Two weeks ago, as a surge of COVID-19 cases loomed, nurse Dawn Kulach worried that she didn’t have the gear she needed to stay healthy and on the job during the worst pandemic in a century.

Wary of running out of N95 masks, Virtua Health System was limiting them to workers at its five South Jersey hospitals who were dealing with COVID-19-positive or suspected patients.

Knowing that people without symptoms can carry the easily spread virus, Kulach, a medical surgical nurse, asked for better equipment for herself and colleagues. She got permission to wear an N95 brought from home, but kept agitating for other nurses who didn’t have the masks.

On Friday, she said, she was dismissed for insubordination.

A Virtua spokesperson wouldn’t talk about Kulach’s case, but said bringing items from home could hinder infection control and staff are expected to adhere to hospital policy.

Nurses like Kulach have been hailed as heroes for their courageous work in dangerous times.

In numerous interviews, nurses told The Inquirer they wave off that title, saying that saving lives is their calling. The work now is physically and emotionally taxing in ways they could never have imagined, but that, too, is part of the job they love.

They understand their employers’ struggles to get the medicines, ventilators, and protective gear that governments around the world have been fighting over. Hospitals note that the shortage of supplies has forced them to make difficult choices.

“N95′s remain a scarce resource,” said Patrick V. Norton, Penn Medicine’s vice president for public affairs. “Given the unpredictability of the pandemic, we remain vigilant in our efforts to procure and conserve PPE to ensure we continue to have an adequate supply of these resources to protect our staff.”

But nurses say what has stunned them is how their employers react when they try to point out the risks they are facing and suggest alternatives.

“I wish [hospital administrators] were saying to us, ‘Hey, this sucks, we’re trying to get you PPE,’” said an emergency nurse at Pennsylvania Hospital who, like most of the nurses The Inquirer interviewed, asked to remain anonymous because she feared losing her job. “But the messaging has been more, ‘It’s fine, don’t worry about it and don’t make a fuss about it.’”

Philadelphia nurses, a dozen of whom spoke to The Inquirer, are far from alone. Twitter is inundated with accounts from health-care workers frustrated by a lack of protection at work. Medical personnel from Los Angeles to New Jersey have faced punishment and termination for speaking publicly. On Wednesday, nurses protested outside several Philadelphia-area hospitals, calling for better safety practices on the job.

Daily danger

Pennsylvania’s Department of Health estimates that about 5% of the more than 23,000 confirmed COVID cases are health-care workers, but that is likely an undercount. Nationally, at least 9,000 in health care had been infected as of April 9, a report from the U.S. Centers for Disease Control and Prevention concluded.

Another recent CDC recent study, of COVID wards in Wuhan, China, validates nurses’ fears. Coronavirus particles were found in the air and on surfaces, even in areas of COVID treatment wards not immediately adjacent to those with COVID patients.

All front-line health-care workers know they’re at risk — the concerns are over how much of that risk is avoidable.

“This is my job, this is my career,” said one Pennsylvania Hospital nurse, who declined to be named for fear she could lose her employment. “I know it’s a lot and some days I do get really upset, but this isn’t going to be a forever thing.”

Social distancing is impossible for nurses, so they carry small bottles of hand sanitizer and try to touch only the people and objects they have to, said Temple University Hospital intensive care nurse Beverly Minch. Their work spaces — phones, counters, even the copier — are regularly cleansed. But without proper PPE, they don’t feel safe.

N95 masks can block at least 95% of very small airborne particles, including viral particles that could slip through surgical or cloth masks. Once they were considered disposable, good for just one patient interaction. Now, because of shortages, CDC guidelines say to keep using the same one as long as it holds up. Only staffers likely to be exposed to an airborne or fluid hazard need them, according to the federal agency’s website.

This change in medical practice violates all their training, nurses say.

“Stuff that was always considered disposable, single use, for my entire career — now they’re saying reuse it,” said the Pennsylvania Hospital nurse. “Or [that] you don’t have to use an N95 for that procedure now, you can use a surgical mask.”

Kulach noted that even though her employers said N95 masks are not needed away from COVID-heavy wards, she knows of nurses in areas considered low-risk who have caught the virus.

Dawn Kulach was let go after asking for better equipment for herself and colleagues. “Part of being a nurse is to protect yourself so you can take care of others,” Kulach said.
TYGER WILLIAMS / Staff Photographer
Dawn Kulach was let go after asking for better equipment for herself and colleagues. “Part of being a nurse is to protect yourself so you can take care of others,” Kulach said.

