April 2, 2020 | Feature
shadowing, safety, and shortages
a reflection on the surgical mask
On one of my last days of shadowing, I ate lunch in the Rhode Island Hospital cafeteria between cases. Even with new, stricter limits on hospital entry due to fears of a COVID-19 outbreak (back when there were only two positive cases in the state), the area bustled with medical staff and patients. Groups of nurses and doctors sat in scrubs, white coats, and surgical caps, chatting about cases or weekend plans. It was just another day.
Now in the midst of a full-blown pandemic, I think about how much I took for granted then: my proximity to others, an accessible public space, the relative normalcy of hospital operations. In the following weeks, the Rhode Island Hospital, like many hospitals around the country and beyond, underwent extensive changes as the threat of COVID-19 increased. Desks were placed at entrances as visitation restrictions expanded; appointments could only be scheduled by physicians (as opposed to automated technologies); tents for screening patients with respiratory issues were set up outside the emergency department. One final change I witnessed, before Lifespan suspended all Brown University undergraduate hospital volunteering and internships, was the onset of the surgical mask shortage.
The shortage itself wasn’t a surprise. The staff in the department I shadowed, cardiac electrophysiology, had seen the news: the mask shortage in Wuhan and the greater Hubei Province, the mask shortage in Italy, the panicked stockpiling of masks across the US. It was only a matter of time. It seemed each time I arrived, there was a new policy posted on the exam room bulletin, instructing hospital staff to not waste masks. Eventually, the boxes of surgical masks—blue earloop masks, orange fluid shield masks, teal anti-fog tie-on masks—that had once filled the shelves of the sink and supply rooms were moved into a secure office, where they were parceled out for strictly essential use. Even lab techs, who provided hands-on support in cardiac electrophysiology procedures, weren’t always allowed one. By then, my shadowing had been restricted to the observation area adjacent to the operating room, where a mask wasn’t required.
Surgical masks had always been an unquestioned necessity in the department. Cardiac electrophysiology procedures, like cardiac ablations and implantable cardioverter defibrillator (ICD) implants, require an aseptic technique, which entails sterile surgical drapes, handwashing, and proper personal protective equipment (PPE)—including masks. These measures help reduce the risk of infection at the wound site, especially since cardiac electrophysiologists often access the veins during procedures, potentially exposing the entire cardiovascular system to foreign microbes. For any given procedure, four to five medical staff members donned masks—as well as the patient themselves. Observing procedures as a volunteer, I recall the countless times I quickly slipped on a mask to gain entry into the operating room.
Cardiac electrophysiology is far from the only area of medicine to utilize surgical masks. The 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Health Care Settings lists mask usage as a standard healthcare precaution for all “procedures and patient care activities likely to generate splashes or sprays of blood, body fluids, [or] secretions.” A 1993 survey conducted in the Manchester Royal Infirmary reported that 96 percent of surgeons used masks. Other healthcare workers, regardless of specialty, are required to wear masks if they are sick or at risk of spreading an infectious agent like influenza. In the clinical settings I frequented as a hospital volunteer—even in common spaces like the cafeteria—mask usage was so ubiquitous that it faded into the periphery.
The medical standard of wearing surgical masks only emerged about 120 years ago, when people began to understand the hidden entities behind diseases and the various ways they can spread from one human to another. The first masks were composed of a few layers of gauze, designed to prevent surgeons from releasing “droplets” from the mouth and nose while they spoke during procedures. This invention followed biologist Louis Pasteur’s germ theory of disease in the 1860s, claiming that microorganisms cause many diseases. Around the same time, physician Robert Koch presented a set of postulates to determine the causal link between disease and bacteria, still a key benchmark in the modern field of infectious diseases.
Development of the surgical mask advanced significantly in 1910 when the great Manchurian plague, a pneumonic (respiratory) epidemic, broke out in Manchuria and Mongolia. Working on the front lines of the crisis, physician Wu Lien-teh theorized that diseases could be airborne—a radical idea at the time. Wu subsequently invented and circulated an “anti-plague mask,” which resembled earlier surgical masks but, according to an article in Medical Anthropology, added “more protective layers and a more complex tying process, designed to keep the mask in place while operating in the adverse open-air conditions of winter-time Manchuria.”
