As the deadly pandemic zeros in on Oregon, health care workers are stepping up daily to serve on the frontlines. But some fear they’re going to war with a gun that’s only half-loaded. Portland area nurses and health care workers say the giant health systems and hospitals they work for lack sufficient beds, their infectious disease controls were casual, and perhaps worst, they are already running low on personal protective gear.

Clearly, no one could have anticipated a disaster of this scale four months ago. Back in those days, lean management and reliance on lower-priced Chinese goods seemed like a sound strategy. The Oregonian/OregonLive has interviewed more than a dozen health care workers, their spouses, union leaders and hospital executives to hear their concerns and gauge the industry’s readiness for an expected surge of coronavirus patients. Most would only share their stories anonymously, saying their employers have threatened to fire or sanction anyone who talks to the press.

“It’s a total insult,” said Lynda Pond, president of the Oregon Nurses Association. “None of us became nurses thinking we’d have to dig up our own equipment.”

Last Wednesday, Gov. Kate Brown conceded that hospitals may have just days’ worth of safety equipment in their inventories. She ordered all hospitals, health care providers, veterinarians and dentists to cancel any non-emergency procedures to preserve surgical masks, gloves and gowns for front line workers treating COVID-19 patients. State officials and hospital leaders are also scrambling to locate available hospital beds across Oregon and popping up medical triage tents in parking lots and county fairgrounds.

Michael Cox, spokesman for the Oregon Association of Hospitals and Health Systems, said that protecting medical staff is of “utmost importance” and that the group is following Centers for Disease Control & Prevention and the Oregon Health Authority guidelines.

“We are urging aggressive government action to preserve personal protective equipment for health care workers, provide flexibility to bring staffing where we need it most, and allow us to quickly increase the number of available hospital beds,” Cox said.

Bruce Goldberg, former head of the Oregon Health Authority and now a professor at OHSU and Portland State University School of Public Health, said the last two months have illustrated both the strengths and weaknesses of Oregon’s health care industry.

“The dedication of our frontline health care workers is apparent and they are a precious resource for all of us,” he said. But the outbreak has also shown “our nation’s lack of an organized and coordinated​ ​health care system able to respond to emergencies such as this (and) our lack of an adequately resourced and prepared public health and emergency preparedness system able to respond to a pandemic, and likely to many other widespread emergencies.”

The sentiment is shared by Oregon’s doctors, nurses and other medical staff who are balancing their dedication to serving patients with concerns about their own safety. Some serve patients and their co-workers. A Portland nurse is spending her spare time at her sewing machine making surgical masks, which are in short supply at her clinic.

She is furious with her employer for putting its workers at risk. But there’s no question about going to work.

“This is the job I signed up for,” she said through tears. “I have a responsibility. I want people to be safe. The nation is under attack.”

8 South

This 8th-floor ward at Providence Portland Hospital is not somewhere you want to be.

It used to be a neurological unit that treated stroke victims, patients recovering from brain and spine surgeries and those with seizure disorders. One Portland nurse is among 45 who work in the ward, most of them stroke specialists.. In recent weeks, 8 South has been turned upside down. The neurological patients were wheeled to other parts of the Northeast Portland hospital and the ward was repurposed as one of Providence’s COVID-19 units. Eight days ago, the patients started arriving, all of them with compromised respiratory symptoms consistent with COVID-19.

“My biggest worry was always hurting myself trying to lift patients that are getting older and more obese,” the nurse said, who also was afraid to give her name for fear of retribution.

“In the back of my mind I knew that I would be exposing myself to dangerous diseases,” she said. “But I didn’t anticipate something like the coronavirus, I didn’t anticipate a national lockdown and a great recession.”

She and her co-workers are becoming infectious disease specialists on the fly. They’re navigating “hot zones” and “warm zones;” comparing the merits of N-95 respirators to surgical masks; mastering donning and doffing protocols. They have devoured the most arcane details of COVID-19, including the ongoing debate over how the virus is transmitted -- does it go airborne or does it spread by droplet and direct contract? The answer to that question will determine what kind of protective gear the nurses will wear when in contact with COVID-19 patients.

The World Health Organization had determined that the virus wasn’t going airborne -- the most deadly kind of transmission. Rather, she said nurses were told, the novel coronavirus can be transmitted only by direct contact (touching a virus-contaminated surface) or by droplet (the mucous and other liquids humans sneeze or cough into the air).

There is some evidence that the virus does, under some circumstances, go airborne. And the 8 South nurses worry that it will happen in the middle of their ward. COVID-19 generally attacks patients’ lungs. That means nurses will almost certainly have to take aggressive action to help patients breath such as intubation – inserting tubes down patients’ tracheas to provide oxygen. Health care workers say these techniques can effectively “aerosolize” the virus and send it airborne.

“That’s a high-risk procedure particularly for the nurses who are standing over the patient,” said Marcus Shabacker, CEO of ECRI, a health care consulting firm. “Those people need the highest level of protection.” Providence says it is carefully following guidelines established by the Oregon Health Authority. “It is our responsibility to protect our front-line caregivers,” said spokesman Gary Walker. “We are being innovative and creative in finding ways to do that.”

