BOSTON — Six weeks in, the dozens of doctors, nurses and other staffers leading the emergency response to the novel coronavirus are crammed into a small conference room. They line the walls and sit on the floor.
They already had confronted shortages of respirators and test kits, and in rapid-fire order they laid out their plans for foreseeable challenges.
If the hospital were overwhelmed with sick patients, they could limit elective surgeries to free up room space. Expand remote virtual care to reach patients who then could stay at home. Establish a pop-up clinic to evaluate people complaining of symptoms of covid-19, the illness caused by the virus.
As the team at Massachusetts General Hospital met late last week, more than 3,000 people had died around the world, and the number of cases of covid-19 was climbing across the United States and in Massachusetts.
Mass General is a renowned medical center with just over 1,000 beds and top research facilities, the kind of place many patients want to be when something terrible happens. Yet in a sign of the enormous challenge covid-19 poses to the health-care system, even emergency-response teams here were bracing for an outbreak that seemed increasingly likely to test staff and resources.
At the ground level — observed during several days at Mass General and in interviews with key planning leaders — teams were working long hours to deal with challenges that the White House was playing down or insisting did not exist.
Each federal pronouncement has had implications for the experts crowded into the conference room.
Even as U.S. cases ticked up, federal health officials at first tightly restricted testing for the coronavirus. Then they suddenly and significantly expanded it, with President Trump — despite the scarcity of test kits at the time and the difficulty of using them — calling the tests “beautiful” and suggesting wrongly that any American could get one with a doctor’s permission.
“Anybody that needs a test gets a test,” Trump said Friday at the Centers for Disease Control and Prevention, just hours after the Mass General team had been discussing how arduous it was to get a patient tested, and how long it took to get a result.
When Biddinger and his colleagues met Friday morning, only three people across Massachusetts had tested positive for the virus. But another three out-of-state residents had just fallen ill with it after attending a meeting held in Boston by the biotech company Biogen, according to company officials. Others who had attended the 175-person company meeting were feeling sick.
The hospital’s experts have been planning and practicing their response to dangerous infectious diseases since at least 2002-2003, when the emergence of SARS — severe acute respiratory syndrome — awakened the world to the potential for deadly new coronaviruses.
Mass General is one of 10 medical centers across the nation federally funded to handle patients infected by Ebola and other special pathogens. When covid-19 began spreading from China earlier this year, Mass General officials wrote a handbook for preparing and coping with the disease that has been used and adapted by hospitals in the United States and abroad.
Even with that foundation, as hospital leaders repeated in sessions with staff, there is much that lies beyond the direct control of doctors and nurses and administrators, from the messaging out of the White House to the availability of tests, protective gear, and negative-pressure rooms designed to contain contagions.
And there is much unknown about the disease, including how long the virus can live on surfaces, how frequently it is transmitted by people who haven’t yet developed symptoms, and its mortality rate in the United States.
During a midweek town hall for Mass General’s 27,000 employees, Biddinger promised the hospital would be transparent about its challenges but also underscored the rapidly changing circumstances they all faced, sometimes hour by hour.
Don’t print any coronavirus information from the hospital intranet, he said, including information about which patients should be tested or what protective gear is required when treating them.
“Printing things and taping them up on the wall, much as that’s a hospital time-honored tradition, is not really the way to go,” said Biddinger, who is director of the hospital’s Center for Disaster Medicine. “In two, three, four days, it will be out of date.”
He was right.
Between Wednesday morning and nightfall Friday, the federal government issued the new rules governing who should be tested. Five more people from the Biogen meeting tested positive for covid-19, according to state health officials, and 113 more needed evaluation, according to Ann Prestipino, the hospital’s incident commander for the outbreak.
Half of them would be coming to Mass General.
Testing challenges
Workers from across the hospital descended to the ambulance bay to set up a makeshift clinic to examine and potentially test dozens who had attended the tech company meeting. A sister hospital across town, Brigham and Women’s, was getting the others.
The bay space buzzed. A clutch of nurses and doctors planned how to efficiently and safely move patients in and out of the negative-pressure room where they would be swabbed for testing. Others rolled in hand-sanitizer stations and computers on wheels, stocked a cart with masks and gowns, and adjusted pink curtains to wall off a private space for taking patients’ vital signs.
Two men set up folding black chairs, snapping the yellow measuring tape they used to ensure that seats were placed at six-foot intervals — the spacing the CDC recommends as safe distancing in crowds.
The pop-up clinic could evaluate and test about four patients per hour, and so the meeting attendees would be seen Friday night and Saturday morning, Prestipino said. And the clinic may stay open to accommodate a surge in the number of people who need evaluations.
As of Monday, of the state’s 41 confirmed or presumptive cases of covid-19, 32 were associated with the Biogen conference, the Massachusetts health department announced.
Beyond the pop-up clinic, Mass General health-care workers who encounter a patient with fever, cough and other symptoms of covid-19 can call a “biothreats” pager at the hospital for advice and help determining whether that patient should be tested. On Tuesday, the pager buzzed about 20 times, according to Erica Shenoy, an infectious diseases doctor and associate chief of infection control.
By Thursday afternoon, the buzzes sounded every 10 minutes and had become a full-time job for Amir Mohareb, a young infectious-diseases doctor who fielded calls from a desk in a medical office building.
His job was to help determine whether to seek a test, and then to discuss each case with state public health officials, who ultimately make the call on whether to approve a testing request in accordance with CDC guidance.
