I’m a surgeon, husband, boss, employee and father. I wear a mask 12-14 hours every day. Why do I do it? Read on…

As we enter the 8th month of the pandemic we have learned a lot and are learning a lot. It’s interesting that issues that are big things in this country are not necessarily the same issues elsewhere. Masks are in that category.  The death toll in the U.S. sits at over 175,000 and yes, a lot had preexisting conditions and many were from minorities but it has touched every race and every age group. We aren’t clear about immunity. We think reinfection can occur but it may be different strains. The Northern Italy experience seems to be watered down as it progresses, although New York was bad. Smaller nations get the gold star for how they dealt with it. The U.S., not so much. It’s interesting how masks have become a dividing line for many, and somehow have become politicized.

I wear a mask when I operate:

It stops me spitting in the wound. It stops blood and body fluids ending up on my face. I’ve done so since I did my first surgery in 1988. It’s 2nd nature to me. I’ve done delicate surgeries 6-10 hours long with the same mask on. For the last 6-9 months I’ve had a set of masks I cycle through. I use a KN95 over my ears in my clinic. I use a N95 in the hospital and put a surgical mask over that one so effectively wear two masks when operating although sometimes come down to one. I have a cloth mask with an insert for a HEPA filter that gets regularly changed for when I am out and about, which is not much. I’ve been to a restaurant twice in those eight months and only take my mask off at home, in my car or when eating or drinking. It’s become routine. I’ve also gotten into social media wars with those who choose not to wear masks.

This is my civilian mask with a filter:

Here is my car kit: My N95 (changed weekly),  my masks with filters (filters change weekly) and some hand sanitizer.

 

This also sits on my belt to push ATM and elevator buttons (available in different styles on Amazon):

Initially masks were hard to get. Getting masks with filters was about impossible. Same for N95s. I managed to get masks with filter pouches. As I obtained them,  I gave my staff of eight these marks and HEPA filters. I also gave them hand sanitizer bottles for work and their cars and wipes.  To date none have tested positive and all were extremely grateful for these items. I think what you’ll see discussed below is pretty uniform for most physicians. What’s surprising is the level of resistance to this simple intervention. All of a sudden science is viewed in a conspiratorial fashion and everyone with a Twitter handle (often using a made up alias) is a critic. Physicians take an oath to put their patient’s health first and do no harm (btw we never really recite the Hippocratic oath). We also value our own health and those of our families. Let’s look at a few things.

Treatments For Coronavirus

OK .I will say this a few times:

The best treatment for COVID-19 is to not get infected

Period. Better than anything else. Don’t get it. It may have become a little watered down but there are reports of long term damage and lingering symptoms. Immunity may not last more than a few months. It’s best not to get it. If you do get sick however, let’s look at some hot topics, namely ventilators, hydroxychloroquine and steroids.

Ventilators

“We need more ventilators”. That cry went out in March and April across the country. The Northern Italian experience was not good. Here’s what we know. The average age in Northern Italy was older than most places. We also know in New York that if you were older than 65 and were intubated and ventilated that the mortality was >95%. This may have been due to the virulence of the virus, rapidly becoming a systemic disease. We learned about the cytokine storm. It may have been to to effects of ventilation on damaged lungs.  We also learned about comorbidities, especially obesity in younger people that came into play. In New York, if you were older than 65 and needed a ventilator, it was a death sentence.

We didn’t need more ventilators. We needed discussions about advanced directives and end of life wishes.

It’s sobering but true. Death is a taboo topic in Western culture. We skirt around it as though it affects someone else. We think our loved ones and us live forever but we don’t. If you’re over 80 and get admitted to an ICU, particularly if you are ventilated, you may never come out or you may end up in a nursing home, a paper mache version of yourself. Advance directives direct your care in the situation of a a serious health condition. If the mortality was so high the ethical dilemma to discuss only was whether intubating and ventilating those who needed it, with a poor prognosis for recovery was worth it.

