Not All Masks Are Created Equal with Dr. David Fieno

In the first episode of MyHeart.net's podcast, three cardiologists discuss face masks in the healthcare field in the face of a pandemic. Dr. Alain Bouchard and Dr. Mustafa Ahmed are joined by Dr. David Fieno to discuss the effectiveness of face masks during the coronavirus pandemic, as well as Dr. Fieno's initiative to provide free N99 masks to medical workers on the frontlines.

You can learn more about Dr. Fieno's mission on his practice's Facebook page as well as his GoFundMe page, where you can also contribute to this cause.

About the Team

Dr. Alain Bouchard is a clinical cardiologist at Cardiology Specialists of Birmingham, AL. He is a native of Quebec, Canada and trained in Internal Medicine at McGill University in Montreal. He continued as a Research Fellow at the Montreal Heart Institute. He did a clinical cardiology fellowship at the University of California in San Francisco. He joined the faculty at the University of Alabama Birmingham from 1986 to 1990. He worked at CardiologyPC and Baptist Medical Center at Princeton from 1990-2019. He is now part of the Cardiology Specialists of Birmingham at St. Vincent’s Health System, Ascension.

Dr. Mustafa Ahmed is a Structural Heart Specialist, Interventional Cardiologist and Scientist, and is the director of the Structural Heart Disease Program at UAB. He is a leading performer of minimally invasive heart procedures, including the Mitraclip procedure. He is credited with several first of their kind procedures and internationally recognized in areas including valvular and surgical heart disease and POTS. He was born in Nottingham, England, and went to medical school at the Victoria University of Manchester. He took postgraduate positions at the Manchester Royal Infirmary, then the Queens Medical Center. Dr Ahmed moved to Birmingham, AL, where he was the first person selected for the Physician Scientist Training Program with specialization in cardiology and interventional cardiology.

Dr. Philip Johnson is originally from Selma, AL. Philip began his studies at Vanderbilt University in Nashville, TN, where he double majored in Biomedical and Electrical Engineering. After a year in the “real world” working for his father as a machine design engineer, he went to graduate school at UAB in Birmingham, AL, where he completed a Masters and PhD in Biomedical Engineering before becoming a research assistant professor in Biomedical Engineering. After a short stint in academics, he continued his education at UAB in Medical School, Internal Medicine Residency, and is currently a cardiology fellow in training with a special interest in cardiac electrophysiology.

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Transcript

Dr. Philip Johnson  0:15  
This is the MyHeart.net podcast. The show is produced by Dr. Philip Johnson in conjunction with VitalEngine.com. Please welcome your host, Dr. Alain Bouchard, in Birmingham, Alabama, at St. Vincent's Medical Center.

Dr. Alain Bouchard  0:30  
Welcome to MyHeart.net podcast. My name is Dr. Alain Bouchard, and I'm part of the cardiology specialists at Birmingham at St. Vincent's, part of Ascension. And my co-host is Dr. Mustafa Ahmed, director of the interventional program and structural program at the University of Alabama in Birmingham. This podcast is made in collaboration with Dr. Philip Johnson at Vital Engine, and our special guest today is Dr. David Fieno, cardiologist at Shelby Medical Center in Birmingham. Today, we'd like to discuss the personal protective equipment, in particular - the mask. We know that we're kind of in the middle of this pandemic, you know, caused by this new virus, the new coronavirus, the COVID-19 virus, and it's been obviously a lot of education to the public as well as to our patient as to how we protect ourselves and- and you know, making sure that we keep the basic always in play, washing our hands, making sure that we cover our mouth when we're coughing or sneezing, and keeping a safe, reasonable distance, and just wearing a mask, and for this reason, we'd like to kind of start the discussion about the wearing of masks since in Birmingham now we have a new ordinance since May 1 that if we're in the city of Birmingham, and we're in public, we should be wearing a mask. Now, not all masks are created equal. And for this reason, I'd like to ask, for example, Dr. Ahmed, to have maybe some description of the different masks that we have available to us. Dr. Ahmed?

