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October 14, 2014

Dr. Sanjay Gupta Demonstrates That CDC's Safety Protocols for Ebola Treatment are Flawed

via @allahpundit.

Update: Via Slate, the CDC's poster for dressing/undressing protocols is here.

They suggest taking the gloves off first.

I don't know about that.

...

What I see here is a strong suggestion not that the Dallas nurse breached protocol, but that the protocols she followed are flawed and inadequate.

Sanjay Gupta dons the protective gear, then takes it off. It's the taking it off part that poses the greatest danger to the health care practitioner, as when she is taking it off, the protective clothing is possibly infected with ebola. Touching one's skin to a smear of ebloa-infected saliva on one's glove, for example, can result in infection.

So the trick is to get the clothing off without touching your own skin with any part of the clothing, or the gloves.

Gupta smears his gloves and his hospital gown with some chocolate sauce to represent possible ebola contact. The trick is then to get the gear off him without getting any chocolate sauce on his skin.

Gupta takes off the clothing following what he says are CDC procedures, and winds up getting chocolate sauce on him.

The problem, I think (and which I've always suspected), is that you really can't take your clothes off with your own dirty, possibly-infected globes.

You need someone with perfectly-clean gloves undressing you.

Or, alternately, you have to have clean gloves placed over your dirty gloves,* so when you undress yourself, you're only touching yourself with a clean glove surface.

Only then, at the end of the process, can you take off your gloves.

And frankly I think this last step is still dangerous because, when you think about it, at some point you will be touching a dirty glove with one naked hand. One of your hands will end up being the first one to be without a glove, after all, when you take off gloves. And when you use that hand, you're touching naked skin to a possibly infected glove.

I found Dr. Frieden's claim that the protocols must have been breached to have been unscientific and dangerous. A scientist should examine the possibility that the protocols themselves are inadequate, and should be experimented with.

He seemed to dismiss all that -- to reassure us, of course.

But when Gupta runs the experiment -- actually trying to follow the protocols -- he finds it to be quite likely that people will touch ebola-infected liquid to their skin in taking off the gear.

Shouldn't a scientist actually look into these things instead of just being a glib reassurance machine?

* This sounds sillier than it is. I don't mean slip on tight latex gloves over the infected gloves. I really have in mind a loose-fitting rubber mitten that is easily slipped on and off.

Bear in mind, this mitten will be used only to remove clothing. The practitioner does not need all his fingers moving independently for this process.

Slip on the clean undressing mitten, right over the filthy gloves, then use the clean undressing mittens to undress. End of process, who knows, perhaps they'd have to then put on a fresh set of undressing mittens (taking off the first ones) in order to then take off the actual gloves.

We're talking about medical parts that would probably cost $0.20 a pair. We can afford to have practitioners use two sets of them per contact.

Suggested Protocol. These protocols assume the existence of "undressing mittens," which are latex like surgical gloves, but looser fitting, so they can be easily slipped over a gloved hand.

1. Put on clean undressing mittens.

2. Use the clean undressing mittens to remove the face shield.

3. Take off the undressing mittens. Dispose of them in medical waste (with the face shield).

4. Put on new, clean undressing mittens.

5. Use them to take off the face mask.

6. Once again, take the mittens off, and dispose of them with the other medical waste (mittens, face shield, face mask).

7. Put on a new, clean undressing mittens.

8. Use these to take off the body garment.

9. Once again, take off the undressing mittens and dispose of them with the other medical waste (now multiple courses of mittens, mask, shield, garment).

10. Put on one new clean undressing mitten.

11. Use that mitten to remove the glove on the opposite hand.

12. Put on one new clean undressing mitten.

13. Use that to remove the other hand's undressing mitten and glove.

14. Dispose of the mittens and gloves in medical waste with all the other items.

That's a lot of steps -- but at each step, the practitioner is guaranteed he cannot be touching himself except with a new, uninfected undressing mitten.

It's idiot proof. Yes, it's a bunch of steps, but they're all simple.

And the "undressing mittens" I have in mind are like $0.20 a pair. It's not like we have to save money on latex mittens.

Simpler Protocol?

Forget the mittens, ace. Arm length surgical gloves beneath the exterior gloves (he shows a two layers being put on) would be the way to go. Put those on first, remove gown and outer gloves, strip long gloves, and THEN face PPE

Here's my problem with that. For the first step, it seems sound. You take off the outer gloves and then undress with the undergloves, which are, presumably, clean.

However, you then take off your face shield. At this point your undergloves must be presumed to have made contact with ebola.

That means you cannot now use your gloves to take off your face mask and body garment. As soon as your gloves touch anything which might have been infected, they are now dirty and cannot be used for subsequent undressing steps.

So this works, I think, for removing the face shield, but I would not want to then take off my face mask -- think how hard it is to take off a face mask (looped around your ears) without making any contact with your body -- with an infected glove.

I think you're going to have to put on proven-clean and new for each potential body-contact maneuver.

Flawed from the Outset? Someone on Twitter, @chbillhorn, says it's impossible to put on clean mittens using dirty gloves without making the clean mittens dirty in the process.

He may be right. It seems like an objection that I can't overcome.

Alternative: Wear three pairs of gloves to start.

When disrobing:

1. Use one glove to remove one layer of glove on the other hand, revealing a presumably-clean glove.

2. Use that clean glove to remove the face shield.

3. Use that glove (now dirty) to remove one layer of glove on the other hand, revealing a presumably-clean glove.

4. Use that glove to remove the face mask.

5. (I think here the dirty gloves can actually be used to pull off the body garment -- this seems like the step least likely to result in a touching off the body. So I'll suggest that.)

6. use one hand to remove one glove on the other hand.

7. use that hand (clean glove) to remove the hand's glove.

I think at this point we are done with gloves.


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posted by Ace at 03:50 PM

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