Until last week, Hannah Borges was a registered nurse for Banner Health, where she’d worked for nearly 14 years.
She felt forced to quit on March 20, after she told her managers that hospital administrators weren't protecting front-line workers like herself from COVID-19, and they dismissed her concerns.
“I am committed to caring for patients but want to feel safe in so doing,” she wrote in a lengthy email to managers late at night on Sunday, March 15, in which she criticized Banner for offering "inadequate" personal protective equipment (PPE) to health care workers.
Banner was miscategorizing the new coronavirus, Borges wrote, by treating it as if it could be transmitted only on droplets while evidence suggested that the virus could be airborne, and thus more easily spread. She backed up her concerns with links to the Centers for Disease Control and Prevention, Johns Hopkins University, and news reports.
Moreover, Banner was basing its PPE policy for doctors, nurses, and other health care workers — who take daily care of people, including ones with suspected or confirmed COVID-19 — on the “possible misinformation” that the virus can be spread only on droplets, she added.
Nurses were being told that they should wear surgical masks, which have openings at the chin and at the side of the mouth, instead of the fitted N95 respirators recommended by the CDC to protect health care workers against COVID-19, Borges pointed out.
She signed off with a plea, for Banner to “resolve to keep the community safe by accurately categorizing COVID-19’s ability for airborne spread and thus supplying and promoting the use of proper PPE.”
The next day, Borges received a bland and brief response from her manager telling her that Banner was taking all of these things very seriously.
Borges wrote her initial email after spending a week on vacation and then trying to catch up on the latest with COVID-19. To her horror, she found chasms between the guidelines issued by public health agencies, like the CDC, and those of her employer.
“It was the downplay of a lifetime,” she told Phoenix New Times.
By the end of that week, Borges had decided to give notice, fearing that without adequate protective gear, she’d bring the virus home to her family.
“I have reviewed the stance that Banner has taken and am understanding that I would be unable to don simple PPE during presumable exposure while being in a hospital that lacks tests that can effectively diagnose and isolate individuals carrying the disease,” she wrote that same manager.
Her manager quickly responded to say that she took Borges’ email as voluntary termination of employment. Within two hours, confirmation arrived from HR.
Borges left her job on the frontlines of a pandemic in protest, out of sense of responsibility to herself and her family. In a tragedy years ago, she had already watched a close family member die while on a ventilator; she refused to do so again.
Many other health workers are not in a position to quit, but they remain terrified and furious that Banner Health is doing little to protect them as they risk their own lives and families to care for the sickest people in their communities, including patients with COVID-19.
For this story, Phoenix New Times spoke with six nurses or ex-nurses and two physicians across different Banner Health hospitals and reviewed internal emails and directives from Banner administrators to staff.
All but one of those workers — Borges — spoke on condition of anonymity because they were certain they would lose their jobs for speaking to media.
“I could get fired on the spot,” one acute care nurse, who said she was her family’s primary breadwinner, wrote in an email to New Times. “It’s scary, because our lives are at stake.”
She added, “There is so much the public doesn’t know and that Banner DOES NOT want leaked regarding [their] handling, or lack thereof, of Covid-19.”
Banner has explicitly told staff that "at this challenging time ... Banner employees may not talk to the media about COVID-19," an internal email obtained by New Times shows.
In response to detailed questions from New Times for this story, Banner spokesperson Becky Armendariz responded with a brief statement.
It said, in full: "We admire the dedication and skill of our health care workers. Their safety and well-being is critical to us. We provide internal lines of communication via email and an employee health line created for the COVID-19 crisis. Team members may reach out to us directly through those channels if they have any questions or concerns that they would like us to address."
Banner Health is the largest employer in Arizona and one of the largest hospital chains in the United States. In 2017, its CEO, Peter Fine, took home $25.5 million in compensation, the Arizona Republic reported — the same year it also completed a restructuring that entailed laying off 500 workers.