Dr. Mustafa Ahmed  2:29  
Thanks, Dr. Bouchard. So, so, David, please chime in as you- as you feel fit here because I know you're kind of an expert on this topic now, with all you've done, we'll talk about your story a little bit, but, so like Dr. Bouchard is saying, all masks are not created equal. But what we do know is any kind of mask is better than no kind of mask. And we've seen every variation, Anyone kind of reading anything online with the news, social media, or whatever it is, is- is aware of this and we've gotten everything from t-shirts over- over heads and noses to bandanas to extraordinary efforts of mask-making, and we're going to talk about Dr. Fieno's story here. And then there's a- the level of protective mask that would protect healthcare workers who are exposed. And so we've got on one hand the masks, "Hey, I'm walking around the street, I'm walking through the shopping mall, I'm walking through the grocery. What can I wear here to maybe give myself some protection and those around me some protection." And then we've got the masks which are, "Hey, I'm in a hospital, I am exposed to patients who actively have COVID, and how do we try not to catch this and how do we prevent healthcare workers spread and spread amongst patients, and the kind of mask's names you may have heard are N95 masks, which at one point seemed to be one of the hottest commodities in the United States. These all-protective masks, and I will tell you a bit of a mask story from my standpoint, which was when we, when- when this whole thing first started, there was fit testing going on in the hospital, and I walked across and watched this happen. It was the strangest thing. There's like a bunch of people with a spacesuit over their head. And I was like, "What are those people doing?" And then two days later, I found myself standing in one of those lines, and you line up, and you put a mask on, they give you these masks called N95 respirators. And they basically put this huge hood over your head like an astronaut suit, and they're spraying this... They spray some stuff in there. And basically, they want to know, "Can you taste this? Can you smell this?" And that's called a fit test. And so those are high-level fit-tested masks, which would prevent droplets even getting into, into- into where you are, and then above that, just to finish off with, there's- there's these p-power masks, which are these- almost like you'd see people going into somewhere that's getting fumigated or a big engineering shop, mechanic shop where people are essentially wearing an entire spacesuit over their head with these, with these, you know, attachments where there's filters on the end of the pipe, which is coming out of the mask. But I've seen all sorts of elaborate, various masks, but- but ultimately, what we're going to talk about today, and is a... How do we get masks that are useful that can be used by a relatively wide variety of people that can protect against droplets that can be reused and that are available for people that need them in the local communities, and a lot of people, when this first hit, this whole COVID thing, it was like, "Oh my gosh, how do we get these masks? Where do we get them from? What do we talk about? Who do we talk to about this? And how do we get our hands on these things?" I can tell you that as a, as a director of an interventional section, you want to- you're wanting to protect everyone you work with. And then you get people like Dr. Fieno over here, who basically said, "You know what, I'm gonna not just find out who to ask and what to do and- I'm actually going to take care of this problem myself," and, David, I'd love for you to start a bit of this incredible story where you took a problem which faced every single healthcare worker person on the front line and you basically said, "You know what, I'm gonna do something about this right now."

Dr. Alain Bouchard  2:46  
Go ahead, Dr. Fieno, and tell us about the Fieno Project.

Dr. David Fieno  6:39  
Thank- thank you, Doctors Bouchard and Ahmed, I really appreciate the opportunity to talk with all of you today. So I think that motivation is exactly what Mustafa just elaborated on, and that is that the very people who we are taking care of are not protected themselves, and, even more concerning, perhaps, is that the people who are charged with triaging these folks and bringing them back to the clinic, and then in your case, in your cases, Dr. Ahmed and Bouchard, doing procedures on these folks, probably have inadequate protection. And what I found was they were unprotected. These folks were without masks completely. And I just said, "There has to be something I can do about it. There has to be something I can do about it." There's a lady in Hoover named Heidi Elnora who found a pattern on the internet, and she converted her dress shop into a shop that made cloth masks, and she did all this for free at her website. And healthcare practitioners could login, request cloth masks, as many as they wanted, and she followed this pattern and turned out these very nice cloth masks. So I requested about 150, spread them out to my staff and my patients, particularly high-risk folks, folks with end-stage lung disease, heart failure, cancer, and made sure personally that they had a mask. And what happened was, as Mustafa is just mentioning, people started talking about these N95 masks, and it doesn't take long looking at the Internet, there aren't many of them, these are the protective standard, they're all being held in other countries, they're all being shipped to hospitals. And basically, we don't have enough of them. There's this incredible shortage of the protection, and exactly as it was just being said, different levels of protection for different types of material that are used. And if the material itself is particularly porous, it will probably provide some protection more than nothing. But if it's less permeable, then it will probably provide more protection. And what happened was I just was walking through the OR, and I found that there were some masks that were available. And I noticed right below the masks, there were a series of paper sheets that these cloth masks that were going out to patients and to our hospital and clinic workers. And so, I saw this pattern and then I saw this material that was labeled as N99 material, and I asked myself, "Is it possible that we can make our own N95-style masks?"

