“Are there circumstances where you treat a patient before you put on your full PPE?”
This question provoked great debate with some saying you absolutely have to put on your full PPE in this age of COVID.
My take on it is it would be great if you could, but it is not always so easy.
Here is a call I did last week.
I am in a fly car driving down the road when I am dispatched to an overdose outside an apartment complex. I hit my lights and sirens on and within two minutes I am pulling to a stop. I can see the man on the lawn being held up by another man. The man is in the frog position, a common position we find heroin overdoses in. His knees are forward, his body bent back over the legs, but his torso bent forward. The man trying to get him up, has lifted his torso up, but now it bends backwards. I get out of the car, run around the back, lift up the rear hatchback, grab my house bag, the blue isolation bag and the heart monitor. I approach the man, and setting my gear down, I reach into my back pocket and take out my latex gloves, which I apply.
The man is cyanotic and is not breathing, but he has a carotid pulse. “Heroin?” I say to the man holding him up. He just shrugs as if to say, “Yeah, I guess you could say so, but I’m not the one saying it is so.”
Now I have already made contact with the patient before putting on my isolation gown. The problem with the isolation gown is it takes a little bit to put on. I have to either first take off my outer jacket or else try to squeeze my arms through the thin sleeves, likely tearing them. I also have to tie the gown, which is open in the back. Our gowns tie only in the back and I can only tie them if I am looking in a mirror or have someone else to tie them for me. I suppose I could ask the guy holding his buddy up, but I think he pretty much has his hands full.
I am already wearing my surgical mask, which I keep looped on my ears and my goggles which I wear always nowadays.
My choice. Put on my gown or take out my narcan and my ambu bag and start treating him. He is after all not breathing, and his brain cells are dying and he is at high risk for going into cardiac arrest. If I use the ambu bag, I definitely have to have on my gown and also switch my mask to a N95 instead of the surgical mask.
I quickly open up my house bag, take out my med pouch, unzip it and take out a vial of narcan, screw it into the bristojet, then attach a needle, which I plunge into his thigh, giving him 1 mg of naloxone.
Only then do I put on my gown, without tying it. It soon starts slipping off my shoulders. What am I going to do? Not much I can beside trying to pull it back up on my shoulders. I get my ambu bag out and start breathing for him.
By the time the ambulance arrives, he has started breathing again on his own, and shortly after now alert, denies he did any drugs at all, despite the needle we find in his pocket.
So did I do right? Some will say yes, some will say no, some will say you had to be here.
I made my choice that he needed to be saved right now, and that outweighed the small risk to me of not having all my PPE on.
If you think that we have to protect ourselves at all costs, then my answer would be then we have no business being out here with the ineffective PPE we are being given unless our services are giving us space suits.
I did find some backing to my decision in the recent International Liaison Committee on Resuscitation (ILCOR), position paper, which often forms the basis for future AHA Recommendations.
The issue for them is not a person in respiratory arrest from opioids, but a patient in possible ventricular tachycardia.
Here’s what they had to say.
Treatment Recommendations
•We suggest that chest compressions and cardiopulmonary resuscitation have the potential to generate aerosols (weak recommendation, very low certainty evidence)
•We suggest that in the current COVID-19 pandemic lay rescuers consider chest compressions and public access defibrillation (good practice statement).
•We suggest that in the current COVID-19 pandemic, lay rescuers who are willing, trained and able to do so, consider providing rescue breaths to infants and children in addition to chest compressions (good practice statement).
•We suggest that in the current COVID-19 pandemic, healthcare professionals should use personal protective equipment for aerosol generating procedures during resuscitation (weak recommendation, very low certainty evidence).
•We suggest it may be reasonable for healthcare providers to consider defibrillation before donning personal protective equipment for aerosol generating procedures in situations where the provider assesses the benefits may exceed the risks (good practice statement).
Justification and Evidence to Decision Framework Highlights
•Given the potential for defibrillation within the first few minutes of cardiac arrest to achieve a sustained return of spontaneous circulation and uncertainty of the likelihood of defibrillation generating an aerosol, we suggest healthcare providers consider the risks versus benefits of attempting defibrillation prior to donning personal protective equipment for aerosol generating procedures.
• The time taken for a team to don personal protective equipment may be up to 5-minutes, although individuals may don equipment in around one-minute(Abrahamson 2006 R3, Watson 2008 333-8). However, once donned we identified evidence that there is a risk of mask slippage during chest compression delivery rendering the protective equipment less effective.
Peace and safety to all.
