On the COVID-19 Front Lines, Providers Feel Exposed

Seeking protection

Dr. Mark Glover is coordinating donations of PPE for the Travis County Medical Society. (Courtesy of Travis County Medical Society)

The reality of the COVID-19 pandemic has settled like an invisible fog over Austin, as residents enter their second week of sheltering in place. Many businesses are now shuttered. Walkers and joggers move away from one another on sidewalks and the chatter on Nextdoor favors threads sharing what can still be found on grocery shelves. Even so, with spring in the air, most people seem happy enough as they head out to walk their dogs, pick up their pizza or stroll their babies in the sunshine.

For health care workers in Cen­tral Texas, a very different reality is looming. They have seen the catastrophic effects of the deadly and highly contagious coronavirus that causes COVID-19 – first in Asia and Europe, now closer to home. Hospitals, clinics and private practices have assessed their own readiness, counted their inventories and adjusted how they see and care for patients to reduce physical contacts and the need for protective gear.

But medical professionals remain worried these measures won't be enough. They fear being left unprotected and overwhelmed by the sick and dying as the pandemic spreads in the coming days and weeks. Some feel betrayed by the people and systems they thought would protect them in a crisis. They see the news that breaks daily about improved testing, ramped-up production of vital equipment, and promising antivirals and therapies, even as the disease continues to rage and spread. But on the ground, they see little evidence that such help is on the way, or will come soon enough.

“We Cannot Wait”

Protecting health care workers and first responders was uppermost in the mind of Austin Interim Health Authority Dr. Mark Escott when announcing the shelter-in-place orders on March 24. Escott warned that the lessons from China, Italy, Seattle, Washington, and New York have been loud and clear: "We cannot wait until the hospitals are already overrun to make decisions and act decisively to prevent this spread."

Local leaders had already made difficult decisions to close festivals, restaurants, bars and businesses, Escott said, but may soon face even tougher decisions, such as who will get scarce masks, gloves and other personal protective equipment, or PPE, if supplies begin to run out. "Do we give it to first responders? Do we give to hospitals? Do we give it to nursing homes?" he asked. Worse still, if we run out of ventilators and intensive care beds, Escott said, we will have to decide which patients get the opportunity to survive.

“I really hope that our government, our leadership, our private corporations, that anybody that can make equipment that is approved is working on it right now.” – Dr. Elizabeth Douglass, UT Dell Medical School

The new "stay home, work safe" rules were prompted by forecasts from UT-Austin researchers that Central Texas deaths from COVID-19 could skyrocket past 10,000 people by mid-August if the health care system were overwhelmed, which it almost certainly would be without more drastic public health measures. To manage the pandemic with the health care system capacity and resources available, the UT model indicates, Central Texans must reduce daily contact with others dramatically — by at least 90 percent from pre-pandemic levels.

By mandating social distancing and banning non-essential activities, local leaders seek to buy precious time to acquire more resources and equipment to protect providers and first responders as COVID-19 surges. "I will not ask them to sacrifice themselves because we failed to act," Escott said. Since the new orders were announced, officials have reported that an EMS medic and an Austin Police Department employee have tested positive for the virus.

One vital piece of PPE is the N95 respirator mask, which filters 95% of the particles - including virus particles – a wearer would otherwise inhale. It's essential for tasks like inserting a tube into the airway of an infected patient, an invasive procedure that releases virus particles into the air. These specialized masks, along with other PPE routinely used in health care – latex or nitrile gloves, surgical masks, face shields and gowns – are in short supply globally as the pandemic spreads, depleting hospital stores, prompting hoarding by the general public, and sparking competitive bidding among state and local governments vying for whatever becomes available.

Concern and Optimism

A survey of 213 American cities (including seven in Texas, but not Austin) published by the U.S. Conference of Mayors on March 27 found that 10% or fewer had all the masks and other PPE they needed for their first responders and medical personnel. The Austin/Travis County public health and emergency management departments are working with the Austin Disaster Relief Network to collect community donations of masks, gloves, gowns, goggles and face shields, along with hand sanitizer, soap, disinfecting wipes and thermometers. (While most groups in need say they appreciate efforts to sew homemade masks, they say these are generally not suitable for use in clinical settings.)

