As Alabama hospitals and public health officials frantically try to get in front of the coronavirus outbreak, a shortage of testing supplies, protective gear and lifesaving equipment threaten to push them even further behind.

“If you only try to respond to the epidemic based on the (number of confirmed cases) today, you will absolutely fail to be prepared two to three weeks from now,” said Don Williamson, president and CEO of the Alabama Hospital Association.

“Based on Seattle, not to mention Italy, we have a tidal wave coming, something we cannot imagine.”

Alabama’s number of confirmed cases increased 40% in the past 24 hours, but only a handful of testing sites are open statewide, due to a scarcity of testing swabs and supplies. And hospitals are staring down a potentially deadly scarcity of ventilators.

Three shortages threaten Alabama’s ability to control the coronavirus epidemic:

1. Testing supplies

Alabama’s relatively small but growing number of confirmed cases masks a much bigger problem, Williamson said.

“It’s a crisis,” said Williamson. “We can’t really get ahead of this epidemic if we can’t identify who’s infected.”

The number is “misleading,” he said, because it’s been impossible to capture an accurate number of people who are infected when there aren’t enough tests.

The shortage is a problem statewide, from specimen-collecting swabs to the liquid used to transport them to the lab to the chemicals that help determine if a specimen tests positive or not.

A drive-thru testing site in Birmingham hit its testing capacity within a couple of hours each day this week despite ramping up the number of tests available by the hundreds. Hospitals across the state are limiting testing to the sickest patients.

An epidemiologist with the Mobile County Health Department told AL.com that testing materials in her area are in short supply, being diverted by federal authorities to areas that need them most.

And Huntsville Hospital had to delay the opening of its drive-thru clinic until it was confident it had enough tests to meet demand. The clinic is scheduled to open today.

State Health Officer Scott Harris said he hoped the state could open another five to 10 testing sites by the end of the week, but difficulty getting “supplies like personal protective equipment, swabs for testing and the like” has been the main barrier.

Read more: Testing sites can’t meet demand in Alabama as kits remain scarce

2. Protective gear

On Wednesday, Madison County Commission Chairman Dale Strong expressed frustration with the difficulty of getting and keeping a supply of personal protective equipment for local healthcare workers, including masks, gowns and gloves.

“The healthcare workers at the hospitals, the nursing homes, fire departments, paramedics, there’s no way they should be having to deal with what they’re having to deal with, watching (supply levels) every day,” he said. “They should be focused on the healthcare of the people in our community.”

“We have an 18-wheeler on standby right now,” he said. “We’re willing to go anywhere to get this equipment.”

The national shortage of protective equipment has grown increasingly dire in the past week. New guidelines from the CDC recommend healthcare workers use bandanas or scarves as a “last resort” when masks aren’t available. Vice-President Mike Pence called for construction companies to donate protective N-95 masks to hospitals and has said he’s asked companies like 3M to increase production.

Keshee Dozier-Smith is the CEO of Rural Health Medical Program Inc., a group of federally qualified health centers in Alabama’s Black Belt that serve many indigent and uninsured patients. She said while her clinics have a few coronavirus test kits, they’re struggling to get the protective gear they need in order to safely test patients.

“I do not have N-95 masks, and my (doctors and nurses) are saying until we have those masks they don’t feel comfortable” testing for coronavirus, she said.

If one or two providers were exposed to COVID-19, they’d have to be isolated for at least 14 days. In a rural area with limited medical resources already, the loss of one or two doctors would be devastating.

“We can’t stop access to primary and preventative care,” Dozier-Smith said. “That has to be the foremost thing we do because we have chronically ill patients who need us.”

Dr. Karen Landers with the Alabama Department of Public Health said she’s heard concerns from hospital officials about low stock of personal protection equipment, and N95 masks in particular. She said the state health department and the Center for Emergency Preparedness have been working to order additional supplies from the Strategic National Stockpile, a federally-owned supply of medical supplies that can be used in public health emergencies.

She said the state had placed supply orders late Tuesday and hopes to see more supplies flowing into Alabama within days.

3. Ventilators

As confirmed cases continue to rise, a new question looms about whether Alabama hospitals have enough equipment to handle a surge of critically ill patients.

“We’ve absolutely been contacted by hospitals that are saying they’re stressed in their capacity,” said Harris at a press conference Thursday afternoon.

A lack of ventilators, which are machines that help patients breathe, has figured prominently in the healthcare crisis unfolding in countries like Italy and even in areas of the United States like Seattle. And while European countries like Germany and the United Kingdom have rushed to stock up on ventilators, the United States has not.

Williamson said he’s heard from colleagues at Seattle hospitals who say they’re running out of ventilators and having to make difficult decisions about who gets a ventilator and who does not.

Alabama currently has 1,344 ventilators, according to the Alabama Hospital Association. On average, about 546 of those are in use on any given day. That leaves about 800 ventilators available for a surge in patients with severe respiratory issues like those seen in COVID-19 patients.

Williamson said those spare 800 ventilators give Alabama hospitals the ability to handle a slight surge from COVID-19. And, he said, there’s a plan in place to move ventilators between hospitals to where they’re most needed.

In the coming days, he said, he would not be surprised to see instances where specific areas of the state need extra ventilators.

“My big concern is as the tsunami approaches us in the coming weeks, that we are going to be challenged to have enough ventilators for the state at large,” he said at Thursday’s press conference.

He said social distancing is one of the most effective ways to prevent the number of COVID-19 cases spiking as they have in Washington state and in countries like Italy.

But if Alabamians don’t take social distancing seriously enough, he said, “we will have a huge spike of disease over a potentially short period of time and our healthcare system will be overwhelmed.

“We won’t have enough doctors, beds, ventilators, PPE and it will be absolutely catastrophic.”

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