Wear A Mask

Over the last few weeks, I have been angered by the large number of hospitals threatening nurses and physicians for wearing masks and telling the truth. Nurses have primarily been told to remove their mask or be fired. While physicians seem to be told to remain silent about shortages and conditions or be fired and while at the same time to remove their masks. I’ve collected a large number of such stories from people I know and trust. They have come from nurses and physicians. One physician, a friend of a friend, was working in an ER and the administration told him to take off his mask or be fired. He quit on the spot rather than take off the mask. The husband of another friend is also an ER physician and he actually had to go to his car and get a mask when a symptomatic patient came in because they had absolutely no N95 masks in the rural hospital.

This was sent to me by a friend who has spent her entire career at the beside.

I can’t speak out publicly and be identified because I cannot afford to lose my job. I can tell you that nurses are being bullied not to use their own PPE especially if they are working in areas that it was previously not routinely necessary. Even nurses and therapists with asthma, COPD, immunosuppression and/or recommendations from their personal physicians are being bullied about not wearing an N95/PPE that they provided themselves. My area was recently told we “can” but are not required to wear a surgical mask after repeated complaints from the Radiation Therapists we work with that their professional body (ASTRO) is recommending they wear a mask during all patient care. However, the administration here has been “working around” the nurses in administration to roll back that protection in the name of not “wasting masks”. None of them wear masks when they come through the clinic. Combined they’ve spent almost no time in the clinic before or after this began. They act as if we are overreacting when we wear masks to work with our patients, but in the same breath tell us to stay out of the clinic if at all possible and “protect ourselves” as if our front line staff is disposable. With the transition to no visitors we have folks that counted on caregivers coming in with them that are now upset and unable to do their own intake paperwork and needing more hands on care. But the culture coming down from the top is that the front end staff are overreacting if they want to protect themselves and patients by wearing masks. I feel like we are a pressure cooker ready to go off. We have young folks that are going home to families and roommates (that are working in Walmart’s and driving busses) and they are the ones helping immunosuppressed patients with their paperwork (so much more because now they can’t have a family member to help them) and when they use a physical barrier mask they get side eye from our nurse manager (whose boss is non clinical and was on the Hoax train up until last week and still makes flippant “just wash your hands, you’ll be fine, comments”) and others. They along with the rest of the management team are hoping/thinking they will “roll back” the decision to allow our folks wear masks this week… all of this from the big executive suite where a few folks, all sitting in private offices are dictating what the hands on people can do to protect themselves. It’s just wrong. They are intentionally talking amongst themselves to reach a consensus against protecting our folks before including equally/higher ranking nurses on any conversations. At a time when nurses should be at the forefront of decision making we are being railroaded and overridden. I am the only one that seems to understand the magnitude of what we are facing. Since our doctors are a separate group they can do what they want for themselves and although they can ask that we protect the patients and employees, they have no sway.
I have been working to make sure we have local seamstresses lined up and donations of fabric surgical masks so that we have some protection. However our hospital system will not allow employees to wear them, even/especially when we are in areas that they don’t deem masks “necessary” which is almost all our front line folks in non COVID19 treatment areas. It’s incredibly short sighted. One of our employees was sent to employee health after they developed a nasty cough this week. They were told no test needed, no quarantine needed, no mask needed, they could go back to work, the cough alone was not concerning.
Thank you.

CDC Failure

The guidance on the use of masks needs to be clear for both clinicians and the public. While CDC says it has been updated that does not appear to be the case and remains so vague that there is great flexibility for facilities to do what they want. Fortunately, the Joint Commission has now been clear in their recommendation that not only should staff be allowed to wear their own PPE if they have it and the hospital is not providing it, but they refute the CDC guidance and cite evidence while admitting it is incomplete. The Joint Commission confirmed that they are receiving reports from across the country of hospitals refusing to let staff bring their own N95, surgical, and homemade masks.

Use of Mask for the Public

As bad as the CDC guidance has been for healthcare personnel it has been equally bad for the general public. Statements have ranged from it isn’t need and handwashing is adequate to masks can increase a person’s risk of contracting the disease. Both are clearly misleading. The rational was first:

  • We need to conserve the PPE for healthcare personnel and the general public is at low risk. Because the virus is spread through droplets from coughing or sneezing you would need to be within 6 feet of the person that is sick.

