In Defense of Masking

Photo credit: Me, with only partial PPE
If you're anything like me, your head is spinning with all of these mask recommendations. In the past few months everything we do has changed so drastically it's hard to know what's true or correct anymore. In an effort to cut through some of that, I put together quick summary of what masks we use, when, and why. Hopefully this will give you a better understand if why most of us are only visible from the eyes up these days.

The “It’s not me, it's you” Masks

N95

Photo Credit: 3M

This makes us safe by filtering out droplet and aerosolized particles. It’s called an N95 because it halts 95% of the particles that are larger than 0.3 microns (and because the mask is Not to be used in environments that contain oil1). Basically this is the most common “high level” protection mask used in healthcare, and for most healthcare workers in most settings this is sufficient. It’s not 100% effective against all aerosols (which is why intubation teams in the hospital will use PAPRs or CAPRs that have higher levels of air filtration and provide more face protection2), but it does a very good job in most situations.

The facts that an N95 is only a half face covering and is only rated to filter out 95% of particles are why a face shield is recommended to be used at the same time, and why even though most EMS providers have N95 on for most patient encounters, we are still being selective in who we use aerosol generating procedures on (like BiPAP, oxygen above 6L via nasal cannula, or intubation). Hence this look in the hospitals:

Credit: USA Today, Chris Young AP

PAPR (Powered Air Purifying Respirator):

Photo Credit: 3M

CAPR (Controlled Air Purifying Respirator):

 

Photo Credit: MaxAir

The “It’s not you, it’s me" masks

Surgical masks

Photo Credit: 3M

This keeps others safe from us. It is designed to trap the secretions of a surgeon and prevent her or him from contaminating a sterile field. This is what we are wearing in the hospital all the time.

Cloth masks

Photo Credit: 3M

This mask is used with a similar purpose to the surgical mask, but it is better used in public. This mask will catch some secretions but (probably) less than a surgical mask.

Which is better? Cloth or Surgical:

In general, surgical masks are going to be safer for those around us. There are regulations and standards that dictate what the mask should be made of and how it is constructed, so overall it will be safer2. That said, not all cloth masks are less protective than surgical masks3.

What should we be wearing on a call?

When you're around patients, the best mask to keep you safe is a N95. This is what the CDC recommends when supplies are ample, and is more than what the WHO recommends. Having this mask on during general patient care enables you to feel protected when the patient's condition changes in an emergency and you need to switch to an aerosol generating procedure during care.

The caveat here is that this is what is recommended when supplies are ample. That is not the case right now, so that is why this is not recommended in all places for all patient encounters. Following your local protocols and policies is important here because they will take into account this balance of what protection is needed by who and (hopefully) based upon the best available evidence and expert opinion, along with supply levels, PPE use rate, and reliability of getting replacement supplies (not all agencies can just ask the Pats to go pick up PPE for them…).

What should we be doing in the station?

A surgical mask or cloth mask is best in these situations. The biggest reason is that we don’t actually know who has COVID and who doesn’t, and we don’t know who can spread it and who can’t. Studies show that between 30 and 60% of people are asymptomatic when the virus is detected in a nasal swab, and a portion of those will never become symptomatic. This not only means you could be spreading it to people before you know you put them at risk, but that you and those around you may never even know they have been exposed. This is another reason why we mask in the hospital even though we are all asymptomatic, and why we are asked to mask in public.

Yes, we could try to increase testing to see who is an asymptomatic carrier and who is not, but everything has limitations. So it is very likely that an unknown percentage of people will test negative, never have symptoms, and still be able to pass the virus around. No, a mask will not protect all people in all circumstances, but it is the cheapest, simplest, and best thing we can do to keep our workforce healthy right now.

What about reusing masks?

