no masks of any kind are available.2

“That’s crazy,” Mitra says. “The last thing we want a month from now — when this situation is even worse than it is today — is half of the ED doctors sick.”

Expressing similar concerns, a group of physicians posted a petition demanding action. It garnered more than 1.2 million signatures as this story was filed.3

“As a physician, I do not know how long it takes to make an N95 mask, but I do know how long it takes to train a physician, a nurse practitioner, a physician assistant, a respiratory therapist, or nurse,” the petition states. “We are the supply chain that needs to be protected.”

In addition to masks, hand hygiene, gloves, gowns, and face shields or goggles were being emphasized to protect healthcare personnel in the absence of a vaccine and effective treatment. Triage and case identification protocols were in place, but given the shortages of coronavirus tests and waning PPE supplies in many areas, the general perception was that a critical moment was at hand.

As this story was filed, at least two U.S. clinicians were in critical condition with COVID-19, according to the American College of Emergency Physicians, while 14 doctors have died fighting the ongoing coronavirus outbreak in Italy. In the U.S., there were media reports of dozens of healthcare workers who were infected or in self-quarantine. Two unrelated deaths of healthcare workers were reported in Georgia, although it was not immediately clear if they acquired the virus at work or in the community.

“The reason this hits home and is a such a concern to us is centered around what we don’t know,” says Hamad Husainy, DO, FACEP, an emergency physician at Helen Keller hospital in Sheffield, AL. “A lot of young doctors like myself — I’m 38 years old and I’ve been in practice for 10 years — haven’t seen something like this.”

An Insidious Virus

Indeed, most U.S. healthcare workers have not experienced anything quite like this novel coronavirus in their careers. Certainly, some have dealt with two other coronaviruses, SARS in 2003 and MERS, which has established a sporadic presence in the Middle East since it emerged in 2012. There also was the 2009 influenza A H1N1 pandemic and the Ebola outbreak in 2014-2015.

From the U.S. perspective, none of these prior threats possessed the combination of morbidity and mortality posed by SARS-Cov-2, a highly transmissible respiratory virus that experts estimate has about 10 times the mortality rate of seasonal flu. This coronavirus can spread insidiously — from people who exhibit mild illness or appear asymptomatic — yet cause severe disease and death in the elderly and those with underlying medical conditions.

“I’m younger, so I feel like I would probably be OK [if infected], but it is still scary,” Mitra says. “There are people [I work with] who are older. Say I have a patient and I ask a nurse, ‘Can you go in and hang this medicine?’ I feel terrible if the nurse is older, [thinking] ‘Am I putting them in harm’s way?’ We all feel scared and anxious about this.”

Concerned that healthcare system may be overrun, emergency clinicians echoed the national sentiment that people avoid becoming patients by staying home and practice social distancing when out. There has been some disconnect in this message, however, as several states and cities moved to enforce lockdowns to stop large gatherings of people. New York City went into lockdown — with essential services exempted — in mid-March, as the city that never sleeps fell silent.

“We definitely have coronavirus patients coming in. We are testing patients and a decent amount of them are positive,” Mitra says. “We have older patients coming in who need to get admitted, and quite a few are going to the ICU. So far at our hospital, we are just kind of at capacity. I have not seen us go over capacity yet. I really do think in the next two weeks we will.”

As in other hospitals, the policy at Beth Israel called for reusing N95 respirators, covering them between patients with examination masks that are then discarded.

“At my hospital, we still have PPE, but they have started rationing it,” says Mitra. “They are giving us one N95 mask to use for the week and they are asking us to put it in a brown paper bag between shifts, which to me seems a little bit unsafe.”

Confusion, Frustration

Companies were stepping in to make more masks and respirators, and it was hoped the situation would be resolved in the near term. There was a concerning undercurrent in these discussions that some healthcare workers may not report for duty if they are expected to work without proper PPE. The purchase of N95 masks and other PPE by the public also frustrated some medical workers on the frontlines desperate for supplies.

“A surgical mask is one thing. That is not unreasonable for a person to wear, and a lot of countries do that,” Mitra said. “But I don’t think somebody who is quarantining right now needs to be wearing an N95 mask. That type of activity should be banned. Whatever manufacturing [capacity] we have should be going to healthcare workers so we are able to care for other people’s parents and grandparents when they get sick.”

There was a sense of confusion and mixed messaging on both PPE and coronavirus testing, which has gone through a series of exasperating changes, from largely unavailable, announced, and delayed, then rolled out as if anybody could be tested. A shortage of testing reagents, swabs, and viral transport media followed in some areas, exacerbated by concerns of using scarce PPE during testing that is needed for frontline staff.

“We ramped up testing, but then we got an update from the NYC department of health saying we should not be testing anymore unless the patient is admitted to the hospital,” Mitra said. “Sinai has a two-hour test, which is very helpful, but we are reserving that for patients that are admitted to the hospital so we can figure out whether they have it and put them in the right type of bed.”

