The iconic image of the current Ebola epidemic is that of the health care worker, dressed in hood, coveralls, and goggles, peering out at the camera, their face clearly dripping with sweat. They are wearing Personal Protective Equipment (PPE), the complete barrier that prevents the virus coming into contact with any part of a healthy person who is about to touch someone with the disease.
PPE changes everything. It is essential to wear if the most remote contact with any of a patient’s body is to be contemplated, but it makes communication infinitely more difficult. It takes time to put on and take off and can only be worn for short periods without risking heat stroke and dehydration. Thus, PPE alters the interaction with the patient, the interventions that can be considered, and the manner in which you conduct yourself on the ward.
Putting PPE on is done slowly and methodically. All the items are collected first – 2 pairs of gloves, a mask, a hood, an apron, coveralls, and goggles – then they are put on (donned) over scrubs in a set order with close supervision from both the people you are entering with and technicians on hand to help. No skin can be left uncovered. None. Your name is written on the hood, and the time that you are entering the ward is written on the sleeve. All movements are slow and deliberate.
Wearing PPE is like wearing a crash helmet, gum boots, and a thick plastic garbage bag covered by a tarpaulin to walk to the shops on a 30 degree summers day, except that if you tear the garbage bag you could get Ebola.
However, despite PPE changing everything, everything somehow manages to stay the same. Patients need and receive care – not routine or robotics, but the same type of care all patients need – and so long as you do not stay for too long and have made sure you were well hydrated before going in, steady, careful movement is possible, as is close and surprisingly intimate communication with patients. Despite the spacesuit appearance, rapport is achievable, I think more through the friendliness and resilience of the patients than the communication abilities of the health worker. Everybody has different tolerances to PPE, and at the first sign of fatigue you leave, because it takes a good 10 minutes to get out.
The most important part of the PPE cycle is taking it off (doffing). A technique sometimes used in training involves sprinkling glitter on the outside of the PPE and seeing if any gets onto the scrubs, hair or face when the PPE is removed. What if the glitter was virus?Doffing takes time. Like donning, it is done in a set order under supervision. However, the supervision required for doffing is far greater than for donning. After stepping into a bucket of chlorine solution for a minute, the doffing supervisor beckons you to approach. They stand across a step, outside the treatment zone, but, standing as close as anyone in that zone gets to surfaces contaminated with Ebola, they wear goggles and gloves themselves and clasp a spray bottle of chlorine solution.
Each step is called out clearly, and you are instructed to wash your hands in chlorine solution between every single step. Firstly you are sprayed from head to toe, front and back (we get through a lot of chlorine solution), then piece by piece the PPE is carefully peeled away.
Finally, after the gumboots are sprayed front, back, left, right and underneath, you step out of the treatment area and back into the comparative freedom of the non-treatment area (still no eating or touching your face) where, after washing your now ungloved hands in lower concentration chlorine solution, you are handed a welcome bottle of water. Your scrubs are saturated as if you had jumped into a pool, and you need to go sit down for a while. It is time to write notes and make plans from the information that has be obtained on your round.