 Welcome everyone to our Grand Rounds this morning. We're all excited to see each other virtually again want to acknowledge our speakers Dr. Orianna Levin and Teresa Long who on their own really have an interest in COVID-19 and personal protective equipment and have produced a rather prepared a Grand Rounds for us today. So if you would look at the chat section as well the chat section is where you'll be able to post any questions. I'll be monitoring questions throughout the presentation. I will jump in if there is a question that I feel like needs to be asked at that moment. Would ask that everyone keeps their microphones muted. If we do get feedback then our AV team will end up muting you on their own and then finally if you would all look in the chat section for announcements about CME the CME phone number the CME code. Do want to just let everyone know that there's a lot of things happening in the education realm for any faculty on if you are interested. There are some rounds that we're doing with residents both resident driven both faculty driven there are opportunities to produce mock world board style questions etc as we work through this time. Again want to thank our presenters today and Dr Arianna Levin comes to us by way of Cornell. She's one of our PGY2 residents and Teresa Long is our PGY3 resident coming to us by way of University of Missouri in Columbia. Turn the time over to you two. Thank you Dr. Petty. I also want to let everyone know if you can watch on a computer it may be better we have a lot of pictures for you today. So as Dr. Petty introduced I'm Arianna Levin I'm a PGY2 with Teresa Long our PGY3 and we're excited today to present to you COVID-19 masks review of the science sustainable innovations and practical use. Today we're going to cover surgical masks N95s cloth masks and most excitingly innovative designs including new ideas for fabrics and 3d prints and for each of these we're going to review the current CDC guidelines recent scientific literature our university guidelines as well as practical use and considerations at Moran Eye Center. There are many challenges to the healthcare system right now we are fortunate to be in an ambulatory center that's sheltered from many of these but one of the challenges is shortages in personal protective equipment. There's even a web page from the CDC that allows healthcare centers to calculate how quickly they're going to burn through their PPE. Do we specifically have a mask shortage yet? Well New York Times has reported on how the world's richest country ran out of a 75 cent mask. Bloomberg News has reported on hospital workers making masks from office supplies amid U.S. shortage. NPR has reported COVID-19 has caused a shortage of face masks. Moran Eye Center is using a lot of masks and about a month ago I wondered if we had any alternatives. I was thinking that if we were able to use fewer masks then maybe our stock could be used elsewhere. I wondered if it would be financially beneficial at a time when our clinic volume is low and I imagined that at the very least we might produce less waste. Here at Moran we're currently using masks in the following settings. In clinic we have physicians, technicians, patients and schedulers all in masks. In the operating room as usual we have our physicians, anesthesia and nurses in masks. All of our administrative faculty and staff are now wearing masks as well. Here's what PPE in New York looks like right now. These are Instagram posts from my friend Dr. Jamie Law who's currently a resident in New York City. In the first panel she writes organic chem goggles from college for the win. In the second panel we see a very blurry syringe and she writes what my vision actually looks like all night. And in the third panel she says also those were presses and a syringe in my pocket. Cowboy night medicine question mark. If we had reusable masks then the solution to we're running out of masks would be an easy solution. It might also reduce the number of disposable masks that we have to purchase and the number that we throw away. So the first question I asked was do reusable masks exist? I asked two of our international fellows Dr. Sophia Fang and Dr. Avni Shah if they had ever seen them. Shown here are our texts and their answers. So I had written to them have you seen any hospital anywhere use reusable masks like our green gowns with masks. And Sophia wrote no just reusing. Avni wrote many would use the same surgical mask all day but then throw it away. I haven't seen reusable ones. I telephoned Marin Eye Center's green gown supplier to ask if they had ever sold them. They told me no we haven't seen reusable masks. We're not in the business of masks because gowns are medical devices and masks are not. But they also made an interesting comment. They said that an increasing number of hospitals are buying their reusable gowns because the hospitals can't buy disposable gowns anywhere due to the shortage. I even then talked to a friend who used to work for a lumber company and she said that she wore PPE to protect from sawdust and she said that they had reusable gowns and reusable goodies but not reusable masks. My conclusion from this was that FDA approved reusable masks or reusable masks validated by studies don't exist for our use. We're going to revisit this point. It was a really interesting discussion but first let's understand the masks that