Monday, October 14, 2002

You can’t take care of others if you’re hurting. Personal Protective Equipment in the era of terrorism.

I learned this lesson between my sophomore and junior year of medical school. My physician father had permitted me to practice histories and physical examination by seeing patients of his at the hospital where he was chief of medicine. One of his patients presented to the ER there short of breath and he called me and told me to examine the patient. When I arrived, the intern—it was 1973 after all—was trying to get an IV started in a wrist vein, after he gave up the effort I volunteered. The patient, a below-the-knee amputee from his diabetes seemed to be in pulmonary edema so an IV was important. I attempted a stick of what appeared to me as a large wrist vein—later I realized it was probably thrombosed. My patient kicked me with his stump. Since I was straddling his amputation you can envision the effect. I spent the next 10 minutes trying to pull myself off the floor and catch my breath.

I’ll never forget that man—I’ve omitted his name from this retelling out of an abundance of caution and concern for confidentiality though I’m certain he’s long since deceased. He taught me a critical lesson: You can’t take care of others if you’re hurting yourself.

As a leader, I owe the same consequences of that lesson to my staff. It’s my responsibility to assure them of safe working conditions. In these times, among the many components of this responsibility is the requirement for personal protective equipment (PPE) sufficient to protect our ED staffs from exposure to various hazardous materials. I don’t have sufficient space to discuss the regulatory basis and the challenges of interpreting OSHA, NIOSH and EPA regulations as applied to circumstances where weapons of mass destruction could be a possibility—there is no simple intersection of these considerations. Healthcare facilities were never a consideration for the regulatory agencies mentioned above when they promulgated their regulations. Nonetheless, bad news doesn’t go away and the need for PPE at each hospital is also a JCAHO standard so if you’ve not yet addressed it, you soon will be doing so. Where might you start?

Fundamentally, you’ll have to decide whether or not to develop a PPE Level “B” capability. Level “B” provides respiratory protection through either self-contained breathing apparatus (SCBA) or supply air by hose from either compressed air tanks or a central source of compressed air. Level “A” capability is infeasible for effective patient care, is expensive and requires extensive training for its use.

Level “A” PPE presumes a fully encapsulating suit that totally protects the body from vapors; level “B” and level “C” do not. Level “B” and level “C” presume the use of a chemical suit that does protect against splash, but may introduce vapors. Level “C” PPE provides respiratory protection through the use of air purification respirators or masks that are specific to the type of exposure.

The problem we confront in the ED is that we are often the first responders “in-place.” Patients come to us whether under their own power or brought by field first responders and we don’t know about their exposure. Level “B” PPE is the lowest level recommended for use in the event of exposure to an unknown agent.

It is for that reason we at Maimonides Medical Center decided in 1999 to train a cadre of staff to operate in Level “B” PPE. Today we have well over 100 staff members from a variety of departments and with a variety of clinical and non-clinical backgrounds trained to work in PPE Level “B.” As a hospital we work hard to schedule staff so that we are able to mount four two-person teams for patient decontamination around the clock. This allows us to operate two decontamination stations and spell the teams at 20-30 minute intervals—an important consideration when wearing an impervious chemical suit, breathing compressed air through a full-face mask and tethered to an air line—especially when as in our drill last week (early August) ambient temperatures are in the high 90’s. Our goal is to maintain an ability to rapidly decontaminate ten patients and up to twenty-five patients total before progressive intoxication would become a pressing patient management concern.

Training staff entails a minimum of a four-hour course in donning and doffing PPE and basic patient decontamination practices and you will need refresher programs and a mechanism to train new employees. As the ECRI Advisory points out there are risks to users of PPE Level “B” such as tripping over an improperly configured airline, so making the decision to go with Level “B” PPE should not be automatic.

The Greater New York Hospital Association has recently circulated a draft consensus statement on hospital decontamination needs and PPE in an effort to help hospitals in our area with their decision. The Department of Veterans Affairs and it’s associated healthcare system—our country’s largest health delivery system—has publisheddetails of an approach recommended by the VA’s Emergency Management Strategic Healthcare Group and its Technical Advisory Committee.

Regardless of your local situation some thoughtful decision-making about PPE and decontamination efforts is necessitated by service and regulatory requirements. The 1995 Tokyo subway Sarin vapor attack senitized us all to the possibilities. Hospital personnel were secondary casualties then in several instances. Personal protective equipment is not a panacea, but it is part of the answer. You can’t take care of others if you’re hurting yourself.

Further resources can be found at the following websites:

Recommendations for Hospitals: Patient Decontamination Algorithm, Staff Protection and Equipment Required During Patient Decontamination” from the California Emergency Medical Services Authority.

A three-volume set of materials entitled “Managing Hazardous Materials Incidents” includes ED management of patients exposed to hazardous materials incidents.

A JAMA piece that addresses PPE, triage and patient decontamination.

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