Soldiers Without Armor on the Front Lines of the COVID-19 War
Publishers' Note: A Cloud of Contagion Continues to Hang Over Hospital Battlefields...the situation has gotten only worse since Dr. Katz published this article in his local newspaper (days after Dr. Slavin appeared on Meet the Press). Doctors are being reprimanded, and some are even being fired for wearing masks.
Soldiers Without Armor on the Front Lines of the COVID-19 War
Dr. Peter Slavin, President of Massachusetts General Hospital, appeared on NBC’s “Meet the Press” and declared:
“We wouldn’t want to send soldiers into war without helmets and armor. We don’t want to do the same with our healthcare workers.”
With that one statement, Dr. Slavin has nailed the critical issue in reference to our current national COVID-19 crisis and has shot holes in the CDC’s guidance of our current country’s pandemic. As a clinical infectious diseases doctor attending to patients with suspected or confirmed cases of the virus, I have witnessed and experienced firsthand the shortage of supplies necessary to protect our most precious resource in the battle against this contagion: our first responders and health care workers, including nurses, doctors, physician assistants, lab techs, and other ancillary personnel. On a daily basis, these medical personnel are risking their own health by taking care of COVID-19 patients. And yet, they are not being given the tools or guidance necessary to do their jobs safely and effectively. Not only do they lack adequate medical equipment, but the necessary facilities preparation, organizational leadership, and advocacy they need to deal with this disease safely. As a result, our current healthcare system is putting workers and ultimately patients at risk.
The primary mode of transmission of this virus is thought to be by droplets produced by coughing and sneezing although small particle airborne transmission may contribute as well depending on the circumstance. An infected patient is likely to cough and expel infectious particles into the air, creating a cloud of contagion that can in turn be breathed in by any bystander within a 6-foot proximity. The best way to avoid this mode of transmission is to keep a safe distance and stay out of the cloud. First responders and providers however, in order to do their jobs, must step into the cloud to examine and care for their patients.
The safest and most reliable means of protection available to medical personnel is either a full positive pressure respirator (PAPR) or an N95 respirator mask. Regrettably, these are in short supply, partly because they are manufactured by affiliates in China, and the Chinese government has, to date, restricted exports of essential equipment to protect their own people. We have not yet been able to meet the production demand for within our own industrial infrastructure. As a result of this supply crisis, the CDC has recommended surgical masks as a suitable alternative for healthcare workers. Surgical masks however do not offer sufficient protection from the contagion and are significantly inferior in preventing transmission than the aforementioned respirators, as small infectious particles can penetrate through the mask's surface.
Physicians, nurses, and others are expected to accept the risks afforded by the inferior equipment and to proceed with care requiring direct access to COVID-19 patients. As a result, engaging in healthcare work has become a primary risk factor for contracting the illness, given the workers’ repeated and prolonged exposure, and for spreading it to others inside and outside of the hospital.
Not a day goes by where I don’t hear that another colleague has contracted the virus. Regrettably, several have died. Yet the lack of optimal protective equipment will likely continue as long as the virus ramps up and our production does not. No creative problem-solving solutions for securing or manufacturing the needed provisions seem to be on the immediate horizon. Meanwhile, nurses and doctors will continue to do their jobs. Some may not be aware of the added risk they are taking by donning the inferior mask deemed a suitable alternative by the CDC. Some may be aware, but either are not concerned with contracting the virus due to low morbidity risk (age less than 50 with no underlying conditions) or are afraid to voice their concerns for fear of losing their jobs.
This presents a problematic scenario for the spread of the disease. If a healthy nurse for instance contracts the disease in a mild form, he or she may in turn unwittingly transmit the disease to the next patient seen and to everyone else encountered each day he or she leaves the hospital. The risk to healthcare workers therefore imparts an additional risk to hospitals in general and to the population at large.
Top-down leadership has been confusing or lacking to date regarding the COVID-19 pandemic. The CDC has been contradictory and vague about its guidelines and recommendations. As a doctor, I have received no guidelines or recommendations at all from the American Medical Association (AMA), the American Osteopathic Association (AOA), or the Infectious Diseases Society of America (IDSA). No strong, clear leadership voice is being heard, and hospitals are struggling to adopt makeshift policies with limited resources. In the hospitals that I am familiar with, these policies are inconsistent, differ from one hospital to the next, and are often flawed.
We need a nationally organized plan for taking care of afflicted patients and their healthcare providers. Special hospital wings for instance, segregating suspected or proven cases must be established. Dedicated COVID-19 provider teams, consisting of low-risk providers (the relatively young and healthy between ages 30 and 50), who are fully informed of their risks, should be tasked to attend to these patients. This kind of organizational plan would preserve precious supplies and in turn mitigate the risk of spread to the rest of the hospital and beyond. If necessary, these young providers should be incentivized with bonuses or extra pay, and they should be assured of sick pay in the event they fall ill. Meanwhile, experienced providers, who are older or who have underlying medical conditions, should be encouraged not to see affected patients. The COVID-19 outbreak is one situation where youth surpasses age or experience as an advantage to care. Older and more experienced doctors should be placed in consulting positions, where they can do the most good without incurring undue risk. Do we really want or even need our older, most experienced, our wisest doctors to be entering sick COVID-19 patients’ rooms?
Why has there been no leadership or advocacy for those who risk the front lines on our behalf each and every day? I agree with Dr. Slavin. It’s time we see this crisis as a war and arm and protect our front line soldiers the best ways we can with supplies, guidance, and nuts-and-bolts ideas for containing and combatting this disease.
Author may be contacted at firstname.lastname@example.org