The coronavirus pandemic is upending health care as usual. Basic infection-prevention items are scarce. Hospital hallways are cleared of visitors. Waiting rooms in doctor’s offices and dental practices are eerily empty. Medical teams are thinning as some members go out on self-quarantine. Unease looms with the possibility that lifesaving equipment like ventilators won’t be available for critically ill patients who need them.
Below, health care workers share their perspectives from the COVID-19 front lines and describe how they’re doing their best to adapt and continue providing safe patient care.
Nurses Need Masks
Gowns, gloves, face shields, surgical or N95 respirator masks — personal protective equipment (PPE in health care shorthand) is the armor nurses wear during the COVID-19 pandemic.
As nurses examine their patients, check vital signs, draw blood samples, give intravenous medicines, apply fresh dressings and provide hands-on, bedside assistance, true social distancing is impossible.
“Coming into work, we’re prepared for anything that happens as we’re constantly surrounded by viruses and different infections,” says Michelle Santizo, a nurse in the hematology-oncology department at UCLA Medical Center. “We can tackle anything full force. The only thing that we fear now as nurses is not having the proper PPE.”
With the highly contagious coronavirus that primarily spreads via respiratory droplets, having a shortage of PPE is a recipe for disaster. And with individual facilities and an entire nation unprepared for such a pandemic, Santizo says, “we didn’t have the surplus of supplies coming in when we needed them.”
Leukemia and other types of blood cancer devastate patients’ immune systems, leaving them at the mercy of infections like COVID-19. “My patients are very fearful, because if they get any type of bacteria or virus in their system, they’re not going to be able to fight it off (unlike) a normal, healthy person,” Santizo says.
A few days ago, the medical center implemented a no-visitor policy to reduce the spread of COVID-19. As it happens, that’s also reduced the strain on PPE supplies. “Everyone’s scared,” Santizo says, and that includes visitors who were stealing boxes of masks. “We’ve had to hide masks or put them away at the nurses’ station or charge nurse’s office.”
Deciding which patients do — or don’t — get tested for COVID-19 is a source of tension and continual conversation among the multidisciplinary team. Testing kits are limited, although more are expected. Not knowing who is or isn’t infected only adds to uncertainty.
Patients want reassurance that nurses and other health team members taking care of them don’t have the virus, and that staff members are being protected, too. “It’s a valid concern,” Santizo says. “For them, these are life-and death fears.”
On Santizo’s unit, not a day goes by without someone requiring an intravenous infusion of packed red blood cells or platelets. Blood products are essential for these patients, she notes. “If I could just put out a message to world: If you’re healthy and you can donate blood or platelets, please do so,” she pleads. “Because we have a high-demand unit and our patients need it.”
Organizations like the Red Cross and hospital blood banks are experiencing severe blood shortages due to an unprecedented number of blood drive cancellations. (You can learn more about donating blood on the Red Cross website or by contacting your local hospital.)
Santizo is troubled by the prospect that she could catch COVID-19 and pass it on to her patients and family. For herself, she’s accepted daily exposure to infectious diseases as an occupational hazard. “But the fact that I come back home to my parents and my siblings, and the possibility of infecting them is my worst fear — because they didn’t sign up for that.”
Santizo is active in the California Nurses Association/National Nurses United’s efforts in demanding that government officials escalate steps to immediately get personal protective equipment to nurses and other health care workers.
“Nurses are on the front line and we’re ready to take on any virus,” Santizo says. “But we need the appropriate PPE so we can protect ourselves, our patients and the public.”
No Social Distance in Surgery
“All the medical students have been sent home,” says Dr. Glenn Whitman, director of the cardiovascular surgical intensive care unit at Johns Hopkins Hospital in Baltimore. “Medical education, to some degree, has come to a halt as we know it.”
Skeletal medical crews are becoming the norm, Whitman says. Essential team members such as anesthesiology residents and nurse practitioners who have had potential or confirmed exposures to the coronavirus are being sent home to self-quarantine.
“Because we’re so worried about the inability to handle the influx of COVID-19 patients, and because they’re going to occupy both ICU and floor beds, all elective surgeries have stopped at Hopkins,” Whitman says. “Our blood supply is 50% of what it was. The Red Cross is running out of blood and so are we.”