In the weeks since the World Health Organization declared the new coronavirus a global pandemic, shortages of PPE including N95 respirators, surgical masks and gowns have hit seemingly every hospital and clinic.
Amid those shortfalls, Banner’s standards on protective equipment are constantly evolving in a way that ensures less and less protection for health care workers, interviews and records show.
In a directive dated March 18, the hospital told its workers that they cannot wear PPE in hallways. In fact, as New Times previously reported, administrations were reprimanding those who still did so, even pulling masks off their faces. Workers have reported being told to remove even PPE they brought to work themselves.
A few days later, it told workers they could bring their own "social comfort" masks, even if those did nothing to protect them.
The March 18 directive also told them to wear N95 respirators (which filter out 95 percent of very small particles) only in highly limited circumstances, like in airborne isolation rooms or when they’re working with potential or confirmed COVID-19 patients.
Since then, nurses say, the list of places and situations in which they can wear N95s has shrunk, because the CDC has issued recommendations to health care providers saying that due to the nationwide limited supply of N95s, they might need to consider measures restricting their use.
“They will not let us wear N95s at all,” said one Banner nurse, who asked to be identified by the pseudonym Katherine.
Protocols were changing so rapidly, Katherine added, that “every single day, I don’t know what I’m going to walk into.”
When she went to work on March 18, she said, all the nurses were wearing surgical masks — anyone who wanted to, as much as they wanted, in and out of patient rooms.
On March 20, she spent the day wearing an N95 mask in and out of patient rooms, shedding protective gear as necessary when she left those rooms. But at shift change that night, the physician told her and others not to wear N95 masks, she said.
“She felt we were being wasteful,” Katherine recalled. “She said, hands down, no one should be wearing an N95 mask at all, it’s inappropriate.”
Three days later — on Monday — in a meeting with different managers, she was told to “do what you feel comfortable with.”
That day, taking care of a probable COVID-19 patient in an isolation room, she wore her own N95 mask — not one provided by the hospital — and hooked a surgical mask over it so that she wouldn’t have to throw out the N95 upon leaving the isolation room, per protocol.
The enforcement of those guidelines varies across units and hospitals, with some managers siding with frontline workers and others with administration.
“Some of the lower level managers are being very empathetic, because they work on the floor as well — they’re nurses, too,” Katherine said. “I feel like upper management and then of course above them, people who are making policies, that they are more concerned about resources than they are about us protecting ourselves.”
Spread by Droplets? Or Airborne?
To nurses and doctors, Banner’s guidelines are dangerous to themselves and to others, and they violate the basic medical ethos of "do no harm."
One concern is that Arizona is testing so few people for COVID-19 — and the state director of public health is urging primary care providers to stop testing at all — that it’s impossible to know who might have it, and therefore illogical to suggest to nurses and doctors that they will be protected from COVID-19 if they wear protective gear only when they’re seeing suspected or confirmed COVID-19 cases. Studies are starting to show that people who have the virus but no symptoms of it are spreading it to others.
Like Borges, several nurses also disagreed with Banner’s apparent insistence, at least as evidenced by its policies, that the virus is borne solely on droplets, and not on finer particles that would cause the virus to be characterized as airborne and necessitate better protective equipment.
The question is still up for debate, but one recent study, published in the New England Journal of Medicine, found that the virus could stay in the air for up to three hours, and nurses argue that Banner should operate out of an abundance of caution. Instead, it's doing the opposite by telling workers to use the slimmest protections possible.
“They’re saying, well, because [airborne] is not the way we believe it’s being transmitted the majority of the time, we think the risk is low, and so we don’t think [better protective equipment] is necessary,” Katherine said of administrators.
Right now, nurses said, Banner is allowing workers and doctors to wear N95s only when they’re doing procedures like intubations that could cause the virus to become aerosolized.
To Katherine, those requirements were grossly inadequate.
“We come into contact with enough patients in the ER on a day-to-day basis that we’re at much higher risk of contracting COVID-19 than most others, and we’re at risk of spreading it,” she said.
