A long foreseen shortage of personal protective equipment (PPE) — including masks, N95 respirators, and gowns — is crippling health workers’ ability to respond to the coronavirus pandemic in the United States. And as doctors and nurses are forced to reuse gear in ways that put themselves and patients at risk of infection, they’re begging the Trump administration to use readily available legal tools to solve the crisis.
In a joint March 21 letter to President Trump, the American Medical Association, the American Hospital Association, and the American Nurses Association called on the administration to “immediately use the Defense Production Act to increase the domestic production of medical supplies and equipment that hospitals, health, health systems, physicians, nurses and all front line providers so desperately need.”
The Defense Production Act of 1950, originally signed during the Korean War, gives the president the authority to demand that businesses manufacture much-needed wartime supplies. In this case, the supplies aren’t titanium artillery; they’re equipment to protect frontline health workers from a highly contagious virus. In using the DPA, the president would order “the diversion of certain materials and facilities from ordinary use to national defense purposes, when national defense needs cannot otherwise be satisfied in a timely fashion.” In other words, he would direct factories that typically make other goods to start making medical resources ASAP.
Although Trump tweeted March 18 that he had signed the DPA, he said he would only be using it in a “worst case scenario in the future.”
I only signed the Defense Production Act to combat the Chinese Virus should we need to invoke it in a worst case scenario in the future. Hopefully there will be no need, but we are all in this TOGETHER!
— Donald J. Trump (@realDonaldTrump) March 18, 2020
And, when asked in a March 21 press briefing why he had not yet compelled companies to manufacture and sell supplies in accordance with the DPA, he said, “We have the Act to use in case we need it, but we have so many things being made right now by so many … they are volunteering.”
Yet the joint AHA-AMA-ANA letter makes it clear that current voluntary efforts are insufficient, and that the “worst case scenario” is already here.
“Even with the infusion of supplies from the strategic stockpile and other federal resources, there will not be enough medical supplies, including ventilators, to respond to the projected COVID-19 outbreak,” the letter reads. “We have heard of health care providers reusing masks or resorting to makeshift alternatives for masks.”
Interviews with doctors and nurses on the frontlines of the Covid-19 pandemic show that there is no time for the confusion surrounding whether Trump actually plans to use the DPA.
“We do not send troops to war with a gun to share between 20 individuals and when bullets run out, say ‘Well, you need to figure it out,’” said one nurse who spoke on condition of anonymity because she was not authorized by her hospital to speak to the media. (Many nurses who spoke with Vox for this story had been told by their managers not to speak with the media.) “We need PPE now and for months to come, and we should not be reusing supplies. It is against everything we have ever been trained as precautionary and scientifically proven as far as containment per diagnosis.”
The shortage is requiring health care officials to stretch their current supplies in creative — and dangerous — ways
Doctors, nurses, and hospital administrators have been warning that they might run out of PPE for weeks now, but the warnings have become more urgent in recent days. For many hospitals, running out of masks is no longer something that “might happen.” The shortage is here.
Among the resources running dangerously low are N95 respirators, the masks that cup the face closely and have been approved by the National Institute for Occupational Safety and Health (NIOSH) to block the inhalation of 95 percent of small airborne particles.
According to NIOSH guidance for extending N95 supply, hospitals should advise their staff to, “discard N95 respirators following close contact with, or exit from, the care area of any patient co-infected with an infectious disease requiring contact precautions.” But as the shortage worsens, reusing these masks is becoming the go-to method of preservation.
“Initially, we had single-use N95 masks,” says one nurse who has been treating Covid-19 patients at Cape Cod Hospital in Hyannis, Massachusetts. “Now we reuse our N95s five times before discarding.” The eye shields she uses are also meant for single use, but nurses are being asked to wear the same eye shield for 12 hours. “We’re bringing them between different patient rooms, which isn’t exactly ideal,” she says.
In cases where providers must reuse PPE such as N95s, the CDC recommends measures such as hand-washing before adjusting the masks and storing them in clean paper bags when not in use.
The shortage of hospital masks, gowns, and eye shields poses a health risk to both providers and the patients they’re treating. Reusing masks or wearing the same eye shield when treating multiple patients further contributes to the spread of Covid-19 at a time when the country desperately needs to be slowing down the rate of new infections, or “flattening the curve.”
While it’s unclear exactly how many health providers in the US have been infected with Covid-19 so far specifically due to the reuse of PPE, Italy’s experience is telling. Equipment shortages have also been dire there, and nearly 4,000 health care workers have been infected.
In the US, the shortage is affecting small clinics and large, well-funded hospitals alike.
The nurse from Cape Cod Hospital, who shared that she and her colleagues had been reusing N95s, said, “We are one of the more fortunate hospitals right now. We have definitely not peaked in this area yet, [but] it’s only a matter of time before we run out of masks. We definitely need more.”
Ani Bilazarian, 25, an ER nurse at a New York City trauma center, says the protocol at her hospital is “truly changing every hour of every day in terms of what we’re wearing.” She says the original protective protocol for nurses at her hospital included wearing an N95 mask layered beneath another mask, layered beneath a disposable face shield, which was to be discarded after treating each patient. “Now it’s definitely getting more drastic, even just within the week,” she says. “We got an email yesterday saying we have one mask to keep for our entire shift, and that we should bring it home with us … that’s our one mask. For I’m not sure how long.”