From the 1910s through the 1940s, the practice of surgery underwent a series of massive advancements including the normalization of asepsis (creating a sterile field and sterilizing surgical tools), the expansion of surgical specialties like anesthesiology, and the employment of other PPE like caps and gloves. Surgical masks also became widely accepted around this time, and diversified into iterations like the paper mask, the absorbing gauze mask, and the compressed cotton mask.
Mask usage became compulsory following the 1918 Spanish Influenza, the most severe pandemic in recent history according to the CDC. This crisis exposed the dangerous shortcomings of masks at the time: inconsistent gauze layers, consequential breathing difficulties, and leakage around the edges, according to the American Journal of Infection Control.
Cornerstone surgical developments such as antibiotics in the 1940s, compounded with the end of World War II, left the surgical mask deprioritized—until the introduction of materials like polyvinyl plastic marked a new phase of mask innovation. As the need for more protective mask models became increasingly evident, medical professionals grew more efficient at evaluating their effectiveness, eventually yielding the most recent, standardized models employed by healthcare workers today.
Even with these evolutions, the “best” surgical masks continue to have their efficacy questioned: Considered alongside other medical and environmental factors, do surgical masks significantly aid in preventing disease transmission? The 2015 study “Unmasking the surgeons: the evidence base behind the use of facemasks in surgery” discusses flaws in modern surgical mask design, like venting (where air escapes between the mask and face), moisture accumulation, and friction during prolonged use—all potential sources of contamination. Personally, I have seen masks grow sweat-stained and leaky during particularly long procedures, their wearers left with red abrasions. A 2003 study of the SARS outbreak in Hong Kong also suggested that surgical masks alone were not sufficient protection against the virus.
Yet, as a review of surgical mask research in the Nursing Times reminds us, “lack of evidence of benefit does not equate to evidence of lack of benefit.” With relatively scarce data measuring masks’ effectiveness, skeptics should weigh factors like proper mask usage (whether a mask is used and disposed of correctly) and the diversity of pathogens (a given mask may protect against one virus, but not another). One 2009 study demonstrated that surgical masks could be just as effective as N95 respirators at protecting healthcare workers from influenza, another viral pandemic-causing pathogen.
A controversial piece of protective equipment, the surgical mask is also a cultural symbol. Consider popularized images of prior outbreaks, like the suited-up healthcare workers battling the 2014 Ebola Outbreak or the masked Seattle policemen standing guard during the Spanish Influenza pandemic. Because masks obscure the identities of wearers, the masks—even more than their wearers—epitomize protection and safety during crises.
Still, when non-healthcare workers put too much trust in surgical masks, many put themselves at elevated risk for disease transmission. In the Canadian Medical Association Journal, the 2016 article “The surgical mask is a bad fit for risk reduction” proposes, “[T]he surgical mask is a symbol that protects from the perception of risk by offering nonprotection to the public while causing behaviors that project risk into the future.” A surgical mask alone will not halt contamination, especially if individuals wear it improperly or neglect other preventative behaviors like rigorous handwashing. In an article for Time Magazine, clinical psychologist Lynn Bufka describes the act of non-healthcare workers wearing masks as a “superstitious behavior”: “Even if experts are saying it’s really not going to make a difference, a little [part of] people’s brains is thinking, well, it’s not going to hurt.” Excessively buying and stockpiling surgical masks may contribute to shortages among high-exposure, elevated-risk healthcare staff who know how to use the masks properly—and benefit more extensively from the limited protection they provide.
Social anthropologist Christos Lynteris notes that the uniform usage of white anti-plague masks by medical staff “accentuates the sense of a united front against the disease.” Particularly in East Asian cultures, masks are a “a symbol and a tool of protection and solidarity” according to University of Hong Kong research fellow Ria Sinha. Some artists have even likened the masked healthcare worker to the masked superhero. Masks characterize an ideal medical worker: at once humble (face obscured) and willing to risk their health for others. Of course, this health risk is lessened by the surgical mask itself: a paper-thin but crucial form of armor.