VOLUME 32, ISSUE 2

Prior to attending medical school, I had the opportunity to be a third-generation steel worker using my undergraduate degree in Industrial Hygiene. The opportunity deeply enriched my view of the world and I frequently draw from lessons I learned while employed in the steel industry. With the recent Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) outbreak and the subsequent challenges with personal protective equipment (PPE), I reflected back on the things I learned in industry as a safety officer. I hope that the lessons we are each learning will enable us to have better solutions in place in preparation for future pandemics.

Our current society has been referred to by many as a “throw-away society.” The idea of sustainability seems to be in direct conflict with the previously common site of garbage cans overflowing with used yellow gowns and N-95 masks that many are accustomed to. As I pondered our current predicament, I began to recall the sustainable, reusable PPE used in industry. Although this PPE was not originally designed for a healthcare application, in many ways it provides as good, if not better, protection; and, per the Centers for Disease Control (CDC), represents an acceptable alternative to what is currently approved.³ Some of the solutions our department of anesthesiology has started to use are the elastomeric respirator, Tyvek gowns, thicker multi-use nitrile gloves, and hard-hats fixed with face-shields. Due to shortages of PPE, we have been required to reuse certain PPE for varying lengths of time. For more reliable protection, many of our perioperative staff have abandoned N-95s altogether in favor of elastomeric respirators.

Elastomeric respirators have long been used in industry. I first used them in the steel industry where I had the opportunity to work side-by-side with operators charged with a task known as “tapping a heat.” This job exposes individuals to extreme heat and multiple metal fumes that present a significant health hazard (for anyone interested can be viewed at the following link: https://www.youtube.com/watch?v=QBLRIEZZEsU). This job is a necessary part of the steel manufacturing process and, like caring for a COVID-19 patient, the work requires a human operator. Since engineering and administrative controls are not possible, we relied on PPE for protection in the steel industry and had an excellent track record of success. We were proud to be able to verify, using blood samples, that our working population had nearly undetectable blood lead levels.

Prior to the COVID-19 pandemic there was only one healthcare institution (The Texas Center for Infectious Disease) using elastomeric respirators as their primary source of respiratory protection.¹ However, the benefits of these respirators suggest that they are an excellent substitute when PPE is scarce. When compared to the standard consumable N-95 filtering mask, elastomeric respirators provide the following benefits: the ability to use a true HEPA type filter (P or N100 filters which are rated to filter 99.9% of airborne particles 3 microns or larger), ability to obtain a more reliable/satisfactory seal that can be easily verified prior to each use, as well as the ability to more easily sanitize and share between multiple users.¹ Lastly, the relatively inexpensive nature of these masks (typically around $30 for a mask and 1 set of filters) make these an economically feasible option. One obstacle we encountered was that, though these respirators do an excellent job filtering inhaled air, the exhaled air is not filtered. We easily remedied this by covering the exhalation valve with surgical mask material to reduce the risk of surgical site infection.

Currently, the literature is lacking in evidence based practice of using sustainable versions of PPE and their ability to be sanitized between patients and users. While there is no consensus on proper sanitization/sterilization processes, there is literature to support the use of elastomeric respirators in the healthcare setting.¹ Moreover, the materials these types of PPE are made from easily withstand bleach solutions and other commercially available sanitizing solutions. In fact one of the largest manufacturers of these masks, citing the CDC and Environmental Protection Agency, advocates the use of bleach to sanitize masks during the current COVID-19 pandemic.^2,4 Our own department has adopted practices of ultraviolet radiation and bleach solution sterilization for reuse of this equipment.

As a department, we have found success in utilizing reusable options for PPE. Many in our department will likely continue to use these reusable PPE options for the foreseeable future as we continue to provide care for patients with COVID-19. We hope that the lessons we have learned will enable us to better care for our patients while minimizing risk of person-to-person transmission of communicable illness.