Virtua confirmed that four nurses have been hospitalized for the virus and one is still in a hospital, but would not say where they worked.

So much about the virus remains unknown that guidance for health-care workers from medical authorities constantly shifts. Different hospitals have different policies. That uncertainty, nurses said, adds to anxiety.

“It’s really hard for us to understand these emails every day,” one front-line Penn Medicine nurse said. “What is real? You guys don’t even know what’s real," she said of executives issuing the memos.

As a result, health-care workers resort to personal protection measures that may not do much for their own health.

“Some nurses are going entire shifts without eating or drinking because they don’t want to risk exposure,” said Peg Lawson, a nurse at Einstein Medical Center in Philadelphia.

Pervasive anxiety

Nurses at Temple joke that Minch is unflappable, the last one to lose her cool even on the most hectic days. She does not agree.

“I am mentally and physically exhausted,” she said last week.

Longtime nurses accustomed to seeing elderly patients die from pneumonia are watching the same thing happen to people in their 40s and 50s.

“What we’re not used to is how sick they’re getting, how fast they’re getting so sick, and how young they are," Minch said. "No matter what we do, some people I can’t fix. We’re not used to that.”

Minch said last week that she held the hand of an older woman whose breathing was so impaired, she had chosen to be placed on a ventilator.

The two of them talked as the sedatives needed to have a tube placed down her windpipe took effect.

“She just wanted to know what her chances were of waking up again,” Minch recalled. “The fact that I couldn’t give her that answer tore me up.”

The patient is recovering and off the ventilator.

“I was so happy for her," Minch said, "I teared up when I went in to speak with her.”

Nurses described watching out for friends who are seeming overwhelmed, and taking them for quick coffee breaks.

“It’s like a little family,” said the Penn Medicine nurse. “You don’t want anybody you know to get this. We all have to look out for each other.”

Doctors, nurses, and technicians are collaborating and supporting each other in unprecedented ways.

“They’ve never asked before, ‘What can I do to make your day easier?’” Minch said of her physician colleagues. “'What can I do so you don’t have to go into this room?'”

In the dark

Until Monday, Penn Medicine dictated that hospital staff not wear N95 masks when treating many COVID-19 patients, reserving them only for those in isolation or having procedures like intubation that spew more of the virus into the air.

In one emergency department at Pennsylvania Hospital, nurses were instructed not to bring N95 masks from home to maintain “continuity" among team members, according to an email obtained by The Inquirer.

The policy shifted Monday to give workers the option to wear N95 masks around any confirmed or suspected COVID-19 patient and in emergency rooms, in response to staff concerns, a Penn spokesperson said.

At Temple, Chinese-made versions of the N95 the hospital recently obtained don’t always fit properly and seem prone to breaking, nurses said.

“I’ve worked for more than 25 years,” said Francine Frezghi, president of the Temple University Hospital Nurses Association, a local of PASNAP. “I’ve never seen this version before.”

Temple did not respond to questions about the new masks, but concerns about the Chinese KN95 masks have been raised in Missouri and Boston, too.

Not only are they using disposable masks repeatedly, nurses say, they are made to feel badly when they need a replacement.

“You almost feel like you can’t ask for another one,” Minch said. “You almost pray yours doesn’t break during the day because you don’t want to get any pushback if you have to ask for another mask."

Beverly Minch is working at Temple University during the COVID-19 outbreak.
JESSICA GRIFFIN / Staff Photographer
Beverly Minch is working at Temple University during the COVID-19 outbreak.

Another source of distress: not knowing how many of their colleagues are out with the virus, said nurses at Temple and Einstein and surgical technicians at Penn Presbyterian Medical Center.

An Inquirer effort to gather staff quarantine policies from large hospitals in the region and a count of how many workers have been forced to stay home due to exposure or infection was largely ignored.

Only Main Line Health provided the information, and its numbers show the toll that the coronavirus is taking on staffing.

Among that system’s four hospitals, 100 workers tested positive for the illness and 97 were awaiting test results as of Tuesday. Workers who have symptoms consistent with COVID-19 are required to quarantine for seven days, said Bridget Therriault, a spokesperson for the health system, and be fever-free for 72 hours before returning to patient care.

But amid the risks that work entails, purpose and focus endure. Nurses describe having little time to worry about hazards while wrestling to heal an onslaught of seriously sick patients.

Being at home, nurses say, is when they ruminate on the same unknowns haunting all Americans, only made worse by their inside knowledge.

Clearing the Record: Kulach’s title, medical surgical registered nurse, was incorrectly reported in an earlier version of this story.