Dr. Alain Bouchard  10:17  
Dr. Fieno, let me interject. So this N95, which is considered the gold standard, the respirator, and in China, they have the NK95, same thing. So, this- this material, the N99, does that mean it actually, it blocks even more the particles as compared to the N95? Or whether, with, you mean, whether with aerosol or air particle, do we know?

Dr. David Fieno  10:44  
So we should- we should talk about what does N95 even mean? And what N95 means is that it's a mask that's been rated to actually prevent 95% of particles, 0.3 microns and larger, from passing through the pores. And the belief is that these respiratory droplets are on that order of size, and that fewer particles passing through the filter to your airways reduces the infection rate. And as Mustafa correctly elaborated on, and I tried to send some pictures, the way in which these are tested is with this hazmat outfit and everything depends on the seal. So, this material was labeled as N99, rather than N95, Dr. Bouchard. So, what I wondered was, is it possible? Do we have a more protective material? And a little bit of research showed that that was exactly the case, it was less porous than the N95 material, so it's more protective. And so I took the exact same pattern that Heidi Elnora was using for the cloth masks, and I contacted a seamstress up the street, who happens to be a wife of a physician, and she turned out an absolutely professional-quality mask. So I went a step further. I asked, which of my 13 partners had N95 masks, and not surprisingly, none of them did. You see, HealthSouth doesn't work for a hospital necessarily. It's a private practice. So these masks that are being delivered across the country to the hospitals are actually not going to the front line. They're going to where the front line brings the sick patients is to the hospital. So what I discovered was the private practices, Jemison and Columbiana and Clanton, all these folks also didn't have N95 masks. So what I did was I just set out on a task, can I make as many N99 masks as possible? And I don't know if the pictures came through that I just sent, but that's sort of what the first iteration looked like.

Dr. Alain Bouchard  13:19  
I think this is really fantastic. I mean, we know that the N95 you know, the respirators, is what is considered at least the first line in the medical field. It's a very, very, it's not a very good fit. I mean, it fits, and it's very, very tight on your face, and that's why you see, for example, a lot of the nurses that have to spend you know, several hours in the ICU doubled masked, you know, having some skin abrasion, you know, from these masks. Then we have the surgical mask, which basically you use the design. Isn't that, isn't that correct, Dr. Fieno? The surgical mask, but with a very tighter fabric, because we know that in the surgical mask, approximately 70% of particles go through the mask and 30% around the mask. So it's not you know, obviously, a very close fit like it is, you know, with an N95, but now having, you know, a better fabric, you know, this polypropylene that is basically, it's nonwoven, and it allows for, you know, not getting moist, which is very important. And I guess, later on can talk about the fabric mask. Doctor Ahmed, you wanted to say something about that.

Dr. Mustafa Ahmed  14:38  
Yeah, just to elaborate on the story further, David. So, you see this problem. And as with anyone, I mean, there's no way to prepare for something which isn't even imaginable. So, this whole thing, I mean, I can remember the weekend where, hey, one week it was okay to travel, and the next weekend, "Oh my gosh, I can't believe you just traveled last week." And it was like, was this very watershed moment, and life just changed overnight, and we turned up and you find yourself, like you say, at work, and it's like, oh my gosh, what is an N95? Where do I get one? How do I get one to everyone? And so you just described a process whereby which your answer rather, rather wonderfully was, well, I'm going to make them, and I'm going to make a ton, and I'm going to get 'em to the front lines, and... But so, you know, you, you, you made a bunch of these, you worked with a cardiology group here in Birmingham, Alabama, just outside there in the surrounding counties, and you managed to get the masks to everyone. But then, then the story goes, goes further, because I can tell you as someone that's benefited from your mask project, as... And Dr. Bouchard, have you, have you found yourself with some of these, these masks, you know? So what happened then? What, then... It sounds like the story took a further step where you were like, "You know what, we need to share this, and we need to expand this." Can you talk about a bit of the scaling and the communication and the, the outreach aspects of this?

