Personal Protective Equipment for Healthcare Workers – My Hospital System is Making Me Do WHAT?

I’m sure by now the rest of my fellow healthcare workers out there have inboxes that look much like mine – email after email about planning and preparation for the Ebola virus.  How to answer questions, what questions to ask, when to quarantine a patient, and of course infographic upon infographic about personal protective equipment.  While I have talked down on it for the general public, you are a different story.  I'd show you a picture of my inbox but I'm pretty sure that's against hospital policy and probably a HIPPA violation as well.  Let's settle for a fun Ebola-gear selfie!

I don’t care if you’re an MD, EMT, ATC, PT, RN, LPN, DO, DDS, DC, PTA, ENT, whatever, we all learned this in school and if you remember correctly, it was important.  While not everyone in healthcare has a high patient volume or is always seeing people who are sick, there is a good chance that some time in your career you are going to be exposed to someone who is a carrier of an infectious disease.  Whether it be Ebola, flu, HIV/AIDS, hepatitis, the common cold, or rabies, someone sometime around you is going to be ill.  They may sneeze, cough, spit, bleed, vomit, defecate, or urinate somewhere on you, on your equipment, or near you.   If this occurs, you should already know what PPE you need to have on hand and ready to go, how to put it on, and especially how to take it off.

Gloves

We’ve all worn gloves, latex or nitrile, probably even the psychologists and psychiatrists in the crowd at least once.  If you need to come into contact with blood or another body fluid, wear gloves.  This should be obvious as it is something we all learn in 9th grade health class, then again in basic first aid, then again in undergrad several times, and on and on.

Put gloves one at a time (duh?) after washing your hands.  If you’re wearing a gown, gloves go on after the gown and over the ends of the sleeves.  Remove gloves as shown in the video, taking the first one off by grasping the outside and pulling, then taking the second off by inserting two bare fingers into the glove and peeling it off without touching the outside.  If you’re wearing a gown, gloves come off all in one piece when you remove it.

Mask or Respirator

Most hospital systems fit all of their employees for N-95 masks or respirators.  You probably did this sometime during your extensive and boring orientation week wherever you were hired, and hopefully you didn’t drool on the poor tech who had to do the fitting.  Masks and respirators should cover the nose and mouth snugly but not overly tightly as you don’t want to end up looking like you spend the afternoon making out with a Facehugger from Portal.  Elastic bands or ties go behind the head, or over the ears if you have that model.  The metal band in the nose can be pushed down to provide a more appropriate fit.  When removing PPE, masks are taken off last.

Gown

Cloth gowns are worn for surgery or patients who might be a little messier.  They keep your clothes fresh and clean and can easily be removed when your patient pukes on you.  If you know that a patient is going to be exuding more fluid than just a little bit of blood or vomit and when there is Ebola potentially present, there are also plastic waterproof or plastic-lined versions available.  As with any other PPE, your gown should be removed or changed if it becomes visibly soiled or has potentially had contact with a highly infectious disease.  If you are wearing full PPE, your gown should be removed first.  Pulling on the front quickly and forcefully will open the back of most models and allow you to pull out your arms, rolling the sleeves down inside out and removing your gloves at the same time.  Touch only the insides of the gown and dispose of it in the appropriate place.

Goggles or Face Shield

Ah, the ever-present joke of the PPE world.  While many surgeons I know frequently don face shields in case of gushers, I’m pretty sure not a lot of us are slipping the goggles on now that we’ve completed our last bio lab of graduate or medical school.  In the case of Ebola however, goggles and face shields are no laughing matter – well, sort of.  Ebola is capable of entering your body through your mucosal membranes, and this includes the tissue around the eyeball.  If a patient vomits at you (yes at), there is potential for a splash to go into your eye.  I’m sure we can think of a dozen other scenarios where you might be better protected with a face shield but we’ll just say that no one wants the eye-vomit Ebola and leave it at that.

As always, remember to take appropriate cleansing measures once you have removed your PPE.  Dispose of PPE, soiled or not, in an appropriate place.  If your work environment has designated a specific procedure or place to dispose of soiled PPE, be aware of this.  If you remove your PPE and your clothing or your person is soiled underneath, remove soiled clothing, shower, and notify a supervisor.

