As the PPE (Personal Protective Equipment) shortage crisis strikes the country, New York remains the hardest hit. To convey the scale, Mayor Bill De Blasio’s team wrote us last week,

“To give a sense of the sheer magnitude, The City of New York, our Department of Health, Emergency Management, Health and Hospitals – all agencies are working together. 20 trucks are on the road delivering to our hospitals 1 million surgical masks, 200,000 N95 masks, 50,000 face shields, 40,000 isolation gowns, 10,000 boxes of gloves. Tomorrow, trucks will be delivering 800,000 more N95s and 2 million more surgical masks, and this is going to be constant from this point on. We’ve had a really amazing outpouring of offers from New Yorkers and people all over the country offering to get us supplies who have sources of their own companies they can draw on. We need it all is the answer.”

“This is going to be constant from this point on” and “We need it all” might be the starkest language we heard in interviews with and statements from several Governors’ and Mayors’ communications teams, but the general “it’s not enough” sentiment aligned.

The conundrum we’re seeing our health care professionals face mirrors the directive parents are given on planes when oxygen masks are released. The parent applies their own mask first to ensure they’ll be able to affix the mask to their child. The same principle is playing out in our hospitals: if our doctors and nurses can’t use PPE, they carry the risk of becoming unable to care for the sick. What then, is the plan if there are no longer enough health care professionals to fully staff hospitals?

This disturbing trend is happening at such an unrelenting clip that headlines like, “Nurses Die, Doctors Fall Sick and Panic Rises on Virus Front Lines” are no longer outliers. It’s why nurses throughout the country are forced to wear either patient gowns, or in one New York hospital, garbage bags. The phrase “American carnage” has now taken on a very different light.

New York Governor Andrew Cuomo and NYC Mayor Bill de Blasio along with Dr. Howard Zucker brief on COVID-19.

Last week, New York Governor Andrew Cuomo distilled the PPE crisis as a “bizarre situation”. In what sounded similar to a Hunger Games battle, he compared it to “like being on eBay with 50 other states bidding on a ventilator”. The eBay metaphor amplifies as states then bid against FEMA. Stacked on that bidding are private distributors and other countries’ purchasers, all without federal oversight of price gouging.

“It’s not that we’re learning things here,” Cuomo said. “What sense does this make?”, he asked. The next question was, “Did you really have to learn that 50 states shouldn’t compete against 50 states, and then FEMA shouldn’t come in and compete with 50 states? It’s not like you had to go to the Harvard Kennedy school to learn this.”

The Federal Response

The federal government’s response is playing out in two key ways: lack of national coordination (all 50 states following a single stay-home order) alongside an inability to coordinate delivery of critical medical equipment to hospitals. Rather than create a unified structure of PPE oversight for every state, last week the administration offered a novel interpretation of the Strategic National Stockpile (SNS). Jared Kushner claimed, “the notion of the federal stockpile was it’s supposed to be our stockpile, it’s not supposed to be states’ stockpiles that they then use.” That new theory negated the “National” part and didn’t clarify who “our” stockpile was for, if not the states. That evening, the website of the Department of Health and Human Services, which maintains the stockpile, revised its mission statement, removing “ensuring” from one section and adding “to supplement’ to another.

Two Washington Post articles addressed the scale of what’s to come. The first confirmed the SNS is near depleted, stating “The government’s emergency stockpile of respirator masks, gloves and other medical supplies is running low and nearly exhausted due to coronavirus, leaving the Trump administration and the states to compete for PPE in a freewheeling global marketplace rife with profiteering and price-gouging, according to DHS officials involved in the frantic acquisition effort.”

The second focused on mask scarcity, “In a normal year, the U.S. health care system uses about 25 million medical N95s, according to Premier, an organization that helps hospitals purchase supplies. Many of the masks are disposable and meant to be used once. HHS has estimated that the U.S. could need as many as 3.5 billion N95 masks during a pandemic.”

It’s unclear how we get from 25 million N95s to 3.5 billion N95s without the Defense Production Act (DPA).

