Routine PPE

[Summit]

To clarify...if there will be airborne goobers and/or blood, I will wear some kind of face protection with eye wear. I haven't worn an N 95/respirator since my vaccination and never have for unknown status for any pathogen. I've no doubt been unknowingly exposed to TB and all kinds of flus. If I'd wear that type of mask after vaccination, it would follow that I ought to wear it long after Covid is gone and I'm not doing that.

Have you not had to care for confirmed/suspected COVID?

I mean, fine if you aren't doing any cases but I find it anecdotally funny that it is anesthesia who I had the most trouble with as far as PPE compliance, COVID infections exposing other staff during this whole thing. I love anesthesia providers (particularly crit care trained), but dang if there aren't some who are just decide they know what is best and they are going to do that despite what anyone else says, and then they are going to play stupid when confronted. "What do you mean I can't have a beard with my N95?" "I need a fit test?" "I need to have both elastic bands on?" Yea I know they weren't ignorant, it sure made for some drama as surgeons and OR staff were unhappy... </general rant, not directed at e-tank>

There is a huge difference in risk stratification working with (infectious disease) sick people vs not sick/screened people. The difference shifts but remains if you are presumed likely immune.

You ought to be wearing airborne protection for any suspected airborne pathogen patient and any or AGP with a suspected droplet pathogen (you can aerosolize flu etc). Vaccines aren't 100% as you well know. You don't go into a disseminated herpes zoster room without PPE just because you had chickenpox as a kid, nor do you go into a measles room without PPE.

Wearing N95 as standard precautions in EMS, well, I never was quite fully onboard with that except in certain situations... but in an airborne pandemic it wasn't a terrible idea either. As we move out of pandemic prevalence levels and mandate vaccinations, I think we can even smartly move away from mandatory airborne precautions for all AGP on low-suspicion unscreened patients.

 

[E tank]

You ought to be wearing airborne protection for any suspected airborne pathogen and really any or AGP with a suspected droplet pathogen (you can aerosolize flu etc). Vaccines aren't 100%. You don't go into a disseminated herpes zoster room without PPE just because you had chickenpox as a kid.

There is a huge difference in risk stratification working with (infectious disease) sick people vs not sick/screened people.

Wearing N95 as standard precautions in EMS, well, I never was quite fully onboard with that except in certain situations... but in an airborne pandemic it wasn't a terrible idea either. As we move out of pandemic prevalence levels and mandate vaccinations, I think we can even smartly move away from mandatory airborne precautions for all AGP on low-suspicion unscreened patients.

Like I said...I haven't worn an N 95/respirator since my vaccination and never have for unknown status for any pathogen. Instead of 'unknown, I should have used 'unsuspected.'

 

[Summit]

Like I said...I haven't worn an N 95/respirator since my vaccination and never have for unknown status for any pathogen. Instead of 'unknown, I should have used 'unsuspected.'

Got it. Thanks for the clarity. I think the airborne precautions for AGP with unscreened (molecular test) but low suspicion patients makes sense as a form of transmission control in the high prevalence/pandemic situation we have had. I think with vaccination and falling prevalence, the justification is weakening and the practice (has been and) will go away. We already have pre-proc screening as a risk reduction to eliminate the need to do airborne precautions on low-suspicion patients. At this point, it is unnecessary to test vaccinated asymptomatic patients. I'm optimistic of a continued return to normal.

It would be silly to airborne precautions for AGP a permanent universal practice.

At the same time, in the future, I'd recommend it if we had epidemic flu. It's also nice that as a result of the COVID pandemic there is widespread deployment of analyzers for flu PCRs that are largely eliminating the (almost useless IMO) rapid flu immunochromatographic antigen assays, so we could test screen during future epidemics.

 

[silver]

Have you not had to care for confirmed/suspected COVID?

I mean, fine if you aren't doing any cases but I find it anecdotally funny that it is anesthesia who I had the most trouble with as far as PPE compliance, COVID infections exposing other staff during this whole thing. I love anesthesia providers (particularly crit care trained), but dang if there aren't some who are just decide they know what is best and they are going to do that despite what anyone else says, and then they are going to play stupid when confronted. "What do you mean I can't have a beard with my N95?" "I need a fit test?" "I need to have both elastic bands on?" Yea I know they weren't ignorant, it sure made for some drama as surgeons and OR staff were unhappy... </general rant, not directed at e-tank>

There is a huge difference in risk stratification working with (infectious disease) sick people vs not sick/screened people. The difference shifts but remains if you are presumed likely immune.