The Travis County Medical Society has also championed an effort that, as of March 30, had collected more than 78,000 pieces of PPE, including more than 1,000 N95 masks, and distributed more than 56,000 of these items to family practice physicians in Central Texas. Dr. Mark Glover, a general surgeon in Austin, said he'd heard concerns from his colleagues in private Facebook groups about COVID-19 preparedness, even before the count of local cases began to climb. "There are doctors that feel that they are not properly protected," Glover said. After talking with a neighbor who had a few N95 masks in his garage, Glover posted a request on Nextdoor, which led to the coordinated TCMS effort to collect and distribute, rather than stockpile, the supplies. A GoFundMe page has been set up to help purchase supplies as well.

The Chronicle reached out to larger hospital and clinic systems in the Austin area to see if they shared the concerns Glover has heard from individual physicians. On the whole, they indicated that while PPE shortages are real, their conservation measures and strategies to reduce in-person contacts mean supplies are adequate for now – but may not be as the COVID-19 outbreak peaks.

The UT-Austin team's modeling, showing major spikes in COVID-19 hospitalizations – far above Austin's hospital capacity – with less than 90% social distancing. At the time the model was prepared, Austin was at 50%, before the current shelter-in-place order – a level that would result in a capacity crisis and thousands of extra deaths.

Many providers have taken steps to increase telemedicine visits that don't require PPE, reserving in-person encounters for more serious conditions and saving N95 masks, in particular, for higher-risk procedures. At Austin Regional Clinic, Chief Medical Officer Dr. Jay Zdun­ek said "judicious and calculated" decisions about when to use PPE, along with various donations, mean that at current patient volumes the 27-location system is "adequately stocked." But, he added "I don't know what that means for two or three weeks from now."

Zdunek said ARC remains "hopeful and optimistic" that manufacturers and suppliers across the country can be mobilized to resolve shortages, but he pleaded with the public to continue to practice good hygiene and social distancing. "We've got an entire country of health care systems and workers who are running into the face of adversity to take care of people. And ...we are not asking for anyone to thank us, [or] do anything other than listen to our medical expertise and help us help them by just practicing the things that we're asking them to do," Zdunek said.

Austin's two largest health care systems, Ascension Seton and St. David's Health­Care, between them operate dozens of hospitals and other facilities in the metro area, with access to nationwide supply chains. In a written statement, Ascension Seton said it currently has adequate equipment to care for patients and is "taking proactive steps ... to ensure access to supplies," including expedited direct shipments, "taking advantage of our abilities as a national system to make intra-hospital inventory transfers," and keeping PPE "stored in a secure location in each of our hospitals." Ascension Seton is also accepting PPE donations "as a precautionary measure for unpredictable circumstances as we work to contain the spread of COVID-19."

So is St. David's, which "is grateful for the generous outpouring of support from our community," according to its spokesperson. "While we have the supplies and equipment we need at this time, we are doing everything possible to secure products, as the worldwide shortage of [PPE] is a reality that we are addressing with realistic, workable solutions. We have also implemented protocols recommended by the Centers for Disease Control and Preven­tion (CDC) to conserve those items."

The safety net providers who care for Austin's uninsured and medically underserved are also making changes. For instance, "to extend the life of the N95 masks, we've employed temporary strategies like wearing regular paper masks over the N95," People's Com­mun­ity Clinic said in a statement. While it's been helped with some donations, People's expects access to supplies "will continue to be a challenge for the duration of the COVID-19 pandemic." The clinic now screens each person upon entry, sees patients with symptoms in a separate and protected area, is deferring preventive visits and has introduced telemedicine "to serve as many patients as possible without putting patients or staff at risk," the statement said.

CommUnityCare has also implemented methods, per CDC guidance, and "temporarily suspended services and consolidated clinical sites at seven of our smaller clinic locations" to conserve PPE, said Associate Medical Director Dr. Nick Yagoda in a statement. The system is conducting many visits over the phone "so patients can receive high-quality care from the safety of their own homes without our teams needing to don PPE." Those clinics that remain open have an adequate supply of N95 respirators now, but that could diminish quickly if a spike in COVID-19 occurs, Yagoda said.

