As the number of COVID-19 cases continues to grow in the U.S., health care facilities nationwide are contending with an increasing crush of patients, and growing more and more desperate for the tools they need to protect themselves from catching and spreading the virus that causes it. A portrait of a desperately ill-equipped medical workforce is emerging from an online survey with 978 respondents, built by a grassroots organization started by doctors trying to get personal protective equipment, commonly called PPE, to facilities where it is needed most.

“We could use body bags. And eye shields and gowns!” wrote an employee at a nursing facility on Long Island in New York. “Please we don’t have anything,” wrote an employee at a regional hospital in Miami, Florida. All its beds were full, the employee wrote. They had no gowns left, and a week or less of most other PPE.

“We are out of everything,” wrote a staffer at a large hospital in Tennessee. “Providers using one mask for 3+ weeks. Many COVID patients. Zero gowns.”

At first, the organization, GetUsPPE.org, just put up a basic request form: What supplies do you need, and where are you? But within three weeks they had more than 7,000 responses. Staff members from many of the major hospital networks in the U.S. were begging for supplies. Workers from every other category of medical facility were writing in too: home health aide agencies, hospices, ambulance squads, and correctional facilities were all asking for anything they could possibly get.

The group, a volunteer assemblage of programmers, physicians, and data scientists, couldn’t possibly get enough PPE to everyone. To better triage requests, the group sent out a second survey that included the question: How long will your current supply of each item last? The results were staggering.

Facilities of all kinds reported that most of their supplies would run out within a week or two, if they had any left at all. Of the 978 institutions, from 47 states and Washington, D.C., that responded to the second survey by April 8, 36% had no supply remaining of face shields. Another 34% had no thermometers, and 19% had no gowns left. Nearly all had no supplies remaining of at least one form of PPE.

In an analysis of the data from a selection of the largest and hardest-hit states, the need was tremendous.

In Massachusetts, 54% of respondents had a week or less of gloves left. In Texas, that number was 57%. Gowns and disinfecting wipes were also badly needed across the board, with the majority of institutions due to run out in a week or less.

Of 47 institutions in Massachusetts, half had less than a week’s supply of N95 masks left, with another 23% having none at all. In California, of 120 institutions, 41% had a week or less left of N95 masks, and 12% had none left. In Florida, of 50 institutions, 40% had a week or less left of N95 masks, and 24% had none at all.

The supply of medical booties appeared dire across the board, with 58% of Florida respondents, 50% of Illinois respondents, and 45% of Massachusetts respondents reporting no supply left, for example. For many institutions, it’s likely that booties were never something they’d thought they’d need—until this pandemic hit. (The U.S. Centers for Disease Control and Prevention recently released research that found SARS-CoV-2, the coronavirus that causes COVID-19, can stick to the soles of shoes, suggesting shoes might spread the virus around a medical facility).

Thermometers were also in acute need; in California, 40% of respondents said they had no thermometers left. In the Tristate area, which includes New York, New Jersey, and Connecticut, the figure was 41%. In Texas, it was 42%, in Florida it was 43%. Both COVID-19 and non-COVID-19 patients must have their temperature checked regularly to check for the signs of the disease.

While the number of responses to the survey are not large enough nor evenly distributed enough to represent the need in the whole country, the responses are striking anecdotal evidence of how critical the lack of PPE is in the U.S. right now.

Fired for speaking out?

We have chosen not to publish identifying information about specific institutions in this story, due to reports of medical staff being fired and threatened with firing for publicly acknowledging a lack of PPE at their jobs. Last week, the American Nurses Association (ANA) put out a statement saying it was “disturbed about reports of employers retaliating against nurses and other health care workers for raising legitimate concerns about their personal safety while caring for patients with COVID-19.” The U.S. Occupational Health and Safety Administration, which makes workplace-safety rules, posted the section of its code barring retaliation against workers for speaking out about safety conditions on a special COVID-19 page on their website. Nevertheless, we’ve chosen to keep responses anonymous.

Even Dr. Shuhan He, an emergency medicine physician at Massachusetts General Hospital and one of the co-founders of GetUsPPE.org, wouldn’t say whether or not he had seen PPE shortages in his own facility. “To get any physician to say that on record will be really hard,” he says. “There are a lot of legal issues with this.”

Workplaces in the U.S. are required by federal law to protect the safety of their employees; shortages mean that likely isn’t possible. And even though The Joint Commission, an organization that certifies many US hospitals, supports allowing healthcare employees to bring safety equipment from home, amid the chaos of PPE donations, there may be little chance for quality control, which may pose questions of liability. “We’re all in this desperate situation. Everyone is struggling with getting it,” He says. Plus, from a hospital perspective, where safety is often the number one publicity concern, acknowledging the lack of equipment also amounts to bad PR.

Broken supply chain makes PPE impossible to get for smaller institutions

To say that hospitals are having trouble acquiring supplies is a vast understatement. But the supply chain for medical equipment is so broken that smaller institutions don’t even stand a chance.

Much of the U.S. PPE supply is manufactured in Asia, and particularly in China. More than 90% of thermometers for the U.S. market, for example, are made in China. The timeline from manufacturing to transport by ship to delivery to U.S. buyers can be as long as three months, according to a USA Today report. When the coronavirus outbreak began, many East Asian countries began to keep supplies within their borders, as a matter of national security, which restricted supply. Now, with U.S. demand outstripping supply, many U.S. brokers are out of stock. Major hospitals are now resorting to using brokers in East Asia to nab supplies at inflated costs, He says. Supplies like N95 masks are now selling for many times their usual price.