Instead of guaranteeing protection for hospital and clinic staff, Banner's March 18 directive tells health care workers in emergency rooms, clinics, and urgent care centers to "mask ALL patients presenting with respiratory symptoms with a procedure mask. This prevents the patient's respiratory droplets from contaminating surfaces or you."
Katherin said those guidelines don't work in real life.
"Patients don't always leave them on," she said. They frequently take them off, including to cough, and do whatever they want with them. “We can’t make a patient keep their mask on," she said. "We can tell them they need to, [but] we can’t force them. People do what they want.”
One nurse at Banner University in downtown Phoenix, who said he comes into contact with COVID-19 patients, said that his biggest fear was contracting the new coronavirus and spreading it to his kids. “That’s kind of on the periphery of your mind every day,” he said. “It’s always hanging over you.”
He said he has been given an N95 mask to reuse when he's working on certain procedures with patients. "We’re to place it in a brown paper bag and carry it around with us,” he said.
That nurse also said that managers were "claiming we don’t need N95 masks" except for "an aerosolizing procedure like intubation or bronchoscopy."
"I don't know if that's true," he said. "But we want the best protection possible."
A nurse who works at a designated COVID-19 unit at a Banner hospital told New Times that the lack of protective equipment is hurting her ability to provide lifesaving care.
The N95 respirator, which fits snugly to a person’s face, covering their mouth and nose, has to be fitted to workers. If a health care worker doesn’t have a mask that fits — this can be because of facial hair, weight loss, or even glasses that don’t sit well on top of the mask — they have to use a powered air-purifying respirator, or PAPR.
Her unit has just one PAPR, she said, and so if two nurses need it at the same time, only one can respond to a patient, even if a patient is going into cardiac arrest.
Another Banner nurse, who said she has multiple underlying conditions that would heighten her risk if she contracted COVID-19, said she was told by her unit director that she wasn't allowed to wear a mask "because it's sending the wrong message," even though she works with suspected COVID-19 patients.
"I was told by management, 'Nobody looks sick,'" she told New Times. "Just because somebody doesn’t look sick doesn’t mean they aren’t."
She added that even though Banner might be facing its own shortages of protective equipment, there was no reason for administrators to stop employees from using their own.
"I do get that they can’t order more and that they are conserving their supply," she said. "But if someone brings in their own, or someone’s high risk, you can’t tell them that they’re not allowed to wear a mask.”
It's not just at hospitals that Banner health care workers are told not to wear protective equipment.
One doctor, who works in an outpatient clinic in Phoenix doing primary care, said that his clinic had only surgical masks (not N95s), masks with eye shields, and mesh cloth gowns "that literally stop nothing from going through."
Banner administrators told the clinic that health care workers could use personal protective equipment only for suspected COVID-19 patients, and if those workers don't follow the rules, he said, higher-ups have threatened them with disciplinary action.
"I really do feel that we ... are treated as expendable,” another Banner primary care physician, in Tucson, told New Times.
Publicly, Banner has refused to say outright that it has a shortage of PPE.
"Banner Health currently has enough important equipment, including respirators, but leaders acknowledge they are experiencing some challenges given the global demand during the COVID-19 pandemic," it said in a recent press release. "Masks, in particular, are in high demand."
According to the nurse at Banner University in downtown Phoenix, administrators have told workers that the hospital does not face shortages of personal protective equipment.
“They’re claiming that we don’t have a shortage just yet,” he said, “and I do believe them, but I think they’re anticipating a possible shortage in May, when we get a peak.”
At his unit, he said, managers had taken all of the PPE supplies and locked it in a central location. “They’re rationing it out a little every day,” he said.
Banner has made the case to its frontline workers that they need to conserve equipment, Katherine said. “We have to save it for when we need it, because we’re gonna run out,” she’s been told.
But to her, if the hospital is going to run out anyway, it should protect its workers now, and deal with the shortage when it comes.
“You save the good china, but you could die tomorrow, before you ever use it,” Katherine said.
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