To avoid having to reuse N95 masks, many hospitals are allocating them only to staff members who are directly entering patient rooms — which, in turn, means limiting the number of staff members who enter patient rooms in the first place.
“Before, if I forgot a medication or had to leave a patient’s room, I would have to take off [all of my PPE] and put it all back on,” says Bilazarian. “But we’re trying to combat that with innovative solutions. We now have people outside the rooms — we’re calling them runners — who can go get you stuff. So we’re definitely trying to limit the number of people requiring PPE and who need to be exposed at all.”
A spokesperson from the Boston Medical Center said his hospital is taking similar measures. “We’re limiting the number of staff that go into patient rooms and the number of times we enter and exit to preserve supply [of PPE],” he said. “We’re looking closely at alternate sources of supplies like construction shields, and thinking creatively to clean, disinfect, and reuse equipment to preserve supply.”
Other hospitals are limiting the use of N95s at all, turning instead to less protective options.
”The management is telling the nurses to wear masks that are not N95, even though most of us would feel more comfortable and safer with the N95,” says another nurse, who works at Baptist Health in Miami. “We are trying to fight for what’s right but when the CDC says you can wear a bandana or scarf in the place of a mask, it’s hard,” referring to the CDC’s guidance for optimizing the supply of facemasks. It notes, “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.”
Some states are requiring dentists and veterinary clinics to donate surplus PPE to hospitals
While health care workers are working to stretch their own supplies, some local officials are rallying other industries that use PPE to funnel it to local hospitals and clinics.
Oregon Gov. Kate Brown signed an executive order requiring all hospitals, ambulatory surgery centers, outpatient clinics, dental clinics, and veterinary clinics with surplus PPE supplies to notify the state’s PPE coordinator to arrange for a handoff. Vets, dentists, and the like are ordered, by law, to participate in the reallocation of this excess equipment to the nurses and doctors directly treating patients. According to the executive order, any person found to be in violation would be subject to the penalties of a Class C misdemeanor.
As for industries that use PPE in other capacities, like construction and farming, the Oregon executive order “strongly encourages” — though does not mandate — that these individuals and entities “cancel or postpone non-essential uses of PPE during the ongoing state of emergency, so that the equipment can be conserved and redirected to the state’s Covid-19 response.”
For the federal government’s part, Vice President Mike Pence has said that “industrial masks that they use on construction sites are perfectly acceptable for health care workers to be protected from a respiratory disease,” and is urging construction companies to donate their supply of N95s. The Families First Coronavirus Response Act, which President Trump signed into law March 19, includes protections for industries manufacturing personal respiratory protective devices — meaning that the government will protect these companies from lawsuits if they sell the masks to health workers.
But as the AHA-AMA-ANA letter to Trump noted, protecting these companies from lawsuits is not enough — the government, they say, must use the DPA to directly order them to manufacture these supplies.
“We need companies to be creative”
As the PPE shortage continues to affect more of our nation’s hospitals — and the DPA-ordered manufacturing remains in limbo — public officials like New York Gov. Andrew Cuomo are also calling on individuals and companies to generate unconventional solutions.
NY has a critical need for PPE including gloves, gowns & masks
We need companies to be creative to supply the crucial gear our healthcare workers need. NY will pay a premium and offer funding.
Need Funding? 212-803-3100
Have Unused Supplies? 646-522-8477
— Andrew Cuomo (@NYGovCuomo) March 20, 2020
In its guidance, the CDC says that “homemade masks are not considered PPE, since their capability to protect HCP is unknown,” and suggests that “homemade masks should ideally be used in combination with a face shield that covers the entire front (that extends to the chin or below) and sides of the face.”
The homemade option is nonetheless listed as a last resort — and one that many hospitals are exploring.
Take for example, Dr. Mark Lewis, a hematologist and oncologist at Intermountain Healthcare in Utah, who shared a step-by-step sewing tutorial on Twitter:
Today my awesome pediatrician wife & my mother-in-law used at-home materials to sew masks
— Mark Lewis (@marklewismd) March 20, 2020
Bilazarian, the New York trauma nurse, says she is grateful for the creative DIY solutions people are coming up with, but has doubts about whether they will be effective enough to protect providers like herself and the patients they’re caring for.
“We have about 15 nurses out now from the ER, and more professionals are getting sick,” she says. “For now, we are managing with the resources that we have, but we are increasingly concerned for staffing and physical resources — not just PPE, but also ventilators, fluids, and pain medication as the virus intensifies, especially here in New York. We have to ask, ‘Is our frontline staff prepared to fill in the gaps in care when we need them?’ I hope so, but I’m not quite sure at this moment in time.”
To safely and adequately protect providers and patients as the pandemic inevitably spreads further, large-scale PPE manufacturing efforts are needed to resupply hospitals with the safest gear. But doing so — and then distributing the gear— could take days and weeks that nurses and doctors don’t have to spare.
“We are desperate,” said another nurse who works at a New York hospital, who said she had spent her one day off running around collecting donations for PPE. “Please urge anybody who can donate any masks, but most importantly N95s, to do so.”
Caroline Hopkins is a Brooklyn-based health and science reporter. She has written for National Geographic, the American Society of Clinical Oncology (ASCO) Daily News, SurvivorNet, and Women’s Health Magazine. She has a master’s degree in journalism from Columbia University and can be found on Twitter at @Ch_Hops.