When it became clear that many cases were actually being spread by asymptomatic people and that the virus may linger in the air longer than they first thought they still did not change their recommendation. They did change their approach.

  • People do not need to wear a mask when outside because they will wear them improperly and may increase their risk because they will be more likely to touch their faces and it will give them false confidence.

Obviously, we all know that we need to conserve N95 and surgical masks for healthcare personnel. They are our front line and deserve all we can do to protect them. However, the government is now telling us that a minimum of 100,000 to 240,000 Americans will die and 50% to 70% of the country may contract COVID-19. Spare us the rhetoric that the risk is low. Also, don’t insult people. No one thinks a mask is a protective forcefield. What the average person feels is that even a homemade mask is better than no mask. When a homemade mask or other non N95 mask is worn and combined with social distancing, handwashing, and not touching one’s face it decreases an individual’s risk when a person must venture outside.

As the nation’s leading public health organization, the CDC should remember that education is critical. If they believe that putting on a mask makes the average citizen suddenly forgets that they should social distance, wash their hands, and not touch their face then the answer is a public service campaign to remind people. If they believe that people will wear masks improperly again education is critical and they should immediately make an infographic or short video demonstrating how to properly put on a mask, take it off, and clean it or dispose of it. The real risk would be people reusing disposable masks and/or not cleaning masks. Of course, this ignores the fact we are asking healthcare personnel to do just that. This is public health 101. Treating the public as if they lack any reasonable amount of intelligence is insulting and not helpful.

What Does the Research Show

In a Lancet article  that reviewed different countries’ use of masks and the available evidence they pointed out that “there is an essential distinction between absence of evidence and evidence of absence.” They concluded, “community transmission might be reduced if everyone, including people who have been infected but are asymptomatic and contagious, wears face masks.” A cluster randomised trial of cloth masks compared with medical masks in healthcare workers found that medical mask are significantly better and should be preferred during a pandemic for healthcare providers. However, they also pointed out that medical masks are not always an option. It was suggested that cloth mask with multiple layers and tighter weaves would be more effective than the current cloth masks that they tested.  Testing the Efficacy of Homemade Masks: Would
They Protect in an Influenza Pandemic provides some insight into what materials may be best for a homemade mask. Smart AIR took the information and put it into a useful graphic that compares homemade masks to surgical masks.

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While the graphic below also isn’t evidence it makes clear that places that routinely do wear masks have fewer cases of COVID-19. Of course, there are other confounding variables and this is just one piece of data.

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Information on Making Your Own Mask

I think everyone should take the time to make their own mask. It will serve as a reminder that we are in a battle to save lives. It will remind us that in many poor countries this is all they have when they care for patients. It will give children a craft project while they are out of school that can be used to teach science, health, public safety, social responsibility, and even math. And most importantly, it may give you just a little extra protection when you absolutely must go out.

Making your own mask is not that difficult for anyone with basic sewing skills.  I’ve provided a couple of links that have instructions.

I wish you all good sewing.


There is No Greater Day to be a Nurse

This morning many of our neighbors woke up without jobs for the first time in their adult lives. They have worked hard to learn a trade, build a business, and build a comfortable life. Due to no fault of their own, they are worried that they will now lose it all. It is new to them because they have always believed in the American dream that through hard work and perseverance they can succeed.

Nurses, physicians, and all those in healthcare that must do their jobs during this crisis do so with dedication and more than a little bravery and self-sacrifice. Sadly, a couple of days ago I saw a post by a nurse practitioner that suggested he should get paid “hazardous duty” pay if others are being paid to work from home. I, of course, replied that he was doing his duty… I’m sure he isn’t the only one that has had a similar thought, but we should work to dispel such ideas.

As nurses, we should be thankful that we are getting paid to do the job we love. At this moment we are asked to do it for our neighbor and our country. When others are worrying about how they will pay their bills, feed their children, and recover when this is over none of us face those concerns.

Once in a lifetime, if we are lucky, we are given the opportunity to serve selflessly. Don’t sully it by making this calling about money.

The American dream will live again in others because you see them through this difficult time and provide them the care they need to recover. There is no greater day to be a nurse.


Let May Registered Nurse Graduates Practice Now

Each May over 100,000 nursing students graduate from programs across the country. Most of those students are now being pulled out of clinical and their classes have moved online. Some are being told their graduation may be delayed. The faculty will make every effort to deliver the content, but it will not be the same as the in-person classes. As anyone who has developed an online class knows it is an extreme amount of work that can’t be done in a few days.

