By Jeremy Urekew, Hazmat Specialist with the FEMA Urban Search and Rescue system
“We rely on clean air with a suitable oxygen concentration to keep our bodies alive. When the world finds a way to deprive of us this, we fight back with respiratory protection.”
In January of 2020 it would have been hard to imagine opening a supply cabinet at a local hospital to find that there are just no more N95 masks to hand out to your staff. It would almost seem preposterous to assume that a point would come where there was just no supplier to even procure them from. Alas, March 2020 arrived and first response agencies, hospitals, other healthcare facilities found themselves in this very position.
Throughout my career I have worn a plethora of respirators to protect me from the hazards of my work. I have worn SCBAs (Self- Contained Breathing Apparatus), PAPRs (Powered Air-Purifying Respirators), APRs (Air-Purifying Respirators), and rebreathing circuits. Respiratory protection always fascinated me in that as resilient as the human body can be, we have an inherent weakness through the openings of the nose, mouth, and ocular membranes. We rely on clean air with a suitable oxygen concentration to keep our bodies alive. When the world finds a way to deprive of us this, we fight back with respiratory protection.
As the need for continuous respiratory protection arose with the uncertainty of COVID-19 transmission, we had an answer. It was the N95. The N95, though never genuinely appreciated, is a formidable opponent to the viral particles allowing workers to be in harm’s way, yet truly protected. When worn with splash glasses, face shield, and other PPE, we had a great way of keeping ourselves safe. This proved to be problematic when our supply nationwide began to dwindle.
The answer: reusable respirators. In healthcare and EMS agencies these solutions have been available yet overlooked. The problem with disposable N95 masks is that they rely on the tightness of the elastic straps to maintain a seal. This tightness can prove to be uncomfortable over extended time. In addition, the lack of comfort causes workers to adjust the mask, pull on the mask, and have a myriad of reflexive motions that almost always lead to cross contamination. Workers also complain of the fatigue from extended wearing as inspiration was difficult and the exhaling of hot air made your next breath even more unbearable. To pile on to this, continuous wearing of the N95 mask results in skin breakdown at the bridge of the nose and in prominent places around the back of the head.
As supplies were noticed to be dwindling or non-existent, workers across the nation are being asked to reuse disposable PPE. They are being asked to doff N95 masks, set them aside, and redon them as needed throughout the shift. To promote this as a practice, several methods of decontamination were designed. Hospitals and emergency services have started using UVC sterilizers, microwaving, Hydrogen Peroxide, and high heat to disinfect the N95 masks for reuse. Several independent studies were performed to validate the efficacy of these treatments, yet all were found to cause some form of breakdown to the filtering medium or worse, to alter the electrostatic charge over time.
“The healthcare system already had a robust respiratory protection plan in place, so all we needed to do was supplement with information pertinent to our respirators.”
The deeply rooted problem is that disposable masks are designed for just that: to be disposable. What if there was an option that was cleanable, reusable, and provided higher filtration? In several organizations that I work for or with, the concept was drafted to begin a reusable respirator plan. The process started at a level 1 trauma center in Charlotte, NC. Several physicians took it upon themselves to purchase any respirators or filters they could find. The program started off with twenty-three full face 3M 6000 series respirators and nineteen 3M 7500 series half face respirators. We were able to buy 102 P100 filters (7093 series). The initial plan was to outfit physicians, nurses, providers, paramedics, and healthcare technicians that would be directly involved in patient care resulting in aerosolizing particles.
Our emergency department has approximately 450 employees between the adult and pediatric units. We did not think we could outfit every employee with their own personal respirator based on time, money, and availability constraints. So, we focused our efforts on employees that would be in the highest harm arena. We quickly established a list of just over 100 people fitting that criteria. Then we began the fit testing blitz. For almost 2 weeks, we performed qualitative fit testing on every person on our list. In addition to the fit testing, we provided quick training on donning, doffing, and care of the respirators. The healthcare system already had a robust respiratory protection plan in place, so all we needed to do was supplement with information pertinent to our respirators.
