due to the risk of spreading the virus within the hospital. Moreover, the critically ill present with respiratory failure

due to the risk of spreading the virus within the hospital. Moreover, the critically ill present with respiratory failure and require intubation and ventilation. Ventilators are a similarly limited resource with an estimated 140,000 for the entire country. In the extreme, reports from Italy suggest that doctors are practicing “wartime triage” in which limited resources such as ICU and ventilators are being allocated to younger, healthier patients over the elderly. What an ethical nightmare.
Note: many hospitals are making changes rapidly to try and expand capacity, but there’s only so much that can be done. Things that are being done almost across-the-board include cancellation of all elective surgeries to reduce inpatient volume. Entire units or even hospitals are being converted to COVID-19 wards/ICUs. For example: HSS (Hospital for Special Surgery — an orthopedic hospital) and an ambulatory surgicenter are both being converted to accommodate COVID-19 patients now that elective surgeries have been cancelled. Between additional space, co-locating patients (shared rooms), and re-purposing medical wards, large medical centers may be able to create 50–100% more ICU space. (3/22: Governor of New York just issued an order for all hospitals to expand capacity by 50% with a goal of 100%).
Personal protective equipment

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PPE for staff is critically important. This is where the US appears to be most in danger of falling short nationwide — not just in the epicenters of NYC or Seattle. COVID-19 is spread through droplets — that is, small particles are coughed or sneezed out and get onto hands and other surfaces. In general, “droplet precautions” in a hospital means a new disposable gown, glove, and mask is worn into a patient’s room and then disposed of before returning to the hallway. The purpose is to both protect the health care provider from the virus, and to prevent spread to other patients. You can do the math on how quickly hospitals normally go through masks and gowns. One report I saw was New York Presbyterian typically uses 4,000 N95 respirators (masks) in a normal day. Since the outbreak, they are using 40,000 in a day, and expect to need as many as 70,000 at the peak of the infections. Hospitals across the country are sounding the alarm that they are down to under a week’s supply of masks and respirators. Physician Facebook groups are filled with anecdotal stories of hospitals rationing masks or asking providers to re-use masks. See for a heartbreaking reaction to the CDC advising that bandanas and scarfs could be used as a mask in a pinch. To place providers at such risk is irresponsible.
Why is PPE critical? On one hand, we need to protect the staff (more on this in #3) or else the available workforce will shrink rapidly. As an otolaryngologist, let me share a frightening finding from our Chinese colleagues. The virus is particularly concentrated in the epithelium of the nasal cavity — this is why we are using nasal swabs for testing. During a transnasal endoscopic pituitary surgery in Wuhan at the beginning of the COVID-19 crisis there, the patient was unknowningly positive for COVID-19 and the aerosolized particles infected all 14 members of the health care team that entered the operating room during that case despite routine precautions of a surgical mask. Providers must have access to N95 respirators and PAPRs/CAPRs as needed to protect themselves as they care for patients. In Italy, the numbers are sobering — up to 20% of the healthcare workforce has been infected. As the number of cases climb, hospitals are increasingly short-staffed. Medical students are being forced into early graduation and recent retirees are being pressed to return to the front lines.