Considering the current 8% nationwide vacancy rate for nurses and that the additional need over the next few months may exceed 100,000 nurses, it would help with the surge needs of hospitals to grant the May graduates their degrees now and waive the NCLEX. I know that some will think this is radical and how will we ensure quality. The truth is most students pass on the first try (88.18%) and if you add a second try (72.85) it is near 100% total pass rate. While students may go back and study more they do no more clinical. Thus the clinical skills they have at graduation are the ones they will have when they enter practice even if they take the exam a second time. If we can get the students out now, it may be a substantial help to hospitals that are likely to become quickly overburdened. Additionally, most of these nurses will be in the age group less impacted by COVID-19.

A second option would be to allow them to graduate now, practice for 6 months as an RN and at the end of that time take the NCLEX. As a faculty member, I prefer option 1 because we know that the longer the student delays the NCLEX the less likely they are to pass on the first attempt. Universities are assessed based on that pass rate and it would be unfair to penalize them, or the students, as the result of a national emergency.

I can hear the uproar now from people saying they need to be oriented, we don’t enough people now, and so on. However, much of the orientation could be condensed. Much of HIPAA is waived during a public health emergency so do they really need that training right now? Most have used the electronic medical record in school, so it could be taught very quickly. They are all required to have the necessary vaccines, CPR, and many other items just to enter their clinical practice settings. The truth is there is a lot of redundancy between what a hospital requires for the new employees and what schools require for students in clinical.

It is time for the National Council of State Boards of Nursing and all Boards of Nursing to take bold action. We should think out of the box and while we are at it break it down and throw it in the recycling bin. If we continue to practice as normal and hold tight to our policies we will do more harm than good if the worst-case scenario occurs with COVID-19. It is the time to act and let our May graduates have their degrees right now. If we wait until we are facing the worst-case scenario it will be too late. We must put the patient first.

Let May graduates practice. Let them join the fight against COVID-19.


Scoop and Run: A Plan for the 4th on the National Mall

The first time I attended the July 4th fireworks in DC it was with a friend’s family who attended every year. As we were on the metro headed to the mall she informed me that when the final volley of fireworks began to “scoop and run”. Pick up all of your stuff and run to the metro as fast as possible to be on the train that would be waiting. Otherwise, we would be stuck in the crowds for hours.

My advice to anyone attending the July 4 celebration this year is to be prepared to scoop and run. Know your exits, know where the metro is, know your way to walk across the bridge if it is too crowded and for goodness sake don’t drive. But also know where there is a safe area close to you. What shops and restaurants are open where you can get through the door and out of the crowd? Be prepared that some places in the event of mass demonstrations will go into lockdown quickly. If you are in you will stay in and if you are out you will stay out.

Events of civil unrest in cities across the United States raise awareness of injustice in our society and they appear to be on the rise. Yet, it is those moments when civil unrest occurs that we often fail to recognize the human dignity of every person. Civil unrest can lead to physical violence as it did recently in Portland. Our instinct may be to respond as we would in a disaster and seek help from police and places like the medical aid stations. However, this may be the wrong action during the unrest. Because of heightened tension between the police and the general population they may view your rapid approach as a threat rather than fear. The presence of police in the medical aid station may not be possible and even if possible, it may only attract the unrest to the area and thus be undesirable.

I doubt there will be any civil unrest at the July 4th fireworks in DC, but if I were ever going to encourage caution this would be the year. Anytime a large, nationally televised event is politicized it increases the risk of clashes. Politization may include the “baby Trump” balloon, flag burning, and white supremacists. We also know that inequalities in society, culture, and finance have resulted in civil unrest, rioting, and intentional violence throughout our history. When one group is given special privileges at an event that has always been egalatarian it increases the risk of problems.

10 tips to a safe July 4th on the National Mall

  1. Stay hydrated and be aware that there are sometimes long lines at vendors. Dehydration alters your ability to think clearly.
  2. Wear sunscreen just because I’m a nurse and we remind you of the obvious.
  3. Dress appropriately for long walks and hot weather. Running or walking shoes will be better than sandals.
  4. Bring your fanny pack first aid kit or put a small one in a bag.
  5. It is always better at large events to carry your belongings in a clear plastic tote bag so that everyone can see there is nothing of danger in it.
  6. Do not bring anything with you that could be perceived as a weapon.
  7. If you see people with weapons other than police move away as quickly as possible and notify law enforcement.
  8. Be aware of your surroundings and know where the exits are located.
  9. Do not engage people who are protesting. Even if you think you agree with them sometimes people surprise you with what offends them and when you are hot and tired your own response may even be a surprise.
  10. Be cool, be calm, be alert, be gone if trouble begins.

