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Where is all the PPE?

Ken Budd , Special to AAMCNews
March 27, 2020

As health care workers across the country plead for more protective equipment, manufacturers and distributors are scrambling to meet an unprecedented need. Here’s how we got here — and what needs to happen for us to get through this crisis.

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Police in East Meadow, New York, lead a donation drive to collect medical equipment such as N95 surgical masks, nitrile gloves, tyvex suits, and antibacterial and disinfecting wipes to battle the coronavirus pandemic on March 24, 2020
Police in East Meadow, New York, lead a donation drive to collect medical equipment such as N95 surgical masks, nitrile gloves, tyvex suits, and antibacterial and disinfecting wipes to battle the coronavirus pandemic on March 24, 2020.
Al Bello/Getty Images

In South Carolina, an emergency room doctor reported that three boxes of N95 respirator masks were recently stolen from a locked office at the hospital where he works. At the University of Washington in Seattle, an entire shipment of N95 masks was stolen off its loading docks. Bruno Petinaux, chief medical officer with George Washington University Hospital in Washington D.C., told the New York Times that people have simply walked into the building and stolen supplies.

As shortages mount, some hospitals and staff are taking desperate measures to cope, whether searching for masks at hardware stories, relying on volunteer sewing groups, or requesting personal protective equipment (PPE) donations via social media. A NewYork Presbyterian/Columbia University Medical Center resident’s plea for PPE donations — including surgical face masks, eye shields, and N95 masks — was recently circulated on Twitter. Others are tweeting their frustrations, fears, and advice with the hashtag #GetMePPE. Doctors and nurses nationwide are also using hospital Facebook groups to share information on everything from buying their own equipment to handcrafting their own masks. In other hospitals, staff members report turf wars over who receives masks and who doesn’t.

Just how widespread are the shortages? In its recently revised guidelines, the Centers for Disease Control and Prevention has proposed using bandanas as a last resort when face masks are unavailable. And in a March survey by the AAMC, member institutions noted shortages of a variety of items, including masks, shields, gowns, gloves, shoe coverings, and hand sanitizers.

“Every clinical institution and leader that I’m talking to is saying PPE, PPE, PPE,” says Janis Orlowski, MD, a practicing nephrologist and the AAMC’s chief health care officer. “That is the number one issue for our health institutions at this time.” On a March 20 phone call, one clinical leader told Orlowski that her hospital was already down to a one-day supply of PPE despite their efforts to conserve. Orlowski has also spoken with hospital leaders about potentially obtaining PPE from dental offices and surgi-centers that have closed. “It’s getting five boxes here, 10 boxes there, that kind of thing — it’s a serious shortage,” she says.

The numbers are staggering. In a “severe event,” the United States will need 3.5 billion N95 masks, according to Robert Kadlec, MD, assistant secretary for preparedness and response (ASPR) at the Department of Health and Human Services. “We have about 35 million,” he told the House Committee on Oversight and Reform on March 3. In a March 21 letter to Kadlec and Secretary Alex M. Azar II, Democrats on the committee wrote: “The United States has only 12 million N95 masks in the Strategic National Stockpile — our country’s largest reserve of medical supplies — and as many as 5 million may be expired. Although President Trump announced that the federal government will order 500 million respirator masks to address these shortages, it may take up to 18 months for orders to be fulfilled despite the immediate need for this lifesaving equipment.” The government has begun releasing supplies from the stockpile, but multiple states report that they have received only 10%-25% of their requests for supplies, such as masks, gowns, and gloves.

“Every clinical institution and leader that I’m talking to is saying PPE, PPE, PPE. That is the number one issue for our health institutions at this time.”

Janis Orlowski, MD
AAMC Chief Health Care Officer

PPE isn’t the only issue. The stockpile includes about 16,600 ventilators, according to a March 24 report by the Center for Public Integrity. But New York City alone expects to need an extra 15,000, the report notes.

If we don’t get the equipment,” New York Governor Andrew Cuomo said on March 22, “we can lose lives that we could have otherwise saved if we had the right equipment.”

Desperation and creativity

When she couldn’t find masks at Home Depot, Lowe’s, or Sherwin Williams, an anesthesiologist at a Midwestern teaching hospital tried a different approach: She spent $350 of her own money to buy masks on eBay. For her, it was all about safety and protection.

“I personally have been exposed to at least two patients who I think are great candidates to have COVID-19, and I’m not sure one of them is still alive,” she says on condition of anonymity. “We are being told, ‘Take care of your patients and we’ll protect you.’ But the protections are not available.”

PPE is also reserved for staff members who work with patients with confirmed cases of COVID-19, not for those with patients who may have it. “Leadership is understandably holding on to masks for known cases,” the anesthesiologist says. Yet providing some staff with masks but not others impacts morale and leads to risks. “I was taking care of a patient in the ICU who had other comorbidities but severe respiratory failure, and I looked around the room and said, ‘No one in here is wearing a mask, and I think she has [COVID-19] — what do I do?’ A friend was on OB yesterday with a patient with respiratory distress and a history of travel. My friend started saying, ‘I don't want to put in this woman's epidural without a mask’ and it was an ordeal for her to get one.”

“We appreciate that the administration announced that PPE production is ramping up, but we need these supplies now and we’re going to need significantly more as cases multiply.”