Dr. David Fieno  16:10  
Sure. So, when, if you- if you look at these masks, which all of you are welcome to at DavidFieno.com, the masks look, even though they're homemade, and you kind of get a feeling like, I don't know, maybe they look kind of rough-drafty, they're very professional-looking masks. And what happened as I started handing them out in my practice is I started getting requests from family members of my colleagues, "Could we please get masks for them?" And I started realizing that the secretaries and EKG techs and the folks doing stress tests, they were just as vulnerable as I was to all the patients that were being seen. So I kind of took on a project to see if I could get 150 masks distributed to my practice and their immediate families, my practice is 80 people. It wasn't enough, but it was something. And so a team of volunteers were assembled, and I was able to order several thousand square feet of this N99 material and hand it off to a group of people volunteering. And without trying, I had a dozen folks who sew volunteer to sew these things if they could get the material, and my practice bought the material for me. And so I handed it out with the patterns that Dr. Bouchard was talking about. And before the 150 masks were made, I had requests from all the neighboring general medicine practices for the exact same thing, I mean, word just spread. And I realized that, oh my goodness, I think I need to organize this whole effort, and there started to be some financial cost with it because you have to order boxes of this material. So I had formed a website and a Facebook page a couple of years ago, and I asked my web designer, would he please establish a site for this exact thing and formalize what we were doing so that we could have people volunteer, we could have people request masks, and he did so, and within about seven days time, a little over $7,000 was contributed to the cause. There were requests from all over the city and very soon all over the country. And the volunteers started coming in by droves to make these. To fast forward to today, we're about 20 days into the project, and about 2000 masks have been delivered directly to the healthcare practitioners, and there's about 11,000 requests now for folks who are in need of these things and have asked that the organization help with their practices. And I think as- as a sociological experiment, I think the volunteers finally felt like there was something that they could do in this terrible crisis to help the healthcare workers and hopefully to protect everyone. Another thing I did, when the volunteers stepped up to make masks, I told them right away, I want you to first make masks for your whole family, the protective ones, the N99 masks, and then, for each one you make for your family, please make sure you make at least two for the healthcare workers. And then I told all the healthcare workers there was no need to pay for these, these are being provided free of charge. And, but if they felt the need to do something, that they were welcome to contribute to the cause at the website. And that was completely voluntary. It was just to sustain the materials and reimburse the volunteers who are traveling to get these distributed.

Dr. Alain Bouchard  20:22  
That's terrific. And it- actually, their gofundme.com so far has raised $8,382, on its way to $10,000 mark, I mean, what an accomplishment, and what a way to empower, you know, these people, you know, these volunteers, I mean, I think their contri- their contribution is very, very significant, I mean, for the city, and also, they're shipping, your shipping these masks all over the United States, isn't that correct?

Dr. David Fieno  20:52  
It is. So we've shipped to California, Texas, Ohio, Florida. We've shipped throughout Alabama. And there have now been requests internationally, which I have no idea if the shipping is prohibitive at this point. And the- the comment about empowering people, I think up until this point, what I observed in my neighborhood was people were at home. Many of these folks were financially in trouble. They were scared by this virus. Many of them are furloughed or laid off of work. And worst of all, they had nothing they could do about it. I think what this project did was it said, "Here, if you want to do something, you can. If you're able to sew, great. If you want to transport these around, great. If you want to say a nice word on Facebook, you can do that." And I think it gave people the power back, to say, "Yes, we're in a difficult spot, but this is what we can actually do." So.

