The hospitals across Nevada have grown quiet.

Elective surgeries have been delayed. Patient volume is down. Expectant mothers who might have brought a troupe of family members and friends with them for delivery are now limited to a single visitor. Hospitalized kids, too, are generally limited to one parent. Most everyone else in the hospital, coronavirus patients among them, are alone.

The quiet is eerie, the result of steps taken by hospitals in recent weeks to reduce their patient volume in anticipation of an influx of seriously ill COVID-19 patients. It's the calm before the storm.

This is the picture painted by more than a dozen health care workers across the state, most of whom spoke to The Nevada Independent on condition of anonymity to talk freely about their experiences on the frontlines of the COVID-19 pandemic: The regular din of hospital life has been reduced to a murmur, the number of coronavirus patients is growing, and, increasingly, health care workers are anxious that they don’t have the proper resources they need to keep themselves safe.

“They’ve been extremely unprepared. Talking to nurses that work at different hospitals in different systems, Las Vegas in general was not prepared for this,” said a nurse who works for the Valley Health System in Southern Nevada. “I feel like they just kind of ignored the situation thinking, ‘Oh, it won’t really happen. It’s not that bad. It’s not going to come across the waters. We’re good.'”

But the novel coronavirus is here. As of Thursday, there were 1,458 confirmed COVID-19 cases in Nevada, and 38 people in the state have died after contracting the virus. It’s a reality that would have been unimaginable for many a month ago, and now as the rest of the state is grappling with the new normal, so, too, are health care workers.

“You don’t know what the rule is going to be when you come in,” a health care provider who works in the surgery department at a Las Vegas hospital said. “Am I going to have enough masks today? Am I going to have to wear this same mask all day whether it’s soiled or not? What is today going to look like?”

Hospitals, in responses to requests for comment for this article, highlighted the strain on the global supply of personal protective equipment, or PPE, and detailed the protocols they have put in place to distribute necessary equipment, like masks, to their employees. A spokesman for University Medical Center, the county-run hospital in Las Vegas, described it as a “marathon,” saying the hospital’s “supply levels remain strong” but that they are preparing for “any future influx of patients.”

Many of the health care workers interviewed for this article acknowledge the limited supplies globally, and some say they believe their hospitals are doing the best they can in a trying time. But many still fault their hospitals for not doing more long term to prepare for a crisis of this scale and for not taking decisive action as the virus was spreading in China.

“It’s kind of hard. This is happening nationwide,” a critical care nurse who works at Renown Regional Medical Center in Reno said. “This isn’t just a Renown issue. Nationwide, nurses and providers are being forced into these situations where they have to choose if they’re going to take care of this patient or if they’re going to walk away. I think that Renown on the whole is probably on the better end of what’s happening nationwide. But the better end of wrong doesn’t make it right.”

‘We are asked to reuse’

Like the rest of the nation, Nevada has struggled to acquire additional personal protective equipment for its health care workers, from the much coveted N95 masks that provide some of the better protection against the novel coronavirus to simple earloop face masks. After the federal government only fulfilled 25 percent of Nevada’s first request, the state had been waiting to finally hear some good news.

It came on Thursday. The Federal Emergency Management Agency and the federal Department of Health and Human Services promised to send Nevada 29,600 gowns, 184,200 gloves, 1,750 coveralls, 60,450 N95 masks, 143,500 surgical masks and 31,200 face shields, and a private-sector task force announced it has secured an additional 241,000 N95 or equivalent masks, 1 million pairs of gloves, 2,000 surgical gowns, 700,000 surgical masks and 100 gallons of hand sanitizer.

The hope is that those supplies will trickle down to health care providers on the front lines of the pandemic. For now, workers say they are under-resourced and have been asked to set aside what they have been taught are the best infectious disease control practices amid the ongoing PPE shortage.

Tima Prieto, an imaging technologist in the CT department at the St. Rose Dominican Hospital’s Siena Campus in Henderson, said she kept one N95 mask for several days and donned it whenever she had a suspected COVID patient. She said the hospital had only been providing N95 masks for confirmed positive cases and surgical masks for so-called “rule out” cases.

