Personal protective equipment, ie clothing used when treating infectious patients, is a key issue in the coronavirus pandemic.

A shortage of personal protective equipment (PPE) in China and Italy greatly contributed to the toll of sickness and death among healthcare workers in those countries. Understandably, Irish doctors and nurses are concerned there will be an adequate supply of PPE here.

The HSE’s current stock of PPE for healthcare workers is “low”, according to its chief clinical officer, Dr Colm Henry. However, it was hoped that a large consignment of masks, gowns and goggles would arrive from China on Sunday.

The wearing of PPE also imposes an immense burden on staff, equivalent to three times the workload with normal patients, as Dr Suzanne Crowe, an intensive care specialist at Crumlin children’s hospital, explains.

Staff have to wear two pairs of gloves – one on top of the other – a full-length gown over a scrub suit, a hat, a tight-fitting mask and a full-face visor worn over the mask to protect themselves adequately from the Covid-19 virus.

“The mask is like the mask you’d use for sanding the floor, while the visor resembles the face protection you might use if you were welding,” she says.

For the mask to do its job, the part over the nose has to fit tightly. “In order for it to work properly it has to be uncomfortable; it has to be tight to the face.”

The reason for this elaborate ensemble is to protect staff from Covid-19 patients needing artificial respiration, who have an extremely high viral load.

“This high viral load is concentrated in the patient’s nose and airways and is actively shed into droplets which are airborne and may be inhaled by any staff within close proximity.”

As a result a doctor or nurse inserting a breathing tube into a patient, or trying to suction secretions from their airways, is at the highest risk of picking up the virus if unprotected.

“It gets hot and claustrophobic in there, and then you can be in this gear for up to eight hours. It gets so uncomfortable it gets hard to concentrate on the job in hand,” says Crowe.

Laborious process

“Donning” and “doffing” the protective gear is a laborious process that takes 20 minutes before and after use and is best done with a “buddy” to ensure maximum protection.

Staff are less inclined to take breaks given the difficulty of removing the gear and are more inclined to stay with the patient, thereby reinforcing the sense of isolation.

“The aim always is to have the minimum number of people coming into the isolation room, so the risk of exposure is kept down,” Crowe says.

The protective gear renders communication between staff, and between staff and the patient, more difficult. “It’s really difficult to hear each other,” Crowe says. Phones and walkie-talkies to aid communication have been trialled during training but they may pose a contamination risk.

Another solution is for staff to use a whiteboard on which to write messages.

Normal ICU staff ratios would see one nurse assigned to each patient; the ratio of staff to patients can be even higher where dialysis or an ECMO device is involved.

However, in the current emergency, the staff to patient ratio has moved to 1:2 or even 1:3, and may worsen as staff go off sick and the crisis deepens.

“You have this sense of not being able to do the best possible job,” says Crowe, adding that nurses and doctors are worried about potential “repercussions”, and about the risk of infection for staff and their families.

The difficulties don’t stop there. “Changing a syringe, for example, can be quite tricky when you’re wearing two sets of gloves.You don’t have the normal contact with the patient,” Crowe says.

Pastoral aspects

Crowe worries too about the psychosocial and pastoral aspects of care, given that many of those in ICUs in general are approaching the end of life.

Sedated and asleep much of the time, the patients are now missing out on the human touch, she says. In the children’s hospitals, parents are allowed to visit, but they too must wear protective equipment.

“There’s no hugging someone if they’re crying and distressed. It feels very weird.

“Only the other day, I gave a mum a hug because she was crying so much and afterwards, I went ‘ugh’. But how could you not do that?”

A constant concern for staff, she says, is a potential shortage of PPE, and this has led to some hoarding of equipment within departments.

Intensive care specialists are also worried about oxygen supplies; the viral pneumonia that the disease can cause requires large amounts of oxygen, far higher flow rates than with other forms of pneumonia.

Other drugs, for example those used to keep patients deeply comatose, will also be in high demand during the peak of the crisis.

Many severely ill patients with the virus are turned onto their tummy, a process known as proning. Crowe says that with many adult patients weighing more than 100kg, a big team can be needed to turn the person without disturbing the attached medical equipment. Up to 10 people can be needed, each one in full PPE.

On leaving the ICU environment, staff have to assume the entire outer surface of their gear is contaminated so they need help to remove and bin it. They are instructed that “hands must be washed in between removal of each piece of clothing – eight times as clothing is removed”.