Skip to main content Accessibility help

Impact of Clinician Personal Protective Equipment on Medical Device Use During Public Health Emergency: A Review

  • Hanniebey D. Wiyor (a1), James C. Coburn (a1) (a2) and Karen L. Siegel (a3)


The aim of this systematic review is to evaluate the impact of personal protective equipment (PPE) on medical device use during public health emergency responses. We conducted a systematic literature search of peer-reviewed journals in PubMed, Web of Science, and EBSCO databases. Twenty-nine of 92 articles published between 1984 and 2015 met the inclusion criteria for the review. Although many medical device use impacts were reported, they predominantly fell into 3 categories: airway management, drug administration, and diagnostics and monitoring. Chemical, biological, radiological, and nuclear (CBRN)-PPE increased completion times for emergency clinical procedures by as much as 130% and first attempt failure rates by 35% (anesthetist) versus 55% (non-anesthetist). Effects of CBRN-PPE use depend on device, CBRN-PPE level, and clinician experience and training. Continuous clinical training of responders in CBRN-PPE and device modifications can improve safety and effectiveness of medical device use during public health emergency response.


Corresponding author

Correspondence and reprint requests to LT Hanniebey D. Wiyor, PhD, United States Food and Drug Administration, White Oak Campus, 10903 New Hampshire Avenue, CDRH Building 66, Room 2563, Silver Spring, MD 20993 (e-mail:


