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Identifying Exposure Points - through the perspective of Health Worker

Let's empathize with healthcare workers on the ground - understand the process/pain points that they go through from start to finish to care for Ebola patients as well as understand what are the highest risk for transmission during that process. By focusing on those most at risk for transmission, the healthcare workers, as well as highest risk during the care, we can design solution to best reduce continued transmission.

Photo of Elaine Mau
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Quick Overview of the Donning (Put on) /Doffing (Take off) PPE Process

Real footage through Nurse's Perspective
 
 
I wanted to find a full lifecycle of taking care of patients and/or doning and doffing PPE. Below is a compliation from various sources of that process to gain an understanding what health careworkers have to go through (If you find one from start to finish that would be best!).  

Donning (~15mins)
1. Caretaker suits up in front a mirror, typically starting out in scrubs.
2. Second person observing to do body checks
3. Put on Boot made of rubber that reach above the ankles
4. Put on thin latex gloves 
5. Put on Hazmat suit
6. Put on Surgical Mask - blocks microbes from entering and exiting the resporatory system
7. Put on Hood goes over the head with built in mask.
8. Put on Water proof apron
9. Put on Goggles, sprayed with antifogging agent
10. Put on Second set of gloves, thick rubber ones.
11. (Optional) Decontamination Sprayer 

(First gut reaction: Why are there so many layers? Can we minimize the layers into one body suit (I'm thinking something like Fire Retardant Clothing (FRC) with sewed on gloves)

Hot Zone - ready to treat patients (Limited to only one hour due to heat -- through out the day this means they go through this process a lot!)
Activities include
- Getting patients from the truck
- Lifting patients to a crowded room - or putting them two toa bed
- Lifting workers from bed to give them water. Screwing off the water top
- Flies might enter the goggles - tempting user to adjust, opening a risk
- Itching, which also may expose caretakers
- IV needles, if puncture suit is of great risk.. "placing an IV, you get nervous... then get fogged up and you could start pulling at your equipment"

Doffing/taking it off - Many articles point to this as the most risk
1. Burn all books/articles/notebooks
2. Workers wash glove covered hands in clorine solution (used every time below when 'wash') and walk through a clorine foot bath - interesting to note, looks like they do some sort of assembly line
3. Apron and suit get sprayed front at back (almost like a car wash!)
4. Outer gloves are dosed or thrown away
5. Off come the goggles
6. Latex gloves are disinfected
7. Head cover is thrown away
8. Remove heavy overalls, which are thrown away
9. Latex gloves are washed again
10. Gloves come off, bare hands are washed again
11. Boots come off to dry, usually upside down on stick in the ground
12. Looks like they are then doused with water to cool off.

(Why is a second person not mentioned here for taking it off?)

Caregivers Mindset
- Wanting to help, deep compassion "somebody has to do it, and I think it's important to give care where there's a need.""
- Strong Mind to deal with unrelenting waves of patients coming in, praying that some live some don't, watching many die
- Consoled that some do live, also will hum to self to confirt themselves in such harsh conditions
- Repeat this day by date

Training
1. Many workers only have one day of training before working (too little research)
2. Complicated procedure to doff; different ways of representing same steps "The CDC’s official poster outlining protective-gear removal has a note at the bottom telling workers to use hand hygiene immediately after removing all protective gear, but it doesn’t depict hand washing after every individual step, as the WHO poster does."


Univerisity of Maryland to doffing PPE 
CDC poster to doffing of PPE
WHO poster to doffing PPE
Dr. Donovan on Training for lowering risk for health care workers
Dr. Sugerman - views on Ebola training

How might we we:
-  make it easy for caretakers to take suits on and off?
- make it more comfortable (heat, itching) or prolong time in the "hot zone" as to reduce the number of times a person must "doff' (the high risk portion of the ?
- how can we boost moral of caretakers?
-  train caretakers easily and effectively (posters, videos, numbering the equipment), esp for those who you only have one day to train?

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Photo of Jab Thorn

About 19 minutes in on this youtube you'll see some live shots of medical workers disrobing (I think in Liberia)

http://www.youtube.com/watch?v=6Ib6WbIKyRE&feature=youtu.be&t=19m22s

Photo of Elaine Mau

This video in general is super useful! I will take a look at this and update this post accordingly.

Photo of Craig Provost

Great and insightful post, awesome ! Heres an idea that sparked while reading your post, what if workers were taught simple calming breathing exercises to do when feeling stress/anxiety in their suits. In yoga these are called Pranayamas. Prana is energy and Yama is breathe( controlling your energy with breathe.)

Many of these exercises are basic and from my personal experience of dealing with anxiety can be very effective. Bringing concentration to your breathing is at the core of many different meditative practices from a wide variety of cultures.

Heres are a couple simple Pranayamas that could be tried by suited up health workers :

1. Make a small O shape with your lips and exhale your breathe through the hole in a long even steady smooth stream...a quiet woooooshhhhhhhhhh...then inhale naturally through your nose or mouth trying to keep some of your intention on the inhale...then repeat the O shaped exhale.....doing this even one time should help but 5-10 cycles would be even better. (this should work even when wearing a mask, but may be hindered if wearing a heavy respirator.

2. If feeling very anxious or panicky in the suit then simply begin to coordinate your inhales and exhales with your movements and goals at hand. For example:
I inhale and reach for the patients shoulders......I exhale and lift the patient up to receive water......I inhale and reach for the water.......I exhale and pour that water into their mouth.......even just doing this for 30 seconds will likely help calm and focus your mind onto the present moment's activities. It is great to first practice this exercise in a non-threatening situation like eating or preparing food.

will post this also as in idea section soon
thanks again for your inspiring insights

Photo of Jab Thorn

I could see this being helpful during their practice exercises, even helping concentration while donning or doffing PPE.

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