we do have. So at our eye center we're all familiar with surgical masks. This is a photo taken earlier this week in that hallway in our in our university hallway that connects us to the cafeteria and it's a recycling bin for disposable masks. Our hospital's preparing just in case we need to reuse disposable masks which is part of CDC crisis planning. This is a recent study in nature of the efficacy of surgical face masks. So they included 246 participants and they examined exhaled breaths from these participants. People were randomized to either wear a surgical mask during their exhalation or wear no mask. They were measuring detection of RNA from influenza virus, the common coronavirus, and rhinovirus in respiratory droplets and aerosols. They reported that their coronavirus was detected in four of the 10 droplet samples that were collected without masks and none of the samples collected with masks. This study came out April 3rd 2020 a couple weeks ago earlier this month. Relevant studies like this one are small. They use viruses other than COVID-19 as models and it's hard to know exactly how to apply results to specific scenarios such as an asymptomatic carrier on our operating table or a symptomatic patient at a slant lamp. The CDC now has a page called healthcare professionals infection control using PPE. They recommend that patients with confirmed or possible infection should wear masks and healthcare professionals should use PPE according to their level of risk of exposure. The CDC also gives strategies for optimizing the supply of face masks. They outline three plans for conventional capacity contingency capacity and this includes using the same mask for multiple encounters and restricting masks to use by healthcare professionals rather than patients and they also outline plans for crisis capacity. I think based on what we're doing in our iCenter right now we are following a plan that lies somewhere between conventional and contingency capacities. It's important to recognize as we've been doing here that the contingency and crisis strategies assume that we have reduced our patient volume, reduced visitors and reduced non-essential healthcare professionals and also maximized telemedicine. So let's move on to N95s. This here is my grandmother. She's 93. She's in Queens right now and she's presenting to us on a tele-meeting that happened last weekend demonstrating her N95s which she had purchased sometime around 2002 when SARS was in the news. What is an N95? By definition an N95 mask blocks 95 percent of 0.3 micron test particles. This here is a meta analysis that compared surgical masks versus N95s. This meta analysis included four randomized controlled trials. The outcomes that they looked at were laboratory confirmed viral respiratory infections or clinical respiratory illness. They conclude from their meta analysis that there is no evidence that surgical masks are inferior to N95. If you want more information about reuse of N95s which we won't delve into today, we'll focus more on surgical masks. Here's one resource from a scientific consortium including University of Utah faculty that publishes on N95 decontamination. So early on we saw many healthcare workers in cloth masks. We've now transitioned our healthcare workers to medical masks at Marin Eye Center but we do see more and more cloth masks in the community. This is a study that compared N95 versus surgical masks versus homemade cloth masks. They did not use human subjects. They modeled respiration with an apparatus built from syringes and they looked at detection of RNA from avian flu which they are using as a COVID-19 model and aerosols. They conclude that N95 blocked almost 100% of the virus, surgical masks blocked 97% and homemade masks blocked 95%. CDC has now published guidelines for the use of cloth face coverings. They write CDC is additionally advising the use of simple cloth face coverings to slow the spread. They recommend fashioning their coverings from household items at low cost. They say the cloth face coverings recommended are not surgical masks and not N95 respirators. These are critical supplies that must be continued to be reserved for healthcare workers. They include in their recommendations that cloth face coverings should be worn in the general public including in places like grocery stores and pharmacies. So I want to spend some time now on innovation highlighting an idea from the University of Florida and return to our initial question. Are reusable masks an option? University of Florida has published on their website that they are making masks for use in their hospital from Halyard H600. What is Halyard H600? Well it's this stuff shown here. It's that blue paper that wraps sterile surgical instruments and trays. The H600 is recommended for heavy instrument trays. Here at Moran Eye Center we carry H100 through H400. The University of Florida site suggests that they think that these Halyard masks are more effective at droplet protection than a standard surgical mask. As I've discussed this with several people over the past few weeks people usually stop me here and say did you say more? Yes they think that it's more effective. From what I can tell from their site this is based on the producer's specs. I called a representative from their team to ask what tests they've been running on their masks to validate them and I haven't received this information