You ought to be wearing airborne protection for any suspected airborne pathogen patient and any or AGP with a suspected droplet pathogen (you can aerosolize flu etc). Vaccines aren't 100% as you well know. You don't go into a disseminated herpes zoster room without PPE just because you had chickenpox as a kid, nor do you go into a measles room without PPE.

Wearing N95 as standard precautions in EMS, well, I never was quite fully onboard with that except in certain situations... but in an airborne pandemic it wasn't a terrible idea either. As we move out of pandemic prevalence levels and mandate vaccinations, I think we can even smartly move away from mandatory airborne precautions for all AGP on low-suspicion unscreened patients.

If i remember correctly there is a study out that demonstrated anesthesia and ICU providers had the lowest rates of infection compared to everyone else in health care.

edit: Since the summer have really only been wearing N95 when we get called to a cardiac arrest, if suspected/positive, or if I think someone would yell at me.

 

[Summit]

If i remember correctly there is a study out that demonstrated anesthesia and ICU providers had the lowest rates of infection compared to everyone else in health care.

edit: Since the summer have really only been wearing N95 when we get called to a cardiac arrest, if suspected/positive, or if I think someone would yell at me.

There is a study that looked a relative risk factors for HCPs and doing AGP, ICU*, COVID units*, and PPE observers all were associated with decreased risk presumably because those settings and activities were associated with proper use of airborne+contact PPE. But if individuals decide not to properly use the proper PPE in those higher risk settings, one can safely assume their risk is higher. As most places also started pre-proc molecular testing and symptom screening, that makes for a lower risk environment for anesthesia, as does higher vaccine uptake amongst the highest education HCPs (physicians and advanced practice providers).

*Note that prime transmissibility is a few days prior and after initial onset of symptoms for most COVID patients while most hospitalizations occur about a week after onset. Thus there was a higher risk in non-COVID units and repeat non-AGP patients as these are more likely to be cryptically infected at maximum contagiousness while the HCP has less robust PPE/practices. In some cases extended COVID cases that have clinically deteriorated often have less viral shedding and are dealing with the sequelae of their infection, though there are certainly exceptions especially in immunocompromised/immunosuppressed patients.

Unsurprisingly, by far the highest risk factor for HCPs was participation in large social gatherings outside of work. This far outclassed occupational related risk factors.

 

[silver]

I feel like I'm going to sound like the quack skeptic now, but there is a paucity of data to suggest that N95s meaningfully prevent infections compared to surgical masks (especially for non-aerosolizing procedures) in health care workers though.

 

[Summit]

I feel like I'm going to sound like the quack skeptic now, but there is a paucity of data to suggest that N95s meaningfully prevent infections compared to surgical masks (especially for non-aerosolizing procedures) in health care workers though.

Doesn't make you a sound like a quack to call out the lack of robust evidence, but I still feel the preponderance of evidence supports additional protective factor of particulate respirator for COVID-19 vs just surgical masks.

We haven't seen good studies looking for that and it is hard to do retrospective because of all the confounders. There are so many unknowns too... what is the ID50? For which variant? How well does that droplet mask work (some can have very good filtration efficiencies (>>80%) if they for aerosols larger than MPPS... if they fit you right).

I also wholeheartedly believe that there was enormous political and financial pressure to avoid looking at this in 2020 just as there was such reticence to call the disease airborne. Why? The simple answer is because an airborne pandemic response with respect to proper PPE and environmental controls lies of the scale of unachievable at the start (and always stays unachievable in non-1st world countries) to economically challenging at best (plenty of hospitals would have gone on reprocessing their N95s forever if CDC didn't say stop). What percent of hospital rooms are AIIR in a first world hospital? Developing nation medical clinic? WHO is acutely attuned and writing accordingly... and everyone was denying it. But how were the Chinese kitted out? They could because they owned first access to supply chains.

We had early Chinese data in January showing good adherence and N95 use was completely protective vs non-N95 and non-strict adherence, but it was small. We had early data showing this spreads like an airborne disease. We had Nebraska's study showing detectable RNA found on aerosol particles with up to several hours of stability, and later we had more data backing airborne spread plus viable virions confirmed on aerosol particles that would not be efficiently filtered by droplet masks. There were the animals studies too...