Not everyone in healthcare is going to be exposed or potentially exposed to someone with Ebola.  In reality, there are quite a lot of us, and almost none of us is really going to encounter an actual patient, at least this early in the game.  That being said, you are still going to encounter a lot of people who think that they have contracted or been exposed to Ebola virus.  Wearing appropriate PPE will be good practice for you and will reassure the public that we’re taking it seriously and actively making efforts to keep them safe, even if it does make us sigh internally and giggle in the break room.

Personal Protective Equipment: Necessary vs Overkill

Last week I got a chuckle when a local radio personality sounded terribly muffled, as though he was talking through a wall.  I had tuned in a bit late, what was the joke?  Low and behold not a joke, the man was wearing a HAZMAT suit to protect himself from potential Ebola exposure.  While I’m sure even the average layperson living in what I’ve been jokingly calling “the hot zone” of Akron is fully aware that this is overkill, it occurs to me that there will be a few people out there willing to go full Breaking Bad if they are forced to venture out in public.  Before you don your plastic suit and Ebola-safe helmet with anti-viral mask, consider the repercussions of dressing in this fashion to go get your groceries or return your movies to Redbox.

Check it out at roverradio.com here

Lifelong Shame from Friends and Family

When this is all over, it’s going to be brought up at every family gathering.  They’re going to want you to pull out the HAZMAT suit and wear it around.  Maybe you can stick some feathers on the rear and be the HAZMAT Thanksgiving turkey.  Put some boots and a fuzzy red hat on it, tada, HAZMAT Santa!  Fourth of July coming around?  What makes a family BBQ more fun than a guy in a HAZMAT suit and an Uncle Sam hat pointing and saying “I want YOU for the CDC!”  Nothing at all.  When we get the disease under control, and yes we will, it’s going to be something to look back on and chuckle about.  Remember West Nile Virus?  SARS?  H1N1?  Did you contract that?  Did you die?  You’re reading this so I’m going to assume that you didn’t.

The Public Menace

After we laugh and giggle about you and strangers stare at you and point and laugh in public, we’re going to have to take a breath, calm down, and clean up the mess you’ve just created.  Like it or not, not everyone out there in the public is completely calm about the Ebola virus.  If regular people start seeing spacemen running around in HAZMAT costumes at work, at school, in the grocery store, etc, they’re eventually going to get worried.  When people get worried in large groups, they start to panic.  A large group of panicking people is not unlike a large group of panicking cattle – they are very loud, very strong, and rather destructive.  At this point, rumors begin to spread, misinformation runs rampant, and we end up with a situation worse than the one we’re already in.  Now that’s scary.


You’re Only Hurting Yourself

Not only is it “Ebola season” right now, it’s cold and flu season.  Those little buggers are floating through the air, living on surfaces, and incubating inside of your friends and neighbors (unlike Ebola virus.)  In order to have immunity from a disease, your body needs to have been exposed to it.  This is how vaccines work – we infect the body with either a dead virus or a synthetic form of a virus so that our body then learns to form antibodies to it.  If you’re out running around in a plastic suit and not coming into contact with small amounts of these little guys in order to boost your immunity to them and stay healthy.

So what is appropriate to be wearing?  I’ve noticed that a lot of people want to don N-95 respirator masks when in public places.  Being again that it is cold and flu season this will probably protect you from the flu virus and a lot of colds, but against Ebola that is just silly unless you have some sort of fetish for people sneezing and coughing on your face.  (See previous post regarding Ebola and air) Gloves are also not a necessity if you practice good hand washing and hand sanitizer use.  If you’re going to be in a high traffic public place like a shopping mall or an airport and would feel more comfortable wearing some sort of protective equipment however, gloves are the way to go – they’re less noticeable, easily changeable, and not super expensive.  Again, wear them only if you have to in order to prevent yourself from having some sort of panic-induced public meltdown.  No one wants to witness that.

As a member of the general public, if you are not in direct contact with a potential Ebola patient then full PPE is overkill.  It is expensive, you look silly, and you’re making other people nervous.  If you have to come in contact with someone who may have been exposed and is experiencing symptoms but has not yet been quarantined then yes, please put on a mask and gloves if you have them.  Otherwise let’s all put the HAZMAT suits back in the closet for a few weeks and save them for Halloween.

If you are a healthcare worker, my next entry will re-address all of this for you, because obviously this is different for your daily life and work environment.

