As a surgeon who has been working in the US healthcare system for the last twenty years. I never imagined I would ever see what has transpired in the first quarter of the year 2020. Never in my wildest imagination did I think I would experience such a retrogression in the delivery of healthcare. Let me explain.
In over 20 years of surgical missions across Africa I have seen and experienced how lack of resources can influence healthcare delivery. Typically, on our trips, we bring along supplies for doing surgeries, most of which are disposable. It is not uncommon to see these disposable supplies being reused several times. These include surgical gowns, drapes, Bovie (diathermy) pencils, Bovie electrode pads, endoscopy instruments, Lonestar retractors and many more. These supplies and equipment are sometimes sterilized and reused. The surgical gowns are sometimes used as cover sheets for the operating room table after they have been used. The Bovie pencils are typically just wiped with betadine (antiseptic) and then reused.
Single use supplies that cannot be shared between patients are sometimes kept for the same patient for reuse, especially for patients who require repeated procedures. For example, some patients who have esophageal strictures may require monthly or bimonthly dilations. In such cases, they may keep the pneumatic dilator (which is supposed to be used only once) for several sessions for the same patient. This is because these supplies are expensive and are not readily available in these countries.
Prior to Covid-19 personal protective equipment (PPE) has always been in abundant supply in the US. These include surgical masks, gowns, eye shields, hats, shoe covers and gloves. In fact, a while back, we were not supposed to wear our face masks and shoe covers outside the operating room. Because we use a lot of disposable supplies, it is not uncommon to see a lot of supplies go to waste because they were opened and not used. I never dreamed or imagined that a day would come when PPEs would be in such short supply that the US of all places would be turned into the likes of a third world country.
COVID-19 has created a world-wide shortage of PPEs and as a result, the need to conserve PPEs has arisen. Taking care of patients with COVID-19 burns through an enormous amount of PPEs and this contributes to the shortage. Part of the reason elective surgeries were suspended across the US was to preserve PPEs so that there will be enough to take care of COVID-19 patients. We have heard of several places where clinical staff taking care of COVID-19 patients have been complaining of not having enough PPEs for their own safety and that of their patients. In fact, some nurses have quit their jobs for this reason.
Since the late 1990s, we have placed a huge emphasis on Evidence-Based Medicine. However, due to COVID-19, all that has been put aside. Decisions are being made based on availability of supplies rather than based on the best available scientific evidence. If what we are being asked to do today is okay, then why were we “wasting our time” with practicing according to evidence. Maybe we were going overboard, which I doubt. If we did go overboard, then the big question would be why spend so much money to go over and beyond what is necessary for no extra gain?
How did we get into this situation, where the most blessed and financially endowed nation on the planet cannot afford to have adequate PPEs? There are several reasons for this;
We have not faced a pandemic of such magnitude in over a century and therefore, the stockpiles of PPEs that the nation had was woefully inadequate for the amounts required.
Most nations of the world were beholden to China as the country that supply most of these PPEs in large enough quantities. Unfortunately, with China being one of the first nations to be affected normal supply chains for most countries were disrupted.
When supplies were available, there was competition for these supplies by all countries.
Also, the US did not have a coordinated effort to obtain PPEs. Instead, the states were competing with each other for these supplies. The federal government did not heed the call to nationalize the procurement of PPEs, which would have had several advantages.
This and other reasons contributed to the shortage of PPEs. Despite an improvement in the PPE situation, there is still a shortage and because of a potential second wave of COVID-19, the shortage of PPEs may last a long time. Simply put, we were caught flat-footed and we were inadequately prepared for this pandemic even though there was ample lead time before it became widespread in the US.
As a result of the shortage of PPEs, clinical staff are now being told to use the same surgical mask and eye shield for a week at a time. Mind you, these were made for single use. Now, it is no longer important to provide adequate sterility for doing some bedside procedures. It is now okay to use the barest minimum of supplies for procedures for which a short while ago someone would have been chastised for using the same amount of supplies for. Suddenly, a lower standard is okay and even mandated. Only time will tell the impact of such practices on patient safety.
Hospitals are also changing how things are done in the operating room. In the past, it was not uncommon to have three or more scrub techs and circulating nurses for one surgical procedure. All the changes in the staff also burns through a lot of PPEs. In teaching hospitals, you may have the attending surgeon, a fellow, a resident and a medical student all scrubbed in the same surgery. Now, all this is changing. Scrub techs are staying scrubbed for the entire duration of the case. Sometimes only one change of scrub tech per case is happening. Most places are mandating only two people scrubbed for a case.
Medical students have been home during the pandemic, further reducing the number of PPE per case. What is going to happen when we are back to full service and all residents, fellows and medical students are back? Certainly, these changes will affect how we train our next generation of healthcare providers.
This situation should teach those of us in the US healthcare system to be humble and have a better perspective when dealing with countries in the developing world. A lot of the problems that we attribute to developing countries when it comes to health and healthcare is simply due to lack of resources. Sometimes people die as a result of the lack of said resources. Some healthcare personnel have died needlessly because they lacked the proper PPE to adequately protect themselves as frontline workers while trying to save others. When resources are scarce for any reason, people have to learn to innovate. Maybe, we will find better ways to deliver healthcare. Regardless of what has happened during this pandemic, we have a great healthcare system, and this too shall pass.
By Dr. Jonathan Laryea a Colorectal Surgeon who practices in Little Rock, Arkansas
Feature photo: Training on wearing PPE at San Antonio Military Medical Center, US Army photo by Army Sgt. 1st Class Tyrone C. Marshall Jr.