Wednesday, March 25, 2020

An important proposal that ameliorates our lack of protective equipment and spares both patients and healthcare workers


There is a huge disconnect between the personal protective equipment (PPE) healthcare workers (HCWs) should be wearing to protect themselves from coronavirus, and what actually exists right now for them to use.  The White House has told the governors to find their own supplies.  The equipment market is in chaos.  CDC is now telling HCWs to make their own equipment.  But Kaiser Permanente threatened to fire nurses for wearing their own N95 respirators.  The WHO says the "shortage of personal protective equipment is endangering health workers worldwide."

What many people don't know is that HCWs change in and out of protective gear, which is almost entirely single use, every time they enter a room to see a patient who may be contagious via the airborne route. One contagious patient may lead to the use of 20 changes of PPE in a single day.

Nurses and doctors deserve congratulations for their bravery and commitment to continue working, even without adequate protective equipment.  Though UK doctors have threatened to quit, and Bulgarian doctors have quit.

Having doctors and nurses work under these conditions is extremely shortsighted.  Given the tremendous propensity of the virus to spread--US deaths are doubling every 3 days, and are believed to lag infection by a month--healthcare workers will be infected disproportionately, as in Wuhan and northern Italy.  But worst of all, HCWs may become viral spreaders, transmitting infection to patients who are in their healthcare facility for other reasons.  Doctors in Italy have warned that 
hospitals might be “the main” source of Covid-19 transmission. 
This situation should not be tolerated by the doctors and nurses, who know better, nor by their non-COVID patients, nor by their healthcare administrators and government.

There is only one solution:  keeping patients with COVID-19 in facilities that treat only COVID-19.  And treating other patients in separate facilities.  This requires government to take control of a very messy situation:  hospitals and clinics are about to become, if they are not already, the locations that put their patients at highest risk of infection. But hospitals will not suddenly create separate COVID facilities by themselves.  Government needs to step in to make this happen.
Creating designated COVID-19 facilities would allow healthcare workers to put on a complete set of protective garments: masks, goggles, face shields and head to toe gowns and shoe covers, at the beginning of their shift.  They would then not change out of the garments between patients, since all the patients are already infected.  It would save tremendous amounts of equipment and time, since HCWs would not have to change up their gowns, gloves, etc. between each patient, and would have enough protective equipment to work in safety.

How do you identify the COVID patients, when PCR tests have again slowed due to lack of reagents and swabs?


In Italy and China, ultrasound exams of the lungs, or CT scans, have been used to differentiate the specific lung pattern caused by this coronavirus (a bilateral ground glass appearance, especially in the lung periphery) from other infections.  This can provide a faster diagnosis than a lab test, with almost as much accuracy, at the point of patient contact. Ultrasound machines may be portable and inexpensive.


Hopefully new rapid laboratory tests will also be available to aid in immediate diagnosis.


Patients would be triaged and separated into those who: 

1.  definitely have COVID-19 based on their history, symptoms and a scan
2.  definitely have a different disorder, or
3.  maybe have COVID-19 

The 'maybe' patients must be situated in separate rooms to avoid cross-contamination, and would require HCWs to change their gowns, masks, etc. between patients. The HCWs caring for non-COVID patients would not require protective gear, except perhaps a mask in case they are asymptomatic spreaders.  Those caring for COVID patients would use only one set of gear for each shift.

By so doing, we keep HCWs and patients safe, and sensibly use the limited personal protective equipment currently available.  We avoid reliance on expensive but untested tech solutions for monitoring patients from a distance.  And it saves patient lives.

By keeping HCWs suited up, they can safely work at the bedside, and, when critical patients need urgent intubation, which is required all too often with COVID-19, our doctors and nurses will avoid the several minute delay of getting dressed in gear before they can take care of the patients' immediate needs.

We need strong leadership to immediately enable healthcare facilities to implement this type of system, the same way we needed strong leadership to impose quarantines to 'flatten the curve.'

1 comment:

Micki said...

This is such an obvious good idea...like it's hiding in PLAIN sight.

I suggested it to our local hospital and community leaders. We are in a unique situation -- we have one hospital in Bellingham, Whatcom County, Washington State, but we have an EMPTY hospital in town.

As your readers probably know, our state is a "hot spot" for Covid-19 (the 1st Dx in the state in our neighboring county)..then the Life Care Center outbreak in Kirkland; now, here in Bellingham we have "Kirkland Redux" at Shuksan nursing facility.

I suggested PeaceHealth St. Joseph Medical Center could get the old St. Luke's Hospital up to speed and use it as the COVID-19 designated facility, for all the reasons you explain.