from them yet. Community and hospital members in Florida are masks producing these masks for use in their hospital. The masks are autoclaved and cleaned with light for reuse. They're not alternatives to N95. They're not FDA approved. So have we been inspired to try this here at Moran? Well of course in fact we've tested them in an autoclave just yesterday. I recruited Dr. Long to help me sew. This is showing her beautiful setup in her backyard including social distancing. This past weekend we got together and sewed masks according to the University of Florida instructions. All of our materials are shown here. One mask takes less than 10 minutes to make from start to finish and as of yesterday the masks survived the autoclave. Challenges in this process so far included materials. Our main operating room probably does have the H600 that is made for heavy instrumentries. There were really long lines at the yarn store. Here I am social distancing. I'm not really savvy at the yarn store yet either so I did spend 10 minutes standing in a line for cutting fabric before realizing that the cut bar is not a checkout line. But finally with Dr. Long's help I got the hang of the foot pedal thing. I understand it's good practice for cataract surgery. So we're getting there. As Dr. Long talks about practical use in her half of the talk I want to invite you to consider these questions. Are reusable masks an alternative to disposable masks at Moran? How about for patient wear with the CDC guidelines in mind? And how about after our current protocols are relaxed? Like what about four intravitual injections? Finally I want to give a quick word about 3D printing. This is my significant other. He's an ENT resident in Philadelphia pictured here modeling bear garb. We have at the bottom the tropical fanny pack inspired by our own Dr. Who. We have the N95, the swim goggles which he told me that their trendy chairman purchased for the whole team. And at the top a 3D printed face shield. People around the country are now 3D printing face shields as well as N95 masks to be fitted with filters. Are we 3D printing here? Of course. This on the left is a photo that I took on March 1st. It's hard to believe but that was before the campus shut down. I had gotten lost in the undergrad library that day trying to print a poster for one of the many conferences that got canceled. And I had come across this flock of 3D printers and was so impressed. I snapped a photo. Now we're using them to print face shields. You can see the link from University of Utah showing those 3D print face shields on the right. All right let me turn it over to Dr. Long to talk about university guidelines and practical use at Moran Eye Center. So I'm going to go over the University of Utah masking policies just to update us all and kind of talk about where the rubber beats the road and see if we can have some good discussion about how to keep ourselves safe, how to keep our patients safe as we navigate this pandemic. So all the information I'm going to go over today is available on the Pulse website. So a lot of this information is here. I'm not going to go over everything but if you are interested there's instructional videos and all the policies online. I also wanted to point out a few more things that as I was reviewing Pulse's website there's actually a recommendation, a list I'll show you next for at home or there's recommendations for at home emergency preparedness and then also recommendations for keeping COVID out of your home for our technicians and front desk staff as well as our physicians and residents. And there's also a really nice collection of well-being resources. There are Zoom group meetings resources for psychiatric consultation also available on the website so I would encourage everyone to check it out and make sure that you're staying up to date. This is something that I thought was also very practical. I think a lot of my colleagues in medicine that I've discussed with over the last few weeks have started implementing a lot of these practices. I think I didn't realize that it was it came in a list but from talking to one of my friends who's a medicine resident she says yes every night I go home I take off my scrubs as I enter my house I wash my scrubs I leave my shoes outside you know I wipe down my pager my phone my keys my id badge with a wipe before I leave work and there were some just very practical tips even as far as removing a watch removing jewelry bringing your lunch in a disposable bag and then of course we're all washing our hands like crazy. So I thought this was helpful and I wanted to share with you all. So as of Friday April 10th we adopted a universal masking policy at the University of Utah Health and so I wanted to go over what exactly does that mean for us and what exactly exactly does that mean for our patients. So in short clinical staff and providers who interact with patients and when in public areas of the hospital and clinics must wear a mask. So this means that all of our physicians all of our technicians all of our imagers who are directly interacting with patients even some of our researchers also interact with patients must wear a procedural mask through the day. I think it's interesting that they have said that they may wear eye protection but they must wear eye protection when caring for a patient with respiratory symptoms. So I know that we have had