Hydroxychloroquine

Amazing how a drug used originally for malaria and some autoimmune conditions became the focus of so much attention and passion. The last study from the New England Journal of Medicine showed no effect of using hydroxychloroquine:

Amazing how, social media account holders suddenly become journal article reviewers, be it the Lancet or the NEJM. It amazed me how seemingly intelligent people suddenly become critics of professional medical and scientific articles. There was a subset of the population who had already made their mind up- masks bad, hydroxychloroquine good and nothing would shake their belief about it. Here’s my take currently:

Wearing a mask and not getting COVID19 is better than getting it and trying to treat it with hydroxychloroquine

Dexamethasone

Not surprising corticosteroids turned up. When i trained “no one in hospital dies without tasting steroids”. Given the proinflammatory nature of the virus and the cytokine storm that can lead to rapid deterioration, it’s not surprising steroids play a role. Cheap, plentiful and available. Here again:

Wearing a mask and not getting COVID19 is better than getting it and trying to treat it with dexamethasone

The Vaccine

Everyone is waiting for the vaccine, even the anti-vaxxers who have been amazingly silent through all this. Here’s the truth. It will take time. It also won’t be completely effective. Our most effective vaccines sit about 75%. The influenza vaccine is about 50% and yes, you should get a flu shot this year.  Making vaccines is HARD. We still have no vaccine for HIV. My kids get ALL their vaccines. I get a flu shot every year. Waiting for a vaccine is no excuse for not doing the right thing now.

Social Distancing

This works. Is it 3 feet or 6 feet? We know a cough or sneeze goes at least as far. It’s been hard on everyone but there are good scientific articles (see below) that support its use. This has been tough on the restaurant industry, tough on bars, tough on everyone but it has helped.

Hand Sanitizers/Hand Washing

I am a big hand washer. Twenty seconds in warm water is tough but I try, after every patient I see. Soap and water do wonders. As medical students we all did the studies where we imprinted our hands in a petri dish full of agar before and after washing in soap and water and for most of us, the results blew us away. Hand sanitizers are fine when soap and warm water is not available (e.g. in the car) but simple soap and hot water is my go to.

Masks

Masks work. Anyone who disputes it is not keeping an open mind. The virus is transmitted in our saliva, our secretions and probably aerosol. We’ve already seen the Southern Hemisphere influenza season just passed (our summer is their winter) to be not as bad as most years. Why is that? Probably the masks and social distancing.

What About The Evidence?

My disclosure is I’ve dealt with evaluating scientific evidence for about 30 years. I have a PhD, authored over 100 scientific articles and sit on half a dozen editorial boards for medical journals. Every week I review half a dozen articles that are submitted for evaluation. I was trained in evaluating medical evidence and it’s part of my profession. Most laypeople, despite their best intentions are not.

Evidence can be broken down into various levels.

The level is how sure we are that the conclusions. The best evidence is level A. Studies are split into classes:

The best studies are Class I. This is a study where there are two groups. One is the control group that usually gets no treatment or placebo treatment. At the start participants can end up in either group. Neither the participant or the person doing the study knows who is going to be in which group. This is called a randomized controlled double-blinded study. These are rare in clinical medicine. They are expensive. Sometimes there are ethical issues the limit their setup. Most of the things we do are not based on class one evidence.

Evidence-Based Medicine

Absence of proof  is not proof of absence

Just because we don’t have strong evidence on how to do something doesn’t mean we don’t know what we should do. An author by the name of David Sackett defined evidence-based medicine as below:

 

Note the second part- “integrating individual clinical expertise”. That’s what we doctors gain over decades of treating patients.

“The proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice.” Let that sink in. It’s the feeling, the hunch a physician gets in managing patients over a long period of time. Thousands of patients sometimes over decades where they get a feel for what to do. You don’t know what that is if you are not a physician treating patients. Dr. Googles don’t know but it’s a crucial part of evidence-based medicine. Remember that if you want to criticize an suggested approach by medical experts. Mostly, you’re not one.

Below is the best article I could find that reviews social distancing and masks. It’s not perfect and reviews different aerosol transmission scenarios but it’s pretty good. In short, masks and social distancing work:

There is No Evidence That Parachutes Work

For those who only want proof in data , mull this over. This interesting article appeared in the British Medical Journal looking at all the available data on the use and safety of parachutes. As there was no control group (who would want to be in the group with no parachute?), they concluded that the evidence supporting the use of parachutes was poor. The article of course was tongue in cheek but it did support something that we apply every day- if common sense says to do something, it’s usually right.

How to Wear Your Mask

Ok. Back to masks.

