In medical school we learn early on that healthcare is constantly changing, recommendations are updated based on new evidence, and treatments are replaced by more efficacious, less harmful counterparts. It takes a lot of time, research and energy to develop protocols, algorithms and the best scoring systems to determine if and when an intervention's benefit outweighs the risk.
The general public is seeing first hand and in real-time the process of applying evidence-based medicine to understanding and managing SARS-CoV-2, the virus that causes COVID19. This includes developing standard of care practices like preventative measures, assessment tools, treatment regimens, and decision-making guidelines. As a result, the entire situation is and remains fluid with updates from CDC, WHO, federal, state, and local governments announced almost hourly. My inbox is inundated with information from hospitals, medical societies, and educational associations that can become overwhelming and difficult to keep up with on a daily basis. I have waited to put this post together until there was more consistency for the public regarding how to protect yourself from COVID19 in order to not overwhelm you as well. I spent a significant amount of time researching all available data and hope this streamlines several of the current recommendations. Understand that this is not complete and I encourage all of you to visit the CDC and WHO for further information.
RECOMMENDATIONS
1. WEAR A MASK IN PUBLIC
The community has been advised now to wear a cloth mask in public and given the severity of the situation, I agree with this measure. According to a Public Library of Science article published in 2008 on Professional and Home-Made Masks, "any type of general mask use is likely to decrease viral exposure and infection risk on a population level," (van der Sande et al., 2008). The SARS-CoV-2 virus is transmitted through respiratory droplets such as when individuals cough or sneeze.
Cloth masks can help stop the spread of large virus-laden droplets being exhaled, to provide a barrier that prevents the virus from being inhaled, and to prevent people from touching their face - this only works if you are conscious about not touching your face to adjust the mask (Freilich, 2020). These can be washed appropriately and reused but keep in mind when removing the masks to handle by the earloops only and do not touch the material of the mask itself. Additionally, wearing a mask does not give you sufficient protection such that you can disregard social distancing. While a cloth mask is considered a last resort, it is better than nothing when it comes to preventing droplet transmission (Davies et al, 2003).
The following graphics depict the effectiveness of different material in filtering out particles:
Recent literature states the pathogen can be what is called aerosolized. This means the respiratory droplets can survive in the air for up to 3 hours after a procedure that converts droplets into a spray such as with a nebulizer treatment. These procedures are most commonly performed in hospitals. With a shortage of personal protective equipment for healthcare providers comes an even higher risk of exposure in an already high-risk environment, especially for those on the front lines. This is why medical-grade protection like N95 masks, P100 respirators, and surgical masks must be reserved for medical professionals. Additionally, you must be fitted to wear the N95 as different facial structures require different sizes to guarantee a tight seal. If we are not protected, we will not be around to treat our patients and protect you. The only other consideration of when to wear a medical-grade mask is if you yourself are infected or you are caring for someone who is positive.
Some tips for those in the medical field: Follow your hospital's protocol but in general, when wearing your N95, place a surgical mask over it to protect it. You can don an additional cloth mask over all of these to add further protection. There were some recommendations to use HEPA filters but I was recently informed this filter carries the health hazard of inhaling fiberglass and causing lung damage. I advise against this addition to PPE.
My colleague, Dr. Marc Katz, put together a great tutorial about wearing masks including a short clip on how to make your own:
In summary:
The following is a simple CDC guide for how to make your own mask at home (they recommend adding a coffee filter for additional protection). Other options can be found HERE.
2. STAY SIX FEET APART
While I and several of my colleagues use the term social distance, what we really mean is PHYSICAL distance. This space prevents the spread of the virus as it can travel between people in close proximity. Six feet apart is better than six feet under.
That being said, the best way to protect yourself and your loved ones is to stay home. Social distancing is not a punishment, it is a privilege. Many of us doctors and other medical personnel are putting our lives at risk to fight on the front lines of this pandemic battlefield. Your efforts are helping us flatten the curve to ensure our hospitals are not overwhelmed and our resources are not depleted.
3. WASH YOUR HANDS
The viral droplets can easily be transferred from your hands to your eyes, mouth, or nose. This is why hand hygiene is crucial to protecting your health. Wash your hands for at least 20 seconds (hint, sing Happy Birthday to yourself twice). You can also use an alcohol-based hand sanitizer.