There is some evolving evidence that reusing masks may be ok. Again, this is not ideal because once you put it on it’s safe to assume it's contaminated. In a situation with ample supplies we should not be reusing any of these masks, but that’s not the world we live in right now, so don’t touch the outside of the mask once you put it on (unless you’re doing a seal check with gloves and then immediately disposing of those gloves) and make sure you clean your hands before and after putting the mask on or adjusting it.

Points to remember (TL;DR):

Wear a surgical mask or cloth mask when outside your house.

Wear a surgical mask or N95 (N95 is better but not always available) when treating patients.

Wear an N95 when doing something that is aerosol generating on someone who does or might have COVID.

Clean your hands often.

Masking is the cheapest, simplest, and best thing we can do to keep our workforce healthy right now. Please do it!

More on this topic: JAMA: https://jamanetwork.com/journals/jama/fullarticle/2764955
3M Mask Types: https://web.archive.org/web/20200304133722/https://multimedia.3m.com/mws/media/1798135O/possible-alternatives-to-surgical-n95-respirators-in-the-us-healthcare-technical-bulletin.pdf
Comparison of N95 type masks from outside the US: https://multimedia.3m.com/mws/media/1791500O/comparison-ffp2-kn95-n95-filtering-facepiece-respirator-classes-tb.pdf
More on EMS and Social Distancing: https://covid.brownemsdivision.org/2020/04/why-do-we-frontlinehealthcare-providers.html

References:

1:https://www.majorsafety.com/blogs/news/whats-the-difference-between-an-n95-and-r95-respirator

2:https://www.cdc.gov/niosh/docs/2018-176/pdfs/2018-176.pdf?id=10.26616/NIOSHPUB2018176

3:https://annals.org/aim/fullarticle/2764367/effectiveness-surgical-cotton-masks-blocking-sars-cov-2-controlled-comparison

4:https://www.thomasnet.com/articles/plant-facility-equipment/papr-vs-capr-respirators/

5:https://www.usatoday.com/story/news/nation/2014/10/20/cdc-new-protocol/17638161/

Patient Refusals in the Age of COVID-19 - PART I

The people you do not bring to the hospital scare the S%*# out of me.  There, it feels good to say that out loud…

If we want to pull on that thread a little more, any EM or EMS doc can tell you a litany of stories/anecdotes about patients who presented to us with benign sounding stories and ended up having something deadly/scary.  Although we tend perseverate on the patients we almost sent home, the ones that really keep us up at night (and our psychiatrist/therapists employed), are the ones we sent home, then realize on our drive back from work that we could have missed something bad.  Sometimes we follow-up with the patient the next day with an innocuous phone call (this is my preferred method to avoid multiple sleepless nights), sometimes we just lose a little sleep and keep that experience for our next shift so you don’t make the same mistake again.  And we always DREAD the words of our colleagues:  “Remember that patient you saw last week…” which usually ends in painful self-reflection and learning for next time.

Those of us who have been in EMS for a while have probably had these moments ourselves.  Picture this:  It is late and you are roused from bed to go to an address you know by heart, for a complaint that sounds like nonsense.  You get there and the patient looks the same as every other time you have been there and does not want to be transported.  You obtain your refusal, entering the patient information by memory and return to the station for some much-needed rest before shift change and heading home. You wake up from your post-shift nap to a text string from your shift relief:  They just cleared the hospital after intubating/stabilizing/coding your refusal from the night before.  After you get over your nausea and period of reflection, you can see already see the QA email coming your way, the root cause analysis meeting with your medical director, and most importantly, a bad outcome for your patient.

So how do we sort this all out? Do we just bring them all to the hospital?  Are we really just playing roulette every time we take a refusal?

Kind of.  Here is the thing:  These patients trust you.  You represent the healthcare system to them and they do not know the limitations of your evaluation.  When you take their vitals and say they “look ok” they hear “you are fine.”  When you look at the EKG and say it “looks good” they weigh this the same as having serial troponins, a cardiology evaluation and stress test in the hospital.  Combine this with an exaggerated fear of the hospital right now and you have a recipe for disaster (and poor patient outcomes). 

