Personal Protective Equipment (PPE) is Only One Part of the Equation

May 12, 2020

Author: Dr. Robert Heinginer is Medical Director of Public Health Management Corporation (PHMC) Health Services.

Levels of Security

Recently, there has been a lot of discussion on the availability of personal protective equipment (PPE) to ensure the safety healthcare workers, essential staff, and ourselves. The scarcity of available PPE is certainly concerning, but it is important to remember that ‘personal’ protective equipment is only one part of a larger protection strategy. We often think that personal protection is just a mask, gloves, and goggles. Protecting oneself against infection or other threats, however, should to be looked at in terms of Levels of Security.

For example, I had the unique opportunity to work with many talented people at the U.S. Army’s Biosafety Level 4 lab. For those of you unfamiliar with biosafety levels, Biosafety Level 4 facilities house infectious agents with a high likelihood for weaponization, causing global pandemics or having no known treatment. Think anthrax, Ebola, or plague, and you get the picture. While my colleagues working with those agents wore the big suits with the respirators attached, that was not the start of their personal protection. In fact, those big suits were the endpoint of their personal protection. Personal protective equipment such as masks, gloves, and goggles represent one of the last levels of security that are only necessary when the other levels of security fail.

My co-worker’s first level of security started, most likely, in a classroom. The first level of security we can gives ourselves is education. The most powerful tool we have against any threat is an understanding of the threat gained through credible and trusted sources. Now, I know what you’re going to say. “There is a lot we don’t know about our current threat, Coronavirus.”  That is true, and we are learning more every day. But, there is a lot we can infer about COVID-19 from what we know about other Coronaviridae, other viruses, and infectious diseases in general. My recommendation is that, prior to devising any personal protection plan, you spend some time on the Centers for Disease Control and Prevention (CDC) website learning as much as you can about COVID-19.

The next level of security starts with a consideration of your physical location. For my colleagues at the lab, their physical security started at the front lawn and continued all the way to their destination in the lab. It began on the front lawn of the building, then progressed to the fence they must pass to get to the doors, and the glass partitions separating them from the security desk. The hallways, the doors to the offices, and the exam room curtains or cubicle dividers, provided physical security, as well as the space they allow between themselves and others. When designing a protection plan, I recommend that you play a bit if chess with Coronavirus. Think what your opponent will do to get from point A to point B. Start at the exterior of your location and perform a physical walk through of it, trying to figure out how the virus can get in. Create as many barriers as you can to that entry. And remember, coronavirus does not travel by itself. It goes where we go.

The next level of security is our personal protective “behaviors,” not equipment. As I’m sure you’ve guessed, this includes regular handwashing and trying to not touch your face too much. I’m happy to report, however, that there is a whole lot more to it than that. Altering our personal behaviors based on what we know about the threat is one of our most empowering and useful tools. Do you usually wear sunglasses when you go out? While I’m sure that they make you look stylish, they are another reason you might touch your face. Consider leaving them at home. Do you really need to stop at the doughnut place for your morning coffee? Or, is now a good time to start making coffee at home and saving some money? As you can see in my picture, I used to have a goatee (in the hopes of hiding my double chin). I’ve since shaved it so that my mask fits a little better (double chin and all). I also don’t shave in the morning before heading to the clinic. I shave the night before so any cuts or scrapes have the chance to heal and prevent one more avenue that Coronavirus might enter my body. Again, put yourself in the shoes of the virus and consider how you can behave to reduce your risks of contact with it. 

PPE Best Practices

The next to last level of security, then, includes Personal Protective Equipment. This not the level of security that we want to rely on solely. Still, there are things we can do to help our PPE supplies function as well as possible.

First, you may want to consider strategies to conserve your PPE resources. In our health network, we found it works well to dedicate our Coronavirus resources to fewer sites and then a few staff within those sites. Additionally, we only provide Coronavirus care in one room in a site. This way, we can move our resources to one location, expose a fewer number of people, and keep everything else functioning as normally as possible. This also gives us the opportunity to rotate staff on and off duty. We are not all fighting Coronavirus every day, and so staff are given a chance to rest and recuperate. It also means that if one of our staff members does become ill, we have a “bench” of healthy, unexposed employees to pull from and reinforce our front lines.

Second, you should be prepared to re-use PPE as safely as possible. Again, I recommend visiting the CDC website on the best ways to use and re-use PPE.  The CDC also provides guidance on making your own masks. My recommendation here is that homemade cloth masks be worn over medical grade surgical or N95 masks. The cloth mask can be safely laundered for re-use while the surgical grade and N95 masks cannot. Surgical grade and N95 masks, however, provide a higher level of protection. So, combining the two allows the washable, homemade cloth mask to protect the surgical and N95 masks for re-use. 

Well fitted, medical grade N95 masks prevent the wearer from contracting the virus. This is the, “It’s not me, it’s you” mask. It is mostly necessary when performing specific medical procedures and should be reserved for healthcare workers as much as possible. A medical grade surgical mask prevents the wearer from spreading the virus through coughs and sneezes. So long as we are all wearing surgical grade masks over our mouths and noses while remaining six feet apart, we are doing a great deal in protecting each other.

Third, I also recommend that you try to distribute your PPE rather than storing it for future use. This is not just for your healthcare settings but for whatever congregate settings you may have (homeless shelters, halfway houses, etc.). There are two reasons for this. One, reducing exposure to the virus reduces cases and thus the need for more PPE. Two, it also helps staff to feel secure and to continue working. Coronavirus will have many effects from the acute illness it causes to the impact it has on our economy. Our job is to mitigate those effects as much as we can. Fighting Coronavirus is not just treating those acutely infected. It is also continuing to feed a person with no home, continuing to provide substance abuse treatment to a recovering client, and continuing to provide a child on the autism spectrum their therapy. Reducing the impact that Coronavirus has is essential work, and essential workers need to feel safe to do that work.  

The Last Level of Security

The Last Level of Security we have, after all of those mentioned above, is our own immune system. One day (hopefully in the not too distant future), we will have a vaccine that will turn our own immune systems into our best defense against this threat. But, between now and that day, we all must take good care of our last level of security. This means taking good care of ourselves. A healthy diet, exercise, and, when possible, abstaining from alcohol and tobacco are all ways we can make our immune systems stronger. Lastly, reduce your stress to boost your immune system. Remember that this pandemic will pass eventually, and that we’re all in it together.


Dr. Robert Heinginer is Medical Director of Public Health Management Corporation (PHMC) Health Services. In this role, Dr. Heininger is an integral senior team leader providing high quality direction and clinical supervision to advance our nurse-led primary health care integrated services. Dr. Heininger joined PHMC following dedicated service in the U.S. Army, where he held a number of key leadership positions, including service as the U.S. Army’s Population Health Physician for the entire Middle East area of operations. Dr. Heininger’s other experience includes serving as the Medical Director at Winn Army Hospital in Fort Stewart, Georgia, and the Director of Training and Education at the U.S. Army Medical Research Institute of Infectious Diseases.

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