Hide All
1. Nakajima, T, Sato, S, Morita, H, Yanagisawa, N. Sarin poisoning of a rescue team in the Matsumoto sarin incident in Japan. Occup Environ Med. 1997;54(10):697701.
2. Suzuki, T, Morita, H, Ono, K, et al. Sarin poisoning in Tokyo subway. Lancet. 1995;345(8955):980981.
3. Diamond, D. Ebola has killed more than 200 doctors, nurses, and other healthcare workers since June. 2015. Accessed June 14, 2014.
4. Ramesh, AC, Kumar, S. Triage, monitoring, and treatment of mass casualty events involving chemical, biological, radiological, or nuclear agents. J Pharm Bioallied Sci. 2010;2(3):239247.
5. Gershon, RR, Vandelinde, N, Magda, LA, et al. Evaluation of a pandemic preparedness training intervention for emergency medical services personnel. Prehosp Disaster Med. 2009;24(6):508511.
6. Scott, JA, Miller, GT, Issenberg, SB, et al. Skill improvement during emergency response to terrorism training. Prehosp Emerg Care. 2006;10(4):507514.
7. Tavares, W. Impact of terrorist attacks on hospitals. J Emerg Nurs. 2018;44(2):188190.
8. McIsaac, JH. Hospital Preparation for Bioterror: A Medical and Biomedical Systems Approach. Amsterdam: Elsevier; 2010.
9. National Standards Authority of Ireland. SR CWA 16106 : 2010: PPE for chemical, biological, radiological and nuclear (CBRN) hazards. Accessed June 9, 2019.
10. British Standard Institute. BS 8467:2006 Protective clothing. Personal protective ensembles for use against chemical, biological, radiological and nuclear (CBRN) agents. Categorization, performance requirements and test methods. Accessed June 9, 2019.
11. Occupational Safety and Health Administration (OSAH). OSHA best practices for hospital-based first receivers of victims from mass casualty incidents involving the release of hazardous substances. Accessed June 9, 2019.
12. Goldfrank, L, Manning, FJ. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: National Academies Press; 2002.
13. Reilly, MJ, Markenson, D, DiMaggio, C. Comfort level of emergency medical service providers in responding to weapons of mass destruction events: Impact of training and equipment. Prehosp Disaster Med. 2007;22(4):297303.
14. Kollek, D, Welsford, M, Wanger, K. Chemical, biological, radiological and nuclear preparedness training for emergency medical services providers. Can J Emerg Med. 2009;11(4):337342.
15. Suyama, J, Knutsen, CC, Northington, WE, et al. IO versus IV access while wearing personal protective equipment in a HazMat scenario. Prehosp Emerg Care. 2007;11(4):467472.
16. Krueger, GP. Psychological and performance effects of chemical-biological protective clothing and equipment. Mil Med. 2001;166(Suppl 2):4143.
17. Hsu, EB, Jenckes, MW, Catlett, CL, et al. Effectiveness of hospital staff mass-casualty incident training methods: A systematic literature review. Prehosp Disaster Med. 2004;19(3):191199.
18. Liberati, A, Altman, DG, Tetzlaff, J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: Explanation and elaboration. PLoS Med. 2009;6(7):e1000100.
19. Castle, N, Bowen, J, Spencer, N. Does wearing CBRN-PPE adversely affect the ability for clinicians to accurately, safely, and speedily draw up drugs? Clin Toxicol. 2010;48(6):522527.
20. Brinker, A, Gray, S, Michel, S, et al. Vascular access skills during cardiopulmonary resuscitation in hazardous environments: 13AP2‐4. Eur J Anaesthesiol (EJA). 2012;29:191192.
21. Brinker, A, Gray, SA, Schumacher, J. Influence of air-purifying respirators on the simulated first response emergency treatment of CBRN victims. Resuscitation. 2007;74(2):310316.
22. Castle, N, Pillay, Y, Spencer, N. Insertion of six different supraglottic airway devices whilst wearing chemical, biological, radiation, nuclear‐personal protective equipment: A manikin study. Anaesthesia. 2011;66(11):983988.
23. Castle, N, Owen, R, Hann, M, et al. Impact of chemical, biological, radiation, and nuclear personal protective equipment on the performance of low-and high-dexterity airway and vascular access skills. Resuscitation. 2009;80(11):12901295.
24. Castle, N. Care after chemical, biological, radiation or nuclear events. Emerg Nurse. 2010;18(7):2636.
25. Castle, N, Pillay, Y, Spencer, N. What is the optimal position of an intubator wearing CBRN-PPE when intubating on the floor: A manikin study. Resuscitation. 2011;82(5):588592.
26. Coates, MJ, Jundi, AS, James, MR. Chemical protective clothing; a study into the ability of staff to perform lifesaving procedures. J Accid Emerg Med. 2000;17(2):115118.
27. Schumacher, J, Runte, J, Brinker, A, et al. Respiratory protection during high‐fidelity simulated resuscitation of casualties contaminated with chemical warfare agents. Anaesthesia. 2008;63(6):593598.
28. Schumacher, J, Gray, SA, Michel, S, et al. Respiratory protection during simulated emergency pediatric life support: A randomized, controlled, crossover study. Prehosp Disaster Med. 2013;28(01):3338.
29. Ben-Abraham, R, Gur, I, Vater, Y, et al. Intraosseous emergency access by physicians wearing full protective gear. Acad Emerg Med. 2003;10(12):14071410.
30. Ben-Abraham, R, Weinbroum, AA. Laryngeal mask airway control versus endotracheal intubation by medical personnel wearing protective gear. Am J Emerg Med. 2004;22(1):2426.
31. Ben-Abraham, R, Flaishon, R, Sotman, A, et al. Cuffed oropharyngeal airway (COPA) placement is delayed by wearing antichemical protective gear. Emerg Med J. 2008;25(12):847850.
32. Flaishon, R, Sotman, A, Ben-Abraham, R, et al. Antichemical protective gear prolongs time to successful airway management: A randomized, crossover study in humans. Anesthesiology. 2004;100(2):260266.
33. Goldik, Z, Bornstein, J, Eden, A, et al. Airway management by physicians wearing anti-chemical warfare gear: Comparison between laryngeal mask airway and endotracheal intubation. Eur J Anaesthesiol. 2002;19(03):166169.
