By Lynn Tougas, RK
Registered Kinesiologist and Founder – Whole Heart Whole Health
Since Ontario’s Allied Health Care Professionals resumed back to regular work post the COVID emergency lockdown, many eager professionals immediately filled up their schedules in excitement to recapture financial losses suffered. In addition to recapturing monies lost and covering past rents due, the sheer joy of human touch and the allowance to resume real-life interactive treatments was enough for anyone to be overly joyful to fill up their schedules and immediately dive back into a regular treatment routine.
But, then came the challenges with PPE.
On one forum I was privy to, the discussion was about the battle with increased symptoms of extreme fatigue. One practitioner asked if this could be related to cognitive related stress and the additional thinking involved in preparing for work now with all of the additional recommended protective gear? Possibly, however I wasn’t fully convinced this was all that was going on. With my health and safety work history that involved mask fit testing at one of our city’s most established tuberculosis treatment centres, I felt I should put this experience to use and do some further research.
I’d already been posting on my private social media my concern with the use of masks while outdoors exercising or simply enjoying a walk where proper distancing was in abundance. My take on the subject was that in these situations not only was a mask not necessary to reduce anyone’s risk to COVID, it is in these very situations that the mask wearer is putting their own self at increased risk of dehydration and amplified fatigue due to hyperventilation from the mouth covering which increases oxygen usage. Should the hyperventilation and dehydration continue for long periods, there are many other health risks one must be aware of. In more extreme cases, low carbon dioxide levels resulting from the increased oxygen use can lead to narrowing of the blood vessels that supply blood to the brain. This reduction in blood supply to the brain can further lead to symptoms like lightheadedness and tingling in the fingers. Moderate hyperventilation can lead to fainting and severe hyperventilation can lead to a complete loss of consciousness.
Back to the fatigue inquiry from my forum of freshly back-to- work Allied Healthcare Professionals. I had many questions boiling inside my brain. Were these professionals given guidance on how long to wear a mask? How about what type of mask is best for their current ventilation? More important, how about the possibility of bacterial buildup on the mask? Is there a difference between fabrics and bacterial contamination? Can we and how should we best re-use a mask? Are we closely monitoring their PPE usage for any symptoms related to hyperventilation, increased fatigue and bacterial build up?
I was determined to answer all of these questions, and if there was any room for a debate, I’m just as determined to keep this discussion as alive and healthy as we wish our businesses and healthcare practices to be during this restart of our economy.
Guidance on how long to wear a mask: In one study on surgeons and surgical masks, it was found that after 2 hours bacterial contamination was evident.[i] Recommendations were made in this study that included monitoring the duration the mask is worn – less than 4 hours with 2 hours most optimal; improving the mask wearer’s mouth hygiene, and the use of double-layered high filtration masks. Now I know we are not all surgeons and we are not wearing surgical masks, but that is what makes this area even more up for debate. We are in unprecedented territory with many of us using substitute cloth masks made of a combination of many different materials not studied in this format at all. I recently questioned a mask being sold at the checkout of my local Shopper’s Drug Mart. The label was all written in Chinese. The fabric was unknown to me as I couldn’t understand the labeling, but from what I could see clearly with my own eyes is that it certainly wasn’t in the least a healthy organic cotton material nor a medical grade mask material.
Guidance on what type of mask is best: In a collaborative paper of research on PPE during the initial SARS breakout in Canada during the early 2000’s, it was determined that even proper mask fitting could not assist with improved PPE compliance.[ii] Suggestions were made to allow the healthcare provider to trial several different face coverings throughout the shift until a comfortable face covering was determined. Emergency front line workers who need to wear respirator masks for extended periods should be provided tactile training and/or build up to full day use. In order to effectively overcome the increase in oxygen usage and build up one’s cardiovascular efficiency, a gradual planned acclimatization is necessary.
Not only are many of us not being mask-fit tested as independently employed Allied Healthcare Workers, once again we are in unprecedented times in terms of available research on the outlined purposes of each of our individual PPE usage guidelines. We must protect ourselves, as well as we must take precautions to protect our patients and clients. However, we have limited research on what is best for each of differing roles.