I hope everyone has an enjoyable July 4 and remembers that the day is a celebration of our independence. It is a time to celebrate a great nation and remember that children will be present.

Nurse Leaders’ Response to Civil Unrest requires preparation. It is a good time to go through your checklist before the events begin on July 4.

 


Book Review: Voices of the Dead

I received a free copy of Voices of the Dead by John Babb, a retired U.S. Public Health Service, Rear Admiral. I read his first book Orphan Hero which I enjoyed, but this one is different. It is a historical novel set in 1878 and tells of Yellow Fever in Memphis and New Orlean. I could feel the humidity as I read of the nurses and physicians responding to the deadly virus and risking their lives to serve others.

There are plenty of nurse heroes in this book, but also everyone from physicians to Sisters, from Priests to Madames stepped up to help their neighbors and some lost their lives in the effort. Whether you are a lover of historical novels, or epidemiological investigations, or an infectious disease nerd this is a great book.

Of course, it could be that I liked it because it had all the things that fascinate me, steamy southern cities, infectious diseases, legislation like the Quarantine Act, selfless physicians and nurses, and the Marine Hospital Service which lead to the Commissioned Corps of the U.S. Public Health Service. It dealt effectively with the fears of quarantine and what citizens do when quarantine is ordered. In many ways, it is a case study of epidemics prior to modern healthcare.

I don’t want to spoil the book, but if you are a public health worker I think you will love it.


Academic Pet Peeve: What’s yours?

Pet peeve of the day: careerism.

My career has been a great pleasure. I loved being a U.S. Public Health Service (USPHS) officer and I now love being an academic. The worlds have commonalities that drew me to them. They are filled with people that are dedicated to service and to making the world more beautiful. At their worst, there are too many careerists that never consider how their secrecy robs the public of knowledge.

I became a USPHS officer because I wanted to work with the poor and the underserved, but was too fearful of being poor to be a missionary or join the Peace Corps. I became an academic because I wanted to create new knowledge and share it to improve health care and quality of life.

Throughout my career, I have grown increasingly intolerant of those that take a taxpayer-paid salary or taxpayer-funded research grants and then refuse to openly share their work. Over and over I have seen people recreate the wheel because others didn’t know it existed or didn’t respect the person that created it and thus felt it necessary to recreate the work and again at taxpayer expense.

Today I heard an expert on nuclear preparedness communication hold forth on the need to, “make research accessible”. He went on to say that research cannot just be in the peer-reviewed literature. This would have had more integrity if he and most of his panelist had not prefaced their presentations by insisting that there be no photography or recording of their presentations as some of their work is copyrighted.

Hypocrisy: the practice of claiming to have moral standards or beliefs to which one’s own behavior does not conform; pretense.

Castle_Romeo_Atmospheric_Testing_Cropped

Nuclear preparedness research on how to best communicate with the public is critical to preparedness, but for it to be truly effective it must be put into practice not just at the higher levels of government, but it must get down to the workers, to the mom at home with children, or to the average nurse. As the speakers stated the average teacher or clinician doesn’t read the peer-reviewed literature. How will research get down to the bedside if researchers don’t freely and openly share their work? How will we be prepared for a nuclear event if those doing the research and government officials will not share?

If you really care about improving healthcare, making us more prepared, or creating new knowledge consider the impact on lives when careerism rules public good. We can’t let advancing a career trump the public good.

End of rant.

 


Good Nursing is Prudence

The intellect and not our will must guide our decisions. Yet, it is often our will that gets in the way of sound reasoning. Don’t we all want what we want? Would we not prefer to get our way? I know I would and at times my own will has gotten in the way of hearing what others had to say.

When I joined the U.S. Public Health Service (USPHS) I wanted to work with the poor and underserved. I had a mental image of what that meant. Simply, it was those in poverty or homeless. It had never occurred to me to consider those in prison or detained by immigration as poor or underserved. Nor did I ever consider the disproportionate impact that disasters have on those that are poor or homeless.

