How a shortage of face masks at KY hospitals makes some nurses feel like ‘collateral’
Dr. Faezah Bux knew she needed to intubate her patient.
The 74-year-old woman had been admitted to Ephraim McDowell Medical Center in Danville with a gastrointestinal bleed and a slight fever, and Bux deemed her medical needs an emergency. All Kentucky hospitals and health care providers have been directed to suspend all non-emergency surgeries and procedures in part to conserve rapidly depleting supplies of personal protective equipment.
The patient needed an endoscopy — when a long, thin tube with a camera at the end is inserted down a patient’s esophagus to look at their digestive tract. But first, since the patient was having trouble breathing, Bux needed to intubate: the insertion of a breathing tube down the trachea, sometimes causing a patient to cough and gag. It’s a quick process perfected with assistance from others.
But Bux, an anesthesiologist, was the only health care provider given an N95 mask in this cramped hospital room with two nurses, and even then, she had only been instructed to don hers when a patient has tested positive for the novel coronavirus. This patient hadn’t been tested, but she was in the high-risk category for contracting it.
So, in a matter of seconds, as many Kentucky providers do myriad times a day, she considered her options: intubate with help from nurses around her, none of whom were wearing proper gear to protect against transmission of the highly contagious virus, almost ensuring, if the patient was positive, exposure. Or, limit their risk by doing it on her own.
She hastily chose the latter, donned her mask, and asked the nurses to stand outside the door.
“It doesn’t make me feel good when I’m wearing an N95 and the people around me aren’t and are scared to death,” Bux said this week, adding that different renditions of this situation have happened multiple times in recent weeks.
At this facility and others across Kentucky, personal protective equipment, or PPE — masks, gloves, gowns, face shields, for example — are in staggeringly short supply. But demand is higher than it’s ever been — a disparity that only becomes more stark as case numbers continue to swell. In Kentucky, more than 821 people have been infected and at least 30 have died. Many health care providers interviewed for this story believe the real virus casualties are significantly higher.
In order to try and conserve a supply that may eventually deplete beyond replenishing, most health care institutions have locked away PPE and painstakingly ration which providers get what supplies. What has resulted is a grim reality: many frontline health care workers’ protection is being sacrificed for the sake of conservation.
Interviews with more than a dozen hospital administrators, physicians, nurses, and other providers across four Kentucky hospital systems show not only inconsistencies in PPE directives across institutions, but how afraid many are, not only of inadequate protection, but of voicing their concerns publicly. The majority of those interviewed were fearful of retribution by their employers and only agreed to share their experiences if their identities could be kept anonymous. Some described being handed a surgical mask and a paper bag for storage and told to reuse the normally single-use mask until it was visibly soiled, while others described being reprimanded for wearing surgical masks too often because supervisors said it was scaring patients.
“Everybody is afraid of retaliation [from] administration,” said Bux, who, as a contracted anesthesiologist not employed by the hospital, feels more comfortable than most speaking up.
Though Bux did say Ephraim McDowell administrators have been receptive to her concerns and are at the mercy of their PPE suppliers, she thinks there’s a “very big disconnect” between hospital administrations, generally, and “those that are dealing with patients on the front line, with direct contact.”
“If they could spend a day with us in the operating room, they would better understand how high risk our population is [with] the procedures we do,” she said. Then, “they would understand our fears and frustrations of not having adequate PPE.”
‘Out there as martyrs’
N95 masks are fitted, specialized respirators that, when worn correctly, give a provider a high chance of not contracting the airborne virus, according to the Centers for Disease Control and Prevention. Compared with a regular paper surgical mask, an N95 filters out 95 percent of small droplets, also known as aerosols, that providers are at a high risk of ingesting when treating COVID-19 patients.
Though UK HealthCare changed its policy on Wednesday, health care staff had been previously directed, with few exceptions, to only use N95s when a patient is formally diagnosed with the respiratory disease, as a means of conserving an already thin supply.