When the coronavirus first hit the United States, the CDC’s testing guidelines were so stringent that they made it impossible to test some of the patients who hospital officials suspected of having been exposed. A person who was ill with symptoms, for example, and who had recently returned from one of the then five countries with serious outbreaks — China, South Korea, Iran, Japan and Italy — could not get tested unless they were so sick that they had to be hospitalized.
“Some cases I thought would get tested were declined,” Mohareb said.
An inability to test has been a key problem nationwide.
As of Thursday, only 25 patients had been tested across Massachusetts, including a handful at Mass General. The strict CDC criteria accounted for some of the low numbers, but so did a nationwide shortage of tests.
The Massachusetts Department of Public Health had the capacity to test only 100 individuals as of the end of February, according to hospital officials who work closely with the state agency. Vice President Pence at one point said that 1.5 million tests would be ready by this past weekend.
But by Friday, public health labs had received tests for up to 75,000 people, and more than 1.1 million tests had been shipped to nonpublic health labs, including academic medical centers and commercial laboratories, federal officials said.
Testifying before Massachusetts legislators on Wednesday, Larry Madoff, an official at the state health department, said his agency expected to receive close to 1,000 that day.
As other nations swiftly ramped up their ability to test thousands, the United States by March 1 had managed to test only several hundred, inviting a barrage of criticism.
It was in that context that Pence said last week that “any American can be tested” subject to a doctor’s order. The CDC formalized that declaration the next day with new, looser rules on eligibility.
To many Americans, the new rule may have sounded as if the door had been thrown open to widespread testing across the country, but that simply wasn’t possible. “It is not true that anyone can just go to their doctor and get tested right now,” Biddinger said.
Tests are still so scarce, and testing still requires so much time and so many resources — in the hospital and at state labs — that they have to be reserved for those who need them most. And the people who most need tests, Mass General officials said, are those who are sick enough to be admitted to a hospital, where health-care workers must know who is infected to protect the fragile inpatient population.
Research cited by the CDC suggests that 80 percent of coronavirus patients experience only mild to moderate symptoms.
“We are currently still trying to explain to state and federal authorities that operationally, we can’t support a very large number of people requesting testing for either screening or for mild illness,” Biddinger said.
He said some people by last week had already shown up at the hospital demanding to be tested.
The gap between the public’s heightened expectation for testing and the hospital’s priority on treating the sickest people puts front-line staff in the position of handling unhappy and sometimes angry people, he said. “It induces strains on the health-care system that we really can’t afford right now,” Biddinger said.
A squeeze on space, a squeeze on masks
Like many hospitals, Mass General operates at near capacity.
“Space is everything,” said Theresa Gallivan, an associate chief nurse who is doubling as director of operations for the coronavirus emergency. “Space is the only thing there’s less of than money.”
In an emergency, Mass General officials would expect to surge up to 20 percent past their licensed bed number, Biddinger said. When it comes to contagious patients, space issues are exacerbated by the need for negative-pressure containment rooms that are expensive to build and hence relatively scarce.
Of Mass General’s 94, 18 are in intensive-care units.
Under the hospital’s emergency plan, the first 10 patients admitted to the hospital will go to a unit designated for patients with special pathogens, a luxury most hospitals do not have. The next six will go to negative-pressure rooms on a floor normally reserved for neurological patients.
If an epidemic continues, the entire 16th floor of one building would convert into one large negative-pressure unit.
Like most hospitals, Mass General also faces concerns about a severe shortage of N95 respirators, the fitted face masks that the CDC recommends health-care workers use to protect themselves from breathing in particles of coronavirus, tuberculosis and other diseases.
The hospital usually receives weekly shipments of respirators manufactured by the Minnesota-based company 3M, said Ed Raeke, the hospital’s director of materials management. But the deliveries had become irregular, leaving Mass General with a dwindling supply.
3M, which has said publicly that it is ramping up production, hadn’t answered Raeke’s questions about why. As of Friday morning, when Raeke met with his colleagues, the hospital had less than a week’s worth squirreled away in a supply closet deep in the building.
Later that day, a shipment of respirators finally arrived, giving the hospital a cushion of a few weeks. But Raeke said he didn’t know when there would be more. “In this environment, it would be nice to have more predictability about what we’re getting or not getting so we can plan for alternatives,” he said.
A spokesperson for 3M did not reply to a request for comment.
In the face of so much uncertainty, hospital officials have turned to conservation.
Medical students and interns who are not essential for giving care are no longer to enter a patient’s room when N95s would be required. Infection prevention specialists no longer offer hands-on practice on how to safely put on and remove protective gear, which would use precious respirators; instead, they do a demonstration.
Mass General officials said they expect that the federal government may eventually relax its guidance on negative-pressure rooms and N95s to match that of the World Health Organization, which says those rooms and respirators are necessary only for procedures that cause the patient to cough, sending tiny virus particles into the air. That move would ease the problem, here and at hospitals across the country, of too little space and too few respirators. Biddinger and Shenoy think the scientific evidence shows that nurses and doctors would still be safe under the WHO policy.
But such a change would also require persuading front-line medical workers — who have been taught they should use N95s to protect themselves — that they will not put themselves at risk by sometimes using a loosefitting surgical mask instead. In the middle of an outbreak, that could be a hard sell. But it could also be the only real choice, if the disease overwhelms the fragile supply chain. The CDC Web page on maximizing the efficient use of N95s already includes a section entitled “When no respirators are left.”
“Not to be melodramatic,” Prestipino said, “but if you’re in a very-worst-case scenario across the country, you will ultimately deal with what you have.”