Health care workers need N95 masks ( or N99 if available):

The best mask for consumers is a cloth mask with a filter pocket. N95s are hard to get and not very comfortable:

A cloth mask with no insert is better than nothing:

For nonmedical uses a mask with a filter insert is best:

Finally, masks with exhale valves, during the COVID-19 pandemic are not a good idea as they can transmit virus from the wearer to everyone else.

 

If you wear a mask every day you should change the filter weekly, about 50 hours of use. Filters for masks can be bought online for $50 cents each. $50 will cover you for a year in terms of filters, hand sanitizer and some cloth masks with filter pouches. Your mask should be washed with soap and cold water every week. Best to have a few to cycle though.

One easy hack is to buy HEPA vacuum bags and cut them up and use them as filters:

These can be bought online as 2-packs for less than $10 with each bag producing 5-10 filters at a minimum.

The rules for masks are pretty simple:

1. Wear it
2. Don’t touch it
3. Ideally get one with a filter pocket and put a filter into it
4. Change the filter every week
5. Wash you mask every week
6. Cover your nose with it
7. When you come home or get to work wash your hands
8. Don’t wear one with an exhale valve
9. Don’t complain. We’re all in the same boat

Type of Mask

N95s are for health workers, everyone else should use a cloth mask. So-called Gaters and Bandanas are probably not so good- it seems to be the wearers touch them a lot.  Get one that has a filter pocket. Get a few and cycle them each week.

Why Masks Make Sense

Masks reduce viral load both ways. There is a lot of rhetoric on virus size and filter size. Fauci eloquently put it as “three football players trying to get through a door at the same time”. No mask filters everything, even N95 or N99 but they significantly reduce viral load. That initial exposure to viral load, especially in healthcare workers seem to be one arbiter of how bad your infection is going to be.

Here is a great infographic spelling it out:

Politics of Masks

This is where we as a country should be ashamed. We are the most technologically advanced country in the world. We have so much of everything. Somehow masks became an assault on individual rights. “You’re not the boss of me”. Other countries recognized the communal gain of wearing masks and social distancing but in the US this became tagged to your political ideation. I wear a mask. I don’t want higher taxes but believe in basic healthcare for all. I also think education is too expensive in this country. At different times, I have voted for both parties over the past 15 years. I’m not wedded to the ideology of either party- for me it’s not a black and white answer across the board. This should never have been a political issue. During World War II Americans all worked together for the greater good and this should have been the same.

Why People Don’t Listen

Young adults have different wiring to mature adults and take more risks:

One of the reasons why our twenty somethings feel bulletproof and are not worried about what may happen down the line and to to the older people out there.

The answer for mature adults is more complex. The well written article below explores reactance theory where people try to establish or regain freedom after losing or perceiving to have lost it, hence resisting:

What Healthcare Workers Think

I’ve talked to nurses, PTs, medical assistants, scrub techs. I’ve talked to pediatricians, hospitalists, infectious disease experts and ER docs. I’m not on the frontline but some of them are. The disease is real. It’s here. They all wear masks. They all disinfect. They see young and old getting it. They worry about their kids. There is no conspiracy. A lot of hospitals slowed down to protect PPE reserves. The overhead still needed to be paid and some staff were furloughed. If the ER was empty that was actually good. Again, this was not a conspiracy. This is a public health crisis. No one who works in the hospital system disputes this reality. None of them want to catch COVID-19. All of them mask up. Some vote Republican. Some Democrat. All wear masks. Whilst we know this affects older people more commonly with comorbidities:

1. No one wants to be the healthy younger adult who gets it and dies or is permanently affected
2. No one wants to bring it home
3. No one wants to pass it onto older loved ones/friends/family/acquaintance

Moving Forward

The best treatment for COVID-19 is to not get infected

This is not going to be overcome after November 2020. We are just going to move to a new normal. Masks on plane flights will be the norm for a long time. No one wants to go back to a lockdown. If we embrace a sensible approach of masks and social distancing we can get there. The vaccine will come but waiting for the vaccine is like waiting for the next Windows operating system update- more promise and expectation  then a harsh reality. We can all be community minded, keep things open, tough it out and get there. Keep you mask on!

Agree? Disagree? Feel free to share or leave a comment below.