Lack of protection unmasked 1

by Keith Cooper If you’re tackling a deadly virus you’d expect to be afforded protection. Not so in the UK where doctors have to make the best of inadequate supplies. Keith Cooper reports
Location: UK
Published: Monday 30 March 2020

The lives of NHS staff and their families are being put at risk owing to poor access to PPE (personal protective equipment) as they fight COVID-19, many doctors have warned.

With low supplies and conflicting advice from managers about the level of protection needed, doctors have been forced to improvise: to source their own sealed masks from DIY stores, builders’ merchants and garages. To beg, and in one case borrow, safety goggles from their nine-year-old daughter’s party bag.

‘I wish this was actually a joke,’ a consultant says in a posting to a BMA portal which has collected 120 experiences from frontline doctors fighting the virus.

Access to PPE was the ‘biggest issue’ facing doctors as they battled the virus, BMA council chair Chaand Nagpaul told an inquiry of the Parliamentary health and social care select committee in late March.

‘This Government expects NHS staff to put themselves at risk of serious illness, or even death, by treating highly infectious COVID-19 patients without wearing proper protection,’ Dr Nagpaul had said in a strongly worded statement the previous day.

The BMA has flagged doctors’ concerns with the prime minister Boris Johnson and is pressing PHE (Public Health England) to offer clearer advice on PPE, which the agency admitted is now under review, under questioning by committee chair and former health secretary Jeremy Hunt.

BMA consultants committee chair Rob Harwood reiterated doctors’ lack of confidence in supplies of protection equipment following the tragic death of Amged El-Hawrani, an ENT consultant working at University Hospitals Of Derby And Burton.

‘Any death, be it doctor or patient, is a death too many,’ he added. ‘Our hearts go out to Mr Amged El-Hawrani’s family.’

Communities secretary Robert Jenrick pledged on 29 March that tens of millions of masks, gloves, apron and gowns would be delivered to hospital trusts as part of the Government’s National Supply Redistribution Response, aided by the armed forces.

Protection sparse

Concern about poor supplies of PPE and its risk to the lives of themselves, their colleagues and families is a common theme in postings to the portal. Almost three-quarters (73 per cent) raised concerns about access to PPE. One in five expressed concerns for the health of NHS staff and their families.

So how is poor access to PPE affecting doctors on the ground? And what is being done about it?

Doctors point to shortages across the UK, in GP practices, hospitals, in emergency departments, intensive care units, and in community settings, including mental healthcare, via the online portal set up by the BMA for them to highlight their experiences.

‘We’ve been sent just six personal protection kits,’ says a GP in Northern Ireland. ‘We have given them to the district nursing team so the doctors have nothing.’

‘Situation so grim we have started to try and source our own PPE,’ a consultant physician posts. ‘I was one of a group of five consultants who sat in a huddle yesterday morning using our mobile phones to try to find and buy PPE for us and colleagues using our own money. Much sold out. No confidence employer will protect us.’

Risky strategies

Those working outside of acute hospitals appear to have worse access and fear they themselves could unwittingly spread the infection for want of access to adequate infection-control equipment.

‘It seems we have been deemed bottom of the priority pile,’ a specialty trainee 2 in paediatrics reports.  ‘While I totally appreciate our adult colleagues are taking the brunt of this, we know that children can be asymptomatic or have mild symptoms so treating paediatricians as lesser priority is a high-risk strategy that puts staff and the population at large at huge risk.’

‘We have no PPE at all for working in outpatients or those working with inpatients,’ a psychiatry associate specialist said. ‘Managers have told us we don't need it.’

Other posters spoke of conflicting and changing advice from health bodies and managers, changes they fear are driven by rationing a scarce, though improving, supply.

‘The goal posts are changing depending on the supply,’ says another doctor. ‘As soon as we run out of [filtering facepiece 3] masks, apparently surgical masks are OK. The consultant microbiologist came up and told the nurses on the COVID ward today PPE is running out and when it does, they will just have to cope.’

‘The situation is horrible regarding the PPE, there is severe shortage,’ an emergency medicine registrar from the West midlands says. ‘Every couple of days they are changing our PPE guidance.’

They’ve seen that there are higher standards of protection in guidelines on protective equipment by the World Health Organisation and the internationally respected CDC (Centers for Disease Control and Prevention) in the US – compared with those enforced by managers on the say of PHE.

