This is one in a series of reports from hospitals responding to the Covid-19 pandemic.
“I just want to say … yesterday was a really hard day,” said Chuck Morris, one of the two people now in charge of Brigham and Women’s Hospital. “Personally speaking, I sort of went home in a tough place. We’re finding some rhythm, and then some bombs went off.”
The room he was addressing had dealt with true explosions before. This was the place where the hospital’s incident command had convened seven years ago, in the aftermath of the Boston Marathon bombing: the war room of a military-style hierarchy that, for the length of an emergency, replaces the executives who normally run the show. This time, the bombs weren’t literal. They were cases of Covid-19 that had popped up in parts of the hospital where no one was expecting them: On Thursday, March 19, two patients had come in for other reasons — abdominal surgery for one, a bleeding episode for the other — only for their coronavirus infections to come to light after they’d bounced from unit to unit, potentially exposing over 100 workers.
“Today is another day,” Morris went on, around 8 on Friday morning. “I’m not going to be hokey about it, but I want everyone to close your eyes, and we’re just going to take three deep breaths as a group, and then get ready to just face the day. Just quietly, everybody, please — ”
But then the door swung open, and in walked Shelly Anderson, the incident command’s section chief for planning, one of the straightest talkers in a room full of straight talkers. “We’re taking deep breaths, Shel,” someone whispered. You didn’t even have to look at Anderson’s face to feel her skepticism. There were laughs. Within minutes, the deep breaths had fallen by the wayside, and attention turned elsewhere: to the hospital’s critical shortage of masks.
It was true everywhere. With Chinese supply interrupted and a global explosion of demand, purchasers were scrambling to find the personal protective equipment, or PPE, that could help keep Covid infections from spreading. Even as hospitals like the Brigham told non-essential staff to stay home, they still had hundreds of employees per shift — from surgeons to nurses, patient transporters to X-ray techs — who had to be there to help treat coronavirus, but also the bleeds and cancers and heart attacks that remained emergencies during a pandemic. They were afraid for their charges and afraid for themselves.
It was hard to track the shortage with precision, though, as the supplies were scattered around the hospital, boxes of them kept in different units for workers to use as needed. Even with caveats, the stats up on the projector didn’t look good. “That says we’re burning through 9,000 procedure masks a day. That says we’re burning through 1,600 surgical masks a day, and we’re burning through 800 N95s a day, which are numbers we’ve never seen,” said Kevin Giordano, section chief for logistics, putting the accent on “never.”
At that rate, the hospital had enough for about two weeks — and the pandemic was supposed to get exponentially worse. “People are grabbing,” Giordano said.
The issue was directly connected to Thursday’s Covid “bombs.” When they were first discovered, guidance from the public health department required that every staff member who’d had close contact with those infected patients for at least 15 minutes be furloughed for two weeks. It would potentially have shut down whole units of the hospital.
Other hospitals were feeling that strain, too — protecting patients, they said, meant having the staff to test and treat them — and they had convinced the state to shift the rules. Now, asymptomatic employees could keep working, as long as they weren’t caring for immune-compromised patients and went home if they felt even the slightest twitch of illness — and wore a mask.
What they were given were surgical or procedure masks, which can protect people from the wearer’s breathed-out germs, but not so much the other way around, only keeping out larger droplets. N95 respirators were sturdier, creating a seal that kept others’ respiratory particles out, but those were in even shorter supply, and were being reserved for caregivers who were doing procedures — inserting throat tubes, swabbing nostrils — that generated a potentially infected mist. Even around the flimsier masks, there was tension. Workers wondered: Why was so-and-so wearing one, but not me?
The best way to keep people feeling safe and to reduce the chances of transmission, incident command decided, was to give every last employee a mask, to use for their entire shift unless it got wet or soiled. They had enough to do that now, but that wouldn’t last.
“We all don’t want to be fools,” said Julia Sinclair, an incident commander, who sat beside, but 6 feet away from, Morris, presiding over the windowless conference room together. “If we can support this for one week, and then we run out of masks, have we really made the right decision?”
No, they all agreed. They knew they needed to consolidate their supplies, so they could better measure how many masks they had and control their use. But before rounding up all unused masks from their usual homes in different units, the group wanted to calm the staff by announcing exactly who would be eligible to get one. The problem was, they were still figuring that out.
“My folks are going to be coming up to people demanding masks,” said Giordano. His voice was deep and slow, soothing as a high school guidance counselor’s. “I think there’s going to be a lot of confrontation.”