That means even when providers were caring for “rule-out” patients, or patients highly suspected of having coronavirus and who meet the high CDC threshold for testing, they were not allowed to wear N95 masks until a patient’s test returned positive, according to multiple provider’s accounts, administrators, and internal guidelines UK communicated to staff in writing and provided to the Herald-Leader.
This was troubling to those interviewed for this story.
Once a patient is deemed as a likely carrier of the virus and admitted at UK, they are tested and monitored by designated nurses and physicians only treating this population.
Before Thursday, these caregivers weren’t given N95s, but surgical, or ear-loop masks — loose-fitting, paper-like material that covers the mouth and nose, and which the CDC notes “does NOT provide the wearer with a reliable level of protection from inhaling smaller airborne particles.”
That included even when conducting coronavirus tests — when a nurse, for example, stands close to a patient’s face and inserts a 10-inch swab deep into their nose to scrape the back of the nasal cavity.
Processing the test itself, which UK now does in-house, typically takes at least a day, sometimes more, extending the time health care staff may have spent with a positive patient without wearing a proper mask.
Only if the test returns positive were nurses allowed to don N95’s. Then, the standard changes to, “any person, any care team member for a COVID-positive patient who is interacting with them in their room [or] within six feet should be wearing an N95 mask,” said Colleen Swartz, vice president of hospital operations at UK.
But at that point, many interviewed for this story said, the damage is already done.
“By the time they are confirmed, you’ve already been exposed, not only to that patient, [but you’ve likely exposed] every other patient,” said one longtime nurse who works with rule-out patients at UK HealthCare.
She said, and others agreed, “it’s pretty much like they’re throwing nurses, radiation technicians, respiratory therapists, [etc.] out there as martyrs, as collateral.”
Prior to the policy change this week, UK administrators tried to contextualize the need for N95s with the low rate of patients testing positive: a little more than 2,000 patients have been tested at UK, and at least 74 have been positive — a rate of about 4 percent.
But a lot of it is the not knowing.
“A part of me would rather work with patients who are positive, because then I know I could get all of the protective equipment that I would need to care for them,” another UK nurse said.
Swartz, said she, too, has heard those concerns, which is in part why the largest hospital system in the state changed its policy to now allow all providers to wear N95s with paper masks over them when dealing with COVID-19 rule-out patients. That, and UK has begun 3D printing N95 filters and is deploying new methods of cleaning N95s, prolonging their use.
Still, it’s a policy change that goes beyond the CDC recommendations, which UK noted in an email to staff: “CDC guidelines have not changed — this is an effort to provide greater protection for staff.”
The CDC recommends only allowing use of N95s with confirmed COVID-19 patients, with few exceptions. That standard was still in place at Ephraim McDowell this week, according to Jason Dean, executive director of clinical effectiveness at Ephraim McDowell.
At CHI Saint Joseph, in an April 1 internal email to staff provided to the Herald-Leader, the hospital said surgical masks are to be worn even when treating both rule-out and confirmed COVID-19 patients, with two exceptions: wear an N95 “if available” when conducting coronavirus tests, and during certain procedures, like intubations or putting a patient on a ventilator.
At Baptist Health, staff are wearing N95s for both rule-out and confirmed patients, a spokeswoman said.
In addition, Ephraim McDowell, CHI Saint Joseph, and UK this week mandated that all hospital staff wear a surgical mask at all times while working, removing it only to eat and drink.
Generally, “I worry about our staff and our ability to make sure they have what they need to be protected,” Swartz said.
But, conservation is the name of the game.
“The bottom line is, we have not gotten into the swell of patients yet, and we’re really trying to keep our eye on the ball here.”
‘Roll the dice and hope’
Since Kentucky’s outbreak of the viral respiratory disease started spreading with more ferocity, UK began burning through “at least 20-times” its normal use of PPE almost daily, Dr. Mark Newman, UK executive vice president for health affairs said on Monday.
To replenish, UK is only able to secure from its normal supplier an amount equivalent to roughly what UK hospitals use over a three-month period.
And, even with stringent conservation efforts, it takes “maybe a week and a half before we’re starting to use that average [amount] up,” Craig Collins, UK’s chief financial officer, said.