Making do

The debate over respirators, N-95 and traditional surgical masks is, to a degree, academic. Most local hospitals don’t have enough of any of them. That’s forcing hospitals to improvise. Providence, a multi-billion dollar operation, put out an emergency call for volunteers to make new facemasks from scratch after its supply of masks fell to just two weeks..

Wendall Potter, a former health insurance executive at Humana and Cigna, is now a vocal critic of the industry. Hospitals moved to a just-in-in-time inventory system in hopes improving their financial performance. Frontline workers are now paying the price, he claims.

“It’s just part of the big health systems’ obsession with the bottom line,” Potter said. “Staffing is nowhere it should be, the hospitals are full, and basic equipment needed to keep healthcare workers safe is just not there.”

To some Portland area workers’ dismay, Providence and other area hospitals are now moving to strategies to lengthen the life of face masks and other protective equipment. At the Portland VA Medical Center in Southwest Portland, nurses get one facial shield a day – shields that are supposed to be disposed after one patient. Instead, nurses at the VA say they are expected to clean their own masks after each patient and then reuse them.

A spokesperson for the Portland VA could not provide a comment before publication. At the PeaceHealth Southwest Medical Center in Vancouver, nurses say they are told they will be assigned one powered air purifying respirator, which they are to use until further notice.

“They want us to use them indefinitely -- the PAPR hoods, the N-95s,” one Vancouver-area nurse told The Oregonian/OregonLive, asking that her name not be printed to protect her job. “I just took PAPR training and this is not even close to best practices.”

With the entire country facing a similar shortage, the U.S. Centers for Disease Control & Prevention has issued guidance that in an emergency “wearing the same face mask for repeated close contact encounters with several different patients” is an acceptable strategy. The CDC concedes that some of its emergency guidance is “​not commensurate with U.S. standards of care.”

PeaceHealth confirmed it “is currently reusing face shields, protective eyewear and respirator hoods after following strict disinfectant protocols with hospital-grade disinfectant. Jeremy Rush, a PeaceHealth spokesman, said the practice “is consistent with the CDC’s PPE conservation guidelines and is being implemented by hospitals across the nation.”

Hospitals are in a serious bind, said Shabacker, the health care consultant. He said it’s understandable that hospitals would try to preserve needed safety equipment for when they absolutely need it.

“On the other hand,” he said, “it is vital that as much as possible, hospitals adhere to normal practices and procedures that are in place to protect workers.”

Old habits

While some hospitals have begun taking steps to separate infected patients with quarantine units and temporary tents, local health care workers say a casual approach at some facilities remains. They say some urgent care clinics and emergency rooms struggle to separate potential virus carriers from the rest of the crowd.

A nurse at a Kaiser Permanente clinic in Vancouver said a greeter without a surgical mask welcomes new arrivals and refers them to the front desk, where an unmasked administrator checks them in, often handling the patients’ credit cards or insurance cards. The potential COVID-19 sufferer then generally sits unmasked in the lobby with dozens of other patients, who are also unmasked.

Kaiser officials say that account is inaccurate. Anyone showing respiratory symptoms is masked, they said.

Some facilities have begun taking the steps to separate potential COVID-19 patients. Providence says it now masks incoming patients with respiratory symptoms. Rachel Gumpert, of the Oregon

Nurses Association, said she recently noticed workers had put up a large partition in the middle of an Oregon Health & Science University emergency department. Those with respiratory symptoms were kept on one side.

But the partition didn’t reach the ceiling, Gumpert said.

Dr. Matthias Merkel, OHSU’s chief medical capacity officer and vice chair of critical care, said the hospital has instituted sweeping changes throughout the facility. Elective surgeries have been postponed and visitors to the ER are quickly screened, and if need be, masked.

“We needed to make these radical changes to protect patients and our co-workers, he said.

“Cry Havoc...”

One doctor from Providence Health Systems said he knows he’s living history – and he’s eager to go into battle. But he’s also plagued by doubts. He shares his peers' concerns about the lack of equipment. He’s concerned about forecasts that COVID-19 patients could vastly outnumber the total hospital beds available at Portland hospitals.

“I just want to rush into it, that’s who I am,” said the doctor, who also asked for anonymity for fear of employment repercussions. “But I don’t know how we do this. This is an epidemic and we have no vaccine. I’m already seeing healthcare workers who think they have it.”

More than anything, he’s afraid he could bring the virus into his home. For weeks, he’s been living in his downstairs guest room while his spouse and kids stay upstairs.

“I love my husband but I don’t want him in the house,” his wife said. “I don’t know how safe we are.”

The little bundle of dirty scrubs her husband brings home from work each day adds to her anxiety. Like PeaceHealth and others, OHSU require some of their doctors and nurses to take the scrubs they’ve worn all day home for laundering.

Before COVID-19, it seemed more of an annoyance. Now it seems downright dangerous. Despite all the questions about the hospital’s response to the coronavirus crisis, the Providence doctor he said he will answer the call without hesitation.

“I don’t know what those answers are,” he said. “I’m just a frontline soldier.”

-- Jeff Manning

jmanning@oregonian.com

971-263-5164

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