The DPA: Invoked, Still Not Fully Activated

Though the President has “invoked” the DPA, he has only used it sparingly. Despite daily, overwhelming requests from Congressmen, Senators, health care workers, activists and citizens to fully activate it, he is primarily letting companies figure it out and have the states battle it out. It remains unclear how much worse this must get before the very thing created to put Americans to work, unite companies to produce critical medical equipment and save lives is deemed urgent.

On January 21, Washington became the first state with a confirmed case of coronavirus. In early April, Mike Faulk, deputy communications director for Governor Jay Inslee, wrote us, “We remain worried about having to bid against other governments for supplies. The Governor has emphatically, repeatedly told the president directly we need to utilize the DPA to address the medical supply crisis. The president has only done that for ventilators; he needs to do it for everything states are saying in unison that they need.”

The President has invoked the Defense Production Act, but is only using it sparingly.

When asked about San Francisco Mayor London Breed’s thoughts on the DPA, her communications director, Jeff Cretan, told us, “She thinks it should be invoked.”

De Blasio’s team also re-iterated their push for the DPA, “as you’ve seen from letters we’ve sent, we’ve been urging our federal partners to use the DPA”.

For weeks, Cuomo has similarly urged the administration to fully mobilize the DPA. While New York has seen more assistance recently, each day confirms it’s not enough to address the surge. Working with Cuomo, Colin Brennan, NYS DHSES director of communications addressed their workaround, “amid a shortage of gloves, masks and gowns, the Governor has asked all PPE product providers to sell to the state any products not essential or not being used. The Governor is also encouraging any company with the proper equipment or personnel to begin manufacturing PPE if possible. The state is willing to provide funding to any company to obtain the proper equipment and personnel.”

Joint Information Centers (JIC) in Washington and San Francisco

Washington’s Joint Information Center (JIC) wrote us, “We continue to receive PPE from our federal SNS, donations, and commercial purchases. However, due to global demand we still are not able to receive enough PPE to meet 100% of the needs of our local and state partners. We are working diligently with our statewide distribution process partners and using the best medical data available to make informed decision on where to distribute this PPE.”

Their statement continued, “Resource shortages are concerning, and we’re doing all we can to help get the right resources to the right places. We are in a global health pandemic – there are resource shortages we simply can’t fill faster than the medical supply chain can replenish. Nationally, distributors are working to fill orders, but many are back-ordered. This indicates the supply chain for PPE is not able to keep up with demand. Our federal partners continue to address the national shortage by working with supply chain vendors and manufacturers to expand production.”

Through early, aggressive steps to mitigate transmission in San Francisco, California’s Governor Gavin Newsom and Mayor Breed bought invaluable time, even if only a few weeks. San Francisco’s JIC wrote us, “By analyzing the needs called for in New York, where the hospital system is undergoing an unprecedented surge in COVID-19 patients, San Francisco estimates it could need as many as 1,500 more ventilators and 5,000 more hospital beds to meet a similar surge.” While they outlined many ways they’re readying, they’re realistic about the weeks ahead. “The Department of Public Health and San Francisco’s hospitals, acting together as part of the Hospital Council of Northern and Central California, are preparing to care for more patients than we could handle with our current capacity.”

On The Ground in San Francisco: Trying to Get Ahead of The Surge

Recently, Mayor Breed’s communications director, Jeff Cretan, and their team relocated from City Hall to the Mosconi Center, a convention and exhibition complex that’s transformed into their pandemic response / emergency operations center (EOC). Cities that want to get ahead of a surge should look to San Francisco.

Cretan laid out their proactive response, “We declared a local emergency on February 25 and what that did was free up city resources, free up staff working on this. We activated our EOC on January 27 and started tracking this thing.” As a result, Dr. Grant Colfax, San Francisco’s Director of Public Health, and [Mary Ellen Carroll] Director of the Department of Emergency Management, “were both seeing what was happening and were alarmed.” Because they were tracking it so early and briefing the Mayor throughout, it perhaps came as less than a surprise when they advised her to declare a total emergency.”

Once they made the emergency declaration official, Cretan outlined the steps they took including, “free up resources, establish override local laws. For example, we waived a bunch of civil service laws through the emergency declaration to get rid of bureaucracy to hire nurses.” Now, “instead of taking six months, we could hire them in a week.”