Dr. Alain Bouchard  21:59  
Dr. Ahmed, did you want to add something? Because, you- I know at your hospital, at UAB, you are using Dr. Fieno's masks, the N99 surgical masks, in addition of the other inventories, and I think it probably has helped a lot in, in a situation where you treated a lot of patients with COVID-19, very, very sick patients. And I'm sure there was- you were in short supply.

Dr. Mustafa Ahmed  22:28  
Yeah, you know, I will tell you, I'm lucky to work at a place, you know, where these things, these N95 became- we managed to get our hands on them relatively quickly, but anyone that's worn an N95 all day and into the evening and worn that with other masks on top, and what I can tell you is, you know, when I'm doing a, I'm doing a procedure on someone that's infected, or when I'm- in that kind of situation, I'm probably wearing a fit-tested N95 with, you know, a face shield, but, very much, I look forward to getting back down, getting my, my Fieno mask back on, which provides an incredible amount of protection and, you know, I will tell you a couple of things about your mask, David. So, one is, one is it's extraordinarily comfortable, but two, which is I felt really cool it, I'll go as far as to say it's the single coolest mask in production right now, and I will tell you, the minute we got these, you know, I was like, "Let me just try one on and walk around," and you had very kindly delivered some over and had them delivered over to, to where to where we were. Within a minute of wearing this thing around, I realized that, "Oh my gosh," like, all 20, all of them had an owner right then, because everyone was like, "How do I get one of those? Those are the greatest masks I've ever seen." And I was, like, "Well, let me tell you a bit of a story behind this is an N99, not an N95." And, of course, that, that enhances the legend of the whole thing. But I've got a very, very important question for you, which... So when are you making a version with a coffee mask that coffee can be drunk through? And when are you making the snack version of the Fieno mask, because, because this clearly is the biggest, the biggest barrier that we're facing now, which is we're wearing these for hours at a time, and you tell me about this, but one thing I learned, and again, I wear this mask all the time now, but, oh my gosh, like how often do you find yourself wanting to touch your face, and you're about to touch your mask, and you're like "Nope." And if anything, wearing a mask all the time, someone asked me this the other day, someone said, "What is the point of wearing a mask? Why am I going to the grocery and wearing a mask?" And you know, my answer was, "Firstly, I don't think you understand how often you will touch your face, and when you wear your mask, you will very, very figure that out, but secondly, and you're- you described something very noble, which is a call to action, you know, when you're a healthcare worker and you're working in the middle of COVID, and you're working this, you have this call to action, you turn up and you get to help and you get to do and, and your mask, your entire mask making process, and everyone that are involved is a very important call to action. But I think it extends beyond that. I think when you leave your house and you wear a mask and you demonstrate you care about the people around you, you want to protect others, you want to not be part of that transmission process, and you develop a culture of the new normal. Someone told me something, you guys comment on this, but someone told me, about two months ago, that if you're in China and you're walking around and you're not wearing a mask, you're getting these death stares, like, "What are you doing?" Whereas in the US two months ago, if you walk around and you're wearing a mask, you're getting these, "What are you doing" stares? "You're a crazy. Why are you wearing that mask?" What's your- I'd love to get some of your guys' thoughts on the whole, not to be shy, you were- you were talking about the, the, what's it called. Global masking, the actual, say, what's it in Birmingham? I don't know what you call it.

Dr. Alain Bouchard  26:08  
The ordinance, ordinance to wear the mask.

Dr. Mustafa Ahmed  26:12  
What's your guys' thoughts on this?

Dr. Alain Bouchard  26:14  
Well, you know, so, you know, most people actually have the fabric mask, which is, you know, obviously it's non-woven, it doesn't have this moisture repellent. And in terms of efficacy, it's probably, you know, not quite as good as even a surgical mask, which is not as good as the N95. But, you know, at least to have the fabric and make sure that the, you know, after using, they wash it, and so it can be reused. Again, I think it's like, it doesn't really, this is not what's gonna stop the infection. This may help, you know, you know, when integrated with other techniques such as washing your hands, don't touch your face, keep a certain distance, maybe we'll help and flatten the curve. And I guess that's the hope, you know, that's the hope that we have that, you know, wearing a mask is, makes us, you know, conscious and cognizant of, of keeping a distance, of being careful because so much of the virus is being spread while the patients are asymptomatic. And that is the problem. I mean, you don't know who's infected and who's not, the individual doesn't know whether he's infected, and you can find out several days later, but I think wearing the mask at this time does make sense as a sign that, you know, you, you care and you want to kind of be, you want to contribute to reduce the rate of infection, and you want to help contribute to flatten this curve, because obviously, this is not what's going to make the virus go away. But if it's, you know, at least in our face, it makes us conscious that not to touch our face. Continue, you know washing your hands and keep a safe distance. Yes, Doctor Ahmed, you wanted to add something. Or maybe Dr. Fieno, sorry.

