Protecting the doctors: The reality of the equipment supply problem

A nurse wearing wearing protective equipment puts on her goggles at the Clinic for Infectiology/Tropical Medicine, Nephrology and Rheumatology in Leipzig.
A nurse wearing wearing protective equipment puts on her goggles at the Clinic for Infectiology/Tropical Medicine, Nephrology and Rheumatology in Leipzig.
Ian Dunt By

The doctors are scared. So are the nurses, the staff and the cleaners. They have looked at Italy and they know what's coming.

"I'm not going to lie, a lot of people here are shitting themselves," one doctor says. "They don't quite know what to expect or how this is going to pan out. We are really going to see what some people are made of. I've seen a lot of horrendous things, but even I'm not sure how well I'm going to cope with all this."

Probably the most significant anxiety is around protective equipment. This is the kit handed to the medical staff treating potential or actual coronavirus patients. There is a widespread fear that doctors and nurses are simply not being given what they need to stay healthy.

"As front line medical workers, we don't have the confidence that we're protected," another doctor said. "We don't know what we are facing and we feel woefully unprepared. We don't feel safe. We'll do the job, but we're putting ourselves at risk by doing it. And if we get sick, there's less of us. It's another doctor down."


At the heart of much of this fear is a downgrade in the advice given to hospitals about the equipment.

The main transmission risk for covid-19 is through droplets. Someone coughs or sneezes, and the droplets produced can be breathed in. This is why the advice is to stay around 6 foot away from others and to self-isolate if you have a persistent cough.

The virus can also spread by people touching surfaces onto which infected patients have coughed or sneezed. If you then touch your face you risk transferring the virus from your hands into your mouth or nose.That's why so much of the advice on protecting yourself is about washing your hands and not touching your face.

For doctors handling potential or actual covid patients, the recommended protective equipment is therefore an apron, gloves, goggles and a surgical mask, of the type that you see everyone wearing when you go to hospital. It's basically just a splash-resistant barrier in case someone sneezes or coughs on them. Then they take off the gear after dealing with a patient, discard it, and get a new set for the next one.

But there is another danger for covid transmission in hospitals. It is through the generation of aerosol. These are tiny droplets that linger in the air. Aerosols are much smaller. They are light enough to stay airborne and therefore have a much higher chance of being breathed in. Because they are small, they can penetrate a surgical mask.

Several procedures in intensive care units generate aerosol, such as intubation, where a tube is inserted through the mouth or nose and into the trachea so a patient can be placed on a ventilator.

Anaesthetists are therefore at particular risk of aerosols, as they have to intubate patients for surgery. But so are many other staff groups such as frontline paramedics and teams dealing with cardiac arrests. When you press a patient's chest, you are pushing air out and there is briefly aerosol in the room.

There are also dangers for dentists. Almost all the procedures in a dentists, including anything involving a drill, the suction unit or the water spray, generate aerosol.

In these situations, the danger is not just for the person delivering treatment. Aerosol stays in the air for around three hours. So others going into the room afterwards could also potentially be infected. In intensive care units, where the air is replaced rapidly, this is less of a problem. But in normal rooms, like that of a dentist, it can be a threat.

Where aerosol is generated, a surgical mask is not enough. Doctors need masks with a fine filter which can catch the air particle. These are called FFP3.

At the start of the covid outbreak in January, Public Health England put out advice which stated that doctors handling coronavirus patients would need gloves, an apron, eye protection and FFP3. But since then, as we've learned more about the disease, that recommendation has now changed so that only health workers dealing with aerosol generation require the FFP3 mask and others are safe with just the surgical mask.

Most experts spoken to for this article were comfortable with the new guidance and believed it was the right use of limited resources. But many frontline staff are deeply suspicious of it. They are anxious that the guidance was changed because it is harder to get FFP3 masks.

They are also concerned about when medical situations change quickly. People can suddenly deteriorate and need a ventilator. The staff around them will have to act, but they'll only have a surgical mask.

There are other dangerous situations too. Covid sufferers who are giving birth through cesarean section, for instance, may suddenly need to convert from epidural to anaesthetic. And then again the same risk emerges.

Some doctors are torn. "For the majority of us, it's safe [to use only a surgical mask]," one consultant said. "Although intellectually I know this, when I am examining a patient coughing on me - with no idea of their status - and I'm in a flimsy plastic apron and surgical mask, I'm shitting it. Psychologically it's a nightmare."

