What was happening in hospitals?

Well, that depends where? New York City had so many cases so fast, they ran out of equipment, let alone PPE. Staff ended up contracting the condition, some of whom died. Critical care communities all over the world, for the first time, were talking to each other and sharing ideas. Social media was the fastest way to share experiences, what worked and what did not. What a frightening time, and yet the proudest time to be in health care. Government support was crucial. That was not always there. Some leaders understood the concern and supported the needs of health-care organizations. Some did not. Some called this a fake pandemic. Some claimed to have done a great job getting a handle on this pandemic… some of those might have been the same people who originally called this pandemic fake. Not all political leaders led by example. Some did. Not all recognized the PPE issues, some did. The health-care providers certainly did. Did the public? Some did and some did not.

Hospitals began filling up fast. So did ICUs. Requests for hand gel, a new mask and more gowns were met with, this is what we have. There is direction to reuse the mask. Organizations are out of gel, so hand wash. In the COVID units, use the gown patient to patient. This was happening everywhere. Those not in health care were in a panic. Buying up toilet paper, bleach wipes, and hand gel like there was no tomorrow. There was such a high demand for health-care grade PPE, and organizations were going through products so fast, shortages occurred. Worse yet, employees of some organizations were found to be stealing PPE to sell on social media platforms for their own financial benefit or stealing for their own personal use. This time brought out the worst and best in people.

After days of hearing about the lack of hand gel, bleach wipes, and masks, the community got together. There were requests on social media from friends and families of health-care workers, and health-care workers themselves first asking, then begging for home donations of “any” products to give to hospitals and first-line responders. It happened in the Midwest, east, and west coasts, internationally. People began making masks in which a filter could be placed into it. Vacuum high efficiency particulate air filters ran out of stock. Truckloads of supplies were delivered to hospitals. Some hospitals allowed the use, some did not. Those frontline workers felt however anything was better than nothing. The support from the public was unsurmountable. Everyone felt like “we are in this together.”

Why was PPE so hard to obtain? This was known to be coming. Hospitals were preparing and ordering supplies like crazy. Suddenly, there were no supplies to be had. Manufacturers were out of masks, gowns, and gloves. No hospital-grade germicidal wipes or sprays were available. Hand gel could not be found. How does this happen? Politicians knew this was coming. Health-care experts knew this was coming. Hospitals knew this was coming. How come manufacturing did not? Or could they simply not keep up with demand? Nearly 4 months after that first patient rolled in, bleach wipes could not be purchased for household use. Hand gel still hard to come by. So much so that liquor manufacturers began making hand gel and giving, yes giving, it away to health-care workers and first-line responders. How does this happen in North America, South America, Europe? Areas of excellent health care are really struggling. Other areas of the world are not. Why the discrepancy? Or is everyone struggling to obtain supplies and some are just not vocal about it? The Governor of the New York State was on the TV every day. He speaks of shortages and how supplies are being shifted from one area to the next. How grave the need is! Some politicians still debunk what is happening. How can this be? A record number of people are dying. Famous people have contracted this disease and said, this is no joke. This is no flu. Why can’t people get what they need?

Surgical masks had always been single use. Once they are moist, they need to be changed. So single use it is. Now, people are told to wear a surgical mask for a week or longer. Keep it in a pocket. Reuse it until visibly soiled. There are suggestions to keep the mask in a brown paper bag. It dries out faster, and there is less chance of contaminants growing in paper than stored in plastic bags. Paper breaths and hopefully this works to protect people in health care. Is something better than nothing?

N95 masks used for particular respiratory infections including COVID-19 are typically a single use. Again, the message is the same as the surgical mask. Wear indefinitely. Keep it in a paper bag, add a name on it, so as not to use someone else’s. If a COVID unit, it stays in the equipment room. If not a COVID unit, take it with even in a multihospital system. Again, is something better than nothing?

Why did this happen? Why the sudden change in practice? For over 30 years, this equipment is single-patient or daily use. Now use until it can’t be used anymore.