Staying Safe: How to Avoid the Ebola Virus

My mother contacted me Wednesday in a panic because my father flew on an airplane sometime in the last few weeks.  She needs to fly on a plane three weeks from now and was considering purchasing special clothing, a respirator, and gloves to take with her.  She's even considering wearing gloves in public.  My response to her is that while yes, you can never be too careful, there is a point where your fearful precautionary measures do nothing but serve to fuel the fire of mass hysteria that is sweeping the country.

The problem currently facing my city is the Ebola-infected nurse who visited before returning to Texas and testing positive for the disease.  While initial reports from the Center for Disease Control have all been very clear in stating that she was not experiencing symptoms during her stay in the area and therefore could not have transmitted the disease to anyone, there has still been an overpowering and terror-stricken response from news media that has caused the Rubber City to dive into an absolute uproar.  My social media pages are exploding with Ebola-talk, be it jokes and sarcasm, tired facts, or straight cold fear.  In public places, people can be overheard discussing the disease left and right, many of them perpetuating myths about the virus and wondering whether they should quarantine themselves like friends and neighbors have.

While certainly a 21 day quarantine of all potentially affected areas would be the absolute best way to swiftly contain and eliminate the problem, this is quite obviously not a practical measure.  Additionally, because of the increased awareness and better health and sanitation practices that the United States has, not only is it impractical but probably rather unnecessary.  Yes, a couple of people in our country are currently infected with the Ebola virus.  Yes, a few people are going to become infected.  Yes, it is possible that someone you know will become infected.  The difference between the current 90% mortality rate in Africa and any projections of Ebola mortality we will see in the United States should be clear: healthcare and sanitation.  We will not see the infection and mortality rates that Western Africa has, because as a fact we have a better healthcare system, we have significantly better sanitation practices, and it is not common cultural practice for us to publicly the bodies of the dead, regardless of condition.

That all being said, it is still cold and flu season in addition to it being Ebola season, so taking basic healthy measures is a good idea and will help to protect you both from Ebola and other things that might be around in your general environment.

Hand Washing

Just as with anything that "goes around" at this time of year, good hand washing practices and use of hand sanitizer are a good start at protecting yourself from possible infection of Ebola.  We have been able to determine that the virus can remain alive in dried body fluids on a surface for several hours, and if kept in body fluids at room temperature can live for several, possibly up to six days.

While we don't need to be quite as vigilant as Filbert, he does lay a good groundwork both for laymen and healthcare workers.  If you come into contact with a frequently touched public surface such as a door handle, counter top, gas pump, money, etc, it is a good idea to wash your hands or (usually the more practical option) use a hand sanitizer afterwards.  Do so before rubbing your eyes, toileting, or eating.  Not sure you're doing it right?  Check out this infographic from the World Health Organization:

If that all seems intimidating, just remember, use soap and warm to hot water, sing the Happy Birthday Song to yourself 2-3 times, rinse, and dry.  

Hand sanitizer is a good substitute for hand washing if it is inconvenient to wash wherever you are.  I recommend purchasing a sanitizer with aloe or lotion in it so that your hands aren't dried out if you're frequently using it.  Our office uses Purell with Aloe Vera.

Protective Equipment

I will cover this in a future post more fully, but if you must come in contact with someone's body fluids other than your own, wear appropriate protective equipment.  For most of us, that means latex or nitrile gloves to be disposed of in an appropriate manner (ie not thrown on the floor for other people to contact) along with whatever you've been contacting the fluids with.

If you are in a situation where someone might sneeze or cough on your face, you can don a mask that covers your nose, mouth, and chin, and secures behind the head.  If being coughed on or sneezed on is an actual danger for you, also consider a face shield as the Ebola virus can enter the body through your mucosal membranes - if you get snot in your eye, the virus can wiggle in through there!

By this time, healthcare workers regardless of profession have probably been provided with PPE at their work sites, including gloves, masks, face shields, and gowns.  If you haven't had a training session to put these on and take them off, refer to the future post regarding donning and doffing PPE for healthcare workers and ask your office manager to show you.

Needle and Sharps Safety

Injectable drug users both medical and recreational, frequent receivers of tattoos and piercings, and cutters/self harmers this one is for you!  As an American 9th grader any time after 1985, you probably heard about blood borne pathogens in health class, though whether or not you were paying attention is a different story.  We should all already be aware of the dangers of sharing needles or sharps with other people - HIV, hepatitis, etc.  Ebola is another pathogen that travels by blood, and can easily enter your body on a dirty needle or blade.