Some experts broadly accept the guidance but remain anxious about it. Although the risk of transmission is lower in non-aerosol cases, it's still not zero. Medical staff are going to be experiencing repeated exposures, especially when things start to reach critical levels in the weeks to come. In an ideal world everyone in the medical profession working on the outbreak would be wearing FFP3.

But the trouble is that supplies are short and the FFP3 masks require testing to make sure they fit. They're designed to prevent particles being breathed in, so they can't just be chucked on the face. They have to completely seal the mouth and nose.

These tests come in a few different forms. You can put a hood on the person, place the mask on and then apply a sweet spray and check if they can taste it. If they can, it doesn't fit. Or you can set up an enclosed space, where you test for particles while the person talks, walks, looks left and right and so on.

There is a particular problem with finding masks for people with large heads and a more pronounced one - mentioned by several people - for female doctors with small faces.

There are lots of reports, from doctors from all over the country, about nightmarish wastes of time. They test two, three, four types of masks, and then find out the models are not available and are asked to test for a different type. Because the masks can't be reused, these tests also use up supply. Some doctors have resorted to buying them themselves by Googling the company in China.

Supplies of the masks come from three sources. The first is the government's pandemic stock. The second is the national NHS supply chain, which operates in each of the four nations. And the third is by NHS foundations. Hospitals can buy their stock through any of these three approaches.

Doctors working in intensive care units and anaesthetics are particularly worried. They are preparing for a massive surge in cases in the next few weeks and they do not have confidence that they have the FFP3 masks to deal with it.

There are also acute concerns about FFP3 masks for doctors rushing to deal with cardiac arrests.

The current guidance from the Resuscitation Council says that "full aerosol generation procedure PPE must be worn by all members of the resuscitation/emergency team before entering the room".

But these are fast moving events, where staff rush to the emergency in order to desperately try to save someone's life. Foundation year doctors are often there first, because they're younger. There'll also be a registrar and critical care doctor. At the moment, it's not likely that they'll have been tested for FFP3. This puts them in a terrible ethical position. What will they do? Not go in, and let them die? Or go in, and know they could become a vector of transmission?

Dentists seemed to have been completely hung out to dry by the government. They are self employed workers, who typically operate by conducting their business in a practice, which they do not own and over whose equipment they have no control.

They are generating aerosol all the time. They do not have FFP3 masks. It also puts patients at risk, because the aerosol can linger in the room.

The chief dental officer in England, Sara Hurley, hadn't bothered to offer any guidance for weeks, desite clarity from all the other UK nations. The British Dental Association started writing to her once every other day expressing "anger and frustration" that "dentists and their teams are being left to cope in the current frightening situation without the benefit of clear official advice".

Dentists across the country were extremely nervous. "It's not a selfish thing," one said. "I don't want a patient coming in and going out infected. I'm willing to take a risk to help people out who are in pain and need my help. But I don't want anyone else to be at risk by coming in."

And it's not just them, but the staff. "There's lots of worried and scared people. Support staff look to us and we don't have answers to tell them."

Finally this morning she clarified that non-emergency aerosol procedures should be avoided, sliding out an announcement which ended routine dentistry as we know it. Again, uncertainty was allowed to prevail, chipping away at confidence in the government approach.

There are widespread and extensive reports of other kinds of shortages.

Some hospitals have a lack of goggles. Intensive care doctors have resorted to making their own by using elastic bands to strap an overhead projector sheet to their face. Anaesthetists have resorted to buying visors in B&Q.

In general, doctors and nurses across the country are crying out about the lack of equipment they have. When you put out a call to hear how they feel about the working environment they are being asked to work in, a wave of outrage and fear comes back.

And that's the thing. That's why medical staff struggle to have confidence in what they're being told about equipment. That's why doctors' bodies like the BMA simply cannot say that they have confidence that their members are being kept safe. Because all around them there is evidence that they do not have the resources they need. The government response looks reactive, sluggish and opaque.

Medical staff need certainty and they need supplies. They will spend the next few months defending the public. In exchange, the public will need to defend them.

A Department of Health and Social Care spokesperson said:

"We will continue to give our NHS and the social care sector everything they need to tackle this outbreak and we have central stockpiles of Personal Protective Equipment. We are working closely with industry, the NHS, social care providers and others in the supply chain to ensure these medical products are delivered to the frontline as quickly as possible, helping minimise any risks to patients and staff."

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