Patient Care in Full-Isolation PPE

Triggered by the AIDS pandemic in the early 1980s, hospital and prehospital clinicians transitioned to wearing exam gloves on every patient. With that came early articles in EMS and nursing publications about how the exam gloves dehumanized our patients and us as clinicians. But we all got used to it.

Now, triggered by COVID-19 in early 2020, comes “full-isolation PPE”—i.e., disposable isolation gowns, N95 masks, face shields, hair covers, shoe covers, and full decontamination protocols for cots and equipment between patients.

Since May of this year I have been honored to work part-time for the California Health Corps and sent to augment nursing staffs with direct patient care at three skilled nursing facilities’ COVID wards as well as the COVID blocks in San Quentin State Prison’s death row. At the SNFs every patient has complex underlying medical conditions, and most occupy rooms with other COVID patients. We are constantly donning and doffing our PPE while checking vitals on every patient twice a shift, passing their medications on schedule, changing their dressings, and managing their hygiene requirements, followed by endless charting. If they completely decompensate, we either resuscitate and call 9-1-1 or, depending on DNR/POLST directives, document their deaths and make notifications. Because none of our patients are on EKGs or other monitors observable at a central nursing station, we must check on them every 15 minutes to see if we have to make this grim determination.

After my first hyperbusy shift in a COVID-19 ward, I realized most of my conscious patients were terrified. They were terrified for two reasons: 1) They might die in their hospital beds; 2) if so, they would die alone and never see their families before they die. As we are all faceless clinicians now, we do not even look human to our patients, which adds to their fear factor. What follows are some tips on how to work effectively in full PPE and rehumanize yourself to your patients.

Working Effectively in Full-Isolation PPE

If you are responding on an ambulance to a medical aid deemed to require full-isolation PPE, the highest-level emergency clinician should be in the passenger seat and don all PPE before arrival at the scene. This way at least one of you can go directly to the patient with the most important medical bags/equipment. It is truly a shame to have another first responder—e.g., a firefighter or police officer—go into a true emergency and take charge of a medical scene while you and your partner are still at the curb donning PPE. This may be our new normal for a while—prepare and get used to it.

Isolation gowns do not breathe and can be hot to work in. You may find yourself sweating in a warm environment or when there is much to do in treating your patient(s). This should not cause contamination, but it can soak your shirt, make you uncomfortable, and even lead to hypothermia later in the shift if you are still wearing wet clothing in an air-conditioned environment. So here are a few tips:

• Unless restricted by agency policy or in a cold environment, shed any heavy uniform shirts prior to donning the isolation gown and wear just a light t-shirt. No one can see your uniform anyway when you’re wearing an isolation gown.
• Bring a few extra t-shirts to every shift in a plastic bag. Between patients you can doff all PPE, decontaminate, and, if your t-shirt is soaked, change it out.

If you wear eyeglasses, you will likely find them steaming up after you don your N95 mask. Here are a few tips:

• Be sure to press and form-fit the metal strip at the top of your mask around the bridge of your nose;
• Be sure the mask is seated underneath your glasses;
• Some clinicians who require glasses apply medical tape along the top edge of the mask;
• Buy one of the many antifog sprays on the market and reapply it to your glasses after several high-impact calls/patients.

After EMS calls be sure to do the following:

• Decontaminate your gurney and all other parts of your ambulance according to your county DPH (department of public health) or agency policy;
• Shed your isolation gown and foot coverings and dispose of them properly;
• Remove your face shield and decontaminate it properly;
• Dispose of your gloves properly;
• Wash your limbs up to your elbows for a minimum of 15 seconds;
• Remove your N95 mask and place it in a secure place;
• If sweaty, replace your t-shirt and place it in a plastic bag to wash later;
• Self-isolate by six feet or more while completing all patient charting;
• Report any exposure to potential infectious patients according to your county DPH or agency policy.

Find the latest recommendations for EMS workers responding to potential COVID-19 patients here.

Rehumanizing Yourself

To start with, wear something that clearly identifies at least your first name so patients remember you as a person. Plan A should be printed, fabricated IDs from machines, laminated in washable plastic, hanging from a lanyard around your neck or attached to an upper corner of your face shield.

There are many ID machines on the market, but they cost hundreds of dollars, and someone in your organization needs to be designated to make the laminated IDs. In EMS agencies the decision to go this route comes from operations or the HR department. In hospitals it is usually the decision of the director of nursing or someone associated.  

The gold standard would be to have the clinician’s name with a friendly picture on the washable name tag. If you’re like some of us in public safety, you take official, expressionless pictures. If this is you, practice in front of mirror before getting the picture taken and try for the friendliest, most caring look. Think of it this way: Your picture may be the last face they see before they die, or it may be one of the caring faces that give them confidence and nurse them back to health.

Plan B: With a felt-tip marker, write your first name across the top of your face shield. Then put a comma and place your title (MD, RN, LVN, paramedic, EMT, CNA, etc.)

If your patient is conscious, ask them how they would like to be addressed. “Sir” or “ma’am” is courteous but generic and impersonal. Some elderly patients will want you to call them by their last name—if so, make sure to put a Mr., Mrs., or Ms. in front of it. If they are not mentating well and you have their ID, use their first name. Nurses in hospitals are used to verifying identity and calling patients by name on every interaction. EMS workers should do the same.

During the current pandemic, patient’s families are rarely allowed to visit them in hospitals even if the patient doesn’t have COVID-19. If they test positive with symptoms, they are likely to stay in the hospital, isolated from their family and friends, for weeks or until they die. After treating more than 400 infected patients in COVID wards, I have only seen one instance where a social worker managed to arrange a meeting in such a situation. I had the honor to put my patient in a wheelchair and wheel him to an isolated screen door, where he could actually see and talk to his family for a while.

So, en route to a hospital with a potential COVID patient, inquire about the patient’s next of kin, significant other, or best friend. Write down the best way to contact them. If the patient does not have a cell phone and charger, most hospitals will provide bedside phones to call out. But all this has to be requested by the patient. You can aid your patient and the hospital staff by obtaining this info and giving it during your turnover. If your patient is sick with COVID, a reliable link to their loved ones on the outside is key to their recovery or spiritual peace in their last hours. You can be part of that link.

Get in the habit of providing a soft, reassuring touch at the completion of medical tasks, especially if they are painful, such as starting IVs, giving shots, glucose checks, nasal COVID testing, etc. A hand on a shoulder or gentle squeeze of an uninjured hand are nonverbal ways of letting your patient know someone actually cares about them.

Keep a positive attitude for yourself and try to generate an attitude of optimism to your patients. A positive attitude boosts our immune system, which helps in killing the unseen enemy. Another proven way to boost your immune system is regular exercise. Even if your gym is closed or the restrictions are too onerous, moderate calisthenics or just a (socially distanced) walk around the block between shifts will help all the above.

Thank you for your service and sacrifice during these dangerous times.

Michael Meoli, EMT-P, TP-C, NAEMT-AF, is CEO of Tactical Rescue Options, LLC. He served 35 years as a paramedic, firefighter, tactical medic, and flight medic in California before retiring from San Diego Fire Rescue in 2018. He is a retired Navy SEAL and Advanced Tactical Practitioner and has served as NAEMT affiliate faculty as well as a personal trainer and SEAL command fitness leader. Reach him at frogmed79@gmail.com.