“I was told to use a surgical mask, and I wasn’t comfortable with that so I put the N95 under,” Prieto said. “As long as I feel like I’m protecting myself, I’m okay to go to work, I’m okay to do my job.”

But Prieto, who has been in the medical field for 25 years, said it’s been a difficult adjustment as health care workers are asked to abandon the practices they have long used.

“As far as PPE, we were always taught they had a one time use and then to discard them. Now, because of rationing and the hospital being afraid of not having enough, we are asked to reuse,” Prieto said. “I understand why they’re doing it, but it still puts my life and the life of the patient and my family’s lives in jeopardy because we were never taught how to put back on a gown or a mask that is potentially contaminated.”

Prieto said that at this point she feels comfortable that she will be able to get more personal protective equipment if she needs it and believes her hospital, owned by Dignity Health, is just being diligent about managing its resources.

“I truly believe that Dignity is trying to save what they have. It’s just making it very difficult to get it,” Prieto said. “Everyone is very cautious about keeping it for their own crew or their department, which is understandable, but it makes things frustrating.”

And Prieto isn’t alone. A survey of members of SEIU Local 1107, which represents 9,000 nurses and health care workers at 11 hospital facilities across the state, found that nearly 72 percent of respondents said they didn’t feel like they had enough PPE, chemicals and other cleaning materials at their work site. Another 66 percent said they didn’t feel they had received sufficient information from their employer to continue to work safely.

“I understand that the hospitals say there is a shortage of PPE to buy ... but if you’re asking for a simple mask, a surgical mask, an N95 mask, there are manufacturers out there,” said Grace Vergara-Mactal, the union’s executive director. “We found one manufacturer that is going to produce a million 3M N95 masks in three or five days. It’s a matter of are they willing to pay and buy it?”

Four of the five hospitals or hospital systems that provided statements to the Independent stressed their commitment to their workers and patients, some outlining specific policies they have adopted. Valley Health System did not respond to a request for comment on Thursday.

HCA, which runs four hospitals in Las Vegas, recently adopted a universal masking policy for all employees, has appointed a PPE steward to oversee deployment of gear and created PPE distribution centers at each hospital.

“Our top priority is protecting our patients, clinicians, nurses, and colleagues so we can best serve our communities through the duration of the health emergency,” HCA spokesman Dan McFadden said in an email.

At HCA hospitals, “level 1 universal masks" are now to be worn by all staff; higher “level 3” masks are used for patient care with PPE, including by staff caring for suspected COVID or COVID positive patients; and so-called PAPR hoods, N95 respirators with eye protection or other similar equipment are used during certain procedures that could aerosolize the coronavirus, McFadden said, adding that the hospitals' PPE supply “remains intact.”

UMC spokesman Scott Kerbs said in an email that the hospital continues to follow Centers for Disease Control and Prevention guidelines and has “developed comprehensive guidelines for the extended use of specific personal protective equipment” based on them.

“Our team remains committed to maintaining an ample quantity of the supplies needed to provide the state’s highest level of care,” Kerbs said.

Dignity Health, which runs three full-service St. Rose Dominican hospitals in Southern Nevada, said in a statement that it continues to work with suppliers around the world to obtain additional supplies, to ensure employees are trained on PPE protocols, and to make sure facility leadership are available to respond to staff.

“Dignity Health-St. Rose Dominican has been working non-stop to ensure that all team members who need personal protective equipment have the right equipment, at the right time and are using it correctly,” the company said.

Renown Regional Medical Center in Reno said in a statement that employees providing care to patients with an “active respiratory illness” wear a mask during “all encounters” and that they also continue to follow the CDC’s guidelines.

Changing guidelines, changing rules

Several hospital workers, however, voiced frustration with the CDC’s changing guidelines on masks, which include a suggestion to use bandanas as a last resort, and to treat coronavirus as a droplet-transmitted illness instead of an airborne one.

