Doctors In Harm’s Way: The Stage Was Set For A PPE Shortage Long Before COVID-19

When the COVID-19 pandemic is finally over, health care providers around the world will be asking themselves how we got here. Buying PPE off eBay. Soliciting the public to sew masks. While, as a country, we could have been better prepared, it would not have been practical to stockpile the 3.5 billion masks that HHS estimates will be needed throughout this pandemic. We are in this situation solely as a result of our health care systems’ reliance on single-use products and a centralized supply chain.

There are plenty of good arguments for using disposables, such as studies demonstrating lower surgical infection rates and contamination when disposable gowns are used or not having to spend time decontaminating equipment. However, as products such as laryngoscope blades, blood pressure cuffs, and pulse oximeter probes are increasingly becoming disposable, we need to ensure the added economic and environmental cost, as well as our lack of self-sufficiency, is justified.

After Hurricane Maria landed in Puerto Rico, we experienced the danger of a centralized supply chain first hand with the shortage of normal saline. As the severity of this shortage became clear, many standards of care were challenged. Some medications that were routinely diluted with IV fluid were switched to IV push, which was hypothesized to benefit some patients due to the reduction of salt intake. Blanket orders for pre-surgical IV fluids were challenged as they lacked evidence to support them. Hospitals switched patients from IV to oral rehydration, with Brigham and Women’s Hospital reportedly decreasing their IV fluid use by 30%.

This result was not surprising as evidence for oral rehydration therapy has been around since the 1960s. Numerous studies show that it requires less fluid than IV rehydration and results in a shorter length of stay, less staff time, and higher levels of caregiver satisfaction in pediatric ED patients with no difference in admission rates. While the shortage empowered us to make evidenced-based decisions to challenge routine standards of care, with the return of saline availability, we have largely returned to our pre-Maria protocols.

As with Maria, our reliance on single-use products has left us in a similar situation. Rather than accepting that disposable gowns are superior to their cheaper and more sustainable reusable counterparts, we should have been asking for a better reusable product. We have complacently accepted standards of care and now lack the data as to which interventions actually protect us and our patients.

For example, while many use sterile gloves to close simple lacerations, numerous studies have shown that they are unnecessary, likely because the illusion of a sterile field is compromised by the unsterile scalp. In the same mindset, we continued to throw out our masks in the interest of infection control, even though they are likely effective for extended periods of time. Because we tacitly assumed that there was an infinite supply of equipment, we never questioned if it was necessary to throw out our masks or developed disinfection procedures as the pandemic spread, throwing out thousands in the two months that we could have conserved them.

As a result, we are faced with seemingly arbitrary policies across the country with guidelines on mask reuse ranging from disinfecting and reusing masks for a maximum of five patient encounters to reusing them for a shift, a week, or indefinitely.

We do know that some methods of reuse are detrimental, such as washing unmolded N95s. However, few studies on mask disinfection exist and often offer an incomplete picture. While we would expect the CDC would offer solutions to this crisis, they have acknowledged that it may be necessary to use scarves or bandanas when masks run out. Unfortunately, the few studies on the efficacy of these homemade masks show they only provide between 4.5% and 72% of the protection of a surgical mask, placing us in a position where we do not understand the risks we are taking.

However, hope is not lost, as hospitals are innovating. They are working with suppliers to 3D print masks, manufacture face shields, and collect community donations of PPE. While it will be painful, we will make it through this. But it is our responsibility to make sure it doesn’t happen again.

Our first step is to acknowledge that we can’t order our way out of a crisis. When everyone orders at once, the supply will never be enough. Stockpiling is also not a solution, as the vast majority of health systems, especially rural hospitals, don’t have the money to invest in extra supplies, the space to warehouse them, or logistics to cycle their cache before it expires. And we’ve learned why we can’t rely on the federal stockpile to bail us out.

It is for this reason that health system procurement needs to consider more than economics; they must include resiliency, prioritizing the purchase of products that will help make them self-sufficient. They can also purchase from local manufacturers, which will help insulate them from national shortages.

At the federal level, the government should offer funding for critical industries to build manufacturing capacity that they can activate during a disaster, such as 3M, which is using extra assembly lines to scale-up N95 production. The FDA should require manufacturers to develop safe protocols for expiration date extensions, disinfection, and reuse of single-use equipment to be utilized during a national emergency when liability is waived, offering a safer alternative than the guidance of engineering students or a cursory search of PubMed. Non-medical industries can also be equipped to pivot their production during emergency shortages.

I know that our bureaucratic health care system is slow to adopt change, however, when the next pandemic hits, and it will, I hope that I am not caring for patients while wearing a trash bag or being punished for wearing a mask.

Daniel Berger is a medical student.

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