When I first started reading about the coronavirus epidemic in Wuhan China, I had returned from a trip to Japan, and my first thought was: “we will all start wearing masks” as is customary for many Japanese. A few weeks later, I was dismayed to see almost none of my colleagues wearing any sort of PPE at work in my hospital at the University of New Mexico. As the weeks went by I started routinely wearing a surgical mask. I was questioned about it by my coworkers. “Why are you wearing a mask;” “You know they don’t really work;” and most worryingly “I’m young and the coronavirus is not going to kill me.” Even as the pandemic gained steam, I saw paramedics, EMTs, triage nurses, my fellow attendings and trainees doing their jobs without wearing masks. Finally, and only beginning this week, we have a policy that requires front line workers like myself to wear a surgical mask. That’s because community spread is ramping up and we have recorded our first death. I diagnosed my first patient who was COVID-19 positive two weeks ago. I fear that we will start seeing cases among health care workers and I wish we had prepared earlier.
Our hospital’s preparations for COVID-19 are finally gearing up so that we can deal with this crisis. We have transformed our ED in anticipation of the surge of patients that we know is coming. Like most places we are dealing with a critical shortage of personal protective gear. Over the last couple of weeks, I saw both N95 masks and surgical masks begin to disappear from the workplace. N95s, which provide the best protection, are now kept under lock and key. When I requested an N95 during my last shift I was told I could not have one unless I was doing an aerosolizing procedure. I was not, so I did not get one. Reports are coming from a number of hospitals that staff are prohibited from wearing an N95, and some nurses have been fired or quit as a result. So let’s start with some facts on the mask issue – should medical workers wear masks and which ones?
Fact #1: You can get COVID-19 by breathing. Mostly by inhaling respiratory droplets, more rarely from aerosolized virus. Respiratory droplets are generated by coughing, of course, but also by talking or laughing. Most human social interactions involve talking, which is one reason why social distancing is so important.
Fact #2: Many patients with COVID-19 are asymptomatic or minimally symptomatic, or they have atypical symptoms. Viral shedding occurs in early stages of infection, and among asymptomatic patients. The first patient to die in my state of New Mexico had no cough. His chief complaint was weakness.
Fact #3: Hospitals can become foci of infection. Health care workers can unknowingly spread virus to patients and other staff.
Fact #4: Health care workers are getting sick even while adhering to CDC guidelines of personal protective gear.
Fact #5: Putting a barrier in between your nose and mouth and the air we breathe prevents viral spread – protecting the healthy from getting infected – protecting the infected from spreading infection to others.
Fact #6: An N95 protects against respiratory droplets (and occasionally aerosolized virus) better than wearing a simple surgical mask. This is what N95 respirators are designed for. N95 masks, along with powered devices called PAPRs, are the gold standard for protecting the wearer from infectious particles. This is because they fit better and because they (probably) protect the wearer from small particles better.
For an at-risk healthy person, wearing an N95 provides some of the highest level of protection from viral illnesses. When the supply shortage is alleviated I guarantee that all health care workers who are potentially exposed to COVID-19 (everybody now) will be wearing N95s because they are simply better at the job. If unavailable, a surgical mask might be as good. But we don’t really know because we don’t have enough data on SARS coronavirus transmission and we will not until the pandemic is over.
Fact #7: N95 masks need to be used with appropriate eye protection, and as part of a program of scrupulous hand hygiene. This trial suggests that it is necessary to use both masks and goggles to prevent influenza infection.
The bottom line: Conventional advice about protecting the population is good but completely inadequate. The CDC, the Surgeon General, innumerable politicians and public health officials have been advising us to wash our hands and not touch our face. If that worked effectively, we would see a slow-down of infection. Do we? No, COVID-19 cases continue an exponential march upward in the US and around the world. Obviously hand washing by itself is not going to “flatten the curve” or prevent infections in a really meaningful way. We need to stop inhaling the virus too. We can achieve that by not being around other people – by quarantine or social or physical distancing. And when that is impossible or impractical, people must wear masks. The countries that have had better success at controlling the virus, e.g. Singapore, also have broad public use of masks. For us in health care, using a surgical mask is the minimum needed step to take. If N95s are available, let us use them. In times of scarcity, encourage re-use and sterilization – heating at 70 degrees C seems to do it.
FINALLY, DO NOT DISCIPLINE OR HARASS HEALTH CARE WORKERS WHO WISH TO PROTECT THEMSELVES. Encourage and enable nurses or doctors who want to wear an N95, for all the reasons above. The fact that we don’t have randomized controlled blinded studies that prove that N95 respirators protect better than surgical masks against SARS-CoV-2 inoculation is irrelevant at some level. We need to feel safe and be able to perform our jobs at a time of maximal stress. In times like this, we health care workers are our communities’ most important resource. #GetUsPPE
Emergency Physician, Educator, Researcher, interested in the microbiome, evolution, and medicine