So does COVID really change this?

You bet it does!  First of all patients are TERRIFIED to come to the hospital right now, which should make you think about how worried they were about their complaint to make them call 911 in the first place.  Some anecdotal data from our system has somewhere around 1/3^rdof the patients who are refusing citing COVID as their main reason. The key is not to anchor on the fact that they are refusing now as proxy for their not being sick.  Additionally, we need to realize there is a lot of potential badness out there in the world that we need to sort through in our assessment and presentation of the risks of refusal to the patient.

Thanks for scaring the S*&# out of me doc, will I ever be able to sleep again?

 Yes!  The key is to obtain a good history and exam on your patients.  Think about what could be causing their symptoms and encourage ED evaluation for patients who call for help.  If the patient insists on refusing, think of all the bad stuff that could happen to them if they were not evaluated and explain that to them.  Do not be overly reassured by vital signs and “normal” EKGs, as you know, these are meant to identify the critically ill, not to screen the population for moderate illness.  Most importantly, the more worried you are about them, the more you play dirty:  Scare the heck out of them, use the words “up to an including death” as part of your refusal spiel, CALL their family members and put the patient on the phone, promise delicious turkey sandwiches, ginger ale and backrubs in the ED.  Finally, seek assistance from online medical control as there is evidence (1) that just speaking to a physician on the phone can encourage 50% of patients refusing transport to come to the hospital!
 

Stay Tuned for Part II:  The "shelter in place" protocol in RI...

Resources:
 

1. Burstein JL, Hollander JE, Delagi R, Gold M, Henry MC, Alicandro JM. Refusal of out-of-hospital medical care: effect of medical-control physician assertiveness on transport rate. Acad Emerg Med. 1998;5(1):4–8. doi:10.1111/j.1553-2712.1998.tb02566.x

18 April - Brown EMS SITREP

Link to 18-April Brown EMS SITREP

15 April - Brown EMS SITREP

Link to 15-April Brown EMS SITREP

8-April Brown EMS Division COVID SITREP

Link to 8-April Brown EMS Division COVID SITREP

Why the $@&% do we, frontline healthcare providers, have to socially distance?

As healthcare providers, we've found ourselves exempt from many of the recommendations and closures related to the current pandemic.  Since we absolutely are essential in this response, we've had a bit more freedom than many of our non-HCW friends.  We've listened, admittedly annoyed, while our friends and family members complain about how bored they are just sitting at home, telling us that we're lucky because we get to go to work.  But, with that being said, we’ve been privy to actually having face-to-face interactions while the rest of the world is hunkering down.  It is this privilege that puts us at such great risk. 

Ideally, you're social distancing since it's unlikely respiratory droplets disperse more than 6ft away with normal talking.  That’s not the case for a forceful cough; but, if you're coughing (or otherwise symptomatic), you shouldn't be at work. 

In our line of work, it can be tough to stay 6ft away from our coworkers.  We've got this covered with PPE on calls, but what about when we're at the station?  That's where masking comes in.  We truly should be wearing a mask anytime there’s potential for close contact (<6ft) with someone outside of our immediate home.  And, that includes the station.  This is exactly why the CDC changed its recommendations last week to include the use of a mask anytime social distancing may be difficult.  That's not to say that you need to wear a N95 to bed, but you should be covering your face so that you don't accidentally infect your partner as an asymptomatic transmitter.  This is the only situation where you should consider wearing a cloth mask at work!

Remember that old six degrees to Kevin Bacon game (also known as Bacon's Law)?  Well every time an infected person accidentally touches or exhales on an item, that item becomes a fomite just waiting for you to touch it and become infected.  You then easily take that home with you to your family.  All of a sudden, it's like your whole family was hugging that infected person.  The good news: when we wear appropriate PPE and DECON our truck, we break this cycle, never putting our loved ones at risk. 

