PPE in EMS Moving Forward: Lessons Learned from COVID-19 | JEMS

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In the last few months, COVID-19, a pandemic-level disease
caused by the virus SARS-COV-2, has inflicted profound effects on virtually all
facets of humanity. Global economies have lost significant momentum, and
international trade has experienced stagnation. Many countries with active cases
of the virus have instituted a variety of drastic safety and security measures
— ranging from encouraging social distancing to full-scale lockdowns — in order
to decrease potential person-to-person spread of the virus.

While all industries have felt the effects of the pandemic,
it is likely that no industry has been hit as hard as the healthcare industry.
Healthcare personnel of all levels are on the frontlines of fighting the
disease, and tens of thousands of providers have been exposed to the disease.
The entire healthcare system has been tested and pushed to its limit with the
pandemic and the effects it has spawned.

Emergency Medical Services (EMS) play a crucial role in
providing prehospital emergency care to millions per year and are currently on the
front-lines of the COVID-19 outbreak.1 As they often respond to
patients in uncontrolled environments, EMS providers face some of the highest
risk of coming into contact with infectious diseases and bloodborne pathogens.2

Personal protective equipment (PPE) is commonly used by EMS
personnel at all levels to mitigate the risk of contracting an unwanted
pathogen. Examples of PPE used in the field range from gloves — used on almost
every call — all the way to body isolation gowns used on the most high-risk
patients. Adoption of PPE by EMS personnel has evolved over the years. Decades
ago, the use of gloves was not widespread, whereas today, they are commonplace
in almost every EMS call.

Specifically, the COVID-19 pandemic has put a lot of focus
on using surgical and N-95 masks during patient contacts to decrease the
likelihood of transmitting an infectious disease or respiratory illness.3
Many guidelines suggest both patients and providers should wear masks in
suspected and confirmed COVID-19 cases.1

COVID-19 will almost certainly not be the last infectious
disease dramatically affecting prehospital care. Even after the virus is
eradicated, cured, or effectively managed, EMS providers will still likely be
facing other infectious diseases or preparing for the next prospective
pandemic. Many of the lessons learned during COVID-19 have the potential to
institute broad-ranging changes to how EMS providers utilize personal
protective equipment in the field moving forward.

Masks on
Providers and Patients

It is likely that the use of masks, including surgical and
N95-grade, will increase. Studies during this pandemic and experience from many
prehospital providers suggests that providers wearing a mask and placing a mask
on patients with suspected contagious infections reduces the risk of healthcare
providers being exposed and subsequently contracting the disease.4
It is likely that, moving forward, masks will be utilized on a greater
percentage of calls, if not on every call with a suspected contagious
infection. There have been a number of studies looking at the possibility of
safely decontaminating and reusing N95 masks.5,6,7

With reusable articles of PPE that are effective and likely
to survive decontamination, there are four types of processes that have been
validated as being effective: spraying articles with vaporized hydrogen
peroxide, exposing them to 70-degree Celsius heat, basking them in ultraviolet
light, or spraying them with 70% ethanol spray. When tested in a laboratory
setting, each of these methods of treatment eliminated all traces of the

However, when specifically applied to masks, the various
methods inflicted varying levels of damage, and some compromised the mask’s
ability to effectively form a tight seal. Ethanol spray could only be used
once, UV and heat exposure could only be used three times, but vaporized
hydrogen peroxide showed the most promise and could be used more than three

Gowns on
Every Patient Interaction

The virulence of the SARS-COV-2 virus has demonstrated that
pathogens can survive on a multitude of surfaces and remain alive, without a
host, for extended periods of time.8 Healthcare providers have
learned the hard way that their uniforms could be carrying and transmitting
these pathogens.9 Gowns have been one effective solution to prevent
pathogens and harmful microorganisms from adhering to provider uniforms.
However, using disposable gowns on every patient interaction is likely both
cost-prohibitive and environmentally-deleterious.

For decades now, EMS providers have changed out linens and
disinfected stretchers after every patient contact. It might be worthwhile for
EMS agencies or the hospitals that they serve to invest in reusable gowns that
can be worn by EMS providers during calls. Perhaps, like linens, these gowns
could be dropped off and cleaned by receiving facilities, or they could be
decontaminated by the EMS agency itself.

The advantages to reusable gowns in the prehospital setting
make a lot of sense. Environments where patients are found in the prehospital
setting are often less controlled and less sanitized than an in-hospital
environment. Furthermore, uniforms visit multiple scenes during a single shift
and can accumulate several strains of harmful microorganisms and pathogens —
even personnel that did not respond to a call are at risk when a contaminated
uniform enters a station’s common area.

EMS clinicians also potentially expose family members if
they arrive home wearing a contaminated uniform. Wearing reusable gowns for the
duration of a call rectifies these problems by creating a barrier between a
provider’s uniform and any pathogens that are found on a call. Furthermore,
changing to a different gown for each patient interaction prevents patients and
other crews from being exposed to pathogens and microorganisms from a previous

In this situation, a provider could don a clean reusable
gown immediately after being dispatched to a call or before entering the scene.
During the call and while wearing the gown, they will be free to perform their
assessments, carry out any needed interventions, and transport the patient to
an appropriate facility — if needed — without fear of contaminating their
actual uniform with patient matter or harmful microorganisms.

When decontaminating their ambulance and disposing of used linens, the providers could remove their gown and, if a partnership with the receiving facility has been established, deposit the gowns for cleaning and pick up new gowns. Alternatively, the EMS agency could be entirely responsible for the gowns and sanitize them inside the station, much like how turnout gear is cleaned after being used at the scene of a fire or hazardous materials incident.


  • Mask Placed on Patients with Suspected Contagious Infection and Worn by Crew Members During Patient Interactions
  • Lightweight Gowns Worn on All Patient Interactions and Changed Between Calls to Prevent the Spread of Pathogens (Gown Use Mimicking Glove Use in the Field)
  • EMS Agencies Becoming Capable of Decontaminating Reusable Gowns (Similar to Turnout Gear) or Partnering with Healthcare Centers to Provide and/or Decontaminate Reusable Gowns (Similar to Linens)
  • Improved Supply Chains for Personal Protective Equipment to Prevent Shortages, and Dramatically Increased Prices During a Pandemic-Level Event
  • Capability to Rapidly Manufacture New PPE During a Pandemic-Level Event and/or Deploy Stockpiles of Ready-to-Go PPE


Perhaps the largest wide-scale pandemic ever…

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