There were ongoing discussions about the appropriate time to test and the sensitivity of results, as COVID-19 has an incubation period of about two to 14 days, with the average onset of symptoms at day five.

“One of my good [physician] friends just got a fever yesterday. He’s out,” Mitra said. “Several of the residents are on seven-day quarantines because they have fevers. Every day the policy is shifting about what to do with them if they are sick. Should you test them or not? Of the people who happened to get sick when the policy was to test them, a couple of them are confirmed positives. Some of the others are just presumed positive and they are at home.”

Temperature Check

At McGowan’s hospital in Oregon, all personnel must take their temperature when they report for duty. Those with a temperature above 100.4°F cannot work. Those with no fever, but respiratory symptoms, must wear a mask.

“My hospital is allowing people to wear a mask at all times if they prefer,” she says. “Every healthcare worker, from the doctors to the housekeepers, has their temperature check when they come. If you have respiratory symptoms, you are required to wear a mask the entire time you are in the hospital. None of our patients are allowed visitors except under very limited circumstances.”

Elective surgeries are being cancelled to preserve PPE so it will be available for caregivers who are working with COVID-19, she says. However, this was not happening in all areas, and 300 clinicians at the University of Pittsburgh Medical Center (UPMC) wrote an open letter to administration calling for the end of nonemergency surgeries. UPMC had not responded to a request for comment as this report was filed.

“While the rationale to continue forward with elective cases and visits at outpatient clinics is that there are very few positive cases in Allegheny County, the reality is that testing is limited, thus the real number of total cases in our community is virtually unknown and likely to be rapidly increasing,” the clinicians wrote. “Additionally, it is well known by now that those affected, especially the young, can be shedding COVID-19 for several days before exhibiting any signs/symptoms such as fever, cough, or shortness of breath.”4

Indeed, McGowan has adopted the view that all patients must be presumed positive. “The best recommendation I have seen right now is assume that everybody you are around is infected, and assume that you are infectious because we think this is spreading from people who have very minimal symptoms or are asymptomatic.”

Testing supplies also were an issue at her hospital, and the practice of only testing patients who were admitted with COVID-19 symptoms was in effect.

“We are setting up tents to isolate our respiratory complaints from nonrespiratory,” she says. “There is a lot of stress among the frontline caregivers. This is all evolving so rapidly. We are getting different information about the science that is coming out looking at how long can this survive in the air and on surfaces. The recommendations for the PPE seem to be driven more by the shortages of PPE rather than what we think is actually best for protection. That’s concerning, and it is creating a lot of stress for caregivers.”

However, healthcare workers in areas where there are few or no reported cases may develop a sense of complacency. “I will say in general for our staff, it hasn’t become as real as it has in other parts of the country,” Husainy says. “They seem to be a little complacent. I hope when this is all said and done they can look at me and say, ‘You were wound a little too tight.’”

Given the lean stock of N95s, masks are worn over respirators that may be used indefinitely, he explained. “With regard to PPE, we really have not been well-prepared,” Husainy says. “We have literally two boxes of N95 masks in the entire hospital. We are being asked to take one and use it until further notice, until it gets visibly soiled or breaks. In dire circumstances, you do dire things.”

The hospital plans to use powered air-purifying respirators (PAPR), which can be cleaned and reused, in the ED if suspect coronavirus cases begin presenting. “Right now, we are reserving them for the emergency medical staff,” Husainy says. “In the ICU, these patients already have been delineated as who is at risk and who is not. In the ED, people come in and you have to find that out. It’s a reality that we are going to run out of N95 respirators. My prediction is that our only option is going to be to use the PAPRs when we have to intubate somebody or place a patient on a ventilator.”

Husainy urges his co-workers to remain on guard, reminding them that some healthcare workers were infected before there was recognized transmission in the community.

“We have to be as vigilant today as we will be when this ED is full of these patients,” he says.

REFERENCES

  1. Centers for Disease Control and Prevention. Strategies for optimizing the supply of N95 respirators: Crisis/alternate strategies, March 17, 2020. Available at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/crisis-alternate-strategies.html
  2. Centers for Disease Control and Prevention. Strategies for optimizing the supply of facemasks, March 17, 2020. Available at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/face-masks.html
  3. Kviatkovsky MJ, Chace C, Thota S. US physicians/healthcare workers for personal protective equipment in COVID-19 pandemic, March 2020. Available at: https://www.change.org/p/hospital-administrators-us-physicians-healthcare-workers-for-personal-protective-equipment-in-covid-19-pandemic
  4. University of Pittsburgh Medical Center residents. An open letter to UMPC, March 21, 2020. Available at: https://www.documentcloud.org/documents/6816644-March-21-Copy-of-Open-Letter-to-UPMC-Re-COVID-19.html