Everyone’s “concerns” over the shortage of N95 masks “are real,” Swartz said. But the fact of the matter is that “it’s a battle to try and secure an allotment.”
Gov. Andy Beshear and Public Health Commissioner Dr. Steven Stack are also getting short-changed on their federal requests for more PPE from the Strategic National Stockpile, a repository of medical supplies states can tap into during public health emergencies like infectious disease outbreaks.
Kentucky has received at least one federal shipment of PPE, and it was “population-based” and “not based on [a] request” made by the state, a Cabinet official said.
Documents provided to the Herald-Leader from an open records request show that, after a shipment of federal PPE arrived in Lexington on March 18, Dr. Stack made a formal request from the U.S. Department for Health and Human Services two days later for more supplies, and again on March 27.
“The resources we received definitely aided in filling a void,” Stack wrote in both letters, “however, to sustain the level of operations necessary ... I respectfully submit the attached request for more resources.” That first request included: 50,000 N95s, 10,000 goggles, 20,000 face shields; 15,000 gowns; 50,000 pairs of gloves; 100,000 COVID-19 collection kits; and 100,000 testing kits.
As of March 25, the Department for Public Health said it had received 83,488 N95 masks; 198,886 face and surgical masks and 37,872 face shields; 30,878 surgical gloves; 109,944 gloves; and 158 pairs of coveralls.
In the March 27 letter, Stack asked for more: 125,000 N95s; 50,000 face shields; 50,000 gowns, 50,000 pairs of gloves, 100,000 COVID-19 collection kits, and 100,000 test kits. In a separate letter on the same day, Stack asked for 50 ventilators.
State officials have not said, to date, what portion of Kentucky’s requests have been filled. Beshear on Tuesday said the state has made multiple requests from the federal government for more PPE, and “we get much less than we asked for, just like everybody else.”
To supplement what the state and feds can’t supply, UK has assembled a small team in what it calls its “war room,” consisting of people making calls directly to suppliers and brokers, doggedly pursuing every imaginable lead for more PPE. Only about half of the team’s leads actually pan out, Collins.
The aim is to consistently procure enough PPE for the next 15 or so days.
“I would say we’re there,” Newman said. “We might be a little more in some areas, might be a little less in others.”
Dean, from Ephraim McDowell, wouldn’t say how many days’ worth of PPE his hospital has, just that it’s a “sufficient amount for our current process.”
Likewise at Baptist, a spokeswoman said “that changes daily as we continue to closely monitor usage and receive supplies.”
A spokeswoman for Saint Joseph wouldn’t provide details on quantity, other than to say, “we continuously monitor our PPE supply levels and work with national, regional and state and local resources to secure the needed supplies.”
The reality is that no one has enough, long-term — a daunting fact for frontline health care workers everywhere, particularly as researchers learn more about the virus and asymptomatic carriers. This week, CDC Director Dr. Robert Redfield said around 25 percent of all people with COVID-19 could be asymptomatic, while others exhibit uncharacteristic symptoms, like gastrointestinal issues, loss of smell and taste, fatigue, and headaches and dizziness, Louisville public health strategist Dr. Sarah Moyer said Wednesday.
These wide variations complicate how patients are screened and treated at hospitals and what protective gear providers are told to don when treating them, especially when hospitals are reserving the most effective PPE for patients with very specific symptoms.
All the while, health care providers are at heightened risk for transmission because “we’re getting multiple exposures with higher viral loads” and from multiple patients, said Dr. Bux, who had to be tested for COVID-19 last week after a nurse she worked closely with contracted the virus. Her test came back negative.
Dr. Ryan Stanton, an emergency physician in Lexington and American College of Emergency Physicians board member, said it’s frustrating to see hospitals everywhere risking exposure of their providers in the name of conservation, not science.
“You have to assume, when we’re dealing with a pandemic, that it’s spreading fast. We’re just going to roll the dice and hope?” he said. “Why go walking across a battle field trusting that they’re not going to shoot at you?”
This story was originally published April 3, 2020 at 4:02 PM.
