Emergency room physician John Gavin can’t identify the exact patient from whom he contracted the coronavirus, but he’s confident he picked up the illness working one of his 12-hour shifts in Amite, Louisiana’s small, rural emergency room.

“There were just so many people who had so many vague symptoms that any of them could have been that person,” he said. “We see a lot of viral-type illnesses.”

But Gavin, 69, is certain that before his coronavirus diagnosis on March 12, officials at Hood Memorial Hospital, where he works, hadn’t made any specific changes to protocols or procedures to protect doctors and nurses from contracting the disease.

“Not at that point they hadn’t,” said Gavin, who is recovering from the disease caused by the virus. “I don’t know if they’ve done anything since then. But during that time there was nothing other than advice to wash your hands frequently and ‘we’ll try to keep the water on,’” a reference to a water cutoff that had taken place in early March.

Gavin also said the ER at the time didn’t have gowns or N95 respirator masks designed to protect medical providers from airborne particles and liquids.

“No, no, we didn’t have any of that,” he said. “They offered us paper face masks, that’s it.”

Gavin later joked that wearing a paper mask was like “putting up chicken wire on your windows to keep the mosquitos out.”

Amid the response to the coronavirus, officials are particularly concerned about doctors and nurses getting sick themselves and being unable to care for others. There is no official data accounting for the number of health care workers who have been exposed or infected so far, but providers worry about what will happen as supplies runs out. On Tuesday, The Washington Post reported that at least 60 providers had tested positive for COVID-19. In Italy, data published in JAMA shows that 9% of those infected are health care workers.

Officials with Hood Memorial Hospital declined interview requests but said in a statement that the facility has protective gear available for staff. The statement also said there was no evidence Gavin contracted the disease at the hospital. The statement quotes the hospital’s CEO, Mike Whittington, saying that “no patient or employee that Hood is monitoring has developed any symptoms of COVID-19 in the eight days since their interaction with the provider.”

Confusion and concerns around supplies extend well beyond Amite. Given the nationwide supply shortages, the U.S. Centers for Disease Control and Prevention recently downgraded its guidelines for how health workers should protect themselves, allowing them to use surgical masks instead of N95 respirator masks in many cases. And this week, the CDC went further, publishing directions that providers “might use homemade masks” like a bandanna or scarf if no masks are available.

Gavin said he was unable to call in sick in the days before his diagnosis because of a shortage of doctors in the area. The small hospital Gavin works at is about 60 miles northeast from Baton Rouge and serves a wide area that stretches to neighboring Mississippi.

“So I went in and worked that shift,” he said. “I’m sure I exposed everybody I saw.”

And on one of the days immediately prior to Gavin having symptoms, there was a period of time where the water in Amite was shut off and he and his colleagues were unable to wash their hands for hours. They relied on hand sanitizer during the outage.

Sick doctors and nurses cause a ripple effect.

Beth Oller, a family physician in rural Rooks County, Kansas, said the five doctors who treat patients in her area are working together to minimize the risk of any of them getting sick with the coronavirus.

“We are terrified of this taking out providers or our nurses,” she said.

The ripple effect of one or two health care workers in the county being sidelined by the virus would be devastating. Oller said she is one of two doctors in the area who delivers babies. Her husband, one of the four other doctors in the county, also cares for patients at the area nursing homes and heads up the local EMS service. There are only a handful of X-ray technicians at the hospital and a small number of nurses.

Oller said the local hospital has a limited supply of masks and gowns. The burden on the local doctors is already beginning to increase because of the virus. The county hospital depends on out-of-area emergency room providers to help cover weekend shifts. One of those, a nurse practitioner based three hours away in Topeka, informed the hospital this week that her travel was being limited by her own hospital because of the virus and she might not be available to cover shifts in Rooks County, Oller said.

Reduced standards due to gear shortages are putting front-line health workers at additional risk.

Medical providers in Washington, Ohio, New York, Connecticut, Oregon, Illinois, Texas and California told ProPublica that in the past week, hospitals have changed recommendations around protective equipment. The moves come after the CDC modified its guidance March 10 on the kinds of precautions health care workers should take in light of supply shortages.

Doctors and nurses in these states said their hospitals initially told them to use sealed face masks like N95s when treating patients presenting COVID-19 symptoms. Providers are now being told to use surgical masks when interacting with a symptomatic patient. In the past week, their hospitals have placed N95s in locked cabinets to make sure they are available for cases requiring intubation.

Some hospitals have gone further in loosening restrictions, recommending staff reuse disposable masks. Medical providers on the front lines are concerned by this move, saying masks are only intended to be used once because the risk of contamination increases as they are reused.