Late in my career, I accepted a job with the Administration for Children and Families (ACF) working for Daniel Schneider, who is now the Executive Director of the American Conservative Union and CPAC. I was fascinated by what he described to me. He wanted an office that would address the human services needs of people impacted by disaster and especially those that were poor or marginalized. He wanted the office and programs to be built on the principles of self-determination, self-sufficiency, federalism, flexibility and speed, and support to states. Of equal importance, he wanted a close working relationship with faith-based organizations. I was free to develop it as I saw fit so long as I understood that I was fully responsible for any success or failure. It was an opportunity to combine my work in disaster management and at the same time return to working with the poor and the underserved. I was all in and then I had my first meeting with faith-based groups that worked in disasters – ouch!

The first meeting was eye-opening. It was clear that people were angry and especially the person from the United Methodist Committee on Relief. There was bad blood and before I would ever be able to make progress fences needed to be mended. Fortunately, I didn’t have to do it alone. Two amazing organizations stepped forward and offered to help. The first was Catholic Charities, USA that filled me in on what had transpired following Hurricane Katrina. While I had worked in the Office of the Assistant Secretary for Preparedness and Response since 2001 I had no interaction with the human services programs. The second organization was the American Red Cross who suggested I let them host meetings on neutral grounds. I was grateful and realized that I needed to do a lot of listening.

While I listened I also knew that good policy had to be evidence-based or adapted from a policy that has historically been effective. It could not be based on emotion or lack intellectual reasoning. I understood that there had been hurt feelings and a lack of listening in the past, but I would not ignore that there were successful programs that could serve as models. While the population served was different the goals and objectives were the same. We needed to get to mutually agreeable principles and we needed to use evidence-based policy.

The stakeholder meetings revealed that health care was largely excluded from the services offered by Voluntary Organizations Active in Disasters (VOADS) and case managers rarely had health care experience. I wanted the case managers to be nurses, but the VOADS and my contracted faith-based organization wanted them to be lay people. We compromised and had a combination of case managers we trained and nurse case managers. When all the research was completed and the program pilot tested it turned out that what was primarily needed was the lay case manager with nurse case managers to be available for people with complicated medical needs and for consultation. Because I first listened and because we were all willing to follow the evidence we ended up with a program that we could all support. You can learn more about the ACF Disaster Case Management program at: https://www.acf.hhs.gov/ohsepr/response-recovery/disaster-case-management .

I considered the development of the Disaster Case Management program a great professional accomplishment. I had an amazing team, exceptional partners, and political appointees that trusted us to do our jobs and have the best interest of the country in mind. There was mutual respect. However, the sense of professional accomplishment paled in comparison to the change in my spiritual life.

When I was in Baton Rogue with Catholic Charities, USA I was asked to stay with them at the retreat center. They gave me free access to the grounds and the chapel and said I could use it anytime. I hadn’t been to a church of any kind since my twenties and so I was amused. Then I listened as CCUSA had to remind the Catholic sisters that they couldn’t give away all of the food. I watched as CCUSA personnel and volunteers worked with compassion and patience and with their dedication exemplified what it means to serve. I, on the other hand, could only see a mission to be accomplished and my cadre of young officers as tools to accomplish it. While CCUSA saw the humanity in everyone I wasn’t even seeing it in my own people. By the time I left something had changed. I was no longer listening with my ears, but with my heart. The VOADS and the faith-based organizations had a different perspective than the government. It wasn’t about sitreps, or numbers proving the success, but rather compassionate care provided to people that were suffering.  I woke up one day shortly after our time in Baton Rogue and announced I intended to retire. Not long after the project was completed I was working for a small Catholic university where I found what I sought and though I left the university after three years what I found and what they nurtured has never left me.

Following the evidence resulted in a policy that ensured better services to the poor and underserved impacted by a disaster. Letting the spirit transform the knowledge into an accomplishment for good put the program in hands that are filled with compassion. By being open to what was good and just rather than tactically efficient government and faith-based organizations were able to bring the best of what each has to offer to serve those in need.

I am forever grateful to Dan for the opportunity, to the administration at the time for prioritizing the poor, and to Brent whose faith I am sure crafted the principles on which the program was built and through which I found my faith. The experience showed me what I lacked as a human being, what I no longer wanted to be, and a path to a more compassionate existence.

Prudence is the birth mother of all virtue.

compassion