“People Are Angry About It”

Yet employees and others we talked to remain anxious and fearful, not confident that administrators have their backs and not certain they can maintain their own personal stores of PPE to protect themselves. One local health care worker, who did not want her name revealed for fear of repercussions from her employer, told the Chronicle she does not now have free access to the masks she feels she needs when seeing patients – as supplies are locked up and metered out – but is supplementing from a personal store of supplies. A doctor at a different system, who also did not want to be identified, shared similar stories of colleagues who are scouring friends and family for "woodworking masks" or other suitable supplies.

We’re about to storm the beach in Normandy without guns. Everybody knows a lot of people are going to die and a lot of people are angry about it.” – Dr. Mark Glover

Mark Glover told us he feels he's been deceived about how bad things really are, and he's skeptical that those caring for patients in the coming days will ever get the supplies they need from any source, including the government. "It's very much a wartime analogy here. We're about to storm the beach in Normandy without guns," Glover said. "Everybody knows a lot of people are going to die and a lot of people are angry about it," Glover said. He feels that hospitals and others that are rationing PPE are not interested in what is the best protection for medical staff. Rather, he said, "They're interested in 'what can we do to follow the rules so that we aren't held responsible for this?'"

While Glover acknowledged that the CDC has relaxed PPE guidelines for COVID-19, which may be driving hospital decisions, he said many doctors no longer trust the CDC's guidance because it changes almost daily, and much remains unknown about the disease. Glover said he and some colleagues literally fear for their lives when thinking about the exposure they will face should local hospitals become swamped with COVID-19 patients and should PPE become even scarcer than it is now. "There are physicians that are working on their medical power of attorney and their advanced directives," he said. In addition to coordinating the TCMS drive, Glover is currently investigating whether other reusable respirators can be found that might substitute for the N95 if needed.

On Monday, March 30, more than 100 local physicians including Glover issued an open letter to city and county officials calling for "better communication to local physicians regarding what is being done about COVID-19 in the community," particularly regarding how to refer patients for testing and isolation options for patients not yet in need of hospital care. The letter also recommended assigning three hospitals to treat all COVID-19 patients to conserve PPE elsewhere, and to use the Austin Convention Center as a temporary isolation facility. (The city announced Tuesday it had leased the Crowne Plaza Hotel at IH-35 and U.S. 290 for emergency purposes, including potential isolation.)

At last week's City Council meeting, Escott said he has a PPE task force looking at supply issues and that the city has received some materials from the Strategic National Stockpile, although they are neither "enough" nor in good condition, with many past their expiration dates. Still, he has people looking to see how many can be used or salvaged, he said, because the additional supplies are "better than nothing." Austin and Travis County may yet receive more help, including federal funding being allocated by the state of Texas for supplies and equipment.

"I really hope that our government, our leadership, our private corporations, that anybody that can make equipment that is approved is working on it right now," said Dr. Elizabeth Douglass, an infectious disease specialist with UT's Dell Medical School. At the same time, she believes that health care providers' measures to conserve PPE, and public efforts to embrace initiatives like telehealth and social distancing are already making a big difference. "We are really slowing down the consumption of protective equipment and we're slowing down the illness," she said.

That probably will change as we approach the COVID-19 peaks predicted by UT's forecasts. But Austinites may yet "rally the community will," as Austin Mayor Steve Adler urged last week, to save lives by staying home, which should go a long way towards lessening the impact on area health care workers, first responders and families. "We have the ability to control what it is that happens in our community," the mayor said, adding that "The biggest challenge we face is that we don't take this as seriously as we need to."

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COVID-19, Mark Escott, sheltering in place, N95 respirator mask, personal protective equipment, Austin Disaster Relief Network, PPE, Travis County Medical Society, Mark Glover, telemedicine, Jay Zdunek, Nick Yagoda, CDC, Elizabeth Douglass

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