Should Hoard Every Gown and Surgical Mask and Lock Up N95s
MARK MOSLEY, MD, MPH
great hero movie has a moment when the enemy is closing in. Everyone in the
audience wants the hero to save the day, but he has only one shot. Too early or
too late, and we all die. He has to make it count. You hear the hero whisper to
himself, “Wait for it, wait for it, wait…now!” Timing is critical for survival.
the timing must depend on the conditions—the location, the site, and the
particular circumstances at that moment. Each emergency department is a
separate battalion with its own stockpile of human and material resources. We
will not meet this virus at the same time or in the same way. We will blow a
quarter or half of all our materials before we need them if a small rural ED in
the South or a freestanding emergency department in a medium-sized midwestern
town follows the protocols of a large metropolitan city like New York.
unnecessary COVID-19 test and every unnecessary gown and mask we use today is
one we won’t have two weeks from now when they may be lifesaving. This is all
about timing and using our resources at the right moment. Perhaps as you are on
shift tonight you will see boxes of surgical masks and N95s. You should know
that federal officials have said the strategic national stockpile contains just
one percent of the masks that experts predict could be needed for this
pandemic. There are plans to add 500 million N95 respirators to the stockpile,
but that could take up to 18 months. (Los Angeles Times. March 21, 2020;
do we control our fear not to pull the trigger when someone comes to work and
says his cousin is an ICU nurse in Seattle and that everyone working in the ED there
is wearing a mask? Or the highly respected doctor who walks down the hospital
hall with a N95 on? How do you calm yourself when you aren’t the lucky soldier issued
is power. And that power will allow us to calm that fear. We must start with
the knowledge that diagnosis is not usually helpful for the vast majority of
emergency patients unless we also have a treatment. Indiscriminate testing will
use up our precious materials. For every false-positive, two or more tests
prove a patient is negative. Our primary objective is the timing of human and
material resource utilization.
Centers for Disease Control and Prevention has stated that we are to “minimize
the number of individuals who need to use respiratory protection.” They
recommend using alternatives to N95 respirators, and they allow for extended
use or limited use under shortages without knowing their effectiveness in this situation.
(CDC. March 28, 2018; https://bit.ly/2QLwfnM.)
types of respiratory protection in the ED are surgical masks (molded cup and
pleated paper), N95 respirators, and Elastrometric respirators (they look like
grasshoppers). Everything is not a mask. Most EDs will have surgical masks or
propose several pillars of basic knowledge from which we should build our
recommendations and protocols. Granted, there will always be important exceptions
(e.g., an ED staff member on immunosuppressive drugs), but the exceptions do
not change the foundation.
is spread predominantly by large droplets. Airborne particles and fomites
appear likely, and they may not routinely come into play with noncritical
respiratory patients, especially with a no-touch or one-touch physical exam.
masks are not necessary for ED staff unless they are seeing a potential COVID-19
patient for respiratory symptoms. If you are sick, you should be home rather
than work with a surgical mask on. The surgical mask is intended primarily for
sick people, not healthy ones. Its purpose is to block water droplets from
being coughed or sneezed out by the wearer. It does not prevent airborne virus
from coming into the health professional’s nose or mouth (respiratory
therapists doing nebulizations and suctioning are exceptions). Healthy people
should not be wearing surgical masks around the community unless they are sick.
And why are they out if they are sick?
have proven more effective than surgical masks in vitro to block
airborne viral particles, but have not proven better than surgical masks in
vivo for real-life situations (whether this is because of improper usage is
unknown). (JAMA. 2019:322:824, https://bit.ly/2JkeFTY; CMAJ.
don’t need an N95 for noncritical respiratory patients, and you certainly don’t
need one in any routine medical situation or community activity. The CDC agrees
that a surgical mask is an acceptable alternative to an N95. (CDC. March 28,
in the ED are needed for all known COVID-19, critical respiratory, and intubated
patients and for those on noninvasive positive pressure ventilation, undergoing
CPR, with peritonsillar abscess, and perhaps for a small handful of other
we should be reminded regularly that there are no good scientific data from the
2009 H1N1 epidemic that surgical masks or N95s actually decrease infection
rates. (Emerg Infect Dis. 2009:15:233; https://bit.ly/2WN6SGe.) The recommendations
to use respiratory protection is based on public health judgment. This makes
complete intuitive sense and should be followed.