“Going from the most protective guidelines to, ‘Okay, you can wear a bandana,” said one labor and delivery nurse in Las Vegas. “We couldn’t believe that. That was a joke to us. We feel — most of my coworkers and I — that the CDC is just changing guidelines to help the hospitals but not protect the workers.”

And health care workers say that hospitals’ mask policies have been quickly changing, which has made it difficult to stay on top of what the current protocol is. Plus, it varies greatly from hospital to hospital.

“As far as personal protective gear, I will say this. It’s very simple. It is widely fluctuant,” said Dean Polce, an anesthesiologist and partner with U.S. Anesthesia Partners. “Valley Health, HCA, and the Roses, and then UMC, and even within HCA, for example, it’s very different. We’re not sure why.”

Polce said that the PPE shortages have not yet affected his anesthesia group, though.

“If there’s not gear, whatever we’re being asked to do will not be done,” Polce said. “Really nobody is cutting corners on that. ‘Hey, go intubate this patient, but we don’t have a mask and gloves.’”

In general, health care workers with direct contact with confirmed COVID patients appear to have better access to personal protective equipment than their colleagues working with the general population. Still, that means at best one N95 mask per day, when under normal circumstances providers don a fresh mask each time they enter the patient’s room. Several health care workers voiced concerns in interviews about the possible cross-contamination associated with wearing one mask for an entire day.

“Just walking through the hallway with a mask you’ve had on with a patient who is COVID positive, who are you transferring it to?” said one respiratory therapist who works at MountainView Hospital in northwest Las Vegas.

“We understand that the hospital and the country is having a shortage of PPE. So we’re not blind to that fact or deaf to that fact,” the therapist continued. “What management has said to us when they get to the limits of their PPE, they say you signed up for this, this is the possibility of joining this profession. Be that as it may, this is callous coming from the people who are supposed to provide protection.”

A handful of health care workers, who wear so-called PAPR or CAPR hoods at their hospitals to work with COVID patients, expressed concerns about whether those devices are being properly sanitized between uses.

“If you use that mask, you’re really relying on the last person to have thoroughly cleaned it,” a health care worker at Sunrise Hospital said.

Others, particularly those not working directly with known COVID patients, have had even more difficulty accessing masks that were once readily available to them, particularly during flu season. The problem is, they say, not only do they need the masks to treat other non-COVID illnesses, but the virus is also becoming so widespread that it’s hard to know whether the patient you’re treating for something entirely different has a mild or undetectable case of the virus.

Several health care workers described personal protective equipment as being under “lock and key” at their hospital.

“Sometimes [pregnant women] will not say they have symptoms when they come to the front of the hospital, where they’re getting their temperature checked and some questions,” the labor and delivery nurse in Las Vegas said. “Then they’ll come up and when we question them a little bit more, we find out they may be presumptive.”

And for those who have had a harder time accessing masks, policies on whether they can bring masks from home vary widely. Some health care workers described being allowed to bring masks from home so long as they were only worn in the hallways and not in patient rooms. Others said that they were technically allowed to, but the equipment would need to undergo a lengthy hospital review first. Still more said they were told not to bring any supplies from home.

“We’ve had charge nurses that have said to us you should’ve brought one from home. When we did bring one from home we were reprimanded by our manager for having a mask on in the hallway and were told if we didn’t like it, there’s the door,” said one Southern Nevada nurse who works with COVID patients. “It’s just frustrating that you have to argue to be able to protect yourself.”

One doctor with patients in several Las Vegas hospitals reported being written up by hospital administration for traveling around with an N95 mask and wearing it while visiting “rule out” COVID cases. The doctor goes so far as to bring the mask home and sanitize it in the oven every night for 30 minutes.

“I’ve been told, ‘Well, until your patient has been ruled out for COVID, you’re not to get an N95,’” the doctor said. “We’re trying to do the right thing.”

HCA, in its statement, said that wearing homemade masks is up to the discretion of hospital employees, though those required to wear PPE while caring for patients in isolation must wear hospital issued PPE. The other hospitals did not address their policies on masks or other equipment brought from home.

