On Friday, Dr. Michael Warner, an ICU physician at Toronto’s Michael Garron Hospital, started calling the city’s veterinary clinics, looking for animal ventilators that could be repurposed for people with COVID-19.
By Saturday, he realized that ventilators were no longer the chief priority: hospitals around the country are burning through personal protective equipment (PPE) for health care workers with such speed that it is only a matter of weeks before they run out. The looming shortages include N95 masks, gowns, gloves, face shields and even scrubs.
“If we run out of personal protective equipment, we cannot treat people with COVID-19, full stop,” says Warner. “That means we can’t even enter their rooms, let alone give them medication, give them meals, put breathing tubes in or provide them with any type of care.”
Warner and other physicians, nurses, pharmacists, midwives and physician assistants across Canada are sounding the alarm that they need more PPE. They’re calling for all Canadians to help find safe, workable protection for health care workers. They want nail salons, dental offices, veterinary clinics and any Canadians who own these items to get them cleaned, sorted and moved to the front lines in Canada’s emergency departments and intensive care units.
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“There is nothing more important in Canada right now,” says Warner. “If this isn’t fixed, it doesn’t matter how many ventilators I have. I won’t be able to walk in the room to put the patient on the machine and they will die.”
It comes down to this: if physicians, nurses, physician assistants, respiratory therapists, pharmacists, paramedics and other health care workers don’t have adequate protection, they are risking their lives by coming into contact with people infected with COVID-19. At present, the number of people infected in Canada is growing by several hundred by the day. Many of the infected do not show symptoms for days after exposure—a study published in Science that mathematically modelled the spread of the coronavirus within China found that for every confirmed case of COVID-19, another five to 10 people likely had undetected infections. This means there is an ever-increasing risk that each patient who enters an emergency department, with or without symptoms, could be infected with COVID-19. Every time a health care worker is infected with the virus, Canada loses a member of the front-line team.
If supplies to protect health care workers run out, so will our workforce, says Warner. “Everything will fall apart.”
More than 84,000 Canadians* have signed a petition calling on the government to launch a “war-like” effort to acquire and manufacture PPE and other protective equipment using whatever means possible.
“We can’t be relying on the manufacturers across the globe for PPE. We should be making it in Canada and have it readily accessible to people here,” says Dr. Melissa Yuan-Innes, the emergency room physician in South Glengarry, Ont., who organized the petition.
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“Medical people are more at risk because we’re with sick people all the time and we’re getting exposed over and over again. We just seem to have a much higher infection rate.”
PPE stocks vary in hospitals around the country, but many expect a shortage everywhere within weeks, if not already. In Victoria, an emergency room physician who asked not to be named says hospitals currently have adequate PPE but “probably not enough to last a week or two.”
“People are going to hardware stores, and our local spa has given us a bunch of masks,” she says. “We’re trying hard to source things from wherever we can, but I should not have to ask my electrician friends if they have N95 they can spare.”
Outside of hospitals, some small clinics are down to the bare minimum, unable to procure any more with a global crunch on supplies. In Waterloo, Ont., Dr. Hasan Habib says his two-doctor clinic has only one box of face masks, one bottle of sanitizer and no viral swab kits. They are “desperately looking for supplies,” he wrote in an email.
In Calgary, emergency room physician Dr. Michael Szava-Kovats moved into an apartment last week to avoid exposing his wife and five-week-old baby to the virus. He plans to see his family only by FaceTime for the next several weeks. E. Perry, a pregnant emergency room nurse in Alberta, says she is torn between what’s best for her family and her sense of service to patients and colleagues. “It’s this huge mental burden of trying to remain selfless,” she says.
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Carol Loffelmann, an anesthesiologist in Toronto, is working to create a list of items that Canadians might have in their homes, art studios or carpentry workshops that can be commandeered for health care workers. Speaking on the phone Saturday, she cried. “COVID kills. That’s my bottom line. It will kill the patient. When we run out of protective equipment, it will kill the people who can’t be treated because we are swamped, and it will kill the health care providers in the short and the long term.”
“Nothing is as it was,” she says.
