As the saying goes, “an ounce of prevention is worth a pound of cure.” So, let’s talk about personal protective equipment (PPE) in the wilderness by comparing precautions available in the hospital to those we can carry or improvise in the wilderness. In the hospital, we typically have handwashing stations, gloves, masks (for ourselves and the patient), goggles or face shields, gowns, and isolation rooms, some with negative pressure. Let’s take each of these and discuss viable outdoor alternatives.

Handwashing:

Hand hygiene is one of the most effective ways to limit the transmission of infectious diseases. This is important not only for COVID-19, but also to limit the fecal-oral transmission of gastrointestinal bugs that can ruin a trip and affect multiple members of the same group. Hand sanitizer or eco-friendly soaps like castile soap are small and lightweight, and should be included in your pack. Wash hands with soap and water for at least 20 seconds. Use the cleanest water possible. Water should be from an improved or protected water source. Learn more at washdata.org. If soap and water are not available, use an alcohol-based hand rub that contains at least 60% alcohol.

Gloves:

Gloves are cheap and easy to pack, especially if you buy pre-packaged glove kits. If you only have one pair, you can consider cleaning off the outside of the gloves to reuse on the same patient with standard cleaning agents used to decontaminate other tools, rather than going through several pairs like we often do in the hospital. Improvising with work or rope gloves is generally not recommended, as most of these are expensive and permeable to body fluids.

Masks:

When working with a patient with a known or suspected COVID-19 diagnosis or when performing aerosolizing procedures (e.g. intubation, chest compressions), you should have an N95 respirator or equivalent. If this is not available, other options, in order of preference, are: surgical masks, layered cloth masks, and doubled-over neck gaiters. Remember, masks are more useful for stopping the spread from the wearer to others when they cough, sneeze, or exhale—so ask the patient to put on a mask. In the event a patient must be carried out by a team, every person who carries the litter is at risk for exposure, so an extra mask for the patient can help mitigate potential spread. Asymptomatic carriers can still spread the virus to others, but classic symptoms can also be confused for other conditions. For example, a mountain rescue team recently picked up a climber with suspected high altitude pulmonary edema, only to find out later they were COVID-19 positive.

When it comes to improvised masks, a go-to for many outdoor enthusiasts has been the ubiquitous neck gaiter. Many already have one in their gear stash. In the past several weeks, however, there has been controversy over its use as a mask. In August, researchers from Duke University published an article analyzing the efficacy of a low-tech way to analyze masks. Within their study, they found that single layer gaiters seemed to aerosolize droplets (Fischer et al, 2020). Aerosols hang in the air longer than droplets, so this new data made gaiters seem worse than wearing no mask at all. Gaiter-wearers and aerosol experts alike think there may be more to the story. Since the publication of the Duke scientists’ article, many independent studies have brought their gaiter-related findings into question. These studies still need peer review but suggest that even single layer gaiters are better than nothing at all. What everyone can agree on is that the best options for improvised masks include multiple layers of fabric and a good fit. If a gaiter is what you have and you need a mask, double it over and you’ll likely increase its efficacy. Until we have more data on gaiters, though, consider adding a surgical or cloth mask for yourself and your patient to your pack.

Goggles or Face Shields:

Obviously, certain outdoor activities already require eye protection, which can be repurposed as PPE in a pinch. Those who wear glasses already have some protection, though not as much as wrap-around goggles. Sunglasses are also usually on hand and useful in daylight. It can be very difficult to convince people who don’t wear glasses of the need for clear lens eye protection, but this offers the dual function of BSI and protection from corneal abrasions.

Fogging eyewear is annoying and may even hinder operations to the point where you must weigh the risks and benefits of wearing both mask and goggles at the same time. Anti-fog spray, gel, or wipes might help but often don’t completely solve the problem. In some cases, the best option may be to wear a mask and goggles while engaged in direct patient care, then removing one while moving. As with everything, the mission dictates what you end up doing. For example, during a search & rescue operation on a hot, humid day, one of the authors wore a mask and clear lens glasses during direct patient care, then took off the perpetually fogged glasses while hiking about six feet away from others. On another mission, as the passenger on an ATV during a night SAR, the author reported that it seemed more important to protect their eyes from tree branches, so they lowered the mask while riding.

Gowns:

A gown is simply a barrier impermeable to droplets, so is easily improvised. One park ranger we worked with had a small rain poncho packed on top of her first aid kit to use if needed. Another mountain rescue expert packed a painter’s tarp—cheap, light, and with a large surface area that packs small—as a waterproof layer to pack hypothermic patients for litter transport. This could also be repurposed as PPE. During the COVID-19 peak earlier this year, some nurses who had run out of proper PPE resorted to wearing trash bags. Finally, rain jackets could be used if necessary. Keep in mind that your shell is likely one of the more expensive items in your pack, and that you won’t want to question whether it’s contaminated once the rain starts.

Isolation Rooms:

How do we replicate isolation rooms? The first step is to do what we’ve known for the last 6+ months: social distancing, six feet apart or more. To apply this to a wilderness setting, let’s say you are on a SAR mission and make contact with a lost and injured hiker. Size up the scene from at least six feet away. I remember seeing a doctor stand outside a patient’s room and pronounce, “LGFD!” I looked at him questioningly and he explained, “looks good from door.” This is the “Sick or Not Sick” label we are all familiar with.

From this distance you can ask the patient the basic screening questions, “Fever, cough, shortness of breath?” and ask them to put on a mask. Avoid enclosed areas with patients who are sick. Don’t go into a shelter or tent to evaluate a patient. If there happens to be a breeze, try to position yourself upwind of the patient, especially if they have concerning symptoms (NOLS Wilderness Medicine, June 2020). Finally, if you are working in a team, assign one low-risk team member to take the lead on direct patient care.

Conclusion:

There are some elements of PPE that can be improvised and some that we simply must bring. Our own awareness, and even simply adjusting our initial assessment position to maintain a bit more distance, can be excellent protection from COVID-19 and other infectious diseases. Ultimately what we use and when depends on the mission at hand, and the context in which we are practicing.