Gowns made of plastic or bunny suits are to protect the wearer. In the COVID units, the staff is wearing a gown room to room. This was never done before. Yet, there does not seem to be any bad outcomes with this practice. Was health care wasteful before? Is health care more prudent now? Is this impact of a shortage teaching valuable lessons? Everyone is doing this across the globe. Why? Because something is better than nothing. Or are there issues simply do not know about? Suddenly, gowns are back to single-patient use. Is it because supply is up? Or is there an issue? Time will tell, as there is more retrospective information to come.

Replacement gowns are shabby, like plastic wrap. Stronger, better made gowns are needed. These cheap gowns tear almost by a breath. The fear of self-contamination is ever present. This is all that is available? Workers refuse to wear, suggest the administrators do. Material managers are told to find quality gowns. They show up. Administrators and material managers are grateful to get their hands on any products, some of which however are subpar. They simply don’t realize it. It is unfortunate. It takes the frontline worker to say, this won’t work. Support is there. They agree. But are the gowns there? Eventually. Hopefully, no self-contamination!

Gloves. Wear two pair. After a patient is examined, remove the outer pair. Clean the pair underneath with hand gel, re-apply a new pair. Go to the next patient. Really? This is being done around the globe. Some don’t even wear two pairs, just one. Consequences? None so far thankfully. Again… something better than nothing.

Clean hands are the mainstay of any infection control issue, including this pandemic. Historically, the plan is clean hands with gel between touching anything. In the room, gel hands. Touch the patient, gel hands. Touch the computer, gel hands. Gel on the way out. Now, a new practice. Gel on the way in and after removing the outer gloves on the way out. Thankfully, no obvious consequences. Wasteful before? Not certain. For now, better than nothing?

Powered air purifying respirators are also known as PAPRS. There won’t be enough for everyone, so they are reserved for those who are in the COVID units for extended periods of time. What? How is this possible? The PAPRS are used so often, they begin to break. Some units have a great supply. Some ICUs and emergency departments (EDs) have barely enough. How does this happen? How can anesthesia have PAPRS for their entire teams, including transport and ICU, and ED can only get for those with extended periods?

Initially, everyone needs a N95 mask. Oh wait, there is another change. There are not enough N95 masks for everyone. New plan. Everyone in the ICU and ED needs a N95 mask for patient care. Outside of these areas, N95s are needed only if the patient has a lot of coughing. Isn’t that the main symptom of this infection? If no significant coughing, a surgical mask on the patient as well as the staff is sufficient. Since when?

What happened to flatten the curve? Well, it all depends on where you live. Some places managed to flatten the curve and others didn’t. The ones who flattened the curve were able to manage better the shortage of PPE. Relying on others, like the government, to flatten the curve is merely impossible. Education and common sense are the way to go. Less patients mean more PPE available for a longer period of time, and no one knows when COVID-19 will be out of our lives. Less patients also mean less exposure for health-care workers. There is no need to manufacture more PPE if less people get infected. We don’t need more PPE factories; we need less exposure which translates into less patients.

The World Health Organization states masks won’t help. The Centers for Disease Control says it does. Why the controversy? People are confused. Staff are confused. The impetus for the mask is to slow down the droplets likely by about 70%. So, less droplets, less virus transmission. The end result is that to wear a mask in public to reduce droplets and in hospitals at all times. Were health-care organizations wasteful before the reuse of masks? Did health care create its own shortage because they were not thoughtful about PPE use? Did providers utilize PPE above and beyond because of fear, and this make a shortage even worse. Is single use really the answers, until there is a shortage, and then the rules change? In the same scenario, what would be desired for PPE? All of it. The desire would be all of it. Is that understandable? Hell yes. Did health care learn something? Unsure. There are no consequences easily found of reuse. Will practice change? Time will tell.

Providers were confused. Messages changed often. They needed PPE to protect themselves and their families at home. The recommendations on the PPE use changed often. Why did this happen? Were organizations better informed? Was in response to shortages? Both? Likely both.

Providers were frustrated. They wanted employers to protect them. Employers were frustrated. The ability to get supplies was a 24 h a day job. Employers really were doing their damnedest to get PPE. Material Managers were working tirelessly with distributors. No one wanted anyone unprotected. Things became available on the black market. There was price gouging. Were certain supplies legit? There were donated supplies. Its ok for use in home, but not in the hospitals? Suddenly, it’s OK to use donated supplies? It’s the only option. Because something is better than nothing.