At Hopkins, they’re testing 200 to 400 people daily for the coronavirus via drive-thru tents to limit everyone’s exposure, Whitman says. “We’re all trying to practice social distancing.” During surgery, of course, that’s impossible. And critical supplies of protective gear are dwindling.
Patient rounds — led by attending physicians like Whitman and including residents, nurses, physician assistants, medical students, nutritionists and social workers — have taken on a new complexion. Whether the entire team should enter each patient’s room, or if it’s even safe to discuss each case while standing in a circle, are issues without clear answers.
“We’re risky to each other, we’re risky to our patients and we don’t have it figured out,” Whitman says. “There’s no consensus on how to do this.”
Colleagues across the globe are digitally sharing emerging evidence and practical suggestions for coping during this health crisis. “We’re learning on the fly with limited resources,” Whitman says. Rapid creation of platforms to organize information on COVID-19 is now a prime focus for medical organizations like the Society of Thoracic Surgeons, he adds.
Whitman notes that, as an older adult, he’s in a higher-risk category for severe complications if he were to be infected with the coronavirus. Yet being younger is no shield. So far at Hopkins, only a handful of COVID-19 patients are on ventilators, he says. Of those patients, two are in their 40s and surviving on maximal ventilator support. “So forget about being almost 70,” he says. “This is a really bad virus — I’ve never seen anything like this. And we don’t know what we’re doing yet.”
[See: Myths About Coronavirus.]
A Different Emergency Department
“All ER physicians are faced with a change in the way we practice on many levels,” says Julianna, an emergency medicine physician in Colorado who asked to be identified only by her first name. “We have an obligation to keep our patients safe, while also trying to keep ourselves safe.”
Throughout the state, hospitals have adopted no-visitor policies (with certain exceptions), Julianna notes. “Most ERs are using a different mechanism of triaging patients in an effort to keep those with respiratory symptoms separate from others,” she says. “Across the board, the message to patients is: If you are stable and feeling flu-ish, stay home. If you have a minor health problem that isn’t an emergency, stay home.”
That’s a different mindset than in the past, she notes. Now, she says, “ERs across the U.S. are worried about running out of supplies and space and trying to prepare for markedly increased volume.”
Julianna misses having the freedom to simply sit and be present with her patients. However, the current focus is on protecting them from time and exposure in the emergency department — part of the new reality.
For protection against becoming infected with COVID-19, Julianna wears either a properly fitted N95 mask or a powered air-purifying respirator. A PAPR includes a face piece, breathing tube, battery-operated blower and an air-particle filter to remove toxic particles like viruses. Eye protection, gloves and a gown are essential, as well.
Julianna counts herself lucky to have access to the protective gear she needs. So far, at her facility, she says, “We have adequate equipment and a well thought-out plan. I have not had to improvise.”
She now works in hospital-issued scrubs, rather than wearing her own. “I immediately change and shower after work prior to going home, and avoid contact with my loved ones until I have done so,” she says. “I am equally worried about infecting my family as I am myself.”
Having practiced emergency medicine for about 20 years, Julianna describes the current outlook as “ominous.” She notes that her entire state, indeed the entire nation, is concerned about the availability of ventilators for patients who are critically ill with COVID-19.
“I am dreading the day when I may have to decide who gets lifesaving treatment and who doesn’t, if there is a huge surge (of patients) and no ICU beds or (ventilators) to help people,” Julianna says. She’s also concerned about the sustainability of people sheltering at home. “I see how it’s stressing out my patients and creating an unfortunate, but necessary, hardship.”
Although many dental practices remain open with staff at the ready, in most cases, regularly scheduled appointments have been wiped off the slate. “The governor of Ohio has suspended all dental practice with the exception of emergencies,” explains Dr. Matthew Messina, clinic director of Ohio State Upper Arlington Dentistry and a consumer advisor to the American Dental Association. “We’re here taking care of emergency patients, not only our own but in the community.”
To minimize travel, the staff is taking advantage of telemedicine capabilities to triage patients. For example, “If someone calls and says they’ve broken a tooth, we can instruct them to take an image of that on their phones,” Messina says. “We’ll take a look and try to determine whether this is something that the patient really does need to come in and be treated for, or if it can wait until the storm passes us here, so to speak.”
