You can’t be too careful … or can you?

My generation never took personal protective equipment (PPE) very seriously – until now. When I started anaesthesia back in the last millennium, gloves were only worn for sterile procedures such as spinals and epidurals – and then they were more often than not our only nod to sterility – we rarely wore gowns and surgical masks for these procedures. I will be honest and admit that until a few weeks ago I would only occasionally wear gloves to give most anaesthetics. I am told that I am quick at neuraxial procedures. If I am, it is only because I cannot bear to wear the facemask, surgical gown and gloves that sterility demands for more than a few minutes. How things change. I now go into theatre looking and feeling a little like a medieval knight, bedecked with those modern versions of the bassinet, gorget, breastplate and gauntlets that are the surgical hood, facemask, long-sleeve surgical gown and pair (or two) of gloves. Although I, like the medieval knights, feel and look a little comical and clumsy in my full fighting gear, I now bear not a shred of resentment at my full-dress microbiological armour. Times have changed. 

The last few weeks have been a bit of a rollercoaster in many ways, not least in terms of the tension between the PPE that we wish to wear and the PPE that Public Health England (PHE) and its devolved equivalents wish us to wear. The situation has not been helped by PHE’s publications, which are sometimes not the easiest to understand. Even from the start, we were all pretty clear that the performance of an aerosol-generating procedure (AGP) in a patient who actually has COVID-19 demands that those nearby wear what is often termed “full PPE”: FFP3 respirator mask, visor, fluid-resistant long-sleeved gown and gloves. However, doubt existed and still exists about what we should do when treating a patient who has not been proven to have COVID-19 but can be termed in a number of different ways: COVID- suspected, COVID- possible or COVID-unknown. What PPE should we wear for these patients, few of whom so far have been proven definitively not to have COVID-19? PHE provides a list of what may and may not be AGPs, although there is even ambiguity in this: as I write there is no clear agreement between PHE and the Resuscitation Council UK as to whether chest compressions are AGPs. However, even in the absence of one of PHE’s AGPs, what about the patient who takes a lungful of air and lets rip with a violent cough as they are wheeled to within one metre of you in the operating theatre? If that’s not an AGP in a COVID-19 possible patient, what is?

The perfect storm of confusion and anxiety has caused many to wear inappropriate PPE. Just walk down the street outside your hospital and this rapidly becomes evident: members of the public stroll past wearing FFP3 masks when they are in short supply and wholly unnecessary for the act of strolling. The situation can be even worse in theatre when several members of the theatre team don PPE designed for protection against AGPs long after the patient has left the theatre and the ventilation system will have swept any infected aerosols far away. And yet I cannot really blame people for erring on the side of safety. Healthcare workers have died in this epidemic and no one wishes to become the next casualty. However, hard as it is to say, it is irresponsible to wear an inappropriate level of PPE. If your protection is too little, you are irresponsible because you are putting yourself, and thereby others, at unnecessary risk. If your PPE is more protective than you need, you are being irresponsible because you are unnecessarily consuming resources that may become scarce. It is our responsibility to know what the appropriate PPE is for the clinical situation in which we are working. This means either (A) being able to understand PHE’s latest guidance or (B) knowing where to find a sensible and comprehensible interpretation of the latest guidance. You can find (A) here and (B) on the joint COVID-19 website by the Faculty of Intensive Care Medicine, the Intensive Care Society, the Association of Anaesthetists and the Royal College of Anaesthetists. Unless you are into lengthy documents that very nearly but not always completely make immediate sense, I would recommend (B) every time.

You cannot be too careful – and yet you can. We are in this for a long haul and need to use our PPE wisely, matching what we wear to the risks to which we are exposed. We can do our bit to conserve PPE supplies by knowing what to wear and when.

Will Harrop-Griffiths