As a gastroenterologist, I have had to get up close and professional (sometimes much more up close and personal than any normal person would want to be) with a host of germ-laden material. Try giving someone a fecal transplant through a colonoscope. And, during the early phase of the AIDS epidemic, gastroenterologists were frequently the first physicians called to see terminally ill men with an ill-defined, yet communicable, wasting disease that was uniformly fatal.
I Know Something About Personal Protective Equipment
Although I have never dealt with the high-volume crisis of an infection like Covid-19 – and I honor those who have risen to that challenge – I have dealt with Influenza A/B, SARS, H1N1, and Clostridia Difficile in hundreds of patients requiring isolation. So I know whereof I speak when it comes to the stress and anxiety of dealing with an invisible contagion and personal protective equipment (PPE).
The principle of universal precautions is based on the concept of treating every hospitalized patient as potentially infected and contagious. It has been with us since 1985 as Dr. Fauci, among others, unraveled the mysteries of clinically silent viruses with long latent periods such as HIV and Hepatitis C. And as a reminder to clinicians, every flu season a hospital re-experiences the inconvenience of barrier protections as clean masks, gowns, and boxes of gloves appear outside hospital room doors while used PPE sprouts from stuffed waste containers.
Can Non-Essential Businesses Observe Universal Precautions?
So, the mind reels when considering the proper use of universal precautions and PPE in every barber shop, restaurant, bar, nail salon, massage parlor, gym, etc. among other non-essential services being teed up to re-open. It seems there are not enough raw materials on the planet to make the number of gloves and masks necessary to properly protect us from our hairdressers, barbers, manicurists, waiters, and bartenders. Or for them to protect themselves from us. And yet, how well these businesses use their gloves and masks and how widely they offer hand sanitizer might dictate how frequently, if ever, we patronize their establishments.
Will Yelp Be the New Public Health Department?
In the hospital setting, universal precautions begin with universal hand washing (at a minimum this is defined to be the washing of hands before entering a hospital room and upon leaving a hospital room). Doctors resisted the process for years, thinking they, as healers, couldn’t possibly be disease vectors. Ultimately “secret sentinels” were established to count how frequently these simple actions were ignored or performed. Private shaming and sanctions were then employed by the hospital safety officers trying to improve physician compliance. Will every restaurant have a safety officer? Will every department of health have a new gown and glove division? Will public shaming on Yelp be the new norm?
Key Point: Barrier Protections Are Task-Oriented
In the workplace, the principal of barrier protection offered by masks and gloves is a bi-directional endeavor designed to protect us from the wearer and the wearer from us. But it also requires the wearer, acting as an intermediary in their work capacity, to protect us from a third party. In the restaurant industry, think of the server as the intermediary between you and the hostess, the cooks, the busboys, and the other diners – not to mention inanimate objects such as door knobs.
All barrier protection is task oriented. And every new task requires a new set of gloves. Every break in mask technique (to be explained later) requires a new mask. In the hospital, tasks can frequently be limited to within a patient’s room. In some ways this minimizes the number of times a doctor or nurse changes out their PPE – certainly, on entering and exiting each room. And frequently gloves have to be replaced more than once during each visit within the room.
Restaurants Have Third Parties (Not Just Waiter and Diner)
But, in the restaurant industry where diners are not separated by partitions and multiple tasks are taking place simultaneously as performed by multiple employees, consider how frequently a waiter should go through this process. In theory, every time that a server touches something that was touched by a third party, gloves should be replaced before delivering anything to you, the client.
In hospital practice, because gloves are slightly porous (N-95 masks filter out only 95 percent of particulate matter) hands must be washed before and after gloving up. And the proper technique for removing gloves (inverting them and inserting them – one into the other without touching the exterior surface to one’s own skin or snapping them and spraying any adherent materials elsewhere) and replacing masks (with immediately washed hands touching only the straps or ear loops) is infrequently seen in the business setting.
It has been my pre-Covid experience to see cooks and waiters (indeed, doctors, nurses, and dentists) pick things up off the floor and place them on counters while wearing gloves and then replace the gloves (or not) without thinking of the contaminated item or countertop. I have seen them clean the fallen item and countertop without replacing their gloves or washing their hands. I have also seen servers repetitively restrain their hair without washing their hands or replacing their gloves. In theory, this all must stop and training to that end is mandatory.
Our post-Covid introduction to grocery store shelf stockers in masks and gloves is a case in point. First, God bless them for the work they are doing. But as they restock empty shelves, every time they touch their masks, adjust their hair, or put their hands on a surface touched by someone else, they have contaminated their gloves and potentially themselves. If they finish their task without changing their gear, they have, in theory, broken the safety barrier, contaminated the stock, and potentially spread the virus.
No Restaurant Can Recreate the Protections Practiced in a Hospital ICU
What happens in states loosening work restrictions with respect to the potential for increasing Covid transmission will be a test of how well those businesses practice viral barrier hygiene and what we consumers demand of them. No barrier system is perfect, not even N-95 masks. And no restaurant can recreate the protections practiced in a hospital ICU. But non-essential services have to establish a track record of good hygiene to convince the wary consumer that patronizing them is safe enough. As you can see from the photo, I need to eat and I am willing to go to the grocery store. But I am holding off on a trip to the barber shop.
Let’s Make This Work. We Are All in This Together
I hope business owners take hospital practices to heart. I hope they can find the supplies they need. I hope they educate their employees. I hope that consumers become vigilant watchdogs for their own safety and the safety of others. And I hope that we can all redefine a safe, hygienic, collegial, and acceptable working environment that allows our service and entertainment industries to rebound and thrive.
We are all in this together.
Wow! I don’t see how this assiduous practice can work in a restaurant. As you say, there won’t be enough gloves. What about the frequent use of hand sanitizers and disinfectants (on surfaces, not ingested or injected, however) instead of gloves changed after every food pickup and delivery? Would that be safe enough?
Exactly! These assiduous practices are too much for the average restaurant to maintain and work only under the right amount of social and professional pressure. They break down when people relax or under circumstances of extreme overload (think overworked emergency room).
Hand sanitizers are a reasonable alternative to washing with hot soap and water for 20 seconds when washing is impossible, but washing is preferred. And using hand sanitizer on dirty gloves is not considered acceptable, although I have seen it done in restaurants.
I would expect every responsible restaurant to have a highly visible system of surface disinfection and an ample supply of complimentary hand sanitizers for customer use. I would expect them to demonstrate periodic hand washing by wait staff to impress consumers.
The proof of efficacy will be established by the number of new coronavirus infections that occur two weeks after opening and when contact tracing is ramped up, an outbreak at any given restaurant will damage its reputation, perhaps irreparably.
I agree. It is unreasonable to expect this level of hygiene.
Frankly, I’m thinking that we will have to develop “herd immunity” to defeat the coronavirus. Those of us who are vulnerable due to age and/or underlying health condition will have to shelter.
Does the public need N95 masks (assuming adequate availability)? If everyone is supposed to wear a mask in a retail establishment, is a plain cloth mask adequate? What do you recommend? Thanks.
The N95 is specifically designed as the best product to protect the wearer from others. I am unsure if it is superior at dampening dispersal of aerosolized material from the wearer, but I should think so – if properly fitted. Therefore, assuming ample supply, it is probably better than a simple cloth mask. But this theoretical benefit might not translate into a practical benefit.
Finding where laboratory proven theory meets real world practicality is the challenge.