Pain and swelling of the gums, or a tooth fracture with sharp edges cutting a patient’s tongue or cheek, are more urgent. “We’re going to concentrate on things that have the potential to affect the overall health of the person,” Messina says. “Because we know that untreated dental emergencies, especially infections, can create medical emergencies later if they get out of control and aren’t treated.”
Social distancing efforts are in place. “If we have a cluster of patients coming in at the same time, we’re asking them to stay in the cars,” Messina says. “We’ll text them so they can come straight into the treatment room and not be congregating in the reception area. We’re looking for simple, creative ways to minimize the collection of patients together.”
Dental care is still safe for patients, he emphasizes. Universal precautions and sanitizing procedures used by all dental practices should protect patients and staff alike from COVID-19. Gloves, masks, glasses and gowns prevent the spread of any infectious organisms. That said, the staff is taking extra precautions.
Before procedures, patients rinse their mouths with a 1.5% solution of hydrogen peroxide, in line with recommendations for dealing with the virus from the Centers for Disease Control and Prevention. “Obviously, we’re attempting to minimize aerosols,” Messina says. Aerosols would increase the distance that droplets could travel in a treatment room. “But that’s not really different from a sneeze, for example,” he notes.
“Dentists and our staff are used to dealing with aerosols in the normal practice of dentistry,” Messina points out. “Our universal precautions are designed to prevent the spread of diseases from patients to health care workers. We also thoroughly disinfect surfaces and equipment in treatment rooms, as we always have. We routinely use high-volume suction in dentistry to reduce the spread of aerosols, as well.”
He adds that it’s still quite safe to use a dental handpiece — the precision instrument used for polishing teeth or preparing teeth for fillings and crowns.
Your dental provider is a good source to call for accurate information and to address concerns and allay fears related to COVID-19, dental or otherwise, Messina says. “If I could get everyone to take a deep breath — panic spreads like wildfire and calm spreads slower. We never talk about an outbreak of peace and calm.”
Messina is proud of his staff for being there on the front lines, providing supportive services that patients need in this time of trouble. “It’s been a crazy week because things keep changing, seemingly minute by minute,” he says. “If we can calm down and relax, it’s all going to be OK. We’re going to get through it.”
Pediatricians in Search of Supplies
“Infuriating.” That’s how Dr. Daniel Summers, a Boston-area pediatrician, sums up the worsening shortage of protective personal equipment for him and his colleagues to use while providing health care to children during the COVID-19 pandemic.
Staff members are improvising as best they can. “We are having to figure out what to do on a rolling basis as supplies have gotten thin,” he says. “We are nearly out of disposable gowns, and are all going to start wearing scrubs we change into and out of for our shifts.” More protective gowns are on order, but the staff has no idea when that order will be filled.
Minimizing opportunities for virus transmission among children and staff is a priority. “We have designated different times of day for well versus sick visits, and only one provider per day for patients coming in for symptoms that could be consistent with COVID-19,” Summers explains. “That provider has — until we’ve gotten low on protective equipment — been in full PPE for all those visits.”
The possibility of taking the coronavirus home and out into the community adds another level of anxiety. “Last week, I stripped down to my underwear on our front porch and put the clothes directly into the wash to avoid the potential of bringing anything on them into my house,” Summers says.
A “massive” drop in patient visits is an effort to keep the possibility of spread as low as possible, he says. “We are asking patients with manageable symptoms to stay home and have rescheduled a lot of patients whose appointments can wait.” The pediatric team is ramping up telehealth capabilities as rapidly as they can.
“Our patients and their families have been amazing,” Summers says. “They all seem to understand the enormity of what we’re dealing with and the limits to what we can offer,” he says. “Some have expressed some very reasonable frustration at the lack of available testing, but have also been very understanding that this has been totally out of our control.” Many have gone out of way to express gratitude, he adds, which really goes a long way.
But the bottom line is that clinicians need more support. Summers spells out his biggest concern: “The failure to provide health care providers with the equipment they need to stay safe will mean that many will become infected, passing the virus on to their own loved ones and increasing the burden on those providers who remain on the front lines of care.”
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Life as a Health Care Worker on the Coronavirus Pandemic Front Lines originally appeared on usnews.com