If you are injecting drugs, legal or not, always use a clean needle.  They are not expensive and can be purchased online - even Amazon has them.  Same goes for cutters and chronic self harmers - do not share blades or use a dirty or questionable blade.  These are also inexpensive, come in sterilizable and disposable versions, and once again can be purchased online (like at Amazon) with no questions asked.

If you're being tattooed or pierced, always but especially in infection "hot" areas, do some research first.  Don't get a tattoo from your brother's friend's sister's uncle's cell mate from the state prison in someones's dirty kitchen.  Shop around, find a clean, certified parlor, and always watch your artist or piercer open the sterile needle bag before starting your procedure.

Use Protection!

You know what I mean - a condom or a dental dam, especially when engaging in sexual activity with a new or unfamiliar partner.  Like it or not, Ebola virus can move through vaginal and seminal fluids, and additionally there is always the possibility of bleeding during both hetero- and homosexual intercourse.  Wah wah wah you don't want to use a condom - in the post-AIDS crisis world that we live in, it is a solid fact that you should be using protection if you're with multiple or new partners anyhow.  Don't be gross.  If you contract Ebola... or gonorrhea or whatever, from being an idiot and engaging in unsafe sexual intercourse then you were asking for it.

Fully Cook All Meats

While this particular item isn't yet a danger for infected countries outside of West Africa, it potentially could be in the future.  Ebola virus can be contracted through consumption of meat of a carrier or infected animal, like the bats that are a common part of the diet for many people in certain parts of Africa.  For now, try to avoid eating people who have been infected with Ebola virus.

If You Think You've Been Infected

If you think that you've honestly been exposed, call a doctor.  Calmly explain the situation of your potential exposure, including date, place, nature of the exposure, and whether or not you are currently showing symptoms.  They will direct you how to proceed from there.

Above all? Stay calm.  (And always know where your towel is!)

What IS Ebola Virus? A Brief Overview

EBOLA!  EBOLA!! EBOLA IS HERE!!!! All of the headlines across newspapers and tv news have been screaming it since the United States patient zero, Thomas Duncan, was first quarantined and later identified as positive for the virus.  We've been bombarded by terror-inducing microscopic images of a work-like organism for weeks now, but how many of us actually know what that little guy is or how it operates?  Let's dig a little deeper.

History

The Ebola virus was first medically described in 1976, discovered by a team of Belgian scientists.  There had been an outbreak, albeit one much smaller than the one causing our current crisis, of deaths due to what was then referred to as simply a "hemorrhagic fever" in Zaire, what we now call the Democratic Republic of the Congo, and they were there to determine the cause and help the people who resided there.  A small sample of blood from an infected person traveled thousands of miles away from Zaire to a lab in Belgium, where scientists examined it and were shocked to see a large worm-like structure.  They named it Ebola, after a river near what is believed to be the origin point of the first outbreak.  There are now five viruses identified within the Ebola family, four of them known to be deadly if patients do not receive proper health care.

The 1976 outbreak itself lasted 26 days, ending in a two week quarantine mandated and enforced by the World Health Organization and the Congolese air force.  Equipment and facilities were sterilized, victims were treated as best as healthcare workers could manage, and appropriate personal protective equipment was worn to protect the uninfected from contracting the virus.  In reality, containment of the virus was relatively easy, and while there was an 88% fatality rate we can at this point say that the residents in the infected area got of easily with only 280 deaths.

The Center for Disease Control has established an easy to peruse chart that summarizes subsequent outbreaks with dates, virus types, deaths, and succinct summaries of the various situations under which they occurred here: http://www.cdc.gov/vhf/ebola/outbreaks/history/chronology.html

So what is it?

Ebola virus is a member of the Filoviridae family, a branch of viruses characterized by their "threadlike" appearance.  Think back to the worm-like structures first noticed by the Belgian scientists, and the pictures of the Ebola virus we've been seeing in the media - it is sort of thread-like, isn't it?

Dr. Ian M. Macay of virologydownunder.blogspot.com has created a fantastic illustration of the cellular anatomy and structure of the Ebola virus.  While to the average person off the street who didn't pay too much attention in high school biology this may just look like a prettied up version of the scary worm creature we see on the news, I'm sure many of us can appreciate the intricate structures of such a fascinating and deadly organism.  Maybe not.