CDC has been wise to emphasize that the recommendations should be used in the
context of local circumstances. If you work in the ED of a respiratory-designated
hospital in a large city and patients are coughing and dying around you, your
approach to respiratory protection, given your site-specific local
circumstances, will be different from a freestanding Kansas ED where you are in
the bunker drinking coffee and having the slowest shift in 25 years. Again, our
primary objective is the timing of human and material resource utilization.
there are laws of unintended consequences in which the desire to protect our patients,
ourselves, and our families lead us to use surgical masks and N95s (and do
COVID-19 tests) unnecessarily, which can lead to increased spread. The CDC
recommendation is for those wearing a single-use surgical mask to wear and
dispose of them properly. How many patients have you met already where the mask
is below their nose and not covering their chin and they leave it behind when
they leave? How many health professionals wearing a single-use disposable
surgical mask all day pull it down to talk, drink, or eat? One study of nurses
showed that nurses touch their faces an average of 25 times each shift. (Am
J Infect Control. 2013;41:1218.)
many times have you seen a surgical mask on a counter and not known if it is
new or used? The surgical mask worn or used incorrectly becomes a viral grenade
with the pin half out. Wear a surgical mask if you are sick at home, and wear a
mask for another week if you are better after seven days and return to work. You
may want to wear a surgical mask if you are working closely with those at high
risk (e.g., elderly in a nursing home).
then there are bandanas for which we have absolutely no data and are reserved
as a last resort, but we know they are no longer as effective if they become
moist (like a surgical mask but worse). A surgical mask or a bandana that is
reused, even if in a limited way, is at great risk for self-inoculation and
ineffectiveness. (J Occup Environ Hyg. 2014;11:115; https://bit.ly/2xohdO2.) The kind people
making these for us is heartwarming, but it is unclear if it is safe to use in
our emergency departments (except out of desperation).
N95s can also have unintended consequences. Does everyone with a beard and mustache
shave them off to use an N95 appropriately? What about not being able to see
the video screen during intubation because your glasses are all fogged up? The
N95, depending on site-specific location and circumstances, should be used
sparingly in the majority of EDs for now. Estimated tolerance for a tight-fitting
N95 on a nonbearded person is about an hour at most. And they are less
effective if they get moist on the inside, like surgical masks.
legitimate fears about running out of N95s prompted the CDC to make allowances for
them to be reused no more than five times with a potentially impractical
recommendation to store them in between patients in a brown bag. Contrary to
hearsay, you can’t use cleansing agents to sterilize them for reuse. Perhaps,
this is why the CDC prefers extended use over reuse. How many N95s will a
single staff member burn through in a 12-hour shift?
I write this, our emergency medicine colleagues are sending messages from the
big cities reporting apocalyptic conditions: no gowns in the COVID-19 ICU, no
N95s, few surgical masks. All emergency department patients and many critical
care personnel are using loose cloth or toilet tissue to cover their nose and
mouth. Meanwhile, some in quieter EDs are gowning up in full PPE with a N95 for
an 8-year-old with a runny nose, cough, and diarrhea. We need to post these
texts from the big cities and read them like letters from war. The angel of
death may be coming. Maybe it will pass over us as we lay quietly, locked down
in the bunker of our town.
there is hope. We must hoard every gown and surgical mask. We must lock up the
N95s. Only by holding on to science can we let go of our fear. And if we can
just wait, we might have the resources when we need them.
an emergency physician in Wichita, KS.