The COVID-19 safety task force (a committee of physicians, paramedics, and nurses) took ownership of the program and went to work. Quickly a cleaning procedure was developed based on manufacture recommendations, OSHA regulations, and the most up to date information from other government agencies. We took over a small patient room and utility closet. Shelves were put in the room and the process was born. Employees would come to the respirator room at the beginning of their shift. They would be assigned a respirator based on their fit testing results and their preference. Each employee has a set of filters (P100 or combination) assigned to them. They return the respirator and filters at the end of their shift and our team wipes them down, separates the filters, and processes the respirator through a sanitizing procedure. The respirators are then dried, inspected, and returned to the storage room for reissuance.
As our program grew, we were able to procure respirators from donations, online buying portals, spare boxes found in storage closets, and from local distributors. We started with 23 respirators and to date, we have over 267 in our cache. We carry 3 series of 3M respirators with 3 different sizes and one size of Binks Millennium 3000s that were donated. Due to national backorder and DLA needs, filters are scarce. Our program has brought together 7 different types of filters/cartridges that are assigned based on a complex algorithm of uses and ability to be cleaned. Totaling 326 filters to date, we have been able to provide formidable respiratory protection to all patient facing employees within the department without taxing our respirator cache.
“A short-term cost/benefit analysis has shown that it will most likely be prudent to continue this program and use it as needed for flu season, biologic hazards, and other pandemics to come.”
The first week of our program only saw 20 respirators per day being issued to employees. By week four that number had grown to 60 per day with over 1400 total respirators issued to employees. To put that into context, we had been asking employees to use and reuse disposable N95 masks and then send them to be cleaned via UVC or Hydrogen Peroxide disinfecting processes. A nurse may use up to three N95s during a shift if they work in high acuity patient areas with high aerosolizing or splash hazards.
Employees would receive a N95 that they would have no idea to whom it belonged to before. In addition, the N95s could not be cleaned throughout a shift so they stood to accumulate viral particles and other biologic contaminants. Employees would don and doff throughout the shift for breaks, fluid intake, and for repose.
Our reusable respirators, along with training, allowed the user to doff in a controlled manner and then clean their respirator between needing to be worn. We have implemented a directive that employees can either choose to use a N95, a KN95, or a reusable respirator for the duration of their shift. The outcry of joy employees have shared when picking up respirators has empowered our team to work even harder to label, organize, and maintain a sanitary storage room. We turned a miserable crisis into a bearable inconvenience, all by changing the way healthcare views respiratory protection.
In addition, we retrofitted 24 – 3M Breathe Easy PAPRs with USB Battery cells due to an inability to find batteries anywhere in the country. We were able to match the voltage and amperage with common USB charging units and altered the power fitting to accommodate USB power. Our PAPRs now have a 12 to 17 hour run time and are completely rechargeable at a retrofit cost of less than $50.00 per unit. It was easy to adapt our PAPRs into the cleaning and reuse strategy once the procedures were in place. Several teammates that could not be QLFT (Qualitative Fitting Test) into tight fitting respirators were assigned PAPRs for their use.
Our concerns lie with the reduced assign protection factors as we are using QLFT for all of our respirators. With more preparation and in the future, the likely shift to move to QNFT will occur to accommodate a more expedient testing process and one that yields a higher confidence factor in our respirators.
As multiple agencies and news outlets report COVID-19 to be leveling out and maybe on the rise in the near future, reusable respirators have definitely taken our largest PPE concern off of the table and given us a weapon against biologic contamination. A short-term cost/benefit analysis has shown that it will most likely be prudent to continue this program and use it as needed for flu season, biologic hazards, and other pandemics to come.
About the Author
Jeremy Urekew is a Hazmat Specialist with the FEMA Urban Search and Rescue system as well as a practicing paramedic. He primarily works as a subject matter expert in WMD, teaching for the Department of Homeland Security. He has been a fireman and paramedic for almost 20 years with several different agencies in Louisville, KY. He resides in Charlotte, NC now, and is the Director of Training for Special Operations Aid and Rescue, a training company that provides tactical medical/rescue training and defense contracting. He maintains his parmaedic certifcation through working at a level 1 trauma center and a high volume EMS agency part-time.
