This weekend, our first medical resident tested positive for SARS-CoV2, the virus that causes COVID-19. Most importantly, they’re doing ok. They stayed home since the first hint of symptoms, are now asymptomatic, and will return to work later this week per our employee health guidelines. Despite this, the news was jarring.
It’s impossible to know whether this resident was exposed to the virus in the community or at work. They cared for a patient with COVID-19, but the timing of their symptoms would be unusual for this to have been the exposure. The resident wore the proper personal protective equipment (PPE), but the patient was hospitalized before the implementation of strict training and protocols for donning (putting on) and doffing (taking off) PPE.
I’m extremely thankful for the resident’s return to good health. But their illness reinforces the importance of rigorous and thoughtful workplace training and protocols to protect those who work in the hospital, from housekeepers to phlebotomists to physicians. For my provider friends, here are a few lessons I have learned:
If you work in a hospital and might go into a patient’s room, shave your beard. We use two categories of masks in medical settings: surgical masks and N95 masks. Based on CDC recommendations, we are using contact and droplet precautions (surgical masks + other PPE) to care for patients with suspected or confirmed COVID-19. We are using airborne isolation (N95s + other PPE) for patients undergoing aerosolizing procedures including, among others, airway suctioning and noninvasive ventilation.
N95s provide a tight seal around the nose and mouth. For people who cannot use N95s, or for the very highest risk procedures including intubation, a machine called a powered air-purifying respirator (PAPR) can be used. In incident command meetings a few weeks ago, I was amazed with the amount of time spent discussing the exact number of N95s and PAPR hoods available, how more could be procured, and how to protect the current stock. Mask shortages have been in the news. We’re very worried about running out of N95s, but our hospitals’ single-use PAPR hood stocks are critically low.
Facial hair precludes the use of an N95 by preventing the mask from providing a tight seal. So, barring religious or medical reasons, please temporarily say goodbye to your beard to preserve the PAPR hoods for those intubating patients and those who cannot use N95s for nonmodifiable reasons.
Get N95 Fit tested ASAP. This test to determine the effective type of N95 mask should happen once per year, but many hospitals do not require this. Assuring the effectiveness of the most important piece of equipment for hundreds of people, all at once, significantly slowed us down in expanding who could safely care for patients with COVID-19. This could have been mitigated through regular testing protocols. Also, save the N95 mask used for your Fit test (it hasn’t been used with a patient so is not contaminated). I’ve been using mine to practice taking it off, which can be tricky without contaminating yourself.
Push your leadership to provide proper PPE training. If your leadership is too overwhelmed to develop PPE training and protocols, develop it yourself. Personal Protective Equipment including gowns, gloves, masks, and face shields is the stalwart of protecting yourself. When properly donned and doffed, the rate of virus transmission between patient and provider is thought to be very low.
At my hospital, we have four steps providers must complete before caring for patients with suspected or confirmed COVID-19: 1) watching a video on hand hygiene/PPE donning and doffing; 2) FIT testing; 3) an online PAPR module, and; 4) in-person donning/doffing training. Doffing in particular is complex and time-consuming; it requires patience, practice, and is best done in a buddy system. This sounds intense, but I really think it’s the best way to protect ourselves.
A few of my colleagues adapted PPE protocols to something that would work at our hospital. Check out the resources page of this blog for UW’s protocols. UW incorporates trained observers, which our hospital did not have the staffing to do. If you want to see our slightly simplified protocols, send me a message and I can show you the checklists my colleagues developed.
Provide a unified message. With rapidly changing protocols, lack of clear communication and mixed messages have led to tensions between groups of providers, as well as wasted PPE (for example, an entire unit’s staff thinking they needed to wear N95s at all times in and out of patient rooms). Most importantly, when any hospital employee does not properly don and doff their PPE, everyone is at increased risk of infection. We have trained “PPE Champions” in each service line in our hospital who train their division and disseminate information.
Be well, to the best of your ability. Some of our residents have found caring for patients with COVID-19 to be particularly emotionally challenging. There are no easy patient deaths, but it is especially distressing when a person dies alone. Stable patients with COVID-19, such as an elderly man we recently cared for, are lonely: They’re not allowed to have visitors and are seen as infrequently as is safe to minimize infection risk and conserve PPE. Hospitals are taking steps to get patients digitally connected with their families, but this means of communication is new for some. I mentioned the concept of “crisis standards of care” in my last post, about the emotional challenges that will arise if we have to compromise our usual practice of medicine during this pandemic.
All this comes at a time when, as a society, we’ve been stripped of many of the activities we usually use to get our minds off of work. Just when I was getting strong, my rock climbing gym closed; when I could finally use the subjunctive, my Spanish class moved online; the book club, concert, and ladies night were cancelled.
It’s nerve-wracking to work on the front line, in a building full of infected patients, but I’m grateful to interact with people in the flesh every day. I’ve tried to adapt my usual exercise routine by doing home video yoga and getting back into running. I heard the concept of “forest bathing” last year, the improvement of health that comes with being in nature. I take the opportunity to be outside, greater than six feet away from people, as often as possible.
For other chiefs – to support residents’ health, we’re moving toward schedules that provide prolonged rest between periods of work. I’ve tried to maintain the educational atmosphere of residency by continuing in-person morning report. With medical students off their rotations, our numbers are very small, and these conferences provide learning and a brief respite from the thick atmosphere that COVID-19 has created. On Wednesday we’ll hold our first weekly “Soul Food” meeting. While eating take-out from local businesses, one of our chaplains will lead a discussion among small groups of residents to help process all that’s going on. These meetings, like everything else, might change soon, but for now, I think they are safe and helpful.
Finally, if this is your thing, Headspace, a meditation app, is offering a free membership to healthcare professionals through the end of 2020. Just register with your NPI! I haven’t done it yet but likely will.
Eventually, and probably soon, we’ll all know people who are affected by this disease. The news gives the impression that things are spinning out of control, but I think of provider wellness and PPE protocols in the hospital like I think of public health measures outside of the hospital. They’re things we can act upon to protect ourselves and slow the course of this pandemic.