patients come in in my experience in the retina clinic who are wearing a mask and do have respiratory symptoms and I've also noticed many attendings are also wearing eye protection. I think this is something we can talk about given the close proximity of our technicians and our ophthalmologists whenever we're doing an exam on a patient. Second administrators and non-clinical staff who interact with clinical staff and in in public areas of the hospitals and clinics. So I think this means all of our staff who works upstairs on the fifth floor you know I think potentially they could also fall into the third category but a lot of our physicians come upstairs to their offices and so one may say that they should wear a procedural mask a standard surgical loop mask and they should keep this mask and reuse it for multiple days. Last the administrators and non-clinical staff who work in offices or labs our current university guidelines recommend that they may wear their own facial covering and they may reuse these for multiple days. Ariana's talked a little bit about this and then I can show you some of the other alternatives. I think anyone you know where I've thought a little bit about where our schedulers and administrators schedulers fit into this. I think that there are probably schedulers who can remember a time when they have been sneezed on by a patient or coughed on by a patient even though they're separated from a window and so certainly I think I would encourage anyone if you want to wear eye protection or you want to upgrade your mask and reuse it. I think that that is a very reasonable thing to do based on personal preference. It's always better to be safer than sorry. Can you just clarify what you just said to upgrade your surgical mask and reuse it? Yes sorry so instead of for example I think that we have for example a lot of our administrative staff Megan, Chandler, Eileen who work on the fifth floor in some ways have contact with the providers as they're coming up to their office. I think it's less likely now now that those staff are working from home or are you know and maybe the the clinic hours are limited but if a person who's working upstairs you know by the university guidelines they should wear a cloth mask their own facial covering that comes from home but I think it's fine if that individual says you know I have contact with clinicians I would prefer to be a little bit safer and I'll just wear one procedural mask and reuse it. So I think that's something very beautiful. Can you say that again? I'm so sorry just saying thank you for that clarification that's perfect. You're welcome. So there are guidelines on making your own cloth coverings from a t-shirt it's actually really easy you just fold it and then you can use rubber bands some benefits to this is that you can rewash the t-shirt and so you could even have multiple masks that you can use out in the grocery store and about in the community. I'm not saying that we should use these in clinics obviously but I think for people you know we still have to go to the grocery store as humans we still have to go to the pharmacy and I think then to then this is a an alternative for us at home. I think the other piece that I'd like to talk on is appropriate use of a surgical mask so I remember being taught as a medical student the sterile technique for the operating room how to appropriately scrub in and part of that training was how to you know the purpose of a surgical mask and so the standard ear loop masks that a surgeon wears in the operating room are meant to prevent the surgeon's can oral you know flora from contaminating the surgical wound and I remember going through a lecture that if you have to sneeze when you're in the operating room and you're holding your retractor you're supposed to stand straight up not turn your head from side to side and sneeze and that way the sneeze goes out the sides of your surgical mask and not into the sterile field and as I've been wandering around you know on consults or on call and and around the clinics I've noticed that there are some inappropriate uses of masks that I wanted to point out so I've seen people wearing it you know when you're at Starbucks and you tuck your mask underneath your chin and I've also seen where masks you know people will be wearing a mask but it's not covering their nose which kind of also defeats the purpose and then the other thing is that you know we're taught that the outside of the mask is not contaminated and so when you take off that mask you know you need to lay it down on a surface on a tissue or a paper towel the other piece is you know when you come out of a room you should be grabbing it by the ear loops and then laying it and then performing hand hygiene before and after and so I just wanted to point out these I thought they were helpful they were on the university website as well just to make sure that we're getting the most out of our masks and last Arianna has already talked about this reprocessing bins I'm not sure if we have one at the Moran I know there is one in the walkway between the Moran and the University Hospital I know that some residents are saving our masks and paper bags in the call room and if in the event we were to need to reuse them and figure out a way to re-sterilize them so then that's all about us and who should be wearing a mask but what about the patients that we're seeing