N95 masks. Surgical masks. Homemade masks. Two months ago, if someone was wearing a mask, we would wonder “why”; these days, we wonder “why” if someone is not wearing one. In response to the coronavirus disease 2019 (COVID-19) pandemic, the wearing of masks has become globally commonplace, from airports and grocery stores to homes and neighborhoods. Many hospital systems have instituted mandatory 24/7 mask-wearing policies for all employees, visitors, and patients who walk through their doors, with the goal of protecting patients and healthcare workers alike and with the hope of decreasing the spread of a disease actively wreaking medical, financial, and emotional havoc across the globe.1
And yes, face masks offer critical protection to providers on the frontline. Face masks decrease the spread of COVID-19 and may be at least partially responsible for “flattening the curve,” thus preventing our healthcare systems from becoming devastatingly overwhelmed.2 But, for all their delivered security, face masks are taking a very real toll on providers themselves: a physical, psychologic, and emotional price that is difficult to describe and quantify.
Most think that, as anesthesiologists, wearing masks is a normal, standard practice, but nothing is “normal” in a pandemic. The process of putting on a mask in the hospital is no longer ordinary; it is no longer routine. It is an act accompanied by undertones of anxiety, worry, and concern, and followed by a barrage of unsettling questions: Does my mask fit appropriately? Is there a leak? Will my mask keep the virus out? Will it protect me from getting sick? Will this mask prevent me from infecting my elderly parents, my spouse, and children? Questions that persist long after our masks have been donned and doffed.
Face masks act as a physical barrier to the disease itself, but they also create an emotional barrier against conveying empathy and compassion, instilling confidence in our expertise, and cultivating trust and reassurance. Likewise, gloves remove the comforting aspect of the human touch. How do you foster and grow a personal relationship with a nervous patient, child, parent, or family with a mask covering your mouth, a shield covering your eyes, and gloves covering your hands?
From birth, humans are programed to observe, identify, and interpret facial cues to learn safety and trust, develop situational awareness, and nurture attitudes and beliefs.3 Our faces are now covered. Our facial cues have vanished. We are no longer able to shake hands. We cannot smile as we comfort each patient, striving to communicate that we will provide the very best care for them, or reassure each parent that we will treat her child as if he is our own. We are left with our words, stifled by our face masks, difficult to understand, muffled and subdued. Words which feel fragile and distanced, all the while hoping that we have adequately conveyed kindness and compassion to our patients and their families, our most revered qualities for our most treasured resource.
Our patients, too, must wear masks. With these physical barriers, clinical cues, once taken for granted, are absent. We cannot examine an airway in preparation for intubation without the fear of exposing ourselves to infection. We are unable to observe the color of our patient’s face and lips to ensure oxygenation or feel his breath on our wrists to confirm ventilation. Using a stethoscope is nearly impossible because of our shield of personal protective equipment.4 We perform our duties alone, to minimize unnecessary exposures. Our setup, once routine and predictable, is fraught with uncertainty.
Behind our personal protective equipment, we are hot, sweaty, and uncomfortable in our normally comfortable surroundings. Our faces hurt from the pressure of the masks. Our skin is breaking down. We rebreathe exhaled carbon dioxide, increasing our metabolic rate and the physiologic stress on our own bodies.5 God forbid if we sneeze. Previously routine procedures are difficult—placing tenuous intravenous catheters covered with multiple layers of gloves; auscultating the lungs of a patient without breaking suit; intubating a newborn with foggy goggles. We are uncomfortable in our regular workspace, our own practice—vulnerable in situations our expertise has previously allowed us to feel secure in.
Our clinical practice is changing, evolving to meet the demands of the COVID-19 pandemic. We are walking a fine line, teetering on wanting to do what is best for our patients while in turn keeping ourselves healthy, burdened by guilt either way we fall—am I not doing enough? Am I exposing myself too much? The practice of medicine no longer feels like the safe haven it was before COVID-19. Hospitals are strange and foreign environments, colored by unease, apprehension, and fear. Face masks symbolize the novel challenges and struggles we now face on a daily basis.
But we still come. Despite our discomfort and uneasiness, anesthesiologists willingly flood hospitals across the country. Every morning, we make the choice to leave the safety of our homes, prepared to don our masks and equipment, ready to provide care to those who depend on us. We have dedicated our lives to people and have no intention of surrendering in the face of the beast. We are charged with the vital task of holding our patients’ lives and well-being in our, now gloved, hands.
Yes, our masks are necessary. They keep us safe, keep our families safe. We wear them for the greater good, for the good of society, to allow our civilization to continue, to persevere. Our masks allow us to continue tending to those in need. They are our crutch, what allows us to continue fighting in this war, but they are isolating. We are practicing medicine surrounded by people but alone. Nevertheless, when we take our masks off, we can breathe again. We are free to express ourselves as we did before. The loneliness of wearing a mask disappears, and we are reminded of who we are, why we do what we do, and what we are fighting for.