Abstract
In the context of Covid-19, personal protective equipment is much needed and often in short supply as a protection against the virus, but nobody until recently was discussing the downside of its prolonged use by its wearers. Increasing numbers of health care workers feel unwell using it and are overheating and some have fainted. Will it impair their professional performance? This article considers this aspect of PPE based upon the personal experience of a Forensic team at AIIMS Bhopal in India who wore it during autopsy work and proposed recommendations to minimise it.
Introduction
PPE comprises protective clothing, helmets, goggles and/or equipment designed to protect the wearer from health and safety hazards at work.1 It also includes respiratory protective equipment (RPE) and aims to make the workplace safe. Proper instructions, training and supervision are needed to ensure that it is used properly.2 They are used at different workplaces in health care including the mortuary where dead bodies which have tested positive with Covid-19 or are suspected positive are either being examined or handled.
PPE must be properly designed, constructed and maintained in a clean and hygienic environment and fit the users comfortably otherwise it can make the difference between being safely covered or dangerously exposed and may discourage its use due to continuous discomfort. Forensic personnel are not used to it and are finding it unpleasant. The shortage of PPE is proving to be a tremendous challenge in the current pandemic,3 so to optimise its usage here it is being worn for longer periods even to the extent of performing multiple autopsies at a stretch that run for hours wearing the same kit.
Needs and limitations of PPE
PPE is essential for healthworkers in the current pandemic, irrespective of whether dead bodies or samples are positive for Covid-19, because of the prevalence of so many latent and unreported cases. The careful selection and proper use of adequate PPE to protect skin, eyes, face, nose, mouth, hands, feet, head and other parts of the body, can provide protection as an effective barrier between the health worker and the contaminated materials like blood, body fluids, respiratory secretions and aerosols. The proper disposal of PPE post procedure is very important.
The current pandemic has put pressure on the health care system’s ability to obtain PPE and it is compelled to accept whatever is available even when it is substandard when delivered by many manufacturers who are new to making this and lacking the requisite experience or who cut corners. The users often do not find their PPE comfortable while working. With high temperatures in the summer season, it is worse for the wearers, particularly when facilities for controlling the environmental temperature like HVACs are unavailable or were shut down for fear of spreading infection.
Apart from discomfort and the heat, users find verbal communications difficult and there is the loss of normal sense of smell, reduced tactile sensitivity, increased difficulty of fine hand movements and impaired visibility due to deposition of water vapours on the eye goggles (Figure 1). So, there may be procedural errors or unintentional self-injury. Some users suffer work stress, anxiety and a feeling of working in a life-threatening environment and psychological claustrophobia and wish to limit its use for these reasons.
Forensic team wearing PPEs while performing autopsy.
Case report
Every member in the Forensic team at AIIMS Bhopal in India felt confident that they would be protected against COVID 19 infection by wearing PPE when handling a dead body or performing autopsies. However, this changed when recently a member of the team in PPE fainted after autopsies were performed one after the other in a stretch of around 4 h which included the gap between completion of the first autopsy and the start of a second. The team that performed the first autopsy decided to take on another body for autopsy to optimise the use of PPE by not discarding it after the first autopsy.
Many of the five team members felt discomfort in some form like feeling excessively hot, and suffered from nausea, headache, backache, neck spasm, fatigue, nervousness, dizziness, enhanced perspiration, dyspnoea, suffocation, dehydration or facial redness. However, one team member near the completion of the second autopsy expressed his inability to continue and, while leaving the post-mortem examination room, fainted near the door and fell down on the floor. Other team members rushed to help him, doffing was done keeping in mind the risk of contamination, and they made him comfortable till he regained consciousness after 10 min.
Discussion
PPE can protect its wearer from contracting Covid-19 but if worn for too long, or incorrectly or the PPE does not fit properly as recommended by protocol, then instead of keeping the wearer safe it offers a false sense of security and can expose him/her to many complications. Many users have reported significant adverse effects including fatigue, dehydration, headaches and hyperhidrosis4 and find working in PPE for long hours a major physical and professional challenge.5 The users may experience dizziness, light‐headedness, and heat‐related illnesses like fainting due to heat syncope.6 PPE causes dehydration and discomfort in the same way as wearing a rubber coat, which hardly permits air.7,8 Italian nurses reported facial bruises and falling asleep over working stations due to constant wearing of PPE.9 The prolonged use of face masks may also cause hypoxia and fatigue10 apart from vasovagal syncope and low blood pressure due to the derangement of physiological parameters.11 Providing constant ventilation and head cooling may increase the tolerability of heat stress12 but wearers of PPE who are working for longer stretches to optimise the use of PPE have to retain urine and experience thirst.13
PPEs may impact on performance and comfort level.14 But poor levels of supply to hospitals caused by the sudden rise of global demand mean that PPE on offer may be inappropriate for its purpose, untested, unproven, unreliable or of inferior quality. This will be so even if just a single component of PPE is incompatible or substandard as it may undermine its effectiveness as a whole and render it useless for the purpose intended. Disproportionately bulkier and heavier PPE makes breathing more difficult and the users so uncomfortable that they are reluctant to wear it. There are many increasing instances of wearers fainting after prolonged use and of people finding it horrible and they become reluctant to work with it any more. Therefore, a clear standard for PPE use is critical to safe practice during the pandemic when the risk of contracting Covid-19 remains high and there is an urgent need for improvement to and modification of the current guidance on its use.15
Recommendations
Supply of standard kit. Informing, educating and training for proper use. Inclusion of powered respirators to facilitate blowing of air inside the mask. Encouraging users to wear PPE but discouraging its use for long periods of time. Readily and easily available replacement supplies. Printed step by step illustrated instructions which demonstrate how best to don, doff and dispose of PPE. There is a need for checks on quality, fitness and comfort. Environmental control of air temperature in post-mortem examination rooms to avoid overheating of PPE wearers. Taking regular feedback from the users and certification of quality. Modification of kit to divide it into upper, middle and lower parts instead of a single piece.
Conclusion
PPE undoubtedly plays a crucial role in protecting the Forensic team involved in handling dead bodies and autopsy-related work against Covid-19 infection during the current pandemic but its use is not free from complications, which range from mild discomfort to fainting. The provision of safe, comfortable and standard PPE is a challenge for the system and we need to consider and research what modifications would improve matters. We need to discover how to limit these complications from PPE, otherwise its role as a safety measure may be undermined.
Key messages
The complications are associated with the usage of PPEs as safety measures. The research on desired modifications to find out the alternatives for limiting these complications is needed.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.