How did it get into humans?

While it is obviously difficult to track the progression of Ebola virus back to its very inception seeing
as we were only able to identify it back as far as 1976, there are environmental and biological cues available to scientists that give us some material to establish concrete educated guesses.

By now I'm sure you've heard about the bats, something I will no doubt be discussing in further detail in a later blog.  Most humans don't know much about bats past finding them mysterious and frightening creatures that swoop around at night and occasionally (and unfortunately) make their way into our homes.  Bats carry with them a dirty secret - they are excellent places or "reservoirs" for viruses to live in.  A reservoir is essentially a creature who has evolved along with a specific pathogen or pathogens.  That creature can live with the pathogen in its system but not suffer the same effects that other creatures do.  Due to a number of factors, bats are excellent reservoirs for a wide range of viruses, including Ebola virus.  Bats in Africa following the 1976 outbreak and up to present day have been found to have the Ebola virus in their bodies, as well as in their feces.

That being said, we humans likely first contracted the virus from a bat bite, from contact with bat feces or "guano," or from consumption of undercooked bat meat.

What does it do?

Ebola virus is one of several known viruses that can cause hemorrhagic or "blood" fever.  After a person is infected with the Ebola, the virus is quiet within their body or "incubating" for 6-21 days.  During this time, the infected person is symptom-free and cannot spread the virus.

After the incubation period, an infected human will develop "flu-like" symptoms, including fever, headaches, joint and muscle aches, chills, and weakness.  It is during this time that carriers of the virus become contagious and may spread it to others, though it is more difficult to do so prior to symptoms worsening.

As symptoms increase, an infected person may begin to develop stomach pain, nausea, vomiting, diarrhea, cough, rash, chest pain, and redness of the eyes.  At this time they have become significantly more contagious as they are spreading bodily fluids including saliva, mucous, feces, vomit, blood, etc much more widely and in much greater volume.

Late in the course of the disease, victims experience the "hemorrhagic" part of the fever, beginning with internal bleeding and moving on to bruising and later external bleeding from mucous membranes, typically the eyes and anus.  At this point the victim is most contagious, again because of the volume of infectious fluids exiting the body.


In my next entry, I will outline basic health practices and reasonable actions you can take as a member of the public or a healthcare worker to keep yourself safe and virus-free.

An Introduction, or How I'm Pretty Sure I Don't Have Ebola

"Of all the gin joints, in all the towns, in all the world, she walks into mine."

Well, in reality she flew, and then probably took a car or a cab, but what we do know that is a week ago today, a young woman who is and was a proven carrier of the Ebola virus visited my city.  Did she infect anyone?  Are we in danger?  Is this time to panic?  As a healthcare worker who deals with public health, emergency medicine, adolescent health, and rehabilitative therapy services in the city of Akron, Ohio, these are probably the least ridiculous questions I have encountered over the past week.  

Increasingly frustrated by mass panic created in part by the news media and in part by what can only be described by saying some of the deepest worries and fears that we face in our communities, I have decided to blog about my experiences with friends, family, and the public.  Partially I seek to relieve stress and frustration gained by dealing with the Ebola hysteria, partially provide some comic relief to other healthcare workers who are becoming as annoyed as I am, and partially I seek to help provide further education to a public that is doing itself more harm than good by going berzerk over an issue that they have decided to panic about due to misinformation and media-produced fears.

Take of it what you want, but if you learn something then pass it on so that someone else might learn something too!

I myself am quite certain that I do not currently have Ebola, nor have I been exposed to it, despite the fact that I live in the Cleveland-Akron area and frequently venture outside of my house to have contact with friends, family, and the general public.  As a healthcare professional, the importance of hand washing and good health and sanitation practices has been impressed upon me since I was a wee high school student just beginning to explore my eventual field of choice.  I wash before eating, after toileting, and sanitize after contacting objects that are frequently touched by other members of the public who might not be so vigilant in their cleanliness.  I always wear appropriate personal protective equipment, or PPE, when in contact with people who may be ill or with blood or other bodily fluids.  I do not have Ebola.  I can almost guarantee that unless you are reading this from West Africa that you probably do not have Ebola either.