Guidance on bacterial build-up: My interest piqued on this subject after I read a circulating Facebook post by a British Columbia woman claiming a retail worker had been admitted to hospital with the doctor stating that the reason for the worker’s admittance and illness was bacterial build-up on her PPE causing a lung infection. First of all, I am not sure if this was true information. The post was not tagged nor blocked in anyway, yet there was no further information provided regarding the type of mask or how long the worker was wearing the mask. What the story did for me in the end was it fueled my interest in researching mask usage one step further than what I was finding was currently available to Allied Healthcare Professionals as well as the general public.
Back up to the first study, where I mentioned about length of wear of surgical masks and bacterial buildup, I can only say that there may be some room for discussion here regardless of the quality of the Facebook post I read that lead me into looking into this further.[iii] Mouth hygiene has not been discussed on any current mask guidelines. With this new information in mind, coupled with the older research completed on surgeons and surgical masks, I believe it should be.
Guidance on the healthiest way to store and reuse a mask: According to this study, the reuse of asks in non-emergency situations has been recommended for decades.[iv] Based on my above research, proper hygiene is important, as well as reducing the risks of hyperventilation. The brown-bag method is a best-case scenario for mask re-use along with proper hygiene before and after use. [v] Further, the “CDC recommends that a respirator classified as disposable can be reused by the same worker as long as it remains functional2 and is used in accordance with local infection control procedures.” For best practice, one must thoroughly wash or sanitize their hands before removing and replacing the mask to be re-used. The mask is said to be best stored in a breathable container and that a clean brown paper bag can be the simplest form of such a container. It is recommended that storage containers should be disposed of or cleaned regularly.
If you are an Allied Healthcare Worker looking for guidance on mask use and re-use, the above information is helpful for when you schedule your breaks, consume food, or use the toilet. A key word here is schedule. Following a strict schedule with regard to breaks, mealtimes and toilet times will only assist with enhancing your overall mask usage as PPE experience. Building up to a fuller capacity day as you adjust to your new environment is also said to help. Taking more scheduled breaks in the beginning of your return-to-work may be essential for the most optimal outcome. Having several fresh masks available to you throughout your day is also highly recommended.
When do I need to where a mask the most and are there any situations where a face shield or no covering at all is safe? A key way to comprehend whether or not a mask is justified is to analyze the Japanese coined 3 C’s. The 3 C’s –crowded spaces, confined spaces, and close-contact. The 3 C’s are a helpful way of knowing in non-emergency situations when a mask may be most beneficial to reduce risks.
There will no doubt be a continued inconsistent use of masks relative to one’s natural and intuitive ways of working within these confines. As we have seen, many lay people will shop around town, eat a bite of a snack or take a sip of coffee and continue to wear the same mask, continuing all day to pull it up and down between sips or bites. In the case of dehydration risk and the Allied Health Professional, one will certainly need to hydrate frequently during their work day. At the present time, folks are taking breaks with their mask left hanging around their necks, or they are getting into a similar habit of pulling the mask down to communicate more effectively or sip a drink only to pull it back up straight after. Who knows if this is the same mask they practiced these same behaviours with the day previous? We must be more aware of these types of behaviours and remember that hygiene is important for proper, safe mask usage.
Food for thought.
Personally, I will continue to focus on appropriate surface and hand hygiene first along with being hyper-cognizant of the 3 C’s. At which point I am aware I cannot control my 3 C’s I will wear a mask. If I can control my 3C’s I may choose not to wear a mask, whereas I may safely remove my mask to take a break in a quiet open space. I would then carefully store the mask accordingly using the paper-bag method described above. I would also continue to monitor my mouth hygiene by brushing or gargling after food and drink. If I’m in a situation where I will need to wear a mask for an extended period of time, I will monitor any symptoms of hyperventilation including the very first signs of dehydration – one being that I might feel a little more fatigued than usual. Last, I will likely only wear a medical grade mask during the entire COVID pandemic as this is the style of mask the bulk of reliable research has focused on. Of course, I may not wear an N95 respirator for daily use, but I will continue to wear my surgical masks.
With a little more training and awareness, all us can have a better pandemic post-lock down experience getting back to business. As the saying goes, practice makes perfect. Ongoing research would be of most benefit to this cause and I am more than happy to assist with this.