For a doctor or nurse, the difference between safely treating a COVID-19 patient and falling ill herself — potentially spreading the virus to other vulnerable patients or her own family — is a thin polymer layer.
Amid a national shortage of personal protective equipment, there is growing fear among health care workers across Texas that they may have to battle the worst of the new coronavirus outbreak without the masks, gowns and gloves needed to keep them safe.
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Some small, rural hospitals say they have so little protective gear that it could be exhausted in hours by even a few COVID-19 patients. Even bigger hospitals, which say their supplies are sufficient for now, don’t know how they will be able to replenish stocks as patient counts grow.
Across the state, hospital administrators are locking up gear like masks, gowns and face shields, and some front line health care workers are taking extreme steps to conserve the limited supply they have.
“Physicians and the rest of the health care team cannot be thrown into battle poorly equipped. We cannot safely test, examine, or treat our patients without protective masks, gowns, gloves, and other equipment,” David Fleeger, the president of the Texas Medical Association said in a written statement Tuesday.
Calling the state’s shortage of gear “unacceptable,” Fleeger said “the time for PPE to go anywhere other than the front lines has passed. All supply chains from industry (oil and gas, technology companies that use clean rooms, construction, auto body shops, and, yes, even dentistry and veterinary medicine) must now go to our doctors’ offices, clinics, and hospitals. There is no other option. This needs to happen immediately.”
As private suppliers struggle to meet demand, hospitals and clinics are seeking donations, accepting cast-offs from university laboratories and community members and exhorting local seamstresses to sew cloth versions they say might be better than nothing.
The state does not maintain a stockpile of such equipment — a proposal to create one failed in the Legislature in 2015 — but Gov. Greg Abbott has promised providers an influx is coming. On Tuesday, Abbott announced purchase orders of more than $80 million worth of supplies, and said the state should soon receive more than 1 million masks per week. But he acknowledged that Texas is competing for protective gear, including with the federal government, and called for donations of any materials that could help.
Earlier this month, Texas officials received supplies from a national stockpile, including 1.15 million surgical masks, 219,000 face shields, 179,000 gowns, 637,000 gloves and 484,000 N95 respirators, which are superior for infectious disease control because they fit more tightly and block out smaller particles than surgical masks. About a quarter of that has already been distributed to every region in the state, and Abbott said on Tuesday that more supplies should be coming to Texas soon.
As they wait, hospital administrators are struggling to find equipment on their own.
Adam Wilmann, the chief executive of Goodall-Witcher Hospital in Clifton, a rural town 40 miles from Waco, has been shopping for medical masks since February — at the hardware store, the tractor supply, the lumber yard. He’s sought help from local veterinarians and was even willing to purchase from sellers he knew were price-gouging.
Wilmann said he had read that between shift breaks and staffing changes, treating a single COVID-19 patient might require as many as 40 masks per day. On Monday, his 25-bed hospital had fewer than 75.
“I don’t sleep,” Wilmann said. “I am worried that we’ll run out. I am worried about having my front line staff not protected the way they should be.”
A shipment Wilmann landed through contacts with a state provider brought decayed masks, their elastic bands disintegrated. He kept the masks and bought more elastic bands.
A spokesman for the Texas Department of State Health Services declined to comment directly on the condition of the supplies coming through the state, but said all the shipments that went out earlier this month came from the national stockpile.
“PPE is our most urgent need at this point, and we’re working around the clock on that issue,” said Carrie Williams, a spokeswoman for the Texas Hospital Association. “We absolutely have to have the supplies to protect our health care workers. We can’t beat this without them.”
Earlier this week, Abbott ordered hospitals to stop elective surgeries, a step providers said may help them conserve critical protective equipment. Many hospitals’ efforts have been aided by patients themselves, who are delaying routine visits until the pandemic subsides.
Even hospitals not facing dire shortages are taking care to conserve what they have, in many cases limiting doctors and nurses to one mask per shift, even surgical staff accustomed to fresh masks for every procedure. In many hospitals, personal protective equipment is locked away. At OakBend Medical Center in Fort Bend County, for example, nurses are required to sign out N95 masks, and are only given one per 12-hour shift. That’s not unusual.
Danielle Hall, a spokeswoman for Ascension Seton in Austin, said the hospital has “adequate” equipment currently, but has “implemented conservation measures, in anticipation of further supply chain disruption over the coming months due to COVID-19.”
HCA Healthcare hospitals in Texas, including St. David’s in Austin and Medical City in Dallas, each have an assigned a clinician to oversee “PPE inventory and stewardship.”
“While we have the supplies and equipment we need at this time, we are doing everything possible to secure products,” said Ken Mitchell, chief medical officer for St. David’s Healthcare, citing a worldwide shortage.
Already, health care providers are being forced to make difficult decisions about when to deploy limited supplies, and to whom.
Jeff Turner, chief executive of Moore County Hospital in Dumas, in the Panhandle, said one of the six clinics affiliated with his hospital recently put in a request for 1,500 N95 masks. He had enough supply to fulfill it, but felt he couldn’t. As of Tuesday evening, the state was reporting the county had no confirmed cases of the new coronavirus, though numbers across the state are likely artificially low given the dearth of testing. (Turner said his hospital received a total of “14 — one four” testing kits.)
Turner said he didn’t want to expend critical resources before absolutely necessary.
“I didn’t want to have a particular clinic burning masks as if it was an endless supply, which it isn’t…. I simply said, ‘No, I will give you X number, you are to make these last for however long,’” he said. “We’ve got to ration these resources.”
Some health care workers said they’re frustrated or even fearful about the steps they’re being asked to take to ration their hospitals’ supplies.
A nurse who works in a hospital in Williamson County, and asked to remain anonymous for fear of retaliation from her employer, said currently she is allowed one mask per shift, and has been told to expect that tightening to one per week should conditions worsen. When they leave the room of a patient who may have the virus, the nurses place their N95 masks in brown paper bags and label them with their names. But reusing the masks — and touching them when they may be contaminated — defeats the purpose of the protective protocol, she said.
“We’re trying to take steps to ration now,” the nurse said. “If things get bad, we are going to run out of PPE. If we end up with a lot of very sick people, our hospital will be unable to keep up with the amount of PPE that we need.”
An Austin patient care technician who works at an ear, nose and throat clinic and St. David’s Hospital, who asked to be identified only by his first name, Travis, said he has been wearing the same N95 mask on his shifts for a week. He purchased it himself at a hardware store.
Meanwhile, the Centers for Disease Control and Protection have put out shifting guidance, including suggesting bandanas or scarves as a last resort if standard supplies are unavailable. Some consider that dubious advice.
“Nobody would expect a firefighter to try to put out a fire with a squirt gun. Why are we expected to effectively do the same thing?” questioned one nurse who works night shifts in a Houston emergency room.
At Anson General Hospital, north of Abilene, the supply of N95 masks was down to 14 on Monday. That’s after a number of patients with COVID-19-like symptoms came in over the weekend — and after a case of masks, more than half the hospital's supply, was stolen about a month ago.
As they wait for state help and private vendors, many hospitals are relying on charity. Austin Public Health, Dell Medical School and UT Health Austin organized a supply drive to collect equipment for clinical providers. At the University of Texas at Austin, labs are donating supplies that won’t be required for student courses this semester to local hospitals. A donor has gifted 300,000 masks to rural hospitals in the state, said John Henderson, chief executive of the Texas Organization of Rural and Community Hospitals.
And sewing guilds across the state have begun making cloth masks that health care providers say can be worn over N95 respirators to prevent them from being soiled and prolong their effectiveness.
Inmates in the state’s Hilltop Unit in Gatesville have also begun sewing cotton masks, according to state Sen. John Whitmire, the Houston Democrat who chairs the Senate’s criminal justice committee. Whitmire said he expects about 25,000 masks by the end of this week, and they’re exploring whether it would be possible to enlist inmates to produce other medical supplies.
In the meantime, health care providers continue to ration what they have.
“Reusing PPE is pretty scary,” said the nurse who works in Williamson County. But “I would rather reuse it than run out. So if those are my choices, I’ll take my brown paper bag.”
Disclosure: The Texas Hospital Association, the Texas Medical Association, Ascension Seton, St. David’s Healthcare, the University of Texas at Austin and the Texas Organization of Rural and Community Hospitals have been financial supporters of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune’s journalism. Find a complete list of them here.