One of the most critical items on the list is N95 masks. How long the current supply lasts depends on how wisely they are used, says Dr. Saroo Sharda, an anesthesiologist in Toronto. Hospital staff in Calgary and Toronto who asked to remain anonymous say supplies of N95 masks are being depleted by staff who use them in situations where they are not required—so much so that the masks have been placed in locked cupboards in some units. The N95 mask is designed to prevent users from inhaling small airborne particles, and they fit tightly to the user’s face. That’s in contrast to surgical masks, which fit more loosely and are designed to protect from microorganism transmission. Both protect against large droplets and sprays. The Public Health Agency of Canada recommends health care workers follow droplet precautions for patients with known or suspected COVID-19, which means gloves, a gown and face protection, like a surgical mask, and eye protection at all times, and upgrading to an N95 mask when performing an aerosol-generating procedure like intubation. But some front-line workers feel they should have N95 for things like performing nasal swabs during COVID-19 testing or being in the operating room for surgery on a patient with trauma and unknown COVID-19 status.
“The reality right now is that we may well end up in a situation of shortage of PPE,” says Sharda.
“What everyone needs to understand is that there are different levels of PPE required for different procedures.”
The anesthesiology section of the Alberta Medical Association has acquired 3M respirators—large reusable masks—for its anesthesiologists, but they are not yet approved for use in hospitals because questions remain about best cleaning practices. The masks are being held in reserve for distribution in the event of a shortage of N95s. In a note to members, they wrote, “we anticipate a N95 shortage if Canada follows a similar course to the rest of the world. We are not taking your safety lightly.”
Critically, some supplies are also running short for testing people for COVID-19. Alberta and British Columbia have kept up a furious pace. Alberta, with 23,742 tests performed as of March 21, has the highest per capita testing rate in North America. But the medical officer of health for Calgary worries the province won’t be able to keep up the pace without more supplies. “We’re not testing everyone we can because there is a global supply chain shortage,” says Dr. Jia Hu. “We’re trying our hardest to get more swabs.”
On Saturday, Italian doctors, writing in the journal NEJM Catalyst, said hospitals are the main carriers for COVID-19 as they are rapidly populated by infected patients. The doctors outlined essential steps for managing the spread, including social distancing, a massive deployment of outreach services to treat patients in their homes and protecting health care workers. “Protection of medical personnel should be prioritized,” they wrote. “No compromise should be made on protocols; equipment must be available.”
On Sunday during his press briefing, Prime Minister Justin Trudeau was asked about the looming shortage. “We are confident in our capacity to ramp up to provide protective equipment for front-line hospital staff and others who need it so importantly,” he said. “This is something that Canada has been working towards for a while now; we will ensure that the equipment is available for those who need it right across the country.”
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Efforts are under way in Canada to collect and manufacture PPE. But so far, the projects are grassroots and not large enough, says Dr. Kyle Saikaley, an emergency medicine resident at McMaster University. Dr. Saikaley set up an initiative to collect unused PPE from dental offices, veterinary clinics, nail salons and construction companies, and is looking for surgical masks, N95 masks, gloves, gowns, hand sanitizer, face shields, goggles, feet/head coverings, disinfectant wipes and UTM certified viral swab kits. His team of residents and medical students collected more than 4,000 masks over the past weekend, and the project is being rolled out in places like Ottawa, London, Toronto and even Cranbrook, B.C.
“Canadians should know that many health care workers are not afraid to get sick themselves, but their biggest fear is getting somebody else sick, including their own family members,” he says.
Other efforts include the TOH 3D Printing program at the University of Ottawa, which is assessing prototypes and materials for printing PPE and ventilator pieces in large productions. In Edmonton and Toronto, scientists are at work on ventilators. In Ontario, organizers at covidhealth.ca are connecting community collaborators with front line efforts. But the job of amassing PPE is a project looking for a leader to step forward.
For Warner, it’s a STAT call to the entire country. He’s set up a website to collect supplies for his hospital at theppedrive.com.
“If we don’t have the personal protective equipment, if the nurses don’t, the respiratory therapists don’t, then people may die,” he says. “It’s really that simple.”
*Correction: An earlier version of this story stated that the petition had been signed by 84,000 health care workers. In fact, the petition was started by health care workers, but is open to all Canadians.