No PPE for Me?
By: Ryan Joseph, DO, DTM&H
Personal Protective Equipment or PPE, has typically been a fleeting thought in most Emergency Medicine (EM) Physician’s minds during our careers. We’d casually put some gloves on to examine the next patient, or perhaps don a yellow gown in the case of a procedure or a trauma patient. For most of us, we would rarely consider wearing an N95 mask, or whether the face seal was adequate or not…… until now.
The recent COVID-19 pandemic has changed the way we all view PPE. No longer do we take for granted the “droplet precautions” or “airborne precautions” sign hanging from the door. No longer do we don an N95 mask and casually toss it in the trash as we leave the room. There is a nationwide shortage of N95 masks leading to a lingering feeling of uncertainty about when our supply will be replenished.
A quick “googling” of PPE shortage reveals numerous articles on the current crisis facing healthcare workers around the country. Phrases such as “You wouldn’t send a soldier in to war without a gun or body armor”, and “We are at war with no ammo” have peppered headlines and made it clear that healthcare workers are in dire need of PPE.
The catastrophe that we are facing as a result of the PPE shortage has been predicted for some time. The title of an article written by the American Hospital Association, published February 7th, 2020, says it all “Concerns rise for PPE shortages with coronavirus”. Since then numerous articles have been written raising concern for the looming shortage. Well, the shortage is here, how are we going to deal with it?
The CDC has made numerous statements and policy changes in an attempt to manage the crisis, however many healthcare workers are raising concerns with the changes. On March 10th, the CDC revised it’s guidelines on PPE and advised that facemasks for clinical providers are an acceptable alternative. At the time of this writing, the CDC statement regarding PPE states that, when the supply chain is restored, facilities with a respiratory protection program should return to use of respirators for patients with known or suspected COVID-19. This statement of course makes it clear that the recommendations are due to a shortage, not evidence based medicine. On the same statement, the CDC stated that “N95 respirators or respirators that offer a higher level of protection should be used instead of a facemask when performing or present for an aerosol-generating procedure”. They go on to state that, “some procedures performed on patients with known or suspected COVID-19 could generate infectious aerosols. In particular, procedures that are likely to induce coughing(e.g., sputum induction, open suctioning of airways)”. Inducing a cough and a patient coughing on their own give the same result, aerosolization of infectious particles. If that is the case, we should all be wearing N95 masks (or equivalent level of protection) when we enter these patients’ rooms. ACEPs clinical statement made on March 20th, 2020 even states that “procedures or processes (including a physical exam), that generate potentially infectious aerosols require a higher level of PPE that includes an N95 respirator. This point is made clear in a study titled “Dispersion and Exposure to a Cough-Generated Aerosol in a Simulated Medical Examination Room”, which states “surgical masks do not provide protection against small airborne particles, and a properly fitted respirator is needed when exposed to infectious bioaerosols. Even when surgical masks were sealed to the test fixtures, they still allowed large numbers of aerosol particles to pass through their media and be inhaled”. Their results also found that not only is there an immediate exposure in the path of the cough plume, but there is a rapid dispersion of the particles throughout the room and that within several minutes anyone in the room will be exposed to these particles, regardless of their location. Even if the patient is coughing while you are in the room, larger particles can be dispersed throughout a patients’ room and remain suspended for longer than 20 minutes.
It is worrying that the CDC and subsequently many large hospital systems are recommending the use of surgical masks, which were originally designed to minimize infection of surgical wounds from wearer-generated bacteria. Another article titled, “Surgical Mask Fit and Filter Performance” found that surgical masks“will collect only a small percentage of airborne particles generated by infectious patients. Even when equipped with filters demonstrating relatively high collection efficiency, 30-50% of particles will leak into the facepiece of a “well-fitting” surgical mask. For aerosols containing organisms with a low infectious dose (eg, tuberculosis), this level of face seal leakage would not prevent a potentially infectious exposure during even a brief encounter with a patient”. And, although we don’t have data yet with regards to health care worker infection rate in COVID-19, HCW susceptibility to airborne pathogens has been well documented in previous outbreaks, such as the SARS (Severe Acute Respiratory Syndrome) outbreak in Toronto in 2003. According to the SARS commission executive summary, “of the almost 375 people who contracted SARS in this outbreak, 72% were infected in a healthcare setting, and 45% of these cases were HCWs, including 3 who died”. An investigation of the outbreak concluded that "…there is no longer any excuse for governments and hospitals to be caught off guard and no longer any excuse for health workers not to have available the maximum level of protection through appropriate equipment and training."
Many professional medical organizations have recognized the seriousness of the PPE shortage and are very concerned with the CDC’s changing of recommendations based on supply rather than evidence. In a joint 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.” But, with the limited prospects for speedy government intervention, many Americans have taken PPE production into their own hands. Everything from making homemade cloth masks to using diapers has made headlines, however, these have of course not been approved for medical use and we are unsure what level of protection they will provide. Numerous frontline healthcare workers have started flocking to hardware stores in search of personal, reusable respirators, but whether these are even allowed at their specific institutions is another barrier to adequately protecting oneself. Fortunately, the American Academy of Emergency Medicine (AAEM) published a position statement, dated March 23, 2020, addressing this exact issue. In the statement AAEM makes it clear that EM physicians can “wear self-supplied PPE including respirators that meet NIOSH standards when, in their medical opinion, hospital or healthcare facility supplied PPE is inadequate”.
The American College of Emergency Physicians also developed several policy statements starting on March 20, 2020 suggesting that individuals wear masks, even if it was a surgical mask, for all patients. ACEP also issued a statement that individuals should be able to wear their own PPE, and shortly after, ACEP reiterated that with a stronger statement regarding PPE- now N95’s.
AAEM goes a bit further to state that they will “offer support to any EM Physician threatened or terminated for attempting to protect themselves and their patients in this manner”. With that said, will healthcare workers even have enough self-supplied PPE? With so many unknowns and uncertainties during this trying time one thing that we can be sure of is that healthcare workers, regardless of PPE supply, will be on the frontlines taking care of the onslaught of patients affected by this virus. And, although we face a formidable enemy, at times with inadequate armor, I am confident that if we all work together and support each other, we can overcome the challenge and never take for granted our PPE again.
Ryan Joseph DO, DTM&H
Assistant Professor of Emergency Medicine
UT Health | Department of Emergency Medicine
Global Emergency Care Curriculum Director
@DocJoseph08
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