Additional preliminary steps the city took included successful early requests for PPE donations. “That was already what we were dealing with two weeks ago,” he said. “I’m hopeful equipment is getting jurisdiction and things are ramping up.” So far, their all hands on deck procurement efforts have been working, as he explained, “We got a million masks from the state. We’re getting them from traditional sources, too.”

One of his primary concerns though, was testing, “Testing remains a huge challenge. We are limited by our capabilities as a local jurisdiction. There’s only so much any local community can do in this area. There’s just a limitation. You need state authority and federal support.”

COVID-19 nasal swab being given in drive-thru testing stations

The other pending shortage are swabs for nasal testing. “To do testing, you need the actual swabs. At our last press conference,” he noted, “Dr. Colfax, said bluntly, ‘We’re short on cotton swabs’, which is a strange thing to be short on in a country like this.”

“We’re not in the surge yet, but we have to prepare for it”, Cretan warned. “I don’t want to give the impression that we’re in a good place.…For everyone, the next few weeks, months ahead are what everyone’s really focused on.”

The View From The Frontlines in San Francisco

“Our Mayor, our Governor – they’ve put on their game faces and they’re really trying to figure it out as they go along,” affirmed Liz Cong, a San Francisco hospital nurse case manager.

Cong began her career as an RN at an ICU trauma center. Now, her job entails identifying when potential patients can be treated elsewhere for non-emergencies. Though she works in an office located in an ER, she doesn’t need to be in the ER except when speaking with new patients. Post-coronavirus, she’s in PPE and remains at the doorway for those conversations.

Though she’s seen patients recover from COVID-19, Cong said, “I feel ok and safe right now, but I just know something’s about to happen because [some] patients end up getting sick real fast.” For now, PPE at her hospital is in manageable mode. Still, she said, “The nurses here are getting concerned…We haven’t seen a spike here or the other hospitals. We’re kind of the calm before the storm.”

She saw the growing request for former nurses like her to re-join as inextricably linked to the ongoing national PPE shortage, “I don’t feel this concern today that we don’t have enough PPE, because we don’t have a surge of patients. But if we do, I don’t know if people are going to show up to work. I don’t know what people are going to do. I could be asked ‘do you want to go to back into the bedside?’ They’ve already asked some of my retired colleagues if they want to come out of retirement. A lot of people are saying ‘No.’ They’d love to but without proper equipment, they don’t. I’m torn. I’d love to help out more than I can directly, but without knowing I’m guaranteed the right equipment, I don’t want to do it either.”

Cong and Cretan expressed similar concerns for the city’s precarious PPE situation. Cretan described relying on Facebook for mask donations and a colleague whose neighbor happened to have a connection to a logistics company CEO. Cong said of Tim Cook’s donation of masks, “I just thought it was so surprising. It was like, wow, the Apple CEO got a bunch of N95s [to some hospitals] but here these other hospitals out here are scrounging”. She poined to the bigger, growing problem of our nation relying on wealthy individuals instead of the government, “Cook donating millions of dollars’ worth of equipment because he can afford it is great. But it’s also kind of absurd.”

Healthcare workers have been relying on donations of supplies, using social media and personal connections to get the PPE they need.

Cong was able to shed light on why the sheer volume of PPE is so vast. “There’s a respiratory therapist (RT), doctor and nurse. In the best case scenario, each has a face shield, N95 mask, gloves, gown, maybe hat,” totaling five pieces of PPE per health care staff for a single patient visit. If there are two additional staff in the room, “that’s twenty-five pieces of PPE to see one patient.” For each visit.

Pre-coronavirus, N95s would typically be disposed of. Now, hospitals are sanitizing them for re-use. While face shields can be cleaned for re-use, gloves and gowns must be disposed of after any visit to each patient every time.

Like the others, Cong has thoughts on the DPA, “Getting things shouldn’t be as hard as they are. But for some reason they are, and it all has to do with not having the DPA enacted right away. I think this is like wartime. During World War II everyone was focused on doing one thing.”

“Right now,” Cong said, “it’s crazy. I wouldn’t want to be a nurse or RT because there’s just too much anxiety about this…We all kind of have this anticipatory grief about what’s going to happen next. We’re all on the edge of our seats.”