Facing mask shortage, US doctors told to use bandanas
20 March 2020
The Centers for Disease Prevention and Control (CDC) guidelines for the management of COVID-19 patients regarding facemasks are particularly troubling. Still, with the level of incompetency and lack of seriousness demonstrated by the White House’s response in the last several weeks, they are not very surprising. The improvisational and reactionary character of the nation’s response to the pandemic permeates down to and through every measure they employ in addressing the health crisis.
It is worth quoting these recommendations directly to gain an evident appreciation that US health care is in extreme distress. These guidelines acknowledge that the outbreak is, for all practical purposes, out of their control. They are essentially telling health care workers on the frontline to “go it alone.”
The proposals include:
- Exclude health care personnel (HCP) at higher risk of severe illness from COVID-19 from contact with known or suspected COVID-19 patients. It confounds logic that physicians and nurses could somehow be selected based on their risk status. In mass casualty scenarios where hospitals are overwhelmed, when there are severe material shortages, there will also be a severe shortage of health care personnel. In many locations, such as rural communities or urgent care centers, physician shortages are commonplace. It would be unethical for physicians to avoid risk when they are desperately needed.
- Designate convalescent HCP for the provision of care to known or suspected COVID-19 patients. It has yet to be determined, after a period of convalescence, when immunity becomes established and the individual is no longer contagious. The World Health Organization had stated that after symptoms abate, isolation should continue for an additional 14 days. Many who are recovering may also continue to be physically worn and unable to care for those seeking medical attention.
- Use a face shield that covers the entire front (that extends to the chin or below) and sides of the face with no facemask. In situations when ER doctors, critical care physicians, and anesthesiologists are intubating a patient, face shields will offer them no protection. These procedures risk aerosolizing the infection, placing them at high risk of contracting the virus. These providers need respirators and proper personal protective equipment (PPE) to perform these procedures safely.
- Consider the use of expedient patient isolation rooms for risk reduction and consider the use of ventilated headboards. It is essential to improvise solutions in mass casualty scenarios to ensure reducing the spread of infection from patients to health care providers, such as expanding the ICU capability of a hospital or building field hospitals. The single most catastrophic development in a pandemic is for the hospital to become a new vector for the spread of the disease. Despite these innovations, doctors, nurses and medical assistants are constantly in contact with patients for blood draws, the taking of vital signs, or changing of linen. Regardless of the capacity to decrease airborne risks, the virus passes through close contact with patients through droplets or by surface contact.
- HCP use of homemade masks. In settings where facemasks are not available, HCP might use homemade masks (e.g., bandana, scarf) for care of patients with COVID-19 as a last resort. Based on multiple reports in the news media, health care providers are already operating under conditions of last resort, and this even before the surge is estimated to hit in the next two to four weeks. These recommendations are a warning to health care workers. They face immense hazards, and the infrastructure will be unable to protect them.
It is preposterous that the CDC should ask health care providers to wear bandanas or scarves, or for that matter, extend the use of a single-use mask beyond its period of wear because it places them at high risk of becoming infected and dispersing the contagion even deeper into the community. Yet, nurses and doctors are having to speak to journalists or the media under conditions of anonymity out of fear of retribution for expressing their concerns. Such an attitude indicates that the negligence being demonstrated runs through the very fabric of capitalist society where hospitals would threaten their workers for exposing unsafe conditions.
Dozens of medical providers have already been taken ill with the coronavirus. Some have succumbed while many have been furloughed at home due to exposure. According to Liam Yore, a board member of the Washington state chapter of the American College of Emergency Physicians, “The risk to our health care workers is one of the great vulnerabilities of our health care system in an epidemic like this. Most ERs and health care systems are running at capacity at normal times.”
With 2.8 hospital beds per 1,000 people and nurse-to-patient ratios that routinely run 1:1 to 1:4, it means that with the expected surge, health systems will assuredly be overwhelmed. The National Nurses United, the largest organization of registered nurses, in a survey of 1,000 nurses, reported that only 30 percent felt their employers had enough PPE in hand. Still, they did not indicate the duration of such estimates. Moreover, 70 percent indicated their employers lacked a plan for the management of a surge of COVID-19 patients. Such admission is startling in the face of recent reports by the Harvard Global Health Institute on the impact of the rapid rise in the United States.
The White House briefings and coronavirus task force have been a fraudulent display of trickery. The administration, Congress and intelligence agencies have been quite well briefed on the course of this pandemic from the beginning. Three weeks ago, while President Trump was telling the American people that all was in control, US Senator Richard Burr expressed his opinion at a business luncheon held at the Capitol Hill Club: “There’s one thing that I can tell you about this—it is much more aggressive in its transmission than anything that we have seen in recent history. It is probably more akin to the 1918 pandemic.”
His comments about travel bans, school closures, military interventions in urban centers, and dire medical consequences had not been shared with the public. A secret recording of the meeting was leaked to NPR, which published the content of those remarks yesterday.
The fallout in the markets and the massive bailouts by the Federal Reserve stand in stark contrast to the pessimistic guidelines being put forward by the CDC for health care personnel, who are mostly being told that they will be facing significant shortages and will face the challenges of treating the surge of infected patients without appropriate protective equipment. There are shortages of testing kits, shortages of testing reagents, shortages of swabs, shortages of masks, shortages of respirators, shortages of ventilators, shortages of beds, and shortages of doctors and nurses—but there never is a shortage of financial aid to the markets.
The World Health Organization unequivocally stated that the combination of testing all suspected cases, isolating them, and tracking the contacts with social distancing is the only solution to fight this pandemic. Every model proposed, from the Imperial College’s to Harvard’s, never takes into account any other strategy than some combination of social distancing, offering only pessimistic estimates of the calamity that awaits Europe and the United States. Such plans will have to be drawn out for months with the anticipation that once they are lifted, the rates of new infections will rebound.
There is no excuse for not testing the population for the coronavirus; no excuse for a shortage of protective equipment; and no excuse for the massive suffering and death that awaits. This requires an immediate reorganization of all productive resources on an international scale put into place to fight this pandemic. No other response is viable.