Dr. David Fieno  28:10  
Yeah, I sent you the message, Alain, I'm sorry. So both, both of you really are speaking exactly to the point. I think, Dr. Bouchard, your comment that these things help, I think, is the key behind the whole thing. I don't know that we can honestly say that we are preventing anything, unfortunately. Prevention is such a strong word that is not really a possible ideal to attain. What I think to your point is, is that everything we do moves us in a direction, and hopefully we go in the direction of flattening the curve, of reducing the spread of this very contagious bug, and also, it helps us to feel like we can do something amidst this crisis. So, I think, to your point, wearing some type of protection over your mouth and nose when we go out, I think it helps. I think bumping that up to a surgical mask with a formable piece over your nose and kind of tightening it up over your face, I think that's a step further. If you're able to get your hands on an N95 mask or a similar one, great. And from my perspective, if you can take that and have something similar, the N99 homemade masks, for example, all of this is moving that in that direction and those things, along with social distancing and attention to hand washing - and Mustafa pointed out being cautious with how often we touch our faces - it's all going to push this situation in the right direction. And I noticed at least two things in the last couple of weeks. The first is, I've tested five people who have had upper respiratory infections recently for the COVID antibody that has just come out, the testing. And all five have tested negative, they don't have antibodies. So despite our hopes of herd immunity, unfortunately, the spread, the contagion factor that can affect any one of us, is still there. And then the second thing I've noticed is what Mustafa was alluding to a little while ago, is we really are - it's gross to talk about - but we're all sharing each other's spit all the time. When we don't have some type of protective feature on our faces, when we sneeze or when we shake hands or when we are just in the grocery store, the truth is, we're breathing in everybody else's salivary particles. And I'm not trying to gross everybody out as much as I'm trying to just say, I think that factoid is relevant to the spread of this novel virus, as it's called, and everything that we can do, even if it's just staying home if you're sick, or avoiding going out to public places if it's not absolutely necessary. Every single thing we do is going to help in our cause to flatten that curve and hopefully control the spread and ultimately help us restore our society.

Dr. Alain Bouchard  32:04  
Well, we really appreciate it, I mean, this was a great roundtable, I mean, here we are, you know, four cardiologists, wore our masks all of our life in the cath lab, and now it's becoming such a, an incredible topic about all the different masks and how do we protect ourself and protect others, you know, around us. And as we go through this coronavirus and the pandemic, and we have, we're looking forward to other virus- viruses that we're going to have to fight, and the flu season starting in the fall, in the winter, at least we have a vaccine for that, and they are working on a vaccine for this COVID-19. It may be another year or 18 months, you know, before we get something and get some protections. The antibodies are very nonspecific, and, and it's hard to know if, you know, if they correlate with some kind of immunity or not. I guess we'll find out later on as, as our studies are going on. But if we could teach our patients and the population the basics of washing your hands, don't touch your face, keep a safe distance with others and cover your mouth when you're sneezing or coughing. I think these are good basics that we can carry forward into all the season- next seasons that we're going to have and future seasons of virus infection and epidemics. I want to thank you, all of you, I mean, Dr. Philip Johnson at Vital Engine, Dr. Mustafa Ahmed at UAB, Dr. David Fieno at Shelby Baptist. What a great contribution, and again, DavidFieno.com and gofundme.com, and support this incredible gesture and, and enterprise that you started with your neighbors and volunteers, again, trying to help and contribute to the betterment of this society. Thank you all.

We'll see you next time.

Transcribed by https://otter.ai