Original Article

Medico-Legal Journal
2020, Vol. 88(1S) 47–49
Problems arising from PPE when worn ! The Author(s) 2020
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DOI: 10.1177/0025817220935880
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Raghvendra K Vidua, Vivek K Chouksey, Daideepya C Bhargava

and Jitendra Kumar

Abstract
In the context of Covid-19, personal protective equipment is much needed and often in short supply as a protection
against the virus, but nobody until recently was discussing the downside of its prolonged use by its wearers. Increasing
numbers of health care workers feel unwell using it and are overheating and some have fainted. Will it impair their
professional performance? This article considers this aspect of PPE based upon the personal experience of a Forensic
team at AIIMS Bhopal in India who wore it during autopsy work and proposed recommendations to minimise it.

Keywords
Covid-19, PPE, safety measure, downside for the wearer – overheating, recommendations

Introduction
PPE comprises protective clothing, helmets, goggles and/
or equipment designed to protect the wearer from health
and safety hazards at work.1 It also includes respiratory
protective equipment (RPE) and aims to make the work-
place safe. Proper instructions, training and supervision
are needed to ensure that it is used properly.2 They are
used at different workplaces in health care including the
mortuary where dead bodies which have tested positive
with Covid-19 or are suspected positive are either being
examined or handled.
PPE must be properly designed, constructed and
maintained in a clean and hygienic environment and
fit the users comfortably otherwise it can make the dif-
ference between being safely covered or dangerously
exposed and may discourage its use due to continuous
discomfort. Forensic personnel are not used to it and are
finding it unpleasant. The shortage of PPE is proving to
be a tremendous challenge in the current pandemic,3 so
to optimise its usage here it is being worn for longer
periods even to the extent of performing multiple autop-
sies at a stretch that run for hours wearing the same kit.
Needs and limitations of PPE
PPE is essential for healthworkers in the current pan-
demic, irrespective of whether dead bodies or samples
are positive for Covid-19, because of the prevalence of
so many latent and unreported cases. The careful selec-
tion and proper use of adequate PPE to protect skin,
eyes, face, nose, mouth, hands, feet, head and other
parts of the body, can provide protection as an effective
barrier between the health worker and the contaminated
materials like blood, body fluids, respiratory secretions
and aerosols. The proper disposal of PPE post proce-
dure is very important.
The current pandemic has put pressure on the health
care system’s ability to obtain PPE and it is compelled
to accept whatever is available even when it is substan-
dard when delivered by many manufacturers who are
new to making this and lacking the requisite experience
or who cut corners. The users often do not find their
PPE comfortable while working. With high tempera-
tures in the summer season, it is worse for the wearers,
particularly when facilities for controlling the environ-
mental temperature like HVACs are unavailable or
were shut down for fear of spreading infection.
Apart from discomfort and the heat, users find
verbal communications difficult and there is the loss
of normal sense of smell, reduced tactile sensitivity,
increased difficulty of fine hand movements and
impaired visibility due to deposition of water vapours
on the eye goggles (Figure 1). So, there may be
Forensic Medicine & Toxicology, AIIMS Bhopal, Madhya Pradesh, India
Corresponding author:
Raghvendra K Vidua, Department of Forensic Medicine & Toxicology,
AIIMS Bhopal, Madhya Pradesh, India.
Email: raghvendra.fmt@aiimsbhopal.edu.in
48
procedural errors or unintentional self-injury. Some
users suffer work stress, anxiety and a feeling of work-
ing in a life-threatening environment and psychological
claustrophobia and wish to limit its use for these
reasons.
Case report
Every member in the Forensic team at AIIMS Bhopal
in India felt confident that they would be protected
against COVID 19 infection by wearing PPE when
handling a dead body or performing autopsies.
However, this changed when recently a member of
the team in PPE fainted after autopsies were performed
one after the other in a stretch of around 4 h which
included the gap between completion of the first autop-
sy and the start of a second. The team that performed
the first autopsy decided to take on another body for
autopsy to optimise the use of PPE by not discarding it
after the first autopsy.
Many of the five team members felt discomfort in
some form like feeling excessively hot, and suffered
from nausea, headache, backache, neck spasm, fatigue,
nervousness, dizziness, enhanced perspiration, dys-
pnoea, suffocation, dehydration or facial redness.
However, one team member near the completion of
the second autopsy expressed his inability to continue
and, while leaving the post-mortem examination room,
fainted near the door and fell down on the floor. Other
team members rushed to help him, doffing was done
keeping in mind the risk of contamination, and they
made him comfortable till he regained consciousness
after 10 min.
Figure 1. Forensic team wearing PPEs while performing autopsy.
Medico-Legal Journal 88(1S)
Discussion
PPE can protect its wearer from contracting Covid-19
but if worn for too long, or incorrectly or the PPE
does not fit properly as recommended by protocol, then
instead of keeping the wearer safe it offers a false sense of
security and can expose him/her to many complications.
Many users have reported significant adverse effects
