A nurse practitioner was well into a medical visit Monday at a clinic in Multnomah County when his patient revealed a cough.
Amid a national shortage of respiratory masks and surgical gowns, neither the nurse nor the patient were wearing personal protective equipment, or PPE, to prevent the spread of germs.
“The patient should've been in PPE before I even saw him,” said the nurse practitioner, who requested anonymity for fear of losing his job.
It wasn’t until after the encounter that the nurse practitioner realized the patient had a potential exposure to COVID-19.
“There could’ve been much clearer guidelines around use of PPE and that we should be using it to protect ourselves and our patients,” he said. “It just feels like a scarcity situation, where we’re being told to use it and told not to use it at the same time.”
While much of the national and state response to the COVID-19 outbreak has focused on testing capacity and hospital bed space, Oregon is burning through its caches of surgical masks, gowns, face shields and gloves so fast that some hospitals and clinics have just a few days' worth of them left. In the midst of a national shortage, there is no resupply in sight.
As a result, nurses and doctors have been forced to risk exposing themselves and future patients, turning health care workers tasked with stopping the virus into the ones who could contract and spread it.
This has happened as Oregon's number of coronavirus cases continues to rapidly increase, with an expected surge in coming weeks. It's expected to further overwhelm the state's health care system.
“Were hospitals providing enough PPE to prepare for these types of events? The answer is clearly no, because we're running out so quickly with so few confirmed cases,” said Kevin Mealy, spokesman for the Oregon Nurses Association.
Mealy said his union has heard from hundreds of nurses across the state in the past few weeks. Nurses in Portland and in Central Oregon told the ONA their hospitals were unprepared for pandemic, offering no guidance for nurses treating COVID-19 patients and no mask fittings to make sure staff had the right size equipment to prevent exposure.
They have been asked to re-use protective masks meant for single-use, which can’t be adequately sanitized between patients.
At least two nurses from major Portland-area hospitals have reported to ONA about health care staff continuing to work at their hospitals after exposures to COVID-19.
Oregon hospitals acknowledged to OPB that protective equipment is in short supply, but said they are taking all the steps they can to protect their workers and patients.
In addition to caring for patients with COVID-19, safely testing for coronavirus also requires that clinicians use protective equipment. Even if states do receive the additional test kits they’ve been requesting, they can’t administer them without the right equipment.
"We are going to be asking the healthcare workforce to choose between safety and duty," Oregon Health and Sciences University emergency physician Dr. Esther Choo said via Twitter. "Who will take care of patients when the caregivers fall ill and are taken out of service?"
In the U.S., we are at the brink of a massive shortage of PPE to protect our healthcare professionals and avoid the spread of disease as we care for COVID19 patients. We are going to be asking healthcare workforce to choose between safety and duty. 2/— Dr. Esther AT LEAST WEAR A MASK Choo (@choo_ek) March 18, 2020
In a call with reporters Wednesday, OHSU said it was not currently rationing protective gear, but was determining how best to use it in the future based on input from the Centers for Disease Control and Prevention and World Health Organization.
“We are not putting our health care workers at risk,” said Dr. Renee Edwards, vice president and chief medical officer at OHSU.
State Scrambles For Adequate Supplies
Hospitals and clinics in the Portland area have two weeks of supply left at their current rate, according to Dr. Jennifer Vines, lead health officer for the tri-county region. In some cases, it’s worse: Some facilities have just 48-hour supplies, according to front-line health care workers.
Hospital workers in Washington state have been making homemade masks out of office supplies. Doctors in the Portland area have taken to social media to request donations of protective gear and other facilities have been attempting to order supplies via sites such as Amazon in lieu of their typical supply chains for medical equipment, in hopes supplies arrive before they run out.
Burning through supplies
In the past two weeks, Oregon has used up a big percent of its stockpile of various personal protective equipment, shown below. That includes using expired medical equipment.
Source: Oregon Health Authority
On Wednesday, Gov. Kate Brown directed all Oregon hospitals, outpatient clinics, and health care providers, including veterinarians and dentists, to cease all non-emergency procedures in the hopes of preserving equipment.
“If we do not take immediate action, the surge in demand in our hospitals for masks, gowns, and gloves will quickly outstrip the limited supplies they have available. We cannot let that happen,” Brown said.
Brown said the state is evaluating how to utilize all of the PPE within its borders for use treating the virus.
“That means stock in dental offices, veterinarians and even contractors,” Brown said. “We fortunately have been receiving calls about donations of PPE from some groups and we’re working on how to facilitate this.”
In the past two weeks, Oregon has already used a half of its stock of non-expired respirator masks, two-thirds of its surgical masks and more than 80% of its surgical gowns, according to the Oregon Health Authority. That’s before an expected surge of cases flood the region’s hospitals. The state is projected to run out by early April.
“I want to stress the initial, initial stages. This is a situation that will not last for weeks. This will last for a month, and potentially a lot of months,” OHA director Pat Allen testified Wednesday during the Joint Special Committee On Coronavirus Response. “Current modeling of the disease shows that the number of individuals in Oregon requiring a hospital level of care may exceed the amount of hospital capacity we have in the state in the next short weeks.”
Bracing For The Worst
Hospitals across the region are bracing for the dire supply situation to worsen.
On Tuesday, Kaiser Permanente announced it was temporarily closing clinics and medical offices in the Portland area to save protective equipment and staffing for an influx of virus patients at its hospitals, as KGW first reported.
A Kaiser spokesperson declined to say how much PPE it had left, but told OPB closing 36 primary clinics and 21 dental offices would save 100,000 masks and 250,000 gloves.
Providence declined an interview request.
Legacy Health declined to say how many days' or weeks' worth of PPE its hospitals had based on its current rate of use.
“Today, we are in good shape,” spokesman Brian Terret said. “Am I confident we'll have enough throughout a pandemic? Probably not as confident.”
PeaceHealth also did not disclose its PPE supply. But spokesman Randy Querin said as PeaceHealth eyes its supplies, he’s also noticing unsettling reports that indicate they will need more masks than they’ve been using.
The New England Journal of Medicine on Tuesday published a study suggesting that under the right conditions, COVID-19 may survive in some hospital settings for much longer than previously thought: up to a half-hour if it’s an aerosol (like fog), which are created under certain conditions by ventilators and flushed toilets. That means clinicians may need better protection than they thought.
“We’ll be relying on this information to be evaluated by experts on the national level and they’ll make a recommendation if we need to go to a higher standard of personal protective equipment,” Querin said.
The novel coronavirus arrived in the midst of flu and allergy season, when hospitals were already using higher amounts of protective equipment to treat patients with similar symptoms to avoid spreading the flu.
A medical team’s proper use of personal equipment for a single patient can churn through six or more sets of masks, gowns and gloves in a few hours.
Hospitals have been unable to restock, OHA director Allen said, because most of their suppliers are in China, where the outbreak began.
Before Oregon's stockpile runs out, Allen hopes to access more of the national stockpile or find creative solutions within the state. In one example, local clothing maker Portland Garment Factory announced it would pivot to making as many as 1,000 gowns and masks per week.
“The problem is, while pursuing all of those things in the absence of a significant federal change, we're going to run out,” Allen said. “I'm deeply concerned within the next short weeks, we will have providers who need to treat patients without masks, without face shields.”
Countries in later stages of the COVID-19 outbreak have already reached that scenario.
Hospitals in northern Italy, where the virus has infected more than 35,000 and caused nearly 3,000 deaths, are without adequate personal protection.
When his hospital ran out of masks, Dr. Roberto Stella faced a choice: Avoid infected patients for his own safety, or treat them.
Stella, 67, kept seeing patients.
He died last Tuesday, from COVID-19.
Troy Brynelson, Erin Ross and Dirk Vanderhart contributed reporting