Unreliable equipment

While watching counterparts in Europe on TV wearing higher-grade protection and hearing stories of staff deaths, they’re offered ‘flimsy paper masks and plastic aprons’.

When ‘fitted’ masks are available for use with riskier patients and procedures their ‘fit’ must be tested. But when these tests fail, there’s no alternative protection available, some doctors said.

‘I have failed my FIT testing on all masks,’ one poster said. ‘No alternative has been provided nor is available on my ward. This has been escalated to my clinical director. I will be the primary doctor responder to acutely unwell patients on a COVID isolation weekend from Saturday night. I am worried about what to do if I am called to such an unwell patient as I won’t have PPE. My bosses don’t seem to be able to help.’

While most posts are from before a major push by an army-aided re-supply of hospitals, concerns continue to come in.

‘Even this morning, I’ve had emails from doctors that masks have run out,’ Dr Nagpaul told the select committee in the week of the re-supply effort. ‘In general practice when we run out and ring up the helpline we’re told to buy them ourselves.’

Royal College of Emergency Medicine president Katherine Henderson told MPs the production of protection should be ‘ramped up’.

‘It would be good to hear about the production and call for manufactures to be making face shields, visors, and masks in the same way as we are hearing about ventilators,’ she added.

Public Health England medical director Yvonne Doyle told the committee there was not agreement on PPE in risky settings between public health agencies, such as itself, the WHO and CDC. NHS guidance had been ‘written on the basis of best infection control’, Prof Doyle added, but was ‘under review in the light of people’s anxieties’.

Separately, Dr Nagpaul also urged NHS England director for acute care Keith Willett in a letter last week to tap into EU stockpiles and procurement processes to compensate for the UK’s shortfall of medical equipment, such as ventilators and PPE. Much-needed masks, gloves, face shields and surgical masks could reach the UK in two weeks.

Cabinet Office minister Penny Mordaunt indicated on 24 March that the Government would not use these supply sources. ‘We have chosen other routes,’ she told Parliament.

‘Geography, not politics, dictates we must work with our European partners to win this fight,’ Dr Nagpaul said.

It is vital that the Government does whatever it takes to protect staff. As Dr Nagpaul told the select committee, thousands of doctors and frontline staff were risking their health and lives caring for COVID-19 patients. ‘They should not have to do so without the right protection.’

 

The fight on the front line

Staff on the front line share their experiences through a dedicated BMA portal

Staff who haven’t had fit-testing are still expected to be on the crash team. No apologies, no remorse at all from management. It’s put forward as though it was totally acceptable despite young, fit, Italian doctors dying. Some of our staff have other health conditions as well such as poorly controlled asthma.

Foundation year 1

Went to Screwfix to buy goggles for my team. They’ve run out. I’m borrowing my nine-year-old daughter’s safety specs she got in a science party bag. I wish this was actually a joke.

HIV consultant

I was thinking about taking up a semi-permanent post locally so that I could be helpful. Tonight, I read that two consultants are in hospital on ventilators. I have diabetes. It’s rarely gotten in the way of work before but this feels different. I'm a bit scared. I have a really strong sense of duty but with the horrendous provision of masks, I feel like I'm exposing myself to certain severe illness.

Foundation year 2

I’m scared for myself, my staff, and my patients. The Government has seemed slow to react at each turn. Really disappointed with PPE. I remember the swine-flu kit; this is rubbish is comparison.

GP

We are asked to risk our lives and our loved ones' lives in flimsy paper masks and plastic aprons. I don't know if I can do it. I just don't know if I can. I don't think it is fair to expect this of us. I am terrified. Terrified. How can this risk to practitioners, other patients, practitioners' families be justified? My husband is not a medic and I cry every day thinking I am going to infect him. I feel like I will be asked to sacrifice myself for this, it feels suicidal. I am seriously considering quitting.

Junior doctor

We have no PPE at all for working in outpatients or those working with inpatients. Managers have told us we don’t need it.

Psychiatry associate specialist

We are testing our patients for coronavirus using only surgical masks, aprons and gloves then also wearing the same once they are confirmed. I find this crazy as we are already short staffed and not only risking our immune-compromised patients but also risk losing more staff.

Senior house officer