In addition to the nervous fatigue about PPE availability, providers experienced other issues. The PPE was hot. It didn’t matter what: bunny suits, plastic gowns, gloves, N95s, and/or PAPRs. Breathing was OK but not normal. Some experienced anxiety. Sounds were muffled. Sounds were difficult to hear. Phone conversations, well they were impossible. Trying to talk on the phone to a consult or family in PPE did not work. Staff required breaks. There were skin breakdown, rashes, and blemishes. Staff were tired. They felt an increase in fatigue and exhaustion. PPE certainly contributed. Staff were afraid, hungry, and frustrated. Yet, back in they went, in full PPE.

Providers were concerned about self-contamination. No one wanted to bring this home to their families. Were they even protected with reused PPE? Apparently so, as so few medical personnel was exposed and suffered dire consequences. There were some that were, but most were not. Can this change practice in the future? Can garbage load on the world be reduced with less plastic gloves, gowns? Maybe? Maybe not? Did this pandemic teach us anything about practice and waste? Certainly yes. Will it change practice. Well, time will tell.

What will be the long-term effect of the use of PPE on providers? Will there be some type of PTSD? Hopefully not. But that won’t know for a while. Will staff become more reactionary to latex and other plastic products? Hopefully not. But that won’t be known for a while either.

Patients also experienced a significant difference in their patient/provider relationship. They no longer could appreciate the genuine, reassuring smile from their health-care providers. They saw eyes, covered by face shields. They felt separated, and they were. Speaking to patients who recovered from COVID, they felt like a leper. They were bustled into exam rooms; they were seen virtually from home; they were separated from everyone whether inpatient or outpatient. They felt isolated from the health-care community. Yet, they were grateful for the care and concern. Those inpatients, they were alone, some of them critically ill. There was no human touch, no skin to skin. It was glove to skin. Even Florence Nightingale spoke of the need for skin-to-skin contact. None of that for staff or patients during this time. Providers stated that they just wanted to hold the hand of a dying patient. Not through a glove. They wanted the last thing that patient felt as they left this earth, was the human touch. Not possible. And as health-care workers, there is grave sorrow for that. Who suffered more? Likely both.

For years, health-care workers in the ICU have been incorporating the presence of the family in the ICU and seeing them as part of the team, but now, they are no longer welcomed in the hospital. Now, patients are alone in their rooms. Are we not allowing any relatives because of the shortage of PPE or because everyone is scared of COVID-19? Anyhow the social aspect of this will likely contribute to significant trauma to patients and staff worldwide. The staff who just wanted to hold that dying persons hand… not gloved… but didn’t because of fear. The patient who in hospital or at home was isolated. Not really experiencing the contact of the provider–patient relationship as it is known because it is separated by physical barriers. Most staff develop relationships with their patients that includes touch. Not here, not now.

Everyone is grateful for the work people put in worldwide to obtain PPE to protect frontline workers. How can this be better, God forbid, there is a next time? Political leaders “need” to rely on their experts, listen to their experts, and make factual statements. A plan must be put into place immediately. A well-needed plan in place not needed is better than one not in place and needed. This is not a blame game, but a work together game. Politicians need to work together with health-care experts for a plan that is thoughtful and beneficial for all. The public needs to heed warnings and take them seriously. During pandemic is a time to put the health of all citizens as top priority. This is not a political issue, but a social issue. Everyone is responsible and accountable.

The proudest moment truly was the sharing of ideas, thoughts, and practices in health care worldwide. What a proud moment for all health-care workers! Experts and bedside clinicians dialoging with those in China, Europe, North and South America, Africa, and Australia. What worked? What didn’t? How were these situations handled? What a consortium! There was no race to be the first. It was working together to handle this. What a proud moment!

In the pursuit of PPE, PPE is much more available worldwide. Many health-care organizations have gone back to old practices, some have not. Bleach wipes and disinfectant sprays however are still not available for personal use. That will come. When everyone has a moment to think, looking at practices for PPE use should be examined. Maybe that worldwide consortium again? Can the garbage load for the world be reduced if everyone did a certain practice? Likely. Most important to remember, the PPE use in hospitals and in public is not political, its social and an important thing to remember. Stay safe all and be well.