His folks arrived soon after the meeting. Giordano wanted the collection to begin the moment the new masking policy was announced. “Literally, as soon as this message goes out, I want a team in place to go out and collect supplies, because I think there could be hoarding — rational, thoughtful, patient-centric hoarding,” he said, smiling ruefully, wishing, like everybody else, that they didn’t have to do this.
This wasn’t where he thought he’d end up. As a kid, he’d wanted to be a doctor, like his grandfather, who worked as a pediatrician out of his home on Broad Street, in South Philadelphia. Giordano had grown up hearing stories about appointments paid for with loaves of bread, hunks of cheese, bits of prosciutto, rainbow cookies, whatever the patient’s family had. He remembers passers-by stopping his grandfather in the street to thank him. But in school, Giordano wasn’t as thrilled by the workings of mitochondria as he was by the intricacies of policy. He became a hospital administrator, with a photo of his doctor grandfather in his office as a kind of guide. Masks weren’t usually part of his job.
Now, he told his people that he wanted seven teams of two to be ready: someone with clinical experience, whom employees on the units would listen to if they questioned what was going on, paired with a redeployed valet driver, say, now that that service had been put on hold for the pandemic. They would leave only enough to last the weekend.
“As the people are going in, they can say, ‘What do you need to get you through ‘til Monday?’” Giordano explained.
Meanwhile, at the other end of the room, near the printer and the table with coffee and apples and stale, individually wrapped pastries, other members of incident command were hashing out exactly who would be getting masks on Monday.
“If environmental services are in inpatient, do they fit into this category?” asked Sinclair, referring to the workers who clean patient rooms.
“No,” Morris offered, a hypothesis more than a definitive answer.
Yet Michael Klompas, an infectious disease physician and the hospital’s epidemiologist, worried about giving out masks according to job title. “That will lead to the misimpression of different standards for different people. I think we should frame it in terms of patient contact,” he said. He spoke in a clipped South African accent, his voice so soft that the five mics hanging from the ceiling often couldn’t pick it up enough for those on videoconferencing to hear.
Right, everyone said. They tended to listen closely to Klompas, as if his words made up in weight what they lacked in volume.
But then he picked at his own suggestion. “If I’m a check-in person, I’d say I have direct patient contact, right?”
“Isn’t direct patient contact less than 6 feet?” Sinclair asked.
They were still talking about it at 10:30, when they started videoconferencing with the clinical chairs of all academic departments, the sense of pressure mounting in anticipation of questions. They were still talking about it at noon, when they trooped off to a different conference room for a webcast to about 1,000 managers within the hospital, to answer questions about redeployment and pay and parking.
“We’ve had seven health care workers who’ve already been diagnosed with Covid and in a number of instances those people did develop symptoms on the job,” Klompas told the chairs. “A universal masking strategy is not going to be a cure-all, it’s not going to be a panacea unto itself. … Say I’m the minimally sick employee and I wear a mask, but as we all do when we wear a mask, we adjust it constantly, and therefore you get virus on your hands. If you don’t wash your hands as well, that’s not going to work.” He emphasized the need for increased screening of employees and patients, increased testing for patients in the emergency and inpatient departments, and better hand hygiene.
They had to be thinking about “mask as talisman,” Morris told the managers, to take seriously people’s belief that a mask was the thing that would best protect them and others, even if that wasn’t always the case.
Right afterward, they fell back into it. What about endoscopy? What about the cleaner cleaning up bodily fluids? They kept returning to the idea of giving everyone a mask. And if they did that, they might run out in weeks. Morris swore, and swore again, his body tensing up in his suit.
They weren’t going to make the 2:30 p.m. deadline they’d set themselves. Only close to 4, back in the headquarters of incident command, did they get close to a document that seemed like it might work. If your job entailed face-to-face contact with a patient for 10 minutes or greater, then you’d get issued a surgical mask. They started sending out the couriers with pushcarts to collect boxes of masks from different units, ready for the conflicts and questions that might come.
Then, within an hour and a half, everything changed. Like a team of fairy godmothers in suits, executives at Partners HealthCare — the health care system that includes the Brigham — had secured a new supplier of masks earlier that same day. It was quite a feat. The day before, the governor of Massachusetts himself had asked President Trump how states were supposed to find supplies when the federal government kept outbidding them. “I gotta tell you, on three big orders, we lost to the feds,” Gov. Charlie Baker had said during a phone call between the president and the governors.