If you choose to wear gloves, understand that germs can survive on gloves and this does not replace handwashing nor does it prevent the ease of transmissibility from you to objects.
4. AVOID TOUCHING YOUR FACE
See #4 before touching your face. Again, the virus infects people through eyes, nose, and mouth. One guideline I have been following is wearing glasses instead of contacts to prevent touching my eyes.
5. CLEAN SURFACES
6. AVOID THE BEACH
7. DO NOT LIE
When a healthcare provider asks about your medical, social, or travel history and any associated symptoms or exposure risk, please be honest. We want to help you and protect you but as much as we are trying to be open and transparent with you, we ask you to do the same.
8. CONTINUE WITH SELF-CARE
Stay hydrated, stay active, stay engaged with your friends, family, and community. Mental and physical well-being are important to maintaining overall health.
9. ADDRESS CODE STATUS
This is a tough and extremely sensitive discussion but important to consider early so as not to have to face difficult decisions later on without knowing the wishes of your loved ones or yourself. Should the time come to make life-sustaining decisions, you must understand what this means. Our default plan of action is to treat patients as if they are FULL CODE, where every medical intervention is to be done for them.
We often use the terms DNR (Do Not Resuscitate), DNI (Do Not Intubate) and CMO (Comfort Measures Only) for patients who wish to have a limited code status. Patients who are in critical condition because of COVID19 require intubation, which is when a tube is placed down their throat and hooked up to a machine called a ventilator to help them breathe. If a patient does not want this done, their wish is to be DNI.
If their heart were to stop beating, the course of action is to perform cardiopulmonary resuscitation (CPR). The patient will receive chest compressions, which can cause ribs to break, shocks to the heart and other medications. If a patient does not want this done, their wish is to be DNR. There are risks to these interventions, which is why establishing code status is necessary to ensure we are following each individual patient's plan for their goals of care.
There are additional components to this discussion including non-invasive interventions for breathing and nutrition methods. My colleague, Dr. Marc Katz, put together a detailed blog post for further information that can be found HERE.
10. BE VIGILANT
While it has been a few weeks since these lockdown and shelter-in-place orders were instated, you cannot lose sight of the end goal. As much as we want to be with our family and friends to celebrate the holidays, we have to put each other's health and our own health first. We must be resilient and persevere as we wait for brighter days ahead.
References:CDC. (n.d.). Retrieved April 8, 2020, from www.cdc.gov
COVID-19: What We Know so Far About the 2019 Novel Coronavirus. (n.d.). Retrieved April 8,
2020, from https://www.uchicagomedicine.org/forefront/prevention-and-screening-articles/wuhan-
coronavirus
Davies, A., Thompson, K.-A., Giri, K., Kafatos, G., Walker, J., & Bennett, A. (2013, August).
Testing the Efficacy of Homemade Masks: Would They Protect in an Influenza Pandemic?
Retrieved April 8, 2020, from https://www.ncbi.nlm.nih.gov/pubmed/24229526
Doremalen, N. van, Vaduganathan, M., & Fineberg, H. V. (2020, March 17). Aerosol and Surface
Stability of SARS-CoV-2 as Compared with SARS-CoV-1: NEJM. Retrieved April 8, 2020, from
https://www.nejm.org/doi/full/10.1056/NEJMc2004973
Freilich, S. (2020, April 1). Health Warning - HEPA Filter. Retrieved April 8, 2020, from
https://www.youtube.com/watch?v=qiYbXsIcI7E
Robbins, G. (2020, March 31). UC San Diego Virus Expert Pleads With Surfers to Stay Out of the
Ocean to Avoid Coronavirus. Retrieved April 8, 2020,
from https://www.sandiegouniontribune.com/news/science/story/2020-03-31/uc-san-diego-
atmospheric-chemist-pleads-with-surfers-and-beach-walkers-to-stay-home
van der Sande, M., Teunis, P., & Sabel, R. (2008, July 9). Professional and home-made face masks
reduce exposure to respiratory infections among the general population. Retrieved April 8, 2020,
from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2440799/
WHO. (n.d.). Retrieved April 8, 2020, from www.who.int
Cover illustration by @sarapaglia
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