Staci McHale, an OB-GYN who runs her own clinic in Las Vegas, has also taken matters into her own hands. When she wasn’t able to order masks through her medical supplier, she acquired filter fabric and has been sewing cloth masks as covers for her staff’s N95 masks, which she acquired by donation, to preserve them as long as possible.

“Offices that tried to order PPE in an effort to protect their office staff or their patients weren’t able to procure it because it was being canceled by their medical supplier,” said McHale, who is also treasurer of the Clark County Medical Society’s board. “I ordered seven boxes of masks. All seven were canceled. I’ve had canceled hand sanitizer, thermometers, isolation gowns, eye protection, face shields, N95 and regular earloop face masks.”

A handful of health care workers shared stories about the disparities in personal protective equipment between hospital staff. In one case, a doctor told another health care worker to stay out of a patient’s room during a procedure because the worker had been given less protective gear than the doctor had. Multiple health care workers also reported sharing some of their unit’s supply of personal protective equipment with hospital cleaning staff.

Workers also voiced concerns that hospitals have not been flexible with work assignments for people who are immunocompromised, elderly or pregnant and therefore more vulnerable to the virus.

“I have one hospital where one of our nurses, she is a cancer survivor and she was assigned to a COVID unit, and she said, ‘Wait, no, I can’t be in this unit. I’m still doing my chemo once in awhile,’ and they said. ‘Well you have to be in this unit,’ and there’s no explanation” Vergara-Mactal said. “So now I have to call HR and say, ‘She’s high risk, she’s a cancer patient, she cannot be in a COVID unit. How many thousands of nurses do you have?’”

Workers at University Medical Center are also reporting being under even greater stress after Clark County Manager Yolanda King announced this week that the county was suspending collective bargaining agreements for more than 9,000 county workers, including those at the county-run UMC, represented by SEIU Local 1107. A UMC spokesman said in an email Thursday that the emergency measure allows the hospital to “quickly address urgent and vital operational needs” — including implementing telework and delayed work — without having to meet with union leadership first.

“UMC’s entire leadership team has great respect for SEIU’s members and leaders. SEIU leadership has been and will continue to be great partners with our hospital,” UMC spokesman Kerbs said. “The temporary suspension of our contract with SEIU 1107 simply allows for us to quickly address emerging issues in the urgent manner that is required during this truly unprecedented time.”

But for hospital workers, the move is creating additional uncertainty in an already uncertain time.

“UMC is our hospital, and we have some ownership with what goes on there and we were very accommodating to anything that the administration asked of us regarding this pandemic and our management of the pandemic at UMC,” said Michael Collins, a charge nurse at UMC and a union steward. “It’s just outrageous what has occurred. Now, in this period of economic uncertainty and all of the stressors going on in people’s lives right now to have the additional safety net of our union pulled away from us is just egregious.”

The union has threatened to take legal action if the county doesn’t reverse its decision.

“It’s in all of our interest to try and deal with the situation we find ourselves in and move forward,” Michael Urban, an attorney for the union, said. “But legal action is going to be taken if we have to. We have to protect our workers.”

Keeping coronavirus at work

Thoughts of coronavirus don’t end for health care workers when they clock out. That’s when the sanitizing rituals before coming home begin. While some health care workers reported changing little about their routines, others described in great detail the steps they have started taking to make sure they aren’t bringing the virus home to their families.

At the most extreme, health care workers strip down while still at the hospital, put their dirty scrubs in a plastic bag, and wash all exposed skin as best as they can before changing into a clean pair of clothes and shoes. Before they get in their car, they might take off that pair of new shoes and sanitize them. When they get home, they’ll strip down again — in the garage, if they have one — immediately place that pair of clothes in the washing machine and hop in a hot shower.

Their spouses know to keep the kids away so they have a clear path to the bathroom and aren’t accidentally ambushed by a hug. In some cases, they have learned to sneak quickly to the shower so no one even knows they’re home until they’re clean.