Most supplies can only be purchased in large lots, if a hospital is lucky enough to find any. Purchases have to be made fast, at inflated cost, and often from unfamiliar companies that have popped up in recent weeks to capitalize on the demand, which may bypass a hospital’s normal procedure of soliciting quotes and verifying quality. “You’re in this uncharted territory where you’re struggling to just at least validate,” Ed Bonetti, head of supply chain for the UMass Memorial hospital network in Worcester, Mass told the New York Times. “The last thing we want to do is put product on a clinician that is not going to protect them.”

States are competing against the federal government for the same small stream of supplies, while countries are competing against each other for them too. Even after a shipment seems secured, it could still be redirected; News organizations are reporting that the U.S. Federal Emergency Management Agency (FEMA) is confiscating orders and redirecting them to the national stockpile at the last minute.

But smaller institutions don’t have the buying power to even enter that fray.

“As a small agency, we do not have the resources to outbid every other provider for equipment, even if we could find any stock,” wrote a member of a volunteer EMS service in New York City in response to the GetUsPPE.org survey.

“Unfortunately and sadly home health care is left at the bottom of the totem pole. We service all elderly and compromised patients and our nurses are exposing themselves on a daily basis,” wrote an employee of a home health agency in Florida.

“Things are very bleak right now,” wrote a staff member at a nursing home in Colorado. At a small hospital in rural Massachusetts, an employee reported they were “being overrun with Covid cases…Any help will be appreciated.”

The disparity in buying power means that healthcare workers who are likely to be in close physical contact with COVID-19 patients in the period before they need to go to a hospital are less protected—which all but ensures the virus will spread faster.

“The smaller hospitals that have no PPE and no masks—that’s really horrifying. We’re all affected by it,” He says. “If staff members at a nursing home don’t have PPE, they’re generating COVID-19 patients who are coming to the hospital.”

Before the coronavirus pandemic, PPE was a relatively niche market. Large hospitals only used it for interacting with the very ill. Small physician’s offices, nursing homes, correctional facilities, and home health care agencies might never have used it at all. “We are an acute psychiatric facility that was never prepared for anything like this,” a staff member in Texas wrote in their survey response.

The situation leaves ambulance workers, home health aides, and nursing home staff to turn to an online form to beg for anything they can get.

GetUsPPE.org’s origin story

On March 20, He bought the domain name GetUsPPE.org. By then, he says, there were 50 or so different spreadsheets circulating online to get PPE to medical workers, and #GetMePPE was trending on Twitter, with medical workers asking the internet for supplies. That weekend, he joined a phone call with some of the people who started such spreadsheets, most of whom were doctors, tech workers, and medical students. They decided to consolidate their efforts under a single banner, opting to use He’s domain name.

Since then, He and co-founders Dr. Megan Ranney, an associate professor of emergency medicine at Brown University, and Dr. Esther Choo, an emergency department physician at Oregon Health & Science University, have led a team of some 200 volunteer data engineers, bioethicists, and physicians to categorize requests and try to find PPE to fill them.

Ram Bala, an associate professor of business analytics at Santa Clara University in California, volunteered to design an algorithm to match PPE requests with people who want to offer PPE but don’t know where to bring it. “It’s almost like an Uber or a Lyft; we’re trying to minimize the mileage,” says He. A volunteer “match team,” which includes bioethicists, also considers where the donation might have the most impact.

Making progress on PPE in the U.S.

As of April 13, GetUsPPE.org has delivered around 150,000 pieces of PPE to medical workers in San Francisco, California, around 140,000 pieces in Michigan, and around 50,000 in Baltimore. The numbers go up every day, and are likely higher by the time you read this; GetUsPPE now has volunteers running local chapters in several states, many of whom don’t report their numbers to the central organization.

The financial donations are pouring in too; He wouldn’t specify a dollar amount, but noted it is “in the millions,” and includes gifts from several celebrities. That money goes towards purchasing large lots of supplies when GetUsPPE.org can find them.

But, He says, the group is careful about making offers on those: “We don’t want to drive up the demand and make the problem worse by bidding against hospitals.” GetUsPPE.org will only make those kinds of purchases for smaller institutions who have been pushed out of the market. It’s a lot like the toilet paper shortages seen in many states in the U.S.; institutions with more buying power were clearing out store shelves, driving up prices and making toilet paper unavailable to other customers in the process. GetUsPPE.org recently made a purchase of N95 masks for a small hospital in Chicago, but only after making sure it was in the category of institutions who were left in the dust by larger hospitals.

One way to relieve demand pressure on the supply chain is to increase supply. For example, He says his group is working with on-demand 3D printing companies, to see if they can get them to start making face shields. And they’re talking to companies that make non-medical products like clothing, to try to get them to shift gears. Some PPE, like simple face masks, are relatively easy to produce if you have, say, a textile factory. “We’ve been talking to people at Nike and Uniqlo,” He says.

The number of COVID-19 cases continue to rise in the U.S., which is now the epicenter of the pandemic. A fit and ready medical workforce will continue to be a key bulwark against them rising faster. That takes a huge volume of PPE; a February report from the European Centre for Disease Control and Prevention suggests that each patient with a suspected case of COVID-19 requires a minimum of between three and six sets of PPE for the doctors, nurses, and cleaning staff working in the facility handling that case. A confirmed case with severe symptoms would require 15-24 sets of PPE. Meanwhile, the GetUsPPE.org survey responses are full of medical staff asked to reuse their masks and other PPE, sometimes for a week at a time.

“We’re going through it so fast. Every single COVID-19 patient takes a lot of PPE,” He says. “The rate we’re burning through PPE is really really high.”

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