Level 2 PPE is essential when screening or evaluating patients with stable or mild symptoms of Ebola. This includes the following:
• Single-use impervious gown extending to mid-calf;
• Single-use full-face shield;
• Optional protective plastic eyewear (not goggles);
• An N-95 respirator or powered air-purifying respirator (PAPR);
• Full impervious head drape;
• Two pairs of disposable nitrile gloves with extended cuffs; and
• Disposable impermeable shoe covers to mid-calf.
If an unstable patient presents to the ED with possible Ebola or potential exposure to Ebola, level 3 PPE is recommended. Level 3 PPE entails the use of an impervious full-body suit along with a PAPR.
In more specialized biosafety level 4 (BSL-4) containment facilities labs such as the ones at Emory University Hospital and Nebraska Medical Center, or the biocontainment center at the National Institutes of Health, personnel wear positive-pressure suits (often referred to as “moon suits” or “space suits”) that contain their own purified air–powered systems. These facilities have showers for decontamination after patient treatment, along with compressed in-line air and an airlock system that prevents any recirculation of air that could lead to contamination.
However, as we know that the Ebola virus is not airborne, using level 2 or -3 PPE would be sufficient depending on the stability of the patient and potential risk for contamination from body fluids such as diarrhea or vomit.
EM Thought Leaders Weigh In
Al Sacchetti, MD, chief of Emergency Services at Our Lady of Lourdes Medical Center in Camden, New Jersey, and a spokesperson for the American College of Emergency Physicians (ACEP), said most emergency medicine clinicians are “concerned but comfortable at present with the potential of treating an Ebola patient.
“That said, the added PPE requirements needed to manage an Ebola patient have the staff a little nervous because of the reports of the nurses in Dallas contaminating themselves while getting in and out of the equipment,” Dr Sacchetti said. “I think that as we get more hands-on practice with donning and doffing PPE, this unease will pass.”
David A. Talan, MD, professor emeritus at the David Geffen School of Medicine at the University of California, Los Angeles, and chairman emeritus of the Department of Emergency Medicine Faculty, Division of Infectious Diseases, Olive View-UCLA Medical Center, expressed similar feelings about the impact of Ebola in his current practice.
“I don’t see panic from the patients at all; I think they seem pretty calm,” said Talan, “A lot of them—since we have made screening at triage so routine—understand that the questions don’t really apply to them.”
“Obviously it’s going to be pretty rare that someone shows up from these high-risk areas with compatible symptoms,” added Talan, “but I think the patients are reassured that we are asking the right questions. But I don’t sense that the patients are scared.”
During the past few weeks, the question has been asked frequently as to whether, as a nation, we are prepared for Ebola in America.
“No, and why would we be?” explained Sacchetti. “I know that we have been warned over and over that a pandemic could spread quickly, given easy access to air travel. But to be honest, until the first case [in Dallas] no one took it seriously.
“And any hospital that claims otherwise is simply deluding itself, with the obvious exception of the BSL-4 sites,” added Sacchetti.
When asked whether more Ebola cases are expected in the coming weeks, Talan said, “Probably; you would expect that there would be. As the epidemic continues to grow in West Africa, the chance of something happening, like [the case of] Mr Duncan, would only be greater.
“At the same time,” added Talan, “we are also becoming much better at screening, much more aware of the consequences and possibilities of missed screening, and we are much more aware of how to protect ourselves.”