How had Partners done it? “If you place orders with the regular manufacturers, they’re going to get picked off for the federal stockpile before you get ‘em. … You’ve got to know how to maneuver your way through,” Peter Markell, the company’s chief financial officer, explained later.
His supply teams’ inboxes were filling with offers of masks, but in some, what might normally sell for 11 cents was marked up to 90 cents or $1.20 — and it was hard to make sure the quality was good enough to actually be protective.
“Part of our issue is who to trust,” said Lisa Scannell, Partners’ director of supply chain management. “Some suppliers are asking for money up front. … There’s a chance that the product may not come in.”
“You can just get scammed,” Markell added. But this offer had come in from a distributor they’d worked with before, and they jumped on it. They could get between 1 million and 2 million masks a month. In return, they could offer a commitment to buy from this supplier long-term. “The premium we’re willing to pay is a function of how squeezed we are. We have to take care of our caregivers and we have to protect our patients.”
Those masks didn’t all go to the Brigham. They would be spread out across the Partners system. They were not the coveted N95s. But it did mean there would be enough surgical and procedure masks for every employee to wear one every day — something that other hospitals with less buying power could only wish for.
Still, Giordano decided to go ahead and send out the trollies and dollies that would collect masks from certain units. “Supply chains are unstable, and our ability to take care of our patients really subsists on us being judicious users of the supplies,” he said. “You don’t want to have a checking account that only has five bucks in it.”
By this Wednesday morning, it looked as though the Brigham had stationed guards against the pandemic at every door. Many were redeployed valet drivers, in screaming red jackets, handing out the same sort of surgical mask they wore to every employee who came in.
“We think we have all the doors covered,” said Giordano. “Believe it or not, there are 122.” He also hoped to add a checkpoint at every entrance, where every worker would attest to the fact that they had no symptoms before going in. If employees needed another mask or something else — a face shield, say, which looks the medical equivalent of a SWAT team visor — they could go to one of the PPE distribution centers, where they would be asked to scan their employee badge.
Giordano headed up to one of those centers now. Red duct tape on the carpet showed people where to stand, so they wouldn’t get within 6 feet of each other. For inpatient units, where coronavirus anxiety was especially high, Giordano had decided not to collect whatever masks were left. “There’s a lot of fear out there,” he said. “So on Friday night, we decided we didn’t want to kind of roll out an infantry. … This way, they can also build some trust and faith in the distribution strategy. They know they can come in and can get what they need.”
That faith wasn’t there yet. Not long before Giordano had to leave to get to the 8 o’clock incident command meeting, a nursing assistant named Francyele Fonseca came down from the 10th floor to pick up a face shield because she would be caring for a patient who was still under investigation for coronavirus, and that meant taking “strict droplet precautions.” She was 27 years old, and lived in East Boston with her parents, both in their 60s. She was concerned that her mom’s history of illness put her at especially high risk.
“We’re not sure if they’re going to continue to provide us with the proper protective equipment,” she said. “It’s just scary. We don’t know if we’re going to be able to come in and have the proper gear to protect not only patients but ourselves as well.”
She worried that this was only the calm before the storm. She worried that her surgical mask wasn’t totally protective, and she’d be safer with something more robust. She worried that she shouldn’t be wearing the same one for her entire 12-hour shift, even as she took extra care not to get it splashed or flecked.
Those worries followed Giordano into incident command. The professional society for anesthesiologists insisted that all their members needed N95s. The Massachusetts Nurses Association was adamant that members needed N95s or other devices, such as power air-purifying respirators, that could protect them from other people’s infections.
The day before, at 4 p.m., there had been 33 Brigham employees infected. By Wednesday afternoon, it would creep up to 45, and then 51 on Thursday. Because those cases weren’t in clusters, the trend seemed to be partially fueled by quicker testing for health care workers and widespread transmission outside the hospital, but it was alarming all the same.
Giordano reported that masks were getting to some 94% of workers at the door. His colleagues scoffed, and laughed. More like 99%, they said. Yet their sense of relief didn’t last. They talked about testing bottlenecks and intensive care units, whether Boston would be as bad as New York.
At the end of the meeting, Maddy Pearson, operations section chief, and in normal times, the hospital’s chief nursing officer, stood up. “I think if we gave everybody an N95, we would see the level of stress in this organization plummet,” she said, pulling her gray suit jacket around her, as if she were suddenly cold.
There ought to be more N95s coming. But within the hospital itself, they only had enough to last a few days.