So yea... Airborne... but... Prospective trials comparing airborne vs droplet PPE for COVID? Haven't seen it.

Patients on airborne precautions are preferentially placed in rooms with better environmental controls (higher ACH and negative pressure relationships) reducing burden in the air and we have plenty of data showing better ventilation means less transmission, which is more of an airborne characteristic than droplet. Of course there is that nebulous definition that doesn't differentiate specifically between these two modes. There was a great conference I e-attended about airborne transmission and control last summer. I'll try to find the links.

 

[silver]

Doesn't make you a sound like a quack to call out the lack of robust evidence, but I still feel the preponderance of evidence supports additional protective factor of particulate respirator for COVID-19 vs just surgical masks.

We haven't seen good studies looking for that and it is hard to do retrospective because of all the confounders. There are so many unknowns too... what is the ID50? For which variant? How well does that droplet mask work (some can have very good filtration efficiencies (>>80%) if they for aerosols larger than MPPS... if they fit you right).

I also wholeheartedly believe that there was enormous political and financial pressure to avoid looking at this just as there was such reticence to call the disease airborne. Why? The simple answer is because an airborne pandemic response with respect to proper PPE and environmental controls lies of the scale of unachievable at the start (and always stays unachievable in non-1st world countries) to economically challenging at best (plenty of hospitals would have gone on reprocessing their N95s forever if CDC didn't say stop). What percent of hospital rooms are AIIR in a first world hospital? Developing nation medical clinic? WHO is acutely attuned and writing accordingly... and everyone was denying it. But how were the Chinese kitted out? They could because they owned first access to supply chains.

We had early Chinese data in January showing good adherence and N95 use was completely protective vs non-N95 and non-strict adherence, but it was small. We had early data showing this spreads like an airborne disease. We had Nebraska's study showing detectable RNA found on aerosol particles with up to several hours of stability, and later we had more data backing airborne spread plus viable virions confirmed on aerosol particles that would not be efficiently filtered by droplet masks. There were the animals studies too...

So yea... Airborne... but... Prospective trials comparing airborne vs droplet PPE for COVID? Haven't seen it.

Patients on airborne precautions are preferentially placed in rooms with better environmental controls (higher ACH and negative pressure relationships) reducing burden in the air and we have plenty of data showing better ventilation means less transmission, which is more of an airborne characteristic than droplet. Of course there is that nebulous definition that doesn't differentiate specifically between these two modes. There was a great conference I e-attended about airborne transmission and control last summer. I'll try to find the links.

Well you could do a large case-control. Almost all health systems already track occupational exposures and place people on quarantine through an occupational health office. You have your exposure (like patient testing positive within 24-48hrs after interaction with employee) and then just look at OR of employee testing positive between wearing N95 or surgical mask at time of exposure.

 

[Jim37F]

We can use goggles, but the ones issued are awfully uncomfortable and fog up easily, making any isolation moot when I'm having to remove them and rub them clear again repeatedly... Could you provide a link to what you use, both the "basic" as you put it and the ski mask version?

I like the idea of a sealed goggle, or nearly-sealed, as they might not fog easily, and probably provide some actual isolation.

These are my blue "ski goggles" I have:

These red "regular" goggles were the other option for issue:

They're both from Bollé Safety.
I initially chose the blue ones because a) they fit over my sunglasses for outdoor calls, and b) the red trim of the others was noticeable in my field of vision when trying them on, felt a tad bit distracting.
Although now I half wish I went with the others because sometimes wearing the full ski goggle set up feels a tad ridiculous, but oh well, not quite enough to go jumping through the hoops to get reissued lol

 

[Carlos Danger]

N95 for suspected or confirmed COVID patients. Regular disposable surgical mask the rest of the time only because it's required. I think eye pro during intubation is a good idea, but admittedly I don't usually do it. The rest of the time I fail to see the necessity of eye pro at all.

 

[NomadicMedic]

Eye pro on every call for me. I recently switched to bifocal eye pro and it made all the difference. I’m very careful about my eyes.

Surgical mask on all as well.

 

[FiremanMike]

Nursing clinical clinical changed my outlook on PPE, where I observed almost every hospital employee in surgical masks and occasional eye pro.

I became even more lax after both contracting covid as well as being fully vaccinated..