“It’s like doing surgery with gloves on one patient and using the same gloves for another surgery,” said John Pearson, an emergency room nurse at Highland Hospital, a public hospital in Oakland, California. The hospital has told staff to reuse surgical masks and place them in paper bags between patients. He said a few of his colleagues have already gotten sick. “It goes against all our training and all the standards and practices we’ve been drilled in year over year.”

Reusing disposable masks is bad practice, but it is understandable in the current situation, experts said. Hospital administrators see reusing masks as a necessary move given the current shortages and the fact that the virus has not hit its peak. The CDC has not issued guidance around mask reuse.

Of the 65 medical providers who wrote into ProPublica this week, 31 said they felt as though they were being asked to take measures that made them uncomfortable, such as reusing protective masks. All but two respondents cited supply shortages as a factor.

A number of hospitals and clinics have advised staff they have less than two weeks of supplies and don’t know when additional orders will be fulfilled, according to emails reviewed by ProPublica. In a private Facebook group, doctors and medical staff are sharing tips for building their own masks from materials they have at home or are ordering from Amazon. After reading through the posts, someone in the group explained they sent a note to a state ACLU chapter to outline conditions and ask if doctors have any recourse to keep themselves safe.

“There is a massive shortage and a dramatic lowering of the quality of care,” Pearson said. “We’ve seen our health care system fall, and we’re paying a huge price.”

Alameda Health Systems, which oversees the hospital, did not respond to questions about supplies and requests for comment.

Protective gear shortages are a national problem.

“This is all driven by shortages of protective gear,” said Dr. Robert Harrison, the director of the University of California San Francisco’s Occupational Health Services. In the United States, surges in demand, lackluster preparation and some overseas suppliers shutting down as their countries grapple with the virus have contributed to the shortages.

Vice President Mike Pence, who is leading the U.S. response to COVID-19, has said a handful of manufacturers are ramping up their production efforts for masks, gloves and gowns. The CDC also has begun fulfilling orders by states requesting masks from the country’s Strategic National Stockpile, which has less than 5% of the 300 million masks public officials estimate the country will need.

Representatives of hospitals and nursing homes shared concerns about a shortage of supplies on a call Monday hosted by the U.S. Centers for Medicare and Medicaid Services. On the call, a high-level official from the U.S. Department of Health and Human Services gave an update on the supply shortage and the hope for replenishment.

The strategic national stockpile “has a significant but, quite frankly, very small percentage of what is needed in today’s crisis,” the HHS official said. Federal officials are coordinating their capabilities with those in the private sector, including group purchasing organizations, distributors and manufacturers, “to basically pull all this together,” he said. Proposals include purchasing a large number of N95 masks, for example, and working with the CDC “to extend the reuse” of what have traditionally been single-use products, he said.

On Wednesday, President Donald Trump invoked the Defense Production Act, which allows for the large-scale diversion of materials and facilities “when national defense needs cannot otherwise be satisfied in a timely fashion.” In recent days, senators and local officials had urged the administration to invoke the legislation that Congress first passed in 1950, during the Korean War.

Front-line health care workers are being pushed to the brink of quitting.

Several health care workers told ProPublica they are already weighing the possibility of quitting if their workplace runs out of protective gear.

A nurse practitioner working in northeast Connecticut says her office has already canceled nonessential surgeries and procedures. Staff are now relying on telehealth, in which they communicate with patients largely over the phone or online, to keep people from coming to the facility.

She has five N95 masks stowed away for patients still coming in. She says she’ll reuse them until they’re “soiled or ruined,” but if her office ultimately runs out of protective gear, she will not come in.

“Zero PPE means zero providers,” she said, referring to personal protective equipment. “And I know that my other colleagues feel the same way.”

One intensive care nurse in Columbus, Ohio, says she has an underlying lung disease that puts her especially at risk for COVID-19. During her latest shift this week, she was told her hospital was on its last few boxes of N95 masks. Nurses were hiding the remaining gear and putting their initials on the masks they reused throughout the day.

She says if she is asked to care for potential COVID-19 patients without the proper protection, she will request a different assignment. Still, the mere risk of possible exposure given her condition scares her husband.

“It’s something that’s on the table that we are going to keep discussing, which worries me because I don’t know if people are going to hire nurses that quit at the time they’re needed,” she said.

Marshall Allen contributed reporting.

Correction, March 22, 2020: This story originally misstated the date John Gavin received his coronavirus diagnosis. It was March 12, not March 9.

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