By Betsy Todd, MPH, RN, nurse epidemiologist and AJN clinical editor. April 3.

One problem central to the experience of nurses during this pandemic is the disastrous lack of essential supplies and equipment. How different would your work days be right now if you had plenty of PPE and ventilators? In the parts of the country with the most COVID-19 cases, this problem is far from being resolved. In many other cities and states, unbelievably (after three months), you are likely to be faced with it soon.

Where is our PPE?

For weeks, nurses and physicians in states that were initially hardest hit by the pandemic (New York, California, Washington) have reported severe shortages of personal protective equipment. (See, for example, this ICU nurse’s anonymously published note to AJN.) Respiratory protection has been in particularly short supply. In many hospitals, staff are reusing one droplet mask or N95 respirator for an entire shift or longer. These dire circumstances were predictable. A  2015 article from researchers at the National Institutes of Health predicted that in a pandemic in which only 20 to 30 percent of the population is infected, up to 7.3 billion N95 respirators would be needed. COVID-19 is likely to infect a considerably higher percentage of the population. Where are our masks?

What about masks for the public?

Here nurse, I have an extra.

Meanwhile, the debate continues about whether or not masks provide added protection for members of the public who are out and about. Most people seem to assume that, if health care personnel need respiratory protection, they do too. But in clinical situations our exposure is considerably closer, “higher dose,” of longer duration, and more frequent than exposures experienced by the general public. The respiratory protection needed by health care workers will always be different from the needs of our families and neighbors.

Over the past week, the White House has repeatedly floated the idea that they will soon recommend that everyone wear a “non-medical mask” when out on the street. (This begs the question of where anyone can buy one.) This seems designed primarily to give people a sense of doing something. But most people don’t know how to handle a mask aseptically, and many will simply end up with a heavily contaminated mask (and hands).

Certainly, people with symptoms should wear a mask in public. For those who are immunocompromised or otherwise at high risk, a surgical mask can protect against droplets. And it is probably a good idea to provide masks to all of the incredible workers outside of health care who are keeping us going—the cashiers, post office clerks, transit workers, delivery people, and others—because of their frequent contact with so many people. But universal masking is likely to worsen the PPE shortage without adding significant protection for most people.

Continuing confusion about airborne transmission.

Adding to the confusion is the still-unanswered question of whether airborne (in addition to droplet) transmission is a factor in COVID-19 spread. This week, a three-page letter from members of the Standing Committee on Emerging Infectious Diseases and 21st Century Health Threats of the National Academy of Sciences did little to clarify the situation, even though many reporters are incorrectly reporting it as confirmation that the virus is airborne . . . and everywhere.

We know that aerosolized particles of this coronavirus have been detected in hospitals under specific circumstances (including, note well, after less-than-careful doffing of PPE in a confined space). This information can’t be interpreted as an indication that the virus routinely travels around on air currents, like tuberculosis or measles. And the actual patterns of person-to-person and neighborhood-to-neighborhood spread of COVID-19 do not suggest airborne transmission.

Ventilator need—the “apex” of moral distress?

As several states near peak numbers of infections, ventilators are in critically short supply. This, too, was predictable during a pandemic, and there was actually planning in recent years to meet this need. For example, in 2010 the federal government teamed up with a small private company to produce thousands of small, inexpensive ventilators that could be deployed during a pandemic. Just as working prototypes of the ventilator were about to receive marketing approval from the FDA, a multibillion-dollar company purchased the small company and derailed the entire project.

Now, ventilator shortages and surging numbers of COVID-19 patients have forced some hospitals into triaging candidates for ventilators. Alternatives to standard ventilation are also being pressed into use: shared ventilators for two patients who require similar ventilator settings; conversion of anesthesia machines into ventilators; and helmet-based oxygenation, successfully used in recent years in place of oxygen face masks, may help decrease the need for ventilators.

A ‘national pause’ that incorporates ‘massive, coordinated testing’?

Without adequate PPE for staff or ventilators for patients, epidemiologists argue that severe limits on person-to-person contact are our only hope of slowing the tide of new cases and preventing hospitals from being further overwhelmed. Some experts have called for an immediate national pause of at least two weeks—maintaining social distancing and stopping all nonessential activities—along with “massive, coordinated testing of the population” across the country to direct containment efforts and to guide the eventual easing of restrictions. Time will tell whether such an approach will gain widespread implementation.