But, how confident are you that someone with whom you work closely hasn't accidentally been contaminated or isn’t an asymptomatic carrier?  This post isn't meant to scare you, but to remind us that we can do a better job social distancing (even though we're still going to work), simply by following the CDC's recommendations for everyone.  This includes social distancing, wearing a mask anytime that you may come within close proximity of another person, washing your hands frequently (or using sanitizer when soap and water aren't available), etc.  

Take a look at this diagram from the New York Times:

Imagine if the person in red had worn a mask at work and didn’t touch their face.  Maybe they wouldn't have infected both their shift and relieving crew...

Some of our agencies are doing a fantastic job of protecting themselves, their partners and their families by making a few changes on shift.

- Limit the number of people in the station to ONLY those on duty

- Spread out sleeping arrangements

- Mask whenever you're not in a private room

- Disinfect boots and leave them in the bay, only wearing slippers in the station

- Wipe down any touched surfaces including door jams, the backs of kitchen table chairs, keyboards, radios, etc. at least 1x/shift

- Eat in rotations to limit the number of members at the kitchen table

Some of these changes are a big shift from our usual station culture.  But, please, be flexible.  The alternative may mean more than just a few days off work.

A few other things to consider:

- Limit the number of people in close proximity to high-risk patients

- Never write your VS on dirty gloves that you'll need to keep around to write your report

- Don’t spread the risk.  DECON early in patient rooms before moving into clean spaces.

- Make sure to wash your neck and wrists after DECON'ing as these areas are not covered by face shields and gowns

- Bring an extra uniform to change into before going home (and, if able, wash your dirty uniform at the station)

I'm not saying that you need to be these guys...

 

But take a look at how easily you can contaminate your surroundings, from the MythBusters

https://www.dmarge.com/2020/03/mythbusters-contamination-experiment.html

I pester because I care.  Please stay safe.

And, thank you.  Thank you so very much for your commitment to our team, patients and community.

Resources:

Use of Cloth Face Coverings to Help Slow the Spread of COVID-19. CDC. Published online April 4, 2020.  https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/diy-cloth-face-coverings.html

Bai Y, Yao L, Wei T, et al. Presumed Asymptomatic Carrier Transmission of COVID-19. JAMA. Published online February 21, 2020. doi:10.1001/jama.2020.2565. 
https://jamanetwork.com/journals/jama/fullarticle/2762028

Roberts, S. You Can Help Break the Chain of Transmission. New York Times. Published online March 19, 2020.  

https://www.nytimes.com/2020/03/19/health/coronavirus-distancing-transmission.html

 

Oxygen! 

It's one of the most basic interventions we provide at all levels of EMS. 

COVID has changed how we think about oxygen delivery. 

Many COVID patients need oxygen. 

We know that certain oxygen delivery methods can put us at risk...

So what ARE the best recommendations for providing oxygen to pre-hospital patients??? 

And why do we need to make changes?

First the why.

COVID is a respiratory pathogen. This means is PRIMARILY spreads via respiratory droplets- the little tiny balls of spit we constantly spew into the air when we talk, cough, sneeze (or sing...https://www.businessinsider.com/two-people-dead-from-coronavirus-after-super-spreading-event-2020-3).

Gross!! These droplets are HEAVY and tend to SETTLE within a few feet of the "sprayer." This is why 6' is recommended for social distancing. These particles also land on surfaces, which can potentially spread the disease when they are fairly fresh (so wipe down high-traffic areas in your homes/stations). This is why we wear the surgical masks- to prevent these big, heavy droplets from getting into our noses/eyes and mouths.

UNDER CERTAIN CONDITIONS, these droplets can become teeny tiny and instead of settling down, become more readily spread in the air. This is essentially what "airborne" means. COVID does not do this very readily on its own, but some things WE do CAN cause it to become airborne. 

Procedures that cause COVID to become airborne (aerosolizing procedures) include nebulizers, high flow oxygen, BVM, CPAP. Potentially when we doff PPE after an event like a code, we could shake small amounts into the air. 