so current university policy as of four nine says that patients with respiratory complaints should be provided with a mask so I think right now we're doing an excellent job everyone is being screened when they're coming into the Moran if they're having respiratory symptoms I believe they are being provided with a mask visitors with respiratory complaints should be denied entry I think here even at the Moran we've gone a little bit further and we're not allowing visitors upstairs patients and visitors without respiratory complaints may wear their own facial coverings but can also enter without a mask now I think this is a very debatable question and I want to also talk about before we get into this what about the really sick patients we are seeing so should you know what kind of gear do we need to wear to take these you know see these patients I don't think this is necessarily applicable to all of our patients in clinic I know we have a room down on the first floor that's designed for seeing COVID positive patients but I do think that this is incredibly relevant for the console residents and the residents taking call and I think it's definitely something we have to consider so this for patients who are confirmed having of having COVID or suspected of having COVID meaning they may be admitted to the hospital for some other issue and they're known as a COVID rule out while we're waiting for that test to come back to see those patients if you are doing a non aerosolizing procedure the standard precautions would be droplet contact and eye protection so this means that you're wearing an ear loop mask you're wearing eye protection and gowns and gloves something that they've added on the floors which I heard from my medicine colleagues was actually an observer for doffing PPE so in particular with other with other things it can be challenging the most common time that a provider is going to be contaminated is when you're doffing your PPE and so there is actually a nurse who is designed to help everyone get out of their PPE on these floors and on these shifts and I think utilizing that person is an outstanding resource and then if you have aerosolizing generating procedure so these would be intubation extubation non-invasive ventilation and then anything with open section or you're thinking about a patient getting a breathing treatment or who's in the ICU on high flow in this case you the provider and the staff taking care of the patient needs to be in either a papper a capper or an n95 mask with eye protection gown and gloves and so and they also have observers for doffing so this is two or three weeks ago when I was on call on Saturday I got a consult of about a 71-year-old patient she was found to have conjunctivitis fever and skin rash and also a rash including her oral mucosa and she was transferred from an outside hospital due to concerns for Steven Schantz and syndrome her preliminary biopsy results had a return and were strongly suspicious for Steven Schantz's per dermatology and she was a quote COVID rule out and so the staff you know the nurse practitioner when she consulted me she's like well we really don't think that she has COVID we think that her fever and her conjunctivitis are probably from her Stevens-Johnson syndrome but she the test outside hospital had started the process of getting the test and it takes them like six days to get their COVID testing back at that time so they reswabbed her here and we're waiting on the results so we didn't know so I went up to the fifth floor and you know this is a patient that needs to be seen there's concerned for Steven Schantz's you know we're obviously concerned about the ocular surface and I went up to the floor and they said hey all the providers up here are wearing pappers and and so I was like well okay so I had a very lovely nurse named Lindsey who helped me get in and out of a papper and so I talked about this with the chief on at the time and I said you know I actually don't fit an n95 mask with my face structure I'm supposed to wear a papper so even if we had one available in the room you know it wouldn't have fit me and one could say well was I not doing an aerosolizing procedure should I have just worn a standard surgical mask and done a dilated exam so I decided with the help of my chief to just perform a surface exam and defer dilated testing given her good visual acuity until it could be done after her test return negative which it later did so her exam without giving you all the measurements she essentially had moderate involvement of the cow people conjuring type up bilaterally and she did go on to get amniotic membrane transplants so I think that this presents us with some challenges that are unique to ophthalmology you know we all see the guidelines that are for aerosolizing procedures and I think in ophthalmology especially we're in close proximity to the patient especially during direct and indirect ophthalmoscopy so I know the neuro ophthalmologists I don't believe are doing direct ophthalmoscopy anymore but even you know our slit lamps now have shields but we can all remember doing an exam a 20-diopter indirect exam on a patient and having them fog up the back of our lens with their breath and we also have a lot of I'm going to say maybe non-sterilizable isn't the the best term but difficult to clean equipment so for the consult resident or even in the room we have