Hamad Husainy, DO
American College of Emergency Physicians

Some institutions are working to reduce PPE shortages with an eager and available labor force: medical students. At Johns Hopkins University, med students are working in a production-line setting at a local warehouse to produce plastic shields for hospital staff. To increase conservation, most hospitals have taken steps such as temporarily ending elective surgeries, though exceptions remain. The University of Pittsburgh Medical Center is still performing elective surgeries and close to 300 employees have signed an open letter asking management to “act responsibly toward society and our patients.” Most institutions, however, are implementing more extreme conservation measures (JAMA is collecting suggestions for conserving PPE and has received 200+ responses on its website, with ideas ranging from wearing snorkel masks to using UV light machines for decontamination).

“The question is, ‘How do you conserve and reuse certain PPE, and when is it safe to reuse?’” says Orlowski. “We would never take a paper gown and then use it again for another patient. But if you could put five COVID-19 patients together in a row, the doctor or nurse could put on one gown and go from patient to patient, examining them, and then take the gown off. That's not where we’ve been before, but it makes sense as we continue to be conservative.”

What went wrong

After 9/11, many large teaching hospitals did, in fact, begin to build decontamination areas and maintain extra supplies such as ventilators. Plans were in place to deal with problems like pandemics and other disasters. Recent N95 purchases were already higher than usual due to fears of an active flu season as well as the coronavirus, but then the numbers skyrocketed. U.S. hospitals and health systems typically buy about 22 million N95 masks each year, according to data from Premier, Inc., one of the nation’s largest health care group purchasing organizations. Yet during January 2020, demand increased by 400%. In February, it was up 585%.

So, what were the blind spots in hospitals’ plans? Orlowski believes one of the most significant involves supply chains — specifically, the large amount of critical medical supplies that are obtained from foreign manufacturers. This includes gowns, gloves, and N95 masks from China and testing swabs from Italy. “We really are a global economy, and once suppliers in China go down, how do we boost up suppliers in another part of the world?” she asks.

The nation will learn lessons from this experience that will help in the future, Orlowski believes, and she’s encouraged by measures such as legislation signed on March 20 allowing companies such as 3M and Honeywell to sell large quantities of N95 industrial-grade masks to health care workers (the companies’ products are primarily made for industrial use). The Department of Defense also announced on March 19 that it would release 5 million N95 masks from the military reserves, with roughly 1 million available for immediate use.

U.S. manufacturers are also ramping up production of ventilators. On March 24, Ford Motor Company announced plans to work with companies such as 3M and GE Healthcare to produce respirators, ventilators, and face shields. Ford projects that it will use its 3D printing capabilities to assemble over 100,000 face shields per week.

The Trump administration cites Ford as evidence that U.S. businesses will voluntarily pitch in to produce much-needed medical products. The president recently issued an executive order allowing him to use his authority under the Defense Production Act, but he has expressed a well-publicized reluctance to use those powers, citing concerns about “nationalizing our businesses.” The act, however, simply gives the federal government the power to control industrial production during emergencies (it was passed in 1950 during the Korean War). That could include prioritizing who receives supplies of gowns, for example, or ordering manufacturers to produce a certain product.

Governors and other officials have urged the president to use the act given the urgency of the current shortage. “When we went to war, we didn’t say, ‘Any company out there want to build a battleship?’” Gov. Cuomo stated on March 24. “The president said it’s a war. It is a war. Well then, act like it’s a war.” New York City requested 2.2 million masks from the federal government but received only about 78,000 from the stockpile, all of which were expired. “The city is currently seeking 3 million N95 masks, 50 million surgical/face masks, 15,000 ventilators, 45 million face shields, 45 million surgical gowns, 45 million coveralls, and 45 million disposable gloves,” the House Committee on Oversight and Reform wrote to the Department of Health and Human Services in its March 21 letter.

Front line workers express similar concerns about the pace of production. “We appreciate that the administration announced that PPE production is ramping up, but we need these supplies now and we’re going to need significantly more as cases multiply,” says Hamad Husainy, DO, a spokesperson for the American College of Emergency Physicians and an emergency physician in Florence, Alabama. “We can’t afford to let emergency physicians and other front line providers get sick.”

“I think in the medium- to long-term of this epidemic, we will start to see PPE coming in from U.S. manufacturers and from manufacturers outside the United States. What we have is this short-term issue that we have to deal with.”

Janis Orlowski, MD
AAMC Chief Health Care Officer

Orlowski remains guardedly optimistic, however, that the situation will improve, citing not only the increased contributions from U.S. businesses but also the gradual return of manufacturing in China. Once supplies are rolling out of Chinese factories, ASPR and other suppliers are considering flying them to the United States, she says. The expense would be higher, but it would reduce the normal packaging and shipping times from six weeks to one or two weeks, ASPR staff members have told Orlowski.

“I think in the medium- to long-term of this epidemic, we will start to see PPE coming in from U.S. manufacturers and from manufacturers outside the United States,” she says. “What we have is this short-term issue that we have to deal with. And that is going to be bridged by the actions of stopping dental surgery, stopping elective surgery, stopping everything that is using a caliper mask and giving it to the health care community.”

She remains concerned about the dangers facing the country. “If we don’t flatten the curve, this will overwhelm our health care system,” Orlowski says. But one thing in particular makes her optimistic, even as hospitals continue to struggle with shortages. “I am a true believer in the intrinsic strength, innovation, and resolve of academic medicine. And so what I see everywhere is academic medicine standing up and being diligent,” she says. “We can work through this.”

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