It’s all in an effort to keep their family members healthy.

“All of those steps, and I still feel like if my family gets sick it’ll be because of me,” a nurse who works at Sunrise Hospital said.

But all of those steps are all for naught if health care workers contract the virus at work. Hospitals contacted by the Independent have not answered questions about whether any of their employees have tested positive for the virus and if so, how many. UMC cited HIPAA, the health care privacy law, while HCA generally cited patient and employee privacy.

HCA, however, said that workers experiencing symptoms that are not acute are “asked to quarantine at home and are monitored with twice daily check-ins by their supervisor,” and that hospitals are only testing acute inpatients or emergent patients.

However, multiple health care workers told the Independent anecdotally that coworkers have tested positive, including at UMC. Brian Shepherd, chief of staff for SEIU Local 1107, confirmed Thursday night that two UMC nurses have tested positive for the virus.

And the Southern Nevada VA Healthcare System announced Wednesday that 11 employees have tested positive for the virus.

Separately, Vergara-Mactal said one of the union’s members had a cough and a difficult time breathing after being exposed to the virus but was unable to get tested by the hospital where she worked. She said that the worker ended up going to UNLV to get tested.

“She’s still not working. She asked for the test, and they didn’t give it to her,” Vergara-Mactal said. “She had to go out to seek testing outside the hospital, which I think is wrong.”

Yet another nurse who works in a hospital in Las Vegas was exposed to the virus but was told to keep coming to work and wear a mask.

“Wear a mask, come to work, and just monitor your temperature. That’s it. There’s very little direction,” the nurse said. “I think we are all just waiting to get sick. We know we’re probably positive and we are just not showing symptoms.”

Health care workers are also keeping their distance from family members who don’t live in their immediate household, including those who have elderly parents or grown children. One even tearfully described sharing end-of-life arrangements with family.

“I just wanted [them] to know that, you know, I had made certain arrangements,” the worker said.

What’s yet to come

Nevada is not yet in a dire situation. But health care workers voiced serious concerns in interviews that Nevadans still aren’t taking the governor’s stay at home orders seriously enough. One expressed frustration about people bringing along their entire families on grocery store runs. Another criticized the Tesla Gigafactory for not shutting down its operations. A third was frustrated to keep hearing people say that COVID-19 is like the flu.

“The one thing that I find kind of depressing is that I don’t think the community understands that if you end up in the hospital or a family member ends up in the hospital, you’re not going to be able to spend that time with them,” said Prieto, the imaging technologist. “You’re not going to be able to encourage them to get better. You’re not going to be able to say goodbye to them. They need to stay home and stay safe.”

The reality for COVID patients who wind up in the hospital is grim. Health care workers who work with the most serious cases describe patients who are sedated, on paralytics and intubated. The good news, they say, is that the patients have no idea what’s happening to them and they shouldn’t remember it. It’s much harder for their family members who can’t come to the hospital to see them.

“A man died alone because no one could come in,” one health care worker at a Las Vegas hospital said. “If it’s end of life and you’re critical and you’re a big risk, you can’t come in. If you have two elderly people and they have a lot of comorbidities, they don’t let a loved one come in.”

The worker reported having younger colleagues who are already talking about getting out of the medical profession because of the stress of the pandemic. Others who care for seriously ill patients on a daily basis say they’re used to crisis, and that makes it a little bit easier to cope with that feeling of being on the precipice of something much worse.

“That’s really a familiar feeling, that crisis type feeling,” the critical care nurse at Renown said. “You’ve got a patient coding on your unit. You’re it. You’re the critical care nurse. You are going to deal with that patient that’s coding to get that patient back. You and the doctors.”

It’s not a war zone yet, but health care workers say they’re hoping for additional support from their hospitals before it gets there.

“It feels like the calm before the storm,” a Sunrise nurse said. “We know it’s coming and we don’t know what to do to make it any better.”

Updated 4/3/20 at 9:08 a.m. to correct details of HCA's mask policy, which were incorrectly provided by the company.