Now, the what:

What's an EMS provider to do? How can we care for our sickest patients AND protect ourselves and our crews from airborne particles?? 

We have created the following "cheat sheet" to provide best practice information on the types of oxygen administration we encounter in the field. Use this as a reference- it is designed to be brief and succinct. We plan more posts to discuss particular topics in greater detail...stay tuned and stay safe!

COVID oxygen and airway cheat sheet for EMS

Oxygen administration

General:

-Early oxygen for ANY respiratory distress when COVID is possible

-Goal should be ≥90%, not 100% (92-93% in pregnant patients)

-Silent hypoxia is a hallmark of COVID; pts can have sats as low as 78% and not appear dyspneic

-Aerosol generating procedures include: nebulizers, CPAP, BVM/CPR, high flow nasal cannula

-Truck ventilation should be non-circulatory mode, with rear exhaust fan used to draw air away from driver

Nasal Cannula

-Up to 6L NC does not aerosolize. 

- Recommended to put surgical mask OVER cannula at all times

>6L creates aerosol-must vent truck and use max PPE

NRB

-MUST ensure a tight fit with mask

-Use surgical mask over to cover side ports

- With tight seal and mask over ports, not thought to generate significant aerosol

CPAP

-No longer first line but still consider for patients in extremis

-Must use max PPE

-Creates significant aerosol but can minimize it by using HEPA filter with a good seal

-Consider administering outdoors long enough to stabilize, then transition to NC or NRB

-If pt on CPAP, stage in ambulance until you communicate with ED for transport plan into department

Nebulizers

-AVOID if possible

-Instead of neb: MDI with spacer 

-Subcutaneous epi for patients in severe distress (first dose within protocol; more doses require med control for A-EMT)

-If neb necessary, consider giving outdoors prior to transport

-DISCONTINUE any nebs prior to  entering emergency department

Airway management

Cardiac arrest

-BVM is an aerosolizing procedure- MAX PPE for all codes

-Place SGA as soon as possible to avoid BVM alone

-Attach BVM to SGA prior to placement -use HEPA filter if available

-REMEMBER ALL personnel that are in same room or compartment with patient must be in full PPE (don't forget LEOs, bystanders)

-Stage in ambulance on arrival until you communicate with ED staff for transport plan

Intubation

-Discouraged due to considerable aerosol risk to provider; RSI best and not widely available for pre-hospital

-Video laryngoscopy preferred method

-Pre-oxygenate as much as possible

-Most experienced provider should do airway- take a minute to prepare so you have best chance of first pass success

-Beware- patients with ARDS (esp young/old/pregnant) can decompensate QUICKLY once intubated.

BVM

-Tight seal, HEPA filter to minimize aerosol

-COVID patients with resp arrest likely have an ARDS picture

-Appropriate ventilation in ARDS MUST avoid hyperventilation and baritrauma

-Avoid barotrauma by bagging with two finger technique (Why?—the typical adult BVM has a 1-2 L capacity. The average ideal tidal volume for an adult is HALF that. Compressing the BVM fully leads to over-inflation of the lungs & barotruma->increased intrathoracic pressure-> decreased preload->worsening hypotension-> overall mortality increase

-Use a PEEP valve if available

Stay tuned for more COVID-related clinical information.

Stay safe!

Resources:

Maryland Airway and Respiratory Considerations for the EMS Clinician: https://www.miemss.org/home/Portals/0/Docs/Infectious_Diseases/COVID-19-Airway-and-Respiratory-Management-Considerations-20200325.pdf?ver=2020-03-25-154521-457

SAS consensus statement on airway management in COVID:

https://first10em.com/covid-airway-management-sas-consensus-statement/

WHO clinical management guidelines for COVID:

https://www.who.int/docs/default-source/coronaviruse/clinical-management-of-novel-cov.pdf