near cards tonal pins we reuse bottles of eyedrops we have a pinhole occluder muscle light all of the slit lamp knobs even if you're wearing gloves and you touch the patient's eyelid and then you touch the slit lamp knob and then also the surfaces of our lenses and I think all of us as consult residents have experienced this in some way or another we go to the children's hospital we see a kid that has flu we wipe down everything with the purple wipes and then we're a jovial bunch as pointed out in Dr. Who's most recent staff pearls article about updates of ocular findings in COVID and we are often coffee or we're often talking to the patient during the exam and we've asked the patients not to talk and things like that so not only in clinic but our residents on call and consults are the first line I think of of defense and we're right there on the front first line in the front line and so I also wanted to point out a lovely lovely I was I was called a fomite with legs a few weeks ago by Dr. Hoffman which I told him was the nicest compliment I'd ever been given but I think it's true we're everywhere on call we're everywhere on consults and so we really have to be cognizant about what we're doing so I would encourage the providers who are in the clinical realm now to really think about our consult resident and our residents on call because it's baby has been a while since you've done an exam in the ICU leaning over a bed on an intubated patient trying to just like squeak your 28 into the field of view and they don't dilate so well or on the floor is thinking about a patient who's COVID positive and on high flow nasal cannula and discerning how to discern patients that need to be seen after hours at Moran or if they have respiratory symptoms should we be sending them through the ER and also the inability to wear it indirect for a dilated fundus exam over a papper or a capper for those residents who maybe don't in my case aren't supposed to wear or aren't fit tested for an N95 a few words about pappers so powered air purifying respirators so you know the N95 as Arianna has discussed with you filters out 95 percent of the particles the pappers are like 99.7 so they are safer papper training is available through work wellness I wanted to give a shout out to our chiefs who I believe have all gone and got papper trained and there are now people that can be like super trainers and come back and train other people on how to use pappers I don't know if this is something that we necessarily need at Moran at this time but I do think that as a resident on the floors it's something that I want to be well versed in. Fit testing for N95 masks is also available through work wellness they have one of my understanding is they have one N95 mask at this time some of the chiefs may be able to comment at the University of Utah and so if you fail that N95 mask then you are to wear a papper they do recommend that it's updated annually and there I provided the number for work wellness and the hours you just give them a call they are a few days out for fit testing because there's a high demand for a patient for nursing and other staff that's there you know and whether or not you know who we should maybe prioritize as far as who's most likely to see patients I think is something that we can also discuss. There are also videos online on pulse that show appropriate donning and doffing techniques if you even just wanted to brush up and didn't want to go buy work wellness in person and get a tutorial from an occupational med physician. Last these are not related to masks but I wanted to talk about a few things in the community so I'm sure many of you have seen the white ribbons. Someone came around from clinic the other day and was giving out white ribbons and in support of healthcare workers I think this is really great I know our techs at Moran wear black but the nurses in the hospital wear white physicians with the white coat and all the all the staff together who is continuing to work through the pandemic you can use the hashtag you talk hairs and it will come up in whatever your social media outlet is and last there's a a this is not an extensive list of benefits from local from businesses so there's free child care available through the you Starbucks is offering free tall coffees on Wednesdays through May 3rd for all healthcare for healthcare providers jiffy lube is 25 off your next oil change crispy cream donuts five dozen free donuts on Mondays that is first come first serve through Monday May 11th and then uber eats has promised lots of free meals to healthcare providers headspace so all healthcare professionals have access to headspace through 2020 it's a great mindfulness and meditation app I've used it personally at so with some of the residents and then pit viper is actually a local sunglasses company and they have discount codes for eye wear protection and so I wanted to point out that a few weeks ago when I was on call these are the emergency medicine residents sporting their pits pit pipes and I was ever so thrilled I told them I had to take a picture because I was so excited that they were protecting their eyes and I will say if you do go to the pit viper's website some content may not be appropriate for young users so all right so I think we have a lot of discussion questions Ariana and I have brainstormed quite a few and I have seen the feed going off but