34. Berkenstadt, H, Arad, M, Nahtomi, O, et al. The effect of a chemical protective ensemble on intravenous line insertion by emergency medical technicians. Mil Med. 1999;164(10):737739.
35. Borron, SW, Arias, JC, Bauer, CR, et al. Intraosseous line placement for antidote injection by first responders and receivers wearing personal protective equipment. Am J Emerg Med. 2011;29(4):373381.
36. Burns, JB Jr, Branson, R, Barnes, SL, et al. Emergency airway placement by EMS providers: Comparison between the King LT supralaryngeal airway and endotracheal intubation. Prehosp Disaster Med. 2010;25(1):9295.
37. King, JM, Frelin, AJ. Impact of the chemical protective ensemble on the performance of basic medical tasks. Mil Med. 1984;149(9):496.
38. Wedmore, IS, Talbo, T, Cuenca, PJ. Intubating laryngeal mask airway versus laryngoscopy and endotracheal intubation in the nuclear, biological, and chemical environment. Mil Med. 2003;168(11):876879.
39. Greenland, K, Tsui, D, Goodyear, P, et al. Personal protection equipment for biological hazards: Does it affect tracheal intubation performance? Resuscitation. 2007;74(1):119126.
40. Udayasiri, R, Knott, J, McD Taylor, D, et al. Emergency department staff can effectively resuscitate in level C personal protective equipment. Emerg Med Australas. 2007;19(2):113121.
41. Garner, A, Laurence, H, Lee, A. Practicality of performing medical procedures in chemical protective ensembles. Emerg Med. 2004;16(2):108113.
42. Castle, N, Owen, R, Clark, S, et al. Comparison of techniques for securing the endotracheal tube while wearing chemical, biological radiological or nuclear protection: A manikin study. Prehosp Disaster Med. 2010;25(6):589594.
43. Castle, N, Owen, R, Clarke, S, et al. Does position of the patient adversely affect successful intubation whilst wearing CBRN-PPE? Resuscitation. 2010;81(9):11661171.
44. MacDonald, RD, LeBlanc, V, McArthur, B, et al. Performance of resuscitation skills by paramedic personnel in chemical protective suits. Prehosp Emerg Care. 2006;10(2):254259
45. Lamhaut, L, Dagron, C, Apriotesei, R, et al. Comparison of intravenous and intraosseous access by pre-hospital medical emergency personnel with and without CBRN protective equipment. Resuscitation. 2010;81(1):6568.
46. Shin, DH, Choi, PC, Na, JU, et al. Utility of the Pentax-AWS in performing tracheal intubation while wearing chemical, biological, radiation and nuclear personal protective equipment: A randomised crossover trial using a manikin. Emerg Med J. 2013;30(7):527531.
47. Tucker, JB. Historical trends related to bioterrorism: An empirical analysis. Emerg Infect Dis. 1999;5(4):498.
48. Bowonder, B, Linstone, HA. Notes on the Bhopal accident: Risk analysis and multiple perspectives. Technol Forecast Soc Change. 1987;32(2):183202.
49. European Paliament. Directorate-general for internal policies, Policies Department C: Citizens’ Rights and Constitutional Affairs. 2011. Accessed January 13, 2015.
50. Center for Disease Control and Prevention. Guidance on Personal Protective Equipment To Be Used by Healthcare Workers During Management of Patients with Ebola Virus Disease in U.S. Hospitals, Including Procedures for Putting On (Donning) and Removing (Doffing). Vol 20152014. Accessed June 9, 2019.
51. Willms, K, Wells, R, Carnahan, H. Glove attributes and their contribution to force decrement and increased effort in power grip. Hum Factors. 2009;51(6):797812.
52. Hur, P, Motawar, B, Seo, NJ. Hand breakaway strength model—Effects of glove use and handle shapes on a person’s hand strength to hold onto handles to prevent fall from elevation. J Biomech. 2012;45(6):958964.
53. Burgert, JM. Intraosseous vascular access in disasters and mass casualty events: A review of the literature. Am J Disaster Med. 2016;11(3):149166.
54. Northington, WE, Suyama, J, Goss, FL, et al. Physiological responses during graded treadmill exercise in chemical-resistant personal protective equipment. Prehosp Emerg Care. 2007;11(4):394398.
55. Blacker, SD, Carter, JM, Wilkinson, DM, et al. Physiological responses of police officers during job simulations wearing chemical, biological, radiological and nuclear personal protective equipment. Ergonomics. 2013;56(1):137147.
56. Hostler, D, Bednez, JC, Kerin, S, et al. Comparison of rehydration regimens for rehabilitation of firefighters performing heavy exercise in thermal protective clothing: A report from the Fireground Rehab Evaluation (FIRE) trial. Prehosp Emerg Care. 2010;14(2):194201.
57. Hanson, M. Development of a draft British standard: The assessment of heat strain for workers wearing personal protective equipment. Ann Occup Hyg. 1999;43(5):309319.
58. Teixeira, RA, Bensel, CK. The Effects of Chemical Protective Gloves and Glove Liners on Manual Dexterity. Natick, MA: Army Natick Research Development and Engineering Center; 1990.
59. Scanlan, S, Roberts, W, McCallum, R, et al. A dexterity and tactility evaluation of the Australian Nuclear Biological Chemical (NBC) glove. Fairbairn, Camberra: Defence Science and Technology Organisation Victoria (Australia) Platform; 2004.
60. Magalhães, MJ, de Magalhães, ST, Revett, K, et al. Chemical, Biological, Radiological and Nuclear (CBRN) protective clothing–A review. In: Proceedings of the International Conference on Global Security, Safety, and Sustainability. ICGS3 2017: Global Security, Safety and Sustainability - The Security Challenges of the Connected World , London, UK, January 18-20, 2017, pp 331341.
61. Gorji, M, Bagherzadeh, R, Fashandi, H. Electrospun nanofibers in protective clothing. Electrospun Nanofibers. Amsterdam: Elsevier; 2017:571598.
62. Chen, P-Y, Zhang, M, Liu, M, et al. Ultrastretchable graphene-based molecular barriers for chemical protection, detection, and actuation. ACS Nano. 2017;12(1):234244.
63. Moseman, J. Are these the right gloves? Solubility & maximum protection. Prof Saf. 2016;61(04):4047.



Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed