Plastic Bag With Holes as an Alternative to Face Shield: Our Experiences.

In the midst of the coronavirus disease (Covid)-19 pandemic, face shields have become an essential component of personal protective equipment (PPE) while carrying out aerosol-generating medical procedures (AGMP) (1). Yet there is a global shortage of PPE that is affecting the care of patients and the safety of health care workers (HCWs), which is forcing the latter to be innovative and identify new sources of PPE across the globe (2). Lee et al. have suggested the use of prefilled plastic bags with oxygen, and Shailesh Kumar advocated wearing a C-Arm plastic cover along with a nasal cannula attached to an oxygen delivery source that delivers oxygen inside the cover to the intubator (3,4).

Although the idea and the works are laudable, it is cumbersome and has some limitations in the busiest emergency departments (EDs). Hence, we suggest usage of a transparent plastic bag with holes for HCWs during AGMP at first referral units and resource-limited hospitals. To ascertain the user's experience and feasibility, we conducted a small study with our hospital emergency physicians and technicians, two in each category, who volunteered and were healthy. The proposed work was explained to each participant and a written informed consent was obtained prior to the procedure.

An oversized rectangular, clear transparent plastic bag (68 × 34 cm) with a thickness of 50 microns was selected to cover the face with a respirator N95 mask and the head of the HCW involved in the AGMP. Two holes, each of 3 cm in diameter, was made on the plastic bag at the junction of the upper and middle third, and middle and lower third levels, with an inter-hole distance of 15 cm. The holes were made to facilitate ventilation and overcome the inconveniences of rebreathing. The users were informed to wear the plastic bag in such a way that the holes would be on the posterior aspect of the head (Figure 1, Figure 2 ). The bag was sterilized by ethylene oxide prior to use. The open end of the plastic bag was tucked inside the head end of the gown and secured well to prevent the plastic bag slipping away during the procedure.

Figure 1

Anterior aspect of the plastic bag on the volunteer.

Figure 2

Posterior aspect of the plastic bag with holes.

Each one of the participants was asked to do endotracheal intubation twice, at an interval of 6 h, one after another independently on a mannequin. The time measured from wearing the plastic bag as a face shield until they removed it, as well as time measured for the procedure, were noted for each by the emergency physician. During that time, their hemodynamic status, oxygen saturation, and mainstream capnography were continuously monitored. The data were analyzed by simple descriptive statistics, and did not reveal any abnormalities among them. Participants did not complain of suffocation, fogging, or sweating. They did not experience any difficulties during the procedure. Two of them wearing spectacles regularly stated that they did not experience any vision problem while using the plastic bag as a face shield.

Hence, we believe that the holes on the posterior aspect of the plastic bag allowed them to breathe comfortably without accumulation of carbon-dioxide (CO2) in the plastic bag. Lack of suffocation, breathing difficulties, sweating, and fogging during the procedure or wearing the plastic bag was attributable to nonaccumulation of CO2.

Based on our observations, we propose that these PPE can be used while handling cases or executing other AGMP, including sample collections from the nasopharynx and throat. These plastic bags may be preferred in the field or at the time of triage as an alternative to regular face shields during this Covid-19 pandemic. However, further field-based studies are required to ascertain the usefulness and limitations.