haven't looked at any of the questions I think we'll I can let Dr. Petty take over and we'll moderate and and we'll go from there first of all thank you Ariana and Teresa extraordinary extraordinary presentation learned a lot personally a few questions Brad cats are going to have you queue up your question here in a moment or at least your comment and then Craig Chia as well after Brad just your comment about the iphone indirects and one thing just while they get their computers off mute so many of you have seen these these are full face scuba masks the Center for Medical Innovation here at the University of Utah recently developed pappers based off of these designs they've been tested by occupational medicine which ended up certifying them actually is better than many commercially available pappers they just sent 125 down to the Navajo Nation whereas we know there's a significant outbreak there and ppe is in short supply so a lot of innovations if I can find a link I'll send that and then at the end of Grand Rounds also post a link there's a project protect you is an organization that will send you supplies you can sew your own mask and then those masks can be sent to them for sterilization and be put into use both at IHC and at the University of Utah hospital so look for that link at the end Brad why don't you go ahead and make your comment on reusable masks hey Arianna and Teresa I think that's awesome that you took the initiative to look up the information that they're using in Florida to use the Halyard material I just I'm a little bit uncomfortable having a mask that is just autoclaved and reusing it because like the mask it's like mucus and stuff on it can those masks be washed and then sterilized I think that's a great point is autoclave enough or do we need them to be washed I think about our green gowns because I think that you're right that reusable gowns do get washed and it's not just autoclave and those certainly maybe less so in our ORs but in main OR must have a lot of bodily fluids on them so I do not think that Florida is washing their masks I think that they're only using autoclave and light and I'm not sure that the material is supposed to get wet but if we were to consider reusable fabrics and materials I think that's a really important point because you're right there may be chunks of something inside the masks I wonder if the green material that's used to make the reusable gowns could be used to make a mask yeah I wondered the same thing I think that it seems a bit heavy but I haven't really tried it and you know that Halyard material I think it can get steam sterilized so maybe it's hardier than we think. Craig Chia I just made a comment about using smartphone technology but I would defer to Eileen she's kind of our resident expert on smartphone ophthalmoscopy yeah Dr. Chia I think that's a great point and Eileen as well I've been watching the chat and I think there's a lot of interest in learning to use smartphones to get the dilated exams that we're otherwise unable to get in our gear. I think it's kind of hard I am pretty good at it but I don't think it's something that can be learned with the online tutorial I think it's in person and me adjusting you but I'm happy to do that with anyone so thank you Eileen and to be clear Eileen is not a resident but she is our resident expert on indirect ophthalmoscopy. One of the questions that came through if either of the speakers have any experience with this was around furnace filters that you can get an N90 furnace filter people have been using that to add a filter layer to homemade masks do either of you have any knowledge of whether or not that's worthwhile? So I would say first of all with the I think several questions about how well do those filters I know people are using people commented vacuum I know other people are using coffee filters how well do these work I think looking at the studies that we talked about today we don't really have a good idea about how any of what we're using including surgical masks are working like I said earlier the studies have relatively small numbers and they typically use other viruses as a model for COVID-19 so I don't think we have a good answer to those that being said the 3D printed N95s that I've seen do have a spot to insert an N95 filter and that's the filtering part with a plastic structure that fits to the face. So for anyone that is calling in just a couple of other comments that have come in a question whether or not you need to dilate for smartphone indirect ophthalmoscopy the answer is yes you do and we'll allow our speakers then it looks like the questions are wrapping up and I'm so sorry it looks like Eileen didn't know that Nepalese Eye Providers could do it non-dilated but I can't because I'm not as skilled so what we will do is we'll go ahead and wrap up with final comments from Dr. Levin from Dr. Long and then I am posting that link to Project Protect again this is a collaboration between University of Utah IHC and LDS charities where you can they'll send you materials and you can sew masks that then can be used in the healthcare environment. Go ahead Dr. Levin and then Dr. Long. I want to thank everybody for their interest today and the comments. You are welcome to come talk to us more if you want to see the masks that we sewed just as prototypes if you have more ideas for what we can be doing here. Thanks everyone.