including fatigue, dehydration, headaches and hyperhi-
drosis4 and find working in PPE for long hours a
major physical and professional challenge.5 The users
may experience dizziness, light-headedness, and heat-
related illnesses like fainting due to heat syncope.6 PPE
causes dehydration and discomfort in the same way as
wearing a rubber coat, which hardly permits air.7,8 Italian
nurses reported facial bruises and falling asleep over
working stations due to constant wearing of PPE.9 The
prolonged use of face masks may also cause hypoxia and
fatigue10 apart from vasovagal syncope and low blood
pressure due to the derangement of physiological param-
eters.11 Providing constant ventilation and head cooling
may increase the tolerability of heat stress12 but wearers
of PPE who are working for longer stretches to optimise
the use of PPE have to retain urine and experience
thirst.13
PPEs may impact on performance and comfort
level.14 But poor levels of supply to hospitals caused
by the sudden rise of global demand mean that PPE on
offer may be inappropriate for its purpose, untested,
unproven, unreliable or of inferior quality. This will be
so even if just a single component of PPE is incompat-
ible or substandard as it may undermine its effective-
ness as a whole and render it useless for the purpose
intended. Disproportionately bulkier and heavier PPE
Vidua et al.
makes breathing more difficult and the users so uncom-
fortable that they are reluctant to wear it. There are
many increasing instances of wearers fainting after pro-
longed use and of people finding it horrible and they
become reluctant to work with it any more. Therefore,
a clear standard for PPE use is critical to safe practice
during the pandemic when the risk of contracting
Covid-19 remains high and there is an urgent need
for improvement to and modification of the current
guidance on its use.15
Recommendations
1. Supply of standard kit.
2. Informing, educating and training for proper use.
3. Inclusion of powered respirators to facilitate blow-
ing of air inside the mask.
4. Encouraging users to wear PPE but discouraging
its use for long periods of time.
5. Readily and easily available replacement supplies.
6. Printed step by step illustrated instructions which
demonstrate how best to don, doff and dispose
of PPE.
7. There is a need for checks on quality, fitness and
comfort.
8. Environmental control of air temperature in post-
mortem examination rooms to avoid overheating
of PPE wearers.
9. Taking regular feedback from the users and certi-
fication of quality.
10. Modification of kit to divide it into upper, middle
and lower parts instead of a single piece.
Conclusion
PPE undoubtedly plays a crucial role in protecting the
Forensic team involved in handling dead bodies and
autopsy-related work against Covid-19 infection
during the current pandemic but its use is not free
from complications, which range from mild discomfort
to fainting. The provision of safe, comfortable and
standard PPE is a challenge for the system and we
need to consider and research what modifications
would improve matters. We need to discover how to
limit these complications from PPE, otherwise its role
as a safety measure may be undermined.
Key messages
1. The complications are associated with the usage of
PPEs as safety measures.
2. The research on desired modifications to find out the
alternatives for limiting these complications is needed.
49
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of
this article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
References
1. https://en.wikipedia.org/wiki/Personal_protective_equip
ment (accessed 13 June 2020).
2. https://www.hse.gov.uk/toolbox/ppe.htm (accessed 13
June 2020).
3. https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-
strategy/index.html (accessed 13 June 2020).
4. https://www.thelancet.com/journals/langlo/article/
PIIS2214-109X(20)30204-7/fulltext (accessed 13 June 2020).
5. http://epaper.dainiksaveratimes.org/m5/2655187/Amritsar-
Savera/Amritsar#page/1/1 (accessed 13 June 2020).
6. CDC. Limiting Heat Burden While Wearing Personal
Protective Equipment (PPE). 2014.NIOSH, https://
www.cdc.gov/niosh/topics/ebola/pdfs/limiting-heat-
burden-while-wearing-ppe-training-slides-healthcare-
workers-site-coordinators.pdf (accessed 13 June 2020).
7. https://www.freepressjournal.in/bhopal/bhopal-doctors-
paramedical-staff-find-ppe-kits-uncomfortable-in-
summer (accessed 13 June 2020).
8. https://www.indiatoday.in/fact-check/story/fact-check-
can-prolonged-use-of-masks-cause-oxygen-deficiency-
and-fatigue-1676405-2020-05-10 (accessed 13 June 2020).
9. https://www.dailymail.co.uk/news/article-8099055/
Italian-nurses-reveal-exhausted-bruised-coronavirus.
html (accessed 13 June 2020).
10. Ambulance driver faints on duty, https://timesofindia.
indiatimes.com/city/ludhiana/ambulance-driver-faints-on-
duty/articleshow/75524734.cms (accessed 13 June 2020).
11. https://stopfainting.com/articles/why-do-i-faint/advice-
for-those-wearing-ppe-its-not-only-our-patients-who-
faint/ (accessed 13 June 2020).
12. Liverman CT, Domnitz SB and McCoy MA. The use and
effectiveness of powered air purifying respirators in health
care: workshop summary. Washington, DC: The National
Academies Press, 2015.
13. https://timesofindia.indiatimes.com/city/ahmedabad/
ahmedabad-in-stuffy-and-hot-ppe-they-shield-you-
from-covid-19-heat/articleshow/75440119.cms
(accessed 13 June 2020).
14. Loibner M, Hagauer S, Schwantzer G, et al. Limiting
factors for wearing personal protective equipment
(PPE) in a health care environment evaluated in a rand-
omised study. PLoS One 2019; 14: e0210775.
15. Elizabeth LB. Call for improvement in personal protec-
tive equipment guidance and research. Am J Infect
Control 2016; 44: 1428.