Ebola nursing: how to safely get out of PPE

10 October 2014

Safely returned Red Cross nurse Donna Collins describes the meticulous and life-saving methods of getting out of personal protection equipment (PPE) used in an Ebola treatment centre in Sierra Leone.

While putting on the right PPE in the right order is important, says Red Cross Ebola nurse Donna Collins, even more crucial is correctly taking off your contaminated PPE.

"That's when you can get contaminated with Ebola, so that's the doozie. It's life or death. If you do it wrong, you are going to get Ebola."

After an hour of working in an Ebola ward in tropical Sierra Leone, Donna Collins says the heat, humidity, and concentration leaves your brain too "befuddled" to do the job of undressing on your own.

So Medicine Sans Frontières (MSF) and Red Cross teams in Sierra Leone have a specially trained “dresser” to instruct nurses and hygienists each time they put on their PPE, and also a trained “undresser” and a “sprayer” to talk, spray, and guide staff step-by-step through the safe way of taking off gear contaminated with the deadly virus.

"You actually come out of the unit and work like a robot to get undressed. You just look that dresser in the eye and follow every word they say."

The nurse or health care worker first queues outside the undressing tent waiting for their turn; they then enter one-by-one and stand spread-eagled behind a line that separates the undresser on the “clean side” of the tent and the nurse on the “dirty side”. The sprayer then sprays them “front to back and top to bottom” with a chlorine solution.

Then the undresser's instructions begin with "wash your hands" and the nurse washes their double-gloved hands in a chlorine solution. Next, the undresser calls for the nurse to remove their goggles.

"You stand with your feet apart and you lean right forward and hold your goggles and pull them out from your face, and then lift them over the top of your head and off," Donna says.

“You dip the goggles in the chlorine three times and then drop them into the water bucket.

"Then you look at the undresser again and she will once again say 'wash your hands'."

After that comes off the first pair of gloves – chucked into the rubbish – and the nurse is instructed once again to "wash your hands" before taking a similar stance and style used for removing your goggles to remove your hood – but with your eyes closed this time.

"As soon as you get that hood off, you think, ‘oh my God, I’m going to survive’," says Donna because of the relief from the oppressive and claustrophobic heat.

The process continues – always with hand washing before and after removing each piece of equipment. Following the duck bill mask and apron comes the “trickiest part”: taking off the all-in-one suit. The protocols call for the nurse not to contaminate themself with the outside of the suit, even though it has been sprayed.

Donna says this is done by keeping hands inside the suit and pushing it down over the shoulders, then getting the arms half-way out and pushing the suit down further to the gumboots, at which point the nurse can pull their hands out completely.

Once the suit is around the nurse’s ankles, they then stand on the suit with one gumboot-clad foot and try pull the other leg out of the suit with gumboot still attached. This is easier said than done, particularly if the gumboots are too big.

Donna says the challenge is compounded by socks that are soaked with sweat, so everything is slippery.

"It's never just a walk in the park. Nothing is simple".

Once both feet are out of the suit, the nurse kicks the suit in front of themselves, where the sprayer once again sprays the suit. The nurse then picks it up and throws it in the rubbish.

Nearing the end, the nurse washes their hands, removes their last pair of gloves, wash their hands yet again, and then the sprayer sprays all sides of their boots.

Now in the home straight, the nurse lifts one boot and the sole is sprayed before the nurse takes their first step into the clean side of the tent. The second boot is lifted and sprayed in the same before the second step into the clean side.

One final wash of now bare hands in a lower percentage chlorine solution, and the undressing process is complete – fifteen plus stress-laden minutes later.

"Rhen you are like YAHOO! I did it! The feeling is like elation. It's just the most amazing feeling," recalls Donna. "You can feel air on your skin again. I just wanted to hug the undresser so many times, but of course, 'no touch', so you just give them a big smile and thank them profusely.

"I've never done something so crucial in my life."

When Donna became a team leader, she would go first so she could be there waiting on the clean side to give her novice team members' moral support.

"The look of terror in people's eyes those first few days when they were just new is quite extraordinary."

She would try to be there to help them deal with any panic arising from an apron string getting caught or losing their balance getting out of their suit.

Once safely through, there is the relieved break before once again donning the gear and returning to nurse the stricken patients – for the maximum of one hour that you can bear to be in the oppressive heat of full PPE in the tropics. Then once again, the pain-staking ordeal of undressing safely.

This is a routine that nurses and other health care workers are repeating three to four times a shift while caring for patients in an Ebola isolation unit.